Difficult Airway Management in a Patient With Post-burn Contracture Neck.

During reconstructive interventions in patients presenting with severe post-burn mento-sternal scar contracture, securing the airway forms a critical part of management. Extreme contracture is more likely to develop in patients who have had thoracic burns with ascending involvement of the neck and mandibular region. When cervical hyperextension and elevation of the mandible are impeded, post-burn contracture of the neck might render endotracheal intubation difficult. The development of rigid scar tissue that distorts the laryngeal and mandibular anatomy, or the development of microstomia following scar tissue retraction in facial burns, may make alternative approaches to direct laryngoscopy challenging. In patients with healed neck burns, intubation difficulties should be anticipated, and equipment for aiding intubation should be kept ready. Furthermore, a surgeon must be present throughout anesthesia induction in case an emergency neck release is required. Although the role of awake fiberoptic intubation has been well established in the general population, it is yet to be assessed in patients with burns. In this report, we present a case of successfully managed post-burn contracture that was planned for awake fiberoptic intubation.

Evaluation of Hematological Parameters in Predicting Intensive Care Unit Admission in COVID-19 Patients.

Hematological parameters like total leukocyte count (TLC), neutrophil, lymphocyte, and absolute eosinophil counts (AEC), and neutrophil-to-lymphocyte ratio (NLR) are known to predict the severity of novel coronavirus disease 2019 (COVID-19) patients. In the present study, we aimed to study the role of complete blood count parameters in triaging these patients requiring intensive care unit (ICU) admission. A retrospective study was done over a period of 2 months. Patients, who were ≥ 18 years of age with COVID-19 confirmed on SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) and whose routine hematology counts were sent within 24 h of admission, were included in the study. Cut-off values of 47.5 years for age, 11.3 × 109/L for TLC, and 9.1 for NLR were predictive of disease severity among COVID-19 patients. Relative neutrophilia ≥ 70% (p < 0.007), relative lymphopenia ≤ 20% (p < 0.002), AEC ≤ 40/cumm (p < 0.001), and NLR ≥ 9.1 (p < 0.001) were significantly associated with ICU admission. Routine hematological parameters are cost-effective and fast predictive markers for severe COVID-19 patients, especially in resource-constrained health care settings to utilize limited ICU resources more effectively.

An Observational Study on Arrhythmia During Cesarean Section Under Spinal Anesthesia: Incidence, Risk Factors, and Effects on Immediate Post-delivery Neonatal Outcome.

INTRODUCTION: Various types of arrhythmia have been reported during cesarean section under spinal anesthesia. But the possible causative factors and the effects of arrhythmia on immediate post-delivery neonatal outcome are not well established. METHODS: This prospective observational study was conducted over a period of one year in a tertiary care hospital on women undergoing cesarean section under spinal anesthesia. The objectives of the study were to determine the incidence of arrhythmia, its types, the possible factors influencing arrhythmia, and the immediate post-delivery neonatal outcome. Data collected were analyzed using Statistical Package for the Social Sciences (SPSS) software version 21 (IBM Corp. Armonk, NY). RESULTS: In our study, the incidence of arrhythmia was 31.9% during cesarean section under spinal anesthesia; and sinus bradycardia was the most common type. Arrhythmia occurred more in women with hypotension, when maximum block height was above T4 level and dose of intrathecal hyperbaric bupivacaine was more than 2.2 mL (P value <0.05). Also, uterine manipulation led to sudden bradycardia and transient cardiac asystole in two patients which was preceded by subjective symptoms of pain and discomfort. None of the neonates required cardiopulmonary resuscitation or neonatal intensive care unit admission within an hour of birth. APGAR (Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration) scores at 1 and 5 minutes were similar in all the newborns born to mothers with or without arrhythmia. CONCLUSION: The occurrence of arrhythmia during cesarean section under spinal anesthesia, though very common, is rarely life-threatening. Keeping maximum level of block height between T4 and T6, using lower possible drug dose to provide adequate level of sensory block, prompt management of hypotension, and strict monitoring during uterine manipulation may reduce the overall incidence of arrhythmia. Intraoperative arrhythmia, however, does not adversely affect the immediate post-delivery neonatal outcome.

Antiemetic Efficacy of Palonosetron Compared with the Combination of Ondansetron and Dexamethasone for Prevention of Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopic Gynaecological Surgery.

Background and aims: For the prevention of PONV, we evaluated the efficacy of palonosetron compared with ondansetron along with dexamethasone in patients undergoing laparoscopic gynaecological surgery. Methods: A total of 84 adults, posted for elective laparoscopic surgeries under general anaesthesia were included in the study. The patients were randomly allocated to two groups (n = 42 each). Immediately after induction, patients in the first group (group I) received 4 mg ondansetron with 8 mg dexamethasone, and patients in the second group (group II) received 0.075 mg palonosetron. Any incidences of nausea and/or vomiting, the requirement of rescue antiemetic, and side effects were recorded. Results: In group I, 66.67% of the patients had an Apfel score of 2, and 33.33% of the patients had a score of 3. In group II, 85.71% of patients had an Apfel score of 2, and 14.29% of the patients had a score of 3. At 1, 4, and 8 hours, the incidence of PONV was comparable in both groups. At 24 hours there was a significant difference in the incidence of PONV in the group treated with ondansetron with dexamethasone combination (4/42) when compared to the palonosetron group (0/42). The overall incidence of PONV was significantly higher in group I (23.81%: ondansetron and dexamethasone combination) than in group II (7.14%: palonosetron). The need for rescue medication in group I was significantly high. Conclusion: Palonosetron was more efficacious compared to the combination of ondansetron and dexamethasone for preventing PONV for laparoscopic gynaecological surgery.

Effect of different doses of intrathecal nalbuphine as adjuvant to ropivacaine in elective lower limb surgeries: A dose finding study.

BACKGROUND AND AIM: Nalbuphine as an adjuvant intrathecally can produce significant analgesia with minimal side effects. However, no research has been done with isobaric ropivacaine. We, therefore, in this prospective, randomised double-blind study tried to find the optimal dose of intrathecal nalbuphine with isobaric 0.75% ropivacaine for elective lower limb surgeries. MATERIALS AND METHODS: One hundred American Society of Anaesthesiologists I and II patients undergoing elective lower limb surgery were divided into four groups randomly: groups A, B, C and D, who received 0.5 mL normal saline or 0.4, 0.8 and 1.6 mg nalbuphine made up to 0.5 mL normal saline added to 22.5 mg (total volume 3.5 mL) isobaric 0.75% ropivacaine, respectively. The onset of sensory and motor block, two-segment regression time, duration of sensory and motor block, Visual Analogue Scale (VAS) and the incidence of adverse effects were compared between the groups. RESULTS: The onset of both sensory and motor blockade was faster with addition of 0.4, 0.8 and 1.6 mg of nalbuphine when compared with ropivacaine alone; however, it was not statistically significant (P > 0.05). Two-segment regression time and duration of analgesia and motor blockade were highest with 1.6 mg of nalbuphine followed by 0.8, 0.4 and plain 0.75% ropivacaine (P < 0.05). The duration of sensory blockade in all four groups was slightly more than the duration of motor blockade. VAS readings were comparable in all nalbuphine groups when compared with ropivacaine group. Haemodynamic variability among the four groups was comparable. Incidence of adverse effects was highest in the 1.6-mg group when compared with others, although it was statistically insignificant (P > 0.05). CONCLUSION: Nalbuphine can be a good alternative to other opioids as an adjuvant intrathecally to prolong postoperative analgesia with a minimal side effect profile. Addition of nalbuphine to isobaric 0.75% ropivacaine gives the added advantage of significant analgesia with early motor recovery. We infer from our study that when compared with 1.6 mg of nalbuphine, both 0.4 and 0.8 mg nalbuphine are equally good as adjuvants to isobaric 0.75% ropivacaine in elective lower limb surgeries with prolonged analgesia, a reliable block with equal efficacy but with lesser side effects.

Comparison of Efficacy of Lateral Branch Pulsed Radiofrequency Denervation and Intraarticular Depot Methylprednisolone Injection for Sacroiliac Joint Pain.

BACKGROUND: Sacroiliac joint dysfunctional pain has always been an enigma to the pain physician, whether it be the diagnosis or the treatment. Diagnostic blocks are the gold standard way to diagnose this condition. Radiofrequency neurotomy of the nerves supplying the sacroiliac joint has shown equivocal results due to anatomical variation. Intraarticular depo-steroid injection is a traditional approach to treating sacroiliac joint pain. For long-term pain relief, however, lesioning the sacral lateral branches may be a better approach. OBJECTIVE: This study compared the efficacy of intraarticular depo-methylprednisolone injection to that of pulsed radiofrequency ablation for sacroiliac joint pain. STUDY DESIGN: This study used a randomized, prospective design. SETTING: Thirty patients with diagnostic block-confirmed sacroiliac joint dysfunctional pain were randomly assigned to 2 groups. One group received intraarticular methylprednisolone and another group underwent pulsed radiofrequency of the L4 medial branch, the L5 dorsal rami, and the lateral sacral branches. RESULTS: Reduction in Numeric Rating Scale (NRS) for pain at 1 month post-procedure remained similar in Group A, while in Group B few patients reported a further decrease in the NRS score (3.333 ± 0.4880 and 2.933 ± 0.5936, respectively). At 3 months post-procedure, the NRS score began to rise in most patients in group A, while in Group B, the NRS score remained the same since the last visit (4.400 ± 0.9856 and 3.067 ± 0.8837, respectively). At 6 months post-procedure, the NRS score began to rise further in most patients in group A. In Group B, the NRS score remained the same in most of the patients since the last visit (5.400 ± 1.549 and 3.200 ± 1.207). There was a marked difference between the 2 groups in Oswestry Disability Index (ODI) scores at 3 months post-procedure (Group A, 12.133 ± 4.486 vs Group B, 9.133 ± 3.523) and at 6 months post-procedure there was a significant (P = 0.0017) difference in ODI scores between Group A and Group B (13.067 ± 4.284 and 8.000 ± 3.703, respectively). Global Perceived Effect (GPE) was assessed in both groups at 3 months post-procedure Only 33.3% (Confidence Interval (CI) of 11.8- 61.6 ) of patients in Group A had positive GPE responses whereas in Group B, 86.67% (CI of 59.5- 98.3 ) of patients had positive GPE responses. At 6 months post-procedure, the proportion of patients with positive GPE declined further in Group A, while in Group B, positive GPE responses remained the same (20% with a CI of 4.30- 48.10 and 86.67% with a CI of 59.5- 98.3, respectively ). LIMITATIONS: Small sample size. CONCLUSION: This comparative study shows that pulsed radiofrequency denervation of the L4 and L5 primary dorsal rami and S1-3 lateral branches provide significant pain relief and functional improvement in patients with sacroiliac joint pain. KEY WORDS: Low back pain, sacroiliac joint dysfunctional pain, radiofrequency, intraarticular injection.