Mid-axillary transversus abdominis plane block and stress response after abdominal hysterectomy: A randomised controlled placebo trial.

BACKGROUND: The hormonal response to surgical trauma can have detrimental effects on patients. Transversus abdominis plane (TAP) block, which can improve analgesia after total abdominal hysterectomy (TAH) might attenuate the peri-operative stress response. OBJECTIVE: To evaluate the ability of the TAP block to reduce stress response, opioid consumption and pain following TAH and multimodal analgesia. DESIGN: Randomised, placebo-controlled double-blind study. SETTING: The current study was conducted at a university hospital from July 2016 to September 2017. PATIENTS: Fifty patients scheduled for TAH were included. Anaesthesia and postoperative analgesia were standardised. INTERVENTION: After induction of anaesthesia, patients were allocated into two groups: ultrasound-guided bilateral mid-axillary TAP block with 20 ml of bupivacaine 0.25% (Group T) or 0.9% saline (Group C). MAIN OUTCOME MEASURES: Levels of free serum cortisol, metanephrine and normetanephrine at 60 min and 6, 12 and 24 h after surgical incision. Pain scores and opioid consumption during the first 24 h after surgery. RESULTS: There was no statistically significant difference between the median [IQR] peri-operative levels of stress hormones and pain scores between groups. Compared with baseline value 9.90 [4.2 to 23.1], free serum median cortisol levels were significantly high at 6 h in Group T, 23.6 [10.1 to 42.9] P = 0.015 and Group C 23.6 [9.9 to 46.3] P = 0.014. Only Group C showed significant elevation from the baseline median levels of plasma metanephrine at 60 min, 52.8 [33.4 to 193.2] P = 0.001, 6 h, 92.70 [2.4 to 202.6] P = 0.005 and normetanephrine at 60 min 83.44 [28.98 to 114.86] P = 0.004, 6 h 78.62 [36.6 to 162.31] P = 0.0005 and 24 h 80.96 [8.6 to 110.5] P = 0.025. Mean ±â€ŠSD opioid consumption was similar in both groups: 39.60 ±â€Š14.87 in Group T vs. 43.68 ±â€Š14.93 in Group C (P = 0.338). CONCLUSION: Mid-axillary TAP block does not improve stress response and analgesia in patients undergoing TAH receiving multimodal analgesia. TRAIL REGISTRATION: ClinicalTrial.gov identifier: NCT03443271.

Efficacy of tramadol in preventing postoperative shivering using thiopentone or propofol as induction agent: A randomized controlled trial.

BACKGROUND: Postoperative shivering (POS) is a common and distressing experience occurring in up to 60% patients postoperatively. This study was designed to compare the efficacy of tramadol in preventing POS when used with two different induction agent, propofol or thiopentone. MATERIALS AND METHODS: One hundred and twenty-four ASA I and II adult patients, aged between 18-60 years, undergoing general anesthesia of intermediate duration (60-240 min) for orthopedic, gynecological, and general surgical procedures were randomly divided to receive either thiopentone or propofol as induction agent. Each group was further subdivided (31 patients in each group) to receive either tramadol or saline 15 min before wound closure. Presence of POS after extubation till discharge from post anesthesia care unit (PACU) was recorded at six different time intervals. RESULTS: The highest incidence of POS was observed in thiopentone-saline (TS) group 77.4%, while the lowest (12.9%) was in propofol-tramadol (PT) group (P > 0.001). Total number of shivering episodes was 122 out of which, 35 (28.7%) were of grade 2 and 3 (significant shivering) requiring treatment. The incidence of significant shivering was similar to the episodes of POS, highest in TS group and lowest being in PT group (P > 0.05). CONCLUSION: The prophylactic use of tramadol in a dose of 1 mg/kg with propofol as an induction agent significantly reduces the incidence of POS in patients recovering from general anesthesia of intermediate duration.

Anesthetic management of a patient with hypertrophic obstructive cardiomyopathy undergoing modified radical mastectomy.

Hypertrophic obstructive cardiomyopathy (HOCM) is a rare genetic disorder characterized by left ventricular outflow tract (LVOT) obstruction. Clinical presentation ranges from absence of symptoms to sudden death. Our 60 year old patient scheduled for left modified radical mastectomy had HOCM since seventeen years with severe LVOT obstruction and mitral regurgitation. An implantable cardioverter defibrillator (ICD) and permanent pacemaker (PPM) was inserted 15 months earlier for ventricular tachycardia. Anesthetic management of these patients presents considerable challenges and requires maintenance of desired hemodynamic parameters and management of specific complications. Factors like tachycardia, hypovolemia, vasodilation and increased cardiac contractility leads to exacerbation of the obstruction. In our patient there was the additional consideration of the ICD which required to be turned off during surgery with full provision for external defibrillation. We managed to successfully maintain the desired hemodynamics throughout the surgery and the patient was discharged home on the seventh postoperative day.