On-Arrival Lumbar Epidural Analgesia for Lower Limb Trauma Pain in Emergency Care: A Superiority Randomized Controlled Trial.

BACKGROUND: Lower limb trauma in emergency settings often leads to pain management challenges. Traditional methods, primarily non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, have limitations. This study explores the efficacy of epidural analgesia in emergency for lower limb trauma patients (ELETRA) as an alternative for managing pain in lower limb trauma patients upon arrival in emergency care. OBJECTIVES:  This study primarily focuses on determining ELETRA's effectiveness in reducing pain for patients with lower limb trauma upon arrival. It also aims to evaluate ELETRA's influence on decreasing stress and shortening hospital stays compared to traditional pain management approaches. METHODS: This study was executed as a prospective, parallel-design, randomized controlled trial in the emergency department of a tertiary care teaching hospital. The interventions were performed in a dedicated induction room adjacent to the emergency operating theater. The trial was registered in the Clinical Trial Registry of India with registration number CTRI/2022/08/044699 dated 16/08/2022. Participants were 18- to 50-year-old patients with lower limb injuries, classified under American Society of Anesthesiologists (ASA) class 1 or 2. Participants were randomized into two groups: one receiving ELETRA and the other standard pain control treatment. The effectiveness of pain relief was measured through a visual analog scale (VAS), and hemodynamic parameters, adverse effects, levels of acute phase reactants, and stress hormones were also measured along with patient satisfaction. RESULTS: The study enrolled 356 participants with lower limb injuries. After excluding participants lost following the intervention, data from 157 individuals in Group A and 160 in Group B were analyzed. Group A's success rate for analgesia (VAS < 2) was 92.35% (n = 145), significantly higher than Group B's 75.62% (n = 121) (p < 0.001). The commonest side effect was hypotension (5.73%) in Group A and nausea in Group B (7.5%). C-reactive protein (CRP) levels rose to 104.71 ± 8.99 mg/dL in Group A and 192.58 ± 9.23 mg/dL in Group B; the difference was statistically significant. Serum cortisol levels were also higher in Group B (67.18 ± 9.21) compared to Group A (44.72 ± 6.14) at one week. Group B had a longer hospital stay, averaging 12.24 ± 4.81 days, against Group A's 10.19 ± 4.91 days. CONCLUSION: ELETRA is a safe and effective alternative for pain management in lower limb trauma patients in emergency settings. It reduces pain, improves patient satisfaction, and has a favorable impact on stress responses.

Enhancing cooperation during pediatric ultrasound: Oral midazolam versus conventional techniques.

BACKGROUND AND AIMS: Ultrasound is a safe and non-invasive method for detecting numerous pathologies. Pediatric patients are often uncooperative which leads to decreased quality and increased time of scan. We compared the conventional means alone and combination of oral midazolam for the above cited purpose. MATERIAL AND METHODS: This double blind prospective study (CTRI/2016/06/007030) was conducted after obtaining due approval from institutional ethical committee. One hundred Children aged 2-6 years belonging to ASA class 1 or 2, posted for high resolution ultrasonography of abdomen were included in the study. They were randomised to receive midazolam 0.3 mg/kg mixed in 20 mL of apple juice (Group I) or 20 mL of apple juice alone (Group II) 20 minutes prior to the procedure. The parameters assessed were level of cooperation, sonologist's satisfaction, total scan time, heart rate and SpO2. RESULTS: Out of 100 patients, 44 patients of group I and 42 of group II were analysed. The cooperation score was significantly higher in Group I (35%) than Group II (19%). Likert scale revealed very satisfied and satisfied rating in 61.3% (Group I) and 21.4% (Group II). The time taken by sonologist and number of attempts were significantly less in Group I than Group II. There was no difference in discharge time between the groups. There was no reportable adverse event in either group. CONCLUSION: Oral midazolam is a safe and effective agent to aid routine abdominal ultrasonography in pediatric patients.

Observational Study to Evaluate the Effect of Epidural Steroid Injection on Bone Mineral Density and Bone Turnover Markers.

BACKGROUND: Epidural steroid injection (ESI) is widely used to manage low back pain. ESIs are commonly performed to treat pain accompanying intervertebral disc prolapse, spinal stenosis, facet joint pathologies, and other degenerative spinal pathologies. Corticosteroids for musculoskeletal conditions, regardless of the route of administration, can reduce bone mineral density (BMD) and increase the risk of fracture. With paraspinal administration of steroids, the severity of risk is enhanced as the steroid is being deposited in close proximity to bone. BMD and molecular markers of bone metabolism are the standard methods to assess the effect of any insult on bone strength and bone metabolism. Carboxy terminal crosslinked telopeptides of type 1 collagen (sCTX) and serum Procollagen Type I N-terminal propeptide (P1NP) are the reference markers of bone resorption and formation, respectively. OBJECTIVE: We conducted this study to determine the effect of ESI on BMD and bone turnover markers. STUDY DESIGN: This was a prospective observational cohort study, involving a cohort of 264 patients between the ages of 40 to 60 years who were advised to undergo ESI at L3-4 or L4-5 by their pain physician. SETTING: Research was conducted at a tertiary care teaching hospital pain clinic in collaboration with the department of orthopaedics and radiodiagnosis. METHODS: Serum CTX-1, P1NP, and pre-ESI BMD of the spine, femur neck, and dual femur were evaluated at baseline; these same parameters were serially evaluated post ESI on follow-ups at 1, 3, and 6 months. Additional follow-up at 10 days post ESI was called for evaluation of bone turnover markers (BTMs). A paired t test was used to analyze changes in BMD and BTMs vs baseline within the group. Cumulative incidence and relative risk of moderate to markedly low BMD were calculated using standard formulas. Any fractures sustained during follow-ups were also evaluated thoroughly and quantified separately. A P value less than .05 was considered statistically significant. RESULTS: The proportion of pre-ESI moderately to markedly low BMD was 10.22% in the study population. There was a statistically significant increase in serum CTX 10 days post ESI which persisted at the one-month and 3-month follow-ups. There was no significant change in serum P1NP level post ESI after 7 days and at the one-month follow-up. The mean value of serum P1NP was, however, significantly higher at the 3-month follow-up. Statistical comparison of the mean BMD value at the spine and femur neck revealed statistically significant decline 3 months post ESI. There was no significant impact of ESI on the total femur BMD. The cumulative incidence of moderately low to markedly low BMD over a period of 6 months in the study population was 45 out of 223, i.e., 20.17%. LIMITATIONS: The study's primary limitations included its high dropout rate, a larger reference range for BTMs, making them a less specific tool for comparison, and the absence of a control group. ESI has a negative impact on the BMD of the hip and spine. Reduced BMD should be considered as a potential side effect of ESI.

Comparative Evaluation of Dexmedetomidine and Pregabalin as Premedication Agent to Attenuate Adverse Hemodynamic and Stress Response in Patients Undergoing Laparoscopic Cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is the most commonly performed laparoscopic procedure. The goal of anesthetic management is to minimize stress response and early discharge. Dexmedetomidine, and pregabalin have been used successfully to attenuate laryngoscopy and intubation response in various surgical procedures. AIM: To compare efficacy of pregablin and dexmedetomidine in attenuating hemodynamic and stress response. SETTING AND DESIGN: A prospective, double blind randomized trial comprising 130 ASA physical status class I and II patients posted for laparsoscopic cholecystectomy. MATERIALS AND METHODS: Patients were randomized in to Group A and Group B. Group A received intravenous dexmedetomidine in a dose of 1 ug.kg-1, through an infusion pump 20 min prior to induction of anaesthesia. Group B subjects received oral pregabalin 150 mg. Parameters observed were vitals, discharge time, cortisol level, side effects if any. RESULTS: Post intervention heart rate got reduced significantly in Group A and it remained low in comparison to baseline during whole peri-operative period. In Group B, immediate post-pneumoperitoneum heart rate, and post exubation heart rate was higher than baseline. Blood pressure (BP) decreased significantly post intervention in Group A which persisted till pneumoperitoneum. In Group B there was statistically significant rise in systolic, diastolic and mean blood pressure postpneumoperitoneum as compared to baseline blood pressure. Post-operative cortisol level was significantly higher than baseline values and the level is more in Group B. CONCLUSION: Intravenous dexmedetomidine is more effective than oral pregabalin in attenuating perioperative stress response.

A retrospective study to correlate breech presentation and enhanced risk of postspinal hypotension during cesarean delivery.

BACKGROUND: Subarachnoid blockade for cesarean section still poses a threat of profound hypotension and can result in unstable maternal and fetal hemodynamics. The correlation of fetal breech and vertex presentation with the occurrence of hypotension under spinal anesthesia is reviewed in this retrospective, double-blind study. PATIENTS AND METHODS: The study was conducted on pregnant females scheduled for a lower segment cesarean section between January 2014 and December 2014. After applying inclusion criteria, 568 patients were recruited in the study out of which 363 had vertex and 184 patients had breech presentation. They were divided into two groups, Group I and Group II. The monitoring and therapeutic data (blood pressure, heart rate, arterial oxygen saturation, and dose of vasopressor/atropine) recovered from automated data analysis were analyzed retrospectively for prevalence of hypotension, bradycardia, and hypotension with bradycardia and nausea ± vomiting. RESULTS: Among Group I, prevalence of hypotension, bradycardia, and hypotension together with bradycardia was 152 (41.83%) patients, eight (2.20%) patients, and seven (1.92%) patients, respectively. In Group II, the prevalence of hypotension, bradycardia, and hypotension with bradycardia was 93 (50.5%) patients, five (2.71%) patients, and six (3.2%) patients, respectively. The difference between the two groups was statistically significant for hypotension. For Group I, 152 patients (41.87%) experienced one, 23 patients (6.33%) experienced two, and three patients (0.82%) experienced three episodes of hypotension. In Group II, 93 (50.5%), 19 (7.89%), and two (1.08%) patients experienced such episodes. The difference was significant with respect of one and two episodes. The prevalence of intraoperative nausea was 11.01% (40 patients) in Group I, whereas 11.41% (21 patients) in Group II. Intraoperative vomiting occurred in 19 patients (5.23%) of Group I and 14 patients (7.60%) of Group II. The height of the block was comparable in both the groups for T6, and the difference was significant in respect to T4 level. CONCLUSION: Incidence of hypotension is more in pregnant females with breech fetal presentation.