Analgesic efficacy of Clonidine as an adjuvant in ultrasound-guided rectus sheath block for midline incisional hernia repair - A randomized double-blind controlled trial.

Background and Aims: Clonidine as an adjuvant has not been evaluated in rectus sheath block (RSB) for postoperative pain management in incisional hernia repair. The study aims to evaluate clonidine as an adjuvant in single-shot RSB along with general anesthesia (GA). Material and Methods: This randomized, double-blind controlled study was conducted following IEC-Human approval and written informed consent from 30 patients of either sex, aged 16 to 60 years, ASA physical status I or II undergoing midline incisional hernia repair under GA. All patients received ultrasound-guided bilateral RSB following administration of GA. The subjects enrolled in the study were randomly allocated to receive either normal saline 1 mL (group B) or clonidine 1 µg/kg diluted to 1 mL with normal saline (group BC) as adjuvant along with 9 mL bupivacaine hydrochloride 0.25%. Inj. tramadol 1 mg/kg was administered for rescue analgesia. The primary outcome was the time to first request for analgesia, and secondary outcomes were total consumption of rescue analgesic over 24 h, numerical rating score (NRS), patients' satisfaction, hemodynamics, and side effects. Unpaired t-test and Chi-square test were used. Results: On intergroup analysis, the mean time to first request for analgesia (in min) was significantly higher in group BC i.e., [9.60 (± 5.23) vs 5.33 (± 3.53); (P < 0.034]; whereas, the mean rescue analgesic consumption in 24 h (in mg) was higher in group B i.e., [(88.00 ± 60.97) vs (46.00 ± 48.08)]; (P < 0.045)]. Hemodynamic parameters i.e., mean blood pressure and heart rate were comparable between the two groups, and there were no side effects. Conclusion: Clonidine as an adjuvant in single-shot ultasonography (USG)-guided RSB along with GA is efficacious for postoperative pain management following midline incisional hernia repair.

Ultrasound-guided transversalis fascia plane block versus wound infiltration for both acute and chronic post-caesarean pain management - A randomised controlled trial.

Background and Aims: Ultrasound-guided transversalis fascia plane block (USG-guided TFPB) has recently been evaluated for post-caesarean acute pain management. We compared it with standard wound infiltration for both acute and chronic post-caesarean pain management. Methods: All patients undergoing caesarean section (CS) under subarachnoid block were included and randomised. Patients in group C received standard wound infiltration (20 ml of 0.375% ropivacaine) and group-T received bilateral USG-guided TFPB (20 ml of 0.375% ropivacaine) at the end of the surgery. Acute pain assessed using numeric rating scale (NRS), time to first request of analgesia and total rescue analgesic consumption in 24 hours. The incidence of chronic persistent post-surgical pain (CPSP), neuropathic pain component and quality of life (QoL) were assessed. Fisher's exact test, Chi-square test, unpaired Student's t-test and Mann-Whitney U test were used. Results: Sixty patients were included with 30 in each group. NRS score on rest at 6th and 24th hour and on active movement at 1st hour was significantly decreased in group T. The "time to first request of analgesia" was statistically higher in group T, that is, 10.77 ± 1.39 h versus 6.30 ± 1.60 h. Five (16.6%) and two (6.6%) patients in groups C and T, respectively, required rescue analgesia in first 24 hours. 30% (n = 6) and 10% (n = 2) patients in groups C and T, respectively, developed CPSP. The neuropathic pain component was significantly reduced and QoL was significantly improved in group T. Conclusion: TFPB is efficacious for management of both acute and chronic post-caesarean pain management.

Awake Prone Positioning in the Management of COVID-19 Pneumonia: A Systematic Review.

Background: The aim was to investigate the efficacy of prone positioning (PP) in the management of coronavirus disease-2019 (COVID-19) pneumonia in various setups, with various modes of oxygen therapy and its optimal duration. Materials and methods: A systematic literature search was conducted from inception until May 15, 2021. Patients with a validated diagnosis of COVID-19 and receiving PP were included. Various factors, including intensive care unit (ICU) or non-ICU setup, mode of oxygen therapy, outcome, duration of proning, and limitations, were noted. Results: We retrieved 36 articles with a total of 1,385 patients for qualitative analysis. Out of 36 articles, there were 17 original articles, 09 case series, and 10 case reports. Out of 1,385 participants, 78.9% (n = 1,093) and 21.0% (n = 292) of patients were managed in ICU and non-ICU setup, respectively. Awake PP with high flow nasal cannula (HFNC) was found to be a promising technique; however, the result was inconclusive with helmet continuous positive airway pressure (CPAP). No study has evaluated the optimal duration of awake PP and the associated long-term outcomes. Conclusion: We encourage the use of early awake self-proning in the management of COVID19 disease. However, the evidence in terms of its use in non-ICU setup, the optimal duration of PP, and various oxygenation devices are insufficient, thereby mandating further well-designed multicentric studies to evaluate its efficacy as an adjunct in the management of COVID-19 pneumonia in context to the aforementioned factor. How to cite this article: Chilkoti GT, Mohta M, Saxena AK, Ahmad Z, Sharma CS. Awake Prone Positioning in the Management of COVID-19 Pneumonia: A Systematic Review. Indian J Crit Care Med 2021;25(8):896-905.

Validation of Complete Hindi Version of Douleur Neuropathique 4 Questionnaire for Assessment of Neuropathic Pain.

OBJECTIVES: The Douleur Neuropathique 4 (DN4) questionnaire is a widely used tool for the diagnosis of neuropathic pain (NP). The aim was to validate the Complete Hindi version of DN4 (CH-DN4) questionnaire. MATERIALS AND METHODS: A systematic translation process was used to translate the original English DN4 into Hindi. The Hindi version was validated among patients appearing in the pain clinic of a tertiary hospital in the capital of Delhi by two different raters. We assessed the internal consistency, test-retest reliability, and inter-rater agreement, validity, sensitivity, specificity, positive and negative predictive values, and area under the curve (AUC). RESULTS: A total of 285 participants, out of which 153 had NP and 132 had non NP (NNP) were included in the study. The results showed our CH-DN4 to have good diagnostic accuracy, a score of ≥ 3.5 was found to be the best cut-off for the diagnosis of NP, with a sensitivity of 0.78, specificity of 0.76, a positive predictive value of 78.5%, and a negative predictive value of 74.5%. Cronbach's α was 0.82 (95% confidence interval: 0.80-0.84), and interclass correlation coefficients was 0.95. The AUC was >0.8 indicating excellent discrimination between NP and NNP. CONCLUSION: The CH-DN4 questionnaire has been found to be a reliable and valid screening tool with an excellent power to discriminate between NP and NNP.

A randomised preliminary study to compare the performance of fibreoptic bronchoscope and laryngeal mask airway CTrach (LMA CTrach) for visualisation of laryngeal structures at the end of thyroidectomy.

BACKGROUND AND AIMS: Various methods have been used to check vocal cord movements as a routine before awakening the patient at the end of thyroidectomy to rule out recurrent laryngeal nerve (RLN) palsy; out of which, fibreoptic-assisted visualisation via laryngeal mask airway (LMA) being the most desirable. METHODS: Thirty patients of either sex, aged 18-65 years, American Society of Anaesthesiologists (ASA) grade I/II, scheduled for thyroidectomy under general anaesthesia (GA) were included and were randomised to receive either fibreoptic assisted (FB) or LMA CTrach-assisted (CT) visualisation of laryngeal structures at the end of thyroidectomy. The primary outcome was grade of view of laryngeal structures and secondary outcomes were time taken to achieve optimal view of laryngeal structures, ease of visualisation, hemodynamic parameters, and complications. RESULTS: In the fibreoptic group, we obtained comparable optimal laryngeal view i.e., grade 1 and 2 in all (100%) patients in comparison to 14 (93.33%) in LMA CTrach group. The "time taken to achieve the optimal view" was significantly lower in the CTrach group when compared to Fibreoptic group (220.67 ± 95.98 vis-a-vis 136.67 ± 68.98). The ease of visualisation of laryngeal structures was comparable (P = 0.713) and the baseline haemodynamic parameters were comparable between the 2 groups and at various designated intervals. In total, 6.66% and 26.66% patients in group FB and CT group, respectively, required manoeuvres. However, difference was statistically significant (P < 0.05). CONCLUSION: Both Fibreoptic-assisted and LMA CTrach-assisted visualization of laryngeal structures in thyroidectomy are equally efficacious in terms of the optimal laryngeal view obtained and ease of visualisation. However, the time taken to achieve optimal laryngeal view was lesser with LMA CTrach.

Perioperative concerns in Pott's spine: A review.

Pott's disease is the most common granulomatous spine infection caused by tubercle bacilli and is a common site of osseous tuberculosis, accounting for 50-60% of cases. The delay in establishing diagnosis and management results in complications such as spinal cord compression and spinal deformity. The aim of this narrative review is to discuss the perioperative concerns in patients for spine surgery. The literature source for this review was obtained via PubMed, Medline, Google Scholar, Cochrane database of systematic reviews, and textbooks until December 2019. On the literature search, we could not retrieve any review article specifically discussing the perioperative concerns of spinal tuberculosis. Therefore, the aim of the present narrative review is to discuss the perioperative concerns of patients for spine surgery along with the specific concerns related to spinal tuberculosis.

A randomized, prospective study of efficacy and safety of oral tramadol in the management of post-herpetic neuralgia in patients from north India.

OBJECTIVE: To evaluate the safety and efficacy of oral tramadol therapy (50 to 200 mg/day) in the treatment for post-herpetic neuralgia (PHN). METHODS: The study was a prospective, single-blind, non-responder vs. responder, randomized trial conducted in 100 outpatients of PHN after oral administration of tramadol for 4 weeks. Those patients who had achieved 50% or greater pain relief after 14 days of oral tramadol treatment were categorized as responders and those reporting < 50% pain relief were categorized as non-responders. Rescue analgesia was provided by the topical application of a cream consisting of the combination of 3.33% doxepin and 0.05% capsaicin to the affected areas of PHN patients of both groups for at least 14 days, along with tramadol therapy. The rescue analgesia was extended to 4 weeks in patients of the non-responder group. The primary endpoints were measured using a numerical rating scale (NRS) at rest and with movement. Secondary endpoints included additional pain ratings such as global perceived effect (GPE), Neuropathic Pain Symptom Inventory scores (NPSI), daily sleep interference score (DSIS), quality of life (QOL) as per WHO QOL-BREF Questionnaire scores, patient and clinician ratings of global improvement. The 2 groups were compared on the basis of pain intensity scores, encompassing primary as well as secondary endpoints, and QOL after 28 days of the treatment regimen. RESULTS: Pain intensity scores measured by NRS (at resting and with movement), NPSI, and DSIS were consistently reduced (P < 0.001) over 28 days at varying intervals in both the groups, but the magnitude of reduction was higher in responders than non-responders. A concomitant improvement (P < 0.001) was observed in GPE on days 3, 14, and 28 as compared to the respective baseline scores in both the groups. Although the WHO QOL-BREF scores showed significant (P < 0.001) improvement in QOL of PHN patients at days 14 and 28 in both the groups, the magnitude of improvement was higher in responders as compared to non-responders. Significant improvement in pain intensity scores and QOL in non-responders is mainly attributed to the use of rescue analgesia for 28 days rather than recommended tramadol therapy. CONCLUSIONS: Treatment with tramadol 50 to 200 mg per day was associated with significant pain reduction in terms of enhanced pain relief, reduced sleep interference, greater global improvement, diminished side-effect profile, and improved QOL in PHN patients from North India. Further categorization of PHN patients may be helpful so that additional or alternative therapy may be prescribed to non-responders.

Relation of soya bean meal level to the concentration of plasma free amino acids and body growth in white rats.

Amino acid (AA) levels in plasma and body growth were determined in rats (n20) fed diets with different soya bean meal levels. Free AA in plasma was determined by reversed-phase high-pressure liquid chromatography. We have used four levels of protein diets like 8%, 15%, 23% and 35% in this trial. Rats which were fed the low-protein (8%) diet with low percentage of soya bean meal were found to be growth-retarded. The body weight gain of high protein group (35%) was lower than that of the 23% groups. In the rats fed with the low-soya bean meal diet, some nonessential AA (NEAA) in plasma like asparagine, aspartic acid, cysteine, glutamic acid and serine increased, whereas the essential AA (EAA), with the exception of arginine, methionine and valine decreased. Here, plasma EAA-to-NEAA ratios were not correlated to growth and experimental diet. We hypothesize that AA metabolism is associated to changes in growth in rats on different protein intake. This study has showed the sensitivity of body mass gain, feed intake, feed conversion rate of rats to four levels of protein in the diet under controlled experimental conditions.

Management strategies for pain in breast carcinoma patients: current opinions and future perspectives.

Breast cancer is the most frequently encountered carcinoma in women worldwide. Pain is the most distressing symptom in patients with breast carcinoma and can occur at all stages of the disease due to the cancer per se as well as due to various diagnostic and treatment modalities. A proper pain assessment helps in identification of pain syndromes and guides in formulating analgesic strategies. Primary therapies of breast carcinoma like surgery, chemotherapy, and radiotherapy for bony metastases can cause substantial pain relief. However, multimodal analgesic approaches incorporating pharmacological, interventional as well as non-conventional techniques should be employed prior to, in conjunction with, and after primary therapies of breast cancer. The prevalence of chronic neuropathic pain following breast cancer surgery may exceed 50% by current estimates, and with the increase in life expectancy of these patients, providing adequate pain relief is of paramount importance to improve their quality of life. In this review, we discuss prevailing methods of evaluation and management of pain in patients of breast carcinoma and the new techniques that may become the mainstay of pain management protocols in future.

Human hemoglobin shares bioactivities ascribed to human tumor necrosis factor-alpha.

Hemoglobin mediated cytotoxicity and apoptosis has been evaluated in Tumor necrosis factor-alpha (TNF-alpha) sensitive cell line, U937 and compared with TNF-alpha. Both species of hemoglobin, Hemoglobin A2 and Hemoglobin A0 induced apoptosis and cytotoxicity in U937 cell as measured by flow cytometry and 3-(4,5-dihydro-6-(4-(3,4-dimethoxybenzooyl)-1-piperazinyl)-2(1H)-quinoline (MTT) assay respectively. Different concentration of Hemoglobin A0 (4 ng/mL to 4000 ng/mL) induced apoptosis ranging from 9% to 16% in U937 cells. 4000 ng/mL hemoglobin A0 showed maximal apoptotic cells. TNF-alpha showed 87% apoptotic U937 cells at concentration of 1 pg/mL. HbA0 displayed cytotoxicity in U937 cell line at higher concentration in comparison to TNF-alpha. 4000 ng/mL of hemoglobin A0 showed optimal cytotoxic response in U937 cells. A dose response curve was also observed with varying doses of hemoglobin A0. U937 cells pretreated with serum activated LPS for 1 hr and incubated with different concentration of hemoglobin or human TNF-alpha for 24 h reduced the cytotoxic effect on U937. Dexamethasone treatment of U937 cells helped in protecting the HbA0 and HbA2 mediated cytotoxicity and anti-TNF-alpha antibody neutralized the hemoglobin mediated apoptosis and cytotoxicity. It is therefore apparent that human hemoglobin shares some of the bioactivities previously ascribed to TNF-alpha. Sharing of bioactivities of TNF-alpha by hemoglobin is interesting and suggests that cell free hemoglobin can mimic TNF-alpha functionally.

Evaluation of PR, RR, QT intervals and QT dispersion following stellate ganglion block in chronic shoulder-hand pain patients.

Right stellate ganglion block (SGB) can increase QT interval, rate-corrected QT interval (QTc), QT dispersion (QTD), rate-corrected QTD (QTcD), and RR interval while left SGB can decrease these intervals in healthy volunteers. No such studies have been conducted in patients with chronic pain, hence this study was designed to investigate the effects of left and right SGB on these variables in chronic shoulder-hand pain patients. In this study, 28 patients with chronic shoulder-hand pain of at least 6 months duration were given right or left SGB depending on the shoulder affected. A 12-lead electrocardiogram (ECG) was recorded before the block, 30 minutes and 60 minutes after the block. PR interval, RR interval, QT interval were recorded in all 12 leads while QTc, QTD, and QTcD were calculated. Right SGB was performed in 21 patients. A significant decrease (P < 0.05) in PR interval and a significant increase (P < 0.05) in RR interval, QT interval, and QTc interval were observed. QTD showed a significant increase (P < 0.05) only at 30 minutes after right SGB. Left SGB was performed in seven patients. A significant decrease (P < 0.05) in QT interval was observed throughout the study period, while QTc showed a significant decrease (P < 0.05) only at 60 minutes after the block. We conclude that right SGB induces significant increase of QT interval, RR interval, QTc interval, QTD, and a significant decrease of PR interval while left SGB produces a significant decrease in QT and QTc intervals in patients with chronic shoulder-hand pain.

An unusual complication of sinus arrest following right-sided stellate ganglion block: a case report.

We present a case of a 29-year-old female patient who had presented to us for the management of her chronic right shoulder-hand pain and developed a sinus arrest following a right-sided stellate ganglion block (RSGB). This patient on receiving a diagnostic RSGB via the anterior paratracheal (C6) approach developed sinus arrest followed by apnea and unconsciousness. On institution of resuscitative measures involving tracheal intubation, positive pressure ventilation, cardiac massage, and intravenous atropine, spontaneous cardiac activity recovered in about 3 minutes. Other signs and symptoms resolved fully in a total of 10 minutes. She had persistent postural hypotension lasting for about 24 hours requiring bed rest and was discharged about 36 hours after the procedure, without any adverse sequelae. As the sinus node is supplied by the right-sided sympathetic chain, its blockade probably resulted in unopposed parasympathetic activity leading to asystole. Available evidence of the role of right stellate ganglion in regulation of cardiac electrophysiology and functioning is also discussed.

Silica induced early fibrogenic reaction in lung of mice ameliorated by Nyctanthes arbortristis extract.

OBJECTIVE: To investigate the pharmacological effect of Nyctanthes arbortristis (NAT) leaf extract in the prevention of lung injury induced by silica particles. METHOD: Lung injury was induced in Swiss mice through inhalation exposure to silica particles (< 5 mu) using a Flow Past Nose Only Inhalation Chamber at the rate of -10 mg/m3 respirable mass for 5 h. Lung bronchoalveolar lavage (BAL) fluid collected between 48 and 72 h was subjected to protein profiling by electrophoresis and cytokine evaluation by solid phase sandwich ELISA. Lung histopathology was performed to evaluate lung injury. RESULTS: Inhalation of silica increased the level of tumor necrosis factor-alpha (TNF-alpha), and of the 66 and 63 kDa peptides in the BAL fluid in comparison to sham-treated control. Pre-treatment of silica exposed mice with NAT leaf extract significantly prevented the accumulation of TNF-alpha in the BAL fluid, but the 66 and 63 kDa peptides remained unchanged. The extract was also effective in the prevention of silica-induced early fibrogenic reactions like congestion, edema and infiltration of nucleated cells in the interstitial alveolar spaces, and thickening of alveolar septa in mouse lung. CONCLUSION: NAT leaf extract helps in bypassing silica induced initial lung injury in mice.