Effect of height versus height/weight-based spinal bupivacaine on maternal hemodynamics for elective cesarean in short stature patients: a randomized clinical trial.

PURPOSE: Doses of spinal bupivacaine adjusted to patient height or height/weight have been shown to provide hemodynamic stability during cesarean section. However, their effects in short stature parturients are unknown. METHODS: In this double-blind, randomized clinical trial, we randomly assigned short parturients (height < 150 cm) undergoing elective cesarean section, to receive doses of intrathecal hyperbaric bupivacaine either height or height/weight-adjusted, in a 1:1 ratio. The primary outcome was post-spinal hypotension (defined as systolic blood pressure [SBP] < 90% of baseline between spinal administration and delivery of the baby). Secondary outcomes included severe post-spinal hypotension (SBP < 80% of baseline), post-delivery hypotension (SBP < 90% and < 80% of baseline), intraoperative bradycardia, nausea and vomiting, shivering, rescue analgesic needed, and spinal block characteristics. RESULTS: A total of 112 patients underwent randomization. Post-spinal hypotension (SBP < 90% of baseline) occurred in 52% of the patients in the height/weight group and in 55% in the height group (difference - 3.5%: 95% confidence interval [CI] - 22 to 14.8, P = 0.705). There was no significant difference between the two groups in the occurrences of post-spinal severe hypotension (SBP < 80% of baseline), post-delivery hypotension, and spinal block characteristics. Six patients (11%) in the height/weight group needed intraoperative rescue analgesic compared to none in the height group (P = 0.027). CONCLUSION: We found that height-based dosing in short parturients provides the optimal trade-off between intraoperative hemodynamic instability and provision of pain-free anesthesia. TRIAL REGISTRATION: clinicaltrial.gov-NCT04082676. https://clinicaltrials.gov/ct2/show/NCT04082676 .

Effect of glycopyrrolate on vasopressor requirements for non-elective cesarean section under spinal anesthesia: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: The study aimed to investigate whether prophylactic use of glycopyrrolate decreases the vasopressor requirements to prevent hypotension following spinal anesthesia during non-elective cesarean section. METHOD: In this double-blind randomized clinical trial, 258 patients undergoing non-elective cesarean section were randomly assigned (1:1) to receive intravenous 0.2 mg glycopyrrolate or normal saline (placebo) before spinal anesthesia. The primary outcome was phenylephrine equivalent needed intraoperatively. Secondary outcomes included incidences of maternal hypotension, reactive hypertension, bradycardia, need for atropine, tachycardia, intraoperative nausea/vomiting, shivering, pruritus, dry mouth, dizziness; neonatal APGAR score at 1 min and 5 min, neonatal resuscitation needed, NICU admission and neonatal death. RESULTS: Three patients withdrew from the study due to failed spinal anesthesia. 128 patients in the glycopyrrolate group and 127 patients in the placebo group were analyzed. The mean phenylephrine equivalent needed was 1108.96 µg in the glycopyrrolate group and 1103.64 µg in the placebo group (mean difference, 5.32 µg [95% CI - 67.97 to 78.62]; P = 0.88). Hypotension occurred in 38 patients (30%) in the glycopyrrolate group as compared with 49 patients (39%) in the placebo group (P = 0.13). Tachycardia was reported in 70% of the participants in the glycopyrrolate group and 57% of those in the placebo group (P = 0.04). No statistically significant difference was noted in hypotensive episodes > 1, reactive hypertension, bradycardia, need for atropine, nausea, vomiting, shivering, and dry mouth between the two groups. Neonatal outcomes were similar in the two groups. CONCLUSION: Prophylactic use of glycopyrrolate does not decrease the requirements of vasopressor to prevent hypotension in non-elective cesarean section under spinal anesthesia. TRIAL REGISTRATION: Registration number: NCT04401345. Date of registration: 26/05/2020. Website: https://clinicaltrials.gov.

Intrathecal morphine does not prevent chronic postsurgical pain after elective Caesarean delivery: a randomised controlled trial.

BACKGROUND: Morphine is frequently added to spinal anaesthesia for Caesarean delivery. We aimed to determine whether intrathecal morphine for spinal anaesthesia decreases the risk of chronic postsurgical pain (CPSP). METHODS: In this randomised, double-blind, placebo-controlled trial, 290 healthy parturients undergoing elective Caesarean delivery were randomly assigned in a 1:1 ratio to receive either intrathecal morphine 100 µg (n=145) or normal saline (control; n=145) as a part of spinal anaesthesia. Anaesthetic care and postoperative pain management were standardised in all patients. The primary outcome was the incidence of CPSP at 3 months. Secondary outcomes included CPSP at 6 months, pain severity, and pain interference, measured by the Brief Pain Inventory questionnaire using an 11-point numeric rating scale, at 3 and 6 months after the surgery. RESULTS: Two hundred and seventy-six patients completed the 3-month follow-up, 139 in the morphine group and 137 in the placebo group. The incidences of CPSP at 3 months were 19% (27 of 139) in the morphine group and 18% (25 of 137) in the placebo group (odds ratio, 1.08; 95% confidence interval, 0.59-1.97; P=0.803). At 6 months, CPSP was present in 23 of 139 (16%) morphine group patients compared with 19 of 137 (14%) in the placebo group (odds ratio, 1.23; 95% confidence interval, 0.63-2.38; P=0.536). Brief Pain Inventory questionnaire scores for pain severity and pain interference at 3 and 6 months were similar between groups. CONCLUSIONS: Administration of morphine 100 µg as a component of spinal anaesthesia for elective Caesarean delivery failed to reduce the incidence of chronic pain at 3 and 6 months after surgery. CLINICAL TRIAL REGISTRATION: NCT03451695.

Association of preoperative pain catastrophizing with postoperative pain after lower limb trauma surgery.

OBJECTIVES: To evaluate an association between preoperative Nepali pain catastrophizing scale (N-PCS) scores and postoperative pain intensity and total opioid consumption. METHODS: In this prospective cohort study we enrolled 135 patients with an American Society of Anaesthesiologists physical status I or II, aged between 18 and 65 years, and scheduled for surgery for lower-extremity fracture under spinal anaesthesia. Maximum postoperative pain reported during the 24 h was classified into two groups, no-mild pain group (Numeric rating scale [NRS] scores 1-3) and a moderate-severe pain group (NRS 4-10). The Pearson's correlation coefficient was used to compare the association between the baseline N-PCS scores and outcome variables, i.e., the maximum NRS pain score and the total tramadol consumption within the first 24 h after surgery. Logistic regression models were used to identify the predictors for the intensity of postoperative pain. RESULTS: As four patients violated the protocol, the data of 131 patients were analyzed. Mean N-PCS scores reported by the moderate-severe pain group was 27.39 ± 9.50 compared to 18.64 ± 10 mean N-PCS scores by the no-mild pain group (p < 0.001). Preoperative PCS scores correlated positively with postoperative pain intensity (r = 0.43, [95% CI 0.28-0.56], p < 0.001) and total tramadol consumption (r = 0.36, [95% CI 0.20-0.50], p < 0.001). Preoperative pain catastrophizing was associated with postoperative moderate-severe pain (odds ratio, 1.08 [95% confidence interval, 1.02-1.15], p = 0.006) after adjusting for gender, ethnicity and preoperative anxiety. CONCLUSION: Patients who reported higher pain catastrophizing preoperatively were at increased risk of experiencing moderate-severe postoperative pain. CLINICAL TRIAL REGISTRATION: www.clinicaltrials.gov Identifier: NCT03758560.

Analgesic effects of intravenous ketamine after spinal anaesthesia for non-elective caesarean delivery: a randomised controlled trial.

OBJECTIVES: This study aimed to determine if low dose intravenous ketamine is effective in reducing opioid use and pain after non-elective caesarean delivery. DESIGN: Prospective, randomised, double-blind. SETTING: Tertiary hospital, Bisheshwar Prasad Koirala Institute of Health Sciences, Dharan, Nepal PARTICIPANTS: 80 patients undergoing non-elective caesarean section with spinal anaesthesia. INTERVENTIONS: Patients were allocated in 1:1 ratio to receive either intravenous ketamine 0.25 mg/kg or normal saline before the skin incision. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the total amount of morphine equivalents needed up to postoperative 24 hours. Secondary outcome measures were postoperative pain scores, time to the first perception of pain, maternal adverse effects (nausea, vomiting, hypotension, shivering, diplopia, nystagmus, hallucination) and neonatal Apgar score at 1 and 5 min, neonatal respiratory depression and neonatal intensive-care referral. RESULTS: The median (range) cumulative morphine consumption during the first 24 hours of surgery was 0 (0-4.67) mg in ketamine group and 1 (0-6) mg in saline group (p=0.003). The median (range) time to the first perception of pain was 6 (1-12) hours and 2 (0.5-6) hours in ketamine and saline group, respectively (p<0.001). A significant reduction in postoperative pain scores was observed only at 2 hours and 6 hours in the ketamine group compared with placebo group (p<0.05). Maternal adverse effects and neonatal outcomes were comparable between the two groups. CONCLUSIONS: Intravenous administration of low dose ketamine before surgical incision significantly reduced the opioid requirement in the first 24 hours in patients undergoing non-elective caesarean delivery. TRIAL REGISTRATION NUMBER: NCT03450499.

Iatrogenic pneumomediastinum followed by bilateral pneumothoraces: A case report.

Major respiratory catastrophe associated with iatrogenic airway injury during the Sistrunk operation is a rare event. A three-year-old patient underwent thyroglossal duct cyst removal under general anaesthesia. An iatrogenic thyroid cartilage injury occurred in the intraoperative period, and it was repaired primarily. Later, in the post-anaesthesia care unit, the patient developed subcutaneous emphysema in the neck and face, and then pneumomediastinum and bilateral pneumothoraces. The patient was managed with bilateral chest drains and endotracheal intubation, and he required mechanical ventilation for three days. So, even after repair of a recognised iatrogenic airway injury associated with the Sistrunk operation, it may be necessary to continue positive pressure ventilation in the postoperative period to avoid serious respiratory complications.

Effect of amino acid infusion during cesarean delivery on newborn temperature: a randomized controlled trial.

BACKGROUND: The effect of maternal amino acid (AA) infusion before and during cesarean delivery on neonatal temperature remains unknown. We hypothesized that thermogenic effects of AA metabolism would help maintain body temperature of newborn babies and their mothers. METHODS: Seventy-six parturients scheduled for elective singleton term cesarean delivery were equally randomized to receive intravenous 200 ml of AA or placebo approximately 1 h before subarachnoid block (infusion rate:100 ml/h). The primary outcome was the newborn rectal temperature at 0, 5 and 10 min after birth. The secondary outcomes included the maternal rectal temperature at six time-points: T0 = before starting study solution infusion, T1 = 30 min after starting infusion, T2 = one hour after starting infusion, T3 = during spinal block, T4 = half an hour after spinal block, T5 = at the time of birth and T6 = at the end of infusion, as well as maternal thermal discomfort and shivering episodes. RESULTS: There were no differences in newborn temperature between the two groups at any of the time-points (intervention-time-interaction effect, P = 0.206). The newborn temperature (mean [95%CI] °C) at birth was 37.5 [37.43-37.66] in the AA and 37.4 [37.34-37.55] in the placebo group. It showed a significant (P < 0.001) downward trend at 5 and 10 min after birth (time effect) in both groups. One neonate in the AA and five in the placebo group were hypothermic (temperature < 36.5 °C) (P = 0.20). There was a significant difference in the maternal temperature at all time points between the two groups (Intervention-time interaction effect, P < 0.001). However, after adjustment for multiplicity, the difference was significant only at T6 (P = 0.001). The mean difference [95%CI] in temperature decline from baseline (T0) till the end of infusion (T6) between the two groups was - 0.39 [- 0.55;- 0.22] °C (P < 0.0001). Six mothers receiving placebo and none receiving AA developed hypothermia (temperature < 36 °C) (P = 0.025). Maternal thermal discomfort and shivering episodes were unaffected by AA therapy. CONCLUSIONS: Under the conditions of this study, maternal AA infusion before and during spinal anesthesia for cesarean delivery did not influence the neonatal temperature within 10 min after birth. In addition, the maternal temperature was only maintained at two hours of AA infusion. TRIAL REGISTRATION: ClinicalTrials.government, Identifier NCT02575170 . Registered on 10th April, 2015 - Retrospectively registered.

The effect of intraoperative lidocaine infusion on opioid consumption and pain after totally extraperitoneal laparoscopic inguinal hernioplasty: a randomized controlled trial.

BACKGROUND: As a component of multimodal analgesia, the administration of systemic lidocaine is a well-known technique. We aimed to evaluate the efficacy of lidocaine infusion on postoperative pain-related outcomes in patients undergoing totally extraperitoneal (TEP) laparoscopies inguinal hernioplasty. METHODS: In this randomized controlled double-blind study, we recruited 64 patients to receive either lidocaine 2% (intravenous bolus 1.5 mg. kg - 1 followed by an infusion of 2 mg. kg- 1. h- 1), or an equal volume of normal saline. The infusion was initiated just before the induction of anesthesia and discontinued after tracheal extubation. The primary outcome of the study was postoperative morphine equivalent consumption up to 24 h after surgery. Secondary outcomes included postoperative pain scores, nausea/vomiting (PONV), sedation, quality of recovery (scores based on QoR-40 questionnaire), patient satisfaction, and the incidence of chronic pain. RESULTS: The median (IQR) cumulative postoperative morphine equivalent consumption in the first 24 h was 0 (0-1) mg in the lidocaine group and 4 [1-8] mg in the saline group (p < 0.001). Postoperative pain intensity at rest and during movement at various time points in the first 24 h were significantly lower in the lidocaine group compared with the saline group (p < 0.05). Fewer patients reported PONV in the lidocaine group than in the saline group (p < 0.05). Median QoR scores at 24 h after surgery were significantly better in the lidocaine group (194 (194-196) than saline group 184 (183-186) (p < 0.001). Patients receiving lidocaine were more satisfied with postoperative analgesia than those receiving saline (p = 0.02). No difference was detected in terms of postoperative sedation and chronic pain after surgery. CONCLUSIONS: Intraoperative lidocaine infusion for laparoscopic TEP inguinal hernioplasty reduces opioid consumption, pain intensity, PONV and improves the quality of recovery and patient satisfaction. TRIAL REGISTRATION: ClinicalTrials.gov- NCT02601651. Date of registration: November 10, 2015.

The effect of intraoperative lidocaine versus esmolol infusion on postoperative analgesia in laparoscopic cholecystectomy: a randomized clinical trial.

BACKGROUND: As a part of multimodal analgesia for laparoscopic cholecystectomy, both intraoperative lidocaine and esmolol facilitate postoperative analgesia. Our objective was to compare these two emerging strategies that challenge the use of intraoperative opioids. We aimed to assess if intraoperative esmolol infusion is not inferior to lidocaine infusion for opioid consumption after laparoscopic cholecystectomy. METHODS: In this prospective, randomized, double-blind, non-inferiority clinical trial, 90 female patients scheduled for elective laparoscopic cholecystectomy received either intravenous (IV) lidocaine bolus 1.5 mg/kg at induction followed by an infusion (1.5 mg/ kg/h) or IV bolus of esmolol 0.5 mg/kg at induction followed by an infusion (5-15 µg/kg/min) till the end of surgery. Remaining aspect of anesthesia followed a standard protocol apart from no intraoperative opioid supplementation. Postoperatively, patients received either morphine or tramadol IV to maintain visual analogue scale (VAS) scores ≤3. The primary outcome was opioid consumption (in morphine equivalents) during the first 24 postoperative hours. Pain and sedation scores, time to first perception of pain and void, and occurrence of nausea/vomiting were secondary outcomes measured up to 24 h postoperatively. RESULTS: Two patients in each group were excluded from the analysis. The postoperative median (IQR) morphine equivalent consumption in patients receiving esmolol was 1 (0-1.5) mg compared to 1.5 (1-2) mg in lidocaine group (p = 0.27). The median pain scores at various time points were similar between the two groups (p > 0.05). More patients receiving lidocaine were sedated in the post-anesthesia care unit (PACU) than those receiving esmolol (p < 0.05); however, no difference was detected later. CONCLUSION: Infusion of esmolol is not inferior to lidocaine in terms of opioid requirement and pain severity in the first 24 h after surgery. Patients receiving lidocaine were more sedated during their stay in PACU than those receiving esmolol. TRIAL REGISTRATION: ClinicalTrials.gov - NCT02327923. Date of registration: December 31, 2014.

A case of hyperventilation leading to apnea and desaturation in PACU.

BACKGROUND: Respiratory adverse events are not uncommon in the post-anesthesia care unit (PACU) following general anesthesia. In this regard, hyperventilation leading to apnea and desaturation is a rare entity. Here we have reported a case of a 15-year-old girl who, following an uneventful general anesthesia, developed severe hyperventilation leading to apnea and desaturation in the PACU. CASE PRESENTATION: The 15-year-old girl underwent cortical mastoidectomy under general anesthesia. After a smooth anesthesia and an uneventful early recovery, she developed hyperventilation after about 15 min in the PACU. The symptom was severe enough to lead to apnea, desaturation and severe respiratory alkalosis. She required bag and mask ventilation and the symptoms resolved only transiently with propofol sedation. Finally, she responded to intravenous haloperidol and did not have any further episode after receiving haloperidol. CONCLUSION: Hyperventilation after a smooth recovery from anesthesia is not a common presentation. In this article we have tried to discuss the possible cause of such symptom in our patient and how we successfully managed this case. We have also proposed an algorithmic approach to diagnose and manage such cases in the PACU.

Effect of Intravenous Lidocaine, Dexamethasone, and Their Combination on Postoperative Sore Throat: A Randomized Controlled Trial.

BACKGROUND: Postoperative sore throat (POST), hoarseness, and cough after tracheal intubation are not uncommon. Although both lidocaine and dexamethasone have been used independently to reduce these events, there is no study assessing the combined effects of lidocaine and dexamethasone. METHODS: This prospective, double-blind, randomized controlled study enrolled 180 patients requiring general anesthesia with endotracheal intubation for >90 minutes. They received 1 of the 4 intravenous agents just before induction of anesthesia: lidocaine (1.5 mg/kg) in group L, dexamethasone (8 mg) in group D, lidocaine (1.5 mg/kg) with dexamethasone (8 mg) in group DL, and placebo as normal saline in group NS. Standard anesthesia protocol was followed. Incidence and severity of a sore throat, cough, and hoarseness of voice were assessed up to 24 hours postoperatively. The primary outcome was the incidence of POST, and the main effects of dexamethasone and lidocaine were the primary interest. RESULTS: Data of 45 patients in D, 44 in L, 44 in DL, and 43 in NS groups were analyzed. The incidence of a sore throat was 36%, 43%, 25%, and 56% in group D, L, DL, and NS, respectively (P = .02). Dexamethasone with or without lidocaine reduced the incidence of the POST (odds ratio, 0.44; 95% confidence interval, 0.24-0.82; P < .01). However, lidocaine was not effective in reducing POST (odds ratio, 0.62; 95% confidence interval, 0.33-1.14; P = .12). No difference was observed in the severity of a sore throat, incidence and severity of a cough, and hoarseness among the groups. CONCLUSIONS: Dexamethasone, with or without lidocaine, was effective in reducing the incidence of POST in patients requiring prolonged tracheal intubation.

Incidence and outcomes of multidrug-resistant gram-negative bacteria infections in intensive care unit from Nepal- a prospective cohort study.

Background: Infections caused by multi-drug resistant gram-negative bacterial infections are the principle threats to the critically ill patients of intensive care units. Increasing reports of these infections from the Nepalese intensive care unit underline the clinical importance of these pathogens. However, the impact of these infections on the patient's clinical outcome has not yet been clearly evaluated. The objective of our study was to determine the incidence and associated clinical outcome of multi-drug resistant gram-negative bacterial infections in intensive care unit from a tertiary care center of Nepal. Methods: A prospective cohort study was conducted among adult patients admitted in intensive care unit of B. P Koirala Institute of Health Sciences from July to December 2017. Patients infected with multi-drug resistant gram-negative bacteria, non-multi-drug resistant gram-negative bacteria and those without infection were included. Identification of gram-negative bacteria and their antibiotic susceptibility pattern was performed with standard microbiological methods. Demographic, clinical profiles and outcomes (in-hospital-mortality, intensive care unit and hospital length of stay) were documented. Results: The incidence rate of multi-drug resistant gram-negative bacteria infections was 47 per 100 admitted patients (64/137) with 128 episodes. Acinetobacter species (41%, 52/128) was the commonest followed by Klebsiella pneumoniae (28%, 36/128) and Pseudomonas spp (21%, 27/128). Patients with multi-drug resistant gram-negative bacteria in comparison to non-multi-drug resistant gram-negative bacteria had high healthcare-associated infections (95%, 61/64 versus 20%, 2/10; p = < 0.001). In-hospital-mortality was 38% (24/64), 20% (2/10) and 10% (4/41) in multi-drug resistant, non-multi-drug resistant and uninfected group respectively (p = 0.007). After adjustment for independent risk factors, compared to uninfected patients, the odds ratio (CI) for in-hospital-mortality in multi-drug resistant and non-multi-drug resistant group was (4.7[1.4-15.5], p = 0.01) and 2.60 [0.38-17.8], p = 0.32) respectively. Multi-drug resistant patients also had longer intensive care unit and hospital stay, however, it was statistically insignificant. Conclusion: The incidence of multi-drug resistant gram-negative bacterial infections was remarkably high in our intensive care unit and showed a significant association with healthcare-associated infections and in-hospital-mortality.

Effect of Co-Morbid Conditions on Persistent Neuropathic Pain after Brachial Plexus Injury in Adult Patients.

BACKGROUND AND PURPOSE: Neuropathic pain (NeuP) associated with traumatic brachial plexus injury (BPI) can be severe, persistent, and resistant to treatment. Moreover, comorbidity associated with NeuP may worsen the pain and quality of life. This study compared persistent NeuP after BPI between patients with and without co-morbid conditions (psychiatric dysfunction and other painful conditions) and tramadol usage as a second-line agent in combination with an antiepileptic and/or antidepressant during a 2-year follow-up. METHODS: The medical records of patients diagnosed with BPI referred to a pain center between 2006 and 2010 were reviewed for 2 years retrospectively. Data regarding patient demographics, injury and surgical profiles, characteristics of NeuP and its severity, and treatment received were compared between patients with and without manifesting co-morbid conditions. The NeuP and pain intensity assessments were based on the DN4 questionnaire and a numerical rating scale, respectively. RESULTS: Of the 45 patients studied, 24 patients presented with one of the following co-morbid conditions: myofascial pain (21%), psychiatric disorder (17%), phantom limb pain (4%), complex regional pain syndrome (21%), and insomnia (37%). Tramadol was required by 20 patients with co-morbidity and, 9 patients without co-morbidity (p<0.001). The mean pain score after 2 years was higher in patients with co-morbidity than in those without co-morbidity (p<0.05). CONCLUSIONS: Persistent pain following BPI was more common in patients manifesting other painful conditions or psychiatric co-morbidity. A higher proportion of the patients in the co-morbid group required tramadol as a second-line of agent for pain relief.

Missed Central Venous Guide Wires: A Systematic Analysis of Published Case Reports.

OBJECTIVE: The inadvertent loss of an entire guide wire during central venous catheterization can lead to serious patient harm and require additional investigations as well as retrieval procedures. We aimed to analyze globally published reports of lost wires during central venous catheterization to understand its possible etiology, presentation, treatment, and outcomes with an objective of finding solutions to make the procedure safer. DATA SOURCES: MEDLINE, Scopus, and CINAHL, supplemented by scanning the reference lists of relevant publications. STUDY SELECTION: All reports describing an inadvertent intravascular loss of a complete guide wire during placement of central venous catheters published up to December 2014 were included. Reports exclusively describing the 1) retrieval method, 2) partially retained guide wires, and 3) entrapped guide wires during withdrawal were excluded. DATA EXTRACTION: In each instance, we collected data about the method of the missed guide wire detection, the time interval between the procedure and detection, the supplementary investigations performed to confirm the diagnosis, and the risk factors associated with such events as well as the complications, the final outcome, and the wire retrieval methods used. DATA SYNTHESIS: A systematic analysis of the accessed publications was performed. CONCLUSIONS: Over the last decade, the number of reported instances of lost guide wires during central venous catheterization has increased rapidly. Unsupervised or improperly supervised insertions of the central catheters by trainees, distractions during insertions, and high workload are the main risk factors. A retained guide wire increases the risk and cost of additional diagnostic and therapeutic interventions, as well as imposing many minor-to-serious life-threatening complications. Continuing education along with simulator-based skill development, vigilant supervision, and a shared workload during out of hours working are likely to prevent such occurrences.