Paravertebral anaesthesia with or without sedation versus general anaesthesia for women undergoing breast cancer surgery.

BACKGROUND: Breast cancer is one of the most common cancers among women. Surgical removal of the cancer is the mainstay of treatment; however, tumour handling during surgery can cause microscopic dissemination of tumour cells and disease recurrence. The body's hormonal response to surgery (stress response) and general anaesthesia may suppress immunity, promoting tumour dissemination. Paravertebral anaesthesia numbs the site of surgery, provides good analgesia, and blunts the stress response, minimising the need for general anaesthesia. OBJECTIVES: To assess the effects of paravertebral anaesthesia with or without sedation compared to general anaesthesia in women undergoing breast cancer surgery, with important outcomes of quality of recovery, postoperative pain at rest, and mortality. SEARCH METHODS: On 6 April 2020, we searched the Specialised Register of the Cochrane Breast Cancer Group (CBCG); CENTRAL (latest issue), in the Cochrane Library; MEDLINE (via OvidSP); Embase (via OvidSP); the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal; and ClinicalTrials.gov for all prospectively registered and ongoing trials. SELECTION CRITERIA: We included randomised controlled trials (RCTs) conducted in adult women undergoing breast cancer surgery in which paravertebral anaesthesia with or without sedation was compared to general anaesthesia. We did not include studies in which paravertebral anaesthesia was given as an adjunct to general anaesthesia and then this was compared to use of general anaesthesia. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted details of trial methods and outcome data from eligible trials. When data could be pooled, analyses were performed on an intention-to-treat basis, and the random-effects model was used if there was heterogeneity. When data could not be pooled, the synthesis without meta-analysis (SWiM) approach was applied. The GRADE approach was used to assess the certainty of evidence for each outcome. MAIN RESULTS: Nine studies (614 participants) were included in the review. All were RCTs of parallel design, wherein female patients aged > 18 years underwent breast cancer surgery under paravertebral anaesthesia or general anaesthesia. None of the studies assessed quality of recovery in the first three postoperative days using a validated questionnaire; most assessed factors affecting quality of recovery such as postoperative analgesic use, postoperative nausea and vomiting (PONV), hospital stay, ambulation, and patient satisfaction. Paravertebral anaesthesia may reduce the 24-hour postoperative analgesic requirement (odds ratio (OR) 0.07, 95% confidence interval (CI) 0.01 to 0.34; 5 studies, 305 participants; low-certainty evidence) compared to general anaesthesia. Heterogeneity (I² = 70%) was attributed to the fixed dose of opioids and non-steroidal analgesics administered postoperatively in one study (70 participants), masking a difference in analgesic requirements between groups. Paravertebral anaesthesia probably reduces the incidence of PONV (OR 0.16, 95% CI 0.08 to 0.30; 6 studies, 324 participants; moderate-certainty evidence), probably results in a shorter hospital stay (mean difference (MD) -79.39 minutes, 95% CI -107.38 to -51.40; 3 studies, 174 participants; moderate-certainty evidence), and probably reduces time to ambulation compared to general anaesthesia (SWiM analysis): percentages indicate vote counting based on direction of effect (100%, 95% CI 51.01% to 100%; P = 0.125; 4 studies, 375 participants; moderate-certainty evidence). Paravertebral anaesthesia probably results in higher patient satisfaction (MD 5.52 points, 95% CI 1.30 to 9.75; 3 studies, 129 participants; moderate-certainty evidence) on a 0 to 100 scale 24 hours postoperatively compared to general anaesthesia. Postoperative pain at rest and on movement was assessed at 2, 6, and 24 postoperative hours on a 0 to 10 visual analogue scale (VAS). Four studies (224 participants) found that paravertebral anaesthesia as compared to general anaesthesia probably reduced pain at 2 postoperative hours (MD -2.95, 95% CI -3.37 to -2.54; moderate-certainty evidence). Five studies (324 participants) found that paravertebral anaesthesia may reduce pain at rest at 6 hours postoperatively (MD -1.54, 95% CI -3.20 to 0.11; low-certainty evidence). Five studies (278 participants) found that paravertebral anaesthesia may reduce pain at rest at 24 hours postoperatively (MD -1.19, 95% CI -2.27 to -0.10; low-certainty evidence). Differences in the methods of two studies (119 participants) and addition of clonidine to the local anaesthetic in two studies (109 participants), respectively, contributed to the heterogeneity (I² = 96%) observed for these two outcomes. Two studies (130 participants) found that paravertebral anaesthesia may reduce pain on movement at 6 hours (MD-2.57, 95% CI -3.97 to -1.17) and at 24 hours (MD -2.12, 95% CI -4.80 to 0.55; low-certainty evidence). Heterogeneity (I² = 96%) was observed for both outcomes and could be due to methodological differences between studies. None of the studies reported mortality related to the anaesthetic technique. Eight studies (574 participants) evaluated adverse outcomes with paravertebral anaesthesia: epidural spread (0.7%), minor bleeding (1.4%), pleural puncture not associated with pneumothorax (0.3%), and Horner's syndrome (7.1%). These complications were self-limiting and resolved without treatment. No data are available on disease-free survival, chronic pain, and quality of life. Blinding of personnel or participants was not possible in any study, as a regional anaesthetic technique was compared to general anaesthesia. Risk of bias was judged to be serious, as seven studies had concerns of selection bias and three of detection bias. AUTHORS' CONCLUSIONS: Moderate-certainty evidence shows that paravertebral anaesthesia probably reduces PONV, hospital stay, postoperative pain (at 2 hours), and time to ambulation and results in greater patient satisfaction on the first postoperative day compared to general anaesthesia. Paravertebral anaesthesia may also reduce postoperative analgesic use and postoperative pain at 6 and 24 hours at rest and on movement based on low-certainty evidence. However, RCTs using validated questionnaires are needed to confirm these results. Adverse events observed with paravertebral anaesthesia are rare.

Spectral entropy monitoring for adults and children undergoing general anaesthesia.

BACKGROUND: Anaesthetic drugs during general anaesthesia are titrated according to sympathetic or somatic responses to surgical stimuli. It is now possible to measure depth of anaesthesia using electroencephalography (EEG). Entropy, an EEG-based monitor can be used to assess the depth of anaesthesia using a strip of electrodes applied to the forehead, and this can guide intraoperative anaesthetic drug administration. OBJECTIVES: The primary objective of this review was to assess the effectiveness of entropy monitoring in facilitating faster recovery from general anaesthesia. We also wanted to assess mortality at 24 hours, 30 days, and one year following general anaesthesia with entropy monitoring.The secondary objectives were to assess the effectiveness of the entropy monitor in: preventing postoperative recall of intraoperative events (awareness) following general anaesthesia; reducing the amount of anaesthetic drugs used; reducing cost of the anaesthetic as well as in reducing time to readiness to leave the postanaesthesia care unit (PACU). SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 10), MEDLINE via Ovid SP (1990 to September 2014) and EMBASE via Ovid SP (1990 to September 2014). We reran the search in CENTRAL, MEDLINE via Ovid SP and EMBASE via Ovid SP in January 2016. We added one potential new study of interest to the list of 'Studies awaiting Classification' and we will incorporate this study into the formal review findings during the review update. SELECTION CRITERIA: We included randomized controlled trials (RCTs) conducted in adults and children (aged greater than two years of age), where in one arm entropy monitoring was used for titrating anaesthesia, and in the other standard practice (increase in heart rate, mean arterial pressure, lacrimation, movement in response to noxious surgical stimuli) was used for titrating anaesthetic drug administration. We also included trials with an additional third arm, wherein another EEG monitor, the Bispectral index (BIS) monitor was used to assess anaesthetic depth. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two review authors independently extracted details of trial methodology and outcome data from trials considered eligible for inclusion. All analyses were made on an intention-to-treat basis. We used a random-effect model where there was heterogeneity. For assessments of the overall quality of evidence for each outcome that included pooled data from RCTs, we downgraded evidence from 'high quality' by one level for serious (or by two for very serious) study limitations (risk of bias, indirectness of evidence, serious inconsistency, imprecision of effect or potential publication bias). MAIN RESULTS: We included 11 RCTs (962 participants). Eight RCTs (762 participants) were carried out on adults (18 to 80 years of age), two (128 participants) involved children (two to 16 years) and one RCT (72 participants) included patients aged 60 to 75 years. Of the 11 included studies, we judged three to be at low risk of bias, and the remaining eight RCTs at unclear or high risk of bias.Six RCTs (383 participants) estimated the primary outcome, time to awakening after stopping general anaesthesia, which was reduced in the entropy as compared to the standard practice group (mean difference (MD) -5.42 minutes, 95% confidence interval (CI) -8.77 to -2.08; moderate quality of evidence). We noted heterogeneity for this outcome; on performing subgroup analysis this was found to be due to studies that included participants undergoing major, long duration surgeries (off-pump coronary artery bypass grafting, major urological surgery). The MD for time to awakening with four studies on ambulatory procedures was -3.20 minutes (95% CI -3.94 to -2.45). No trial reported the second primary outcome, mortality at 24 hours, 30 days, and one year with the use of entropy monitoring.Eight trials (797 participants) compared the secondary outcome, postoperative recall of intraoperative events (awareness) in the entropy and standard practice groups. Awareness was reported by only one patient in the standard practice group, making meaningful estimation of benefit of entropy monitoring difficult; moderate quality of evidence.All 11 RCTs compared the amount of anaesthetic agent used between the entropy and standard practice groups. Six RCTs compared the amount of propofol, four compared the amount of sevoflurane and one the amount of isoflurane used between the groups. Analysis of three studies (166 participants) revealed that the MD of propofol consumption between the entropy group and control group was -11.56 mcg/kg/min (95% CI -24.05 to 0.92); low quality of evidence. Analysis of another two studies (156 participants) showed that the MD in sevoflurane consumption in the entropy group compared to the control group was -3.42 mL (95% CI -6.49 to -0.35); moderate quality of evidence.No trial reported on the secondary outcome of the cost of general anaesthesia.Three trials (170 participants) estimated MD in time to readiness to leave the PACU of the entropy group as compared to the control group (MD -5.94 minutes, 95% CI -16.08 to 4.20; low quality of evidence). Heterogeneity was noted, which was due to the difference in anaesthetic technique (propofol-based general anaesthesia) in one study. The remaining two studies had used volatile-based general anaesthesia. The MD in time to readiness to leave the PACU was -4.17 minutes (95% CI -6.84 to -1.51) with these two studies. AUTHORS' CONCLUSIONS: The evidence as regards time to awakening, recall of intraoperative awareness and reduction in inhalational anaesthetic agent use was of moderate quality. The quality of evidence of as regards reduction in intravenous anaesthetic agent (propofol) use, as well as time to readiness to leave the PACU was found to be of low quality. As the data are limited, further studies consisting of more participants will be required for ascertaining benefits of entropy monitoring.Further studies are needed to assess the effect of entropy monitoring on focal issues such as short-term and long-term mortality, as well as cost of general anaesthesia.

Esophageal polyp as a posterior mediastinal mass: Intraoperative dynamic airway obstruction requiring emergency tracheostomy.

Anesthesia in the presence of a mediastinal mass is difficult and challenging as the mass can involve or compress the heart, great vessels, tracheo-bronchial tree and the surrounding structures. We describe a case of severe tracheo-bronchial obstruction requiring emergency tracheostomy during the intraoperative period after an uneventful induction of anesthesia in a patient with a large esophageal polyp presenting as a posterior mediastinal mass.

Comparative evaluation of continuous infusion versus programmed intermittent bolus techniques in erector spinae plane block in modified radical mastectomy - A preliminary randomised controlled trial.

Background and Aims: Single-shot erector spinae plane block (ESPB) provides excellent analgesia in mastectomy in the immediate post-operative period but is not sufficient to maintain for prolonged duration. This study compares the efficacy of programmed intermittent bolus (PIB) versus continuous infusion (CI) techniques after ESPB by placing a catheter for mastectomy. Methods: After ethical approval and patient consent, ESPB was performed at the T4 level in 50 patients with an initial bolus of 20 mL 0.375% ropivacaine and a catheter placed 30 min before surgery. In the postoperative period, they were randomised to Group I - intermittent bolus of 20 mL 0.2% ropivacaine every 4 h for 24 h and Group C - continuous infusion of 0.2% ropivacaine at 5 mL/h for 24 h. The primary outcome was the 24-h fentanyl consumption by patient-controlled analgesia device. Data was analysed using Stata 14.0. Results: Group I patients had reduced post-operative fentanyl consumption {mean [standard deviation (SD)]: 166 (139.17) µg vs 332 (247.96) µg, P = 0.002} and lower median NRS scores (1 h: 3 vs 5), (2 h: 3 vs 5), (4 h: 3 vs 5), (6 h: 4 vs 5) with a higher mean (SD) Quality of Recovery-15 score {134.4 (8.53) vs 127 (12.89), P = 0.020} compared to Group C, respectively. The 24-h dermatomal sensory coverage was more comprehensive in Group I compared to Group C. Conclusion: The PIB technique after ESPB provides decreased postoperative opioid consumption, better post-operative analgesia and quality of recovery compared to the CI technique in patients undergoing mastectomy.

Perioperative concerns in pediatric patients u10/1/2013ndergoing different types of scoliosis correction surgery: A retrospective observational study.

BACKGROUND: Advances in scoliosis surgery have now made it possible for younger patients to be taken up for scoliosis correction. OBJECTIVES: To ascertain the patient profile, perioperative complications and need for intensive care management in children undergoing posterior fusion and instrumentation (PF), anterior release (AR), and growth rod (GR) insertion surgery. PATIENTS AND METHODS: After taking parental consent, data were collected retrospectively for 33 patients who underwent 37 procedures (four patients had both anterior and posterior procedures) on 2 days of the week mainly from August 2008 to February 2010 at a tertiary care institution. RESULTS: Children undergoing GR surgery were younger (8.1 ± 2.1 years) than patients undergoing AR (12.9 ± 1.7 years) or posterior fusion (14.2 ± 2.2 years). AR children had a significantly higher Cobb's angle and more rigid curves. (P = 0.057) Associated congenital abnormalities especially neurological were commoner in the GR children. Surgical duration and blood loss was significantly more for PF (2207.5 ± 1224.13 ml) than GR (456 ± 337.5 ml), or AR (642.85 ± 304.72 ml), (P = 0.0002). PF patients needed Intensive care unit (ICU) care mainly due to the blood loss and prolonged surgery (35%). AR performed via thoracotomy was associated with the need for mechanical ventilation in 28.6%. The GR patients had major intraoperative hemodynamic events and 20% needed ICU care. CONCLUSIONS: Post-operative ventilation may be required in 20-35% patients undergoing procedures for scoliosis correction. Despite GR insertion involving lesser blood loss; younger age, congenital abnormalities, positioning, and surgical manipulation resulted in life threatening events in these patients.

Comparison of continuous transmuscular quadratus lumborum block and continuous psoas compartment block for posterior total hip arthroplasty: A randomised controlled trial.

Background and Aims: Analgesia for hip surgery involves cutaneous anaesthesia at the site of the skin incision and the anterior hip capsule. This study aimed to compare continuous ultrasound (US)-guided transmuscular quadratus lumborum block (TQLB) with psoas compartment block (PCB) for analgesia in patients undergoing total hip arthroplasty (THA) under general anaesthesia (GA). Methods: This randomised, observer-blinded trial included 18-70-year-old American Society of Anesthesiologists physical status I-III patients undergoing THA under GA with either US-guided continuous TQLB or PCB. Primary objectives included a visual analogue scale (VAS; 0-100 mm) at rest and mobilisation at 6 h postoperatively (analysed by intention to treat and per protocol) using a non-inferiority margin of 20 mm. Secondary objectives included VAS at other time points, 24-h fentanyl consumption (analysed using the Wilcoxon rank-sum test), sensory dermatomes anaesthetised, motor weakness 30 min after block, and haemodynamic response to skin incision (analysed using the Chi-squared or Fisher's exact test). A P value less than 0.05 was considered statistically significant. Results: VAS (0-100 mm) score at 6 h on rest was 25.34 ± 14.25 and 27.3 ± 9.6, mean difference (MD) was 1.9 [-3.3, 7.1] and at movement was 35.1 ± 23.0 and 38.6 ± 17.0, MD was 3.5 [-5.2, 12.2], in the PCB (n = 29) and QLB (n = 30) groups, respectively (i.e. less than the non-inferiority margin). However, VAS (rest) at 1, 12, and 24 h postoperatively and median (IQR) 24-h fentanyl consumption was significantly higher in the QLB group (1212.5 [300-2345] µg] when compared to the PCB group (635 [100-1645] µg; P = 0.0004). Conclusion: Though statistically, continuous QLB was non-inferior to continuous PCB for pain at rest and mobilisation at 6-hours postoperatively, a higher 24-hour perioperative fentanyl consumption and VAS show that QLB was clinically inferior to PCB.

Quadratus lumborum block vs. transversus abdominis plane block in laparoscopic trans-abdominal pre-peritoneal repair of inguinal hernia in adults: A randomised controlled trial.

Background and Aims: Laparoscopic trans abdominal preperitoneal (TAPP) repair of hernia is one of the most commonly performed surgeries and may cause significant postoperative pain. Among different truncal block techniques, quadratus lumborum (QL) and transversus abdominis plane blocks (TAP) are used during this abdominal surgery. We aimed to investigate whether, bilateral QL block by trans-muscular approach provided better analgesia as compared to posterior TAP block in these patients. Methods: Forty adult patients with American Society of Anesthesiologists physical status I and II, undergoing inguinal hernia repair were randomized to receive either QL or TAP block, with 20 mL of 0.25% ropivacaine bilaterally. The primary objective of the study was to compare the total fentanyl consumption (in µg) within 24 hours postoperatively. The secondary objectives studied were dermatomal spread, quality of recovery at discharge and at 3 months postoperatively. Results: There was a significant reduction in total 24-hour fentanyl consumption (552 ± 229.56 vs 735.5 ± 264 µg, P =0.01) in the QL group, with longer duration of analgesia [282.5 ± 89.9 min group TAP vs. 354.8 ± 107 min QL, (mean difference -72.34,95% confidence interval -135.516 to -9.024), P =0.03], as compared to TAP group. At T8 and T9 dermatomes, greater proportion of patients in the QL group attained analgesia. Quality of Recovery at 24 hours and at 3 months of follow-up were comparable. Conclusion: QL block provided better perioperative analgesia than TAP block, in patients undergoing laparoscopic hernia repair. It also leads to greater dermatomal spread but without any decrease in the incidence of chronic pain at 3 months postoperatively.

Efficacy of Clonidine as an Adjuvant to Ropivacaine in Transversus Abdominis Plane Block in Adult Renal Transplant Recipients: A Double-blinded Randomized Controlled Trial.

Background and Aims: Transversus abdominis plane (TAP) block has been used to provide analgesia in renal transplant surgery with varying results. This study was designed to assess if the addition of clonidine in TAP block would decrease 24-h postoperative morphine consumption in adult renal transplant recipients. Materials and Methods: Forty adult patients undergoing renal transplantation under general anesthesia in a tertiary care hospital were randomized into either group RC (TAP block with 20 mL of 0.5% ropivacaine plus 2 µg.kg-1 clonidine) or group R (TAP block with 20 mL 0.5% ropivacaine) after induction of anesthesia. Postoperative analgesia was provided using patient-controlled morphine. The primary outcome was 24-h patient-controlled morphine consumption. The secondary outcomes were a) intraoperative hemodynamics, b) fentanyl and ephedrine requirement, c) postoperative pain using the Visual Analog Scale at 0, 2, 6, 12 and 24 hours, d) time to first postoperative analgesia, e) postoperative hemodynamics, and f) side effects. Results: There was no significant difference in postoperative morphine consumption between the groups (25 mg in group RC vs. 28.5 mg in group R) (median interquartile range) (P = 0.439). Postoperative pain scores were comparable between the groups. Intraoperatively, fewer patients required rescue fentanyl in group RC (7 patients) as compared to group R (17 patients) (P = 0.003). Significantly more patients in group RC required ephedrine boluses as compared to group R (9 patients in group RC vs. 2 in group R, P = 0.014). Conclusions: The addition of 2 µg.kg-1 clonidine to ropivacaine in TAP block did not reduce 24-h postoperative morphine consumption after renal transplantation. It reduced the need for intraoperative analgesics but increased the need for intraoperative ephedrine administration.

Analgesic efficacy of superficial versus deep serratus plane block for modified radical mastectomy under general anaesthesia: A randomised comparative study.

Background and Aims: Serratus anterior plane (SAP) blocks can be given either superficial or deep to the serratus anterior muscle to block the branches of intercostal nerves providing analgesia to the anterolateral chest wall. This prospective randomised comparative study aimed to compare the analgesic efficacy of superficial and deep SAP block in breast surgeries. Methods: Forty female patients scheduled to undergo elective modified radical mastectomy under general anaesthesia (GA) were randomly assigned to receive ultrasound guided SAP block with 30 ml 0.375% ropivacaine either superficial (group S, n = 20) or deep (group D, n = 20) to the serratus anterior muscle, before the induction of GA. The primary outcome was post operative fentanyl requirement over 24 hours and secondary outcomes were comparison of numerical rating scale (NRS) scores for pain, sensory block mapping, time to perform the block, number of needle attempts, etc. Results: The post operative 24-hour fentanyl requirement was comparable between group S and D (318.75 ± 80.65 versus 272.5 ± 80.25 µg, P = 0.07). NRS pain scores were comparable between the groups. Sensory block mapping done at various levels showed T3-T7 block in most of the patients with no difference between the groups. Block performance time (6.05 ± 3.27 versus 8.35 ± 3.26 minutes, P = 0.034) and number of needle attempts was significantly lesser in group D. Conclusion: There was no difference in analgesic efficacy when SAP block was given superficial or deep to serratus anterior muscle for modified radical mastectomies. However, deep SAP block required less time and number of attempts to perform than superficial technique.

A Double-Blind, Randomized Controlled Pilot Trial to Assess the Analgesic Efficacy of Ultrasound-Guided Preemptive Caudal Morphine as an Adjunct to Bupivacaine for Lumbosacral Spine Surgeries in Adults.

Background The analgesic efficacy of preemptive administration of caudal morphine for spine surgeries in adults is not well studied. In a double-blinded, randomized controlled trial, safety and analgesic efficacy of preemptive, single-shot caudal morphine and bupivacaine was compared with caudal bupivacaine alone in lumbosacral spine surgeries. Methods After Institutional Ethics Committee approval, 40 patients aged 18-60 yrs planned for lumbosacral spine surgery were randomized to groups of 20 patients each. After induction and prone positioning, an ultrasound-guided caudal block was performed with morphine 50 µg/kg with 20 ml 0.25% bupivacaine in the study group (LM) and only bupivacaine in the control group (LA). Postoperatively, both groups received intravenous morphine via patient-controlled analgesia (PCA) pump (No basal, 1 mg/bolus, 10 minutes lockout interval). Intraoperative fentanyl use, postoperative 24-h morphine consumption, visual analogue pain scores (VAS) and adverse effects of morphine were noted. Results Demographics and baseline data were comparable. Postoperative 24-hour morphine requirement was more in LA group (34.3 ± 10.7 mg vs 19.65 ± 11.8 mg, p=0.0001). Total intraoperative supplemental fentanyl requirement was similar (79.25 ± 67.60 µg in LA vs 54 ± 50.20 µg in LM group, p=0.28). VAS scores at 2/4/6/12-hour in group-LM were significantly less than group-LA (p=0.005, 0.002, 0.001 and 0.047) but were comparable at 18 and 24 hours (p=0.25, 0.42). Postoperative incidence of adverse effects of morphine was comparable. Conclusions Ultrasound-guided, single-shot preemptive administration of caudal morphine with bupivacaine is a safe and effective modality of analgesia for patients undergoing lumbosacral spine surgeries.

Entropy monitoring decreases isoflurane concentration and recovery time in pediatric day care surgery--a randomized controlled trial.

AIM: To assess if titrating anesthesia with entropy would result in faster awakening in children undergoing day care surgery. BACKGROUND: Entropy, an EEG-based anesthesia depth monitor, has been used in children; however, only one other study has evaluated the effectiveness of entropy monitoring in decreasing awakening time and for titrating anesthetic agents in children undergoing short procedures under anesthesia. METHODS: In a randomized prospective single-blind parallel group trial, 50 ASA grade I-II children, aged 2-12 years, scheduled for lower abdominal or urological surgeries were studied after ethics committee approval and parental consent. The children were randomized to the entropy or control group. Following laryngeal mask airway insertion and caudal analgesia, anesthesia was maintained with nitrous oxide, oxygen, isoflurane. In the control group, anesthesia was titrated according to the hemodynamic parameters and the simultaneously monitored entropy values obscured from the anesthesiologist. In the entropy group, the entropy values (between 45 and 65) were used to titrate the anesthesia. RESULTS: Time to awakening from anesthesia was 7 (3-18) min in the entropy group when compared to 10 (5-21) min in the control group. (P < 0.05) The difference in the mean time to awakening was 2.72 min 95% CI (0.34, 5.1). The end tidal isoflurane concentrations were lower in the entropy group when compared to the control group 15 s following airway insertion (0.78 ± 0.14 vs 1.24 ± 0.19), 15 s post caudal and skin incision (0.68 ± 0.40 vs 0.84 ± 0.05, 0.68 ± 0.03 vs 0.77 ± 0.32, respectively) as well as 5 min after skin incision 0.67 ± 0.04 vs 0.79 ± 0.02), (P ≤ 0.05). CONCLUSION: In pediatric day care surgery, entropy monitoring resulted in statistically though not clinically significant faster awakening and significantly lower end ­ tidal isoflurane concentrations.

Granular cell myoblastoma of tongue: a rare cause of unanticipated difficult intubation.

INTRODUCTION: Intubation with direct laryngoscopy may be impossible in 0.05%-0.35% patients due to an undetected supraglottic mass despite an apparently normal pre-operative airway assessment. We report a case of granular cell myoblastoma of the tongue, as a cause of an unanticipated impossible intubation. CASE REPORT: A 55-year-old ASA III male weighing 75 Kg was taken up for emergency exploratory laparotomy with perforation peritonitis. On preoperative airway examination there was no indication of difficult intubation. After induction of anesthesia (rapid sequence with rocuronium) we performed direct laryngoscopy. There was a mass arising from the base of the tongue because of which no recognizable epiglottis or glottic structure could be identified. Despite repeat laryngoscopy, optimal external manipulation and direct laryngoscopy performed by an ENT surgeon, the airway could not be secured. As no fibreoptic laryngoscope was available, a surgical tracheostomy had to be performed.

Anaesthetic management of a COVID-19 parturient for caesarean section - Case report and lessons learnt.

The corona virus disease 2019 (COVID-19) pandemic sweeping across the world has severely strained health care resources (equipment and personnel) forcing us to rethink strategies to provide obstetric care while judiciously using resources. We describe the anaesthetic management of a mildly symptomatic, COVID-19 positive, 28-year-old second gravida with term pregnancy who was taken up for an elective caesarean section under subarachnoid block in a standalone maternity facility. Challenges encountered and modifications of standard procedures so as to optimize patient care and minimize exposure of health care professionals are also discussed.

Comparison of transversus abdominis plane block and intrathecal morphine for laparoscopic donor nephrectomy: Randomised controlled trial.

BACKGROUND AND AIMS: Postoperative pain following laparoscopic donor nephrectomy (LDN) is significant and no suitable analgesic technique is described. Opioid analgesia in standard doses is often suboptimal and associated with numerous adverse effects. Transversus abdominis plane (TAP) block has been evaluated in various laparoscopic procedures. Intrathecal morphine (ITM) has been seen to provide long-lasting analgesia of superior quality in laparoscopic colorectal procedures. METHODS: The present study was undertaken to evaluate the analgesic efficacy of single-dose ITM 5 µg/kg for LDN. After ethics approval, 60 adult patients scheduled for LDN were randomised to receive intravenous fentanyl, ultrasound-guided TAP block or ITM for postoperative analgesia. Postoperative 24-h patient-controlled analgesia (PCA) fentanyl consumption, visual analogue scale (VAS) score and intraoperative fentanyl and muscle relaxant requirements were compared. Statistical analysis was performed using appropriate statistical tests by using Stata 11.1 software. RESULTS: Haemodynamic stability at pneumoperitoneum and in the post anaesthesia care unit was significantly better in patients receiving ITM. Intraoperative rescue fentanyl requirement (P = 0.01) and postoperative fentanyl requirement until 24 h (P = 0.000) were significantly lower in the morphine group. Postoperative VAS at rest and on movement was significantly lower in the morphine group at all points of assessment (P = 0.000). CONCLUSION: ITM 5 µg/kg provides better intraoperative and postoperative analgesia and reduces postoperative PCA fentanyl requirement in laparoscopic donor nephrectomy compared to TAP block or intravenous fentanyl.

Comparison of topical lignocaine gel and fentanyl for perioperative analgesia in children undergoing cataract surgery.

BACKGROUND: Opioids continue to remain the primary analgesics in children undergoing ophthalmic surgery, and their use may be associated with adverse effects like vomiting and respiratory depression. Topical anesthesia avoids these adverse effects and also complications of regional blocks. We designed this study to verify whether topical anesthesia with lignocaine gel is a feasible alternative to intravenous (IV) fentanyl for pediatric cataract surgery. METHODS: One hundred ASA I and II children aged 3-12 years, scheduled for cataract surgery were included in this study. After induction of anesthesia, children were randomized to Group F (fentanyl), who received 2 mcg.kg(-1) IV fentanyl for analgesia and Group G (lignocaine gel), who received 2% lignocaine gel applied over the cornea of the operative eye. Anesthesia was maintained with isoflurane and oxygen in nitrous oxide. All children received intramuscular ketorolac. Intraoperative supplementary analgesia was provided with 0.5 mcg.kg(-1) IV fentanyl to manage increases in heart rate or blood pressure of 20% above baseline. In the postoperative period, Aldrete score and objective pain score were assessed. Rescue analgesia was provided with fentanyl in the postanesthesia care unit and syrup ibuprofen in the ward. RESULTS: Significantly more children in group F (8/48) required intraoperative supplementary fentanyl as compared with group G (1/48) (P = 0.0291). In the PACU, 7/48 children of group G needed fentanyl as compared with 5/48 children in group F. Time to reach Aldrete 10 was significantly longer in group F (P = 0.01). CONCLUSIONS: Topical lignocaine gel is an effective analgesic and may be used as an adjunct to fentanyl during cataract surgery in children.