A cohort study of anatomical landmark-guided midline versus pre-procedure ultrasound-guided midline technique of spinal anesthesia in elderly patients undergoing orthopedic surgery.

BACKGROUND AND AIMS: The primary objective of the study was to compare the number of attempts and number of passes of spinal needle insertion and secondary objective was to compare complications, bloody tap, and patient discomfort in anatomical landmark-guided versus pre-procedure USG-guided midline technique of spinal anesthesia in elderly patients posted for orthopedic surgery. MATERIAL AND METHODS: In this a prospective observational cohort study, 60 patients of either sex, ASA grades I-III, and aged more than 65 years were randomly allocated to 2 groups of 30 patients each. In group AG (Anatomical landmark guided), standard landmark technique was used. In group UG (Ultrasound guided), pre-procedure ultrasound guided marking for insertion point of a spinal needle was done before giving spinal anesthesia. Patients in both the groups were compared on the basis of number of attempts, number of passes, vascular injury (bloody tap), pain score, complications, and procedure time. RESULTS: Successful dural puncture on the first needle insertion attempt was achieved more in UG group (90%) than in AG group (50%) (P < 0.05). Dural puncture was not achieved in only 3.3% patients in the UG group even after three midline attempts at spinal needle insertion. Mean of the number of passes was more in AG group (1.90) than in UG group (1.07) (P < 0.05). VAS (Visual Analogue Scale) score was 0.4 in AG group and 0.3 in UG group (P > 0.05). Group UG had shorter procedure time (2.25 min) than AG group (4.35 min). CONCLUSION: Preprocedure ultrasound imaging is a very useful tool to facilitate the performance of central neuraxial blockade in patients with difficult anatomical landmarks, especially in elderly patients.

Retrospective Analysis of Pain Relief in Total Knee Replacement Surgeries.

BACKGROUND AND AIMS: The aim of the study is to measure the postoperative adequacy of pain relief and functional recovery after unilateral primary total knee arthroplasty or total knee replacement (TKR) with a multimodal approach. SETTINGS AND DESIGN: This was a retrospective observational study done in a tertiary care center. MATERIALS AND METHODS: Eighty patients aged 18-65 years (yrs) with ASA Physical Status Classes I, II, and III operated for unilateral primary TKR surgery under suitable Anaesthesia and was administered ultrasound-guided adductor canal block + periarticular infiltration (PI) from January 2018 to January 2019 were included. Thereafter, the patients visual analog scale (VAS) scores at rest, 45° knee flexion, and mobilization as well as additional analgesia given were noted after going through the records at following time points: 12 hourly for 24 h and thereafter on postoperative day 1 (POD1) and POD2. Level of block, adverse events, and functional recovery (time up and go [TUG] test, 10 s walk test) on POD1 and POD2 were also noted. STATISTICAL ANALYSIS AND RESULTS: The statistical software namely SPSS 18.0 were used for the analysis of the data. The mean VAS score at 12 h was 4.33 ± 1.3 which worsened at 24 h with steady improvement over the next 2 days. Similarly, the case with a mean VAS score at 45° flexion and on mobilization showed a similar trend. At 12 h postadductor block, besides intravenous (i.v.) paracetamol, 32.6% of patients were given tramadol 50 mg i.v. whereas one patient was given a buprenorphine patch in addition to tramadol. The number of patients requiring additional tramadol and buprenorphine patch steadily increased over the next 2 days. The average time taken for the TUG test at 24 h was 30.98 ± 4.77 s, and the average time taken for the 10 s walk test at 24 h was 6.16 ± 1.10 steps with improvement in performance over the next 2 days. CONCLUSION: In our study, our multimodal analgesia model did not provide satisfactory analgesia though mobilization was not hampered.

Ultrasound-guided subarachnoid block in a case of osteogenesis imperfecta in an adolescent girl presenting with femur fracture - A case report.

Osteogenesis imperfecta (OI) is a rare congenital bone disorder with underlying Type 1 collagen defect, in which patients are prone to fractures. The disease is associated with increased spinal curvature, short stature, loose joints, and poor muscle tone, all contributing to difficulty in identifying landmarks and hindering successful subarachnoid block. We report an interesting case of a successful ultrasonogram (USG)-guided subarachnoid block given in an adolescent girl with OI for fixation of femur fracture. This report underlines the importance USG in managing difficult neuraxial blocks.

Prolonged Interscalene Blockade for 30 Hours with 0.5% Plain Bupivacaine in a Case of Shoulder Arthroscopy.

We present a case of unusually prolonged motor and sensory block for 30 hours after a successful single injection of ultrasound-guided interscalene block with 0.5% plain bupivacaine. All safety measures such as negative aspiration of blood injection at every 3 mL of drug with usual resistance, slow rate of injection and ultrasound documentation of spread of drug around C 5 and C 6 were followed. There was no evidence of neurological injury, but we should always be prepared to consider the possibility of nerve injury and take appropriate measures to prevent them.

Conscious sedation for balloon mitral valvotomy: A comparison of fentanyl versus sufentanil.

CONTEXT: Analgesia and sedation are required for the comfort of patient and the cardiologist during balloon mitral valvotomy. AIMS: In this study, efficacy of analgesia, sedation, and patient satisfaction with sufentanil was compared with fentanyl. SETTINGS AND DESIGN: Single-centered, prospective single-blind study of sixty patients. MATERIALS AND METHODS: Patients between 15 and 45 years of rheumatic mitral stenosis with valve area of 0.8-1 cm2 undergoing elective balloon mitral valvotomy, randomly divided to receive bolus injection fentanyl 1 mcg/kg (Group 1, n = 30) followed by infusion at 1 mcg/kg/h or bolus of injection sufentanil 0.1 mcg/kg (Group 2, n = 30) followed by continuous infusion at 0.1 mcg/h. Both the groups received injection midazolam bolus 0.02 mg/kg followed by infusion at 15 mcg/kg/h. Pain intensity (by visual analog score [VAS]), level of sedation (by Ramsay sedation scale), overall patient and operator's satisfaction, effect on cardiorespiratory parameters, and discharge score (by modified Aldrete score) were assessed. STATISTICAL ANALYSIS USED: Statistical analysis used Student's unpaired t-test and Chi-square test. P < 0.05 was considered statistically significant. RESULTS: Mean number of bolus doses in fentanyl group was 0.9 versus 0.13 in sufentanil group (P < 0.01). The mean value of mean blood pressure in fentanyl group was 83.52 mmHg versus 88 mmHg in sufentanil group (P < 0.05), but the value was within normal range in both the groups. The mean VAS - patient's opinion in fentanyl group was 8.97 versus 9.53 in sufentanil group (P < 0.05). Mean discharge score in fentanyl group was 17.87 versus 18.23 in sufentanil group (P < 0.05). No statistically significant difference was found with respect to heart rate, respiratory rate, oxygen saturation, PaCO2values, and anxiety scores. CONCLUSION: Sufentanil was found to be better with respect to analgesia, patient satisfaction, and recovery however not cost-effective for continuous infusion technique.

Cardioversion: What to choose? Etomidate or propofol.

CONTEXT: Electrical cardioversion is a short painful procedure to regain normal sinus rhythm requiring anaesthesia for haemodynamic stability, sedation, analgesia and early recovery. AIMS: To compare propofol and etomidate as sedatives during cardioversion. SETTINGS AND DESIGN: Single centred, prospective and randomized single blind study comprising 60 patients. SUBJECTS AND METHODS: Patients more than 18 years, American Society of Anesthesiologists I/II/III grades undergoing elective cardioversion, randomly divided to receive propofol 1 mg/kg intravenous (IV) bolus followed by 0.5 mg/kg (Group P, n = 30) or etomidate (Group E, n = 30) 0.1 mg/kg followed by 0.05 mg/kg. All patients received IV fentanyl (1 µg/kg) before procedure. Heart rate, blood pressure (BP) (systolic BP [SBP], diastolic BP [DBP], mean arterial pressure), respiratory rate, Aldrete recovery score (ARS) and Ramsay sedation score (RSS) were assessed at 1, 2, 5, 10, 15, 20 and 30 min post cardioversion. Incidence of hypotension, respiratory depression and side effects were compared. STATISTICAL ANALYSIS USED: Student's unpaired t-test, Chi-square test and Mann-Whitney test. P < 0.05 was taken as significant. RESULTS: Group P showed significant fall in SBP, DBP, and mean BP at 2 min after cardioversion. Hypotension (33.3% Group P vs. 16.65% Group E) occurred more with propofol (P < 0.05). Group E showed better ARS at 1, 2, 5, 10, 15 and 20 min. Time required to attain RSS = 2 (659.1 s Group P and 435.7 s Group E) indicated longer recovery with propofol. Left atrial size (35.5-42.5 mm) did not affect success rate of cardioversion (80% Group P vs. 83.3% Group E). Incidence of myoclonus (Group E 26.67% vs. Group P 0%) showed significant difference. CONCLUSIONS: Etomidate/fentanyl is superior over propofol/fentanyl during cardioversion for quick recovery and haemodynamic stability.

Depth of central venous catheterization by intracardiac electrocardiogram in adults.

BACKGROUND: Central venous catheterization is done frequently in cardiac surgery and intensive care settings. Faulty positioning of the catheter can cause many complications. OBJECTIVES: The aim of our study was to study the average depth of insertion and formulate a general guideline through the right internal jugular vein (IJV). PATIENTS AND METHODS: The right IJV was cannulated over a period of four months and catheter tip positioning was guided by means of an intracardiac electrocardiogram (ECG). Insertion depth was registered at the position of maximum P wave amplitude and the catheter was fixed after withdrawing 2 cm. Pearson's correlation coefficient was calculated to categorize any relationship between plots of distance versus patient's height, and regression lines and equations were also calculated. Bland-Altman analysis of data was done to compare the old formulae with our derived formulae. RESULTS: A total of 155 adult patients were studied. Distances measured were found to be highly correlated with a patient's height, followed by body surface area (BSA) and weight. For right IJV cannulation in valvular surgeries in adults, the depth of insertion (cm) was (height in cm / 15) + 2 ± 1.58 (SD) and in non-valvular surgeries in adults, it was (height in cm/15) + 1.4 ± 1.47 (SD). The bias was very small when the new formulae were compared to the existing formulae. CONCLUSIONS: The devised formulae predicted the required depth of catheters thereby reducing the possibility of complications and need for radiographic confirmation.