Bilateral pericapsular end nerve blocks for steroid-induced avascular necrosis following COVID-19 infection requiring bilateral total hip replacement

BACKGROUND

Osteonecrosis or avascular necrosis (AVN) of the hip was one of the dreaded complications of coronavirus disease 2019 (COVID-19), which emerged in patients who received steroid therapy. Corticosteroids have been a mainstay in the treatment protocol of COVID-19 patients. Popular corticosteroid drugs used in patients suffering from COVID-19 were intravenous (IV) or oral dexamethasone, methylprednisolone or hydrocortisone. The use of such high doses of corticosteroids has shown very positive results and has been lifesaving in many cases. Still, long-term consequences were drug-induced diabetes, osteoporosis, Cushing syndrome, muscle wasting, peripheral fat mobilization, AVN, hirsutism, sleep disturbances and poor wound healing. A significant number of young patients were admitted for bilateral total hip replacements (THR) secondary to AVN following steroid use for COVID-19 treatment.

AIM

To assess the efficacy of bilateral pericapsular end nerve group (PENG) blocks in patients posted for bilateral THR post-steroid therapy after COVID-19 infection and assess the time taken to first ambulate after surgery.

METHODS

This prospective observational study was conducted between January 2023 and August 2023 at Care Hospitals, Hyderabad, India. Twenty young patients 30-35 years of age who underwent bilateral THR were studied after due consent over 8 months. All the patients received spinal anaesthesia for surgery and bilateral PENG blocks for postoperative analgesia.

RESULTS

The duration of surgery was 2.5 h on average. Seventeen out of twenty patients (85%) had a Visual Analog Score (VAS) of less than 2 and did not require any supplementation. One patient was removed from the study, as he required re-exploration. The remaining two patients had a VAS of more than 8 and received IV morphine post-operatively as a rescue analgesic drug. Fifteen out of seventeen patients (88.2%) could be mobilized 12 h after the procedure.

CONCLUSION

Osteonecrosis or AVN of the hip was one of the dreaded complications of COVID-19, which surfaced in patients who received steroid therapy requiring surgical intervention. Bilateral PENG block is an effective technique to provide post-operative analgesia resulting in early mobilization and enhanced recovery after surgery.

Lung preconditioning in anesthesia: Review of the literature

Lung injury can arise during or after anesthesia and can lead to a complicated postoperative course with great implications for the patient. Unfortunately, treatment of acute lung injury is at the moment mainly supportive and rates of recovery have not really improved in the recent years. In many cases, lung injury can be anticipated and preventive measures seem possible. This represents a unique challenge to the anesthesiologist, as some new opportunities to reduce the frequency and/or severity of lung injury seem now available. These chances may arise from the potency of preconditioning the lungs before the main injury, with smaller injurious insults. Although preconditioning began to be applicated first on the myocardium, experimental studies have shown potentially beneficial results also for the lungs. This review summarizes the main methods of lung preconditioning that have been tried in experimental studies in the literature and the main mechanisms that are perhaps involved. Emphasis is given in the two main methods of preconditioning that seem readily applicable in the clinical praxis, that is ischemic preconditioning, as well as preconditioning with volatile anesthetics. The few, but interesting clinical studies are also summarized and the future research points in this evolving field of anesthesia are stressed.

Cement-related embolism after lumbar vertebroplasty: A case report

BACKGROUND

Cement-related embolism is a rare but potentially fatal complication in spinal surgery. Cardiac echocardiography can provide valuable information for the early identification.

CASE SUMMARY

A 66-year-old woman who underwent lumbar vertebroplasty and internal fixation under general anesthesia experienced an episode of supraventricular tachycardia and ventricular tachycardia at the end of surgery. Point-of-care echocardiogram revealed a foreign body in the right heart. After conservative treatment in the intensive care unit, her family decided on comfort care and she expired.

CONCLUSION

Transthoracic echocardiography may provide early valuable information in patients undergoing vertebroplasty, and mild-moderate pericardial effusion may be a significant sign of a poor outcome.

Dexmedetomidine vs propofol in intensive care unit patients

Dexmedetomidine is indicated as a sedative agent in intensive care units (ICUs). While several clinical trials and two meta-analyses have compared this agent with propofol or midazolam, the results were variable depending on the specific end-point (e.g., duration of mechanical ventilation, ICU mortality, maintaining a target depth of sedation, incidence of delirium episodes, length of hospital stay). Hence, the effectiveness of this new agent vs the comparators seems to be controversial. Trial sequential analysis (TSA) is a statistical technique that can estimate the optimal, cumulative number of patients that would be needed to generate a conclusive result. We therefore applied a TSA model to the most recent meta-analysis evaluating dexmedetomidine. A total of 10 randomized controlled trials were included in our analysis. According to our results, the comparison of dexmedetomidine vs propofol showed no proof of incremental effectiveness for the end-points of length of ICUs stay and incidence of delirium episodes. In contrast, futility (i.e., proof of no incremental effectiveness) was demonstrated for the end-point of mechanical ventilation. Hence, the results for the comparison of dexmedetomidine vs propofol were inconclusive for the first two end-points; on the other hand, conclusiveness was reached for the third end-point. We conclude that the place of dexmedetomidine in therapy of critically ill patients is very uncertain and further controlled trials are still needed.

Predictive value of extravascular lung water indexed to predicted body weight

AIM: To investigate extravascular lung water indexed to predicted body weight (EVLWIp) and actual body weight (EVLWIa) on outcome of patients with severe sepsis.

METHODS: Transpulmonary thermodilution was prospectively used to measure cardiovascular hemodynamics, EVLWIp and EVLWIa via an arterial catheter placed in each patient within 48 h of meeting the criteria for severe sepsis from a medical intensive care unit (ICU) at a university affiliated hospital. Survival was the single dependent variable. In order to examine and compare the predictive power of EVLWIp, EVLWIa and other clinically significant factors in predicting the in-hospital survival status of severe sepsis patients in the medical ICU, a receiver operating characteristic (ROC) curve method to analyze the significant variables and the area under the ROC curve (AUC) of the variables, P value and 95%CI were calculated.

RESULTS: In total, 33 patients were studied. In the ROC curve method analyses, EVLWIp (the AUC: 0.849; P = 0.001, 95%CI: 0.72-0.98) was as predictive for in-hospital survival rate as variables with EVLWIa (AUC, 0.829; P = 0.001, 95%CI: 0.68-0.98). The proportion of patients surviving with a low EVLW (EVLWI < 10 mL/kg) was better than that of patients with a higher EVLW, whether indexed by actual (HR = 0.2; P = 0.0002, 95%CI: 0.06-0.42) or predicted body weight (HR = 0.13; P < 0.0001, 95%CI: 0.05-0.35) during their hospital stay with the Kaplan-Meier method (76% vs 12.5%, respectively).

CONCLUSION: This investigation proposed that EVLWIp is as good a predictor as EVLWIa to predict in-hospital survival rate among severe sepsis patients in the medical ICU.

Paroxetine vs pregabalin for the management of neuropathic pain in multiple sclerosis

AIM: To compare the effectiveness and tolerability of paroxetine vs pregabalin for the management of multiple sclerosis (MS)-induced neuropathic pain (NPP).

METHODS: A randomized, flexible-dose open-label 8-wk study involving 21 relapsing-remitting MS patients with MS-induced NPP was conducted to evaluate the effectiveness and tolerability of pregabalin versus paroxetine for pain management. The trial included a 3-wk dose titration phase followed by a 5-wk stable dose phase. Primary outcome measures included daily patient-reported pain intensity as measured using a 100 mm visual analogue scale (VAS_pain) and daily impact of pain on daily activities (VAS_impact). Hierarchical regression modeling was conducted on each outcome to determine if within person VAS trajectory for pain and impact differed across study groups, during 56 d follow-up.

RESULTS: Attrition rates were significantly greater (P < 0.001) in the paroxetine versus pregabalin study group (70% vs 18.2%, respectively). Average study duration between study groups also significantly differed (P < 0.001). Paroxetine participants completed an average of 27.3 d of treatment vs 49.5 d in the pregabalin group, with the majority of patients withdrawing due to adverse events. Due to the high attrition rates in the paroxetine study arm, the investigators stopped the study prior to achieving complete recruitment. As such, no significant differences between pregabalin and paroxetine study arms were noted for the primary outcome measures (VAS_pain, VAS_impact). Comparative assessment of baseline patient characteristics also revealed no significant differences between the study arms.

CONCLUSION: High attrition rates associated with paroxetine use suggest that it be used with caution for MS-induced NPP. Efficacy outcomes could not be assessed due to attrition.

Anesthesia for bronchoscopic amniotic membrane grafting to treat non-healing bronchial dehiscence

Airway complications after lung transplantation remain a significant cause of morbidity and mortality. Many of these occur at the anastomotic sites, which are susceptible due to poor collateral circulation. Of the possible complications, bronchial dehiscence is particularly formidable. These cases have been successfully treated bronchoscopically with metallic stents, which likely promote healing through granulation tissue formation. However, limited options exist in cases where the dehiscence fails to heal following stent placement. Here, we present the case report of a 65-year-old male who developed bronchial dehiscence status post bilateral lung transplantation for idiopathic pulmonary fibrosis that failed to heal with simple stent placement. Eventually, the patient underwent amniotic membrane grafting with stenting as a novel therapy for non-healing bronchial dehiscence, for which we describe the anesthetic management. His anesthetic plan included inhalational induction with sevoflurane, propofol infusion for total intravenous anesthesia, rocuronium for muscle relaxation, and closed-circuit assisted ventilation. His existing tracheostomy was used as the airway for oxygenation and induction. In summary, our anesthetic plan for the lung transplant patient was effective; future amniotic membrane grafting for bronchial dehiscence through bronchoscopy may follow a similar technique. Ultimately, the choice of anesthesia in this patient population requires judicious consideration of the requirements of the procedure as well as the pathophysiology of the transplanted lung.

Unusual bronchoscopic value in percutaneous dilatational tracheostomy: A case report

BACKGROUND

The usage of bronchoscopy during percutaneous dilatational tracheostomy remains under debate. The proponents of bronchoscopy advocating safety of the procedure, whereas the critics raising the concerns about the cost, possible delay in the procedure, and waiting for the device.

CASE SUMMARY

We are highlighting a case of percutaneous dilatational tracheostomy where bronchoscopy aided in diagnosing a rare situation of wire entrapment within the endotracheal tube, treated by withdrawing the wire from the endotracheal tube with good outcome.

CONCLUSION

The bronchoscopy guided approach permitted early diagnosis and helped to end the procedure without complication or possible major surgery in a case of accidental wire puncture of the endotracheal tube.

Anesthetic management of patient with hypertrophic cardiomyopathy and automatic implantable cardioverter defibrillator with a hand fracture

A 26-year-old male with a history of hypertrophic cardiomyopathy (HCM) and ventricular arrhythmias s/p automatic implantable cardioverter defibrillator (AICD) placement presented for open reduction and internal fixation of an open third metacarpal fracture and extensor tendon repair. He underwent successful surgery after placement of an ultrasound-guided infraclavicular brachial plexus block with ropivacaine 0.5% as the main anesthetic. This case report discusses the anesthetic management of patients with HCM and AICD, different approaches available for brachial plexus blockade, and potential complications of anesthesia and surgery in this group of patients.

Translating the expression of pain in the face of uncertainty: The importance of human pain experiments for applied and clinical science

This brief commentary attempts to provide a concise synthesis of social psychology experiments that inform an interpretation of clinical pain. From a social perspective the expression of pain is a complex phenomenon that is greater than the patient’s physiology. Numerous experiments show that pain is modulated by social and contextual factors. These experiments point to the role of the listener as a social agent that can modulate the patient’s expression. Within the clinical setting the patient’s pain experience can be understood as the uncertainty of physical damage and their expression as an attempt to reduce that uncertainty. How successfully this occurs is in part dependent on the empathetic reception of the provider. Chronic pain is a state that is challenging to effectively model in humans but may persist in patients due to an inability to receive effective empathetic reception at the critical time of need (at or near onset). Rather than focusing on pain’s alleviation future avenues of pain interventions may do well by turning attention to the most effective ways to impart a message that the patient will be “okay” in a genuinely empathetic manner.

Review of essential understanding of ultrasound physics and equipment operation

Ultrasound (US) is being extensively used an imaging tool in regional anesthesia (RA) and pain practice. Although it was first used in a regional block in 1978, it was only in 1994 that the first direct use of US in RA was reported. Like any other medical tool, its utility is only realized when the performing physician is able to understand the principles behind its application. Efficient use of US also requires an understanding of physical variables which can be suitable modified to produce a clear image of the structure of importance. This brief narrative review summarises the advantages of US in RA and pain practice over the conventionally used localising or imaging tools. The second section deals with the physics behind US. It highlights the necessary physical concepts such as wavelength, frequency and generation of US waves. It also informs the reader about the possible US and tissue interactions, use of US transducers and their differences. The third section deals with understanding the control variables in a typical US machine and how they could be modified to improve the image quality. The final section highlights the various artifacts that could be associated.

Anaesthesia and pancreatic surgery: Techniques, clinical practice and pain management

Pancreatic cancer continues to pose a major public health concern. The incidence of the disease is nearly equivalent to the death rate associated with the diagnosis of pancreatic cancer. Thus, there exists a need for continued improvement in the diagnostic, therapeutic and palliative care of these patients. There have been significant advances made over the years in the areas of critical care, anesthesia, and surgical technique, which have led to improved mortality rates and survival after resection for pancreatic cancer. Resections are performed with the goals of negative margins and minimal blood loss and referral to high-volume centers and surgeons is encouraged. However, 5-year survival rate after curative resection still remains at less than 20%. Perioperative management of pancreatic and periampullary cancer poses a considerable challenge to the pancreatic surgeon, anesthesiologist and the intensive care team. Major morbidity is often secondary to pancreatic anastomotic leakage and fistula or infection. The anesthesiologist plays a crucial role in the perioperative management of such patients and in the pain control. Pancreatic ductal adenocarcinoma has a high rate of neural invasion (80%-100%) and can be associated with moderate to severe pain. In the recent past, new information has emerged on many issues including preoperative biliary drainage, nutritional support, cardiovascular assessment, perioperative fluid therapy and hemodynamic optimization. Careful patient selection and appropriate preoperative evaluation can greatly contribute to a favorable outcome after major pancreatic resections.

Bradycardia and hypotension during pediatric scoliosis surgery-hypovolemia or spinal shock?

We present the case of a 13-year-old boy undergoing scoliosis repair utilizing skull-femoral traction who developed sudden, sustained bradycardia and hypotension during scoliosis repair, associated with loss of somatosensory evoked potentials and motor evoked potentials to all four limbs. A diagnosis of spinal shock and hypovolemia was made after ruling out primary cardiac causes, sepsis, anaphylaxis and intra-spinal pedicle screw placement. Acute complications of surgical scoliosis repair are reviewed along with anatomy of the sympathetic nervous system. In this case spinal shock may have been due to hypovolemia as well as spinal cord manipulation during T12 vertebral column resection that was needed to effect scoliosis correction. Treatment included volume expansion and inotropic support. Anesthesiologists caring for these patients should be mindful of the possibility of spinal shock during correction of severe scoliosis, particularly when vertebral column resection is undertaken.