Erector spinae plane block for peri-operative analgesia in a patient undergoing surgery for Ewing's sarcoma of the clavicle

The erector spinae plane block is a regional anaesthetic technique originally developed to manage thoracic neuropathic pain. It is popular because of its ease of learning and its applicability in various types of surgeries, providing both cutaneous and visceral analgesia. We report a case of a 30-year-old man who underwent excision of Ewing's sarcoma of the clavicle with brachiocephalic vein repair and pectoralis major myocutaneous flap reconstruction under general anaesthesia, with bilateral erector spinae plane block, with catheter insertion on the side of the lesion. The operation necessitated peri-operative anticoagulation, and so erector spinae blocks were performed to provide analgesia where epidural insertion was contraindicated. Adequate pain relief was achieved during the entire postoperative stay. The erector spinae plane block is thought to work due to the direct spread and diffusion of local anaesthetic into the posterior rami of spinal nerves located deep to the erector spinae muscles, and anterior spread into paravertebral space with additional effect potentially due to systemic absorption This case highlights the role of the erector spinae plane block in complex clavicular surgery requiring peri-operative anticoagulation, and potentially obviates the need for neuraxial analgesia.

A Rare Case of Vincristine-Induced Neuropathy Presenting as Foot Drop in the Postoperative Period

Patients with cancer receiving chemotherapy are at risk of neuropathy development. Many of them may have subclinical neuropathies, which may be missed before planning anesthesia, especially in emergency scenarios. This case report highlights the importance of a thorough neurologic examination in patients with subclinical neuropathy to avoid any complications and medicolegal issues. A patient with a diagnosis of diffuse large B-cell lymphoma being treated with vincristine-based chemotherapy was scheduled for an emergency laparotomy. There was no history of any neurologic deficit before surgery. The surgery was done using general anesthesia, and intrathecal morphine was given for postoperative analgesia. This patient experienced bilateral foot drop postoperatively. A bilateral lower limb and upper limb sensory-motor neuropathy was detected on a nerve conduction study, probably due to vincristine-induced peripheral neuropathy. The literature is deficient regarding manifestations of neurologic complications in previously asymptomatic patients in the immediate postoperative period. These patients pose a diagnostic dilemma perioperatively that may lead to medicolegal challenges to the anesthesia provider. Anesthesia providers should be wary of the possibility of exacerbation of any subclinical neuropathy in patients with cancer receiving neurotoxic chemotherapy and should probably avoid any neuraxial intervention in such patients if possible.

A prospective randomized double blind study to evaluate the effect of infusion of amino Acid enriched solution on recovery from neuromuscular blockade

Hypothermia is a common occurrence under anaesthesia and may prolong the duration of action of neuromuscular blockade. By limiting fall in temperature, an infusion of amino acid enriched solution may speed the recovery from neuromuscular blockade. We studied 60 ASA Grade - I/II patients of aged between 20 to 60 years scheduled for elective surgery under general anaesthesia. The patients were randomly divided into four groups to receive amino acid infusion with vecuronium bromide AV, normal saline with vecuronium bromide(CV), amino acid with atracurium besylate(A-At) and normal saline with atracurium besylate(C-At). Although there was a significantly lesser decrease in the core temperature from the baseline in all the patients receiving amino acid infusion (p<0.05), it significantly reduced the time to 25% recovery from the time of injection of vecuronium only. (60.59 +/- 11.39 in CV vs 51 +/- 14.72 min in AV) (P < 0.05), and not for atracurium.

An Unusual Complication After Ganglion Impar Block for Chronic Cancer Pain Management

Patients with advanced pelvic malignancies present with pain of varying severity. Their pain can be effectively managed using a systemic pharmacologic approach, including oral administration of morphine. However, morphine can lead to constipation, which may be especially troublesome in patients with rectal carcinoma. Neurolytic blocks such as of the ganglion impar may alleviate sympathetically mediated pain and help in reducing opioid requirement. However, use of a ganglion impar block may rarely be associated with side effects such as rectal puncture, neuritis, and cauda equina syndrome. We report a rare neurologic complication after a fluoroscopic-guided ganglion impar block.

Myotonic dystrophy: an anaesthetic dilemma

Myotonic dystrophy (dystrophia myotonica, DM) is a chronic, slowly progressing, highly variable inherited multisystemic disease that can manifest at any age from birth to old age. We present a 32-year-old female with adenexal mass posted for exploratory laparotomy. She was a known case of dilated cardiomyopathy (DCMP).The ECG suggested incomplete RBBB & LAHB & the ECHO revealed mild mitral regurgitation, tricuspid regurgitation, pulmonary artery hypertension with severe left ventricular dysfunction (ejection fraction of 30-35%). General anaesthesia (GA) with epidural anaesthesia was planned. The patient was haemodynamically stable through out the surgical procedure. The patient was reversed and shifted to post anaesthesia care unit. On the 2nd postoperative day patient developed respiratory distress and hypotension. ABG revealed Type 1 respiratory failure. Since the patient didn't improve with oxygen therapy and nebulisation, she was intubated and shifted to ICU. Patient was tolerating the tube without sedation and relaxants so, consultant anaesthesiologist asked for neurologist referral to rule out myotonic dystrophy. Subsequent muscle biopsy and genetic analysis was suggestive of myotonic dystrophy. Despite all possible efforts we were unable to wean her off the ventilator for 390 days. Patients with myotonic dystrophy are a challenge to the attending anaesthesiologist. These patients can be very well managed with preoperative optimized medical treatment and well-planned perioperative care.

Cardiopulmonary Exercise Testing as a Predictor of Postoperative Outcome in Patients Undergoing Oesophageal Cancer Surgery Following Neoadjuvant Chemotherapy

OBJECTIVE

Neoadjuvant chemotherapy improves resectability rates of oesophageal cancer, but the process may also take a toll on the patients' exercise capacity and may adversely affect the postoperative outcomes. It can be assessed objectively using cardiopulmonary exercise testing.

METHODS

Patients with oesophagus cancer performed a baseline test and a second test after neoadjuvant chemotherapy during the week preceding oesophagectomy. They were followed up for postoperative complications, length of hospital stay, and 30-day mortality.

RESULTS

Thirty-three patients completed the study. The mean pre-chemotherapy peak oxygen uptake (VO2 peak) was 1128.39 ± 202.79 mL min-1 (19.46 ± 3.06 mL kg-1 min-1 ) which declined to 1010.33 ± 195.56 mL min-1 (17.24 ± 2.55 mL kg-1 min-1 ) in the postchemotherapy period (P < .001). Pre-chemotherapy anaerobic threshold was 906.85 ± 176.81 mL min-1 (15.54 ± 2.24 mL kg-1 min-1 ) which declined to 764.76 ± 158.79 mL min-1 (13.01 ± 2.22 mL kg-1 min-1 ) (P < .001) in the post-chemotherapy period. Six patients developed complications of modified Clavien-Dindo grade 3 and above. Two (6.1%) patients succumbed to complications within 30 days. The mean anaerobic threshold in patients who suffered complications modified Clavien-Dindo grade ≥3 was 693.33 ± 140.99 mL min-1 (11.2 ± 1.17 mL kg-1 min-1 ) while patients with mild to moderate complications had a mean anaerobic threshold 13.41 ± 2.21 mL kg-1 min-1 (P < .006). An optimal cut off value for anaerobic threshold was 12.5 mL kg-1 min-1 Conclusion: Cardiopulmonary exercise testing accurately predicts outcomes in cancer oesophagus patients who undergo neoadjuvant chemotherapy followed by surgery.

Assessment of Symptom Burden and Quality of Life in Patients With Primary Brain Tumours Attending Palliative Care in a Tertiary Cancer Care Centre

Background: Patients with primary brain tumors navigate a distinct illness trajectory, characterized by an uncertain prognosis, a rapid decline in physical functioning, and a significant deterioration in the quality of life. These unique challenges underscore the importance of our research in understanding and addressing the needs of these patients. Methods: The EORTC QLQ C30 & EORTC BN 20 questionnaires assessed the quality of life and symptom burden in patients with primary brain tumors. The scores were analyzed using SPSS statistical software. Results: 100 patients - 61 males and 39 females-were included with radiological or histopathological diagnoses of primary brain tumours. Seizures (38%) was the most common presenting symptom, followed by headache (18%), loss of consciousness (13%), focal neurological deficit (9%), and blurring of vision (8%). The mean quality of life at baseline was 78.29, with a standard deviation of 9.67 on a scale of 0 to 100, and the brain tumor-specific symptom burden score was 46.9, with a standard deviation of 17.95 on a scale of 0 to 100. There was a significant difference in the global health status score between the first and third visits at 3 months (P value = .03). Conclusion: Despite the aggressive and often incurable nature of primary brain tumors, there is hope in the form of palliative care. By addressing unmet symptoms, uncertainties about the future, and social functioning, palliative care can significantly improve the quality of life of these patients.

Quality of life and symptom burden in hematological cancer patients receiving hematopoietic stem cell transplantation: an observational study at Regional Cancer Centre, India

PURPOSE

Hematopoietic stem cell transplant (HSCT) is an intense form of treatment, resulting in major symptom burden but can prove curative. The quality of life (QOL) is a major endpoint for these patients as the survival rate in them has improved over time. The aim of the study is to assess the QOL and symptom burden of hematological malignancy patients at admission to hospital for HSCT, at 1 month and at 3 months following HSCT.

METHODS

This prospective observational study was done on hematological malignancy patients who were admitted for HSCT in a regional cancer center. The study subjects were assessed by the Functional Assessment of Cancer Therapy-Bone Marrow Transplant Scale (FACT-BMT Scale), Edmonton Symptom Assessment Scale-revised (r-ESAS), and Depression, Anxiety and Stress Scale-21 Items (DASS-21) at the time of hospital admission for transplantation, on day 30 (~ 1 month) and day100 (~ 3 months) of transplantation.

RESULTS

A total of 68 patients were included in this study. FACT-BMT scores have decreased from baseline (F0) to the first follow-up (F1) and then increased in the third follow-up (F2). The maximum r-ESAS mean score was for tiredness among all other symptoms at F0 as well as at F1 and at F2. The DASS 21 scores for depression, anxiety, and stress were maximum during F1 and minimum during F2.

CONCLUSION

Symptom burden is maximum during the first month of BMT, which improves later and QOL becomes improved with time.

Comparison of various video laryngoscopes for nasotracheal intubation in simulated difficult airway scenarios: a randomized self-controlled crossover trial

BACKGROUND

Nasotracheal intubation (NTI) is particularly challenging in patients with rigid neck or micrognathia. Advancements in video laryngoscopy may improve NTI outcomes. We compared performance of direct laryngoscope (DL), King Vision videolaryngoscope (KVL), and C-MAC videolaryngoscope (VL) in normal, rigid neck, and micrognathia airway.

METHODS

A randomized, self-controlled crossover trial was conducted with 20 anesthesiologists who performed NTI on a high-fidelity mannequin under three airway conditions. Device order was randomized using a computer-generated sequence, and outcome assessors were blinded to the sequence of devices used. Primary outcomes were time to glottic view and intubation. Secondary outcomes included ease of intubation and force on incisors.

RESULTS

The median difference (95%CI) in time to intubation suggested that CMAC was better than KVL in normal airway (-9.0[-13.0 to-6.0], p < 0.001), rigid neck (-12.0[-18.0 to -6.5], p < 0.001) and micrognathia (-16.5[-20.0 to -13.5], p < 0.001). When compared to DL, CMAC was better for micrognathia (-8.0[-5.5 to-10.5], p = 0.001) but comparable for normal airway and rigid neck. C-MAC also exerted the least force on incisors, minimizing dental trauma.

CONCLUSION

The C-MAC VL demonstrated superior performance across all airway conditions, offering faster, safer, and easier NTI, making it the preferred device in challenging scenarios.

TRIAL REGISTRATION

Clinical Trial Registry of India: (CTRI/2022/05/042821) www.ctri.nic.in.

Tube migration during laparoscopic gynecological surgery

BACKGROUND

The positioning (trendelenburg) and pneumoperitoneum during laparoscopic gynecological surgeries may cause cephalad movement of diaphragm and subsequent endobronchial intubation. PATIENTS #ENTITYSTARTX00026;

METHODS

50 ASA I/II patients posted for laparoscopic ligation were included in the study. Standardized anaesthesia technique was employed in all the patients. The distance of endotracheal tube to carina was measured in supine position, trendelenberg position, 5 min and 25 minutes post pneumoperitoneum and after deflation of pneumo-peritoneum.

RESULTS

The mean distance from the tip of the ETT to the carina was 3.41± 1.3 cm, 2.96 ± 1.4, 2.0 ± 1.5 and 1.7 ± 1.6 in supine position, trendelenburg position and 5min and 25 min post pneumoperitoneum. (P<0.01) Following deflation the carina moved back to its position to some extent and was 2.5 ± 1.5 from the tip of endotracheal tube.( P< 0.05)

CONCLUSION

We conclude that pneumoperitoneum and trendelenburg position during laparoscopic surgeries may lead to cephalad migration of carina.