Correlation of pain perception and fentanyl consumption after major abdominal surgery with CGRP 4218T/C polymorphism: A prospective interventional study

Background and Aims

Genetic polymorphisms contribute to patients' variability in pain perception and response to opioid treatment. The present study evaluated the association of calcitonin gene-related peptide (CGRP) 4218T/C polymorphisms with fentanyl consumption over 24 h postoperatively in patients after major abdominal surgery.

Methods

Eighty-five patients undergoing major abdominal surgery under general anaesthesia were recruited. For postoperative analgesia, epidural fentanyl and intravenous paracetamol were provided. The CGRP 4218T/C genotype was analysed, and the association between the genotype of the patient and the total consumption of fentanyl in the first 24 h after surgery was assessed. The association between different genotypes, the severity of postoperative pain and the side effects of opioids were also studied.

Results

Our study population distribution included 52.9% of the T/T genotype (wild homozygote), 35.3% of the T/C genotype (heterozygote) and 11.8% of the C/C genotype (mutant homozygote). Mean (standard deviation) total fentanyl consumption in the first 24 h was found to be highest in the C/C group (212.0 [7.5] μg), followed by the T/T group (182.8 [9.9] μg) and was the least in the T/C group (159.6 [7.5] μg). The C/C group reported higher pain scores in all the study periods. There was no significant difference in the side effects of opioids, such as nausea, vomiting, sedation among different genotypes of CGRP 4218T/C.

Conclusion

The polymorphism of CGRP 4218T/C affects postoperative pain perception and analgesic consumption. Patients with the C/C genotype had higher postoperative fentanyl consumption and pain scores.

Phase 2 randomised placebo-controlled trial of spironolactone and dexamethasone versus dexamethasone in COVID-19 hospitalised patients in Delhi

BACKGROUND

In this phase 2 randomised placebo-controlled clinical trial in patients with COVID-19, we hypothesised that blocking mineralocorticoid receptors using a combination of dexamethasone to suppress cortisol secretion and spironolactone is safe and may reduce illness severity.

METHODS

Hospitalised patients with confirmed COVID-19 were randomly allocated to low dose oral spironolactone (50 mg day 1, then 25 mg once daily for 21 days) or standard of care in a 2:1 ratio. Both groups received dexamethasone 6 mg daily for 10 days. Group allocation was blinded to the patient and research team. Primary outcomes were time to recovery, defined as the number of days until patients achieved WHO Ordinal Scale (OS) category ≤ 3, and the effect of spironolactone on aldosterone, D-dimer, angiotensin II and Von Willebrand Factor (VWF).

RESULTS

One hundred twenty patients with PCR confirmed COVID were recruited in Delhi from 01 February to 30 April 2021. 74 were randomly assigned to spironolactone and dexamethasone (SpiroDex), and 46 to dexamethasone alone (Dex). There was no significant difference in the time to recovery between SpiroDex and Dex groups (SpiroDex median 4.5 days, Dex median 5.5 days, p = 0.055). SpiroDex patients had significantly lower D-dimer levels on days 4 and 7 (day 7 mean D-dimer: SpiroDex 1.15 µg/mL, Dex 3.15 µg/mL, p = 0.0004) and aldosterone at day 7 (SpiroDex 6.8 ng/dL, Dex 14.52 ng/dL, p = 0.0075). There was no difference in VWF or angiotensin II levels between groups. For secondary outcomes, SpiroDex patients had a significantly greater number of oxygen free days and reached oxygen freedom sooner than the Dex group. Cough scores were no different during the acute illness, however the SpiroDex group had lower scores at day 28. There was no difference in corticosteroid levels between groups. There was no increase in adverse events in patients receiving SpiroDex.

CONCLUSION

Low dose oral spironolactone in addition to dexamethasone was safe and reduced D-dimer and aldosterone. Time to recovery was not significantly reduced. Phase 3 randomised controlled trials with spironolactone and dexamethasone should be considered.

TRIAL REGISTRATION

The trial was registered on the Clinical Trials Registry of India TRI: CTRI/2021/03/031721, reference: REF/2021/03/041472. Registered on 04/03/2021.

Refractory hypertension after phenylephrine infusion in cesarean section under subarachnoid block

A 21-year-old female was scheduled to undergo elective cesarean section for breech presentation under the subarachnoid block (SAB). The pre-operative examination was unremarkable and baseline vitals were normal. Under all aseptic precautions and American society of anesthesiologists standard monitoring, SAB was administered with 2.2 ml of 0.5% hyperbaric bupivacaine. Soon after administration of SAB, prophylactic infusion of phenylephrine was started at the rate of 50 μg/min; after pre-treatment with 0.2 mg glycopyrrolate intravenous immediately after the start of the infusion, the patient complained of severe headache. Blood pressure (BP) recorded at that time was 191/102 mm of Hg. Phenylephrine infusion was stopped immediately but the BP remained high and came to within 20% of baseline value only after 9 min of discontinuing the infusion. We report this case of refractory hypertension following phenylephrine infusion in a healthy parturient undergoing elective cesarean section under SAB.

Comparison of oropharyngeal leak pressure of LMA Protector and LMA-ProSeal in different head and neck positions in anaesthetized and paralyzed patients; A prospective randomized study

Background and Aims

Oropharyngeal leak pressure (OLP) of LMA Protector is reported to be higher compared to other second generation supraglottic devices (SGDs) indicating better seal with patient's airway and hence enhanced safety. To ascertain its benefit in patients undergoing surgeries where head and neck position other than neutral is required, we conducted a prospective randomized study to compare OLP of LMA Protector with LMA-ProSeal (PLMA) with head and neck in neutral, extension, flexion, and rotation position.

Methods

80 American Society of Anesthesiologists (ASA) I-II patients aged more than 18 years undergoing elective surgery under general anaesthesia were recruited. Patients were randomized in the LMA Protector or PLMA group. After induction of anaesthesia, OLP was measured in both the groups in different head and neck position. The insertion characteristics of both SGDs were also recorded and compared.

Results

The OLP of LMA Protector and PLMA was found to be comparable in neutral head position (p = 0.08). There was no significant difference in OLP of both devices in extension, flexion, or head rotation. In both the study groups, head extension position led to significant decrease in OLP compared to supine position. With the flexion and rotation positioning of head and neck, significant increase in OLP in each group was noted.

Conclusion

The OLP of LMA Protector and PLMA are comparable in different head and neck position. With both the devices, there was significant decrease in OLP with extension whereas significant increase was noted in flexion and rotation of head and neck.

Role of power distance phenomena in blended learning in higher education post-Covid-19

COVID has posed several challenges for higher education. There is a rise in blended teaching and learning models that can improve the quality of education, observed Raman. Classroom interaction vital in quality of education is affected by power distance between the teacher and students, states Kasuya. Much research has been done on blended learning but hardly any on the role of power distance in blended learning in higher education, specifically post COVID. Keeping in mind the growing significance of blended learning shortly, it becomes strategically important to understand the role of power distance in blended learning in higher education post-COVID-19. This research paper tries to address the research gap. The study is exploratory, exploring the role of power distancing in blended learning formats during post-COVID-19. The findings indicate that there is a relationship between power distance and the autonomy of an individual. The higher the power distance between a teacher and a student from the teacher’s perspective, it becomes teacher-centred learning. So blended learning with the best of low power distances in terms of the media and delivery mechanism of offline and online ensures the mitigation of power between the teacher and the taught. The research will help the universities create a perfect blended learning format that enhances the quality of higher education. Due to the paucity of time and resources and a ban on respondent interaction due to pandemics, this research is based on secondary data analysis.

Comparison of cuff inflation method with curvature control modification in thermosoftened endotracheal tubes during nasotracheal intubation - A prospective randomised controlled study

Background and Aims:

Thermosoftening of endotracheal tube (ETT) is a simple method which reduces risk of epistaxis during nasotracheal intubation (NTI). This method, however, decreases the stiffness of ETT and necessitates frequent manipulation with Magill forceps. Cuff inflation technique has been found effective for navigating ETTs during NTI. Another method is using an ETT, modified with a silk thread which can be used to control its curvature. We conducted the present study to compare the ease of navigation of thermosoftened ETT using curvature control modificationwiththe cuff inflation technique.

Methods:

Depending on the method used for navigating thermosoftened ETT to glottis, 70 patients undergoing general anaesthesia with NTI were randomly divided into two groups. The primary outcome was ease of navigation of thermosoftened ETT. Secondary outcomes were time taken for moving tube from oropharynx to glottis and incidence of epistaxis during NTI.

Results:

Both techniques resulted in successful navigation of thermosoftened ETT in all patients with majority of cases resulting in smooth engagement to glottic inlet. The difference in ease of navigation between the groups was 7% [95% CI (−9.21% to 23.28%)] and it was not found to be statistically significant (P = 0.395). Cuff inflation method resulted in faster alignment to glottis compared to use of modified tube (12. 39 ± 7 Vs 18.73 ± 11.5 sec; P = 0.003).

Conclusion:

For thermosoftened ETT, both cuff inflation method and the technique of curvature controlled modified ETT can be used for navigation of tube to glottis with ease.

Comparative study of recovery of airway reflexes and cognitive function following sevoflurane versus desflurane anaesthesia

Background and Aims

Sevoflurane and desflurane have almost similar blood-gas solubility but recent studies suggest that desflurane compared to sevoflurane leads to faster recovery of airway reflexes, but the recovery of cognitive function varies significantly. We conducted this study to compare the times of recovery from anaesthesia following desflurane versus sevoflurane anaesthesia.

Methods

This randomised double-blinded study was conducted on 60 patients of American Society of Anesthesiologists (ASA) classification I-II, age between 18 and 60 years with body mass index (BMI) ≤30 kg/m² who underwent elective cholecystectomy. A standard general anaesthesia protocol was followed with either sevoflurane (group A = 30 patients) or desflurane (group B = 30 patients) along with bispectral index and neuromuscular monitoring. Following extubation, tests for recovery of airway reflexes and cognitive function were conducted and various time intervals were noted. Statistical analysis was carried out using Statistical Package for Social Sciences (SPSS) standard software version 17.

Results

The mean time from first verbal response to first passing the swallowing test was comparable in both the groups (5.50 ± 3.45 vs. 4.10 ± 3.42 min, P value = 0.120). Patients receiving desflurane showed faster response to verbal commands (5.93 ± 4.13 vs. 8.20 ± 3.39 min, P value = 0.024), passed the swallowing test earlier (10.03 ± 4.97 vs. 13.70 ± 3.48 min, P value = 0.009) and Short orientation memory concentration test (SOMCT) earlier (9.83 ± 4.51 vs. 14.10 ± 4.31 min, P value ≤0.001) compared to sevoflurane.

Conclusion

In patients undergoing laparoscopic cholecystectomy under controlled conditions, earlier recovery is seen with desflurane compared to sevoflurane.

Anaesthetic Management of Non Traumatic Diaphragmatic Hernia as a Co-existing Disease: Combined Spinal Epidural to Rescue

Diaphragmatic hernia is a congenital or acquired defect in diaphragm, resulting in herniation of abdominal viscera into thoracic cavity. Acquired diaphragmatic hernia are seen mostly in patients with blunt or penetrating abdominal injuries. Nontraumatic acquired diaphragmatic hernias have been reported in literature but are extremely rare. Anaesthetic management of a patient presenting with nontraumatic diaphragmatic hernia as a co-existing disease offer unique challenges and considerations. This report was about the successful anaesthetic management of a 66-years-old male. He had Osteoarthritis (OA) of left knee with long standing massive right diaphragmatic hernia as a co-existing disease. He was scheduled for left Total Knee Replacement (TKR). Combined Spinal Epidural (CSE) with low dose Subarachnoid Block (SAB) was the anaesthetic technique of choice. Femoral sciatic block is an alternate technique of anaesthesia for such patients.

Intravenous Clonidine versus Intraperitoneal Clonidine for Postoperative Analgesia After Total Abdominal Hysterectomy: A Randomised Controlled Trial

Objective

This prospective randomised double-blind study was conducted to compare the effect of intravenous (IV) with intraperitoneal (IP) administration of clonidine with respect to analgesic efficacy and side effects.

Methods

A total of 60 American Society of Anaesthesiologists (ASA) physical status class I and II patients, aged 35–60 years, undergoing total abdominal hysterectomy, were randomly divided into 2 groups. Standard general anaesthesia technique was used. All the patients in group IV received 3 μg kg⁻¹ of IV clonidine after resection of the uterus along with 0.25% bupivacaine (20 mL intraperitoneally and 10 mL as wound infiltration), whereas patients in group IP received 10 mL of normal saline intravenously and 3 μg kg⁻¹ of clonidine mixed with 0.25% bupivacaine (20 mL intraperitoneally and 10 mL as wound infiltration). Postoperative analgesia was provided with IV diclofenac every 8 hours and IV fentanyl (1 μg kg⁻¹) on demand. Pain at rest, opioid consumption, level of sedation and severity of nausea were recorded for 24 hours. The heart rate (HR) and blood pressure (BP) were recorded at an interval of 15 minutes for 2 hours followed by routine hourly monitoring.

Results

Both the groups were found to be similar with respect to demography and ASA physical status. The maximum pain was felt at 6 hours in both the groups. The mean visual analogue scale score at 6 hours (p=0.47) was comparable. However, patients in group IV had significantly higher sedation (p<0.001) and nausea (p=0.013) scores on arrival at post-anaesthesia care unit along with a significant reduction in HR (p=0.001) and BP (p=0001) for the first 2 hours postoperatively.

Conclusion

Although IP clonidine is comparable with IV clonidine with respect to postoperative pain scores and supplementary opioid requirement, the side effects are significantly less with IP clonidine.

Preventing inadvertent Endobronchial intubation: Upper incisor to manubriosternal joint length as a predictor of airway length in children

BACKGROUND

Malpositioning of the endotracheal tube within the airway can lead to serious complications. The estimated insertion depth of the endotracheal tube should be accurate and reliable.

AIMS AND OBJECTIVES

To study whether the upper incisor-manubriosternal joint length in the extended head position can be used as a predictor of airway length to guide the depth of insertion of endotracheal tube in children and to evaluate the correlation of upper incisor-manubriosternal joint length with the upper incisor-carina length in the neutral head position, in Indian pediatric population.

MATERIALS AND METHODS

After induction of anesthesia, upper incisor-manubriosternal joint length was measured using a flexible metallic tape. Endotracheal tube was inserted and secured in the midline over the upper incisors. The degree of the maximum head extension was recorded with a goniometer, and the upper incisor-carina length was measured with the help of a fiberoptic bronchoscope.

RESULTS

Analysis revealed a positive correlation between upper incisor-carina length and upper incisor-manubriosternal joint length (R = .456, R²  = .208, P = .000) and also between upper incisor-carina length and the height of the patient (R = .528, R²  = .279, P-value .000). The degree of maximum head extension did not influence the upper incisor-carina length and the upper incisor-manubriosternal joint length relationship.

CONCLUSION

The upper incisor-carina length shows a positive correlation with the patient's upper incisor-manubriosternal joint length and the patient's standing height, while the degree of maximum head extension has no significant bearing on this relationship. The upper incisor-manubriosternal joint length can be used as a predictor of airway length and the depth of insertion of endotracheal tube in children.

Preoperative pregnancy testing in surgical patients: How useful is policy of routine testing

Surgery in a patient with unrecognised pregnancy has serious ethical and medicolegal implications. There are no guidelines in India for preoperative pregnancy testing (POPT) in surgical patients. This review was undertaken to ascertain utility of routine POPT and whether any specific indication for POPT could be suggested. We performed a literature search to identify publications pertaining to POPT in surgical patients. Searches included PubMed, Google Scholar and internet search for national guidelines. Studies pertaining to incidence of unrecognised pregnancy, cost-effectiveness of POPT, effect of surgery and anaesthesia on pregnancy are included. We excluded articles which were available in languages other than English and those whose full texts were unavailable. Most of the literature about reproductive outcomes after anaesthesia exposure is based on old data. The evidence for teratogenic effect of anaesthetic drugs on human foetus is still inconclusive. Apart from anaesthesia and surgery, the outcome after surgery in unrecognised pregnant patient depends on other factors such as indication for surgery, high incidence of foetal loss in early pregnancy, stress and lifestyle of patient. As it is difficult to unsnarl the effect of these factors, POPT should be offered to all patients who based on history could be possibly pregnant. The cost-effectiveness of POPT appears doubtful, but considering costs associated with miscarriages and medicolegal litigations due to unclear association with anaesthesia, it may indeed be cost-effective.

Regional Anaesthesia for the Neonate

Numerous regional and local anaesthesia techniques are available for safe use in neonates and can be administered either in combination with general anesthesia or in the awake neonate. Regional anaesthesia provides effective analgesia with reduced drug requirement which is especially beneficial in view of the immature physiology and metabolism in the neonate. The reduced requirement of anaesthetic drugs facilitates stable hemodynamics, faster recovery and a decreased length of stay in the neonatal intensive care unit.