Effect of glycopyrrolate on vasopressor requirements for non-elective cesarean section under spinal anesthesia: a randomized, double-blind, placebo-controlled trial

Background

The study aimed to investigate whether prophylactic use of glycopyrrolate decreases the vasopressor requirements to prevent hypotension following spinal anesthesia during non-elective cesarean section.

Method

In this double-blind randomized clinical trial, 258 patients undergoing non-elective cesarean section were randomly assigned (1:1) to receive intravenous 0.2 mg glycopyrrolate or normal saline (placebo) before spinal anesthesia. The primary outcome was phenylephrine equivalent needed intraoperatively. Secondary outcomes included incidences of maternal hypotension, reactive hypertension, bradycardia, need for atropine, tachycardia, intraoperative nausea/vomiting, shivering, pruritus, dry mouth, dizziness; neonatal APGAR score at 1 min and 5 min, neonatal resuscitation needed, NICU admission and neonatal death.

Results

Three patients withdrew from the study due to failed spinal anesthesia. 128 patients in the glycopyrrolate group and 127 patients in the placebo group were analyzed. The mean phenylephrine equivalent needed was 1108.96 μg in the glycopyrrolate group and 1103.64 μg in the placebo group (mean difference, 5.32 μg [95% CI − 67.97 to 78.62]; P = 0.88). Hypotension occurred in 38 patients (30%) in the glycopyrrolate group as compared with 49 patients (39%) in the placebo group (P = 0.13). Tachycardia was reported in 70% of the participants in the glycopyrrolate group and 57% of those in the placebo group (P = 0.04). No statistically significant difference was noted in hypotensive episodes > 1, reactive hypertension, bradycardia, need for atropine, nausea, vomiting, shivering, and dry mouth between the two groups. Neonatal outcomes were similar in the two groups.

Conclusion

Prophylactic use of glycopyrrolate does not decrease the requirements of vasopressor to prevent hypotension in non-elective cesarean section under spinal anesthesia.

Trial registration

Registration number: NCT04401345. Date of registration: 26/05/2020. Website: https://clinicaltrials.gov

Association of preoperative pain catastrophizing with postoperative pain after lower limb trauma surgery

OBJECTIVES

To evaluate an association between preoperative Nepali pain catastrophizing scale (N-PCS) scores and postoperative pain intensity and total opioid consumption.

METHODS

In this prospective cohort study we enrolled 135 patients with an American Society of Anaesthesiologists physical status I or II, aged between 18 and 65 years, and scheduled for surgery for lower-extremity fracture under spinal anaesthesia. Maximum postoperative pain reported during the 24 h was classified into two groups, no-mild pain group (Numeric rating scale [NRS] scores 1-3) and a moderate-severe pain group (NRS 4-10). The Pearson's correlation coefficient was used to compare the association between the baseline N-PCS scores and outcome variables, i.e., the maximum NRS pain score and the total tramadol consumption within the first 24 h after surgery. Logistic regression models were used to identify the predictors for the intensity of postoperative pain.

RESULTS

As four patients violated the protocol, the data of 131 patients were analyzed. Mean N-PCS scores reported by the moderate-severe pain group was 27.39 ± 9.50 compared to 18.64 ± 10 mean N-PCS scores by the no-mild pain group (p < 0.001). Preoperative PCS scores correlated positively with postoperative pain intensity (r = 0.43, [95% CI 0.28-0.56], p < 0.001) and total tramadol consumption (r = 0.36, [95% CI 0.20-0.50], p < 0.001). Preoperative pain catastrophizing was associated with postoperative moderate-severe pain (odds ratio, 1.08 [95% confidence interval, 1.02-1.15], p = 0.006) after adjusting for gender, ethnicity and preoperative anxiety.

CONCLUSION

Patients who reported higher pain catastrophizing preoperatively were at increased risk of experiencing moderate-severe postoperative pain.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov Identifier: NCT03758560.

Analysis of Prognostic Factors of Bell's Palsy in a Tertiary Care Centre of Eastern Nepal

Background Bell's palsy is the most common cause of acute facial peripheral neuropathy commonly encountered in otolaryngology clinics. Studies regarding epidemiology, risk factors, treatment and prognosis of Bell's palsy are sparse in our settings. Objective To analyze the prognostic factors of Bell's palsy in tertiary care Centre of eastern Nepal. Method A retrospective chart review of patients diagnosed with Bell's palsy from 1st January 2005 to 31st December 2018 was done. Records of the patients were obtained from medical record section of BP Koirala Institute of Health Sciences. Result A Total of 208 patients were included for analysis. After six months 72.6% patients had complete recovery. Patients who presented with lower House Brackmann (HB) grade had significantly better complete recovery than those with high grade (89.1% vs 45.6%). The complete recovery was 80.3%, 73.8%, 63.5% and 50% for the patients of more than 30 yrs, 31-45 years, 46-60 years and more than 60 years respectively and the difference was significant (p= 0.012). Alcohol significantly reduced the complete recovery (p= 0.043). Multivariate analysis showed high HB grade score at presentation to be significant predictor of poor prognosis. (p= 0.001 odds ratio 11.262). Conclusion Old age, use of alcohol and the severity of facial nerve palsy at the time of presentation were the bad prognostic factors, severity of the palsy was found to be most significant predictor.

Analgesic effects of intravenous ketamine after spinal anaesthesia for non-elective caesarean delivery: a randomised controlled trial

OBJECTIVES

This study aimed to determine if low dose intravenous ketamine is effective in reducing opioid use and pain after non-elective caesarean delivery.

DESIGN

Prospective, randomised, double-blind.

SETTING

Tertiary hospital, Bisheshwar Prasad Koirala Institute of Health Sciences, Dharan, Nepal PARTICIPANTS: 80 patients undergoing non-elective caesarean section with spinal anaesthesia.

INTERVENTIONS

Patients were allocated in 1:1 ratio to receive either intravenous ketamine 0.25 mg/kg or normal saline before the skin incision.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the total amount of morphine equivalents needed up to postoperative 24 hours. Secondary outcome measures were postoperative pain scores, time to the first perception of pain, maternal adverse effects (nausea, vomiting, hypotension, shivering, diplopia, nystagmus, hallucination) and neonatal Apgar score at 1 and 5 min, neonatal respiratory depression and neonatal intensive-care referral.

RESULTS

The median (range) cumulative morphine consumption during the first 24 hours of surgery was 0 (0-4.67) mg in ketamine group and 1 (0-6) mg in saline group (p=0.003). The median (range) time to the first perception of pain was 6 (1-12) hours and 2 (0.5-6) hours in ketamine and saline group, respectively (p<0.001). A significant reduction in postoperative pain scores was observed only at 2 hours and 6 hours in the ketamine group compared with placebo group (p<0.05). Maternal adverse effects and neonatal outcomes were comparable between the two groups.

CONCLUSIONS

Intravenous administration of low dose ketamine before surgical incision significantly reduced the opioid requirement in the first 24 hours in patients undergoing non-elective caesarean delivery.

TRIAL REGISTRATION NUMBER

NCT03450499.

The effect of intraoperative lidocaine infusion on opioid consumption and pain after totally extraperitoneal laparoscopic inguinal hernioplasty: a randomized controlled trial

BACKGROUND

As a component of multimodal analgesia, the administration of systemic lidocaine is a well-known technique. We aimed to evaluate the efficacy of lidocaine infusion on postoperative pain-related outcomes in patients undergoing totally extraperitoneal (TEP) laparoscopies inguinal hernioplasty.

METHODS

In this randomized controlled double-blind study, we recruited 64 patients to receive either lidocaine 2% (intravenous bolus 1.5 mg. kg ^- 1 followed by an infusion of 2 mg. kg^- 1. h^- 1), or an equal volume of normal saline. The infusion was initiated just before the induction of anesthesia and discontinued after tracheal extubation. The primary outcome of the study was postoperative morphine equivalent consumption up to 24 h after surgery. Secondary outcomes included postoperative pain scores, nausea/vomiting (PONV), sedation, quality of recovery (scores based on QoR-40 questionnaire), patient satisfaction, and the incidence of chronic pain.

RESULTS

The median (IQR) cumulative postoperative morphine equivalent consumption in the first 24 h was 0 (0-1) mg in the lidocaine group and 4 [1-8] mg in the saline group (p < 0.001). Postoperative pain intensity at rest and during movement at various time points in the first 24 h were significantly lower in the lidocaine group compared with the saline group (p < 0.05). Fewer patients reported PONV in the lidocaine group than in the saline group (p < 0.05). Median QoR scores at 24 h after surgery were significantly better in the lidocaine group (194 (194-196) than saline group 184 (183-186) (p < 0.001). Patients receiving lidocaine were more satisfied with postoperative analgesia than those receiving saline (p = 0.02). No difference was detected in terms of postoperative sedation and chronic pain after surgery.

CONCLUSIONS

Intraoperative lidocaine infusion for laparoscopic TEP inguinal hernioplasty reduces opioid consumption, pain intensity, PONV and improves the quality of recovery and patient satisfaction.

TRIAL REGISTRATION

ClinicalTrials.gov- NCT02601651. Date of registration: November 10, 2015.

Postoperative Visual Loss Following Spine Surgery: A Case Report

Postoperative visual loss is a rare but devastating complication of non-ophthalmic surgery. Its aetiology is poorly understood and multiple associated factors have been proposed. We present a report of a 33-year-old female who developed irreversible diminution of vision on the right eye (non-arteritic-posterior-ischemic-optic-neuropathy) following general anaesthesia for pedicle screw fixation and plating for fracture vertebrae and hip in prone position and then screw placement for fracture calcaneum in supine position. The vision loss, limited to finger count close to face on the right eye, did not improve till follow-up at one-year. The combination of mild intraoperative hypotension, anaemia, prone positioning, prolonged surgery and anaesthesia may have contributed to postoperative visual loss in our patient.

Bacteriological Evaluation of Tonsillar Surface and Tonsillar Core Micro Flora in Patients Undergoing Tonsillectomy

Background: Acute tonsillitis is the most common disease for the ENT surgeons. Effective treatment of the tonsillitis depends on knowledge of the infecting organism but there is always a dilemma whether the antibiotics prescribed for the tonsillitis is sufficient for the different organisms in the surface and core of the tonsils.Objective: To study the microorganism on the surface and in the core of the tonsil among the patients undergoing tonsillectomy and to correlate clinical profile of the patients with various microorganisms isolated.Methods: This was a cross sectional study conducted on fifty patients’ age ranging from 3 years to 45 years. The swabs obtained from the surface of the tonsil prior to tonsillectomy and core of the tonsil post tonsillectomy were sent for isolation of micro organism and microbial susceptibility technique by standard microbial method.Results: The common age group for tonsillitis was below 15 years (n= 26) and having male predominance and more common in patients from hilly region. The commonest indication for tonsillectomy was recurrent tonsillitis (n=47). There was 82% similarity in microorganisms isolated from the surface and core of the culture. Conclusion: This study highlights that the culture from the surface of the tonsil reflects the organism in the core. Staphylococcus aureus was the commonest isolated organism in the surface and core of the tonsil.Health Renaissance 2014;12(3): 149-153

Foreign body stone in oesophagus: a unique case

Foreign body ingestion is a common occurrence in children and in specific high-risk  groups. It is usually diagnosed based on a history of ingestion given by the patient  or an observer. However, children and mentally retarded adults may be unable to  give an accurate history, and a high index of suspicion must be maintained in these  groups. We report a rare case of foreign body stone in an mentally retarded adult  which presented with drooling and impaired feeds, thence enabling for high index  for suspicion.  Health Renaissance 2014;12(2): pp: 140-142

Large versus Small Dose Magnesium Sulfate Infusion in Tetanus

Introduction: Evidence based guidelines regarding the use of magnesium sulfate in tetanus is lacking. Hence, our objective was to compare two infusion doses of magnesium sulfate to control the tetanic spasms. Methods: Data of 14 adult male patients admitted in the intensive care unit were retrieved. Twelve adult ventilated patients received magnesium infusion as an adjunct to diazepam therapy to control tetanic spasms. We retrospectively divided them into two groups for comparison. Group 1 patients (n=7) received a smaller dose (<1 g.h-1) than group 2 (n=5) (1.5 to 2 g.h-1). Results: The duration of symptoms before arrival to hospital was significantly longer in group 1 than group 2. The Ablett severity grade was II in three patients in group 1 and III in all patients of group 2. In Ablett severity grade III patients, the diazepam dose used was significantly higher in group 1 (n=4) (292±48 mg.d-1) than group 2 (n=3) (106±9 mg.d-1) as magnesium infusion dose was restricted due to hypotension in group 1. Amongst the patients who received MgSO4 for ≥10 days, the requirement of diazepam was significantly reduced in the second week (174.1±59.2 mg/d) than the first week (325.4±105.9 mg.d-1) of infusion in group 2 (n=4) but not in group 1 patients (n=4). Conclusions: The larger dose of MgSO4 infusion was titrated to control tetanic spasms as an adjunct to diazepam in select group of patients without hypotension. Uncontrolled hypotension, cardiac arrhythmia and renal failure were the factors to limit its infusion dose.Keywords: MgSO4; magnesium sulphate; tetanus.

Large versus Small Dose Magnesium Sulfate Infusion in Tetanus

INTRODUCTION

Evidence based guidelines regarding the use of magnesium sulfate in tetanus is lacking. Hence, our objective was to compare two infusion doses of magnesium sulfate to control the tetanic spasms.

METHODS

Data of 14 adult male patients admitted in the intensive care unit were retrieved. Twelve adult ventilated patients received magnesium infusion as an adjunct to diazepam therapy to control tetanic spasms. We retrospectively divided them into two groups for comparison. Group 1 patients (n=7) received a smaller dose (<1 g.h(-1)) than group 2 (n=5) (1.5 to 2 g.h(-1)).

RESULTS

The duration of symptoms before arrival to hospital was significantly longer in group 1 than group 2. The Ablett severity grade was II in three patients in group 1 and III in all patients of group 2. In Ablett severity grade III patients, the diazepam dose used was significantly higher in group 1 (n=4) (292±48 mg.d(-1)) than group 2 (n=3) (106±9 mg.d(-1)) as magnesium infusion dose was restricted due to hypotension in group 1. Amongst the patients who received MgSO(4) for ≥10 days, the requirement of diazepam was significantly reduced in the second week (174.1±59.2 mg/d) than the first week (325.4±105.9 mg.d(-1)) of infusion in group 2 (n=4) but not in group 1 patients (n=4).

CONCLUSIONS

The larger dose of MgSO(4) infusion was titrated to control tetanic spasms as an adjunct to diazepam in select group of patients without hypotension. Uncontrolled hypotension, cardiac arrhythmia and renal failure were the factors to limit its infusion dose.

A single blind controlled study comparing bipolar elecrocautery tonsillectomy to cold dissection method in pediatric age groups

Background: Tonsillectomy is one of the most commonly performed operations in otolaryngology. There are many proven methods of tonsillectomy, including cold dissection and bipolar electrocautery. Objective: To compare bipolar elecrocautery tonsillectomy with cold dissection method in pediatric age groups. Methods: Single blind controlled study to compare bipolar technique against the conventional dissection/snare technique. Results: The average amount of bleeding on electrocautery side was 4.07ml and on the cold dissection side was 14.58 ml. The mean time of operation for electrocautery and cold dissection was 12.04 and 16.57 minutes respectively. On the second post operative day, 35% of the patients complained of pain on the cauterized side, 30% complained of more pain on the dissection side while 35 % experienced equal pain on both sides. Post-operative complication such as hemorrhage was not seen in both the techniques employed. Conclusion: In the present study, bipolar diathermy tonsillectomy had advantages in having less post-operative time and blood loss intraoperatively but patients experience slightly more pain than cold dissection. DOI: http://dx.doi.org/10.3126/hren.v11i3.9651 Health Renaissance 2013;11(3):270-272

Ganglioneuroma of small bowel mesentery presenting as acute abdomen

Ganglioneuroma is a rare benign tumor, usually seen in children and young adults, arising in the central nervous system. Ganglioneuroma of the mesentery is extremely rare; only one case has been recorded. We report the second case of a primary mesentery ganglioneuroma. The patient underwent surgical intervention for diagnostic and therapeutic purposes.

Fluoroscopy guided chemical lumbar sympathectomy for lower limb ischaemic ulcers

The purpose of this study was to assess the effectiveness of chemical lumbar sympathectomy in relieving pain and healing ischaemic ulcers in patients with peripheral vascular diseases. Thirty-one consecutive patients with ischaemic/ gangrenous lower limb ulcers, referred to the BPKIHS, Pain Clinic were observed prospectively after chemical lumbar sympathectomy using modified Reid Technique with 3 ml of 70% alcohol each at L2 and L3 level under fluoroscopic guidance. Pain relief and ulcer healing were noted in the follow up. Moreover, patients' abilities to resume at least part of their day to day work were also noted at three months follow up. Of the total 31 patients, 16 had Buerger's disease and the remaining 15 had non-Buerger's ischaemic ulcers of which 7 were diabetic. There was significant decrease in the pain score from mean+/-SD of 8.3+/-0.9 (pre-block) to 4.2+/-2.5 (post-block after 3 days) in zero to 10 Numerical Analogue Scale (NAS). By 3 months, 6 patients declined for follow up; 19(76%) of the remaining 25 patients reported pain relief, 18(72%) reported healing or decrease in the size of ulcers and 11(44%) were able to resume at least part of their usual work. Minor complications occurred in 5 patients and amputation was needed in 6 patients. Fluoroscopy- guided chemical lumbar sympathectomy is feasible, safe and effective in relieving pain and promoting ulcer healing in patients with ischaemic lower limb ulcers due both to Buerger's disease and non-Buerger's peripheral vascular diseases.

Central neural blocks: a quality assessment of anaesthesia in gynaecological surgeries

Quality of anaesthetic care can be improved only after identifying the factors contributing to patients' discomforts and dissatisfaction. The purpose of this prospective observational study was to assess the quality of central neural blocks in terms of physiological alterations and undesired events and to find out modifiable factors associated with patients' discomforts and dissatisfaction. Total 204 female patients (ASA I and II) undergoing gynaecological surgeries received either of the subarachnoid block (SAB), combined spinal epidural anaesthesia (CSEA) or lumbar epidural anaesthesia (LEA) depending on the nature of the procedure. Intra-operative and immediate post-operative physiologic alterations and undesired effects, surgeons' rating of the operation condition and patient satisfaction (using 10 cm visual analogue scale) and acceptability of the technique were analyzed. Out of 204 patients, hypotension, bradycardia and nausea occurred in 45.1%, 17.6% and 14.7% respectively. Fifty-six (27.4%) patients experienced discomforts whereas 10.8% had tolerable pain and 4.9% patients required conversion to general anaesthesia. The main causes of discomfort in these patients were inability to move lower limbs in 35.7% and discomfort in the upper limbs in 32.1% of patients. Operating conditions were suboptimal and unacceptable in 3.9% and 4.3% of patients respectively. The mean patient satisfaction VAS score was 8.2 +/- 1.3 and patient acceptability was 90.2%. Significant failure or unacceptability (approximately in 10.0%) along with a high incidence of preventable discomforts demand improvement in preoperative patient education, intra-operative care and liberal uses of sedation to improve the quality to bring the acceptability closer to 100.0%.

Analgesia after inguinal herniotomy in children: combination of simplified (Single Puncture) ilioinguinal and iliohypogastric nerve blocks and wound infiltration vs. caudal block with 0.25% bupivacaine

OBJECTIVE

To assess whether simplified ilioinguinal and iliohypogastric nerve block in combination with minimal wound infiltration with local anaesthetic is better than caudal block with local anaesthetic alone in children undergoing inguinal herniotomy for easy transition to safe oral analgesia.

SUBJECT AND METHODS

Sixty children of both sexes undergoing herniotomy were allocated randomly to receive either simplified (single puncture) ilioinguinal and iliohypogastric nerve block described by Dalens in combination with small volume wound infiltration with 0.1 ml/kg of 0.25% bupivacaine (Group I) or caudal block with 1 ml/kg of 0.25% bupivacaine (Group II) at the end of surgery under general anaesthesia using halothane in oxygen and nitrous oxide mixture. Duration of analgesia, complication associated, parents and children's satisfaction were compared.

RESULTS

The mean duration of analgesia was 253+/-102.6 minutes in group I as compared to 219.6+/-48.4 minutes in group II. Six (20%) patients in group I and two (6.67%) patients in group II required parenteral analgesic. Complications and parents and children's satisfaction were comparable in both the groups.

CONCLUSION

Simplified ilioinguinal and iliohypogastric nerve blocks described by Dalens in combination with small volume local anaesthetic wound infiltration with its longer mean duration of analgesia offers better safety margin to start oral analgesics than caudal block with local anaesthetic alone in children undergoing herniotomy. Larger studies may further confirm the findings.

Effectiveness of addition of neostigmine or dexamethasone to local anaesthetic in providing perioperative analgesia for brachial plexus block: A prospective, randomized, double blinded, controlled study

Background: Various local anaesthetic agents are used for brachial plexus block.We compared effectiveness of addition of Dexamethasone versus Neostigmine to Lignocaine, adrenaline admixtures for Brachial plexus block in providing perioperative analgesia. Methods: Ninety patients were randomized in three groups and were received 24ml of study drugs. The group A [Lignocaine with adrenaline (1.5%)], group B [Lignocaine with adrenaline (1.5%)] +500?g Neostigmine, and group C (Lignocaine with adrenaline (1.5%) +4mg Dexamethasone) for brachial plexus block through supraclavicular approach. The observed parameters were onset of analgesia, completion of sensory and motor blockade, Duration of analgesia, Surgeon's score, side effects, number of supplemental analgesics doses and Visual analogue scale (VAS) score for pain in 12 hour of post-operative period. Results: Mean onset of analgesia 4.6±1.1 , 4.4±0.8 , 3.8±1.8 mins in group A, B and C respectively and the Mean onset of motor blockade were 7.7±2.0, 7.0±1.8, 6.0±2.1mins in group A, B and C respectively. Similarly Mean Complete sensory block in 10.6±3, 10.4±2.5, and 8.9±2.2mins and Mean complete motor block in 17.3±4.3, 17.2±4.0 and 14.7±3.5 mins in group A, B and C respectively were achieved. Duration of analgesia was 176.5±53.5, 225.7±53.3 and 454.2±110.7 mins in group A, B and C respectively. Duration of analgesia in group C was statistically significant in comparison with other groups. The number of mean analgesic requirement by group C (0.9±0.4) was significantly (p- 0.005) lower. The mean VAS was significantly lower in group C in 12 hours post-operatively. Conclusion: The onsets of action, duration of analgesia were better in dexamethasone group and also need less number of rescue analgesics requirement. doi: 10.3126/kumj.v6i3.1704 Kathmandu University Medical Journal (2008), Vol. 6, No. 3, Issue 23, 302-309