Predicting postoperative pain by using preoperative pain threshold in response to electrical stimulus in women undergoing gynaecological cancer surgery - Single-arm, prospective, observational study

Background and Aims

Individual variability leading to different pain experiences makes pain prediction challenging. This study aimed to evaluate whether preoperative electrical pain threshold testing is predictive of postoperative pain.

Methods

Following ethics committee approval and registration of the trial, 40 consenting patients undergoing open laparotomy (interval debulking surgery) for ovarian cancer were included in the study. Electrical stimulus (maximum of 256 μA) was used preoperatively to determine the current perception threshold (CPT) and pain equivalent current (PEC). A numerical rating scale (NRS; 0-10, with 0 indicating no pain and 10 indicating severe pain) was used to assess pain. All patients received intravenous paracetamol in accordance to body weight, diclofenac (1 mg/kg, maximum 50 mg), and tramadol (1 mg/kg, maximum 50 mg) eight hourly for 24 hours. The preoperative PEC was compared with worst pain score (PS) at movement at the end of 24 hours. PEC was also compared with average PS at rest, at movement, and with opioid requirement (24 hours).

Results

The median values of CPT and PEC were 12.51 (45 [10.1-14.6]) μA and 94.75 (174 [48.8-94.7]) μA, respectively. A moderate correlation was observed between PEC and worst PS (P = 0.01, r = -0.402), with patients having PEC less than 60 μA being associated with moderate-to-severe PS. There was no correlation between PEC and average PS at rest (P = 0.16, r = 0.225), at movement (P = 0.46, r = 0.119), and the postoperative opioid consumption in the first 24 hours (P = 0.50, r = -0.110).

Conclusion

There is a moderate association between preoperative pain threshold in response to electrical stimulus and worst PS in the postoperative period following interval debulking surgery for ovarian cancer.

Comparison of double lumen tube insertion using the McGrath MAC versus direct laryngoscopy in adult patients with a limited glottis view: A prospective interventional study

Background and Aims

Passage of double-lumen tubes (DLT) can be challenging in patients with limited glottis view. This study aims to determine the usefulness of McGrath® MAC videolaryngoscope (VL) in cases with limited glottis view on direct laryngoscopy with Macintosh blade.

Material and Methods

After study approval and registration of trial, consent was sought from all adult patients planned for elective DLT insertion for lung isolation during the course of general anesthesia. Patients not consenting, less than 18 years, with anticipated difficult mask ventilation or need for rapid sequence induction were excluded. Following routine anesthetic induction, laryngoscopy was attempted by an experienced anesthesiologist using Macintosh scope. If the view obtained was Cormack and Lehane (CL) view IIB and above or the attempt at intubation using DLT failed despite a CL I/IIA view, the patient was included in the trial. The laryngoscope was removed and after ensuring adequate oxygenation and depth of anesthesia, intubation was attempted using McGrath® MAC VL. The percentage of glottis opening (POGO) score was noted for both the scopes.

Results

DLT insertion was attempted in 76 patients in the study period. Eight patients were included in the trial on account of limited glottis view/failure with Macintosh scope. Insertion of DLT with McGrath MAC was tried only in six patients, in two patients, the VL was not available for use. The mean (standard deviation) POGO score with Macintosh scope was 9 (±20), which significantly improved with the use of VL to 71 (±24), P = 0.01.

Conclusion

McGrath MAC is helpful in inserting DLT in patients with limited glottis view with Macintosh scope.

Role of video-based learning on competency level of direct laryngoscopic skills of novice anaesthesiologists - A randomised clinical trial

BACKGROUND AND AIMS

Video laryngoscopes are often used for education and training of intubation skills. This study aimed to examine the influence of video-assisted guidance and video replay on intubation skills of novice anaesthesiologists.

METHODS

Adult patients of American Society of Anesthesiologists physical status grade I-II, with a normal airway and scheduled to undergo elective surgical procedures requiring general anaesthesia and orotracheal intubation were included in this randomised study. Ten trainee anaesthesiologists, with no prior experience of performing tracheal intubation were enroled and randomly divided into group STD (received traditional learning) and group VL (received video-based learning). After initial mannequin training, the first seven intubations in patients in both the groups were done under supervision. In group VL, in addition to traditional cues, posttracheal intubation, the trainee and instructor had a session of video replay to discuss the entire process of laryngoscopy and tracheal intubation with areas of improvement. For the subsequent 15 intubations in patients, the trainees intubated independently using a standard Macintosh blade. The primary objective was to compare time required to intubate (TTI) for both groups using Mann-Whitney U test. Secondary objectives included comparison of difficulty in intubation (using a 5-point Likert scale), self-confidence scores (1-10, 10 - most confident), and intubation-related trauma.

RESULTS

The mean TTI was significantly lower in group VL than in group STD - 40s [Interquartile range (IQR): 32-50] versus 52s [IQR: 39-76], P = 0.002. No difference was seen in self-assessed confidence levels, rating of difficulty in intubation, and airway trauma.

CONCLUSION

Video replay of the intubation process has a positive impact on direct laryngoscopy learning.

Effect of patient information leaflet on working pattern and patient satisfaction level in a busy Indian day care operative theater complex

Background and Aims:

In a day care setting, communication of preprocedure instructions prior to general anesthesia (GA) is critical. Verbal information may be inadequate at times leading to unnecessary rescheduling. The aim of the study is to evaluate the use of patient information leaflet (PIL) and its impact on rescheduling and patients’ satisfaction levels.

Material and Methods:

Adult ASA I-III patients scheduled for elective day care Head Neck procedures such as direct laryngoscopy, examination under anesthesia, and biopsy under GA were recruited. In the outpatient department (OPD), the attending surgeons verbally instructed the patients as well as handed them the PIL. The process was streamlined over a month and thereafter patients’ satisfaction levels and rescheduling rates were captured over 2 months. This was compared to the data from the pre-PIL phase.

Result:

Prior to PIL, 12% cases were rescheduled due to avoidable causes. After introducing of the PIL, only 8% case were rescheduled (P = 0.02). There was a significant improvement seen in patient satisfaction with 89% patients reporting that the PIL was good or better while 77% were willing to recommend it to the others.

Conclusion:

PIL is an effective way of imparting perioperative instructions to patients which will improve not only satisfaction but also reduce patient rescheduling. The institution is in the process of implementing PIL to provide instructions to patient posted for day care procedures.

Preparation, validation, and evaluation of an information leaflet for patients undergoing day-care surgeries under general anesthesia at a busy tertiary care hospital

Background and Aims:

It is essential that patients posted for day-care surgeries are adequately prepared preoperatively. Verbal information alone may not be always effective. This study aimed to prepare, validate, and evaluate the efficacy of a patient information leaflet (PIL) for patients undergoing day-care surgeries under general anesthesia (GA).

Material and Methods:

After approval from the hospital ethics committee a PIL was prepared in English. Readability and design of the leaflet were checked using standard tests: Flesch readability ease test (FRE), Flesch Kincaid grade level (FKGL), and Baker Able leaflet design (BALD). It was translated into three regional languages. The PIL was tested among patients using a questionnaire. Seventy-nine adult patients posted for elective day-care procedures were included while emergency surgeries were excluded. Patient knowledge pre and post-PIL was compared using paired 't' test. The influence of age, gender, and education level on the usefulness of PIL were analyzed using the Chi-square test and knowledge was compared using ANOVA.

Results:

The English leaflet had an FRE Score of 63.9 and FKGL of 6.4, which is “standard“. The BALD score for all leaflets was 25 (“above standard“). The overall knowledge scores significantly improved from 52.6% (preintervention) to 70.7% (postintervention), P < 0.001. Knowledge improvement was seen with the use of PIL in all four languages. Sixty eight percent of patients strongly recommended the PIL while 31% were willing to recommend it to others.

Conclusion:

The PILs developed in this study have standard readability, good design and validated for efficacy.

Influence of interpretation of pain scores on patients' perception of pain: A prospective study

Background and Aims:

Assessment of pain using pain scales is essential. In the Numeric Rating Scale (NRS), patients are asked to score their pain intensity on a scale from 0 to 10 (10- worst pain). This requires some abstract thinking by the patient, also the pain scores (PS) may not essentially communicate the patients’ need for more analgesia. We planned a study to evaluate the change in patients’ self-assessed PS after understanding clinical interpretation of the NRS.

Methods:

This prospective study was registered after approval from our hospital ethics board. Sample size estimated for the trial was 360 patients. All postoperative patients were recruited after informed consent. Patients having prolonged stay in Intensive Care Unit (more than 48 h), or those who underwent emergency surgeries were excluded. During Acute Pain Service (APS) rounds, patients were asked to rate their PS on the NRS. This was followed by a briefing about the clinical interpretation of the scale, and the patients were asked to re score their pain using the same scale. The change in pain severity was compared using Chi-square test.

Results:

Following explanation, a change in severity was seen for PS at rest [X² (9, N- 360) = 441, P < 0.001] and at movement [X² (9, N- 360) = 508, P < 0.001]. Overall, a change in PS severity was seen in 162 patients (45%). A decrease and an increase in the severity of pain was seen in 119 and 41 patients respectively.

Conclusion:

Explaining the clinical interpretation of PS on a NRS does lead to a change in patients’ self-assessed PS.

A randomised controlled trial to evaluate the peri-operative role of intraoperative dexmedetomidine infusion in robotic-assisted laparoscopic oncosurgeries

Background:

Robotic and minimal invasive surgeries pose challenges to the anaesthesiologists. Dexmedetomidine (dexmed), with distinct properties of sedation and analgesia has emerged as a promising drug. Our primary aim, in this double-blinded study, was to evaluate reduction in the intraoperative opioid requirement with the use of intravenous dexmed infusion. Secondary objectives included effect on intraoperative anaesthetic and postoperative analgesic requirement.

Methodology:

After approval from Ethics board and registration of the trial, 46 eligible patients planned for robotic oncosurgeries (abdomen) were included. As per computer generated randomisation chart, patients were randomised into either dexmed or saline group. Five minutes after insufflation of the abdomen, the study drug bolus—saline or dexmed (1 μg/kg) was given over 10 min and was followed by maintenance infusion (0.2 μg/kg/h) until release of pneumoperitoneum. Study drug titration, fentanyl boluses, and changes in minimum alveolar concentration (MAC) of inhalational agent were protocolised.

Results:

The mean intraoperative fentanyl requirement was significantly lower in the dexmed group 192.6 μg (±66.4) versus the saline group 260.7 μg (±88.6), P = 0.013. The MAC requirement of inhalational agent was significantly lower in the dexmed group. Intraoperative episodes of hypotension and bradycardia were similar in both groups. First analgesic request, 24 h postoperative pain scores and side effects profile were comparable in both groups.

Conclusion:

Intraoperative dexmed (bolus of 1 μg/kg followed by 0.2 μg/kg/h infusion) has an opioid and inhalational anaesthetic sparing role during robotic oncosurgeries. However, no benefit of the infusion is seen in the postoperative period.

Audit of pain management following emergency laparotomies in cancer patients: A prospective observational study from an Indian tertiary care hospital

Background:

Emergency laparotomies present a challenge in pain management given sick patients, odd timings and poor outcomes. Current recommendations favour multimodal opioid-sparing analgesia following elective laparotomies. No recommendation exists for emergency surgeries.

Methodology:

After approval and registration of the trial, adult patients posted for emergency laparotomy in the hospital (tertiary centre for cancer care) starting August 2015, for 6 months, were included in this prospective study. Patients' details including indication for emergency surgery, preoperative haemodynamic parameters, baseline coagulation status were captured. Patients were followed for pain scores, satisfaction with pain management and outcome. The number of anaesthesiologists present and their experience concerning regional techniques were noted.

Results:

Intestinal obstruction was the commonest cause of emergency laparotomy. Most patients belonged to the ASA IE/IIE class (91%). Intraoperatively, opioids were the mainstay of pain management with an epidural catheter inserted in only 9% of cases even though most cases were conducted by anaesthesiologists confident/expert in thoracic epidural insertion. There was no correlation of choice of pain management technique with the time of surgery (P = 0.22), ASA grading (P = 0.28), predicted mortality by p-Possum scores (P = 0.24). Pain at movement was moderate-severe in more than 50% of patients within the first 24 h. The regional group had better satisfaction when compared to opioid and non-opioid based management. (P < 0.001).

Conclusion:

Regional techniques for pain management in emergency laparotomies are less preferred, therefore, opioids are the mainstay. Lack of experience is essentially not the primary reason for regional techniques not gaining popularity. Pain management in this group needs a thorough re-evaluation.

Ignorance may be Bliss (for Intensivists), but not for ICU Patients!

How to cite this article: Bakshi SG, Kulkarni AP. Ignorance may be Bliss (for Intensivists), but not for ICU Patients! Indian J Crit Care Med 2019;23(4):161-162.

McGrath MAC video laryngoscope versus direct laryngoscopy for the placement of double-lumen tubes: A randomised control trial

Background and Aims

Role of video laryngoscopes (VLs) in the management of difficult airway with single-lumen tubes (SLTs) is established. VLs provide improved glottis view but are associated with longer time to intubate (TTI). We aimed to compare the TTI for double-lumen tube (DLT) insertion using the McGrath^® MAC VL versus direct Macintosh laryngoscope (DL).

Methods

Eleven senior anaesthesiologists experienced in SLT insertion, but not DLT insertion with VL participated. Seventy-four adults belonging to American Society of Anesthesiologists physical status I-II posted for elective surgery needing lung isolation were randomised to both intubator and laryngoscope (VL/DL). Primary endpoint was TTI; secondary endpoints included glottic view assessed by the Cormack and Lehane (CL) grade, need for external laryngeal manipulation, ease of intubation [scored using Numeric Rating Scale (1 - easiest, 10 - most difficult)] and associated complications. TTI was compared using Student's t-test.

Results

No difference was found in TTI with DL and VL [(56.6 ± 14) s vs (64.4 ± 24) s, P = 0.104] as well as ease of use of laryngoscope [median score of 2 (1-3) in both]. Use of VL resulted in more patients with CL I glottic view - 86.0% versus 58.0% (P = 0.007). Fewer patients required external laryngeal manipulations (19% vs 47%, P = 0.013), and complications were fewer in the VL group (5% vs 24%, P = 0.023).

Conclusion

TTI for DLT insertion was similar with VL and DL. However, VL was associated with better glottis visualisation, reduced need of external laryngeal manipulation and fewer complications.

Incidence and management of post-dural puncture headache following spinal anaesthesia and accidental dural puncture from a non-obstetric hospital: A retrospective analysis

Background and Aims

Post-dural puncture headache (PDPH) is one of the complications following spinal anaesthesia (SA) and accidental dural puncture (ADP). In our institute, we routinely practice epidural analgesia (EA) for supra-major surgeries. Our previous audit on EA revealed 4% incidence of ADP. This lead us to a clinical initiative to follow-up patients with dural puncture (DP) to note the incidence, presentation, associated symptoms and treatment of PDPH. Herewith, we present the retrospective analysis over a 2-year period.

Methods

Following institutional review board approval, the follow-up notes of patients who had DP from May 2011 to April 2013 were analysed retrospectively (using SPSS 20 version) with respect to the needle size, level of DP, reinsertion of epidural catheter, details of ongoing analgesics, incidence and severity of PDPH and treatment received.

Results

In 2 years, we found that the incidence of PDPH in the patients who received SA was 3.9% and 25% in the ADP group. There was a positive association between needle size, type and PDPH, and it was seen more in the 20-40 age group. The commonest presentation of PDPH was occipital/frontal headache within 96 h and lasted for a mean of 3 days. All patients received pharmacological treatment. Seventy-one per cent of patients (25) were either on coffee or caffeine tablets. One case of intractable PDPH responded well to oral pregabalin 75 mg.

Conclusion

PDPH severity and incidence following ADP in our centre is lower than the reported incidence from obstetric centres and can be effectively controlled with drug treatment only.

Role of WhatsApp-based discussions in improving residents' knowledge of post-operative pain management: a pilot study

Background

To provide a platform for the dissemination of basic knowledge of pain management, a WhatsApp group was created by residents and consultants. Common clinical scenarios, resident queries, and important instructions to be followed by residents with respect to running the Acute Pain Service were discussed in the group. This study evaluates the benefits of this interaction.

Methods

This study was approved by the hospital ethics board and was registered with the Clinical Trial Registry of India. Second- and third-year anesthesia residents were included in a WhatsApp group, along with consultants (board certified anesthesiologists with a special interest in pain). Pain knowledge assessment was performed pre- and post-discussion using a standard 22-point questionnaire. A feedback form, which included self-rated confidence scores (1–10, 10-most confident) and opinions about the 3-month WhatsApp discussion, was collected. Improvements in the documentation in clinical sheets post-discussion were also analyzed.

Results

A total of 38 residents were included in the WhatsApp group. An improvement in the percentage of correct answers from 69.1% (pre-discussion) to 73.6% (post-discussion) was observed (P = 0.031). Improvements in the self-rated residents' confidence levels were also noted (P < 0.05). A total of 37 residents felt that the WhatsApp-based discussion was useful. Documentation of the details of epidural blockade in clinical sheets improved from 30% to 100%.

Conclusions

The WhatsApp discussion improved residents' knowledge and confidence levels, and also resulted in improved documentation of essential details in the clinical notes. This form of education is promising and should be explored in future studies.

Transversus abdominis plane catheters for postoperative pain relief in pediatric patients

Regional techniques provides excellent post operative pain relief in pediatric patients. Transversus abdominis plane (TAP) block is a newer regional technique available. Though there is emerging evidence proving the efficacy of TAP blocks, there is limited literature on use of TAP catheters in pediatric patients. TAP catheters were placed in two children following laparotomy with transverse incisions and in both epidural was avoided, with good post operative pain relief. Ultrasound guidance was used in one child, while in the other the catheter was placed under direct vision after dissection of the plane between transversus abdominis and internal oblique. Intermittent boluses of high volumes of local anesthetic (0.6-0.7 ml/kg) were used through the TAP catheter, ensuring that the maximum permissible level of bupivacaine was not exceeded. In adults, continuous abdominal catheters have found a place for post-operative pain management, when epidural analgesia is contraindicated. At present, the use of TAP catheters by pediatric anesthesiologists is limited, though there exists diverse clinical scenarios when these catheters may be of benefit. Contraindication of neuraxial blockade and septic patients are the two scenarios we have reported. In conclusion, TAP catheters are effective analgesia technique for laparotomies with transverse incision in pediatric patients.

Acute pain services in India: A glimpse of the current scenario

BACKGROUND AND AIMS

Acute postoperative pain is still a neglected and unresolved issue in day to day practice. Acute pain services were conceived three decades ago to form a dedicated team to monitor pain assessment and treatment as per laid down pain protocols and guidelines. The concept of acute pain service (APS) is slowly evolving in India.

MATERIAL AND METHODS

This nationwide questionnaire survey was conducted to identify the status of postoperative pain, the prevalent treatment practices, and the prevalence of acute pain services in India. An electronic communication was sent to 4000 Indian Society of Anesthesiologists life members.

RESULTS

We received only 146 responses mainly from faculties/consultants from few corporate hospitals or medical colleges. About 68 APSs were functioning, however, 20 APS do not have any training programs and 34 have no written protocols. Anesthesiologists were involved in postoperative pain management only when epidural analgesia was employed.

CONCLUSION

This survey found that majority of anesthesiologists agree to establish an APS, however administrative issues seem to be a major barrier.

A prospective, randomised, clinical study to compare the use of McGrath(®), Truview(®) and Macintosh laryngoscopes for endotracheal intubation by novice and experienced Anaesthesiologists

Background and Aims:

Video laryngoscopy has been recommended as an alternative during difficult conventional direct laryngoscopy using the Macintosh blade (MAC). However, successful visualisation of the larynx and tracheal intubation using some of the indirect laryngoscopes or video laryngoscopes (VL) requires hand-eye coordination. We conducted this study to determine whether non-channel VLs are easy to use for novices and whether there is any association between expertise with MAC and ease of tracheal intubation with VLs.

Methods:

Anaesthesiologists participating in the study were divided into three groups: Group novice to intubation (NTI), Group novice to videoscope (NVL)- experienced with MAC, novice to VLs and Group expert (EXP) experienced in all. Group NTI, NVL received prior mannequin training. VLs- Truview^® and McGrath series 5 (MGR) were compared with MAC. One hundred and twenty six adult patients with normal airway were randomised to both, the intubating anaesthesiologist and laryngoscope. The time taken to intubate (TTI) and participants’ rating of the ease of use was recorded on a scale of 1–10 (10-most difficult).

Results:

In Group NTI, there was no difference in mean TTI with the three scopes (P = 0.938). In Group NVL, TTI was longer with the VLs than MAC (P < 0.001). In Group EXP, TTI with VL took 20 s more (P < 0.001). There was significant difference in participants’ rating of ease of use of laryngoscope in Group NVL (P = 0.001) but not in the NTI (P = 0.205), EXP (P = 0.529) groups. A high failure was seen with MGR in Group NTI and NVL.

Conclusion:

In Group NTI, TTI and the ease of use were similar for all scopes. Expertise with standard direct laryngoscopy does not translate to expertise with VLs. Separate training and experience with VLs is required.

An assessment of basic pain knowledge and impact of pain education on Indian Anaesthesiologists - a pre and post questionnaire study

Background and Aim:

Under-treatment of pain is a global phenomenon and the basic knowledge of pain amongst health care providers continues to be deficient. The aim of this study was to determine the basic prevalent knowledge of pain among Indian anaesthesiologists and the impact of a pain educational programme on their existing knowledge.

Methods:

A nine lectures pain continuing medical education (CME) program was conducted for 114 young anaesthesiologists. All delegates were given 21-item questionnaire in a pre and post-test design. The 69 paired responses were compared for individual questions using McNemar test and the overall improvement in knowledge was analysed using paired t-test.

Results:

The pre-test score for correct answers was 61.9%. The post-test score was 69.8% and this improvement was found to be statistically significant (P < 0.001). A significant improvement in perception was detected that ‘opioids usage was less likely to cause addiction’ (correct responses increased from 4.2 to 77.4%, P = 0.001).

Conclusion:

The questionnaire study found that the current basic knowledge about pain amongst young anaesthesiologists is deficient. The physician's major concerns were opioid addiction and respiratory depression with opioid usage. The results of pre and post-test questionnaire survey have shown that pain education can help in improving knowledge of pain management.

Opioid-prescribing Practices in Chronic Cancer Pain in a Tertiary Care Pain Clinic

Introduction:

Under treatment of pain is a recognized global issue. Opioid analgesic medication is the mainstay of treatment in cancer patients as per the World Health Organization (WHO) pain relief ladder, yet 50% of cancer patients worldwide do not receive adequate pain relief or are undertreated.

Aim:

The aim of this study was to audit the ongoing opioid-prescribing practices in our tertiary cancer pain clinic during January–June 2010.

Materials & Methods:

The prescribed type of opioid, dose, dosing interval, and laxatives details were analyzed.

Results:

Five hundred pain files were reviewed and 435 were found complete for audit. Three hundred forty-eight (80%) patients were prescribed opioids. Two hundred fifty-nine (74.4%) received weak opioids while 118 (33.9%) received strong opioids. A total of 195 (45%) patients had moderate and 184 (42%) had severe pain. Ninety-three (26.7%) patients received morphine; however, only 31.5% (58 of 184) in severe pain received morphine as per the WHO pain ladder. Only 73 of 93 (78.4%) patients received an adequate dose of morphine with an adequate dosing interval and only 27 (29%) were prescribed laxatives with morphine.

Conclusion:

This study shows that the under treatment of pain and under dosing of opioids coupled with improper side effect management are major issues.

Patient controlled analgesia: redefining its role in an Indian cancer hospital

This report describes a noninterventional audit of current patient-controlled analgesia (PCA) use in an Indian cancer hospital over a 1-year period. Because there appeared to be an underutilization of PCA in the authors' hospital, they performed this audit. A major reason to start PCA was inadequate analgesia despite ongoing epidural or standard PRN analgesic regimes, especially in thoracic, major abdominal, and pelvic bone surgeries. PCA was used for an average 52.13 hours. The reason to stop the PCA in 72 patients was minimal usage due to decreased need after the second postoperative day. Multiple triggers at the same time were a common problem encountered in 21 patients. A blocked intravenous (IV) line was encountered in 12 patients. Thirty-one patients ranked their pain relief with PCA as excellent and 39 patients stated it as good. Their protocols shall be suitably amended to ensure that PCA shall be used in immediate postoperative period as a principal modality of pain relief, especially in the above-mentioned group in absence of epidural analgesia.