A Multidisciplinary Approach to Tracheoesophageal Fistula Repair in a Newborn: A Case Report

This case report details the emergency management and successful surgical repair of a tracheoesophageal fistula (TEF) in a newborn delivered by lower segment cesarean section. Despite immediate crying after birth, the neonate's distress was evident, with an Apgar score of 4, prompting an urgent referral to the Neonatal ICU (NICU). Diagnostic investigations, including ultrasonography and two-dimensional echocardiography (2D Echo), revealed associated anomalies, such as a patent ductus arteriosus, arterial septal defect, and a TEF. An anaesthetist was urgently involved due to postnatal desaturation, leading to challenging intubation and surgical repair performed under general anaesthesia, which involved separating the trachea from the oesophagus. Postoperative imaging confirmed the successful closure of the fistulous connection. This case highlights the significance of prompt diagnosis, collaborative management, and surgical intervention in optimising outcomes for neonates with complex congenital anomalies like TEF.

Influence of transcutaneous electrical nerve stimulation on pain intensity and functional activities following lower segment cesarean section

BACKGROUND

Postoperative incisional pain following lower segment cesarean section (LSCS) is one of the commonly reported complaints which may affect mother-infant bonding, and restrict mobility and functional activities.

PURPOSE

To study the influence of transcutaneous electrical nerve stimulation (TENS) on pain intensity and functional activities using the Numerical Pain Rating Scale (NPRS) and the Patient Specific Functional Scale (PSFS) following LSCS from the postoperative day (POD) 1 to POD 4.

METHODS

This quasi-experimental study consisted of 50 postpartum women who underwent LSCS and were assigned to an intervention group (IG) that received TENS and a control group (CG) that received routine hospital care.

RESULTS

NPRS scores between CG and IG (pre-TENS application) showed a statistically significant difference (ηp2 = 0.542, p < .001) from POD 1 to POD 4. Study participants showed an improvement in PSFS scores (ηp2 = 0.412, 0.488, 0.661, 0.304, 0.262, and 0.395, p < .001) in IG compared to CG for bed transitions, bed transfers, sitting, sit to stand, walking, and toileting activities respectively from POD 1 to POD 4 which was statistically significant.

CONCLUSIONS

Our study results suggest that administration of TENS following LSCS shows an improvement in pain intensity and functional activities as reported on NPRS and PSFS respectively.

Comparison of Two Different Doses of Nalbuphine With Isobaric Ropivacaine in Patients Undergoing Lower Segment Cesarean Section Under Subarachnoid Block: A Randomized Controlled Trial

INTRODUCTION

Obstetric analgesia and anesthesia is a challenge in itself. It requires an understanding of the physiological changes during pregnancy and labor and the effect of anesthetic agents on the fetus and newborn. Because neuraxial techniques provide superior analgesia and materno-fetal benefits, their use have increased significantly over the past three decades or so. A combination of local anesthetics like ropivacaine with opioids like nalbuphine has been shown to have additive beneficial effects in subarachnoid block (SAB) in lower segment cesarean section (LSCS). However, the optimal dose combination of ropivacaine and nalbuphine to maximize their benefits and minimize side effects remains to be established. Our study has compared the clinical efficacy and safety of 0.75% isobaric ropivacaine (15 mg) with two different doses of nalbuphine (0.4 mg and 0.6 mg) when given intrathecally for LSCS in terms of quality of sensory and motor blocks, hemodynamic parameters, duration of effective analgesia, Apgar score in newborn, and associated side effects.

METHOD AND MATERIALS

In this prospective, randomized, double-blind study, a total of 69 parturients between the age of 20-45 years, belonging to American Society of Anesthesiologists (ASA) grade I and II, undergoing cesarean section under SAB were evaluated. Patients were randomly allocated into three groups of 23 each by using the draw-of-lots technique. The patient and the observer were kept blinded as to which dose of drug (intrathecal) was being given to the patient. Patients in Group A received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.3 ml normal saline; patients in Group B received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.4 mg of nalbuphine (0.2 ml) + 0.1 ml normal saline; patients in Group C received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.6 mg of nalbuphine (0.3 ml). The total volume of drug solution in all three groups was 2.3 ml.

RESULT

 We found that the time to onset of sensory block was shortest in Group A (5.87±1.290 minutes) followed by Group C (6.00±1.087 minutes) and Group B (6.17±1.696 minutes); time to two-segment regression of sensory block was longest in Group C (101.74±8.996 minutes) followed by Group B (85.87±15.348 minutes) and Group A (65.00±7.071 minutes); duration of effective analgesia was longest in Group C (206.09±18.766 minutes) followed by Group B (183.91±15.880 minutes) and Group A (121.74±11.833 minutes); and time from SAB to complete regression of motor block was longest in Group C (216.52±15.553 minutes) followed by Group B (203.48±20.138 minutes) and Group A (174.78±14.731 minutes). Side effects were comparable among all three groups.

CONCLUSION

The optimal dose combination in SAB for cesarean section was 15 mg of 0.75% isobaric ropivacaine + 0.6 mg nalbuphine, with minimal side effects.

Obese Parturient: A Modern-Day Obstetric Challenge

Obesity has become a growing pandemic with a significant increase in incidence in recent years. The complications associated with pregnancy in obese patients can lead to increased morbidity and mortality in pregnant women. A 41-year-old morbidly obese female with primary hypertension and 32.4 weeks pregnant, presented with severe oligohydramnios, breech presentation, and a history of previous lower segment cesarean section (LSCS). The patient experienced abdominal pain, lower backache, and leaking per vaginal, and a decision was made to perform LSCS. Challenges were encountered during the procedure related to anesthesia management and the need for specialized equipment and additional assistants. A multidisciplinary approach was chosen for managing this patient with the special role of anesthetists. Intra-operative and post-operative management was crucial for a successful recovery. Obesity during pregnancy presents unique challenges for healthcare providers, and it is necessary to increase resources and prepare skilfully to manage these patients effectively.

Anesthetic management of a young primigravida a case of symptomatic long QT syndrome with a permanent pacemaker in-situ undergoing lower segment cesarean section delivery: A case report

The patient with Long QT syndrome (LQTS) presents a unique challenge to the anesthesiologist. The anesthetic management of such patients requires a good knowledge of the pathophysiology of this rare disease. General anesthesia (GA) or combined spinal epidural anesthesia (CSEA) are the most preferred anesthetic techniques among anesthesiologists for such patients posted for the lower segment cesarean section delivery. In this report, we would like to share our experience of anesthetic management of a young primigravida, a case of symptomatic LQTS with a permanent pacemaker in situ. Anesthetic technique used for the lower segment cesarean section delivery was single-shot spinal anesthesia using a combination of a local anesthetic and strong opioid in the lumber subarachnoid space. Until recently, only one report in the literature has described this single-shot spinal technique for such cases. The advantages of single shot spinal over GA and CSEA can be utilized in a select group of these patients, which include fast onset, dense, reliable block with low local anesthetic toxicity, reduced catecholamine release, and relatively prolonged analgesia when combined with an opioid.

Low dose and the conventional dose of 0.5% hyperbaric bupivacaine produce comparable outcomes in the lower segment caesarean section. An observational study

Background

Spinal anesthesia with 0.5% hyperbaric bupivacaine is an approved technique for lower segment cesarean sections. This study compared two different hyperbaric bupivacaine doses for spinal anesthesia in the lower segment cesarean section. We hypothesized that low-dose spinal anesthesia had similar outcomes as conventional doses of bupivacaine.

Methods

This was a comparative observational study involving seventy healthy parturients who were posted for elective cesarean section. Patients were supposed to receive 0.5% hyperbaric bupivacaine and were divided into groups, low dose (LB-1.8 ml) and conventional-dose (HB-2.2 ml) group. The extent of motor blockade, sensory blockade, hemodynamic effects, visual analog scale for pain, and patient satisfaction were measured. The data were analyzed using the median and interquartile range for all parameters. A statistical package SSPS version 25.0 was used to do the analysis.

Results

Hemodynamic stability was well maintained in both groups. Almost 100% of the patients in both groups achieved a grade 3 motor blockade in 8 min. T6 level of sensory blockade was achieved in 6 min by 100% of the patients. The low-dose group made a faster recovery compared with the high-dose group.

Conclusion

Low-dose spinal anesthesia can cause similar hemodynamic and analgesic effects as the conventional-dose group. The only benefit of low dose spinal as compared with conventional-dose group was faster recovery from the anesthetic effects.

Pathogenic bacteria and their antibiotic sensitivity in ophthalmia neonatorum

CONTEXT

Emergence of coagulase-negative staphylococci as pathogens in ophthalmia neonatorum.

AIMS

To analyze the bacteriological spectrum of ophthalmia neonatorum and its associated risk factors.

SETTINGS AND DESIGN

Retrospective analysis in a tertiary care hospital in India.

SUBJECTS AND METHODS

A retrospective review was performed in a tertiary care center in India on 139 neonates presenting with conjunctivitis over a period of 3 years. All the neonates presenting to the out-patient department, those admitted in the Neonatal Intensive care Unit and in-patient wards were included in our study. The neonates were clinically examined and followed-up by a single experienced ophthalmologist. Details including demographic data, age of the infant, type of delivery, investigations, and treatment outcomes were analyzed.

STATISTICAL ANALYSIS USED

Frequency calculation using Microsoft Excel for windows 10.

RESULTS

In the 92 samples with growth (66.2%), the most common organisms isolated were coagulase-negative Staphylococci (35.9%), Klebsiella pneumoniae (16.3%), and Acinetobacter species (16.3%). Others were Staphylococcus aureus (14.1%), Pseudomonas aeruginosa (8.7%), and Escherichia coli (8.7%). Ophthalmia neonatorum was significantly higher in preterm infants born out of lower-segment cesarean section and those requiring ventilatory support.

CONCLUSIONS

Unlike gonococcus, which is implicated in ophthalmia neonatorum, our study shows varied microbiological spectrum and sensitivity patterns with coagulase-negative staphylococci as the key pathogen. The role of coagulase-negative staphylococci as a disease-causing pathogen becomes increasingly important with an imperative need for prudent use of common antibiotics in treating these pathogenic bacteria.

Comparison of Local Wound Infiltration with Ropivacaine Alone or Ropivacaine Plus Dexmedetomidine for Postoperative Pain Relief after Lower Segment Cesarean Section

Context:

Dexmedetomidine, α₂-adrenergic agonist, when coadministered with local anesthetics, improves the speed of onset, duration of analgesia and decreases the dose of local anesthetic used.

Aims:

The aim of this study was to compare the efficacy of local subcutaneous wound infiltration of ropivacaine alone with ropivacaine plus dexmedetomidine for postoperative pain relief following lower segment cesarean section (LSCS).

Subjects and Methods:

The study was a prospective, randomized control, double-blind study. Sixty female patients belonging to physical status American Society of Anesthesiologists Grade I or II scheduled for LSCS under spinal anesthesia were randomly allocated into two groups of thirty patients each. Group A: local subcutaneous wound infiltration of 0.75% ropivacaine (3 mg/kg) diluted with normal saline to 40 ml. Group B: local subcutaneous wound infiltration of 0.75% ropivacaine (3 mg/kg) plus dexmedetomidine (1.5 μg/kg) of the body weight diluted with normal saline to 40 ml. Standard spinal anesthesia technique was used and LSCS was conducted. The allocated drug was administered by local subcutaneous wound infiltration before closure of the skin. In postoperative period, pain was assessed using visual analog scale (VAS) over a period of 24 h, time of giving first rescue analgesic consumption, mean analgesic consumption, patient satisfaction, and incidence of side effects in 24 h postoperative period was noted.

Statistical Analysis Used:

All observations were tabulated and statistically analyzed using Chi-square test and unpaired t-test.

Results:

A total number of patients requiring rescue analgesic, mean VAS each time rescue analgesic was given, and the mean analgesic required in 24 h postoperative period was lesser in Group B than in Group A.

Conclusions:

Dexmedetomidine added to ropivacaine for the surgical wound infiltration significantly reduces postoperative pain and rescue analgesic consumption in patients undergoing LSCS. No serious adverse effects were noted.

Relative Efficacy of Ultrasound-guided Ilioinguinal-iliohypogastric Nerve Block versus Transverse Abdominis Plane Block for Postoperative Analgesia following Lower Segment Cesarean Section: A Prospective, Randomized Observer-blinded Trial

BACKGROUND

Quality of postoperative analgesia after cesarean section makes difference to mother in child bonding, early ambulation, and discharge. Ilioinguinal iliohypogastric (ILIH) and transverse abdominis plane (TAP) block had been tried to reduce the opioid analgesics, but the relative efficacy is unknown. Hence, this study was designed to compare the efficacy of these two regional analgesic techniques in sparing postoperative rescue analgesic requirement following lower segment cesarean section (LSCS).

METHODS

Sixty patients who underwent LSCS were randomly allocated into two groups to receive either US-guided TAP block or ILIH nerve block using sealed envelope technique at the end of the surgery. In the postoperative ward, whenever patient complained of pain, pain nurse in-charge administered the rescue analgesics as per the study protocol. A blinded observer visited the patient at 0, 2, 4, 6, 8, 10, 12, and 24 h postoperative intervals and recorded the quality of pain relief and the amount of rescue analgesic consumed.

RESULTS

All patients in both the study groups required one dose of rescue analgesics in the form of injection diclofenac sodium 50 mg intravenously but subsequently 57% of patients did not require any further analgesics till 24 h in the TAP block group whereas in ILIH group, only 13% did not require further analgesics (P = 0.00), correspondingly the cumulative tramadol dose was significantly higher at all the time interval in the ILIH group when compared to the TAP group.

CONCLUSION

Quality of postoperative analgesia provided by TAP block was superior to ILIH block following LSCS.

Successful pregnancy after excision of cesarean scar endometriosis with uterovesicocutaneous fistula: A rare case report

Scar endometriosis is an infrequent type of extrapelvic endometriosis. The most common extrapelvic form of endometriosis is cutaneous endometriosis, involving scar tissues occurring after obstetric or gynecologic procedures such as episiotomy, hysterotomy, cesarean section, and even laparoscopic surgery. The clinical presentation of scar endometriosis, i.e., tender swellings, mimics other dermatological and/or surgical conditions and delays the diagnosis. Scar endometriosis very rarely can get complicated with uterocutaneous fistula with a reported incidence of very few cases in world literature. We report a case of a 36-year-old woman presenting with scar endometriosis with complicated uterocutaneous fistula 11 years after her last lower segment cesarean section, managed successfully with laparotomy-fistulectomy and sleeve resection of the bladder with repair followed by successful subsequent spontaneous conception and pregnancy terminated by lower segment cesarean section.

0.2% ropivacaine with fentanyl in the management of labor analgesia: A case study of 30 parturients

BACKGROUND

Epidural infusion of 0.2% ropivacaine is recommended by the manufacturers for labor analgesia.

AIMS

The aim of this study is to evaluate the analgesic efficacy, degree of motor blockade, obstetric outcome in the form of incidence of normal vaginal, assisted vaginal and lower segment cesarean section.

SETTINGS AND DESIGN

Pilot study.

MATERIALS AND METHODS

In this pilot study, 30 nulliparous parturients in active labor had epidural analgesia established using 0.2% ropivacaine with 25 mcg fentanyl for initiation when cervical dilatation was 3-4 cm and then analgesia was maintained with 0.2% ropivacaine at 10 ml/h till the delivery of baby.

STATISTICAL ANALYSIS

It was done by Wilcoxon sign rank test and paired t-test as applicable.

RESULTS

There was a significant difference (P < 0.05) between prebolus, postbolus and postinfusion with respect to visual analog score. There was a significant difference (P > 0.05) between prebolus, postbolus, and postinfusion with respect to Bromage motor score, (Wilcoxon sign rank test). Six out of 30 paturients complained of tingling and heaviness in lower limbs after continuous infusion of 2-2.5 h.

CONCLUSION

We conclude that 0.2% ropivacaine (8 ml) with fentanyl 25 mcg is good for initiation of ambulatory labor analgesia. But for maintenance of labor analgesia lower concentration of ropivacaine may be preferred.

Comparative evaluation of two doses of tranexamic acid used prophylactically in anemic parturients for lower segment cesarean section: A double-blind randomized case control prospective trial

Background:

Postpartum hemorrhage (PPH) and anemia thereafter can be a life threatening condition in parturients undergoing lower segment cesarean section (LSCS), especially when anemia is present.

Aim:

The objective of this study was to assess two doses of Tranexamic acid (TXA) in reducing intra operative blood loss and incidence of PPH, in terms of both efficacy and safety profiles, when used prophylactically.

Methods:

A monocenter prospective case control double blind randomized study was carried out on a consecutive series of 90 anemic patients undergoing LSCS, with hemoglobin between 7-10 g percent. Three random groups were formed. Group T1 (n=30) received 10mg/kg TXA in 20 ml of 5% dextrose intravenously, while T2 group (n=30) received 15mg/kg. Group C (n=30) received a placebo. Drug was administered prophylactically 20 min before skin incision. Blood loss was measured from placental delivery up to 24 hours by method of weight and volume.

Staistical Analysis:

To compare quantitative data between two groups, t-test, and for more than two groups ANOVA was used. To compare the mean for non- parametric data between two groups Mann – Whitney test was used, while in case of more than two groups Kruskal – Wallis test was employed. Probability (p) value was considered significant when it was 0.05 or less.

Results:

TXA significantly reduced blood loss in both the study groups. Mean total blood loss was 527.17±88.666 ml, 376.83±31.961ml and 261.17±56.777 ml in group C, T1, and T2 respectively. While reduction of blood loss in T1 group compared to control group was 146.34±56.32ml, it was 262±31.51ml in T2 group. Difference between T1 and T2 was 115.66±24.81ml, which was statistically significant (P<0.05). Postoperative blood loss was insignificant in all three groups. Pre- and post-operative hemoglobin levels differed significantly when compared to control group. Blood transfusion was needed in two patients in the control group, whereas no patient in groups T1 and T2 needed transfusion (P=0.02). No significant adverse effect was seen in all the three groups.

Conclusion:

Hence, TXA was found to be effective in reducing blood loss and transfusion in anemic parturients undergoing LSCS. 15mg/kg dose of TXA was more efficacious than the 10mg/kg dose and without any undue increase in adverse events. Postpartum anemia is a public health problem worldwide and TXA could prove to be a very useful drug to prevent blood loss and transfusions in patients undergoing LSCS, especially in the anemic subgroup.