Indian Journal of Anesthesia and Analgesia

Low back pain is one of the commonest and leading causes of hospital visits, functional limitation and absence from work in the world.1 Low back pain can occur at any age, but its highest prevalence is in third decade of life. Avascular necrosis of Hip commonly presents at the age of 35-50 years with mean age being 36 years.3 Presenting complaints of both lumbar spine and hip pathologies are overlapping which include low back pain with associated buttock, groin, anterior thigh, and knee pain. Therefore, identifying the exact pain generator becomes crucial, where clinical evaluation plays a vital role.

A 63-year-old male with a history of Rheumatic heart disease with post-balloon mitral valvuloplasty (BMV) presented with a carcinoid tumor of the right lower lobe, posted for lobectomy plus regional lymph node resection. Anesthetic challenges and management of this patient is well described here. A rare post-operative complication i.e, blood clots in the bronchus, resulting in hypoxia and desaturation was found during the extubation time. Handling such complications with a bronchoscope is also discussed in this case report.

Managing pts with DVR, PPM, AF and HTN is a challenge to anesthesiologist because of risk due to endocarditis, bleeding, thromboembolism, malfunction of pacemaker and MI. Displacement of dental implant in paranasal sinus is not very rare but it primarily occurs in patient with severe pneumatization of maxillary sinus/or defect of alveolar process. The present case report highlights the anaesthetic management of a patient with double valve replacement (DVR), atrial fibrillation (AF) and permanent pacemaker (PPM) for misplaced dental implant in the paranasal sinuses. Successful non-cardiac surgeries in patients who have heart disease depends on good preoperative assessment, intraoperative and post-operative management.

Introduction: Diaphragmatic hernia is a condition in which abdominal contents enter the thoracic cavity through an abnormal opening in the diaphragm. Though diaphragmatic hernia in pregnancy is a rare occurrence it imposes challenges in terms of mode and time of delivery along with repair of hernia.

Case Report: A 34-year female G2 P1 L1 with 37 weeks 4 days gestational age presented in latent labour. Patient had undergone an Emergency LSCS with B/L Tubectomy under General Anaesthesia anda live male baby of birth weight 3.74 kgs was delivered. After extubation the patient had one episode of drop in saturation and oxygen supplementation was started immediately and patient was shifted to icu for observation.

A chest x-ray was done which showed bowel loops in the thoracic cavity. Later an HRCT was done confirming large defects of 5 x 7 cm of stomach, small bowel loops, large bowel loops and mesentery herniating into the left hemithorax with mild mediastinal shift to right and complete collapse of left lung suggesting diaphragmatic hernia. There was no evidence of a gastric volvulus or bowel ischemia.

Patient gives history of abdominal pain radiating to back and thigh along with fever and dry cough since 2 days. No history of chest pain, breathlessness, palpitations, epigastric pain, nausea, vomiting, headache, blurring of vision or burning micturition. No significant past or family history. General surgery and pulmonology opinion was taken which explained the need for cardio thoracic surgery intervention and the patient was referred to higher centre.

Conclusion: Diaphragmatic hernia complicating pregnancies are rare in occurrence imposing severe complications. Early diagnosis clinically and radiologically should be evaluated in pregnant women having gastrointestinal symptoms not responding to standard treatments.

Key Message: Usually diaphragmatic hernia presents in early childhood and needs surgical intervention. This was a rare presentation in the third trimester of pregnancy with mild gastrointestinal symptoms. In diaphragmatic hernia the most complicating symptom is obstruction which need immediate surgical intervention.

Introduction: LPG, a combination of aliphatic hydrocarbon gases, is utilized as a source of fuel for cooking appliances and vehicles. LPG mainly comprises butane (80%) and propane (20%), which are combustible gases, along with small concentrations of propylene and butylene. Mercaptans are included in the mixture to enable easy detection of any gas leakage due to their unpleasant smell. Because propane gas is heavier than air, it tends to settle at floor level. Due to the non-specific and diverse nature of its signs and symptoms, the timely and accurate diagnosis of LPG poisoning remains challenging. Due to easy access to LPG, there has been an increase incidence of its use for suicidal purposes and abuse. The current case report focuses on the effects of the abuse potential of LPG and its toxic effects.

Case Report: In this case report, four individuals of same family (19 yrs, 23 yrs, 24 yrs, 25 yrs old brothers) who have abused LPG for recreational purpose under alcoholic intoxication and subsequently, of four of them three individuals showed acute toxic myocarditis with ECG changes and elevated cardiac biomarkers, hypoxia, neurological manifestations such as generalized weakness, unconsciousness. The fourth person was brought dead to casualty and it was determined that approximately 22% of the people who used inhalants died during their first use. Sudden deaths are usually caused by abuse of butane, propane, or butane/propane mixture and it is due to cardiac arrhythmia.

Conclusion: The gas mixture of propane butane is among the most lethal inhalant substances. The substance abuse is increasing especially in adolescents and young adults. The public population must be educated about dangers of this gas abuse and its bad outcomes and should be recommended to stay away from it.

Context: Neuraxial anesthesia is the preferred choice for infraumbilical surgeries due to its advantages. The incorporation of midazolam alongside local anesthetic drugs in spinal anesthesia has demonstrated positive outcomes. This study was undertaken to assess the effectiveness of midazolam in terms of analgesic and anesthetic efficacy, as well as potential adverse effects, in patients undergoing infraumbilical surgeries.

Aims: To compare the analgesic and anaesthetic effect of mixture of midazolam - bupivacaine as compared to bupivacaine alone in patients undergoing infra-umbilical surgeries under spinal anaesthesia.

Settings and Design: The present study is a prospective, observational study.

Methods and Material: Fifty patients posted for elective infra-umbilical surgery were randomly divided into two groups of 25 each for intrathecal drug administration. (n=25). After administration of block, patients were assessed for analgesic and anesthetic effect of the drug.

Statistical Analysis used: The study analyzed through the statistical programming software SPSS-22 and it involved the application of the student’s t-test, with a significance threshold set at a P value of <0.05.

Results: Analgesic duration of patients in Midazolam Group was signiÞcantly longer compared to Bupivacaine Group for sensory block. More patients in the midazolam group were sedated and easily arousable.

Conclusions: This study concludes that the addition of intrathecal preservative-free midazolam to hyperbaric bupivacaine improved intra - operative anaesthesia and prolonged duration of analgesia. Also, it was observed that there was a significant reduction in the

consumption of analgesics during the postoperative period in patients undergoing infra-umbilical surgeries without causing any significant haemodynamic changes.

Introduction : Transforaminal epidural steroid injections (TFESI) have demonstrated their efficacy in both short-term and long-term treatment of radicular pain with their targets being the anterolateral epidural space and dorsal root ganglion. Although the evidence for transforaminal injections in treating radiculitis secondary to discherniation and lumbar stenosis is strong, evidence is limited regarding its effect on axial pain and in patients with failed back surgery syndrome (FBSS)

Methodology : patients were registered in this retrospective comparative study who underwent lumbar TFESI for lumbosacral radiculopathy from March 2021 to March 2022. All patients were assessed for difference in pain relief, disability and functional outcome at baseline and at the time of follow up using NRS, ODI & PROMIS. As a secondary objective the patients were divided into two groups those with previous history of spine surgery (Group A) and non-operated patients (Group B) to Compare the mean levels of pain relief, functional outcome and disability in spine surgery patients compared to non-operated patients. After Ethical committee approval and informed consent from patient baseline scores (NRS, ODI & PROMIS) were accessed from the MRD and follow up scores were obtained by sending a questionnaire across to the patient by email. The average follow up time was 1 year and 4 months.

Results and Observations: A minimum clinically important difference (MCID) of >2.0 was selected for the change in NRS to further determine the proportion of responders who experienced a clinically significant reduction of pain. Success in achieving MCID is defined by ≥3 t score change for all PROMIS instruments. Success in achieving MCID for ODI is defined as at least 30% score change at follow up from baseline score. There is no significant difference in pain relief, disability improvement, functional outcome as assessed by NRS, ODI & PROMIS between the two groups. In this study the success in achieving MCID for NRS was 70% in Group A and 63% in group B and overall 67% indicating that total 41 patients (67%) had significant reduction in NRS after TFESI. In this study success of achieving MCID for ODI was 38.7% among Group A which was comparable to 23.3% among Group B and the difference was not statistically significant. The overall success of achieving MCID for ODI was total 19 patients (31.1%) indicating only 31% patients had significant improvement in disability post TFESI. There is no significant difference in functional outcome as assessed by PROMIS instruments between the two groups. For PROMIS PF, PI, SD the success of achieving MCID was greater than 70% overall and for both the groups.

Conclusion: There is no doubt regarding the efficacy and therapeutic effect of TFESI in axial lumbosacral pain/radicular pain in non-operated patients. This study demonstrates the success rate of TFESI in spine surgery patients (FBSS) as well by utilizing PROMIS as an outcome measure and by use of a control group demonstrating improved Physical Function, less pain interference & improved sleep.

Background: Infraclavicular brachial plexus blockade provides anesthesia for surgeries of upper limb. In contrast to interscalene and supraclavicular block, infraclavicular blockade has the advantage of minimal risk to intravertebral, intrathecal or epidural injection, as well as reduced incidence of phrenic nerve and stellate ganglion block.

Aim: To evaluate the effect of dexmedetomidine with bupivacaine on the onset and duration of sensory and motor block and duration of analgesia in infraclavicular blocks.

Methodology: A prospective, double blind, randomized control trial was conducted among 50 patients under going elective surgery of hand, for earm, elbow and distal humerus. Patients were randomly divided into two groups based on random numbers generated by a computer program (www.randomwqqqizer.org). Group A consisted 25 patients received block with bupivacaine + dexmedetomidine Group A and Group B consisted 25 patients received block with bupivacaine + 20 ml normal saline. This study compared Onset and duration of sensory and motor blockade, duration of analgesia, post-operative pain score and hemodynamic parameters between the two groups.

Results: There was significant difference in mean onset of sensory block between two groups, (Group A 9.20 ± 0.98 vs Group B 11.06 ± 1.24 min p value < 0.001. Similarly there was significant difference in mean onset of Motor blockade between two groups (Group A 10.66 ± 1.06 min vs Group B 11.80 ± 1.10 min p value < 0.001). There was a statistically significant longer duration of sensory block (Group A was 8.88 ± 1.04 hrs and in Group B was 7.60 ± 0.78 hrs, p value <0.001), longer duration of motor block (Group A was 7.79 ± 0.82 Hrs vs Group B was 6.62 ± 0.49 hrs p value < 0.001). Statistically significant longer duration of motor block

(Group A was 9.78 ± 0.73 vs Group B 6.99 ± 1.10 hrs p value < 0.001.

Conclusion: Dexmedetomidine as an adjuvant hastens the onset and prolongs the duration of both sensory and motor block and has better analgesia when compared to bupivacaine alone.

Background and Aim: Laparoscopic cholecystectomy is one of the most commonly performed minimally invasive intra abdominal surgeries to remove the diseased gallbladder. Though associated with complications like pneumoperitoneum. Major benefits include reduced postoperative pain and fewer wound related adverse effects. Growing need for opioid sparing analgesia has led to use of regional techniques for post-operative pain relief.

Aim of this study is to compare quality and duration of post-operative analgesia between subcostal transverses abdominis block and erector spinae plane block.

Methods: It is a prospective study, where 40 patients were randomly allocated into two groups of 20 each. All the patients received 40 ml of inj 0.25% bupivacaine + 10 mcg inj dexmedetomidine in total. Erector spinae plane (EPS) block was performed in one group of patients and other received sub costal transverses abdominis plane (SCTAP) block. Quality of post-operative analgesia is documented using visual analogue score (VAS) and duration being assessed by the need for rescue analgesia for the set duration of post-operative stay.

Results: In the erector spinae plane block group the VAS is considerably lower compared to subcostal transverses abdominis block group. Need for rescue analgesia with NSAIDs was lower in erector spinae plane block group patients. No complications related to the block were documented in either group.

Conclusion: In conclusion ultrasound guided bilateral erector spinae plane block provides analgesia superior to bilateral subcostal transverses abdominis plane block.