Comparison of Tubeless Mini Percutaneous Nephrolithotomy with Conventional Technique in a Tertiary Care Center

Introduction: Mini Percutaneous Nephrolithotomy (mPCNL) is a safe and efficient method for management of nephrolithiasis. Post procedure nephrostomy tube drainage is considered as the standard practice. In recent years, tubeless mPCNL with the use of double J (DJ) stent alone has replaced the placement of the nephrostomy tube. Aims: This study intends to evaluate the safety and efficacy of tubeless Mini Percutaneous Nephrolithotomy. Methods: A total of 80 patients with Nephrolithiasis, admitted to Urology Unit of Nepalgunj Medical College, between September 2018 and September 2019 were enrolled in the study and divided into two groups: Tubeless group where tube was omitted and Standard Group where it was placed. The two groups were compared with respect to hemoglobin drop and blood transfusion requirement, hospital stay and analgesic requirement in the post-operative period. Results: Mean age of the patients was 34.30 ± 13.19 years. Mean stone size was 19.03 mm. The mean change in hemoglobin after standard mPCNL was 1.68 gm/dl and that in the tubeless group was 1.11 (p=0.018). The tubeless group had a significantly (p=0.001) shorter hospital stay (3.05 ± 1.23 days) compared to standard group (3.85 ± 0.86). The postoperative pain as assessed by visual analogue scale, was more in the standard group necessitating additional analgesia. It was significantly higher in the standard group at 12, 24, 48 hours, as compared to the tubeless group. Conclusion: Placement of nephrostomy tube can be omitted as a routine practice as Tubeless mini PCNL has an added advantage of significantly reduced postoperative pain, less analgesic requirement, shorter hospital stay, less postoperative blood loss.

Safety and Efficacy of IV Dexmedetomidine as an Adjunct to Propofol to Sedate Anxious and Uncooperative Pediatric Dental Patients: A Randomized Controlled Trial

Objective : To evaluate the safety and efficacy of dexmedetomidine (dex) as an adjunct to propofol sedation in pediatric dental patients. Study design: This RCT enrolled 30 anxious ASA-I 2-5 year olds. Allocated into 2 groups either receiving IV propofol (1 mg/kg)(Gp-P) or [IV dex (1ug/kg) with propofol(1 mg/kg)] (Gp-D) after oral midazolam premedication (0.5 mg/kg). Sedation maintained with propofol infusion at 50–75ug/kg/min. Additional bolus/es of propofol (1mg/kg) was/were administered in case of inadequate sedation. Primary outcome was to compare requirement of propofol in two groups. Secondary outcomes were to compare vital signs, depth of sedation, induction, treatment and recovery time, intra & post-operative complications and analgesic requirement post-operatively. Results : Total propofol (in mgs) used and number of additional boluses were significantly higher in group P (p<0.05). Although within normal limits, heart rate was significantly lower in group D. Respiratory rate, oxygen saturation, NIBP were comparable. Depth of sedation achieved was comparable at all steps (p>0.05). Induction time (mins) was significantly lower in Group P (p<0.05), however treatment and recovery time were similar (p>0.05). Desaturation was observed in 3/15(group P) & 0/15(group D). Analgesic requirement post-operatively was significantly higher in group P (p<0.05). Conclusion: Dexmedetomidine is a safe and effective adjunct to propofol.

Socioeconomic status and use of analgesic drugs before and after primary hip arthroplasty: a population-based cohort study of 103,209 patients during 1996–2018

Background and purpose — Total hip arthroplasty (THA) is an effective and common procedure. However, persistent pain and analgesic requirement up to 2 years after THA surgery are common. We examined the trends in the utilization of analgesics before and after THA, overall, and in relation to socioeconomic status (SES) in a populationbased cohort. Patients and methods — We used the Danish Hip Arthroplasty Register to identify 103,209 patients who underwent THA between 1996 and 2018. Data on prescriptions and SES markers was obtained from Danish medical databases. Prevalence rates of redeemed prescriptions for analgesics with 95% confidence intervals were calculated for 4 quarters before and 4 quarters after THA for the entire THA population, and by 3 SES markers (education, cohabiting status, and wealth). Results — Overall, the prevalence of analgesic use prior to surgery was 42% at 9–12 months and 59% at 0–3 months before the THA. The prevalence of analgesics reached its highest at 64% 0–3 months after THA but declined to 27% at 9–12 months after THA. Low education, living alone, and having low wealth (low SES) were associated with higher prevalence of analgesics use both before and after THA. Interpretation — 59% of patients used analgesics 0–3 months before surgery, which could indicate that THA might not be considered the last option for treatment and that surgery criteria might depend more on factors such as patient preferences or hip function. Moreover, health professionals should prioritize the use of a detailed plan when phasing out analgesics after THA to counteract unnecessary use, especially when treating patients with low SES.

Comparison of Efficacy between Intramuscular Diclofenac and Transdermal Diclofenac Patch for Postoperative Analgesia in Patients Undergoing Lower Limb Surgery Under Sub Arachnoid Block in Jawaharlal Nehru Medical College, Wardha, India

Background: To compare the analgesic efficacy of transdermal Diclofenac patch (100 mg) with intramuscular Diclofenac sodium (75 mg) for postoperative analgesia and to know the side effects of transdermal Diclofenac patch. Methods: 60 ASA I and II patients, of either sex, aged 15 and above, scheduled for lower limb surgery under subarachnoid block were included in the study. All were allocated randomly by computer generated randomization sheet into two groups of 30 each. Subarachnoid block was administered using 0.5% hyperbaric Bupivacaine. Participants in the study group were applied with a transdermal Diclofenac patch containing 100 mg of Diclofenac diethylamine at the beginning of the surgery. In the control group 75 mg of Diclofenac sodium was given intramuscularly half an hour before the end of surgery. Pain was assessed postoperatively using visual analogue scale. Injection Tramadol 2 mg was administered intramuscularly as rescue analgesia. The data obtained was analyzed using chi - square test and unpaired student’s ‘t’test. Results: The mean time at which rescue analgesia was administered in the control group was 7 hours 28 min and in study group was 20 hours 6min.The time at which rescue analgesics were required in the study group was significantly prolonged (p<0.0001). The amount of Inj. Tramadol required as rescue analgesia in the control group was 189.33 mg. ± 16.38 mg. and in study group it was 97 mg. ± 7.24 mg and this was found to be statistically significant (p<0.0001). When the side effects were compared they were not significant. Conclusions: Based on the results obtained we conclude that, the intraoperative application of 100 mg transdermal Diclofenac diethylamine patch significantly prolongs the time at which patient requires rescue analgesia without any significant side effects. Rescue analgesic requirement was also significantly lower in the study group.

Effect of Magnesium Sulfate on the Total Anesthetic and Analgesic Requirements in Neurosurgery

Introduction: The intraoperative anesthetic and postoperative analgesic requirements are of great importance especially in neurosurgical anesthesia. This requires balancing a deep and effective anesthesia and postoperative analgesia versus the risks of delayed recovery and postoperative respiratory depression from excessive analgesics. Magnesium sulfate is an antagonist of the N-Methyl-D-Aspartate (NMDA) receptors in a voltage-dependent fashion. Propofol also inhibits the NMDA subtype of the glutamate receptor. Therefore, magnesium sulfate when coadministered with propofol potentiates anesthetic effect and NMDA antagonism of propofol. Majority of the studies that evaluated the anesthetic and analgesic requirement in patients receiving magnesium sulfate depended on the clinical parameters, for example, hemodynamic parameters and measurement of pain scores. In this study, we added bispectral index (BIS) and neuromuscular monitoring using train-of-four (TOF) to adjust intraoperative anesthetic requirements in addition to the clinical parameters. Methodology: This randomized controlled double-blind study included 50 adult ASA I and II male and female patients undergoing neurosurgical maneuvers. Patients were randomly divided into two equal groups. Routine intraoperative monitoring including invasive BP and in addition TOF and BIS were applied. In a blind fashion, patient in group I (Magnesium group) received magnesium sulfate 20 mg/kg as bolus dose over 5 min followed by 0.1 ml/kg/hr of 10% solution as infusion, while patient in group II (Control group) received saline with the same bolus and infusion rates after the induction of anesthesia. Anesthesia was induced in both groups by fentanyl 2 µg/kg, propofol 1.5–2 mg/kg, and rocuronium in a dose of 0.6 mg/kg to facilitate ETT insertion. This is followed by continuous infusion of propofol 6–10 mg/kg/hr and fentanyl 1–2 mic/kg/hr. The parameters which were assessed included hemodynamic parameters (HR and BP), TOF, and BIS. Total consumptions of propofol, fentanyl, rocuronium, and postoperative analgesic requirements (PCA morphine) were recorded. In addition, recovery time and postoperative pain score by visual analog scale (VAS) were recorded. Result: There was no significant difference in patient characteristics between the two groups. As regard the hemodynamic changes and BIS, no significant difference was seen between the two groups except the HR change which was significantly reduced (p = 0.005) with surgical stimulation in group I compared to the other group. Results also showed that the mean fentanyl, propofol, and rocuronium consumption, recovery time, degree of postoperative pain, and postoperative analgesic requirements were significantly less in patients that received magnesium sulfate infusion compared to those in the control group. Conclusion: Magnesium sulfate is most likely a safe and cost-effective supplement to the general anesthesia in neurosurgery as it reduces the total anesthetic and analgesic requirements and postoperative pain.

P127 ROBOTIC TRANSABDOMINAL RETRO-RECTUS HERNIA REPAIR VS. LAPAROSCOPIC INTRAPERITONEAL ONLAY MESH REPAIR: IMPROVING POSTOPERATIVE OUTCOMES

Aim “The optimal repair technique for small and medium-sized ventral hernias in obese patients remains unknown. We aimed to evaluate results after robotic-assisted laparoscopic transabdominal repair with retro-rectus mesh placement (rTARUP) compared with laparoscopic intraperitoneal onlay mesh repair (IPOM).” Material and Methods “Retrospective cohort study of consecutive patients undergoing rTARUP or IPOM repair for small or medium-sized primary ventral and incisional hernias. The primary outcome was postoperative need for transverse abdominis plane (TAP) block or epidural catheter, and secondary outcomes were 30-day complications, and length of stay. All patients underwent elective surgery and were followed for 30 days postoperatively.” Results “A total of 27 patients (rTARUP) and 32 (IPOM) were included. Patients in the two groups were comparable in terms of age, sex, comorbidities, smoking status, body mass index (BMI), and type of hernia. The median BMI was 32.4 kg/m2 and the fascial defect area was comparable (rTARUP median 16.8 cm2 vs. IPOM 11.7 cm2, P = 0.303). The duration of surgery was longer in the rTARUP group (median 117.2 min. vs. 84.4, P = 0.003), whereas the postoperative need for TAP block or epidural analgesics was less in the rTARUP group compared with IPOM (n = 14 vs. n = 1, P = 0.002). There were no severe complications or reoperations in the two groups. The length of stay was shorter in the rTARUP group (median 0 vs. 1 days, P &lt; 0.001).” Conclusions “rTARUP was associated with reduced postoperative analgesic requirement and shorter length of stay compared with laparoscopic IPOM.”

Effect of IV Infusion of Magnesium Sulfate on Postoperative Pain after Spinal Anesthesia: A Prospective Randomized Trial

Background: The current study attempts to evaluate the effect of intravenous (IV) infusion of magnesium sulfate during spinal anesthesia on postoperative pain and postoperative analgesic requirements in lower limb surgeries. Methods: In this double blind, randomized controlled study, 60 patients undergoing elective lower limb surgeries, were selected and randomly divided into two groups. Group I received isotonic saline and group II was administered magnesium sulfate 50 mg Kg-1 IV for 15 min and then 15 mg Kg-1 h-1 by continuous IV infusion till the end of surgery or 2 hours, whichever was earlier. Ramsay sedation scores, VAS scores for pain, time of first administration of rescue analgesic and total analgesic requirement were noted in both the groups. Results: Statistically significant difference was observed in the VAS score between the two groups at 1st, 2nd, 3rd, 6th, 9th and 12th hour intervals; with VAS scores being lower in the magnesium group (p<0.05). The mean time of first rescue analgesic requirement in control group was 144.00 mins, while in magnesium group was 246.00 mins (p<0.05). The total rescue analgesic requirement was found to be 251.67 mg and 181.67 mg at the end of 24 hours, in control and magnesium groups, respectively (p<0.05). Conclusion: This study demonstrates statistically significant lowering of postoperative VAS scores, delayed need of postoperative analgesia and reduced total postoperative analgesic requirement in patients receiving intraoperative IV magnesium sulfate compared to the control group. Magnesium sulfate did not cause sedation or any other significant adverse effect in the doses used in the study.

Postoperative Pain Relief: The Comparison of Bupivacaine before Incision and Near Closure of Wound

Background: Pain is the most common and most difficult problem faced by patients after operation. Due to inadequate management 30-70% patients suffer from post-operative pain. Acute pain resulting in chronic pain reduces quality of life and creates economic burden. Aim: To compare post-operative pain relief between infiltration of 0.25% bupivacaine into skin and subcutaneous tissue in the line of incision before incision and along edges of wound near completion of procedure. Study design: Randomized control trial Methodology: Sixty four patients were randomly divided into two groups i.e. (0.25% Bupivacaine 6 to 30ml) at the site of incision into skin and subcutaneous tissue Preincision (Group P) and (0.25% Bupivacaine 6 to 30ml) along the edges of wound at near closure of procedure (Group C). Intensity of pain was assessed on visual analogue scale in the recovery room, 3, 6 and 24 hours postoperatively.The time of first dose of rescue analgesia within 24 hours was also noted in both groups. Results: There was no statistically significant difference between two groups regarding age (p-value = 0.324), gender i.e. males (p=0.545) females (p=0.763) and duration of operation (P=Value=0.208). The mean time of rescue analgesia in Group P and Group C in minutes was 318.12±149.47 and 374.84±125.67 respectively (p value =1.5) reflecting no statistically significant difference. Conclusion: Postoperative analgesia and analgesic requirement do not differ significantly whether bupivacaine is infiltrated before incision or just before closure of wound. Keywords: Postoperative pain, bupivacaine, rescue analgesia, Preincision

Comparison of The Analgesic Outcomes of Local Wound Infiltration using Bupivacaine with Tramadol in Pediatric Inguinal Hernia Repair

Objective: To compare the time for first analgesic requirement after local wound infiltration with tramadol and bupivacaine in pediatric inguinal herniotomy. Materials and Methods: A total of 130 children aged 4 to 12 years who underwent inguinal herniotomy were included in this randomized comparative study. The study was conducted in anesthesiology unit of a tertiary care center in Qatar from Nov-2020 to July-2021. Patients in Group T received wound infiltration by Inj. Tramadol 2 mg/kg diluted in 10cc distilled water while patients in Group B received Inj. Bupivacaine 1mg/kg diluted in 10 cc distilled water. Postoperatively Pain score using Wong Baker Faces Scale was noted from ½ hour to 6 hours after surgery. Time of first rescue analgesia was noted. Results: The mean age was 7.98±2.40 years in group B versus 7.49±2.58 years in group T (p-value 0.26). There were 42 (64.6%) in group B versus 45 (69.2%) in group T (p-value 0.93). Mean surgery duration was 46.66±4.73 minutes in group T and 45.50±4.37 minutes in group B. The Wong-Baker pain score at different time intervals was significantly lower in group T in comparison to group B. Time of first analgesia requirement was 6.87±0.76 hours in group P versus 5.67±0.97 hours in group P, this duration was significantly prolonged in group T with p-value <0.001. Conclusion: Local wound infiltration with tramadol provides a longer time for first analgesic requirement as compared to the bupivacaine in children undergoing inguinal hernia repair. Keywords: Inguinal hernia, wound infiltration, tramadol, bupivacaine, post-operative pain.

Laparoscopic Versus Open Inguinal Ligation of Varicocele: A Study of 60 Cases

Objective: To compare the results of trans-peritoneal laparoscopic varicocelectomy with open inguinal technique in terms of operation time, post-operative pain and analgesic requirement, post-operative complications and hospital stay. Study design: Randomized controlled trial. Place & Duration of study: Department of Urology, Jinnah Postgraduate Medical Center (JPMC) Karachi, from January 2017 to December 2020. Methodology: This prospective study composed of 60 patients diagnosed as primary varicocele clinically or as asymptomatic on Doppler U/S. They were divided into two groups on the basis of type of operation by alternate methods. In Group A (n=32), laparoscopic varicocelectomy was performed while in Group B (n=28), open inguinal method was used. Their clinical presentations, operation times, postoperative pain, analgesic requirement, hospital stay and postoperative complications were noted and analyzed. Results: Out of 60 patients included, the age range was from 18-30 years.41.6% patients were asymptomatic and were referred to us because they were declared unfit for recruitment. Left sided varicocele was diagnosed in 81.6% patients, while 16.6% were bilateral. Grade II was most common seen in 60% of patients. Operation time for unilateral laparoscopic varicocelectomy was 17.25±2.1minutes, while open unilateral time was 42.5±3.4 minutes. Post-operative pain and hospital stay were significantly better in laparoscopic group (p value<.001). Postoperative wound related complications and secondary hydrocele was more in open group. In laparoscopic group, subcutaneous emphysema was noted in early postoperative period in 3 patients (9.3%) and portside hernia in one patient (3.1%). Recurrence rate was more in open cases (14.2%), versus 6.2% in laparoscopic group. Conclusion: Laparoscopic varicocelectomy is a simple and safe technique causing minimal morbidity with early recovery and better surgical outcome. Keywords: Varicocele, Laparoscopic Ligation, Open ligation