No Difference between Spinal Anesthesia with Hyperbaric Ropivacaine and Intravenous Dexmedetomidine Sedation with and without Intrathecal Fentanyl: A Randomized Noninferiority Trial

To enhance the duration of single-shot spinal anesthesia, intrathecal fentanyl and intravenous dexmedetomidine are widely used as adjuvants to local anesthetics. This noninferiority trial evaluated whether hyperbaric ropivacaine alone can produce a noninferior duration of sensory block in comparison to hyperbaric ropivacaine with intrathecal fentanyl in patients under dexmedetomidine sedation. Methods. Fifty patients scheduled for elective lower limb surgery under spinal anesthesia were randomly assigned in a double-blind fashion to receive either hyperbaric ropivacaine 15 mg (Group R) or hyperbaric ropivacaine 15 mg with intrathecal fentanyl 20 μg (Group RF). Intravenous dexmedetomidine (1 μg/kg for 10 min, followed by 0.5 μg/kg/h) was administered in both groups. The primary outcome of this study was the time to two-dermatomal regression of sensory block. The noninferiority margin for the mean difference was −10 min. Characteristics of the block, intraoperative and postoperative side effects, postoperative pain score, and analgesic consumption were assessed as secondary outcomes. Results. There was no difference in the two-dermatomal regressions of sensory block between the two groups (Group R 70.4 ± 10.2 min, Group RF 71.2 ± 12.4 min, p = 0.804) with a mean difference of 0.8 min (−7.2 to 5.6, 95% confidence interval). Thus, the noninferiority of hyperbaric ropivacaine alone was established. There were no significant differences in the secondary outcomes between the two groups. Conclusions. Under intravenous dexmedetomidine sedation, the duration of spinal anesthesia with hyperbaric ropivacaine alone was noninferior to that of hyperbaric ropivacaine with intrathecal fentanyl. This suggests that addition of intrathecal fentanyl to hyperbaric ropivacaine may not be necessary in patients receiving intravenous dexmedetomidine.

Change in the optic nerve sheath diameter after deflation of a pneumatic tourniquet: a prospective observational study

Applying a pneumatic tourniquet provides surgeons with a bloodless surgical field. However, application of the tourniquet induces various physiological changes. We evaluated the effect of tourniquet deflation on the intracranial pressure by using ultrasonography to measure the optic nerve sheath diameter (ONSD) in patients undergoing lower limb surgery. The ONSD was measured in 20 patients at five time points: after anesthetic induction (T0) and immediately before (T1), immediately after (T2), 5 min after (T3), and 10 min after tourniquet deflation (T4). Hemodynamic and respiratory variables were recorded. The ONSD showed significant differences at each point (P < 0.001). The ONSDs at T2 and T3 were significantly greater than that at T1 (P = 0.0007 and < 0.0001, respectively). The change in the end-tidal carbon dioxide partial pressure (EtCO2) was similar to the change in the ONSD. The change in the ONSD was significantly correlated with the change in the EtCO2 after tourniquet deflation (r = 0.484, P = 0.030). In conclusion, the ONSD, as an indicator of intracranial pressure, increased after tourniquet deflation in patients undergoing lower limb surgery. This was correlated with an increased EtCO2 and arterial carbon dioxide partial pressure.Trial registration: ClinicalTrials.gov (NCT03782077).

Tranexamic Acid Alters The Immunophenotype of Phagocytes After Lower Limb Surgery

Introduction: Tranexamic acid (TXA) is an antifibrinolytic agent frequently used in elective surgery to reduce blood loss. We recently found it also acts as a potent immune-modulator in patients undergoing cardiac surgery.Methods: Patients undergoing lower limb surgery were enrolled into the “Tranexamic Acid in Lower Limb Arthroplasty” (TALLAS) pilot study. The cellular immune response was characterised longitudinally pre- and post-operatively using full blood examination (FBE) and comprehensive immune cell phenotyping by flowcytometry. Red blood cells and platelets were determined in the FBE and levels of T cell cytokines and the plasmin-antiplasmin complex determined using ELISA.Results: TXA administration increased the proportion of circulating CD141+ conventional dendritic cells (cDC) on post-operative day (POD) 3. It also reduced the expression of CD83 and TNFR2 on classical monocytes and levels of circulating IL-10 at the end of surgery (EOS) time point, whilst increasing the expression of CCR4 on natural killer (NK) cells at EOS, and reducing TNFR2 on POD-3 on NK cells. Red blood cells and platelets were decreased to a lower extent at POD-1 in the TXA group, representing reduced blood loss. Discussion: In this investigation we have extended our examination on the immunomodulatory effects of TXA in surgery by also characterising the end of surgery time point and including B cells and neutrophils in our immune analysis, elucidating new immunophenotypic changes in phagocytes as well as NK cells. This study enhances our understanding of TXA-mediated effects on the haemostatic and immune response in surgery, validating changes in important functional immune cell subsets in orthopaedic patients.

5-HT3 receptor antagonists decrease the prevalence of postoperative delirium in older patients undergoing orthopedic lower limb surgery

Background Delirium is an important postoperative complication. Recent research suggested that 5-hydroxytryptamine 3 (5-HT3) receptor antagonists may have clinical effect in the treatment and prevention of delirium. We investigated the association between 5-HT3 receptor antagonists and the occurrence of postoperative delirium (POD). Methods Retrospectively, the electronic medical records were reviewed in patients aged ≥ 65 years who underwent orthopedic lower limb surgery under regional anesthesia (spinal or combined spinal-epidural anesthesia) and administered intravenous 0.075 mg palonosetron or 0.3 mg ramosetron prior to the end of surgery between July 2012 and September 2015. POD incidence and anesthesia-, surgery-, and patient-related factors were evaluated. To investigate the association between 5-HT3 receptor antagonists and the occurrence of POD, multivariable logistic regression analysis was performed. Results Of the 855 patients included, 710 (83%) were administered 5-HT3 receptor antagonists. POD was confirmed in 46 (5.4%) patients. 5-HT3 receptor antagonists reduced the POD incidence by 63% (odds ratio [OR] 0.37; 95% confidence interval [CI], 0.15–0.94; P = 0.04). Moreover, the POD incidence decreased by 72% (OR 0.28, 95% CI 0.10–0.77, P = 0.01) when palonosetron was administered. Other identified risk factors for POD were emergency surgery, older age, hip surgery, lower body mass index, and intraoperative propofol sedation. Conclusion 5-HT3 receptor antagonists may be related with a significantly reduced risk for POD in older patients undergoing orthopedic lower limb surgery. Notably, palonosetron was more effective for POD prevention.

Comparison of Ultrasound Guided Ankle Block versus Anatomical Landmark Guided Ankle Block in Minor Ankle and Foot Surgeries

Background: Regional anesthesia has increasingly expanded its role in perioperative care of patients undergoing foot and ankle surgery. The use of regional anesthesia has been widely implemented among anesthesiologists and pain providers. Multiple approaches for sephanous nerve blockade have been used including nerve stimulation, anatomical landmarks and ultrasound. It has been observed in previous studies that USG ankle block is more successful as compared to conventional anatomical landmark guided nerve block; so this study was planned to get precise and reliable results regarding both techniques in our local population. Objective: To compare the methods of surgical anesthesia of Ultrasound-guided ankle block versus conventional anatomic landmark-guided techniques in lower limb surgery under regional anesthesia. Materials and methods: This randomized control was carried out at Department of Anesthesia Mayo Hospital Lahore. After meeting the inclusion and exclusion criteria 50 patients (25 in each group ) were enrolled. Patients were randomly divided into two groups using lottery method. Group A patients underwent USG ankle block while group B patients underwent conventional anatomic landmark guided ankle block. Results: Mean age of patients was 46.96±11.578 years; 40(80%) patients were male and 10(20%) patients were females. Successful anesthesia was achieved in 42 (84%) patients; in which in USG block group the successful anesthesia was achieved in 22(88%) patients and in ALG block group successful anesthesia was achieved in 20(80%) patients (p value =0.702) Conclusion : Findings of this study conclude that both techniques have statistically insignificant difference in terms of success rate , however USG ankle block for surgical anesthesia showed higher success rate as compared to anatomic landmark guided technique in lower limb surgery under regional anesthesia. Keywords: Ultrasound-guided Ankle Block, Anatomic Landmark-guided Ankle Block, Lower limb surgery.

Comparision of dexmedetomidine and clonidine with hyperbaric bupivacain in spinal anaesthesia

Background: Alpha-2 adrenergic agonists used as adjuvant to spinal anaesthesia produce substantial sensory and motor blockade of bupivacaine. This study was planned to compare the sensory and motor blockade characteristics of intrathecal combinations of adjuvants dexmedetomidine and clonidine with hyperbaric bupivacaine in the cases who underwent lower limb surgery under spinal anaesthesia.Methods: This was prospective, randomized, double blind study. 90 patients of age group between 18-60 years, ASA grade I and II were allotted into 3 equal groups. Group B received 15 mg bupivacaine plain, group BD and BC received dexmedetomidine (5mcg) and clonidine (50mcg) as adjuvants to bupivacaine respectively.Results: The duration of 2 dermatome regression time, sensory blockade and motor blockade were longest in dexmedetomidine group (129.37±4.87; 386±58.43; 353±48.87) in compared to clonidine (109.77±5.95; 296.53±57.19; 269.7±51.2) and bupivacaine group (81.03±6.83; 211.1± 30.47;181.03±20.8). Both drugs do not affect the peak level of sensory blockade, sensory block onset and motor block onset time. Dexmedetomidine and clonidine do not cause sedation in intraoperative and postoperative period.Conclusions: We conclude that addition of dexmedetomidine and clonidine in spinal anesthesia with hyperbaric bupivacaine increase the duration of ‘2 dermatome regression’ time, sensory and motor blockade and both are more with dexmedetomidine than with clonidine.

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.

Post Operative Pain Management and Patient Satisfection : Experience at a Tertiary Care Hospital

Background: Pain is an inevitable part of the postoperative experience. Current study was designed to assess the pattern of analgesic use, the adequacy of post operative pain control by documenting pain scores and patient satisfaction by documenting the pain perception score of the postoperative patients 48 hours after surgery. Materials and methods: This was a formative research and includes a mix of descriptive cross-sectional study carried out in the Department of Gynecology and Obstetrics, General Surgery and Orthopedics Surgery of Chattagram Maa-O-Shishu Hospital Medical College (CMOSHMC) during the month of January, 2018 to July, 2019. Results: A total of 180 patients underwent surgery were included in this study. Baseline data were collected both retrospectively and prospectively. Only analgesic used immediately after operation in three departments were Pethidine (100%). Diclofenac sodium suppository were used in appendectomy and cesarean section (50/60, 83%) and (26/60, 43%) respectively. Mostly, Diclofenac Sodium IV (55/60, 91%) was used in lower limb surgery. The maximum pain score were 5.3 (SD=2.3), 5.6 (SD =1.9), and 6.1 (SD =1.3) during coughing in the first 8 hour and minimum pain score 2.4 (SD =1.0), 2.2 (SD = 0.8) and 1.7 (SD=1.3) at rest 48 hours after cesarean section, appendectomy and lower limb surgery respectively. But pain score eventually increased during coughing 48 hours after surgery. After 48 hours of surgery maximum pain perception score 3.9 (SD = 0.9) in lower limb surgery and minimum perception score were 3.5 (SD =1.8) in cesarean section. Majority of the appendectomy patient (76%) satisfied with pain management where as only 43% satisfied in case of cesarean section. Conclusion: This study enabled the researchers to get a precise picture of the current state of POPM in different hospitals, as well as identify particular needs for improving such practices in health care facilities and implementing an educational intervention in order to improve the post operative pain management. Chatt Maa Shi Hosp Med Coll J; Vol.20 (2); July 2021; Page 69-73

The Comparison of Inflammatory Cytokines between Spinal and General Anesthesia following Changes in Ischemic Reperfusion due to Tourniquet during Lower Limb Surgery

Background and Objective. The injuries caused by reperfusion of blood can lead to significant adverse effects after surgery. This study aimed to compare the effects of spinal and general anesthesia on inflammatory cytokines following changes in ischemic reperfusion due to tourniquet in lower limb surgeries. Methods. In this randomized controlled clinical trial, 34 patients with lower limb surgery admitted at the orthopedic ward of Imam Reza Hospital, Birjand, Iran, were selected by the available sampling method. They were randomly divided into two groups as follows: general anesthesia (n = 17) and spinal anesthesia (n = 17). Venous blood samples were taken from the patients of both groups at baseline (before the use of tourniquet) and 12 and 24 hours after reperfusion. Interleukin-6 (IL-6), tumor necrotizing factor-α (TNF-α), high-sensitivity C-reactive protein (hs-CRP), and ferritin were measured and recorded. The data were analyzed using independent t-test, chi-square, and repeated measure at the significant level of 0.05. Results. The results showed that hs-CRP and IL-6 significantly increased during the study ( p < 0.001 ); however, the mean changes of TNF-α and ferritin were not significant during the study. Moreover, none of the inflammatory cytokines indicated significant differences between these two study groups ( p < 0.05 ). Conclusion. According to the results, the use of tourniquet can lead to inflammation, and the inflammation is similar in both groups.

Successful use of ultrasound-guided peripheral nerve block for lower limb surgery in a patient with heart failure with reduced ejection fraction: a case report

The number of patients with heart failure with reduced ejection fraction (HFrEF) is increasing. These patients have a reduced cardiorespiratory reserve. Therefore, preoperative evaluation is essential to determine the best type of anaesthesia to use in patients with HFrEF. A 70-year-old man with HFrEF was scheduled to undergo debridement of skin necrosis due to thrombotic occlusion of the right common iliac artery. He had undergone wound dressing changes under local anaesthesia every other day for several months, and treatment for heart failure was on-going. A sciatic nerve and fascia iliaca compartment block was performed under ultrasound guidance because of the patient’s cardiopulmonary function. After confirming adequate sensory blockage, surgery was performed without any haemodynamic instability or complications. Thereafter, debridement was performed twice more using the same block technique, and a skin autograft was also successfully performed. We successfully performed an ultrasound-guided sciatic nerve and fascia iliaca compartment block in a patient with HFrEF who was scheduled to undergo lower limb surgery. Peripheral nerve block is an alternative option for patients with HFrEF.