Journal of Society of Anesthesiologists of Nepal

Comparative study on Postoperative Analgesia with Transversus Abdominis Plane block to Local Anesthetic Infiltration with Ropivacaine in Laparoscopic Cholecystectomy

Tue, 12 Mar 2024 00:00:00 +0000

Introduction: Pain is distressing and detrimental in post-operative patients. We compared post operative analgesia provided by the ultrasound guided transversus abdominis plane block to the local anesthetic infiltration of ropivacaine in patients who underwent laparoscopic cholecystectomy.

Methodology: We conducted comparative, interventional study among 100 patients. The patients were randomly assigned into two groups having 50 in each group. The TAP block group received 20 ml of 0.2% Ropivacaine each on bilateral transversus abdominis plane with ultrasound guidance at the end of surgery. For Local infiltration group (n=50), 20 ml of 0.2% ropivacaine was deposited intraperitoneally in the gall bladder bed and under the right crus of diaphragm before abdominal de-sufflation. Local infiltration group also received infiltration with ropivacaine (0.2%) 20 ml total on three port sites. Visual analog scale at rest and movement measured at 2, 4, 8, 12 and 24 hours after intervention was our primary outcome. Secondary outcome measures were duration of analgesia, total pethidine consumption and ketorolac consumption for the first 24 hours postoperative period.

Results: Visual analogue pain score at rest at 2, 4 and 8 hours and on movement at 2 hours and 4 hours was significantly lower in TAP block group compared to Local infiltration group. TAP block group had significant difference in duration of analgesia compared to Local infiltration group (361 vs 153 min, p < 0.05). TAP block group also had significantly lower consumption of pethidine and ketorolac during the first 12 hours compared to Local infiltration group (p <0.05).

Conclusion: Transversus abdominis block had lower pain score, increased duration of postoperative analgesia and reduced requirement of rescue drugs in the post operative period compared to combined port site and intraperitoneal local infiltration.

Hemodynamic Response During Laryngoscopy and Endotracheal Intubation With or Without Low Dose Dexmedetomidine Premedication : An Observational Study

Prasant Silwal, Nabin Pokhrel — Tue, 12 Mar 2024 00:00:00 +0000

Introduction: Laryngoscopy and endotracheal intubation are important airway securing techniques for patients undergoing general anaesthesia in operating room. This procedure is associated with significant hemodynamic changes putting undue stress in the heart and the brain circulation . Multiple drug therapies have been used to attenuate these responses, but none have been entirely successful till date. Hence aim of the study is to evaluate effects of single, low dose dexmedetomidine premedication on hemodynamic stress response during laryngoscopy and endotracheal intubation in patient posted for elective surgeries under general anaesthesia requiring endotracheal intubation.

Methodology: A prospective, observational study conducted in Bir Hospital and National Trauma Center after approval from Institutional Review Board with enrollment of 52 patients of American Society of Anesthesiologists Physical Status I and II divided into two equal groups. Dexmedetomidine group received 0.5 microgram per kilogram premedication infusion over 10 minutes. Haemodynamic parameters (heart rate and blood pressures) at baseline, after induction, just before intubation, 1, 3, 5 and 10 minutes after intubation were recorded. The general anaesthesia technique was standarized for both groups. p-value < 0.05 was considered statistically significant.

Results: Demographic data were comparable. Statistically significant decrease (p < 0.05) in heart rate, systolic, diastolic, and mean arterial pressures in dexmedetomidine group. None of the patients in dexmedetomidine group had hypotension, bradycardia hypertension and tachycardia.

Conclusion: Dexmedetomidine premedication with 0.5 μg/kg is better for attenuating stress response due to laryngoscopy and endotracheal intubation.

Preoperative Use of Gabapentin or Pregabalin on Acute Postoperative Pain Following Laparoscopic Cholecystectomy

Nirman Gyawali, Ashish Ghimire, Satyendra Narayan Singh — Tue, 12 Mar 2024 00:00:00 +0000

Introduction: Pain is the earliest most common complain after elective laparoscopic cholecystectomy. Different modalities has been suggested to provide better relief from postoperative pain and to reduce opioid related side effects. Pregabalin or gabapentin on reducing postoperative pain following laparoscopic cholecystectomy has been suggested but comprehensive data regarding the optimal dosage are limited. We designed this study to compare the effectiveness of gabapentin or pregabalin for preemptive analgesia.

Methodology: Seventy two patients undergoing laparoscopic cholecystectomy under general anaesthesia were randomized to receive either gabapentin 600 mg [Group A (n=36) or pregabalin 150 mg [Group B (n=36)] 1 hour before surgery. Intraoperatively hemodynamics were monitored. The duration of analgesia, total doses of rescue analgesics, sedation score and postoperative complications were recorded at 0, 30mins, 1, 2, 6,12 and 24 hours.

Results: Patients in Group B had significantly longer duration of postoperative analgesia as compared to Group A (207.08±54.82min vs 245.97±56.15min p=0.004). Requirement of rescue analgesics for the first 24h was more in Group A (Tramadol 70.83±25mg vs 56.94 ±17.53mg p=0.008). Intra and postoperative haemodynamics, postoperative sedation scores and complications were comparable.

Conclusion: Pregabalin provides longer duration of postoperative analgesia as compared to gabapentin following laparoscopic cholecystectomy.

Comparison of Epinephrine and Vasopressin as Second line Vasopressor in Patients with Septic Shock

Tue, 12 Mar 2024 00:00:00 +0000

Introduction: Septic shock continues to be a significant contributor of ICU mortality. Norepinephrine stands as the primary choice for vasopressor therapy. Either epinephrine or vasopressin is added to norepinephrine or vasopressin to attain the desired mean arterial pressure target. Head-to-head comparisons of these second-line options are scarce. We aimed to compare the effect of epinephrine and vasopressin on 7-day and 28-day mortality, occurrence of acute kidney injury, the duration of mechanical ventilation, as well as the lengths of stay in the ICU and hospital among patients diagnosed with septic shock.

Methodology: Our study included 22 adult patients diagnosed with septic shock who were admitted to the intensive care unit (ICU). When the dose of norepinephrine reached 15 mcg/min, either epinephrine (Group E) or vasopressin (Group V) was added according to the discretion of attending intensivist. Patients were followed-up for a period extending up to 28 days following the initiation of these vasopressors.

Results: In this study of septic shock patients in ICU, epinephrine (n=7) vs. vasopressin (n=15) showed similar 7-day mortality (57% vs. 67%, p=1) and 28-day mortality (0% vs. 7%, p=0.6). While Acute Kidney Injury rates were comparable (71% vs. 47%, p=0.38), epinephrine significantly shortened ventilation (2.8 vs. 5.2 days, p=0.04) and ICU stay (3.2 vs. 5.6 days, p=0.03). Duration of hospital stay remained similar (4.5 vs. 6.4 days, p=0.17).

Conclusion: Administration of either epinephrine or vasopressin as a second line vasopressor has similar effect on 7 and 28-day mortality, incidence of acute kidney injury and the overall duration of hospital stay. Nevertheless, individuals administered with epinephrine experienced a reduced duration of mechanical ventilation and shorter ICU length of stay.

A Decade of Critical Care Medicine in Nepal

Subhash P Acharya — Tue, 12 Mar 2024 00:00:00 +0000

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Ultrasound guided localization of inferior gluteal artery for identification sciatic nerve: a case report.

Prajjwal Raj Bhattarai, Anup Bista, Hemant Adhikari — Tue, 12 Mar 2024 00:00:00 +0000

Various approaches to sciatic nerve blocks at different levels have been described. In the nineteenth century, landmark techniques were employed for the nerve block, while nowadays, ultrasound-guided nerve blocks are gaining popularity. Despite the array of techniques available, challenges arise due to factors like the intricate gluteal anatomy, challenging sonoanatomy, patient positioning issues, and the learning curve associated with ultrasound and nerve locators. Among these landmarks, the inferior gluteal artery stands out as an easily identifiable feature with ultrasound assistance. We report a case where we used ultrasound to locate the inferior gluteal artery that guides in the identification of the sciatic nerve. In this t echnique, we can identify the nerve immediately as it emerges from the greater sciatic notch. At this level, we can block the nerve to achieve adequate surgical anesthesia and analgesia for tourniquet pain.

A Decade of Critical Care Medicine in Nepal: Where Have We Reached?

Subhash P Acharya, Kabita Sitoula, Hem Raj Paneru, Shital Adhikary — Tue, 12 Mar 2024 00:00:00 +0000

The first ICU in Nepal started in 1973 at Bir Hospital and now there are 1595 ICU beds in Nepal and 840 ICU Beds with ventilators but only 35 Intensivists and only 2.8 ICU Beds/100,000 population. Anesthesiologists are the main physicians working in ICU and almost all ICUs are open or semi closed. Society of Anesthesiologist of Nepal was established since November 1987 whereas after 2010 Nepalese Society of Critical Care Medicine was established.

Nepal Critical Care Development Foundation was established in 2012 which started workshops & training for Nurses and also organizes various awareness programs on Sepsis Day and Hand Hygiene Day. Critical Care Nurses Association of Nepal was established in 2016 and organizes CCN instructor training program and also critical care nurse training program that has certified more than 300 Critical Care Nurses. Doctorate of Medicine in Critical Care Medicine was started at Institute of Medicine, Tribhuvan University as the first academic program in CCM from 2013 after which fellowship in CCM was started at National Academy of Medical Sciences (2020) and by NSCCM (2023).Masters in Nursing in Critical Care has been started from 2023 at Maharajgunj Nursing Campus, Institute of Medicine from 2023.

Nepal Intensive Care Research Foundation was established in 2020 and started ICU Registry which is now running in 19 ICUs and also working in research and clinical trials. Although COVID has brought in huge investment in infrastructure and equipments, the parallel growth in trained human resources and implementation of standard of care is still awaited. The current need of Critical Care in Nepal is trained human resources, more resources in clinical research, patient safety and quality