Shearing and Migration of Interscalene Catheter After an Uncomplicated Ultrasound Guided Placement

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Vol 2 | Issue 2 | July-December 2021 | Page 137-140 | Shashank Rane, Vijay Shetty, Sitaram Prasad, Rajat Bhargava

DOI: 10.13107/ijra.2021.v02i02.042

Authors: Shashank Rane [1], Vijay Shetty [1], Sitaram Prasad [2], Rajat Bhargava [3]

[1] Department of Anaesthesia, Fortis Hospital, Mumbai, Maharashtra, India.
[2] Department of Plastic Surgery, Fortis Hospital, Mumbai, Maharashtra, India.
[3] Department of Radiology, Fortis Hospital, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Shashank Rane,
Department of Anaesthesia, Fortis Hospital, Mumbai, Maharashtra, India.
E-mail: shankrane81@gmail.com

Abstract

We report on the case of shearing and migration of an interscalene nerve catheter in 68- year-old female who underwent a left shoulder surgery. The catheter was placed under ultrasound guidance without any apparent complications. Continuous interscalene nerve block was successfully used to complement General Anaesthesia and provide postoperative pain relief. On the second day, at the time of catheter removal, the catheter inadvertently sheared at the point of insertion with the distal 7 centimetres migrating under the skin. The axial and coronal CT scan sections confirmed the migration of the catheter posterolateral to subclavian artery in the vicinity of the Brachial plexus. Patient did not have any pain or neurological deficit. Surgery was performed to extract the catheter, which was found in brachial plexus sheath between lower end of Scalenus Anterior and Scalenus Medius.
Keywords: Interscalene catheter, Shearing, Migration

References

1. Capdevila X, Pirat P, Bringuier S, et al. Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: A multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients. Anesthesiology 2005;103:1035–45.
2. Ates Y, Yucesoy CA, Unlu MA, Saygin B, Akkas N. The mechanical properties of intact and traumatized epidural catheters. Anesth Analg 2000;90:393–9.
3. Hadzic A, ed. New York School of Regional Anesthesia. Textbook of Regional Anesthesia and Acute Pain Management. New York: McGraw-Hill Medical Pub. Division; 2007:412–3.
4. Despond O, Kohut GN. Broken interscalene brachial plexus catheter: surgical removal or not? Anesth Analg. 2010 Feb 1;110(2):643-4. doi: 10.1213/ane.0b013e3181c62a05. PMID: 20081147.
5. Mitra R, Fleischmann K. Management of the sheared epidural catheter: Is surgical extraction really necessary? J Clin Anesth 2007;19:310–4.
6.  Bowens C Jr, Briggs ER, Malchow RJ. Brachial plexus entrapment of interscalene nerve catheter after uncomplicated ultrasound-guided placement. Pain Med. 2011;12:1117-20.
7. Ilfeld BM, Morey TE, Enneking FK. Infraclavicular perineural local anesthetic infusion: A comparison of three dosing regimens for postoperative analgesia. Anesthesiology 2004;100:395–402.
8. Brenier G, Salces A, Magues JP, Fuzier R. Peripheral nerve catheter entrapment is not always related to knotting. Can J Anaesth 2010;57:183–4.

How to Cite this Article: Rane S, Shetty V, Prasad S, Bhargava R | Shearing and Migration of Interscalene Catheter After an Uncomplicated Ultrasound Guided Placement | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 137-140.

 

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Clinical Pearl for a Successful and Safe PNS Guided Peripheral Nerve Block

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Vol 2 | Issue 2 | July-December 2021 | Page 143-144  | Ritesh Roy, Himjyoti Das, Neha Singh, Surajit Giri, Hetal Vadera, Vrushali Ponde

DOI: 10.13107/ijra.2021.v02i02.044

Authors: Ritesh Roy [1], Himjyoti Das [2], Neha Singh [3], Surajit Giri [4], Hetal Vadera [5], Vrushali Ponde [6]

[1] Department of Anaesthesia and Pain management Care Hospitals, Bhubaneswar, Odisha, India.
[2] Anesthesia and Critical care, Nazareth Hospital, Shillong, Assam, India.
[3] Department of Anesthesiology and Critical care, AIIMS, Bhubaneswar, Odisha, India.
[4] Department of Anesthesia, Pragati Hospital, Sivasagar, Assam, India.
[5] Department of Anaesthesia, Sterling Hospital, Rajkot, Gujarat, India.
[6] Department Anesthesiology, Surya Children Hospital, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Vrushali Ponde,
Consultant Paediatric Anaesthesiologist, Surya Children Anaesthesia Services, Mumbai, Maharashtra, India.
E-mail: vrushaliponde@yahoo.co.in

Clinical Pearl for a Successful and Safe PNS Guided Peripheral Nerve Block

PRE OP PREPARATION
 Pre-procedural evaluation with history of antiplatelet or antithrombotic drug use
 Assess neurological status in patient with trauma and neuropathy
 Explain the procedure and complications
 Possibilities of failure of the procedure, multiple injections and conversion to GA must be explained
 Obtain informed written consent

PRE PROCEDURE PREPARATION ( AORA Check list)
 Perform the block in a dedicated block room or in OT
 Confirm the site before starting the procedure
 Block room must be equipped with monitoring devices and equipment
 Ensure all resuscitative emergency drugs, equipment and Intralipid present in the cart
 Secure venous access before performing the procedure
 Connect monitor for ECG, Non-invasive blood pressure (NIBP), and peripheral oxygen saturation

BEFORE GIVING BLOCK
 STOP BEFORE YOU BLOCK: Confirm again about patient and site of block
 Calculate and keep drugs needed for block in labelled syringes ready before the procedure
 Maintain asepsis throughout the procedure
 A small dose of sedative / anxiolytic may be necessary for anxious patients. Infiltrate the injection site with lignocaine.
 Positive electrode is Red, and negative is Black (Positive is attached to patient, negative end is attached to the Needle). Machines may have different colour coding for the electrodes
 PNS stimulation is not possible in patient receiving neuromuscular blocking agent
 Presence of neuraxial anaesthesia doesn’t affect the stimulation of intact motor unit by PNS

BLOCK PROCEDURE
 Always use insulated needle
 For superficial blocks: Use 50 mm needle, current at 1.0 mA.
 For deeper blocks: Use 100 mm needle, current at 1.5 mA
 Set PNS in 0.2ms current duration & frequency at 2 Hz.
 End motor response (EMR) between 0.3mA to 0.5mA is considered safe and ideal (except lumbar plexus block where below 0.5mA is unsafe).
 For children 25mm needle is preferred.
 Repeated aspiration before injection of drug at 3-5ml aliquot is a safe practice.
 Never try to inject against high resistance, use of injection pressure monitoring device is advisable.
 Keep talking to the patient while injecting the drug for early detection of the signs of the toxicity.
 Injection of Dextrose solution is preferred over sodium chloride for hydro dissection as saline will abolish muscle twitches.

DESIRABLE END MOTOR RESPONSE

Nerve Block Response
Interscalene Brachial plexus block Any two contractions of pectoralis major, deltoid, triceps or biceps.
Supraclavicular Brachial plexus block Finger or wrist twitches (flexion or extension)
Infraclavicular Brachial Plexus Block Posterior cord response is desirable (Extension of wrist and fingers)
Axillary Brachial Plexus Block Median nerve- Flexion of first three fingers

Musculocutaneous nerve- Elbow flexion Radial nerve- Fingers extension

Ulnar nerve- Flexion of fourth &little finger along with apposition of thumb towards little finger
Femoral Nerve Block Dancing of patella (Twitches of quadriceps muscle)
Sciatic Nerve Block Planter flexion or dorsi flexion
Lumbar Plexus Block Quadriceps contraction
Ilioinguinal & Iliohypogastric Nerve Block Lower Abdominal muscle & Inguinal region Twitches (T10-L1 territory)
Thoracic Paravertebral Block Corresponding intercostal muscles twitches
Serratus Anterior Plane (SAP) Block Serratus anterior muscle twitches/ Dancing of Scapula.
PEC1 Block Pectoralis Major muscle twitches

AFTER PROCEDURE

 Document the procedure. Date, Time, Needle type, size, disappearance of EMR at what current, setting of the PNS before injection of the drug, injection resistance or ease of injection, tingling or numbness during or immediately after injection, vitals etc.
 Assessment of Dermatome, Myotome and osteotome at 30minute. If all are blocked, then only we can proceed for incision and surgery

 

How to Cite this Article: Roy R, Das H, Singh N, Giri S, Vadera H, Ponde V | Clinical Pearl For A Successful And Safe PNS Guided Peripheral Nerve Block | July-December 2021; 2(2): 143-144.

 

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Continuous Caudal Catheters in Neonatal Population: A Focussed Review

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Vol 2 | Issue 2 | July-December 2021 | Page 124-130 | Vrushali Ponde, Kriti Puri, Nandini Dave

DOI: 10.13107/ijra.2021.v02i02.040

Authors: Vrushali Ponde [1], Kriti Puri [2], Nandini Dave [3]

[1] Department of Anaesthesia, Surya Children Anaesthesia Services, Mumbai, Maharashtra, India.
[2] Department of Anaesthesia, Ganga Hospital, Coimbatore, Tamil Nadu, India.
[3] Department of Anaesthesia, NH SRCC Children’s Hospital, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Vrushali Ponde,
Consultant Paediatric Anaesthesiologist, Surya Children Anaesthesia Services, Mumbai, Maharashtra, India.
E-mail: vrushaliponde@yahoo.co.in

Abstract

Caudal epidural block is one of the most commonly administered blocks in paediatric population. Continuous caudal technique offers several advantages like its ability to cater to long duration surgeries, higher thoracic procedures and to deliver extended, titratable post-operative pain relief. Current advances in this technique like use of fluoroscopy, electrical stimulation and Ultrasound to secure continuous caudal catheters facilitate enhanced accuracy and safety and should be adopted wherever feasible. An understanding of local anaesthetic dosages for infusion and their fine tuning is a prerequisite. The potential benefits and risks should be assessed on a case-to-case bases
Keywords: Caudal anaesthesia, Post-operative pain, Neonatal regional anaesthesia

References

1. Wiegele M, Marhofer P, Lönnqvist PA. Caudal epidural blocks in paediatric patients: a review and practical considerations. Br J Anaesth. 2019 Apr;122(4):509-517.
2. Bosenberg AT, Bland BAR, Schulte-Steinberg O, Downing JW. Thoracic epidural anaesthesia via the caudal route in infants. Anaesthesiology 1988;69:265-9.
3. Kil HK. Caudal and epidural blocks in infants and small children: historical perspective and ultrasound-guided approaches. Korean J Anesthesiol. 2018;71(6):430-439. doi:10.4097/kja.d.18.00109.
4. Simpao A, Gálvez J, Wartman E, England W, Wu L, Rehman M et al. The Migration of Caudally Threaded Thoracic Epidural Catheters in Neonates and Infants. Anesthesia & Analgesia. 2019;129:477-481.
5. Baidya D, Pawar D, Dehran M, Gupta A. Advancement of epidural catheter from lumbar to thoracic space in children: Comparison between 18G and 23G catheters. Journal of Anaesthesiology Clinical Pharmacology. 2012;28:21.
6. Ponde VC, Bedekar VV, Desai AP, Puranik KA. Does ultrasound guidance add accuracy to continuous caudal epidural catheter placements in neonates and infants? Paediatr Anaesth. 2017 Oct;27(10):1010-1014.
7. Bachman SA, Taenzer AH. Thoracic caudal epidural catheter localization using ultrasound guidance. Paediatr Anaesth. 2020 Feb;30:194-195.
8. Daftary S, R Jagtap. Caudal epidural as a sole anaesthetic in preterm, former preterm and high-risk infants. Indian J. Anaesth. 2005;49:195-198.
9. Uguralp S, Mutus M, Koroglu A, Gurbuz N, Koltuksuz U, Demircan M. Regional anesthesia is a good alternative to general anesthesia in pediatric surgery: Experience in 1,554 children. J Pediatr Surg. 2002 ;37:610-3.
10. Raghavendran S, Diwan R, Shah T, Vas L. Continuous caudal epidural analgesia for congenital lobar emphysema: a report of three cases. Anaesth Analg. 2001Aug;93:348-50.
11. Carolis MPD, Bersani I, Piersigili F et al. Peripheral nerve blockade and neonatal limb ischemia: Our experience and literature review. Clinical and applied thrombosis/ haemostasis. 2014 Jan:55-60.
12. Luz G, Ladner E, Innerhofer P, Deusch E. Accidents following extradural analgesia in children. The results of a retrospective study. Paediatr Anaesth 1995;5:273.
13. McNeely J, Faber N, Rusy L, Hoffman G. Epidural analgesia improves outcome following paediatric fundoplication: a retrospective analysis. Reg Anaesth 1997; 22: 16-23.
14. Lin, Y.C, Sentivany Collins S.K, Peterson K.L, Boltz M.G and Krane E.J. Outcomes after single injection caudal epidural versus continuous infusion epidural via caudal approach for postoperative analgesia in infants and children undergoing patent ductus ligation. Paediatr Anaesth 1999; 9:134-143.
15. Bosenberg A. Benefits of regional anesthesia in children. Paediatr Anaesth. 2012 Jan;22:10-8.
16. Koo BN, Hong JY, Song HT, Kim JM, Kil HK. Ultrasonography reveals a high prevalence of lower spinal dysraphismin childrenwith urogenital anomalies. Acta Anaesthesiol Scand. 2012;56:624–8.
17. Tsui BC, Seal R, Koller J. Thoracic epidural catheter placement via the caudal approach in infants by using electrocardio- graphic guidance. Anesth Analg. 2002;95:326–330.
18. Tsui BC, Seal R, Koller J, Entwistle L, Haugen R, Kearney R. Thoracic epidural analgesia via the caudal approach in pediat- ric patients undergoing fundoplication using nerve stimulation guidance. Anesth Analg. 2001;93:1152–1155.
19. Tobias J.D. Caudal epidural block : Review of test dosing and recognition of systemic injection in children. Anaesth Analg. 2001;93:1156-61.
20. Suresh S, Ecoffey C, Bosenberg A, et al. The European society of regional anaesthesia and pain therapy/American society of regional anesthesia and pain medicine recommendations on local anesthetics and adjuvants dosage in pediatric regional anesthesia. Reg Anesth Pain Med 2018; 43: 211-6.
21. Gibbs A, Kim SS, Heydinger G, Veneziano G, Tobias J. Postoperative Analgesia in Neonates and Infants Using Epidural Chloroprocaine and Clonidine. J Pain Res. 2020;13:2749-2755.
22. Giaufre E, Dalens B, Gombert A. Epidemiology and morbidity of regional anaesthesia in children: a one-year prospective survey of the French-Language Society of Paediatric Anaesthesiologists. Anaesth Analg 1996; 83:904 912.
23. Suresh, Santhanam MD*; Long, Justin MD*; Birmingham, Patrick K. MD*; De Oliveira, Gildasio S. Jr MD, MSCI† Are Caudal Blocks for Pain Control Safe in Children? An Analysis of 18,650 Caudal Blocks from the Pediatric Regional Anesthesia Network (PRAN) Database, Anaesth Analg. 2015< 120 151-156.
24. Breschan C, Krumpholz R, Jost R, Likar R. Intraspinal haematoma following lumbar epidural anaesthesia in a neonate. Paediatr Anaesth 2001; 11:105 –108.
25. Apthorp M, Challands J, Visram A. A survey of the usage of caudal catheters amongst paediatric anaesthetists practising in the UK [Abstract]. Paediatr Anaesth 2000; 10:692.
26. Walker SM, Yaksh TL. Neuraxial analgesia in neonates and infants: a review of clinical and preclinical strategies for the development of safety and efficacy data. Anesth Analg. 2012;115(3):638-662. )
27. Lejus C, Surbled M, Schwoerer D, et al. Postoperative epidural analgesia with bupivacaine and fentanyl: hourly pain assessment in 348 paediatric cases. Paediatr Anaesth 2001; 11:327-332.
28. Breschan C, Krumpholz R, Likar R, et al. Can a dose of 2 mg kg71 caudal clonidine cause respiratory depression in neonates? Paediatr Anaesth 1999; 9:81-83.
29. Bouchut JC, Dubois R, Godard J. Clonidine in preterm-infant caudal anesthesia may be responsible for postoperative apnea. Reg Anesth Pain Med 2001; 26:83-85.
30. Wood CE, Goresky GV, Klassen KA, et al. Complications of continuous epidural infusions for postoperative analgesia in children. Can J Anaesth 1994; 41:613-620.
31. Boos K, Beushausen T, Ohrdorf W. Peridural catheter for postoperative long- term analgesia in children. AnaÈ sthesiol Intensivmed Notfallmed Schmerzther 1996; 31:362-367.
32. Aram L, Krane EJ, Kozloski LJ, Yaster M. Tunneled epidural catheters for prolonged analgesia in pediatric patients. Anesth Analg 2001; 92:1432- 1438.
33. Fujinaka W, Hinomoto N, Saeki S, et al. Decreased risk of catheter infection in infants and children using subcutaneous tunneling for continuous caudal anesthesia. Acta Med Okayama 2001; 55:283-287.
34. Vas L, Naik V, Patil B, Sanzgiri S. Tunnelling of caudal epidural catheters in infants. Paediatr Anaesth 2000; 10:149-154.
35. Bubeck J, Boos K, Krause H, Thies K. Subcutaneous Tunneling of Caudal Catheters Reduces the Rate of Bacterial Colonization to That of Lumbar Epidural Catheters. Anesthesia & Analgesia. 2004;99:689-693.
36. Kinirons B, Mimoz O, Lafendi L, et al. Chlorhexidine versus povidone iodine in preventing colonization of continuous epidural catheters in children: a randomized, controlled trial. Anaesthesiology 2001; 94:239-244.
37. BuÈttner W, Finke W. Analysis of behavioural and physiological parameters for the assessment of postoperative analgesic demand in newborns, infants and young children: a comprehensive report on seven consecutive studies. Paediatr Anaesth 2000; 10:303-318.
38. Lejus C, Surbled M, Schwoerer D, et al. Postoperative epidural analgesia with bupivacaine and fentanyl: hourly pain assessment in 348 paediatric cases. Paediatr Anaesth 2001; 11:327-332.
39 Joselyn A,Bhalla T, Schloss B, Martin D,Tobias J.A case report of a retained and knotted caudal epidural catheter.Saudi J Anaesth 2014;8:424.

How to Cite this Article: Ponde V, Puri K, Dave N | Continuous Caudal Catheters in Neonatal Population: A Focussed Review | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 124-130.

 

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Changing Scenario of Regional Anaesthesia Practice in Northeast India

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Vol 2 | Issue 2 | July-December 2021 | Page 117-123  | Himjyoti Das, Surajit Giri, Langpoklakpam Chaoba Singh

DOI: 10.13107/ijra.2021.v02i02.039

Authors: Himjyoti Das [1], Surajit Giri [2], Langpoklakpam Chaoba Singh [3]

[1] Department of Anaesthesia & Critical care, Nazareth Hospital, Shillong, Meghalaya.
[2] Department of Anaesthesia, Pragati Hospital & Research Centre, Sivasagar, Assam.
[3] Department of Anaesthesia & Critical care, RIMS, Imphal, Manipur.

Address of Correspondence
Dr. Surajit Giri,
Pragati Hospital & Research Centre, Sivasagar, Assam.
E-mail: drsurajitgiri@outlook.com

Abstract

The North-East (NE) region of India comprises of eight states- Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura. (Fig 1) The anesthesia services in remote areas of this region are greatly restricted due to inadequate qualified manpower and infrastructure, as very few postgraduate and DNB (Diplomate National Board) seats are available each year across 4 out of 8 states through the NEET PG Test. (Fig 2a & 2b) Regional Anesthesia (RA) has several benefits in certain patients over general anesthesia. It not only allows for better post-operative pain management and a comfortable post-operative patient, but also allows for safer surgeries in patients with comorbidities that carry potentially life-threatening risks with general anesthesia, especially in a resource limited areas. The practice of RA took a backseat in the recent past due to lack of proper training in RA and the absence of a structured curriculum during PG training. However, during the last decade, we have witnessed a paradigm shift in RA and PNB (Peripheral nerve block) anesthesia with continued support from Academy of Regional Anaesthesia (AORA) & Indian Society of Anesthesiologists (ISA). For better understanding of the changing scenario of regional anesthesia practice in this region over years, we may divide the timeline into two phases, late 20th century and the 21st century.

How to Cite this Article: Das H, Giri S, Singh LC | Changing Scenario of Regional Anaesthesia Practice in Northeast India | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 117-123.

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The Anatomy Table – Is it the Future Learning Tool for Regional Anaesthesiologists?

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Vol 2 | Issue 2 | July-December 2021 | Page 111-116 | Rajkumar Elanjeran, Anitha Ramkumar, Sandeep Ganni

DOI: 10.13107/ijra.2021.v02i02.038

Authors: Rajkumar Elanjeran [1], Anitha Ramkumar [1], Sandeep Ganni [2]

[1] Department of Emergency Medicine, GSL Medical College and General Hospital, Rajahmundry, Andhra Pradesh, India.
[2] Managing Director, GSL Educational Society, Rajahmundry, Andhra Pradesh, India.

Address of Correspondence
Dr. Rajkumar Elanjeran
Manager, Clinical Lead of Simulation, and Consultant Emergency Physician, GSL Medical College and General Hospital, Rajahmundry, Andhra Pradesh, India.
E-mail: seran50.raj@gmail.com

Abstract

Cadaveric dissection has been the main stay of anatomy training for regional anaesthesia over the years. Advent of advance visualisation hardware and software has revolutionised anatomy teaching and it is only a matter of time before this technology transcends into regional anaesthesia training. This article demonstrates the innumerable capabilities of virtual dissection table using one specific use case- the supraclavicular approach to the brachial plexus block.
Keywords: Simulation, Virtual dissection, Virtual anatomy

References

1. Fyfe, Sue & Fyfe, Georgina & Dye, Danielle & Radley-Crabb, Hannah. (2018). The Anatomage table: Differences in student ratings of usefulness from first implementation to established use.
2. Alessandro Stecco, Francesca Boccafoschi, Zeno Falaschi, Giulio Mazzucca, Andrea Carisio, Simone Bor, Irene Valente, Sergio Cavalieri, Alessandro Carriero,. Virtual dissection table in diagnosis and classification of Le Fort fractures: A retrospective study of feasibility, Translational Research in Anatomy, Volume 18, 2020, 100060.
3. Taoum, Alexandre & Sadqi, Rihab & Zidi, Mustapha & Tassigny, Alexandra & Megdiche, Kawtar & Ngote, Nabil. (2019). On the Use of Anatomage Table as Diagnostic Tool. 13. 20-25.
4. J. Brown, S. Stonelake, W. Anderson, M. Abdulla, C. Toms, A. Farfus, J. Wilton, Medical student perception of anatomage – A 3D interactive anatomy dissection table, International Journal of Surgery, Volume 23, supplement 1, 2015, Pages S17-S18.
5. Smith, K.E., Ruholl, H.O. and Gopalan, C. (2019), Utilization of Anatomage Table Technology Enhances Knowledge, Comprehension, and Application of Human Anatomy and Physiology in Multiple Settings. The FASEB Journal, 33: 598.19-598.19.

How to Cite this Article: Elanjeran R, Ramkumar A, Ganni S | The Anatomy Table – Is it the Future Learning Tool for Regional Anaesthesiologists? | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 111-116.

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Randomized Controlled Trials

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Vol 2 | Issue 2 | July-December 2021 | Page 107-110 | Nidhi Bhatia, Anju Grewal
DOI: 10.13107/ijra.2021.v02i02.037

Authors: Nidhi Bhatia [1], Anju Grewal [2]

[1]  Department of Anaesthesiology & Intensive Care, PGIMER, Chandigarh, India.
[2]  Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Address of Correspondence
Dr. Anju Grewal, Professor & Head,
Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.
E-mail: dranjugrewal@gmail.com

Abstract

A randomized controlled trial (RCT) is a prospective, comparative, quantitative experiment/study that is performed under controlled conditions with random allocation of interventions to comparison groups. Among all the clinical study designs, evidence generated from RCTs is considered to be at top of the evidence pyramid. There are many different RCT designs and they can be classified on the basis of interventions evaluated, participants’ exposure and level of blinding. All RCTs should be planned prospectively, a research question should be formulated, sample population approached and informed consent obtained from participants of the trial. These consented subjects are randomly assigned to any of the study arms and the changes are then measured over time. The basic principles to designing an RCT include formulating a research question, developing a protocol, randomization, allocation concealment, blinding, sample size calculation and registering of RCTs. Appropriate guidelines for reporting RCTs should be followed and RCTs should only be conducted if they are ethically viable, economical and clinically worthwhile.
Keywords: Randomised Control Trial (RCT)

References

1. Zabor EC, Kaizer AM, Hobbs BP. Randomized Controlled Trials. Chest 2020; 158: S79-S87.
2. Bhide A, Shah PS, Acharya G. A simplified guide to randomized controlled trials. Acta Obstet Gynecol Scand 2018;97:380-387.
3. White H, Sabarwal S, De Hoop T. Randomized Controlled Trials (RCTs): Methodological Briefs 2014 ; Impact Evaluation No. 7, Methodological Briefs no. 7.
4. Stolberg HO, Norman G, Trop I. Randomized controlled trials. AJR Am J Roentgenol 2004;183:1539-44.
5. Thiruvenkatachari B. Randomized controlled trials: The technique and challenges. J Indian Orthod Soc 2015;49:42-7.
6. World Medical Association. World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects. JAMA. 2013;310(20):2191–2194. doi:10.1001/jama.2013.281053.
7. Elliott TR. Registering randomized clinical trials and the case for CONSORT. Exp Clin Psychopharmacol. 2007 Dec;15(6):511-8. doi: 10.1037/1064-1297.15.6.511. PMID: 18179303; PMCID: PMC2518067.
8. Akobeng AK. Understanding randomised controlled trials. Arch Dis Child 2005 ;90:840-4.

How to Cite this Article: Bhatia N, Grewal A | Randomized Controlled Trials | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 107-110.

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Anatomy of Lumbar Plexus and Implications to Regional Anaesthesiologist

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Vol 2 | Issue 2 | July-December 2021 | Page 102-106 | G. Amudha, Sandeep Diwan

DOI: 10.13107/ijra.2021.v02i02.036

Authors: G. Amudha [1], Sandeep Diwan [2]

[1] Department of Anatomy, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India.
[2] Department of Anaesthesia, Sancheti Hospital Pune, Maharashtra, India.

Address of Correspondence
Dr. G.Amudha,
Department of Anatomy, PSG Institute of Medical Sciences and Research, Coimbatore, India
E-mail: ammuramesh@gmail.com

Abstract

Lumbar plexus is one of the two nerve plexuses which supply the lower limb. It is formed in the posterior abdominal wall within the psoas major muscle. The branches of the plexus exit via the medial and lateral borders as well as its ventral surface. It is a complex plexus which gives a branch to complete the formation of lumbo sacral plexus. The branches mainly supply the groin, anterior and medial compartments of thigh. They also supply the hip and knee joints. The cutaneous innervation by the branches of lumbar plexus is limited to the anterior, lateral and medial parts of the thigh, medial side of the leg and foot and also the lower part of anterior abdominal wall and perineum. Regional anaesthesia is a highly skilled and precise technique used widely in the patients to reduce the drug usage and decrease the intra and post operative complications. Lumbar plexus block can be used in surgeries related to hip joint and anterior part of thigh and groin. To execute the procedure successfully, sound knowledge in anatomy of lumbar plexus is required.
Keywords: Lumbar plexus, Branches, Regional anaesthesia.

References

1. Standring S. Gray’s Anatomy: The anatomical Basis of Clinical Practice. In pelvic girdle, gluteal region and thigh:41st edition: London. Elsevier; 2015; 1371-73.
2. Mahakkanukrauh P et al. A cadaveric study of the anatomical variations of the lumbar plexus with clinical implications. J.Anat. Soc. India, 2016;65:24-8.
3. Javier J. Polania Gutierrez; Bruce Ben-David .2020. Lumbar plexus block. https://www.ncbi.nlm.nih.gov/books/NBK556116.
4. Philip A Anloague, Peter Hujibregts. Anatomical variations of the lumbar plexus: A descriptive anatomy study with proposed clinical implications. The J. Man. Manip.Ther. 2009;17(4): e107-e114.
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How to Cite this Article: Amudha G, Diwan S | Anatomy of Lumbar Plexus and Implications to Regional Anaesthesiologist | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 102-106.

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Effect of Neuraxial Anaesthesia on Left Ventricular Diastolic Function Assessed by Transthoracic Echocardiography

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Vol 2 | Issue 2 | July-December 2021 | Page 131-136 | Maithriye Kavishree, Srinath Damodaran, Sharanu Patil, Kumar Belani, Muralidhar Kanchi

DOI: 10.13107/ijra.2021.v02i02.041

Authors: Maithriye Kavishree [1], Srinath Damodaran [1], Sharanu Patil [2], Kumar Belani [3], Muralidhar Kanchi [1]

[1] Department of Cardiac Anaesthesia, Narayana Institute of Cardiac Sciences, Narayana Health City, Bangalore, Karnataka, India.
[2] Department of Anaesthesia and Intensive care, Sparsh Hospital, Bangalore, Karnataka, India.
[3] Department of Cardiac Anaesthesia, Masonic Children’s Hospital, University of Minnesota, Minneapolis, United States of America.

Address of Correspondence
Dr. Muralidhar Kanchi
Academic Director, Senior Consultant & Professor, Department of Cardiac Anaesthesia, Narayana Institute of Cardiac Sciences, Narayana Health City, Bangalore, Karnataka, India.
E-mail: muralidhar.kanchi.dr@narayanhealth.org

Abstract

Purpose: To evaluate the effect of neuraxial anaesthesia on left ventricular (LV) diastolic function in clinical setting using transthoracic echocardiography (TTE).
Methods: This prospective observational study was performed in 50 adult patients undergoing elective orthopaedic surgical procedures under neuraxial anaesthesia for lower limb surgery. TTE was performed before, 20, 40 and 60 minutes after neuraxial anaesthesia. Pulsed wave Doppler of the transmitral flow (TMF), pulmonary venous flow (PVF), deceleration time (DT) and propagation velocity (Vp) were measured. Septal and lateral wall mitral annular velocities (E’, A’) were assessed by tissue Doppler imaging (TDI). The maximum diameter of left atrium (LA) and right atrium (RA), LA volume index, left ventricular (LV) and right ventricular (RV) end-diastolic area (EDA), end-systolic area (ESA), fractional area change (FAC),LV end-diastolic volume (EDV), end-systolic volume (ESV), were measured from apical 4-chamber view (A4CV) view.
Results: There were 50 patients in the cohort of whom 48 had normal diastolic function preoperatively. Following neuraxial anaesthesia, mean arterial pressure decreased (96.61.52 to 83.70.3, p <0.001) while heart rate remained unchanged (84.416.6 to 85.315.0, p =0.436). The dimensions and volumes of cardiac chambers, LV FAC and RV FAC transmitral pulse wave Doppler, DT, Vp, PVF and mitral annular TDI did not vary after neuraxial anaesthesia (p>0.05).
Conclusion: In patients with normal diastolic function, neuraxial anaesthesia does not alter diastolic function indices and grading. “It is recommended that the study be performed in patients with documented diastolic dysfunction to demonstrate beneficial or detrimental effects of central neuraxial blockade, if any.”
Keywords: Spinal anaesthesia, Neuraxial anaesthesia, Transthoracic echocardiography, Diastolic function, Left ventricle

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How to Cite this Article: Kavishree M, Damodaran S, Patil S, Belani K, Kanchi M | Effect of Neuraxial Anaesthesia On Left Ventricular Diastolic Function Assessed By Transthoracic Echocardiography | July-December 2021; 2(2): 131-136.

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Difficult subarachnoid anaesthesia Prediction and Performance

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Vol 2 | Issue 2 | July-December 2021 | Page 92-99 | André Van Zundert

DOI: 10.13107/ijra.2021.v02i02.034

Authors: André Van Zundert [1, 2]

[1] Department of Anaesthesia, The University of Queensland, Faculty of Medicine, Brisbane, Queensland, Australia.
[2] Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia.

Address of Correspondence
Professor Dr. André Van Zundert,
Professor & Chair Anaesthesiology, The University of Queensland, Faculty of Medicine,
Brisbane, Queensland. Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia.
E-mail: vanzundertandre@gmail.com

Introduction

Spinal anaesthesia (SA) has enjoyed a long history of success, celebrating soon its 125th anniversary. Puncturing the dura mater is considered a simple procedure, followed by a subarachnoid injection of a local anaesthetic (LA) agent into the cerebrospinal fluid (CSF). Even when the technique is performed perfectly, there is no guarantee that the block sits perfectly. Failure is not uncommon and encompasses a range from total absence of any neuraxial blockade, a partial block (insufficient height, quality or duration) or a patchy block. Table 1 lists a large number of potential causative factors that may result in a failed spinal anaesthetic, providing suggestions of solutions. Analysing each distinct phase of the procedure, i.e., spinal puncture, injection of local anaesthetic solution, spread of the local anaesthetic solution through the cerebrospinal fluid, action of the drug on subarachnoid neural tissue and patient management, are the keys to success at each stage. Mechanisms of failure of spinal anaesthesia include insufficient preparation and check of equipment and drugs, suboptimal positioning of the patient, unsuccessful puncture due to inadequate training or experience and inadequate use of needles and local anaesthetic solution.1-5 Besides operator, preparation, technique-dependent and patient-related factors (anatomical variations), there are also organisational factors (lack of block room, lack of adequate monitoring and trained personnel, insufficient time between block and onset of surgery, subsequent management following block). The use of the correct local anaesthetic (dose, volume, concentration) injected at the correct lumbar interspace is of paramount importance to produce an adequate spinal block for the right surgical intervention.
Nevertheless, failures may still occur. Therefore, the anaesthetist should always have a contingency plan for a failed spinal block. Indeed, patients expect reliable surgical anaesthesia when undergoing an operation under regional anaesthesia. If the block fails, we need to be ready to offer a solution, using rescue techniques. The alternatives are either to repeat the spinal anaesthesia or to convert to a general anaesthetic.
Failed spinal anaesthesia has roughly three reasons: a) the local anaesthetic solution does not reach the subarachnoid space; b) the drug has been injected at the right location, but the block is not what is expected; and c) the local anaesthetic solution works well, but the dosage chosen is not correct or results in unilateral or patchy blocks as the resulting block is deficient in quantity, quality or duration.

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How to Cite this Article: Van Zundert A | Difficult Subarachnoid Anaesthesia Prediction and Performance | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 92-99.

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Regional Anaesthesia in Enhanced Recovery After Surgery Pathways – A Quintessential Component

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Vol 2 | Issue 2 | July-December 2021 | Page 87-91 | Abhijit S. Nair, Sandeep Diwan

DOI: 10.13107/ijra.2021.v02i02.033

Authors: Abhijit S. Nair [1], Sandeep Diwan [2]

[1] Department of Anaesthesia, Ibra Hospital, Ministry of Health-Oman, Ibra, Sultanate of Oman.
[2] Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Abhijit S. Nair, Department of Anaesthesia, Ibra Hospital, Ministry of Health-Oman, Ibra-414, Sultanate of Oman.
E-mail: abhijitnair95@gmail.com

Introduction

Enhanced recovery after surgery (ERAS) is a multimodal, perioperative care pathway designed to achieve early recovery for patients undergoing major surgery. [1] Initially described by Henry Kehlet in 1995 for colonic surgeries, the enhanced recovery pathways have now evolved and are now validated for more than 30 different types of surgery which include but are not limited to emergency laparotomy, neonatal surgeries, and lower segment cesarean sections. [2] Not only is the patient benefited from this by having an enhanced recovery and early discharge from the hospital, the cost of treatment is reduced and also leads to more turnover of patients thereby reducing the waiting list of patients scheduled for various surgeries. [3]

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How to Cite this Article: Nair AS, Diwan S | Regional Anaesthesia in Enhanced Recovery After Surgery Pathways – A Quintessential Component | International Journal of Regional Anaesthesia | July-December 2021; 2(2): 87-91.

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