Encephalocele and myelomeningocele are congenital defects in the cranium and spine with herniation of contents into an extracranial and extraspinal sac, respectively. The occurrence of encephalocele and myelomeningocele in the same patient has rarely been described in the literature. The anesthetic management of such cases is associated with multiple challenges, which include difficulty in securing the airway, prone positioning, blood loss, electrolyte imbalance, hypothermia, cardiorespiratory disturbances, and perioperative care. The main aims are, to prevent hemodynamic fluctuations and excessive pressure on the sac to avoid premature rupture and manage a possible difficult airway due to the head and neck mass. We report such a rare case to highlight and share our experiences faced during perioperative management of a giant vascular occipital encephalocele with impending rupture and thoracic myelomeningocele requiring surgical excision and repair. Previous similar case reports were also reviewed, and potential perioperative complications were discussed.
BACKGROUND: Ant nociceptive treatment started before surgery is more effective in reducing postoperative pain than if started in early postoperative period. Pregabalin has demonstrated efficacy in clinical trials as pre-emptive analgesic in postoperative pain management. OBJECTIVE: This was a prospective, double blind, controlled, randomized, comparative study between pre-emptive oral pregabalin and placebo. Randomization was done by computer generated random table method; random sequence was generated by random allocation software. It was conducted in order to evaluate postoperative analgesic benefit in patients administered pregabalin for below umbilical surgeries to be performed under subarachnoid block (SAB) using 3ml 0.5%bupivacaine & to compare their postoperative efficacy with respect to duration of analgesia,24hrs postoperative requirements of total analgesics and study side effects. MATERIAL & METHODS: sixty patients of either sex (30 per group,20-65yrs, ASA gr I-II) received either oral placebo (group PC) or pregabalin 300mg (group PG) one hr preoperatively. The postoperative Visual Analogue Scale (VAS) score was assessed for 24hrs every 2hrly. The patients were given iv Diclofenac75mg as rescue analgesic at VAS ≥4.The time at which patient demanded rescue analgesic for first time & total requirement of 24 hrs postoperative analgesics was noted. STATISTICAL ANALYSIS: Software used in the analysis was EPI info software (3.4.3). Data was reported as mean value ± SD, P-value of < 0.05 was considered statistically significant. Unpaired T-test was used to find out significance between two samples. The comparison of normally distributed continuous variables between the groups was performed by means of one-way analysis of variance (ANOVA) and, if appropriate, followed by Dunnett multiple comparison tests. Nominal categorical data among study groups were compared using the chi-square test. RESULTS: Total duration of analgesia in Group-PG was significantly more than Group-PC. (632.83±103.95, Group-PG and 264.83±13.67 min. Group-PC, p=0.000), lower rescue analgesic requirement in Group-PG than in Group-PC (1.73±0.44 Group-PG, 4.03±0.66 Group-PC, p=0.000). CONCLUSION: Pregabalin proved to have a better analgesic effect, reducing the total consumption of postoperative analgesic and prolonging first rescue analgesic dose with haemodynamic stability. The main side effects were somnolence & dizziness.
Background and aimRespiratory Rate-Oxygenation (ROX) and modified ROX (mROX) indexes have been proposed to detect early high-flow nasal cannula (HFNC) therapy failure. We evaluated the utility and relationship of ROX and mROX indexes in COVID-19 patients started on HFNC oxygen therapy. MethodsThis pilot study collected data from adult COVID-19 patients requiring HFNC oxygenation from 29 Jan -29 Jun 2021. The patients were divided into two cohorts based on HFNC therapy success. ROX and mROX were compared using statistical diagnostic testing, including receiver operating characteristics and area under the curve (AUC) using online Epitools (https://epitools.ausvet.com.au/) and MedCalc software (MedCalc Software Ltd, Ostend, Belgium, https://www.medcalc.org/); p<0.05 was considered significant. ResultsTwenty-seven patients fulfilled the inclusion criteria; 48.15% of therapy failed. The cohort's mean ± standard deviation age was 53.93 ± 10.67 years; 74.1% were male. The accuracy of predicting failure for mean ROX versus mROX at baseline and six-hour values was 59.81 versus 70.68 and 67.42 versus 74.88, respectively (all p>0.05). The AUC for ROX and mROX at baseline and at six hours were statistically indifferent. Only an mROX of 4.05 (mean value) and 3.34 (Youden's J cut-off) had a sensitivity plus specificity at 156% and 163%, respectively. ConclusionBoth ROX and mROX at baseline and six hours had fair-to-good accuracies and AUC; the differences were insignificant. Both ROX and mROX had better accuracies at six hours. However, only mROX < 4.05 at six hours fulfilled the sensitivity plus specificity criteria to be a clinically valuable screener.
Background and aim: There is an unmet need to prolong analgesia duration following regional anesthesia; dexmedetomidine as an adjuvant for the intrathecal block has gained popularity over the last few years. The present study compares the onset, duration of sensory and motor block, postoperative analgesia, hemodynamic changes, and adverse effect of dexmedetomidine or fentanyl as an adjuvant to hyperbaric bupivacaine administered intrathecally.Methods: With approvals, 60 American Society of Anesthesiologists (ASA) physical status I and II adult patients undergoing lower limb surgeries under subarachnoid block were randomized to receive either 5 µg dexmedetomidine (group BD, n=30) or 25 μg fentanyl (group BF, n=30) intrathecally along with 12.5 mg hyperbaric bupivacaine. The time to onset of sensory and motor blockade, time to peak block, intraoperative hemodynamic variations, duration of postoperative analgesia, and associated intraoperative and postoperative complications, if any, were recorded and compared statistically. SPSS v16 (IBM Corp., New York, United States) was used, and P<0.05 was considered significant.Results: The onset of sensory block in group BD was 1.54 ± 0.38 minutes and 3.4 ± 0.40 minutes (P<0.001) in group BF. Time taken for the sensory level to reach T10 in group BD was 3.11± 0.43 minutes and 5.55 ± 0.60 minutes (P<0.001) in group BF. Time taken for two-segment regression in group BD was 160.06 ± 6.85 minutes and 110.4 ± 6.03 minutes (P<0.001) in group BF. The onset of motor block was 2.58 ± 0.437 minutes in group BD and 4.43 ± 0.43 minutes (P<0.001) in group BF. The total duration of analgesia in group BD was 365.8 ± 24.76 minutes and 213.33 ± 20.19 minutes (P<0.001) in group BF. Minimum intraoperative hemodynamic variations were found in group BD, and two groups had comparable side effects. Conclusion: Dexmedetomidine 5 μg added to intrathecal bupivacaine produced early-onset and prolonged block compared with fentanyl 25 μg. No significant attributable adverse effects were noted for both the drugs except the fall in blood pressure, which was gradual in dexmedetomidine but a steep fall in fentanyl.
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