Analgesic Efficacy of Fascia Iliaca Compartment Block for Positioning During Spinal Anesthesia in Patients with Femur Fractures

Background Positioning patients with femur fractures for spinal anesthesia is associated with excruciating pain. Fascia iliaca compartment block has the potential to block all nerves supplying the femur and therefore may provide effective analgesia during positioning these patients for spinal anesthesia. Objective To assess the analgesic efficacy of Fascia iliaca compartment block, during positioning patients with femur fracture for spinal anesthesia. We also assessed the duration of analgesia and the requirement for rescue analgesics in the postoperative period. Method Seventy adult patients with fracture femurs were randomly divided into two equal groups (A and B). Patients in both groups received fentanyl one mcg/kg intravenously, 20 minutes before positioning them for spinal anesthesia. Patients of group B additionally, received ultrasound-guided Fascia iliaca compartment block with 40 ml of 0.25% Ropivacaine, immediately after intravenous fentanyl. Numerical rating score (0-10) was used for the assessment of pain at five, 10, and 20 minutes after the block and immediately after positioning patients for spinal anesthesia. Result Immediately after positioning patients for spinal anesthesia, the numerical rating score of pain was 5.06±1.5 in group A and 2.49±1.2 in group B (p<0.001). The duration of analgesia was 799.7±62.1 minutes in group B and 314.65±118.9 minutes in group A (p<0.001). One (2.8%) patient of group B and 18(51.4%) patients of group A required rescue analgesics within four to twelve hours in the postoperative period (p=0.001). In group A, seven patients were satisfied with the analgesia technique while in group B, 17 were satisfied and eight patients were strongly satisfied (p<0.001). Conclusion Ultrasound-guided Fascia iliaca compartment block is effective in reducing pain during positioning patients with femur fractures for spinal anesthesia. Patients receiving this block had a prolonged duration of analgesia, required lesser analgesics, and were more satisfied in the postoperative period as compared to patients not receiving the block.

Pilonidal sinus of the cheek: an extremely rare clinical entity-case report and brief review of the literature

Background

Pilonidal sinus is commonly seen at the sacrococcygeal region and few other sites, usually located at the midline, at areas where hairs collect or near protuberances or some adjacent rubbing surfaces. Its presence elsewhere is uncommon. We share an interesting case of a recurrent discharging sinus from the cheek bulge of a male which turned out to be a pilonidal sinus containing tuft of hairs on exploration and wide excision.

Case presentation

A 37 years old hirsute male presents to us with a non-healing discharging sinus at the bulge of the cheek. Exploration after a course of antibiotics showed 2 subcutaneous cavities with tuft of hairs. The area was excised along with a margin, thorough irrigation and curettage was done and the wound was closed primarily; a Z-plasty was incorporated in the central part to break the resultant suture line. Histopathological examination was done to confirm the diagnosis and rule out an off-midline dermoid cyst or an underlying/coexisting malignancy. Post-operative course was uneventful. The patient has been recurrence free for 1.5 years and is satisfied with the nature of the scar.

Conclusions

Pilonidal sinus of the cheek bulge is an extremely rare entity. Complete excision and clinical suspicion are important for cure of this nagging ailment, especially at unexpected areas.

Intraoperative Infusion of Magnesium Sulphate does not Reduce Laryngospasm and Agitation during Emergence from Anaesthesia in Children

Background Laryngospasm and agitation during emergence from general anaesthesia are frequent in children. Magnesium sulphate may have the potential of reducing both of these adverse events. In addition, magnesium has analgesic and anaesthetic properties. Objective To find out the effectiveness of magnesium sulphate in reducing the occurrence of emergence laryngospasm and agitation and other adverse events if any in children. Method Randomized, placebo controlled study was conducted at a tertiary care hospital in 132 children, aged 3-12 years undergoing general anaesthesia for hernia and hydrocele surgery. Children with American Society of Anaesthesiologist Physical Status > II were excluded. After insertion of laryngeal mask airway, 20 ml of either magnesium sulphate 15 mg/kg (Group M) or normal saline (Group N) was infused at the rate of 1 ml/min. The severity of laryngospasm and agitation was assessed. We also noted other adverse events, if occurred. Result Laryngospasm occurred in 7(10.6%) patients of group M and in 10(15.1%) patients of group N(p=0.40). While 14(10.6%) patients developed laryngospasm immediately after removal of LMA, only 3(2.2%) patients developed it in the post anaesthetic care unit. Two (3.0%) patients of group M and four patients (6.0%) of group N were agitated (p=0.40). Three (4.5%) patients of group M and 14(21.2%) patients of group N coughed during emergence (p=0.004). Conclusion Intraoperative infusion of 15 mg/kg magnesium sulphate, does not reduce the occurrence of emergence laryngospasm and agitation in children. However, it significantly reduce emergence cough.

Effect of Positive Airway Pressure During Preoxygenation on Safe Apnea Period: a comparison of the supine and 25° head up position

Background Preoxygenation is performed before induction of anaesthesia which increases oxygen reserve and provides delayed onset of hypoxia during period of apnea. Several techniques such as positive airway pressure and head-up tilt during preoxygenation have shown to prolong safe apnea period compared to conventional technique. However, uniform recommendations have not yet been made. Objective To find out the effect of combination of 5 cmH2 O continuous positive airway pressure (CPAP) and 25° head up position during preoxygenation on safe apnea period. Method In this comparative study 60 non-obese adult patients were divided into three equal groups; Group C receiving preoxygenation in conventional technique, Group S receiving preoxygenation with 5 cmH2 O continuous positive airway pressure in supine position and Group H receiving preoxygenation in 25° head-up position with 5 cmH2 O continuous positive airway pressure. After 3 min of preoxygenation, intubation was performed after induction of anaesthesia with propofol, fentanyl and succinylcholine. After confirming the tracheal intubation by direct visualization, all patients were administered vecuronium to maintain neuromuscular blockade. Postintubation, patients in all groups were left in same position with the tracheal tube exposed to atmosphere and without being ventilated till the SpO2 dropped to 92%. The primary outcome compared between the groups was the safe apnea period (time from loss of consciousness to fall of SpO2 to 92%). Result The duration of safe apnea period was longer (p < 0.05) in Group H patients (405.9 ± 106.69 s) as compared to the Group C (296.9 ± 99.01s) and Group S (319.65 ± 71.54s). Although the duration of safe apnea period was longer in the Group S as compared to Group C the difference was not statistically significant. Conclusion Preoxygenation in 25° head-up position with 5 cm H2O continuous positive airway pressure significantly prolongs safe apnea period in non-obese adults compared to supine position, with or without 5 cmH2O continuous positive airway pressure.

Implications of Subarchnoid Block in Senile Kyphosis

Since the literature related to safety or efficacy of placing spinal blocks in patients with kyphosis is lacking, we aim to discuss about the anaesthesia implications of spinal anaesthesia in senile kyphosis. We successfully administered spinal anesthesia in three elderly patients with predominant kyphotic deformity with absent or mild scoliosis. The needle insertion attempts did not exceed two and a smaller dose of anesthetic was sufficient. While choosing spinal anaesthesia in patients with kyphosis, a risk benefit analysis needs to be performed based on the co-presence of scoliosis and its severity, desired level of anesthesia, and associated or coexisting systemic illness.

Utilization of Maternal Health Care Services in Kihun Village Development Committee of Tanahun District of Nepal

Introduction Nepal had significant improvement to reduce the maternal mortality ratio. Still, the maternal deaths are common in rural areas. The proper utilization of maternal health care services is important to reduce maternal death in Nepal.Objective This study was conducted to know current maternal health care service utilization at Kihun Village Development Committee (VDC) of Tanahu District.Methodology A community based cross- sectional study was conducted from st th 1 Nov 2014 to 30 Dec 2014 among 570 household of Kihun VDC. The pretested semi-strutured questionnaire was used to collect the required information. The obtained data was enter into Microsoft excel analyzed.Results The majority (65%) of the family was nuclear. Majority (90.90%) had Hindu as a common religion. The major occupation was agriculture (68.95%). Age of marriage before 18 years was 44.70% and pregnancy below 18 years was 25.5%. The knowledge of ante natal care (ANC) check up was reported from 96.3% but only 93.20 % went for ANC check up. Almost 41% had 4 times ANC visit as suggested by world health organization (WHO). Majority (69.40% ) had home delivery and 56.8% of them, family members were involved to conduct such delivery. Though 31.20% were aware about post natal care (PNC) visit but only 22% had visited for PNC.Conclusion The ANC and PNC care practices were not up to the mark. For improvement of maternal health, we need to improve maternal health care service utilization.Birat Journal of Health Sciences 2016 1(1): 56-60

Colonization and infection in tracheostomized patients at tertiary care hospital in Eastern Nepal

Introduction: Tracheostomy is a life saving emergency procedure and provides many benefits for long term ventilator dependent patients. However, colonization and infection of airways after tracheostomy is one of the serious complications increasing patient morbidity and mortality. Objective: To find out the colonizing agent in the trachea of tracheostomized patients and the type and frequency of post tracheostomy infection. Methods: Study was conducted in 30 consecutive, adult patients requiring either elective or emergency tracheostomy at BPKIHS, Nepal. First and second tracheal swab was obtained immediately after tracheostomy and on the seventh day. Micro-organisms isolated from the culture of tracheal swab were noted. Patients were observed for infectious complications after tracheostomy. Results: Eighteen (60%) tracheostomies were performed electively and 12(40%) as an emergency. Sixty-eight isolates were grown from the culture of tracheal swabs. Out of 60 tracheal swabs, nine showed sterile culture. Single micro-organism was isolated from 35(58.33%) tracheal swabs and polybacterial isolation was seen in 16(26.66%) swabs. Pseudomonas aeroginosa was the commonest micro-organism isolated. After Pseudomonas, Staphylococcus aureus in the first culture and Acinetobacter anitratus in the second culture was the commonest organisms isolated. Five (16.6%) patients developed stomal infection and three (10.0%) developed pneumonia as a complication of tracheostomy. Conclusion: Trachea of the tracheostomized patients is heavily colonized by Pseudomonas aeruginosa, Acinetobacter anitratus and Staphyloccus aureus . Stomal infection and pneumonia are the infectious complication occurring within seven days of tracheostomy.Health Renaissance 2014;12(2): pp. 68-73

Adverse Events in Children Receiving General Anaesthesia with Laryngeal Mask Airway Insertion

INTRODUCTION

Perioperative adverse events are more common in children compared to adult population. Reporting an adverse event proves effective in identifying problems and helps in prevention and early management. Our objective was to identify the types, incidence, and the time of occurrence of perioperative adverse event. We also aimed to find out whether the occurrence of the types of adverse events differ in children below and above five years.

METHODS

This was a prospective study in 242, ASA Physical Status I and II children aged day one to 14 years, receiving general anesthesia with laryngeal mask airway for various elective surgeries. Adverse events observed in the perioperative period were recorded.

RESULTS

Adverse events related to respiratory system (n=26, 55%) were the most common followed by cardiovascular system (n= 14, 30%). Adverse events were observed in 24(10%) children in the operating room and in 20 (8%) children in the post anaesthesia care unit. In the operating room, majority (14 of 27, 52%) of the events occurred immediately after removal of laryngeal mask airway. Respiratory events were more common in children below five years (p=0.007), whereas cardiac events were more common in children above five years (p=0.02).

CONCLUSIONS

The commonest adverse event in children is related to respiratory system. Adverse events occur more frequently in the operating room, mostly immediately after removal of laryngeal mask airway. Respiratory events are more frequent in children below five years whereas cardiac events are more frequent in children above five years.

Iodized Salt Use and Salt Iodine Content among Household Salts from Six Districts of Eastern Nepal

BACKGROUND

Universal salt iodization is considered the best strategy for controlling iodine deficiency disorders in Nepal. This study was done to find iodized salt use among Nepalese population and the iodine content of household salts.

METHODS

Six districts (Siraha, Saptari, Jhapa, Udayapur, Ilam and Panchthar) were chosen randomly from 16 districts of eastern Nepal for the study. In each district, three schools (private and government) were chosen randomly for sample collection. A total of 1803 salt samples were collected from schools of those districts. For sample collection a clean air tight plastic pouch was provided to each school child and was asked to bring approximately 15 gm of their kitchen salt. The information about type of salt used; 'two child logo' iodized salt or crystal salt was obtained from each child and salt iodine content was estimated using iodometric titration.

RESULTS

At the time of study, 85% (n=1533) of Nepalese households were found to use iodized salt whereas 15% (n=270) used crystal salt. The mean iodine content in iodized and crystal salt was 40.8±12.35 ppm and 18.43±11.49 ppm respectively. There was significant difference between iodized and crystal salts use and salt iodine content of iodized and crystal salt among different districts (p value <0.001 at confidence level of 95%). Of the total samples, only 169 samples (9.4% of samples) have iodine content<15 ppm.

CONCLUSIONS

Most Nepalese households have access to iodized salt most salt samples have sufficient iodine content.

Postoperative nausea and vomiting in patients undergoing total abdominal hysterectomy under subarachnoid block: a randomized study of dexamethasone prophylaxis

BACKGROUND

Postoperative nausea and vomiting is a common distressing problem in patients undergoing gynaecological surgery under anaesthesia including central neuraxial blockade, which requires frequent medical interventions.

OBJECTIVES

We aimed to find out the antiemetic effect of prophylactic dexamethasone for prevention of postoperative nausea and vomiting in patients undergoing total abdominal hysterectomy under subarachnoid block. Influences of dexamethasone on patient satisfaction and postoperative analgesia were also observed as secondary objectives.

METHODS

This was a prospective, randomized, double blind, placebo controlled study conducted in BPKIHS, from January 2009 to April 2009. This study involved 80 American Society of Anaesthesiologist Physical Status I and II patients undergoing total abdominal hysterectomy under subarachnoid block. Patients were divided into two groups of 40 each to receive either 4 mg of dexamethasone (group D) or normal saline (group N) in volume of 2 ml intravenously 1 hour prior to subarachnoid block. Surgery was allowed to start with block height of at least T8 dermatome. Intraoperative and postoperative nausea and vomiting was observed using nausea and vomiting scale every 4 hour for 24 hours.

RESULTS

Seven (17.4%) patients in group D and 11 (27.5%) patients in group N had nausea and vomiting in the intraoperative period (P=0.284). Sixteen (40%) patients in group D experienced nausea and vomiting in the postoperative period as compared to 27 (67.5%) in group N (P =0.0136). Accordingly, the mean requirement of rescue antiemetic was less in group D compared to Group N (P=0.042). Further, only 15 (37.5%) patients in group D required postoperative supplemental analgesic as compared to 23 (57.5%) in group N (P=0.058). After 24 hrs of surgery, 26 (65%) patients expressed satisfaction in group D as compared to 16 (40.0%) in group N (P =0.025).

CONCLUSIONS

Use of dexamethasone prior to subarachnoid block in patients undergoing total abdominal hysterectomy significantly reduces the incidence of nausea and vomiting and the requirement of antiemetic in the postoperative period, with better patient satisfaction.

Ambiguous Phorate Granules for Sesame Seeds Linked to Accidental Organophosphate Fatal Poisoning

Ingestion of organophosphate compound for suicidal attempt is a major health problem in developing countries. However, unintentional ingestion by an adult is rare. An 80-year-old lady and her 30-year-old granddaughter consumed phorate (organophosphate) granules thinking it to be the seeds of sesame. After grinding the granules and mixing with pickle, they consumed the preparation with rice. The granddaughter was brought dead at emergency department and the older lady after resuscitation shifted to intensive care unit. She was extubated on 17th day and discharged on 23rd day. Pesticide formulation resembling any edible items must be withdrawn from the market at the earliest. Stringent regulation on vendors, apparent formulation or packaging and education about the hazards of these compounds can prevent this type of unintentional poisoning. Keywords: Ambiguous, organophosphate, phorate, sesame seeds, unintentional poisoning.

Ambiguous phorate granules for sesame seeds linked to accidental organophosphate fatal poisoning

Ingestion of organophosphate compound for suicidal attempt is a major health problem in developing countries. However, unintentional ingestion by an adult is rare. An 80-year-old lady and her 30-year-old granddaughter consumed phorate (organophosphate) granules thinking it to be the seeds of sesame. After grinding the granules and mixing with pickle, they consumed the preparation with rice. The granddaughter was brought dead at emergency department and the older lady after resuscitation shifted to intensive care unit. She was extubated on 17th day and discharged on 23rd day. Pesticide formulation resembling any edible items must be withdrawn from the market at the earliest. Stringent regulation on vendors, apparent formulation or packaging and education about the hazards of these compounds can prevent this type of unintentional poisoning.

KEYWORDS

Ambiguous, organophosphate, phorate, sesame seeds, unintentional poisoning.

Surgical site fire: a case of evil spirit or lapsed communication?

Electrocautery has become an indispensable tool in the operating room mainly to achieve bloodless surgical field. However, it does carry several risks including fire burn. Abundant fuels and oxidizer in operation theatre in the presence of electrocautery can easily get ignited, imposing serious risk to the patient and health professionals. This report of a case of surgical site burn injury due to unintentional reuse of a spirit soaked gauze piece intends to create awareness among health professionals and staff regarding such serious complication.

Comparison of modified mallampati test between sitting and supine positions for prediction of difficult intubation

Background: Modified Mallampati test is a standard method of assessing the airway for predicting potentially difficult laryngoscopy and intubation. This test requires the patient to be in sitting position for airway evaluation. Although applicable to the majority of patients, airway evaluation in sitting position may not always be convenient or advisable. Objectives: To compare modified Mallampati grades between sitting and supine position and to find out their corelation to Cormack and Lehane laryngoscopy grade. Materials: This prospective study was conducted in 215, ASA I and II patients undergoing various routine surgical procedures under general anaesthesia, in BPKIHS, Dharan over a period of 3 months. The airway assessment was done using modified Mallampati grade in sitting and supine positions. Mallampati grade of III or IV was defined as the predictor of difficult airway. The laryngoscopy grade was assessed using the Cormack and Lehane grading scale. Grade III or IV of Cormack and Lehane grades was defined as the difficult laryngoscopy and assumed as the predictor of difficult intubation. Statistical measures including sensitivity, specificity, positive and negative predictive values and accuracy were used for comparing the two positions for predicting difficult or ease of intubation. Results: Out of 215 patients, majority 146(68%) were females. Mallampati grade III or IV was observed in more patients in supine position compared to sitting position (48.3% vs. 35.8%, p = 0.008). Difficult laryngoscopy was observed in 13(6%) patients. Sensitivity of modified Mallampati test was 77% in both the positions. Predictive value of Mallampati grading for difficult intubation were 13% and 10% and for easy intubation were 96% and 97% respectively in sitting and supine position. Specificity and accuracy of modified Mallampati test were both 67% in sitting position, where as they were 54% and 55% respectively in supine position. Conclusion: Modified Mallampati grade significantly worsens in supine position compared to sitting. However, airway evaluation in both the positions almost equally predicts for difficult intubation. DOI: http://dx.doi.org/10.3126/hren.v10i1.6000 HREN 2012; 10(1): 12-15