Comparison of Efficacy of Different Concentration of Bupivacaine in Ultrasound-Guided Transversus Abdominis Plane (TAP) Block for Postoperative Pain Relief in Lower Segment Cesarean Section

INTRODUCTION: Women undergoing cesarean delivery present distinctive set of challenges to the anaesthesiologist in the immediate postoperative period. These women want to be active in the postoperative period to care their child. The American college of obstetrics & gynecology states that the objective of postoperative analgesia in cesarean section patients is to hasten early ambulation, postoperative recovery and promote maternal infant bonding. Various modalities of treatment are available for controlling postoperative pain effectively like usage of opioids/NSAIDS, regional techniques and field blocks. As a part of postoperative analgesic regimen, initially opioids are required for effectual analgesia. But opioids can cause side-effects like emesis, nausea, itching, sedation, and respiratory depression. Hence alternative regimen that reduces opioid requirements will be beneficial in this population. Post-cesarean section pain and discomfort may be anticipated due to skin incision, uterine incision and uterine contraction. A significant amount of pain the patients feel is due the surgical incision. Hence blocking sensory nerve supply of the anterior abdominal wall will provide effective postoperative analgesia. TAP block is one of the regional anaesthetic techniques that block the innervation of abdominal wall. McDonnell and his colleagues demonstrated the effectiveness of transversus abdominis plane (TAP) block for postoperative analgesia in cesarean section patients. He performed TAP block with 1.5 mg/kg ropivacaine and demonstrated reduced postoperative visual analog scale pain scores. It has been very well proved by various studies that TAP block is a promising approach in providing good postoperative analgesia. Mcmorrow and his collegues in their study used 1mg/kg of 0.375% bupivacaine in landmark based approach of TAP and showed its effectiveness. Especially use of ultrasound for TAP block, provides real time images that can be seen during the procedure and drugs can be given more exactly into the desired location than performing a blind technique to block the nerves. This technique increases the safety of the procedure. In a study done by Hyun jung shin and his colleagues, in patients undergoing gynecological surgeries, they used 0.375% ropivacaine in TAP block under ultrasound guidance and concluded that US-TAP block has decreases narcotic use and improves the patient satisfaction. Costello and colleagues used 20 ml of 0.375% ropivacaine bilaterally in TAP under ultrasound guidance and demonstrated its opioid sparing effects in postoperative analgesic regimen. Baaj and his colleagues used 40 ml of 0.25% bupivacaine in ultrasound guided TAP block and proved its effectiveness. Though there are many clinical trials using various local anaesthetics in different concentrations in TAP block, there is no standard guidelines regarding the choice of local anaesthetics, its dose and concentration to be used. Since there have been no published dose-response studies investigating the effective analgesic dose of bupivacaine for use in a TAP block for postoperative analgesia, we proposed a study primarily examining the effect on requirement of first dose of rescue analgesia when 0.25% bupivacaine, and 0.375% bupivacaine are used for TAP blocks. Hence the goal of our study is to compare the effectiveness of 0.25% Bupivacaine and 0.375% Bupivacaine in ultrasound-guided TAP (Transversus Abdominis Plane) and the intensity of blockade provided by them as a part of postoperative analgesic regimen in patients undergoing lower segment cesarean section via pfannensteil incision. AIM OF THE STUDY: The aim of our study is to compare the efficacy of 0.25% Bupivacaine and 0.375% Bupivacaine in ultrasound-guided TAP (Transversus Abdominis Plane) block for postoperative analgesia in lower segment cesarean section under standardized general anaesthesia. MATERIALS AND METHODS: This study was conducted in Government Kilpauk Medical College after obtaining ethical committee approval of our institute. 40 Parturients belonging to ASA physical status I & II undergoing elective Lower segment cesarean section were enrolled in our study. All the patients were explained about the purpose and details of the study. Informed written consent was obtained from each patient. This study was conducted between the period of July 2012-October 2012. Study Design: Our study was a prospective double blinded randomized control study. Patient Selection Criteria: All these 40 patients were examined, evaluated clinically and biochemically and made familiar with study plan were assessed for Elective LSCS after considering the inclusion and exclusion criteria under General Anaesthesia with physical status ASA I & II and were Grouped into two Groups with 20 patients in each Group. Inclusion Criteria: 1. ASA Class I & II, 2. Patients undergoing elective LSCS under pfannensteil incision. Exclusion Criteria: 1. Age 35 years, 2. BMI >30, 3. ASA Class III & IV (Severe PIH, Stenotic Valvular Heart disease), 4. Emergency Surgery (Includes Fetal distress, threatened rupture, hemodynamic compromise) , 5. History of allergy to local anaesthetics, 6. Patients not willing for TAP block/General Anaesthesia, 7. patients with a history of diabetes mellitus, 8. patients undergoing a vertical midline skin incision, 9. Psychiatric patients, 10. Bleeding diathesis, 11. Difficult Airway. Study Group Selections: The 40 selected and assessed patients planned for Elective LSCS under General Anaesthesia with physical status ASA I & II were randomly divided into two Groups of 20 patients each, as GROUP A : 20 patients received bilateral TAP Block with 15ml of 0.25% Bupivacaine on each side labeled as Standard Drug solution A. GROUP B : 20 patients received bilateral TAP Block with 15ml of 0.375% Bupivacaine on each side labeled as Study Drug solution B. The analyzer then allotted them into 2 Groups. 20 patients who had received 30ml of 0.25% bupivacaine were assigned to Group A or study Group. Remaining 20 patients who had received 30ml of 0.375% bupivacaine were allocated to Group B. All the patients were given test dose of Bupivacaine pre-operatively. Study Period: The study period was from the time of initiation of block upto the requirement of first rescue analgesic dose. Observation Period: Patients in both the Groups were monitored and observed in the PACU for 24 hours for any side effects and complications. Materials Used in our Study: 1. Ultrasound machine with a transducer (7-13 MHz), 2. Sterile gloves, 3. Ultrasound probe cover, 4. Antiseptic solution for skin disinfection, 5. ultrasound gel, 6. 23 gauge spinal needle, 7. 20ml syringe with injection tubing. SUMMARY: A prospective randomized double blinded study was designed to compare the efficacy of 0.375% and 0.25% bupivacaine in ultrasound guided transversus abdominis plane block in patients undergoing elective lower segment ceaserean section under general anesthesia. Based on the analysis of the results and discussion in our study, the conclusions arrived at are summarized as below. • There was no statistically significant difference in demographic profiles between the two studied Groups. • There was no statistically significant difference in Onset of analgesia between the two studied Groups. • The duration of analgesia was significantly prolonged with 0.375% Bupivacaine than 0.25%.[mean duration of analgesia –average of 365min with Group A vs 544min with Group B]. • Both the Group of patients very well maintained their vital parameters throughout the study period. • There was no failure of TAP block in either of the Group and all patients had post operative pain relief for 6-10 hours. • Patient satisfaction in all the patients in both the Groups are good. • There was no adverse reactions or side effects in either of the Groups. • There was no complications like local anaesthetic toxicity noted in both the Groups. CONCLUSION: Hence, we conclude that usage of 0.375% of Bupivacaine in USG guided TAP block significantly provide more prolonged duration of post operative pain relief after Elective LSCS compared to equivolume dose of 0.25% bupivacaine We also conclude that 15 ML of 0.375% of Bupivacaine can be safely used in each side of TAP block for providing post operative pain relief after Elective LSCS without producing any adverse or toxic effects

Twelve tips for organising speed mentoring events for healthcare professionals at small or large-scale venues

Mentors play a critical role in the development of professionals, influencing their job satisfaction, career aspirations and evolving professional identity. A variety of mentoring models exist, each with distinct benefits and challenges. Speed mentoring, based on the concept of speed dating, provides mentees with opportunities to meet multiple mentors over a short time and pose focussed career development questions. At large-scale events such as the annual AMEE (Association for Medical Education in Europe) meeting, speed mentoring sessions can successfully connect aspiring, novice and mid-career educators with international educational leaders to facilitate transfer of valuable insights for professional growth. For some mentors and mentees, this might spur ongoing communications or even longitudinal relationships. In this paper, we aim to provide strategies for planning and implementing speed mentoring events, combining insights gained from the literature and our experience of organising speed mentoring at the 2019 AMEE meeting in Vienna. These tips will be useful to a variety of professionals planning to organise speed mentoring initiatives

From clinical educators to educational scholars and leaders: strategies for developing and advancing a career in health professions education

This toolbox article provides ideas and recommendations for academic and clinical educators seeking roles as educational scholars and leaders

Use of Electronic Health Records to Support a Public Health Response to the COVID-19 Pandemic in the United States: A Perspective from Fifteen Academic Medical Centers

Our goal is to summarize the collective experience of 15 organizations in dealing with uncoordinated efforts that result in unnecessary delays in understanding, predicting, preparing for, containing, and mitigating the COVID-19 pandemic in the US. Response efforts involve the collection and analysis of data corresponding to healthcare organizations, public health departments, socioeconomic indicators, as well as additional signals collected directly from individuals and communities. We focused on electronic health record (EHR) data, since EHRs can be leveraged and scaled to improve clinical care, research, and to inform public health decision-making. We outline the current challenges in the data ecosystem and the technology infrastructure that are relevant to COVID-19, as witnessed in our 15 institutions. The infrastructure includes registries and clinical data networks to support population-level analyses. We propose a specific set of strategic next steps to increase interoperability, overall organization, and efficiencie

Restoration of IFNγR Subunit Assembly, IFNγ Signaling and Parasite Clearance in Leishmania donovani Infected Macrophages: Role of Membrane Cholesterol

Despite the presence of significant levels of systemic Interferon gamma (IFNγ), the host protective cytokine, Kala-azar patients display high parasite load with downregulated IFNγ signaling in Leishmania donovani (LD) infected macrophages (LD-MØs); the cause of such aberrant phenomenon is unknown. Here we reveal for the first time the mechanistic basis of impaired IFNγ signaling in parasitized murine macrophages. Our study clearly shows that in LD-MØs IFNγ receptor (IFNγR) expression and their ligand-affinity remained unaltered. The intracellular parasites did not pose any generalized defect in LD-MØs as IL-10 mediated signal transducer and activator of transcription 3 (STAT3) phosphorylation remained unaltered with respect to normal. Previously, we showed that LD-MØs are more fluid than normal MØs due to quenching of membrane cholesterol. The decreased rigidity in LD-MØs was not due to parasite derived lipophosphoglycan (LPG) because purified LPG failed to alter fluidity in normal MØs. IFNγR subunit 1 (IFNγR1) and subunit 2 (IFNγR2) colocalize in raft upon IFNγ stimulation of normal MØs, but this was absent in LD-MØs. Oddly enough, such association of IFNγR1 and IFNγR2 could be restored upon liposomal delivery of cholesterol as evident from the fluorescence resonance energy transfer (FRET) experiment and co-immunoprecipitation studies. Furthermore, liposomal cholesterol treatment together with IFNγ allowed reassociation of signaling assembly (phospho-JAK1, JAK2 and STAT1) in LD-MØs, appropriate signaling, and subsequent parasite killing. This effect was cholesterol specific because cholesterol analogue 4-cholestene-3-one failed to restore the response. The presence of cholesterol binding motifs [(L/V)-X1–5-Y-X1–5-(R/K)] in the transmembrane domain of IFNγR1 was also noted. The interaction of peptides representing this motif of IFNγR1 was studied with cholesterol-liposome and analogue-liposome with difference of two orders of magnitude in respective affinity (KD: 4.27×10−9 M versus 2.69×10−7 M). These observations reinforce the importance of cholesterol in the regulation of function of IFNγR1 proteins. This study clearly demonstrates that during its intracellular life-cycle LD perturbs IFNγR1 and IFNγR2 assembly and subsequent ligand driven signaling by quenching MØ membrane cholesterol

The Electroencephalogram as a Biomarker Based on Signal Processing Using Nonlinear Techniques to Detect Dementia

Dementia being a syndrome caused by a brain disease of a chronic or progressive nature, in which the irreversible loss of intellectual abilities, learning, expressions arises; including memory, thinking, orientation, understanding and adequate communication, of organizing daily life and of leading a family, work and autonomous social life; leads to a state of total dependence; therefore, its early detection and classification is of vital importance in order to serve as clinical support for physicians in the personalization of treatment programs. The use of the electroencephalogram as a tool for obtaining information on the detection of changes in brain activities. This article reviews the types of cognitive spectrum dementia, biomarkers for the detection of dementia, analysis of mental states based on electromagnetic oscillations, signal processing given by the electroencephalogram, review of processing techniques, results obtained where it is proposed the mathematical model about neural networks, discussion and finally the conclusions