Ultrasound-Guided Transversus Abdominis Plane Block Versus Intraperitoneal Instillation of Bupivacaine after Laparoscopic Cholecystectomy – A Randomized Control Trial

Background: Postoperative pain prolongs hospital stay after laparoscopic cholecystectomy and remains a major challenge during the postoperative period. Effective pain control encourages early ambulation, which significantly reduces postoperative complications. In recent years, multimodal analgesia has been recommended with fewer adverse effects and more effective analgesia. The primary objective of this study was to compare the efficacy of analgesia between Transversus Abdominis Plane Block (TAP) Block and intraperitoneal instillation of bupivacaine by comparing the meantime of the first dose of rescue analgesia in either group and the total supplementary analgesia required. Methods: This retrospective observational study was conducted on 150 patients who underwent laparoscopic cholecystectomy Group 1 comprised of patients who had received Intraperitoneal Bupivacaine for analgesia and Group 2 received TAP Block for pain relief. Results: Time of the first dose of analgesia after surgery was observed earlier in Group 1 as compared to Group 2 (Time – hours: 9.2 ± 2 vs. 12.3 ± 1.6; p = 0.0001. The Total dose of analgesic was higher in the Intra Peritoneal Bupivacaine Group as compared to the TAP group. Conclusion: AP block provided for a better quality of analgesia as assessed by the reduced requirement of intravenous supplementary analgesia which was less in patients who were given TAP Block as compared to local instillation of Bupivacaine. Keywords: Cholecystectomy, Bupivacaine, Transversus abdominis plane bloc

The ASCEND-NHQ trial found positive effects of daprodustat on hemoglobin and quality of life in patients with non-dialysis-dependent chronic kidney disease

The ASCEND-NHQ trial evaluated the effects of daprodustat on hemoglobin and the Medical Outcomes Study 36-item Short Form Survey (SF-36) Vitality score (fatigue) in a multicenter, randomized, double-blind, placebo-controlled trial. Adults with chronic kidney disease (CKD) Stages 3-5, hemoglobin 8.5-10.0 g/dl, transferrin saturation 15% or more, and ferritin 50 ng/ml or more without recent erythropoiesis-stimulating agent use were randomized (1:1) to oral daprodustat or placebo to achieve and maintain target hemoglobin of 11-12 g/dl over 28 weeks. The primary endpoint was the mean change in hemoglobin between baseline and the evaluation period (Weeks 24-28). Principal secondary endpoints were proportion of participants with a 1 g/dl or more increase in hemoglobin and mean change in the vitality score between baseline and Week 28. Outcome superiority was tested (one-sided alpha level of 0.025) among 614 randomized participants. The adjusted mean change in hemoglobin from baseline to the evaluation period was greater with daprodustat (1.58 vs 0.19 g/dl). The adjusted mean treatment difference (AMD) was significant at 1.40 g/dl (95% confidence interval 1.23, 1.56). A greater proportion of participants receiving daprodustat showed a significant 1 g/dl or more increase in hemoglobin from baseline (77% vs 18%). The mean SF-36 Vitality score increased by 7.3 and 1.9 points with daprodustat and placebo, respectively; a significant 5.4 point Week 28 ADM increase. Adverse event rates were similar (69% vs 71%); relative risk 0.98, (95% confidence interval 0.88, 1.09). Thus, in participants with CKD Stages 3-5, daprodustat resulted in a significant increase in hemoglobin and improvement in fatigue without an increase in the overall frequency of adverse events

Atrasentan and renal events in patients with type 2 diabetes and chronic kidney disease (SONAR): a double-blind, randomised, placebo-controlled trial

Background: Short-term treatment for people with type 2 diabetes using a low dose of the selective endothelin A receptor antagonist atrasentan reduces albuminuria without causing significant sodium retention. We report the long-term effects of treatment with atrasentan on major renal outcomes. Methods: We did this double-blind, randomised, placebo-controlled trial at 689 sites in 41 countries. We enrolled adults aged 18–85 years with type 2 diabetes, estimated glomerular filtration rate (eGFR)25–75 mL/min per 1·73 m 2 of body surface area, and a urine albumin-to-creatinine ratio (UACR)of 300–5000 mg/g who had received maximum labelled or tolerated renin–angiotensin system inhibition for at least 4 weeks. Participants were given atrasentan 0·75 mg orally daily during an enrichment period before random group assignment. Those with a UACR decrease of at least 30% with no substantial fluid retention during the enrichment period (responders)were included in the double-blind treatment period. Responders were randomly assigned to receive either atrasentan 0·75 mg orally daily or placebo. All patients and investigators were masked to treatment assignment. The primary endpoint was a composite of doubling of serum creatinine (sustained for ≥30 days)or end-stage kidney disease (eGFR <15 mL/min per 1·73 m 2 sustained for ≥90 days, chronic dialysis for ≥90 days, kidney transplantation, or death from kidney failure)in the intention-to-treat population of all responders. Safety was assessed in all patients who received at least one dose of their assigned study treatment. The study is registered with ClinicalTrials.gov, number NCT01858532. Findings: Between May 17, 2013, and July 13, 2017, 11 087 patients were screened; 5117 entered the enrichment period, and 4711 completed the enrichment period. Of these, 2648 patients were responders and were randomly assigned to the atrasentan group (n=1325)or placebo group (n=1323). Median follow-up was 2·2 years (IQR 1·4–2·9). 79 (6·0%)of 1325 patients in the atrasentan group and 105 (7·9%)of 1323 in the placebo group had a primary composite renal endpoint event (hazard ratio [HR]0·65 [95% CI 0·49–0·88]; p=0·0047). Fluid retention and anaemia adverse events, which have been previously attributed to endothelin receptor antagonists, were more frequent in the atrasentan group than in the placebo group. Hospital admission for heart failure occurred in 47 (3·5%)of 1325 patients in the atrasentan group and 34 (2·6%)of 1323 patients in the placebo group (HR 1·33 [95% CI 0·85–2·07]; p=0·208). 58 (4·4%)patients in the atrasentan group and 52 (3·9%)in the placebo group died (HR 1·09 [95% CI 0·75–1·59]; p=0·65). Interpretation: Atrasentan reduced the risk of renal events in patients with diabetes and chronic kidney disease who were selected to optimise efficacy and safety. These data support a potential role for selective endothelin receptor antagonists in protecting renal function in patients with type 2 diabetes at high risk of developing end-stage kidney disease. Funding: AbbVie

Effect of oral clonidine premedication on perioperative haemodynamic response and post-operative analgesic requirement for patients undergoing laparoscopic cholecystectomy

Clonidine has anti-hypertensive properties and augments the effects of anaesthesia, hence we considered it to be an ideal agent to contain the stress response to pneumoperitoneum. We studied the clinical efficacy of oral clonidine premedication in patients undergoing laparoscopic cholecystectomies. Fifty patients scheduled for elective laparoscopic cholecystectomy under general anaesthesia were randomly allocated to receive premedication with either oral clonidine 150 μg (Group I, n = 25) or placebo (Group II, n = 25) 90 minutes prior to induction. The patients were managed with a standard general anaesthetic. The two groups were compared with respect to haemodynamic parameters, isoflurane concentration, pain and sedation scores, time to request of analgesic and cumulative analgesic requirements. Oral clonidine was found to be significantly better in terms of maintaining stable haemodynamics, having an isoflurane sparing effect and having a prolonged time interval to the first request of analgesia postoperatively compared to the control group. Administration of oral clonidine 150 μg as a pre-medicant in patients undergoing laparoscopic cholecystectomy results in improved perioperative haemodynamic stability and a reduction in the intra-operative anaesthetic and post-operative analgesic requirements

Management of a case of ankylosing spondylitis for total hip replacement surgery with the use of ultrasound-assisted central neuraxial blockade

Management of a case of ankylosing spondylitis can be very challenging when the airway and the central neuraxial blockade, both are difficult. Ultrasound-assisted central neuraxial blockade may lead to predictable success in the field of regional anaesthesia. We present a young patient with severe ankylosing spondylitis where conventional techniques failed and ultrasound helped in successful combined spinal-epidural technique for total hip replacement surgery

Case series: Dexmedetomidine and ketamine for anesthesia in patients with uncorrected congenital cyanotic heart disease presenting for non-cardiac surgery

The number of patients with uncorrected congenital cyanotic heart disease is less but at times some may present for non-cardiac surgery with a high anesthetic risk. Some of these may even be adults with compromised cardiopulmonary physiology posing greater challenges to the anesthesiologist. The authors have used a combination of dexmedetomidine and ketamine for anesthesia for non cardiac surgery in five patients with cyanotic heart disease and right to left shunt (3-Eisenmenger′s syndrome, 2-Tetralogy of Fallot). The sympathoinhibitory effects of dexmedetomidine were balanced with the cardiostimulatory effects of ketamine, thereby maintaining good cardiovascular stability. The analgesia was good and there was no postoperative agitation.This drug combination was effective and safe for patients with cyanotic heart disease for non cardiac surgeries

Dapsone-induced methemoglobinemia: "Saturation gap"-The key to diagnosis

Two cases of Acquired Methemoglobinemia are presented. The significance of a high index of suspicion for diagnosisis emphasized, especially in the presence of a "saturation gap". The various causes of acquired methemoglobinemia are enumerated and the management reviewed