Mild Sedation Research Articles

Awake Percutaneous Fixation for Unstable Fractures of the Spine in High-risk Patients: A Retrospective Study.

Unstable fractures in sick or elderly patients are on the rise. These patients who are at high risk for surgery present a challenge for surgeons and anesthesiologists. In patients with American Society of Anesthesiologists (ASA) scores 3 to 4, the risk is even higher because of the high rate of intraoperative complications. All patients with ASA scores 3 to 4 who presented with unstable fractures of the spine to a level-one trauma center were assessed, and they underwent awake spinal percutaneous fixation, with mild sedation and local anesthesia. Demographics, radiology, and the outcome were collected. Nineteen patients were operated between the years 2019 and 2021. Average follow-up was 12 months (range 8 to 24 months); six patients were female and 13 males. The average age was 77.7 years; the ASA score was 3 to 4 in all patients. There were 10 extension-type injuries, six unstable burst injuries, two chance fractures, and one teardrop fracture. All patients underwent unilateral fixation, and just one patient underwent bilateral fixation; cement augmentation was done in 16 of the patients. No neurologic complication was observed. One case of infection presented 4 months after surgery. All patients were discharged ambulating. Awake fixation in extreme cases is safe and feasible; a dedicated team including an anesthesiologist and radiologist is needed to treat these cases safely and quickly.

Comparison of landmark-guided and ultrasound-guided technique for superior laryngeal nerve block to aid fibreoptic intubation - An observational study.

Awake fibreoptic intubation (AFOI) is the gold standard in the management of the difficult airway. Several methods to achieve airway anesthesia to aid AFOI include superior laryngeal nerve block (SLNB). This study aimed to compare land-mark-guided and ultrasound-guided techniques for SLNB to aid AFOI. This was a prospective, observational study. Patients in both groups received 1 mg Midazolam and 50 μg of fentanyl for mild sedation before intubation, nasal passages were anaesthetized using lignocaine-coated nasopharyngeal airways, nebulization of 3 ml of 2% lignocaine, and intratracheal injection of 2 ml of 2% lignocaine given through cricothyroid membrane. Patients in Group L received SNLB, at the lateral end of the thyrohyoid membrane (2 ml of 1.5% lignocaine). Patients in Group U had their thyrohyoid membrane visualized using linear ultrasound probe (8 - 13 Hz) and the injection was placed just superficial to the membrane using out of plane method. The groups were compared with respect to quality of anesthesia (assessed on a 5-point scale), patient comfort during AFOI, time taken to intubation and Haemodynamics. A total of 25 patients were enrolled: 13 in Group L and 12 patients in Group U. The demographics were comparable. Quality of airway anesthesia, time taken to intubation, haemodynamics and patient comfort were comparable. All were intubated successfully and there were no complications. USG-guided SLNB was comparable to landmark-based method with respect to quality of airway anesthesia and patient comfort. USG-guided block did not add any advantage over the landmark-based method.

Anesthetic management for large anterior mediastinal mass compressing great vessels of heart.

Dear Editor, Anesthesia management for large mediastinum masses poses distinctive challenges. With the induction of anesthesia, complications are usually the consequence of extrinsic compression of the airway, obstruction of the venous return, or obstruction to the output of the heart.[1] We present a case of large mediastinal mass which necessitated the use of one-lung awake intubation with beat-to-beat hemodynamic monitoring. A 14-year-old boy presented with history of chest pain, weight loss, facial puffiness, dyspnea for 3months and Computed tomography (CT) thorax revealed a heterogeneous mass lesion of 9 × 8 × 12 cm, involving anterior mediastinum, abutting cardiac chambers, pulmonary vessels, and trachea [Figure 1]. Echo cardiography revealed shifting of heart to right hemithorax but with normal ejection fraction.He was diagnosed with mature teratoma in the anterior mediastinum and was planned for excision through left anterolateral thoractomy with one-lung ventilation. On the day of surgery, standard monitors were attached. Two large-bore intravenous (IV) access were taken. Premedication was done with midazolam 1 mg IV and fentanyl 50 μg IV. Awake intubation was done under mild sedation and recurrent laryngeal nerve block. An Eighteen G epidural catheter was placed in T9-10 space. Right radial artery was cannulated and transduced. The child was intubated using a 6.5 mm Univent single-lumen tube with bronchial blocker/fixed at 20 cm. Anesthesia was maintained with O2:N2O, sevoflurane, and intermittent dose of muscle relaxant. The right internal jugular vein was cannulated. Just before thoracotomy, the bronchial blocker was inflated and one-lung ventilation was initiated. The patient’s hemoodynamic and ventilatory parameters were maintained throughout. For analgesia, he was administered 2 mg morphine with 0.25% bupivacaine(total volume 6 ml) through the epidural catheter. At the end of the surgery, the bronchial blocker was deflated and the neuromuscular blockade was antagonized, and the trachea was extubated. A volume of 2500 ml of crystalloids was infused over 4 h with 700 ml blood loss. The patient was discharged on 8th postoperative day.Figure 1: Computed tomography thorax showing large heterogeneous mass compressing cardiac chambers, pulmonary vessels, and tracheaThe most useful information for the anesthesiologist to guide management is imaging studies. Any deviation or compression of heart, airway, or great vessels needs to be evaluated. Head elevated position and awake intubation was adopted to avoid respiratory distress and hemodynamic instability due to superior vena cava (SVC) obstruction. Maintaining spontaneous respiration may be a good alternative because positive pressure ventilation may increase the risk of hypotension. Chemotherapy with bleomyc in used in this child may have further contributed to pulmonary toxicity.[2] In case of SVC involvement, it is prudent to place a large IV cannula in the femoral vein to facilitate transfusion of blood and drug administration. In the event of complete loss of airway or cardiovascular collapse, institution of extracorporeal membrane oxygenation was kept ready.[3] Atelectasis post one-lung ventilation is the main cause of difficulty in weaning these patients off mechanical ventilation. Intraoperatively, anesthesiologist should be vigilant for excessive hemorrhage, herniation of heart or pulmonary torsion, dysrhythmias, and even cardiac arrest. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Microwave ablation of thyroid nodules: effects on recurrence and outcome

Background: Microwave ablation developed into an accepted treatment for benign thyroid nodules. Definition and risk factors for recurrence are under discussion. We assumed recurrence in case of a second procedure for the same reason or if clinical symptoms reappear after initial relief, and analyzed our prospectively collected data for risk factors and outcome. Methods: Indications included benign thyroid nodules (n=24), cystic nodules (n=9), autonomous functioning nodules (n=9), recurrent cancer (n=3) and Basedow’s disease (n=2). For microwave ablation, a CE certified generator was used. All procedures were conducted under ultrasound control and with general anesthesia or mild sedation. Followup included ultrasound, laboratory parameters and a standardized questionnaire. Results: A total of 47 patients were enrolled into the study. Among them were 19 cases with risk factors for recurrence which were defined as nodule size exceeding 4 cm with or without cystic appearance. Recurrence occurred in 9 cases leading to conventional hemithyreoidectomy (n=1), reablation (n=5) or sclerotherapy (n=1). The association of recurrence with the presence of a risk factor was statistically significant (p<0,001, Chi square test). In case of recurrence, statistically significant less energy was deployed in comparison to successful MCT (0,39 +/- 0,31 kJ/mL vs. 1,57 +/- 2,37 kJ/mL, p< 0,005, t-test). Conclusion: Recurrence is a common problem following microwave ablation of thyroid nodules. Nodules > 4 cm and cystic disease seem to predispose for treatment failure. Further studies are required to define recurrence and the best indications for microwave ablation of thyroid nodules.

Fasting for Less Than Three Hours Is Non-Inferior to Prolonged Fasting When Preparing Patients for Cardiac Interventional Procedures Without General Anaesthetic

There is a paucity of evidence to determine the time required to fast a patient before safely performing a cardiac interventional procedure under local anaesthetic with or without mild sedation that does not require airway support.

Anaesthetic considerations for high-risk patient kyphoplasty.

Patients with vertebral compression fractures are often indicated for balloon kyphoplasty. Many of them are elderly with severe comorbidities, which puts them at high risk for general anaesthesia. Surgery under infiltration of local anaesthetic with or without mild sedation is therefore the preferred technique used by many surgeons. However, patients reported moderate‑to‑severe pain during the procedure. A combination of regional anaesthesia with analgo-sedation offers an interesting alternative to general anaesthesia as well as infiltration administered by the surgeon. In this article we present, apart from general anaesthesia, various regional anaesthetic techniques suitable for high-risk patients, including neuraxial anaesthesia, paravertebral block as well as a novel "erector spinae plane block" at the level of the fractured vertebra. We explore their effectiveness and safety profile, as well as advantage of supplementation of adequate analgo-sedation (Ref. 40). Keywords: erector spinae plane block, kyphoplasty, regional anaesthesia, paravertebral block, neuraxial anaesthesia.

Awake spinal surgery: simplifying the learning curve with a patient selection algorithm.

There is a learning curve for surgeons performing "awake" spinal surgery. No comprehensive guidelines have been proposed for the selection of ideal candidates for awake spinal fusion or decompression. The authors sought to formulate an algorithm to aid in patient selection for surgeons who are in the startup phase of awake spinal surgery. The authors developed an algorithm for selecting patients appropriate for awake spinal fusion or decompression using spinal anesthesia supplemented with mild sedation and local analgesia. The anesthetic protocol that was used has previously been reported in the literature. This algorithm was formulated based on a multidisciplinary team meeting and used in the first 15 patients who underwent awake lumbar surgery at a single institution. A total of 15 patients who underwent decompression or lumbar fusion using the awake protocol were reviewed. The mean patient age was 61 ± 12 years, with a median BMI of 25.3 (IQR 2.7) and a mean Charlson Comorbidity Index of 2.1 ± 1.7; 7 patients (47%) were female. Key patient inclusion criteria were no history of anxiety, 1 to 2 levels of lumbar pathology, moderate stenosis and/or grade I spondylolisthesis, and no prior lumbar surgery at the level where the needle is introduced for anesthesia. Key exclusion criteria included severe and critical central canal stenosis or patients who did not meet the inclusion criteria. Using the novel algorithm, 14 patients (93%) successfully underwent awake spinal surgery without conversion to general anesthesia. One patient (7%) was converted to general anesthesia due to insufficient analgesia from spinal anesthesia. Overall, 93% (n = 14) of the patients were assessed as American Society of Anesthesiologists class II, with 1 patient (7%) as class III. The mean operative time was 115 minutes (± 60 minutes) with a mean estimated blood loss of 46 ± 39 mL. The median hospital length of stay was 1.3 days (IQR 0.1 days). No patients developed postoperative complications and only 1 patient (7%) required reoperation. The mean Oswestry Disability Index score decreased following operative intervention by 5.1 ± 10.8. The authors propose an easy-to-use patient selection algorithm with the aim of assisting surgeons with patient selection for awake spinal surgery while considering BMI, patient anxiety, levels of surgery, and the extent of stenosis. The algorithm is specifically intended to assist surgeons who are in the learning curve of their first awake spinal surgery cases.

Percutaneous Endoscopic Gastrostomy Placement under NIV in Amyotrophic Lateral Sclerosis with Severe Ventilatory Dysfunction: A Safe and Effective Procedure

Introduction: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder with an inexorably progressive course which leads to a progressive neuromuscular weakness. Weight loss is one of the major bad prognostic factors in ALS. The placement of percutaneous endoscopic gastrostomy (PEG) is of paramount importance in patients with dysphagia to improve the disease outcomes, although some fear exists regarding the possible ventilatory complications during the procedure. The aim of this study was to evaluate the safety and effectiveness of PEG tube insertion under non-invasive ventilation (NIV) in patients with ALS and severe ventilatory impairment. Methods: A retrospective study of all consecutive PEGs placed in our department from May 2011 to January 2018 in patients with ALS was performed. The procedure was performed under non-invasive positive-pressure ventilation for ventilatory support. Results: We included 59 patients with ALS with severe ventilatory impairment, 58% were female, with a mean age of 67.2 ± 10.1 years and a median follow-up of 6 [2–15] months. The main indication for PEG placement was dysphagia (98%). The median time for PEG tube insertion since the established diagnosis of ALS was 12 [6–25] months and 4 [2–18] months since the beginning of bulbar symptoms. The majority of the patients had placed a 20-Fr PEG (63%) and under mild sedation with midazolam (80%), all under NIV. There were no immediate complications during and after the procedure (no episodes of aspiration or orotracheal intubation) and mortality. Conclusion: The placement of PEG is a very important procedure in patients with ALS and severe ventilatory impairment. The interdisciplinary department collaboration permitted the placement of PEG under NIV, in a safe and effective procedure in this special population.

Bioguided Isolation of Alkaloids and Pharmacological Effects of the Total Alkaloid Fraction from Aspidosperma pyrifolium Mart. (Apocynaceae).

Aspidosperma pyrifolium is used in traditional medicine to treat inflammatory disorders. The aim of the study was to perform phytochemical characterization and evaluate the anti-inflammatory, anti-nociceptive and acute toxicity effects of the total alkaloid fraction (TAF-Ap) from stem barks. Two monoterpenic indole alkaloids were isolated by high performance liquid chromatography coupled with mass spectrometry (HPLC-MS) and the structural elucidation was performed using 1D and 2D NMR analysis. As for toxicity, no animals died at 50 mg kg−1 and this concentration presented mild sedation and forced breathing within the first 24 h. The lethal dose capable of killing 50% of the animals (LD50) was estimated to be 160 mg kg−1. In the pharmacological tests, the models used were 1% carrageenan-induced paw edema and peritonitis, 1% formalin-induced nociception and 1% acetic acid-induced abdominal writhing in Swiss mice. The study made it possible to isolate 15-methoxyaspidospermine and 15-methoxypyrifolidine, corroborating the results of pharmacological assays, which showed anti-inflammatory and analgesic potential, especially at 30 mg kg−1 (p < 0.001). Thus, the species was shown to be a promising source of active substances, with special attention paid to its toxicological potential.

Brain Functional Connectivity as Biomarker for Propofol-Induced Alterations of Consciousness.

Understanding neural correlates of consciousness and its alterations poses a grand challenge for modern neuroscience. Even though recent years of research have shown many conceptual and empirical advances, the evolution of a system that can track anesthesia-induced loss of consciousness is hindered by the lack of reliable markers. The work presented herein estimates the functional connectivity (FC) between 21 scalp electroencephalogram (EEG) recordings to evaluate its utility in characterizing changes in brain networks during propofol sedation. The sedation dataset in the University of Cambridge data repository was used for analyses. FC was estimated using the debiased estimator of the squared Weighted Phase Lag Index (dWPLI2). Spectral FC networks before, during, and after sedation was considered for 5 EEG sub-bands. Results demonstrated significantly higher alpha band FC during baseline, mild and moderate sedation, and recovery stages. A striking association between frontal brain activity and propofol-sedation was also noticed. Furthermore, inhibition of frontal to parietal and frontal to occipital connections were observed as characteristic features of propofol-induced alterations in consciousness. A random subspace ensemble framework using logistic model tree as the base classifier, and 18 functional connections as features, yielded a cross-validation accuracy of 98.75% in discriminating baseline, mild and moderate sedation, and recovery stages. These findings validate that EEG-based FC can reliably distinguish altered conscious states associated with anaesthesia.

Bedside Neck Exploration for Venous Flow Coupler Signal Loss in Postoperative Free Tissue Transfer Monitoring.

To describe the role and efficacy of bedside neck exploration following free tissue transfer. Retrospective case series. Single tertiary care institution. A retrospective chart review was conducted of 353 patients who underwent free tissue transfer between January 2017 and April 2021. Bedside exploration was performed under mild sedation in patients who had loss of venous Doppler signal with equivocal clinical signs of venous insufficiency. A total of 11 patients underwent bedside assessment of the microvascular pedicle. In 6 cases, a return to the operating room was avoided. Five of these patients had coupler malfunction, and in 1 patient a venous kink was discovered and remedied at the bedside. Five patients required return to the operating room. Venous thrombosis requiring thrombectomy and revision of the venous anastomosis was discovered in 3 patients. One patient had a developing hematoma necessitating evacuation in the operating room, and 1 returned to the operating room due to sternocleidomastoid muscular compression of the venous pedicle. There were no flap failures within the study group. In all cases, broad-spectrum intravenous antibiotic coverage was prophylactically used, and no instances of wound infection were observed. Avoidance of returning to the operating room prevented an estimated $9222 of hospital charges per event. Bedside neck exploration can be incorporated as a safe and cost-effective intermediary for definitive determination of need for return to the operating room.

Comparison of Analgesic Efficacy of Oral Flupirtine Maleate and Ibuprofen in Patients Undergoing Laparoscopic Cholecystectomy: A Randomized Control Trial

Aims and Objective: To evaluate the efficacy of Flupirtine in reducing acute postoperative pain after laparoscopic cholecystectomy as compared to Ibuprofen when administered by oral route prior to surgery and to observe and compare side effect profile of oral Flupirtine maleate and Ibuprofen. Method: This study was conducted in 60 patients of ASA1/2,21to70 years of age who were randomly divided into two groups to receive either 200mg oral flupirtine maleate or 800 mg oral Ibuprofen 2 hrs prior to the procedure. Post operatively patient was observed for vas score, RSS, rescue analgesia requirement and post-operative nausea and vomiting. Result: Patients from flupirtine group had lower VAS score than that of ibuprofen group in first 6 hours. RSS score was satisfactory in first 4 hours in flupirtine group than ibuprofen group. Rescue analgesia requirement was more in ibuprofen group than flupirtine group also post-operative nausea and vomiting was seen more in ibuprofen group than flupirtine group. Conclusion: This study concluded that, patients undergoing laparoscopic cholecystectomy, pre-emptive use of oral flupirtine 200 mg is more effective compared to oral ibuprofen 800 mg and flupirtine provides better pain relief with additional muscle relaxation and mild sedation in early post-operative period. Keywords: Laparoscopic Cholecystectomy; Flupirtine; Ibuprofen; Pre-emptive Analgesia.

Hemodynamic, Echocardiographic, and Sedative Effects of Oral Gabapentin in Healthy Cats.

The study objective was to evaluate sedative, hemodynamic, and echocardiographic effects of cats receiving single-dose, oral gabapentin. A prospective, double-blinded, placebo-controlled, crossover study was conducted with 10 client-owned cats. Vital parameters, physical exam, blood pressure, echocardiography, and sedation scoring were performed at each visit within 2 hr of receiving either a placebo or gabapentin capsule. Vital parameters, blood pressure recordings, and echocardiographic measurements were compared between baseline, gabapentin, and placebo; interobserver agreement for sedation scoring and correlation between variables were also evaluated. Seven of 10 cats exhibited mild sedation within 120 min after receiving gabapentin, and no adverse events occurred. Significant differences were detected with two-dimensional fractional shortening (P = .022), left ventricular internal diameter in systole using M-mode (P = .014), and left atrial volume (P < .0001). Interobserver agreement for sedation scoring was near-perfect (κ = 0.84). No significant correlation was found for gabapentin dosage and sedation score. Single-dose oral gabapentin is well tolerated in healthy cats and produces a modest decrease in several echocardiographic parameters of systolic function; however, all affected variables remained within established reference ranges. These results suggest gabapentin may be an appropriate sedative to administer before echocardiography in cats necessitating mild sedation.

Substance consumption and intoxication patterns in a medically supervised overdose prevention program for people experiencing homelessness

Background: Opioid overdose is a leading cause of death among homeless individuals. Combining psychoactive substances with opioids increases overdose risk. This study aimed to describe intoxication patterns at a drop-in space offering medical monitoring and harm reduction services to individuals who arrive intoxicated and at risk of overdose. Methods: We examined data from visits to the Supportive Place for Observation and Treatment at Boston Health Care for the Homeless Program between January 1, 2017 and December 31, 2017. We used k-means cluster analysis to characterize intoxication patterns based on clinically assessed sedation levels and vital sign parameters. Multinomial logistic regression analysis assessed demographic and substance consumption predictors of cluster membership. Linear and logistic regression models examined associations between cluster membership and care outcomes. Results: Across 305 care episodes involving 156 unique patients, cluster analysis revealed 3 distinct intoxication patterns. Cluster A (26.6%) had mild sedation and normal vital signs. Cluster B (44.5%) featured greater sedation with bradycardia and/or hypotension. Cluster C (28.9%) was comparable to cluster B but with the addition of hypoxia. Self-reported consumption of non-opioid sedatives prior to arrival was common (63.3% of episodes) and predicted membership in cluster B (aOR 2.75, 95% CI 1.40, 5.40) and cluster C (aOR 3.38, 95% CI 1.48, 7.70). In comparison to cluster A episodes, cluster C episodes were longer (mean 4.8 vs. 2.3 hours, p < 0.001) and more likely to require supplemental oxygen (27.3% vs. 2.5%, p < 0.001). Few episodes required hospital transfer (4.7%) or naloxone (1.0%). No deaths occurred. Conclusions: In a medically supervised overdose monitoring program, reported use of non-opioid sedatives strongly predicted more complex clinical courses and should be factored into overdose prevention efforts. Low-threshold medical monitoring in an ambulatory setting was sufficient for most episodes, suggesting a role for such programs in reducing harm and averting costly emergency services.

Voluntary Oral Ingestion of a Sedative Prior to Euthanasia with CO2: Behavioural Responses of Mice.

Simple SummaryCarbon dioxide (CO2) inhalation is the most common euthanasia method for laboratory mice despite causing distress, pain and suffering. Since many laboratories will continue to use CO2 until a suitable alternative is identified, there is merit in exploring options for reducing its aversiveness. We evaluated the potential of using a voluntarily ingested sedative (tiletamine-zolazepam; Zoletil®) prior to euthanasia. Male and female C57BL/6 mice were offered cream cheese mixed with Zoletil® in one of the following doses: 0, 10, 20, 40, 80, or 100 mg/kg. Behaviour during the sedation and euthanasia periods was recorded. A dose of 20 mg/kg was found to achieve mild sedation and was likely to reduce the aversiveness of euthanasia with CO2. Higher doses also produced sedation, but these resulted in an incomplete intake of the dosed cream cheese in some mice. The voluntary ingestion of a sedative (20 mg/kg) prior to CO2 deployment could be a valid option for reducing the stress of this euthanasia method for both mice and staff. Additionally, we suggest that since mice readily ingested dosed cream cheese, this could also be an easy, effective, non-invasive, and low-cost means of reducing stress in other applications (e.g., repeated handling or sampling).Laboratory mice are commonly euthanised with carbon dioxide (CO2); however, there is ample evidence that this gas is aversive. Previous work suggests that sedation achieved via injection with benzodiazepines prior to CO2 administration could reduce aversive behaviours during euthanasia. We explored the potential of using a voluntarily ingested sedative (tiletamine-zolazepam, Zoletil®) prior to euthanasia. Male and female C57BL/6 mice were allocated into one of the five experimental groups, which differed in the dose of Zoletil: 0, 10, 20, 40, 80 or 100 mg/kg. A dose of 20 mg/kg was found to achieve mild sedation prior to euthanasia; mice which received this dose numerically reared and walked on the cage lid less, and showed ataxia, immobility and recumbency for longer than mice that received a lower dose. During euthanasia, mice that received 20 mg/kg showed fewer aversive responses to CO2. Doses of 40 to 100 mg/kg were associated with signs of moderate to severe sedation, but resulted in an incomplete intake of the sedative, which made the interpretation of the aversiveness to CO2 difficult. Voluntary oral administration of a sedative is an effective, affordable, and easy way to minimize the stress of mice to euthanasia with CO2.

Cesarean Section in Cattle: A Review

Cesarean section is one of the oldest surgical procedure performed on cows for delivery of the fetus at parturition. Depending upon the health status of dam and fetus cesarean section has been classified as emergency, non emphysematous and emphysematous procedure. The common maternal indications for performing cesarean section include pelvic fractures, cervical dilation failure and uncorrectable uterine torsion whereas the fetal indication include oversized fetuses and maldisposed calves. Many anesthetic protocols are available for cow however, most cesarean section in cattle can be satisfactorily performed under mild sedation and local infiltration anesthesia using 2% lidocaine. Operative sites for cesarean section in cattle include right and left flank, midline, paramedian, parammary and oblique ventrolateral. The choice of operative sites depends upon facility and patient condition. Peri-operative (before, during and after the operation) care appears to be of utmost significance, post-operative complications of cesarean section include peritonitis, seroma formation, hernia and poor fertility. On the successful outcome of cesarean section in cows in terms of dam and calf survival and future fertility of cows underdoing cesarean section. Previous handling, delay in presentation to referral centers results in poor outcome and thus animal owners must be explained the benefits of prompt presentation of cow to cesarean section for optimal benefits.

Life‐threatening pharyngeal oedema secondary to severe perianaesthetic regurgitation in a French bulldog: Management with topical adrenaline and nasotracheal tube

AbstractPostoperative upper airway obstructions in brachycephalic dogs (BDs) mainly occur following brachycephalic airway surgery. Tracheostomy is the most frequently reported technique to relieve upper airway obstructions. A 10‐year‐old French bulldog presented repeated regurgitation during anaesthesia for orthopaedic surgery. Oesophageal and pharyngeal lavage were performed. Seven hours after recovery, the dog displayed severe stertor and hypoxemia, which were not relieved with oxygen flow‐by and sedation. Emergency anaesthesia and tracheal intubation were performed. Laryngoscopy revealed severe pharyngeal inflammation. A nasotracheal tube (NTT) was placed while the dog remained intubated, and diluted adrenaline was sprayed on the pharynx using a mucosal atomization device. Mild sedation and oxygenotherapy through NTT were maintained for 3 days. The dog was discharged after 5 days. This report describes an uncommon complication of perianaesthetic repeated regurgitation in a BD, and an unusual technique for managing an upper airway obstruction.

Bone Metastases: State of the Art in Minimally Invasive Interventional Oncology.

Bone is the third most common site involved by cancer metastases, and skeleton-related events such as intractable pain due to direct osseous tumor involvement, pathologic fracture, and neurologic deficits as a consequence of nerve or spinal cord compression often affect patients' functional independence and quality of life unfavorably. The annual medical-economic burden related to bone metastases is a substantial component of the total direct medical cost estimated by the National Institutes of Health. There have been substantial recent advances in percutaneous image-guided minimally invasive musculoskeletal oncologic interventions for the management of patients with osseous metastatic disease. These advances include thermal ablation, cementation with or without osseous reinforcement with implants, osteosynthesis, thermal and chemical neurolyses, and palliative injections, which are progressively incorporated into the management paradigm for such patients. These interventions are performed in conjunction with or are supplemented by adjuvant radiation therapy, systemic therapy, surgery, or analgesic agents to achieve durable pain palliation, local tumor control, or cure, and they provide a robust armamentarium for interventional radiologists to achieve safe and effective treatment in a multidisciplinary setting. In addition, these procedures are shifting the patient management paradigm in modern-era practice. The authors detail the state of the art in minimally invasive percutaneous image-guided musculoskeletal oncologic interventions and the role of radiologists in managing patients with skeletal metastases. ©RSNA, 2021.

The neurobehavioral effects of flumazenil in chicks

Flumazenil is choosy and competitive GABA receptor blocker that serves as an antidote to benzodiazepines overdose. Its administration in humans and some animal’s model is connected with nervousness, anxiety responses, or seizures attacks. The objective of this study was to scrutinize the neurobehavioral reaction as well as sedative and anxiolytic actions of flumazenil in chick’s model. The Median effective dose of flumazenil injected chicks was 0.114 mg/kg i.p. Flumazenil at 0.04 and 0.08 mg/kg diminished the locomotors activity, prolonged the period of tonic immobility and have anxiolytic action in chicks. Flumazenil at 0.1, 0.2 and 0.4 mg/kg cause mild sedation in chicks. Flumazenil at 0.1 and 0.2 mg/kg have antagonistic effects in chicks sedated with diazepam at 10mg/kg. Flumazenil demonstrated fairly unexpectedly a depressant effect in the open field test and sedative and anxiolytic bias attention test in the chick’s model. These findings indicate that the impact of flumazenil is indicative of the characteristics of partial agonists when given on its own and antagonist when given after diazepam according to the neurobehavioral tests.

AYURVEDIC PROTOCOL FOR THE MANAGEMENT OF WILSON’S DISEASE – A CASE REPORT

Wilson’s disease (hepatolenticular degeneration) is a rare important autosomal recessive disorder caused by dys- function of the copper transporter ATP7B, which leads to snagging in copper transport by the hepatic lysosomes resulted in the deposition of copper in the brain, liver, kidney, or skeletal system. The symptoms are jaundice, Kayser-Fleischer rings, dysarthria, ataxia, and muscle spasticity etc. Current therapeutic modalities for the manage- ment of Wilson's disease include zinc, trientine, penicillamine etc. In Ayurvedic classics there is no exact correlation is available for this disease entity that exactly matches the feature of Wilson disease, but it can be correlated with Vatavyadhi under the Sahaja Vyadhi (Heredity) or Janamjata Vyadhi (congenital). The treatment1 mentioned for Vatavyadhi is Snehana (oleation), Mrudu Swedana (mild sedation), Anuvasana Basti (oil enema) and Niruha Basti (Decoction Enema). Material and methods: An 18-year-old male patient with Wilson disease complained of short stepping gait, persistent constipation, tremors, changed speech, generalised stiffness, and frequent eye blinking. S. Ceruloplasmin was found to be 18.33 mg/dL (usually 20 mg/dl to 40 mg/dl), S. copper was found to be within normal limits, and a slit lamp assay for the KF ring was negative. Ayurvedic therapy was used in conjunction with oral medicine throughout the treatment. Results: Clinical observations revealed that the patient's earlier symptoms had significantly improved, and he was able to carry out his usual activities with ease. Duration of treatment:three months. Conclusion: From the case study it can be concluded that the Ayurvedic medications and Panchkarma therapy in such patients may help in providing supportive care and improving the quality of life. Keywords: Vatavyadhi, Shaman Chikitsa, Bastikarma, Wilson's disease.