T10 Dermatome Research Articles

Pain during caesarean delivery in a tertiary maternity hospital: a retrospective cohort study (2022–2023)

BackgroundIntra-operative pain during Caesarean delivery (PDCD) is the leading cause of successful litigation against obstetric anaesthesiologists. PDCD may require conversion to general anaesthesia (GA). The aim of this analysis is to assess our incidence of PDCD and associated GA conversion. MethodsData were collected from electronic patient records. Data included baseline demographics, incidence of PDCD and rates of GA conversion, proportion of PDCD cases attributable to failed epidural (EA) or spinal anaesthesia (SA), and level of sensory and motor blockade in cases of PDCD. Results were audited against current standards set by the Royal College of Anaesthetists ‘rates of PDCD should be <5% for category 4, <15% for categories 2-3, and <20 % for category 1 CD ’ and that ‘rates of conversion to GA due to neuraxial complications should be <1% for category 4, <5% for categories 2-3 and <15% for category 1 patients’. ResultsDuring the 12-month study period, 2,429 patients underwent CD, of whom 52 (2.1%) experienced PDCD. The incidence of PDCD was 3.1% (41/1,309) for category 1-3 patients, while 1% (11/1,120) of category 4 patients experienced PDS. Of the 52 patients with PDCD, 17 patients required GA (33%). SA was used in 24/52 (47%) cases and EA in 28/52 (53%) cases. The median level of sensory block in patients with PDCD was located at the T4 dermatome, the median level of motor block was Bromage level 2. ConclusionsPDCD occurred in 2.1% of CD, one-third required conversion to GA. Most patients experiencing PDCD met current motor and sensory blockade criteria.

Comparison of Analgesic Method in Laparoscopic Gastrectomy Using External Oblique Intercostal Block Versus Wound Infiltration: A Randomized Controlled Trial.

Background: External oblique intercostal block (EOIB) is effective in relieving pain in the T6 to T10 dermatomes; however, there is limited evidence comparing EOIB with conventional regional anesthesia. In this randomized controlled trial, it was hypothesized that EOIB would provide more effective analgesia than wound infiltration (WI) in laparoscopic gastrectomy. Methods: Thirty-two patients (aged 20-85 years) with American Society of Anesthesiologists Performance Status of 1 to 2, scheduled for laparoscopic gastrectomy, were randomly divided into EOIB and WI groups. Both procedures were performed using 40 mL of 0.25% levobupivacaine. The primary outcome was the numerical rating scale (NRS) score 12 h postoperatively. Secondary outcomes were NRS at 2, 24, and 48 h postoperatively, variation in quality of recovery-15 score on postoperative days 1 and 2 from preoperative baseline, postoperative fentanyl consumption, and variation in World Health Organization Disability Assessment Scale 2.0 scores between baseline and 3 months postoperatively. Plasma concentrations of levobupivacaine and pinprick sensation in the T4-11 dermatomes post-EOIB were evaluated to determine the exploratory endpoints. Results: There were no differences in the NRS scores 12 h postoperatively at rest and during movement between the EOIB and WI groups (mean standard deviation 1.3 [1.1] vs. 1.5 [1.4] and 3.1 [1.6] vs. 3.8 [1.7], respectively). Secondary outcomes did not differ significantly between the groups. The time to peak plasma concentration of levobupivacaine following EOIB was 45 min. Conclusions: No significant differences in NRS scores were observed between the analgesic effects of EOIB and WI at 12 h postoperatively.

Comparison of Ropivacaine with or without Fentanyl in Spinal Anaesthesia for Lower Limb Surgeries

Introduction: Spinal anaesthesia is a preferred technique used for lower limb orthopaedic surgeries. Ropivacaine with its short duration of motor blockade and provision for early ambulation along with addition of spinal additives has proven beneficial to the patient. This prospective, double-blind, randomized controlled study set out to evaluate the effects of 0.75% isobaric ropivacaine with fentanyl versus 0.75% isobaric ropivacaine during lower limb orthopaedic surgeries performed under spinal anaesthesia. Methods: The study enrolled 74 patients, aged 18-65 years of either sex, ASA PS I and II, planned for lower limb orthopaedic surgeries. Patients were randomly allocated to receive either 2.5 ml of 0.75% isobaric ropivacaine and 0.5ml of normal saline (Group R) or 2.5 ml of 0.75% isobaric ropivacaine and 0.5ml of fentanyl (25mcg) (Group RF). Results: The demographic profile, onset time of sensory block to T10 dermatome, time for complete motor blockade, maximum block height, duration of motor block, and haemodynamic parameters did not significantly differ between the two groups. Group R took 200.27 ± 21.28 minutes for the S2 dermatome segment regression, while Group RF took 284.59 ± 32.88 minutes (p-value&lt;0.001). Group RF experienced analgesia for a longer duration (335.68±22.18 min) than Group R (240.00±28.28 min) (p-value&lt;0.001). Conclusion: Fentanyl greatly extends the duration of S2 segment regression and analgesia when combined with ropivacaine; the effects on haemodynamics and motor blockade is clinically negligible and side effects are minimal.

Effect of Transcutaneous Electrical Nerve Stimulation of T6 Dermatome on Appetite and Weight Reduction in Obese Individuals: A Pilot Study

Background: Previous work demonstrated the beneficial effect of T6 dermatomal stimulation by the percutaneous method in managing obesity. However, a simple, cost-effective, and feasible intervention stimulating the dermatome can be a potential solution for obesity care. Objective: The objective of this study was to find the effect of transcutaneous electrical nerve stimulation (TENS) of T6 dermatome on appetite and weight loss in obese individuals. Material and Methods: In this prospective single-arm experimental study, 20 obese patients received TENS treatment of T6 dermatome for 30 min, once a week and for 12 weeks. Outcome measures such as appetite level in the visual analog scale (VAS), weight in kg, and basal metabolic index (BMI) in kg/m2 were assessed at baseline, 12 weeks -post-intervention, and at 8 weeks of follow-up. Results: A statistically significant difference in all the variables was found from baseline to 12 weeks of intervention (P &lt; 0.001) and maintained till 8 weeks of follow-up. From pre- to post-treatment, the effect size for appetite reduction was large (&gt;1) while for weight and BMI loss was (0.14, 0.16), respectively small. Additionally, a weak correlation was found between pre- and follow-up appetite and weight loss (r = 0.25, P = 0.294). Conclusions: Twelve weeks of TENS treatment of T6 dermatome showed a positive effect in reducing appetite with sustained reduction up to 8 weeks of follow-up even after completion of the intervention. However, in the absence of dietary modification, TENS treatment was associated with low effect sizes weight and BMI loss.

P 022: Myopericarditis associated with herpes zoster infection presented with STEMI

We describe a case of an 18-year-old male with no known medical illness who presented with a history of fever and skin rash for the previous 2 days. The patient presented with symptoms of acute nausea, vomiting, and chest discomfort. The initial electrocardiogram (ECG) revealed an inferior ST-segment elevation myocardial infarction (STEMI), which prompted the administration of thrombolysis using streptokinase at the district hospital. However, consecutive ECGs showed no change, prompting the patient to be referred to our centre for a rescue percutaneous coronary intervention (PCI). The coronary angiography showed normal coronaries, whereas an echocardiogram showed good LV functions without any regional wall motion abnormalities and with normal valves. Upon further examination, the patient exhibited herpes zoster lesions along the T5–T6 dermatome. Blood investigations revealed elevated levels of thyroid hormones, as well as increased creatinine kinase and troponin I. The cardiac MRI showed the presence of mid-wall enhancement in the septal and lateral myocardium of the left ventricle, sub-epicardium of the right ventricle, and apical region of the left ventricle, which is indicative of myocarditis. The patient was diagnosed with myopericarditis and was treated with IV acyclovir, colchicine, high-dose aspirin, and carbimazole. He subsequently showed significant improvement and was successfully discharged. Although type 1 STEMI remains the prevailing diagnosis, this case emphasises the distinctive differential diagnosis of myopericarditis in patients presenting with chest discomfort and herpes zoster. Clinicians must obtain a thorough medical history and conduct a comprehensive evaluation to identify potential secondary aetiologies.

Effect of the Location of Tetanic Stimulation on Autonomic Responses: A Randomized Cross-Over Pilot Study.

Tetanic stimuli are used as standardized noxious inputs to investigate nociception. Previous studies have applied tetanic stimuli to various anatomical locations without validating that the resulting physiological responses were independent of the location where tetanic stimuli were applied. Our aim was to investigate the effects of three anatomical tetanic stimulus application sites on physiological variables reflecting autonomic nervous system responses as measured by photoplethysmography (PPG). Under general anesthesia, a five second, 100 hertz, 70 milliamp tetanic stimulus was applied to the ulnar nerve, medial side of the tibia, and thorax (T5 dermatome) (N=12). The effect of tetanic stimuli on PPG-derived variables (AC, DC, and ACDC) and pulse rate at each stimulus location was determined using repeated-measures analysis of variance (ANOVA) followed by Dunnett's post hoc test. Maximum tetanic stimulus-induced changes in PPG-derived variables and pulse rates were compared among the three stimulus locations using ANOVA. AC and ACDC values of PPG decreased, and the DC values of PPG increased in response to tetanic stimuli-induced vasoconstriction at each location (p<0.001 for all). The maximum changes in the AC, ACDC, and DC values did not differ between locations (p=NS). There were no significant changes in pulse rate (p=NS). The results showed that tetanic stimulation at either of these three locations provides the same autonomic nervous system responses, as measured by PPG. ClinicalTrials.gov; NCT03648853.

Effect of i.v. Magnesium Sulphate versus i.v. Dexamethasone on Intraoperative Haemodynamic and Postoperative Analgesia after Spinal Anaesthesia in Lower Limb Surgeries: A Randomised Clinical Study

Introduction: Intrathecal adjuvants have gained favour in recent years with the goal of extending the duration of a block. Among these, Dexamethasone possesses anti-inflammatory and analgesic action and can be given as an adjuvant to local anaesthetics to enhance the efficacy of regional anaesthesia, as well as to decrease the intensity of shivering. The addition of Magnesium sulphate (MgSO4 ) to spinal anaesthesia helps in improving postoperative analgesia in an orthopaedic setting. Aim: To compare the effects of Intravenously (i.v.) MgSO4 and i.v. dexamethasone on intraoperative haemodynamics, the time to achieve dermatome T10 intraoperatively, and to compare postoperative Visual Analogue Scale (VAS) scores between the two groups at 1, 3, 6, 12, and 24 hours after surgery. Materials and Methods: This randomised clinical trial was conducted, and patients were randomly divided into two groups. Group M (n=40): MgSO4 40 mg/kg given 15 minutes before spinal anaesthesia in 100 mL normal saline infusion i.v. Group D (n=40): Dexamethasone 8 mg given 15 minutes before spinal anaesthesia in 100 mL normal saline infusion i.v. The parameters assessed included haemodynamic parameters, time to achieve dermatome T10 intraoperatively, postoperative VAS score at 1, 3, 6, 12, and 24 hours after surgery, and any side-effects like sedation, respiratory depression, nausea, vomiting, pruritus, urinary retention, bradycardia, and hypotension. Statistical testing was conducted using the statistical software Statistical Package for Social Sciences (SPSS) 28.0. Results: There was no significant difference in demographic variables (age and gender) between the two groups (p-value&gt;0.05). However, the decrease in mean heart rate, Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), and Mean Arterial Blood Pressure (MAP) was greater in group D compared to group M at different time intervals (p-value&lt;0.05). Additionally, dermatome level T10 was achieved earlier in group D by approximately two minutes compared to group M (6.95±0.39 minutes versus 5.03±0.16 minutes, respectively, p-value&lt;0.001). Conclusion: An i.v. infusion of 8 mg dexamethasone in 100 mL normal saline was more effective compared to an i.v. infusion of 40 mg/kg MgSO4 in terms of achieving more stable haemodynamics intraoperatively and achieving the T10 dermatome level earlier.

Transüretral Cerrahi Vakalarinda, Sürekli Spinal ve Tek Doz Spinal Anestezi Tekniklerinin Hemodinami, Duyusal ve Motor Blok Seviyesi Üzerine Etkilerinin Karşilaştirilmasi

Aim: In this study, it was aimed to compare in patients undergoing transurethral resection surgery: 1- The effectiveness of single-dose and continuous spinal anesthesia techniques, 2- Hemodynamic changes, sensory-motor block levels and durations, anesthetic drug doses and side effects. Method: Forty American Society of Anesthesiology I–III patients in the age group of 40–75 years who were scheduled for transurethral surgery were randomly divided into two groups: single dose spinal anesthesia (Group 1) (n = 20) and continuous spinal anesthesia (Group 2) (n = 20). The patients' hemodynamic data, analgesia status and motor block levels were evaluated. Results: With regard to the hemodynamic parameters, the mean values of systolic–diastolic blood pressure and heart rate were found to be significantly lower in the single dose spinal anesthesia group (Group 1) than in the continuous spinal anesthesia group (p &amp;lt; 0.05). In terms of sensory and motor block levels, the maximum block level was T9 in the continuous spinal anesthesia group, while it was T8 in the single dose spinal anesthesia group (p &amp;lt; 0.05). Upon reaching T10, two-segment regression and sensory and motor block termination times were found to be significantly lower in the continuous spinal anesthesia group when compared to the single dose spinal anesthesia group (p &amp;lt; 0.05). There was no difference between the two groups in terms of Bromage score values (p &amp;gt; 0.05). In the continuous spinal anesthesia group, the mean dose and volume of the local anesthetic required to achieve analgesia in the T10 dermatome were found to be 7.12 ± 1.46 ml and 1.4 ± 0.29, respectively. Furthermore, the amount of fluid administered intraoperatively was found to be significantly lower in the continuous spinal anesthesia group than in the single dose group (p &amp;lt; 0.05). Conclusion: With the continuous spinal anesthesia method, it can be titrated and by using lower doses of local anesthetic, a level of sensory-motor blockade close to the single-dose spinal anesthesia method and a more stable hemodynamics can be achieved.

Multidermatomal herpes zoster triggered by psychological stress in an immunocompetent young adult: a rare case report and clinical insights

Introduction and Importance: Herpes zoster (HZ), a reactivated varicella zoster virus infection arising from dormant viral latency after initial chickenpox, manifests as localized skin rashes along dermatomes. Multidermatomal involvement, especially in immunocompetent individuals, is rare. The potential link between psychological stress and HZ reactivation remains underexplored. The authors present a case of multidermatomal HZ triggered by psychological stress in a young immunocompetent adult. Case presentation: A 26-year-old male presented with vesicular lesions spanning C5, C8, T1, and T2 dermatomes, triggered by psychological stress. The disease exhibited a unique midline-crossing presentation. The Varicella zoster virus IgM test result was positive. Treatment included acyclovir, pain management, and stress reduction strategies, yielding complete resolution within 3 weeks. Clinical discussions: The case highlights a distinctive multidermatomal HZ presentation, defying conventional dermatomal restrictions. Psychological stress potentially influenced viral reactivation. Immunocompetence and stress interplay merit further exploration. Multidermatomal HZ necessitates prompt clinical recognition and comprehensive evaluation. Antiviral therapy and integrated stress management may contribute to successful outcomes. Conclusion: This case underscores the rare occurrence of multidermatomal HZ in an immunocompetent young adult triggered by psychological stress. The atypical presentation and potential role of stress in viral reactivation emphasize the complex interaction between the nervous and immune systems. Integrated clinical management, stress reduction strategies, and antiviral therapy were effective in resolving the condition. Further research is warranted to elucidate the mechanisms underlying stress-induced viral reactivation and its clinical implications.

COMPARISON OF HYPERBARIC LEVOBUPIVACAINE/ BUPIVACAINE FOR CESEREAN SECTION

Background : Bupivacaine is the most popular local anesthetic agent in obstetric practice Levobupivacaine showed a lower risk of cardiovascular and central nervous system (CNS) toxicity compared to Bupivacaine The aim of this study was to investigate the clinical efficacy of levobupivacaine compared with hyperbaric bupivacaine for spinal anesthesia for cesarean section. Methods: 60 pregnant women in ASA I - II group scheduled to have elective cesarean operation were allocated into the study. Patients were randomly divided into two groups. 10 mg levobupivacaine (0.5%) for Group L (n = 30) patients, 10 mg hyperbaric bupivacaine (0.5%) for B (n = 30) patients were intrathecally administrated a total of 2.0cc. Sensory and motor block characteristics of the groups were assessed with pinprick and Bromage scale observed hemodynamic changes and side effects were recorded. Results: The time to reach maximum dermatome for the sensory block, time to regression by two dermatomes and time to regress to T12 dermatome was found to be significantly long in Group B. It was observed that in Group B, the motor block was faster and lasted longer. Where as hypotension, bradycardia and nausea were less in Group L, the need for ephedrine was higher in Group B (p &lt; 0.05). Conclusion: Since motor block time is shorter, and side effects like hypotension, bradycardia and nausea are less, levobupivacaine can be a good alternative in cesarean sections.

PANCOAST TUMOR PRESENTING WITH HORNER SYNDROME: A CASE REPORT

Case Report: A 50-year-old man was referred to Dr. Moewardi General Hospital with history of right chest pain that radiate to the right back and hand for 2 months. His complaint did not improve with medication and physical therapy. On physical examination we observed multiple nodules on the right axilla, scapula, and colli region. Neurological examination revealed right sided partial ptosis, anisocoria, ipsilateral weakness, and ipsilateral allodynia, and anhidrosis T1 dermatome. CT-scan showed a right lung mass in the superior lobe of the apical segment. The diagnosis of Horner syndrome is then established caused by multiple lymphadenopathies. His symptoms then relieved after lymphadenectomy. Conclusion: Horner syndrome, characterized by ipsilateral pupillary anisocoria, ptosis and anhidrosis, is one of the complications of Pancoast tumor invasion to the sympathetic nervous system in the C8, T1, and T2 nerve territory.

Comparison of dexmedetomidine and clonidine as an adjuvant to levobupivacaine in transversus abdominis plane (TAP) block for postoperative analgesia following inguinal hernia repair

Postoperative analgesia for inguinal hernia procedures can be provided safely and effectively with USG guided TAP blocks. In the TAP block following inguinal hernia repair, we compared the analgesic effectiveness of dexmedetomidine and clonidine.: Seventy four patients undergoing inguinal hernia repair under spinal anesthesia were randomly divided in to Group LD (n=37) and Group LC (n=37). Patients in Group LD received a unilateral USG-guided TAP block with 0.5% levobupivacaine 18ml and dexmedetomidine 1 μg/kg in NS to make a total 20ml at the conclusion of surgery after regression of sensory block to the T10 dermatome, whereas patients in Group LC received 0.5% levobupivacaine 18ml and clonidine 1 μg/kg. Duration of postoperative analgesia, quality of analgesia (VAS), total rescue analgesic consumption in 24 hours and adverse effects were noted.Time for the initial application of rescue analgesia took substantially longer in Group LD (1006.49± 29.89 min) than in Group LC (512.35 ±27.14 min) (p ≤0.0001). At 8h, 16h, and 20h postoperatively, Group LD had a significantly lower VAS score both at rest and during hip flexion. It was discovered that Group LD had considerably decreased overall analgesic consumption. Incidence of postoperative side effects was comparable between two groups.: In comparison to clonidine, TAP block with dexmedetomidine as an adjuvant to levobupivacaine greatly prolongs postoperative analgesia and lowers 24-hour analgesic use.

Spinal Venous Vascular Ectasia With Unusual presentation of Abdominal Pain: Case Report

BACKGROUND AND IMPORTANCE: Spinal venous vascular ectasia associated with a low-flow fistula of paravertebral location is a very low-frequency entity. It usually manifests with myelopathy; however, in the present case, the symptomatology corresponded to thoracic radiculopathy, which can be difficult to diagnose and may be the cause of chronic pain refractory to analgesic management. CLINICAL PRESENTATION: An adult patient who consulted about a 1 year and a half of flank pain refractory to analgesic management and hypoesthesia on palpation in the left T8 dermatome, therefore, pain of radicular origin was suspected. MRI of the thoracic spine was requested, showing an image suggestive of vascular malformation at the level of T8. After identification of the lesion, the patient was taken to spinal angiography to delimit the vascular malformation, finding an image suggestive of spinal venous vascular ectasia associated with a low-flow fistula of paravertebral location at T8. Subsequently, the case was discussed by a multidisciplinary team that established endovascular embolization as the best option for treatment. Thus, achieving complete occlusion of the lesion without complications and a slow improvement of the symptoms. CONCLUSION: Spinal venous vascular ectasia associated with a low-flow fistula of paravertebral location is a very low-frequency entity that despite manifesting with myelopathy in some cases may generate radicular irritative symptoms and is differentiated from other lesions by its unusual location in spinal angiography.

A TRIAL TO INVESTIGATE THE CORRELATION BETWEEN THE SPINAL COLUMN LENGTH AND ABDOMINAL GIRTH, AND THE LEVEL OF SENSORY BLOCKADE IN SUBARACHNOID BLOCK IN PARTURIENTS REQUIRING SPINAL ANAESTHESIA FOR LOWER SEGMENT CAESAREAN SECTION.

Introduction Spinal anaesthesia (SA) is a type of regional anaesthesia which obstructs nerve roots coursing through the subarachnoid space. It is a reliable technique that has become a preferred technique in lower segment caesarean section. Sensory blocking up to T4 dermatome level is required during Caesarean section, as this not only suppresses somatic sensations but also removes visceral discomfort caused by peritoneum manipulation. However, because of this, the nal extent of anesthesia remains unpredictable which may cause inadequate local anaesthesia or excessive block which may increase hemodynamic instability and be hazardous to the patients. Hence, predicting and controlling the spread of local anaesthesia in the cerebrospinal uid is crucial which can be achieved by studying the factors that inuence the extent of spinal anaesthesia. Such factors include the patient's general features, the characteristics of the injected solution, the clinical technique used and so on. The current study was undertaken to investigate the correlation between patient's general features such as the spinal column length and abdominal girth, and the level of sensory blockade in subarachnoid block for a given amount of local anaesthetic. The current prospective study cohort includes 100 parturients who rece Methods ived 2mL of 0.5% hyperbaric bupivacaine for subarachnoid block. Height, weight, spinal column length, and abdominal girth were measured and recorded. Sensory level of blockade achieved was noted at 3 minutes and 25 minutes. The data was recorded in Microsoft excel and the analysis was done using SPSS version 20. Results Analysis indicated a negative association between abdominal girth and thoracic dermatome levels at 3 minutes (r-value=-0.042) and this association was found statistically insignicant (p-value=0.410&gt;0.05). Similarly, at 25 minutes, there was a negative association between abdominal girth and thoracic dermatome levels (r-value=-0.201), however, this association was statistically signicant (p-value=0.017&lt;0.05). The spinal column length and thoracic dermatome levels showed negative association that was statistically insignicant at both the 3 (r-value=- 0.409, p-value = 0.673&gt;0.05) and 25-minute (r-value=-0.148, p-value=0.530&gt;0.05) time points. From o Conclusion ur study we concluded that spinal column length was not a contributing factor to the level of blockade either at the onset of blockade or the nal spread. However, abdominal girth did have an inuence on the level of blockade. In order to conrm these results and reach a more satisfactory conclusion, studies in larger population need to be conducted.

The Minimum Effective Concentration (MEC95) of different volumes of ropivacaine for ultrasound-guided caudal epidural block: a dose-finding study

BackgroundCaudal epidural block (CEB) may be beneficial in anorectal surgery because its use may extend postoperative analgesia. This dose-finding study aimed to estimate the minimum effective anesthetic concentrations for 95% patients(MEC95) of 20 ml or 25 ml of ropivacaine in with CEB.Patients and methodsIn this double-blind, prospective study, the concentration of ropivacaine administered in 20 ml and 25 ml for ultrasound-guided CEB were determined using the sample up-and-down sequential allocation study design of binary response variables. The first participant was given 0.5% ropivacaine. Depending on whether a block was successful or unsuccessful, the concentration of local anesthesia was decreased or increased by 0.025% in the next patient. Every five minutes for 30 min, the sensory blockade using a pin-prick sensation at S3 dermatome compared to at T6 dermatome were evaluated every 5 min within 30 min. An effective CEB was defined as a a reduction of sensation at S3 dermatome and the existence of flaccid anal sphincter. Anesthesia was considered successful if the surgeon could perform the surgery without additional anesthesia. We determined the MEC50 using the Dixon and Massey up-and-down method and estimated the MEC95 using probit regression.ResultsThe concentration of ropivacaine administered in 20 ml for CEB ranged from 0.2% to 0.5%. Probit regression with a bias-corrected Morris 95% CI derived by bootstrapping showed an MEC50 and MEC 50 of ropivacaine for anorectal surgical anesthesia were 0.27% (95% CI, 0.24 to 0.31) and 0.36%(95% CI, 0.32 to 0.61). The concentration of ropivacaine administered in 25 ml for CEB ranged from 0.175 to 0.5. Probit regression with a bias-corrected Morris 95% CI derived by bootstrapping showed an MEC50 and MEC95 for CEB were 0.24% (95% CI, 0.19 to 0.27) and 0.32% (95% CI, 0.28 to 0.54).ConclusionWith ultrasound-guided CEB, the MEC95 of 0.36% ropivacaine at 20 ml and 0.32% ropivacaine at 25 ml provide adequate surgical anesthesia/analgesia 95% of patients undergoing anorectoal surgery.Trial registrationClinicaltrails.gov: Retrospectively registered (ChiCTR2100042954; Registration date:1/2, 2021).

A Case of Haemorrhagic Herpes Zoster

Background: Varicella-zoster virus (HHV3) is one of the virus in herpes family. Herpes zoster results from the reactivation of varicella-zoster virus in the dorsal root ganglion. This reactivation occurs in immunocompromised conditions such as people with cancer, organ transplant recipients or those receiving chemotherapy, and people with HIV. Old age is also an important risk for the development of herpes zoster. Immunocompromised patients are at increased risk of VZV reactivation because of reduced T cell-mediated immunity. Emotional stress has also been mentioned as an associated factor in people with herpes zoster. The Classic clinical presentation consists of clear vesicular eruptions in dermatomal distribution which are painful. An immunocompromised individual may have frequent attacks of herpes zoster, cutaneous dissemination, organ involvement, and hemorrhagic herpes zoster. Haemorrhagic herpes zoster is an atypical form of herpes zoster develops in patients who are immunosuppressed and people of advanced age who are taking antiplatelets, and anticoagulants, and also in patients with thrombocytopenia due to any cause. The most common Association of herpes zoster is observed with lymphocytic leukemia and less frequently with myeloid leukemia. Management icludes antiviral therapy along with management of haemorrhagic conditions. Case Report: A nondiabetic male of 60 years attended the medicine outpatients department with complaints of epistaxis for two days. No history of bleeding from other sites was evident. There was no history of trauma or taking of anticoagulants or antiplatelets. No history of fever. The patient was anaemic and an erythematous rash was evident along the right T6 dermatome. He was admitted to the general medicine ward. On the second day of his admission, our patient developed painful haemorrhagic bullous lesions over the right T6 dermatome resembling a bunch of grapes and erythematous popular lesions all over his body (Figure 1). The bullous lesions became larger in size in the subsequent two days of admission. On query, he mentioned that he had suffered from Varicella Zoster in his early childhood. Patients haemoglobin was 10.70 gm/dl, total count of white blood cell (WBC) was 13.20 K/ mm3 (normal value 4.00 – 11.00 K/ mm3), neutrophil and lymphocyte counts were 2.38 K/ mm3 (normal value 2.16 – 6.04 K/ mm3) and 10.38 K/ mm3 (normal value 0.6 – 3.06 K/ mm3) respectively. His platelet count was 5.00 K/ mm3 (normal value 150.00 – 400.00 K/ mm3). The patient denied skin biopsy. A diagnosis of haemorrhagic herpes zoster was made after a dermatology consultation and oral valacyclovir was started along with oral and topical antibiotics and regular dressings. After six units of platelet transfusion patients, the platelet count was raised to 30 K/ mm3. Peripheral blood film was suggestive of acute leukaemia. A bone marrow examination was suggestive of acute myeloid leukaemia. The patient was transferred to the haemato-oncology ward for further planning and management. Conclusion: Haemorrhagic herpes zoster may occur in different clinical conditions and one of them although rare, is acute myeloid leukaemia. Clinical scenario along with bone marrow and blood picture helps to reach a diagnosis in such cases.

Effect of dexmedetomidine and fentanyl on hemodynamic changes and block profile following spinal anesthesia with ropivacaine among patients with femoral fractures undergoing lower limb surgery.

The aim of this study was to compare the effect of dexmedetomidine and fentanyl on hemodynamic changes and block characteristics following spinal anesthesia with ropivacaine among patients with femoral fractures undergoing lower limb surgery. In this double-blind clinical trial, 64 patients who were candidates for lower limb surgery. Patients were divided into two groups based on the block pattern. In the first group, dexmedetomidine was prescribed. In the second group, fentanyl with ropivacaine was prescribed. Sensory and motor blocks at or above the T8 dermatome in each group were measured. Furthermore, the sensory block was evaluated every 1 minute after anesthesia with a needle (pin prick method) and also the motor block was evaluated every 5 minutes by the bromage scale. There was a statistically significant difference between the two groups in terms of the time for achieving sensory block to T8 or higher dermatome (p = 0.0001). The time elapsed until the onset of motor block was shorter in the dexmedetomidine group, and dexmedetomidine had a shorter time for achieving sensory block to T8 or higher dermatome than fentanyl. A statistically significant difference was found in terms of the time elapsed until the motor block and the time for achieving sensory block to the T8 dermatome or higher (p <0.05). The time elapsed until the onset of motor block was shorter in the dexmedetomidine group, and dexmedetomidine had a shorter time for achieving sensory block to T8 or higher dermatome than fentanyl. Our findings revealed a statistically significant difference in terms of the duration of sensory block for reaching the T12 to L1 dermatome and the duration of obtaining bromide scores 0 and 1 (p = 0.0001). The time for achieving sensory block to dermatome T12 to L1 and the time of obtaining bromage scales of 0 and 1 were longer in dexmedetomidine group (p = 0.0001). Pain in dexmedetomidine group was less than fentanyl group in 2 to 8 hours after surgery (p <0.05). The duration of analgesia was longer in the dexmedetomidine group (p = 0.001). In summary, it can be suggested that adding dexmedetomidine to the anesthetic ropivacaine may be beneficial.

Quadratus lumborum block vs. transversus abdominis plane block in laparoscopic trans-abdominal pre-peritoneal repair of inguinal hernia in adults: A randomised controlled trial.

Laparoscopic trans abdominal preperitoneal (TAPP) repair of hernia is one of the most commonly performed surgeries and may cause significant postoperative pain. Among different truncal block techniques, quadratus lumborum (QL) and transversus abdominis plane blocks (TAP) are used during this abdominal surgery. We aimed to investigate whether, bilateral QL block by trans-muscular approach provided better analgesia as compared to posterior TAP block in these patients. Forty adult patients with American Society of Anesthesiologists physical status I and II, undergoing inguinal hernia repair were randomized to receive either QL or TAP block, with 20 mL of 0.25% ropivacaine bilaterally. The primary objective of the study was to compare the total fentanyl consumption (in μg) within 24 hours postoperatively. The secondary objectives studied were dermatomal spread, quality of recovery at discharge and at 3 months postoperatively. There was a significant reduction in total 24-hour fentanyl consumption (552 ± 229.56 vs 735.5 ± 264 μg, P =0.01) in the QL group, with longer duration of analgesia [282.5 ± 89.9 min group TAP vs. 354.8 ± 107 min QL, (mean difference -72.34,95% confidence interval -135.516 to -9.024), P =0.03], as compared to TAP group. At T8 and T9 dermatomes, greater proportion of patients in the QL group attained analgesia. Quality of Recovery at 24 hours and at 3 months of follow-up were comparable. QL block provided better perioperative analgesia than TAP block, in patients undergoing laparoscopic hernia repair. It also leads to greater dermatomal spread but without any decrease in the incidence of chronic pain at 3 months postoperatively.

Comparison of Bupivacaine (0.5%) and Bupivacaine (0.5%) with Dexmedetomide for Spinal Anesthesia in Lower Abdominal and Pelvic Surgery

Background: Dexmedetomiodine has also been used intrathecally to enhance the duration of motor and sensory blockade produced by hyperbaric bupivacaine. By increasing the dose of intrathecal dose of intrathecal dexmedetomidine it has been found that there is a significant increase in duration of motor and sensory blockade produced by intrathecal hyperbaric bupivacaine. Purpose of this study was to evaluate whether addition of dexmedetomidine changes the characteristics of bupivacaine 0.5% analgesia and other effects when injected intrathecally. Materials &amp; Methods: This prospective, double-blind, randomized, controlled study was conducted in 100 patients of ASA PS I-II, aged between 20-60 yrs, of either sex, scheduled for elective lower abdominal and pelvic surgery were chosen and divided into two groups. Patients were randomly allocated to receive intrathecally either 3ml of 0.5% hyperbaric bupivacaine plus 1ml normal saline (group X) or 3ml of 0.5% hyperbaric bupivacaine plus dexmedetomidine 4 µg in 1 ml (group Y). The time taken to achieve peak sensory (T10 dermatome) and motor blockade (Bromage score 3), duration of block, recovery characteristics and hemodynamic changes were recorded. Any adverse symptoms like nausea, vomiting, shivering, pruritis, and sedation etc were noted.Results: The mean time of sensory block to reach T10 dermatome was 5.56±1.23 minutes in Group Y, 6.48±1.18 minutes in Group X.The mean time to reach Bromage 3 scale was 8.94±1.62 minutes in Group Y and 11.88±1.42 minutes in Group X. The regression time to Bromage 0 was 291.7±30.2 minutes for Group Y and 144.8 ±10.5 minutes for Group X. Onset and regression of sensory and motor block were highly significant ( p&lt;0.0001). The mean time for 2 segment regression was 111.1±14.96 for group Y and 89.2±9.11 for group X (p&lt;0.0001).&#x0D; Conclusion: The onset of sensory and motor blockade was shortened by dose of dexmedetomidine. The duration of sensory and motor block was also prolonged. Therefore it can be concluded that dexmedetomidine has effect on sensory and motor block when used as an adjuvant to bupivacaine in spinal anaesthesia

Giant Spinal Schwannomas. Presentation of Two Cases with Interdisciplinary Surgical Resection

Purpose: To report two quite rare cases of giant schwannomas of the cervical and thoracic spine. Surgical resection is usually the treatment of choice for these neoplasms. Methods: The first patient is a 48-year-old male that came to our department, complaining about weakness and paresthesia of both lower extremities and upper left extremity, and a considerably big dorsal palpable lump. MRI and CT scan were used to diagnose giant cervical schwannoma. Because of the intensity of symptoms, he was subjected to surgery. Multidisciplinary resection involving neurosurgical and oncosurgicalteamn was performed for intravertebral and extravertebral approaches. The second patient is a 55-year-old female that came to the hospital complaining about incapacitating pain and dysesthesia involving T6, T7, and T8 dermatomes, with no other deficits. MRI and CT scan were used to diagnose giant thoracic schwannoma. Because of the intensity of the pain, surgery was decided as the treatment of choice. Video assisted thoracoscopic surgery was performed and total resection was achieved, with improvement of the symptoms. Results: Both patients showed complete remission of the symptoms, with no major deficits after surgery. Conclusion: Although infrequent, giant spinal schwannomas may be the cause of visible lumps in the back with radicular symptoms. When asymptomatic, conservative treatment could be viable, but when they present symptoms, surgery offers good results.