Turk J Anaesthesiol Reanim: 47 (5)
Volume: 47  Issue: 5 - October 2019
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REVIEW
1.The Effect of Transversus Abdominis Plane Block for Analgesia in Patients Undergoing Liver Transplantation: A Systematic Review and Meta-Analysis
Ankur Sharma, Akhil Dhanesh Goel, Prem Prakash Sharma, Varuna Vyas, Sumita Pravesh Agrawal
doi: 10.5152/TJAR.2019.60251  Pages 359 - 366
Objective: Ultrasound-guided regional anaesthesia using transversus abdominis plane (TAP) block is a newer and safer method that can be used in patients undergoing liver transplant surgeries. This systematic review and meta-analysis was done to quantify the analgesic potential and opioid-sparing capability of TAP block in these patients.

Methods: The studies comparing TAP‑block to conventional analgesic regimens for liver transplant were searched. The studies evaluating the comparative 24-h morphine consumption during postoperative period in patients undergoing liver transplant surgeries were searched and included as the primary outcome in the analysis.

Results: We found two randomised controlled trials and two retrospective studies that on meta-analysis showed that TAP block group had significantly lower requirement of morphine (WMD=27.59 mg; 95% CI: 33.47–21.70) at 24 h for pain mitigation. Also, postoperative nausea and vomiting was lower (RR=0.76; 95% CI: 0.47–1.22) but not statistically significant.

Conclusion: Ultrasound-guided TAP block provides postoperative analgesic efficacy in patients undergoing liver transplant surgeries. This study was registered in International prospective register of systematic reviews [PROSPERO: CRD42018094595].

2.The Role of Transcranial Doppler Ultrasonography in the Diagnosis of Brain Death
Umut Sabri Kasapoğlu, Murat Haliloğlu, Beliz Bilgili, İsmail Cinel
doi: 10.5152/TJAR.2019.82258  Pages 367 - 374
Klinik bir tanı olan beyin ölümü tanısında nörolojik muayenenin ve apne testinin yapılamadığı durumlarda doğrulayıcı testlere başvurulmaktadır. Transkranial doppler ultrasonografi (TKD) beyin ölümü tanısında kullanılan noninvazif, tekrarlanabilir, hasta başı uygulanabilen geçerli ve kullanışlı doğrulayıcı bir ek testtir. Beyin ölümü tanısında TKD’nin değişen oranlarda duyarlılığı ve özgüllüğü olsa bile yöntemin birçok üstünlüğünün olması nedeni ile yoğun bakım klinik pratiğinde kullanımının giderek artması kaçınılmazdır. Bu derlemede serebral sirkülatuar arrest ve beyin ölümü tanısı için doğrulayıcı bir test olan TKD’nin kullanımı irdelenmiştir.
Ancillary tests can be used for the diagnosis of brain death in cases wherein uncertainty exists regarding the neurological examination and apnoea test cannot be performed. Transcranial Doppler ultrasonography (TCD) is a useful, valid, non-invasive, portable, and repeatable ancillary test for the confirmation of brain death. Despite its varying sensitivity and specificity rates with regard to the diagnosis of the brain death, its clinical use has steadily increased in the intensive care unit because of its numerous superior properties. The use of TCD as an ancillary test for the diagnosis of brain death and cerebral circulatory arrest is discussed in the current review.

CLINICAL RESEARCH
3.Postoperative Analgesic Efficacy of Preemptive and Postoperative Lornoxicam or Tramadol in Lumbar Disc Surgery
Esma Coşkun, Emine Dinçer, Güldem Turan, Asu Özgültekin
doi: 10.5152/TJAR.2019.60963  Pages 375 - 381
Amaç: Anestezi indüksiyonunda verilen tramadol ve lornoksikamın lomber diskektomi uygulanacak hastalarda preemptif ve postoperatif analjezik etkinliklerinin karşılaştırmaktır.
Yöntemler: Bu randomize, çift kör çalışma ASA I ve II, lomber diskektomi uygulanacak 60 hasta üzerinde gerçekleştirildi. Grup L’ye 3x8mg/gün lornoksikam ve Grup T’ye 3x1.5 mg/kg/gün tramadol verildi. Postoperatif 30. dakikada, 1., 2., 4., 6., 8., 12., ve 24. saatlerdeki Sözel Ağrı Skalası (Verbal Rating Scale-VRS), efektif analjezi süresi, kullanılan ek analjezik sayısı, yan etkiler ve hasta memnuniyetleri değerlendirildi.
Bulgular: Grup L ve T arasında demografik ve klinik özelliklerin yanı sıra ek analjezik sayısı, efektif analjezik süresi, yan etkiler ve hasta memnuniyeti açısından anlamlı bir farklılık yoktu. Grup T’deki hastaların postoperatif 30. dakikada (p = 0.050) ve 1.saatteki (p = 0.005) VRS skorları Grup L’deki hastaların skorlarından anlamlı yüksekti.
Sonuç: Lomber disk cerrahisinde preemptif ve postoperatif analjezide kullanılan lornoksikam, en az tramadol kadar yeterli ve etkin bir analjezi sağlamıştır. Ayrıca, preemptif aneljezikler postoperatif ağrının önlenmesinde ve tedavisinde oldukça etkilidir.
Objective: To compare preemptive and postoperative analgesic efficacy of tramadol and lornoxicam administered before anaesthesia induction in lumbar discectomy.
Methods: This randomised, double-blind trial was conducted on 60 ASA I and II patients undergoing lumbar discectomy. Group L (n=30) received 3×8 mg day-1 lornoxicam, and Group T (n=30) received 3×1.5 mg kg-1 day-1 tramadol. A verbal rating scale (VRS), the duration of effective analgesia, the number of additional analgesics used, adverse effects and patient satisfaction were evaluated at the postoperative 30th minute and 1st, 2nd, 4th, 6th, 8th, 12th and 24th hours.
Results: There were no significant differences between Groups L and T regarding demographic and clinical characteristics, the number of additional analgesics and the duration of effective analgesia, adverse effects and patient satisfaction. VRS scores of the patients in Group T were significantly higher than those in Group L at the postoperative 30th minute (p=0.050) and the 1st hour (p=0.005).
Conclusion: Lornoxicam, which was used for preemptive and postoperative analgesia in lumbar disc surgery, had provided adequate and effective analgesia such as tramadol. Moreover, preemptive analgesia was quite effective in prevention and treatment of postoperative pain.

4.Clinical Analysis of Propofol, Etomidate and an Admixture of Etomidate and Propofol for Induction of General Anaesthesia
Vikram Singh Rathore, Shalendra Singh, Priya Taank, Ankur Khandelwal, Ashutosh Kaushal
doi: 10.5152/TJAR.2019.53806  Pages 382 - 386
Objective: To compare the clinical outcome following induction of general anaesthesia with intravenous (IV) injection of propofol (P), etomidate (E) or a 50% admixture of propofol and etomidate (PE).
Methods: In this prospective, randomised, double-blind controlled study, patients 18–60 years of age who were undergoing elective surgery with general anaesthesia were randomised to receive either propofol 2.5 mg kg−1 IV (group P; n=30), etomidate 0.3 mg kg−1 IV (group E; n=30) or an admixture of etomidate 0.2 mg kg−1 IV and propofol 1 mg kg−1 IV (group PE; n=30) as the induction agent. The haemodynamic response was first recorded at baseline, then at 1 minute following administration the study drug, and 1, 3, 5, 10, 20, 30 and 40 minutes following intubation. Perioperative symptoms such as myoclonus, pain upon injection and/or vomiting upon induction as well as postoperative nausea were recorded.
Results: We observed a decrease in systemic haemodynamics from baseline following induction in group P compared to groups E and PE (p<0.05). Incidence of myoclonus was reduced from 76.6% in group E to 6.6% in group PE (p<0.001). There was also a reduction in reported pain upon injection in group PE compared to group P (p<0.001). Although we found no statistically significant difference between the three groups when assessing postoperative nausea and vomiting, these symptoms were more prevalent in groups E and PE than in group P.
Conclusion: Using an admixture of etomidate and propofol as the induction agent reduced the incidence of side effects observed with use of either drug alone such as pain upon injection, myoclonus and haemodynamic instability.

5.Fibreoptic Orotracheal Intubation of Obese Patients Using Parker Flex-Tip vs. Standard Endotracheal Tube
Lee C. Chang, Susan C. Lee, Andrew L. Ding, Suman Rajagopalan
doi: 10.5152/TJAR.2019.28909  Pages 387 - 391
Objective: Advancement of the endotracheal tube through a fibreoptic scope can sometimes prove to be challenging in obese patients. The Parker Flex-Tip endotracheal tube was developed with a curved and tapered distal tip to facilitate easier placement in the trachea. This study examined the use of the Parker Flex-Tip tube as compared to standard endotracheal tubes in patients with a body mass index of 30 or greater.
Methods: Sixty patients undergoing surgery requiring general anaesthesia were randomised into two groups. Using the fibreoptic scope, one group was intubated with the Parker Flex-Tip tube and the other group with a standard polyvinyl Portex tube. The time for intubation and the number of attempts required to place the endotracheal tube were measured and recorded.
Results: Using the Mann-Whitney U rank sum test, the median time needed for intubation with the two types of endotracheal tubes did not show a significant difference. The chi-square analyses were conducted for the number of attempts needed to place the endotracheal tubes, which also did not demonstrate any significant difference.
Conclusion: Parker Flex-Tip endotracheal tube was not superior to the standard endotracheal tubes for fibreoptic intubation in obese patients.

6.Effect of Concurrent Lidocaine, Remifentanil and Methylprednisolone Use on the Clinical Effect of Sugammadex under General Anaesthesia in Rats
Tünay Kandemir, Erbin Kandemir, Tuğba Aşkın, Selda Muslu, Gonca Oğuz Tuncel, Süheyla Ünver
doi: 10.5152/TJAR.2019.67760  Pages 392 - 395
Amaç: İnvitro bir çalışmada lidokain, remifentanil ve metilprednizolonun sugammadeks ile inklüzyon kompleksi oluşturarak sugammadeksin serbest ve aktif konsantrasyonlarında azalmaya sebep olduğu bildirilmiştir. Eş zamanlı olarak kullanımlarında tek başlarına kullanımlarına göre sinerjik farmakokinetik veya farmakodinamik etkileşim ile sugammadeksin nöromüsküler blokajı geri döndürme zamanında uzamaya sebep olması muhtemeldir. Biz bu çalışmada sugammadeks ile eş zamanlı olarak remifentanil, lidokain ve metiprednizolon kullanımının sugammadeksin NMBA rokuronyum ile oluşan nöromüsküler blokajı geri döndürücü etkisinde azalmaya sebep olup olmadığını araştırmayı amaçladık.
Yöntemler: Bu çalışma 42 adet sıçan üzerinde yapıldı. Sıçanlar rastgele her grupta 6 sıçan olmak üzere 7 gruba ayrıldı. 1. gruba serum fizyolojik, 2. gruba metilprednizolon ve remifentanil, 3. gruba lidokain ve metilprednizolon, 4. gruba remifentanil, 5. gruba lidokain, 6. gruba metilprednizolon ve 7. gruba lidokain ve remifentanil uygulandı.Tüm gruplara çalışma ilaçlarının uygulanmasının ardından nöromüsküler blokaj için rokuronyum uygulandı. TOF 0 olduğu zaman tüm gruplara nöromüsküler bloğun geri çevrilmesi için sugammadeks uygulandı. TOF Watch cihazı üzerinde TOF un ≥ 0.9 olma zamanı kaydedildi.
Bulgular: Kontrol grubu ile grup 3,4,5,6,7 karşılaştırıldığında istatistiksel olarak anlamlı fark bulunmadı. Ancak kontrol grubu ile grup 2 karşılaştırıldığında sürenin istatistiksel olarak anlamlı uzadığı bulundu.
Sonuç: Sonuç olarak sıçanlarda sugammadeks ile birlikte eş zamanlı kullanılan remifentanil ve metilprednizon büyük olasılıkla yerdeğiştirme ile, sugammadeksin serbest ve aktif konsantrasyonunda azalmaya sebep olarak sugammdeksin reversal etkisinde azalmaya sebep oduğunu düşünmekteyiz.
Objective: In an in vitro study, lidocaine, remifentanil and methylprednisolone produced inclusion complexes with sugammadex, which lead to a decrease in free and active concentrations of sugammadex. When used concurrently with these drugs, it is likely that the time for sugammadex to reverse a neuromuscular blockade is going to be prolonged due to a synergistic pharmacokinetic or pharmacodynamic interaction. The aim of the present study was to investigate whether concurrent use of sugammadex with remifentanil, lidocaine and methylprednisolone led to a decrease in the neuromuscular blockade reversal effect of sugammadex produced with neuromuscular blockade agent (NMBA) rocuronium.
Methods: The present study included 42 male Wistar rats. They were randomised into 7 groups, with 6 rats per group. The first group was the control group, the second group received remifentanil and methylprednisolone, the third lidocaine and methylprednisolone, the fourth remifentanil, the fifth lidocaine, the sixth methylprednisolone and the seventh lidocaine and remifentanil. All groups were administered 3.2 mg kg-1 rocuronium for neuromuscular blockade after the administration of study drugs. When the train of four (TOF) value was 0, all groups were administered 16 mg kg-1 sugammadex for the reversal of neuromuscular blockade. With a TOF Watch SX device, the time to TOF ≥0.9 was recorded.
Results: When the control group was compared with Groups 3, 4, 5, 6 and 7, no statistically significant difference was found. However, in Group 2, time to TOF ≥0.9 was prolonged significantly when compared with the control group.
Conclusion: We suggest that remifentanil and methylprednisolone used concurrently with sugammadex lead to a decrease in sugammadex reversal effect by giving rise to decrease in its free and active concentrations probably via displacement in rats.

7.Comparison of the Effects of Desflurane and Sevoflurane on Cerebral Oxygen Saturation in Patients Undergoing Thyroidectomy: A Randomised Controlled Clinical Study
Lerzan Akçay, Celaleddin Soyalp, Nureddin Yüzkat, Nurçin Gülhaş
doi: 10.5152/TJAR.2019.23911  Pages 396 - 401
Amaç: Tiroid cerrahilerinde sık kullanılan yarı oturur pozisyon ve baş ekstansiyonunun serebral oksijenizasyonu olumsuz yönde etkileyebileceği düşünülerek bu çalışmada; tiroid cerrahilerinde, NIRS monitörizasyonu yardımı ile sık kullanılan iki anestezik gazın (sevofluran ve desfluran) serebral oksijenizasyon üzerine olan etkileri açısından kıyaslanması amaçladık
Yöntemler: ASA fiziksel durumu I-II-III olan, 18-65 yaş arası, elektif tiroid cerrahisi planlanan 60 hasta randomize olarak 2 eşit gruba ayrıldı. Hastalar, anestezi idamesinde kullanılan volatil anestetik maddenin türüne göre Grup S (sevofluran) ve diğeri Grup D (desfluran) olarak iki gruba ayrıldı. Hastalar entübe edildikten sonra 45 derece yarı oturur pozisyon verildi. Vital değerler ve bilateral frontal serebral hemisferler için oksijen satürasyon seviyeleri; anestezi indüksiyonu öncesi-sonrası, entübasyon sonrası, yarı oturur pozisyon verilmesinin ardından, ani değişiklikler olduğunda ve her 5 dakikada bir kaydedildi
Bulgular: Çalışmaya dahil edilen 60 hastanın yaş, boy, vücut ağırlığı, ASA risk sınıflaması, cerrahi süresi gibi demografik özellikleri değerlendirildiğinde iki grup arasında istatistiksel olarak anlamlı fark saptanmadı (p>0.05). Grup D ve Grup S’de periferik O2 satürasyonu, nabız, sistolik kan basıncı, diastolik kan basıncı, ortalama kan basıncı ve soluk sonu CO2 değerleri istatistiksel yönden benzerdi. Sağ ve sol serebral hemisfer rejyonal oksijen satürasyonu (rcSO2R) açısından gruplar karşılaştırıldığında iki grup arasında istatistiksel olarak anlamlı fark olmadığı görüldü (p>0,05).
Sonuç: Yarı oturur pozisyonda tiroid cerrahisi yapılan hastalarda desfluran veya sevofluranın serebral oksijen satürasyonu üzerine olan etkilerinin benzer olduğu saptandı.
Objective: The commonly performed sitting position with head extended during thyroidectomy has been shown to cause adverse effects on cerebral regional oxygen saturation (CrSO2). Therefore, the present study aimed to investigate the effects of two well-known anaesthetic agents, desflurane and sevoflurane, on CrSO2 in patients undergoing thyroidectomy in the semi-sitting position by near-infra-red spectroscopy monitoring.
Methods: The study included 60 patients aged 18-65 years, with an American Society of Anesthesiologists (ASA) physical status classification score I-III, who underwent elective thyroidectomy in the semi-sitting position. The patients were randomly divided into two groups, depending on the anaesthetic agent administered: (1) sevoflurane group (Group S; n=30) and (2) desflurane group (Group D; n=30). After intubation, the patients were placed in a 45-degree semi-sitting position. Vital signs and the CrSO2 levels in both hemispheres were recorded both pre-induction and at the induction minute 1, post-intubation, post-positioning, every 5 minutes intraoperatively and in the case of sudden changes.
Results: No significant difference was found between the groups in terms of age, height, body weight, the ASA score, operative time and left- and right-hemisphere CrSO2 (p>0.05). Moreover, the two groups were statistically similar to each other with regard to peripheral capillary oxygen saturation, heart rate, systolic and diastolic blood pressure, mean artery pressure and end-tidal CO2 (ETCO2) levels.
Conclusion: Desflurane and sevoflurane had similar effects in the preservation of CrSO2 in patients undergoing thyroidectomy in the semi-sitting position.

8.The Results of Cardiac Surgery in Terms of Patient Blood Management in Our Hospital
Gökçe Selçuk Sert, Mine Çavuş, Perihan Kemerci, Şerife Bektaş, Zeliha Aslı Demir, Ayşegül Özgök, Doğan Sert, Ümit Karadeniz
doi: 10.5152/TJAR.2019.02058  Pages 402 - 406
Amaç: Türkiye Yüksek İhtisas Eğitim Araştırma Hastanesi, Anestezi Kliniği’nde 2014 yılında uygulamaya giren hasta kan yönetimine (HKY) göre, hasta ve koşullara göre bireyselleştirmekle birlikte, komorbiditesi olmayan hastalarda transfüzyon eşik hemoglobin 7 gr dL-1 kormorbiditesi olan hastalarda 8-9 gr dL-1 olarak belirlenmiştir. Bu çalışmada amacımız; kliniğimizde HKY protokolü uygulanan ve uygulanmayan iki ayrı dönemde kalp cerrahisi ameliyatına alınan hastaları, transfüzyon gereksinimleri, transfüzyonla ilgili maliyet ve sağ kalım açısından kıyaslamaktır.
Yöntemler: Hastanemizde 2012 yılının ve 2017 yılının ilk 4 ayında kardiyopulmoner baypas kullanılarak açık kalp cerrahisi geçiren hastalar retrospektif, kesitsel çalışmamıza dahil edildi. 2012 yılının ilk 4 ayında kardiyopulmoner baypas kullanılarak elektif açık kalp cerrahisi geçiren 229 hasta ve 2017 yılının ilk 4 ayında ameliyata alınan aynı kriterlerdeki 283 hasta retrospektif, kesitsel çalışmamıza dahil edildi.
Bulgular: Hastalarda preoperatif veriler açısından gruplar arasında fark saptanmadı. Kan ve kan ürünü kullanımının HKY programının uygulandığı dönemde anlamlı derecede daha az olduğu gözlendi. Eritrosit süspansiyonu kullanımının medyan 2 Ü iken, 0 ܒye düştüğü, taze donmuş plazma kullanımının ise medyan 2 ܒden 0 ܒye düştüğü gözlendi. Postoperatif mortalite açısından da gruplar arası fark gözlenmedi.
Sonuç: Bu kesitsel retrospektif çalışmamızın sonuçlarına göre HKY programı uygulaması hastalara gereksiz kan ve kan ürünü transfüzyonunu azaltılmış ve buna bağlı olarak maliyet düşmüştür. Bu sonuçlarla birlikte postoperatif 30 günlük mortalite kan ve kan ürünü kullanım oranlarından etkilenmemiştir.
Objective: Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas Training and Research Hospital, beginning in 2014, the patient blood management (PBM) protocol is individualised based on patients’ comorbidities, and the threshold for transfusion is 7 g dL-1 of haemoglobin for patients without comorbidities and 8-9 g dL-1 for patients with comorbidities. In this study, our aim was to compare patient outcomes, requirement for transfusion and the cost of transfusion between two different periods with and without PBM protocol.
Methods: 229 and 283 patients who underwent open-heart surgery using cardiopulmonary bypass during the first 4 months of 2012 and the first 4 months of 2017, respectively, were included in this retrospective, cross-sectional study.
Results: There were no differences between the groups in preoperative data. Blood and blood product usage was observed to be significantly lower at the time of the PBM protocol. The use of packed red blood cells decreased from 2 units to 0and that of fresh frozen plasma decreased from 2 units to 0. In terms of postoperative mortality, there were no differences between the groups.
Conclusion: According to the results of this study, the transfusion of unnecessary blood and blood products was reduced and the cost decreased with PBM protocol. Blood product usage did not affect 30-day mortality. It will be possible to achieve more valuable results if more patients are assessed, PBM protocol is implemented and postoperative results are evaluated in detail.

9.Prognostic Value of Blood Lactate and Base Deficit in Refractory Cardiac Arrest Cases Undergoing Extracorporeal Life Support
Romain Jouffroy, Pascal Philippe, Anastasia Saade, Pierre Carli, Benoit Vivien
doi: 10.5152/TJAR.2019.65391  Pages 407 - 413
Objective: Cardiac arrest (CA) resuscitation is associated with an ‘ischaemia-reperfusion’ syndrome characterised by lactic acidosis as assessed by lactate and base deficit (BD). Both biomarkers are usually measured in patients suffering from refractory CA (RCA) subjected to extracorporeal life support (ECLS) to evaluate tissue reperfusion. However, their prognostic value has never been compared. The aim of the present study was to compare the prognostic value of both biomarkers measured at 0 and 3 h after the initiation of ECLS in patients with RCA on mortality.
Methods: Patients who were admitted to the intensive care unit with RCA were consecutively included in the study.
Results: Sixty-six patients were included. Lactate correlated with BD (R2=0.44, p<0.001). An area under the curve of 0.72 (95% confidence interval (CI) 0.59-0.84) was found for lactate and of 0.60 (95% CI 0.46-0.73) for BD. Using multivariable logistic regression, lactate (odds ratio (OR) 1.22, 95% CI 1.03-1.48) remained associated with mortality on day 28, but not BD (OR 0.99, 95% CI 0.86-1.14).
Conclusion: We report a difference in the prognostic value of lactate and BD on mortality. Three hours from the initiation of ECLS in patients with RCA, lactate should be preferred to BD to predict the efficiency of ECLS.

10.Comparative Efficacy of Methylprednisolone Acetate and Dexamethasone Disodium Phosphate in Lumbosacral Transforaminal Epidural Steroid Injections
Nilay Chatterjee, Chinmoy Roy, Samaresh Das, Wala Al Ajmi, Naila Salim Al Sharji, Ahmed Al Mandhari
doi: 10.5152/TJAR.2019.69741  Pages 414 - 419
Objective: Transforaminal epidural steroid injection (TFESI) is an effective treatment for lumbosacral radicular pain. But in view of accidental intravascular injections and consequent neurological injuries, the safety profile of particulate steroids has been questioned. Dexamethasone (DEXA), being non-particulate, is presumed to be a safe replacement for earlier particulate agents. However, the efficacy of DEXA is still doubtful as compared to particulate steroids. The present study aims to determine the comparative efficacy of DEXA and methylprednisolone (MP) in terms of pain relief and improvement of disability.
Methods: Seventy-six patients were sorted into two groups (MP and DEXA) to receive lumbar TFESI. A protocol of one-time single- or two-level TFESI with equipotent doses of MP or DEXA was followed. Numeric Rating Scale (NRS) and Roland-Morris Disability Questionnaire (RMDQ) scores were collected pre-treatment and at different times for a duration of 6 months at follow-up appointments.
Results: Overall, the extent of pain relief (determined from NRS) and quality of life (determined from RMDQ) were significantly better (p<0.01) in patients belonging to MP group following TFESI. NRS was 2.8±1.2, 3.3±1, 5.1±1.6 and 3.9±1.4, 4.5±1.3, 6.2±1.1 respectively in MP and DEXA group at 1 month, 3 months and 6months of follow-up, whereas RMDQ was 7.9±2.8, 7.4±2.3, 8.5±2.4 and 10±2.2, 11.4±2.6, 12.4±2.7 respectively in MP and DEXA group at similar time points.
Conclusion: The immediate and short term pain relief following TFESI in lumbar radicular pain remained satisfactory and is comparable between MP and DEXA groups, but the long term benefit is significantly more with the use of MP, as evidenced by the NRS and RMDQ scores.

CASE REPORT
11.Anaesthetic Challenges in a Rare Syndrome: Perioperative Management of a Patient with POEMS Syndrome Who Underwent Umbilical Hernioplasty
Sajil M. Sajan, Neeraja Ajayan, Gayatri Devi Nair, Karen Ruby Lionel, Ajay Prasad Hrishi
doi: 10.5152/TJAR.2019.53824  Pages 420 - 422
Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome also known as ‘Crow Fukase syndrome’ is a rare paraneoplastic disorder, first described by Crow and Fukase with distinctive features of polyradiculoneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes. There is a paucity of literature about anaesthetic management of patients with POEMS syndrome with isolated case reports of surgery under general anaesthesia and central neuraxial blockade. We present here the anaesthetic management of a patient with POEMS syndrome posted for umbilical hernia repair, which was successfully managed with a transverse abdominis plane (TAP) block.

12.Prolonged Interscalene Blockade for 30 Hours with 0.5% Plain Bupivacaine in a Case of Shoulder Arthroscopy
Pradeep Tiwari, Valmik Avhad, Shraddha Mathkar, Deepa Kane
doi: 10.5152/TJAR.2019.80217  Pages 423 - 425
We present a case of unusually prolonged motor and sensory block for 30 hours after a successful single injection of ultrasound-guided interscalene block with 0.5% plain bupivacaine. All safety measures such as negative aspiration of blood injection at every 3 mL of drug with usual resistance, slow rate of injection and ultrasound documentation of spread of drug around C 5 and C 6 were followed. There was no evidence of neurological injury, but we should always be prepared to consider the possibility of nerve injury and take appropriate measures to prevent them.

OTHER
13.Contact Dermatitis with a Nylon Non-Invasive Blood Pressure Cuff after Elective Surgery
Vijay Adabala, Nishith Govil
doi: 10.5152/TJAR.2019.09476  Page 426
Abstract | Full Text PDF

14.Arachnoiditis Ossificans of the Lumbosacral Spine
Ivan Urits, George Chesteen, Omar Viswanath
doi: 10.5152/TJAR.2019.63239  Pages 427 - 428
Abstract | Full Text PDF

LETTER TO THE EDITOR
15.Optimal HbA1c Threshold to Predict Post-Operative Mortality
Yasser Ali Kamal
doi: 10.5152/TJAR.2019.58897  Pages 429 - 430
Abstract | Full Text PDF