Ultrasound-guided bilateral superficial cervical plexus block is more effective than landmark technique for reducing pain from thyroidectomy Tjokorda Gde Agung Senapathi, I Made Gede Widnyana, I Gusti Ngurah Mahaalit Aribawa, Made Wiryana, I Ketut Sinardja, I Ketut Wibawa Nada, AA Gde Putra Semara Jaya, I Gede Koko Swadharma Putra Department of Anesthesiology and Intensive Care, Sanglah Hospital, Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia Purpose: Thyroidectomy causes postoperative pain and patient discomfort. Bilateral superficial cervical plexus block is a regional anesthesia technique that can provide analgesia during and after surgery. This study aims to compare the effectiveness of ultrasound (US)-guided versus landmark (LM) technique for bilateral superficial cervical plexus block in thyroidectomy. Patients and methods: Thirty-six patients undergoing thyroidectomy were divided into two groups randomly (n=18); either US-guided (US group) or LM technique (LM group) for bilateral superficial cervical plexus block. Patient-controlled analgesia was used to control postoperative pain. Intraoperative opioid rescue, postoperative visual analog scale (VAS) score and opioid consumption were measured. Results: The number of patients who required intraoperative opioid rescue was significantly lower in the US group (p≤0.05). There was no significant difference in postoperative VAS score at 3 hours (p>0.05), but postoperative VAS score at 6 and 24 hours was significantly lower in the US group (p≤0.05). Twenty-four hour postoperative opioid consumption was significantly lower in the US group (p≤0.05). Conclusion: Ultrasound-guided bilateral superficial cervical plexus block is more effective in reducing pain both intra- and postoperatively compared with landmark technique in patients undergoing thyroidectomy. Keywords: peripheral nerve block, superficial cervical plexus block, ultrasound-guided, pain, thyroidectomy

Purpose: Combined regional and general anesthesia are often used for the management of breast cancer surgery. Thoracic spinal block, thoracic epidural block, thoracic paravertebral block, and multiple intercostal nerve blocks are the regional anesthesia techniques which have been used in breast surgery, but some anesthesiologists are not comfortable because of the complication and side effects. In 2012, Blanco et al introduced pectoralis nerve (Pecs) II block or modified Pecs block as a novel approach to breast surgery. This study aims to determine the effectiveness of combined ultrasound-guided Pecs II block and general anesthesia for reducing intra- and postoperative pain from modified radical mastectomy. Patients and methods: Fifty patients undergoing modified radical mastectomy with general anesthesia were divided into two groups randomly (n=25), to either Pecs (P) group or control (C) group. Ultrasound-guided Pecs II block was done with 0.25% bupivacaine (P group) or 0.9% NaCl (C group). Patient-controlled analgesia was used to control postoperative pain. Intraoperative opioid consumption, postoperative visual analog scale (VAS) score, and postoperative opioid consumption were measured. Results: Intraoperative opioid consumption was significantly lower in P group (P≤0.05). VAS score at 3, 6, 12, and 24 hrs postoperative were significantly lower in P group (P≤0.05). Twenty-four hours postoperative opioid consumption was significantly lower in P group (P≤0.05). There are no complications following Pecs block in both groups, including pneumothorax, vascular puncture, and hematoma. Conclusion: Combined ultrasound-guided Pecs II block and general anesthesia are effective in reducing pain both intra- and postoperatively in patients undergoing modified radical mastectomy. Ultrasound-guided Pecs II block is a relatively safe peripheral nerve block.

Background: Accuracy of consciousness level assessment is very important. It may determine and influence further clinical decisions, thus influences patients’ outcomes. The widest method in determining the level of awareness is the Glasgow Coma Scale (GCS). Despite its common use, GCS scores obtained by one clinician may differ from others depending on their interpretations and past experience. One of the tools used to assess the level of consciousness objectively is bispectral index (BIS). The aim of this study was to identify the correlation between BIS and GCS score in patients with traumatic brain injury. Patients and Methods: A total of 78 patients who were admitted to emergency room for traumatic brain injury were included in this study. One observer evaluated the GCS of all patients to minimize subjectivity. Another investigator then obtained the BIS values for each patient. Spearman’s rank correlation coefficient was used to determine whether GCS correlated with BIS value. Results: In 78 patients, the BIS was found to be significantly correlated with GCS (r=0.744, p<0.01). The BIS values increased with an increasing GCS. Mean BIS values of mild, moderate, and severe head injury were 88.1±5.6, 72.1±11.1, and 60.4±11.7, respectively. Conclusion: In this study, a significant correlation existed between GCS and BIS. This finding suggests that BIS may be used for assessing GCS in patients with traumatic brain injury. However, the scatters of BIS values for any GCS level may limit the BIS in predicting GCS accurately.

Purpose: Cesarean section is a surgical procedure. Surgical procedures will induce stress responses, which may have negative impact on postoperative recovery. Ketamine plays a role in the homeostatic regulation of inflammatory response in order to attenuate stress response. We tried to determine the effectiveness of low-dose intravenous ketamine to attenuate stress response in patients undergoing emergency cesarean section with spinal anesthesia. Patients and methods: Thirty-six pregnant women undergoing emergency cesarean section with spinal anesthesia were randomly divided into two groups (n=18). Ketamine 0.3 mg/kg (KET group) or NaCl 0.9% (NS group) was administered intravenously before the administration of spinal anesthesia. C-reactive protein (CRP) and neutrophil levels were measured preoperatively and postoperatively. Results: Elevation of CRP stress response was lower in the KET group and significantly different (P≤0.05) from that in the NS group. Neutrophil level was elevated in both the groups and hence not significantly different from each other (P>0.05). Postoperative visual analog scale pain score was not significantly different between the two groups (P>0.05), but there was a statistically significant (P≤0.05) positive and weak correlation between visual analog scale and CRP level postoperatively. Conclusion: Low-dose intravenous ketamine effectively attenuates the CRP stress response in patients undergoing emergency cesarean section with spinal anesthesia.

Background: Maintaining brain oxygenation status is the main goal of treatment in severe traumatic brain injury (TBI). Jugular venous oxygen saturation (SjvO₂) monitoring is a technique to estimate global balance between cerebral oxygen supply and its metabolic requirement. Full Outline of Responsiveness (FOUR) score, a new consciousness measurement scoring, is expected to become an alternative for Glasgow Coma Scale (GCS) in evaluating neurologic status of patients with severe traumatic head injury, especially for those under mechanical ventilation. Methods: A total of 63 patients with severe TBI admitted to emergency department (ED) were included in this study. SjvO₂ sampling was taken every 24 hours, until 72 hours after arrival. The assessment of FOUR score was conducted directly after each blood sample for SjvO₂ was taken. Spearman’s rank correlation was used to determine the correlation between SjvO₂ and FOUR score. Regression analysis was used to determine mortality predictors. Results: From the 63 patients, a weak positive correlation between SjvO₂ and FOUR score (r=0.246, p=0.052) was found upon admission. Meanwhile, strong and moderate negative correlation values were found in 48 hours (r=-0.751, p<0.001) and 72 hours (r=-0.49, p=0.002) after admission. Both FOUR score (p<0.001) and SjvO₂ (p=0.04) were found to be independent mortality predictors in severe TBI. Conclusion: There was a negative correlation between the value of SjvO₂ and FOUR score at 48 and 72 hours after admission. Both SjvO₂ and FOUR score are independent mortality predictors in severe TBI.

Background: Intubation is crucial in the management of anesthesia because it is related to the maintenance of oxygenation and ventilation during general anesthesia. Clinical markers for predicting difficult airway have limitations, including requiring coordination with patients. The use of ultrasonography (USG) to measure the distance of the skin to epiglottis is expected to estimate the difficulty level of intubation. Patients and Methods: This was a cross-sectional study of 128 patients who underwent surgery under general anesthesia. We examined the skin-to-epiglottis distance using US prior to surgery. We then assessed the Cormack–Lehane scores during direct laryngoscopy for intubation. The unpaired t-test was used to assess differences in the skin-to-epiglottis distance between patients with easy intubation (Cormack–Lehane I and IIa) and difficult intubation (Cormack–Lehane IIb, III, and IV). Results: The cutoff value of skin-to-epiglottis distance between easy and difficult intubation was 26.05 mm. The sensitivity and specificity of this method to predict difficult airway were 69.4% and 93.5%, respectively. The positive and negative predictive values were 80.6% and 88.7%, respectively. Conclusion: The skin-to-epiglottis distance of >26.05 is a risk factor for difficult intubation.