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Background and objective The management and treatment of nociception remain one of the major challenges in anesthesiology, and hemodynamic variations may occur due to inadequate analgesia, which at times can be injurious. Pupillometry is a new noninvasive tool to assess nociception during anesthesia. The amount of pupillary reflex dilation (PRD) is directly proportional to the intensity of nociceptive stimuli and inversely proportional to the opioid dosage. This study aimed to assess the use of pupillometry as reflex pupillary dilatation in response to surgical stimulus in children under general anesthesia and to guide intraoperative opioid consumption. Materials and methods After obtaining approval from the institutional ethics committee and written consent from parents, children with an American Society of Anesthesiology (ASA) classification of I and II and aged 2-12 years who were undergoing surgery under general anesthesia were enrolled in this prospective randomized observational study. General anesthesia was standardized with propofol, sevoflurane, and O 2 and N 2 O (50:50%), and fentanyl administration was guided by pupil diameter changes. The primary outcome was to measure pupillary dilatation in response to pain and fentanyl administration guided by it. Results A total of 72 patients were included in the study. The mean pupil diameter significantly increased after surgical stimulus from 1.37 ±0.87 to 2.40 ±1.95 mm (p<0.001). The heart rate (116.2 ±12.25 to 118.50 ±8.20 beats/minute, p=0.18) and systolic BP (114.60 ±17.73 to 118.50 ±12.25 mmHg, p=0.12) did not change significantly on stimulus. The mean fentanyl consumption was 2.4 ug/kg and the side effects were not remarkable. Conclusion Based on our findings, pain has a significant influence on the pupil dilatation reflex in anesthetized children, and opioid administration based on pupil diameter can be valuable in clinical settings. We recommend the use of pupillometry as a pain index in children undergoing surgery under general anesthesia, and it can be a beneficial tool for assessing intraoperative pain. Newer techniques and developments are required in this field., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Singh et al.)

Introduction: Obstetric analgesia and anesthesia is a challenge in itself. It requires an understanding of the physiological changes during pregnancy and labor and the effect of anesthetic agents on the fetus and newborn. Because neuraxial techniques provide superior analgesia and materno-fetal benefits, their use have increased significantly over the past three decades or so. A combination of local anesthetics like ropivacaine with opioids like nalbuphine has been shown to have additive beneficial effects in subarachnoid block (SAB) in lower segment cesarean section (LSCS). However, the optimal dose combination of ropivacaine and nalbuphine to maximize their benefits and minimize side effects remains to be established. Our study has compared the clinical efficacy and safety of 0.75% isobaric ropivacaine (15 mg) with two different doses of nalbuphine (0.4 mg and 0.6 mg) when given intrathecally for LSCS in terms of quality of sensory and motor blocks, hemodynamic parameters, duration of effective analgesia, Apgar score in newborn, and associated side effects., Method and Materials: In this prospective, randomized, double-blind study, a total of 69 parturients between the age of 20-45 years, belonging to American Society of Anesthesiologists (ASA) grade I and II, undergoing cesarean section under SAB were evaluated. Patients were randomly allocated into three groups of 23 each by using the draw-of-lots technique. The patient and the observer were kept blinded as to which dose of drug (intrathecal) was being given to the patient. Patients in Group A received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.3 ml normal saline; patients in Group B received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.4 mg of nalbuphine (0.2 ml) + 0.1 ml normal saline; patients in Group C received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.6 mg of nalbuphine (0.3 ml). The total volume of drug solution in all three groups was 2.3 ml., Result:  We found that the time to onset of sensory block was shortest in Group A (5.87±1.290 minutes) followed by Group C (6.00±1.087 minutes) and Group B (6.17±1.696 minutes); time to two-segment regression of sensory block was longest in Group C (101.74±8.996 minutes) followed by Group B (85.87±15.348 minutes) and Group A (65.00±7.071 minutes); duration of effective analgesia was longest in Group C (206.09±18.766 minutes) followed by Group B (183.91±15.880 minutes) and Group A (121.74±11.833 minutes); and time from SAB to complete regression of motor block was longest in Group C (216.52±15.553 minutes) followed by Group B (203.48±20.138 minutes) and Group A (174.78±14.731 minutes). Side effects were comparable among all three groups., Conclusion: The optimal dose combination in SAB for cesarean section was 15 mg of 0.75% isobaric ropivacaine + 0.6 mg nalbuphine, with minimal side effects., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Shekhar et al.)

Objective: We aim to find the time in which a thawed citrate plasma sample that was preserved can be analyzed for routine coagulation testing without losing precision., Methods: Whole blood samples from 30 healthy volunteers were collected in 3.2% sodium citrate vacutainer and centrifuged to separate platelet-poor plasma. Each sample was then aliquoted, one aliquot was used immediately for prothrombin time (PT)-international normalized ratio (INR) and activated partial thromboplastin time (APTT), four were stored at -20°C, and four were stored at -80°C for 24 hours. After 24 hours, the aliquots were taken out and thawed at 37°C in water bath and analyzed after 15, 30, 60, and 120 minutes., Statistical Analysis: Data were presented as mean with standard deviation (SD). Repeated measures ANOVA with Tukey post-hoc test was performed for multiple comparisons. All analysis was done using GraphPAD Prism 8.0 software (GraphPad Software, San Diego, California, USA).  Results: In the case of PT and INR, no statistically significant difference was found between the mean values after thawing for 120 minutes when compared with the mean baseline value. However, the APTT showed a statistically significant difference (p = 0.0232) after 30 minutes of thawing when the sample was stored at -20°C. Furthermore, a statistically significance difference (p = 0.0001) was found after 60 minutes of thawing when the samples were stored at -80°C., Conclusion: Plasma samples for the PT and INR may be accepted for assessment up to 120 minutes, when stored at -20°C and -80°C for 24 hours. In the case of APTT, the plasma sample can be used for assessment up to 30 minutes after thawing when stored at -20°C and up to 60 minutes when stored at -80°C., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Reddy et al.)

Background:  Endotracheal intubation for airway management in general anesthesia is associated with post-intubation morbidities due to tracheal mucosa injury caused by endotracheal tube (ETT) cuff. Nitrous oxide (N 2 O) diffuses into tracheal tube cuffs filled with air. The rate of diffusion of N 2 O through the membrane is proportional to its concentration gradient. High-volume low-pressure cuffs expand with only a slight increase in pressure until fully inflated. At this point, owing to the inelasticity of the material, the cuff pressure rises rapidly. This increased pressure can damage the tracheal mucosa. This phenomenon can be avoided, if we inflate the cuff with either a liquid or a gas mixture identical to the inspired gas and monitor the cuff pressure and volume at regular intervals. When lignocaine is used to inflate the ETT cuff, it diffuses to the underlying tracheal mucosa. Thus reducing local irritation and inflammation of the airway through its local anesthetic action. Alkalinization of lignocaine increases its rate of diffusion across the ETT cuff. It also reduces the dose of local anesthetic required to achieve the desired result., Aims and Objectives:  We sought to determine the benefits of filling the ETT cuff with alkalinized lignocaine 2% over normal saline, to prevent ETT-induced emergence phenomenon and reduce the incidence of post-intubation morbidities like sore throat, hoarseness, and nausea., Material and Methods: This prospective, randomized, double-blind, and comparative study was done at a multispecialty hospital. A total of 120 individuals of American Society of Anesthesiologists (ASA) physical status 1 and 2, posted for surgery under general anesthesia, were randomly selected and divided into two groups: alkalinized 2% lignocaine group (group L) and normal saline group (group S). After induction of general anesthesia, the airway was secured with appropriate-sized ETT. The ETT cuff was inflated with either of the study media. Continuous cuff pressure monitoring was done to keep cuff pressure below 30 centimeters of water (cm of H 2 O), at all times. At extubation, the response was evaluated in terms of percentage change in heart rate (HR) and blood pressure from baseline, coughing, bucking, and restlessness. All the surgeries lasted more than two hours. Post-operatively, the patients were evaluated for sore throat and hoarseness, at regular intervals of up to 24 hours., Observations and Results: ETT cuff pressure was initially less in group S, which rose to a significantly higher level at extubation, compared to group L (p <0.001). At extubation, there was a significant increase in HR and systolic blood pressure (SBP) from baseline, in group S than in group L (p <0.001 and p=0.001, respectively). The incidence of cough and restlessness was less in group L, compared to group S (p<0.001 and p=0.002, respectively). Mean extubation time and emergence time was more in group S than in group L (p<0.001). Post-operatively, the incidence and severity of sore throat were significantly higher in group S than in group L (p<0.001). Meanwhile, the incidence of hoarseness and nausea was comparable in the two groups., Conclusion:  Continuous ETT cuff pressure monitoring helps to keep cuff pressure below tracheal mucosa capillary occlusion pressure. Filling the ETT cuff with alkalinized lignocaine further reduces extubation response and post-intubation morbidities., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Sony et al.)

A femoral neck fracture is a very common injury in the elderly. However, its incidence is low among young adults, usually presenting as an emergency. In young adults, implant choice is one of the important factors. This systematic review aims to analyze the femoral neck system (FNS) versus cannulated cancellous (CC) screw for the fixation of femoral neck fractures in young adults through well-defined objectives. A comprehensive search from the electronic database (PubMed, Google Scholar, Web of Science, Cochrane Library) was conducted from the beginning till February 18, 2022. The data regarding study type, authors, year of publication, country, union time, Harris hip score, intraoperative blood loss, operating time, neck shortening, and hospital stay were extracted from the selected articles and analyzed using RevMan 5.4.1 software. For continuous data, e.g., healing time, intraoperative blood loss, operation time, Harris hip score, neck shortening, and hospital stay, the mean difference (MD), either weighted mean difference (WMD) or standardized mean difference (SMD), with a 95% confidence interval (CI) was recorded. A p-value less than 0.05 was taken as statistically significant. The Newcastle Ottawa scale was used for the risk of bias assessment. Six retrospective cohort studies including 427 patients were selected for the meta-analysis. There was significantly less healing time (WMD= -1.10, 95% CI: -1.73 to -0.47), shorter operation duration (WMD=7.70, 95% CI: -0.06 to 15.46), and better Harris hip score (WMD=4.79, 95% CI: 2.12-7.46) in the FNS than CC screw fixation method. However, intraoperative blood loss was significantly less in the CC screw system (WMD=21.27, 95% CI: 8.20-34.35). There was no significant difference between the two approaches in-hospital stay duration and femoral neck shortening. This can be concluded that FNS is better than CC screw fixation for treating neck of femur fractures in adults on the outcome basis of union time, less operation time, and better Harris hip score (HHS) with significant heterogeneity., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Gupta et al.)

Background Periarthritis or frozen shoulder, also called adhesive capsulitis, is characterized by stiffness and pain along with gradual loss of active and passive movement in the glenohumeral joint. More than 2-5% of the population suffers from periarthritis with a higher incidence in the age group of 40-60 years. The various treatment modalities used for its management include simple physiotherapy, short-wave therapy, ultrasonic therapy, transcutaneous electrical nerve stimulation, hydrotherapy, analgesics, intra-articular injections, manipulation under general anesthesia (MUA), and surgical management. The application of intra-articular steroid injection has been a common and efficacious option in rapidly diminishing shoulder pain and disability. Some recent studies reported a better outcome using platelet-rich plasma (PRP) injections in frozen shoulder cases. Hence, this randomized controlled trial was conducted to compare the efficacy of intra-articular injections of PRP and triamcinolone in patients of shoulder periarthritis in a population from the eastern region of India Methodology A total of 60 patients with periarthritis shoulder were allocated into two groups after randomization. Group A received 2 mL autologous PRP, and Group B received 2 mL of triamcinolone (40 mg/mL) intra-articular injection. Patients were followed up on the 4th week, 12th week, and 24th week. The assessment of pain and function using the visual analog scale (VAS) score and the Disabilities of Arm, Shoulder, and Hand (DASH) score, respectively, was done at each follow-up. The primary analyses of both primary and secondary outcomes were conducted in the intention-to-treat (ITT) population. SPSS version 24 (IBM Corp., Armonk, NY, USA) was used for data analysis. Results The mean VAS score in the PRP and triamcinolone groups was 14.33 ± 3.79 and 31.63 ± 7.62, respectively (p = 0.0001) after 24 weeks. The mean DASH score in the PRP and triamcinolone groups was 18.08 ± 8.08 and 31.76 ± 3.63, respectively (p = 0.0001), which shows significant improvement in both pain and disability scores in the PRP group after 24 weeks. Conclusions The triamcinolone group showed better short-term outcomes whereas PRP showed better long-term outcomes in reducing pain and disability scores in terms of VAS and DASH scores., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Gupta et al.)

Introduction Intrahepatic cholestasis of pregnancy (IHCP) is characterized by pruritus of the hand and sole with abnormal liver function test and bile acid metabolism. IHCP occurs in the second and third trimesters of pregnancy and usually resolves after delivery. The overall prevalence is about 1.2 to 1.5%. This study was conducted to assess the fetomaternal outcome according to maternal serum bile acids levels and its correlation with liver function tests in patients with IHCP. Material and methods This ambispective observational study was conducted in the department of Obstetrics and Gynecology (OBG) for two years at AIIMS Jodhpur, Rajasthan. It included all the pregnant women attending the outpatient department of OBG with the complaint of pruritis in the palm and sole after 28 weeks of pregnancy and diagnosed with intrahepatic cholestasis of pregnancy after investigations. Results Only 152 patients were diagnosed with IHCP out of 4,148 deliveries, with a prevalence of 3.6%. Among these, 140 (92.11%) had mild IHCP, 10 (6.58%) had moderate IHCP and two (1.32%) had severe IHCP. There was a significant difference between the birth weight in mild, moderate and severe IHCP (P-value 0.004). About 12.5% (n=19) of patients had meconium-stained liquor during delivery. Two patients (1.32%) with moderate IHCP had intrauterine fetal death in the third trimester, and 6.58% (n=10) neonates were kept on continuous positive airway pressure. Conclusions IHCP is associated with adverse fetal outcomes like spontaneous or iatrogenic preterm delivery, low birth weight, increase in the rate of lower section cesarean section (LSCS) and intrauterine death of a fetus. A significant correlation found between raised bile acid levels and variables of liver function test, hence cost-effectiveness and feasibility of liver function test (LFT) should be considered for the management of IHCP., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Jhirwal et al.)