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Opiates are generally used to relieve dyspnoea in advanced diseases such as cancer and lung diseases. However, little is known regarding the safety and efficacy of morphine for refractory dyspnoea in coronavirus disease 2019 (COVID-19) patients. We retrospectively reviewed records of 18 COVID-19-positive patients who were administered morphine for refractory dyspnoea during hospitalisation between May 2021 and June 2021. Details of morphine usage, vital signs, an 11-point dyspnoea numeric rating scale (DNRS) and adverse events at baseline, 24 h and 72 h after the start of treatment were abstracted from records. The final clinical outcome in terms of death or discharge was noted. All patients had severe refractory dyspnoea (DNRS score ≥7) at the time of administration of morphine and had not been relieved from standard care for the past 3 days. In the results, the mean (standard deviation [SD]) age was 47.1 (12) years, male was 13 (72.20%) patients and modified Medical Research Council Grade 4 was present in all 18 patients. The mean (SD) 1st day dose of morphine was 7.03 (1.53) mg and the mean (SD) duration of morphine use was 5.22 (3.00) days. Significant decreases in DNRS, respiratory rate and oxygen saturation were observed 24 h and 72 h after the start of morphine administration. Meanwhile, blood pressure and heart rate were not significantly altered after treatment. The finding of this single-centre retrospective study indicates that morphine may be considered for use in the management of refractory dyspnoea among COVID-19 patients.

Objectives Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with increased morbidity and mortality. We retrospectively analysed the perioperative anesthetic management in patients undergoing HIPEC surgery. Methods After ethics approval, we reviewed the records of patients who underwent CRS/HIPEC from 2015 until 2020. We noted the peritoneal carcinomatosis index (PCI), blood loss, anastomoses done, total amount of fluid given, delta temperature and duration of surgery. These were correlated with the need for postoperative ventilation, length of ICU stay, Clavien–Dindo score and 30 day mortality. Results Of the 180 patients reviewed, the majority were women (85%) with a mean age of 48 years who had ovarian tumors (n=114). The total amount of fluid given was associated with an increased length of ICU stay (p=0.008). Prolonged surgery resulted in increased length of ICU stay (p Conclusions PCI, duration of surgery and blood loss were major predictors of postoperative morbidity. Additionally, the amount of fluid given and delta temperature affected patient outcome and should be individualized to the patient’s needs.

COVID-19 is associated with rarer extra-parenchymal manifestations, namely pneumothorax (PTX) and pneumomediastinum (PM) leading to complications and increased mortality. The study aims to describe the prevalence, risk factors for mortality, radiological characteristics and outcome of PTX/PM in patients admitted with COVID-19. This was a retrospective, single-centre, observational study in patients with confirmed COVID-19 presenting with non-iatrogenic PTX/PM from April 2020 to May 2021. Details pertaining to demographics, presentation, radiological characteristics, management and outcome were collected. Cases were classified into spontaneous and barotraumatic PTX/PM and a between-group comparison was performed using Chi-square and t-test. A total of 45 cases (mean age: 53.2 years, 82% males) out of 8,294 confirmed COVID-19 patients developed PTX/PM, the calculated incidence being 0.54%. 29 cases had spontaneous PTX/PM and the remaining 17 cases were attributed to barotrauma. The most common comorbidities were diabetes-mellitus (65.3%) and hypertension (42.3%). The majority of the cases had large PTX (62.1%) with tension in 8 cases (27.5%). There were predominant right-sided pneumothoraces and five were diagnosed with bronchopleural fistula. 37.7% of cases had associated subcutaneous emphysema. The median duration of PTX/PM from symptom onset was delayed at 22.5 and 17.6 days respectively. The mean CT severity score (CTSS) was 20.5 (± 4.9) with fibrosis (53.8%), bronchiectatic changes (50%) and cystic-cavitary changes (23%). There was no statistically significant difference between the spontaneous and barotrauma cohort. 71% of cases died and the majority belonged to the barotrauma cohort. It is imperative to consider the possibility of PTX/PM in patients having COVID-19, especially in those with deterioration in the disease course, both in spontaneously breathing and mechanically ventilated patients. These patients may also have a high incidence of death, reflecting the gravity of COVID-19.

Background: Patients with chronic kidney disease (CKD) on maintenance hemodialysis are highly vulnerable to coronavirus disease 2019 (COVID-19) infection and poorer outcomes and mortality. Objectives: The study aimed at identifying the various clinical and biochemical predictors of in-hospital mortality in this particular group of patients. Methods: In this retrospective cohort study, the baseline demographic, clinical, and laboratory data were collected from patients with preexisting CKD on maintenance hemodialysis and with COVID-19 infection. The statistical analysis of the collected data was performed using SPSS version 24 (SPSS Inc, Chicago, IL, USA). Results: The data obtained from 35 patients from the first wave of the pandemic were analyzed. The mortality rate was 23% (8 patients). Analyzing the comparison between survivors and non-survivors revealed that the older age (49 [IQR, 42 – 55] years vs. 70 [IQR, 54 – 74] years, P = 0.016), severe disease at presentation (15% vs. 75%, P = 0.004), and need for invasive mechanical ventilation (0% vs. 75%, P = 0.001) were the factors significantly associated with in-hospital mortality. Among baseline biochemical markers, severe lymphocytopenia (11 [IQR, 7 – 16] vs. 4.2 [IQR, 3 – 8], P = 0.011), high serum glutamic oxaloacetic transaminase (23 [IQR, 15.6 – 48] vs. 80 [IQR, 60- 105], P = 0.001), blood urea (71 [IQR, 28 - 120) vs. 160 (IQR, 142 - 355), P = 0.002) and higher value of inflammatory markers, interleukin-6 (IL-6), and procalcitonin, as well as fibrinogen and low baseline albumin, were also significantly associated with in-hospital mortality. Conclusions: The older age, severe disease at presentation, need for invasive mechanical ventilation, raised baseline IL-6, procalcitonin, serum glutamic oxaloacetic transaminase, blood urea, and lower level of albumin may have been valuable predictors of in-hospital mortality and poor outcomes in patients with COVID-19-infected chronic kidney disease on maintenance hemodialysis.

India has a high share in the global burden of chronic terminal illnesses. However, there is a lack of a uniform system in providing better end-of-life care (EOLC) for large patients in their terminal stage of life. Institutional policies can be a good alternative as there is no national level policy for EOLC. This article describes the important aspects of the EOLC policy at one of the tertiary care institutes of India. A 15 member institutional committee including representatives from various departments was formed to develop this institutional policy. This policy document is aimed at helping to recognize the potentially non-beneficial or harmful treatments and provide transparency and accountability of the process of limitation of treatment through proper documentation that closely reflects the Indian legal viewpoint on this matter. Four steps are proposed in this direction: (i) recognition of a potentially non-beneficial or harmful treatment by the physicians, (ii) consensus among all the caregivers on a potentially non-beneficial or harmful treatment and initiation of the best supportive care pathway, (iii) initiation of EOLC pathways, and (iv) symptom management and ongoing supportive care till death. The article also focuses on the step-by-step process of formulation of this institutional policy, so that it can work as a blueprint for other institutions of our country to identify the infrastructural needs and resources and to formulate their own policies.

BackgroundHypoxia in patients with COVID-19 is one of the strongest predictors of mortality. Silent hypoxia is characterized by the presence of hypoxia without dyspnea.. Silent hypoxia has been shown to affect the outcomes in previous studies.Research QuestionAre the outcomes in patients presenting with silent hypoxia different from those presenting with dyspneic hypoxia?Study design and MethodsThis was a retrospective study of a cohort of patients with SARS-CoV-2 infection who were hypoxic at presentation. Clinical, laboratory, and treatment parameters in patients with silent hypoxia and dyspneic hypoxia were compared. Multivariate logistic regression models were fitted to identify the factors predicting mortality.ResultsAmong 2080 patients with COVID-19 admitted to our hospital, 811 patients were hypoxic with SpO2P=0.202). The odds ratio of death was 1.1 (95% CI 0.41-2.97) in the patients with silent hypoxia after adjusting for baseline characteristics, laboratory parameters, treatment, and in-hospital complications, which did not reach statistical significance (P=0.851).InterpretationSilent hypoxia may be the only presenting feature of COVID-19. Since the case fatality rate is comparable between silent and dyspneic hypoxia, it should be recognized early and treated as aggressively. Since home isolation is recommended in patients with COVID-19, it is essential to use pulse oximetry at the home setting to identify these patients.

Background and objective It has been observed that peripheral oxygen saturation (SpO

BackgroundPatients with chronic kidney disease (CKD) on hemodialysis are highly vulnerable to COVID-19 infection with a mortality rate higher than the rest of the population. There are several clinical and laboratory parameters that can predict the course and the outcomes in this group of population.MethodsWe retrospectively collected the baseline demographic, clinical, in-hospital, and laboratory data of the patients with CKD on maintenance hemodialysis who were admitted to our COVID-19 hospital during the first and the second wave.ResultsWe obtained data for 35 patients from the first and 5 patients from the second wave. The analysis of the data for 35 patients from the first wave revealed shortness of breath (62.9%), and fever (54.3%) being the most common presenting symptoms, and the majority of the patients (57.2 %) presented with moderate to severe disease at admission with 57 % had bilateral lung infiltrates, and required oxygen support (65.7%) at admission. The comparison of clinical and laboratory markers between survivors (27 patients, 77.1%) and non-survivors (8 patients, 22.9%) revealed an older age, severe disease at presentation, invasive mechanical ventilation, baseline severe lymphocytopenia, high serum glutamic oxaloacetic transaminase, blood urea, and inflammatory markers like Interleukin-6 and procalcitonin, fibrinogen and low albumin in non survivors.ConclusionsThe older age, severe disease at presentation, the requirement of invasive mechanical ventilation, raised baseline Interleukin-6, procalcitonin, serum glutamic oxaloacetic transaminase, blood urea and a low albumin level could be valuable predictors of poor outcomes.

The "second wave" of the COVID-19 pandemic hit India from early April 2021 to June 2021. We describe the clinical features, treatment trends, and baseline laboratory parameters of a cohort of patients with SARS-CoV-2 infection and their association with the outcome.This was a retrospective cohort study. Multivariate logistic regression models were fitted to identify clinical and biochemical predictors of developing hypoxia, deterioration during the hospital stay, and death.A total of 2080 patients were included. The case fatality rate was 19.5%. Among the survivors, the median duration of hospital stay was 8 (5-11) days. Out of 853 (42.3%%) of patients who had COVID-19 acute respiratory distress syndrome at presentation, 340 (39.9%) died. Patients aged45 years had higher odds of death as compared to the 18-44 years age group. Vaccination reduced the odds of death by 40% (odds ratio [OR] [95% confidence interval [CI]]: 0.6 [0.4-0.9], P = 0.032). Patients with hyper inflammation at baseline as suggested by leukocytosis (OR [95% CI]: 2.1 [1.5-3.1], P0.001), raised d-dimer500 mg/dL (OR [95% CI]: 3.2 [2.2-4.7], P0.001), and raised C-reactive peptide0.5 mg/L (OR [95% CI]: 3.7 [2.2-13], P = 0.037) had higher odds of death. Patients who were admitted in the 2This study shows that vaccination status and early admission during the inflammatory phase can change the course of illness of these patients. Improving vaccination rates and early admission of patients with moderate and severe COVID-19 can improve the outcomes.

Although unexpected airway difficulties are reported in patients with mucormycosis, the literature on airway management in patients with mucormycosis associated with Coronavirus disease is sparse.In this retrospective case record review of 57 patients who underwent surgery for mucormycosis associated with coronavirus disease, we aimed to evaluate the demographics, airway management, procedural data, and in-hospital mortality records.Forty-one (71.9%) patients had a diagnosis of sino-nasal mucormycosis, fourteen (24.6%) patients had a diagnosis of rhino-orbital mucormycosis, and 2 (3.5%) patients had a diagnosis of palatal mucormycosis. A total of 44 (77.2%) patients had co-morbidities. The most common co-morbidities were diabetes mellitus in 42 (73.6%) patients, followed by hypertension in 21 (36.8%) patients, and acute kidney injury in 14 (28.1%) patients. We used the intubation difficulty scale score to assess intubating conditions. Intubation was easy to slightly difficult in 53 (92.9%) patients. In our study, mortality occurred in 7 (12.3%) patients. The median (range) mortality time was 60 (27-74) days. The median (range) time to hospital discharge was 53.5 (10-85) days. The median [interquartile range] age of discharged versus expired patients was 47.5 [41,57.5] versus 64 [47,70] years (P = 0.04), and median (interquartile range) D-dimer levels in discharged versus expired patients was 364 [213, 638] versus 2448 [408,3301] ng/mL (P = 0.03).In patients undergoing surgery for mucormycosis associated with the coronavirus disease, airway management was easy to slightly difficult in most patients. Perioperative complications can be minimized by taking timely and precautionary measures.

PurposeAlthough unexpected airway difficulties are reported in patients with mucormycosis, the literature on airway management in patients with mucormycosis associated with Coronavirus disease is sparse.MethodsIn this retrospective case record review of 57 patients who underwent surgery for mucormycosis associated with coronavirus disease, we aimed to evaluate the demographics, airway management, procedural data, and mortality records.ResultsForty-one (71.9%) patients had a diagnosis of sino-nasal mucormycosis, fourteen (24.6%) patients had a diagnosis of rhino-orbital mucormycosis, and 2 (3.5%) patients had a diagnosis of palatal mucormycosis. A total of 44 (77.2%) patients had co-morbidities. The most common co-morbidities were diabetes mellitus in 42 (73.6%) patients, followed by hypertension in 21 (36.8%) patients, and acute kidney injury in 14 (28.1%) patients. We used the intubation difficulty scale score to assess intubating conditions. Intubation was easy to slightly difficult in 53 (92.9%) patients. In our study, mortality occurred in 7 (12.3%) patients. The median (range) mortality time was 60 (27–74) days. The median (range) time to hospital discharge was 53.5 (10–85) days. The median [interquartile range] age of discharged versus expired patients was 47.5 [41,57.5] versus 64 [47,70] years (P = 0.04), and median (interquartile range) D-dimer levels in discharged versus expired patients was 364 [213, 638] versus 2448 [408,3301] ng/mL (P = 0.03).ConclusionIn patients undergoing surgery for mucormycosis associated with the coronavirus disease, airway management was easy to slightly difficult in most patients. Perioperative complications can be minimized by taking timely and precautionary measures.

BackgroundDue to the unprecedented speed of SARS-CoV-2 vaccine development, their efficacy trials and issuance of emergency use approvals and marketing authorizations, additional scientific questions remain that need to be answered regarding vaccine effectiveness, vaccination regimens and the need for booster doses. While long-term studies on the correlates of protection, vaccine effectiveness, and enhanced surveillance are awaited, studies on breakthrough infections help us understand the nature and course of this illness among vaccinated individuals and guide in public health preparedness.MethodsThis observational cohort study aimed at comparing the differences in clinical, biochemical parameters and the hospitalization outcomes of 53 fully vaccinated individuals with those of unvaccinated (1,464) and partially vaccinated (231) individuals, among a cohort of 2,080 individuals hospitalized with SARS-CoV-2 infection.ResultsCompleting the course of vaccination protected individuals from developing severe COVID-19 as evidence by lower proportions of those with hypoxia, abnormal levels of inflammatory markers, requiring ventilatory support and death compared to unvaccinated and partially vaccinated individuals. There were no differences in these outcomes among patients who received either vaccine type approved in India.ConclusionWith a current rate of only 9.5% of the Indian population being fully vaccinated, efforts should be made to improve the vaccination rates as a timely measure to prepare for the upcoming waves of this highly transmissible pandemic. Vaccination rates of the communities may also guide in the planning of the health needs and appropriate use of medical resources.Research in contextEvidence before this studyThe Government of India started vaccinating its citizens from the 16thof January 2021, after emergency use authorization had been received for the use of two vaccines, BBV152, a COVID-19 vaccine based on the whole-virion SARS-CoV-2 vaccine strain NIV-2020-770, (Covaxin) and the recombinant replication-deficient chimpanzee adenovirus vector encoding the spike protein ChAdOx1 nCoV-19 Corona Virus Vaccine (Covishield). These have been approved by the Indian regulatory authority based on randomized controlled studies. In these studies, was found that the vaccines led to more than 90% reduction in symptomatic COVID-19 disease. However, there is scarce evidence of the efficacy of these vaccines in real-world scenarios. A few studies have looked at vaccinated cohorts such as health care workers in whom the vaccines had an efficacy similar to the RCTs. In a study of patients with SARS-CoV-2 infection admitted to a tertiary care hospital in New Delhi, it was found that mortality in fully vaccinated patients was 12.5% as compared to 31.5% in the unvaccinated cohort.Added-value of this studyThis cohort of hospitalized patients with SARS-CoV-2 infection was studied during the peak of the second wave of COVID-19 in India during which the delta variant of concern was the predominant infecting strain and had 26% patients who were partially vaccinated and 71.4% who were unvaccinated. Only 3% of the patients were fully vaccinated and developed a breakthrough infection. At the time of presentation, 13% of the individuals with breakthrough infection and 48·5% in the non-vaccinated group were hypoxic. Inflammatory markers were significantly lower in the completely vaccinated patients with breakthrough infection. The need for use of steroids and anti-viral agents such as remdesivir was also significantly low in the breakthrough infection group. A significantly less proportion of the individuals with breakthrough infection required oxygen supplementation or ventilatory support. Very few deteriorated or progressed to critical illness during their hospital stay. Only 3 individuals (5.7%) out of the 53 who developed breakthrough infection succumbed to illness while case fatality rates were significantly higher in the unvaccinated (22.8%) and partially vaccinated (19.5%) groups. Propensity score weighted multivariate logistic regression analysis revealed lower odds of developing hypoxia, critical illness or death in those who were completely vaccinated.Implications of all the available evidenceThe real-world effectiveness of the vaccines against SARS-CoV-2 seems to be similar to the randomized controlled trials. The vaccines are very effective in reducing the incidence of severe COVID-19, hypoxia, critical illness and death. The reduced need for oxygen supplementation, mechanical ventilation and the requirement of corticosteroids or other expensive medications such as anti-viral drugs could go a long way in redistributing scarce health care resources. All nations must move forward and vaccinate the citizens, as the current evidence suggests that ‘prevention is better than cure’.

BackgroundThe second wave of the COVID-19 pandemic hit India from early April 2021 to June 2021 and more than 400,000 cases per day were reported in the country. We describe the clinical features, demography, treatment trends, baseline laboratory parameters of a cohort of patients admitted at the All India Institute of Medical Sciences, New Delhi with SARS-CoV-2 infection and their association with the outcome.MethodsThis was a retrospective cohort study describing the clinical, laboratory and treatment patterns of consecutive patients admitted with SARS-CoV-2 infection. Multivariate logistic regression models were fitted to identify the clinical and biochemical predictors of developing hypoxia, deterioration during the hospital stay and death.FindingsA total of 2080 patients were included in the study. The case fatality rate was 19.5%. Amongst the survivors, the median duration of hospital stay was 8 (5-11) days. Out of 853 (42.3%%) of patients who had COVID-19 Acute respiratory distress syndrome at presentation, 340 (39.9%) died. Patients aged 45-60 years [OR (95% CI): 1.8 (1.2-2.6)p =0.003] and those aged >60 years [OR (95%CI): 3.4 (2.3-5.2), p500 mg/dL [OR (95% CI): 3.2 (2.2-4.6), p 0.5 mg/L [OR (95% CI): 3.8 (1.1-13), p=0.037] had higher odds of death. Patients who were admitted in the second week had lower odds of death and those admitted in the third week had higher odds of death.InterpretationThis is the largest cohort of patients admitted with COVID-19 from India reported to date and has shown that vaccination status and early admission during the inflammatory phase can change the course of illness of these patients. Strategies should be made to improve vaccination rates and early admission of patients with moderate and severe COVID-19 to improve outcomes.Research in contextEvidence before this studyThe COVID-19 pandemic has been ravaging the world since December 2019 and the cases in various regions are being reported in waves. We found that the case fatality rates ranging from 1.4% to 28.3% have been reported in the first wave in India. Older age and the presence of comorbidities are known predictors of mortality. There are no reports regarding the effectiveness of vaccination, correlation of mortality with the timing of admission to the health care facility and inflammatory markers in the ‘second wave’ of the COVID-19 pandemic in India.Added-value of this studyThis study reports the real-world situation where patients get admitted at varying time points of their illness due to the mismatch between the availability of hospital beds and the rising number of COVID-19 patients during the pandemic. It reports the odds of developing severe hypoxia necessitating oxygen therapy and death thus helping identify priority groups for admission.Implications of all the available evidenceThis study found increased odds of requiring oxygen support or death in patients older than 45 years of age, with comorbidities, and those who had hyper-inflammation with raised C-reactive peptide, d-dimer or leukocytosis. Patients who were admitted in the second week of illness had lower odds of death as compared to those admitted in the third week implying that treatment with corticosteroids in the second week of the illness during the ‘inflammatory phase’ could lead to reduced mortality. These findings would help triage patients and provide guidance for developing admission policy during times where hospital beds are scarce. Vaccination was found to reduce the odds of deterioration or death and should be fast-tracked to prevent further ‘waves’ of the pandemic.

Studies comparing the utility of dexmedetomidine with other drugs for sedation during medical thoracoscopy are lacking. In this pilot study, we compared dexmedetomidine with midazolam for sedation in thoracoscopy.Consecutive subjects were randomized to receive either dexmedetomidine (n=30) (group D) or midazolam (n=30) (group M). All received fentanyl for procedural analgesia. The primary endpoint was pulmonologist-rated overall procedure satisfaction on the visual analog scale (satisfaction VAS). Key secondary outcomes were pulmonologist-rated cough on VAS (cough VAS), patient-rated faces pain scale scores, change in hemodynamic variables, total additional fentanyl dose, and adverse events during procedure.The satisfaction VAS score (mean±SD) was significantly greater in group D versus group M (7.5±1.4 and 6.5±1.1, respectively) ( P =0.003). The cough VAS scores (mean±SD) were 2.1±1.5 (group D) and 3.1±1.3 (group M) ( P =0.014). The scores (mean±SD) for patient-rated faces pain scale were 2.9±1.8 and 4.2±2.3 ( P =0.019) in group D and group M, respectively. The additional dose of fentanyl administered in group M was significantly greater than in group D ( P =0.001). The responses at the local anesthesia infiltration, skin incision, thoracoscope insertion, and biopsy between both groups were similar. The hemodynamic parameters were comparable in both groups. Also, more patients were willing for repeat thoracoscopy if needed; in the dexmedetomidine group.The findings of this pilot RCT indicate that dexmedetomidine may be more efficacious than midazolam for sedation in patients undergoing medical thoracoscopy. These observations need to be confirmed in an adequately powered RCT.

ObjectiveTo compare the analgesic efficacy of two techniques of morphine titration (intermittent intravenous bolus vs infusion) by calculating rescue dosage in a day at 1 week after analgesic titration.MethodsOne hundred and forty cancer patients were randomised into two groups. In group 1, intravenous morphine 1.5 mg bolus given every 10 min until Numerical Rating Scale (NRS) pain score ResultsThe rescue dosage in a day at 1-week post discharge from the palliative care unit was significantly higher in group 1 as compared with group 2.ConclusionIntravenous infusion morphine may be a better analgesic titration technique for analgesia in patients with advanced cancer.Trial registration numberCTRI/2018/04/013369.

Pain adversely affects the quality of life in cancer patients. Although conventional oral analgesics and co-analgesics manage 80%-90% of pain, interventional pain management techniques may be useful in the management of cancer pain refractory to opioid analgesia or in patients unable to tolerate systemic opioids. Herein, we report three cases depicting the successful role of erector spinae plane block in our palliative care unit for the management of different chronic cancer pain.

The cavitary lesions in the lungs are rare radiological findings in patients infected with COVID-19. The most common causes for such lesions are secondary infections with either bacterial, fungal, or viral pathogens, preexisting malignancy, or autoimmune diseases. In our patient, none of the above-mentioned obvious reasons could be found. Pulmonary embolism and lung infarction have also been observed to be possible causes in COVID-19 patients. The persistent positivity of nasopharyngeal swab sample for coronavirus disease by reverse transcriptase-polymerase chain reaction test, clinical and laboratory evidence of thromboembolic phenomenon suggested the lesion to be a result of a complication of the COVID-19 infection with a possible microangiopathic mechanism.

Glossopharyngeal nerve (GPN) block is used for pain management in patients' head and neck malignancy. The GPN is a mixed nerve containing both motor and sensory fibers. The usual approaches for GPN blocks are usually topical, intraoral, or peristyloid. Topical anesthesia may be difficult in patients with limited mouth opening or when there is inflammation in the area of interest. Intraoral and peristyloid approaches have risk of inadvertent neurovascular injection. The intraoral technique may lead to long-lasting oropharyngeal discomfort. Hence, GPN block is done at the pharyngeal wall level for pain relief.

Background and Aims: Ultrasound-guided serratus anterior plane (SAP) block is a field block with high efficacy. We studied the analgesic effect of the addition of dexamethasone to ropivacaine in SAP block for modified radical mastectomy (MRM). Methods: Sixty patients undergoing MRM were randomised into two groups. Patients in Group P (n = 30) received 0.375% ropivacaine (0.4 ml/kg) with normal saline (2 ml) and those in group D (n = 30) received 0.375% ropivacaine (0.4 ml/kg) with 8 mg of dexamethasone (2 ml) in ultrasound-guided SAP block. The primary objective was to compare the time to first rescue analgesia and the secondary objectives were to compare the intraoperative fentanyl requirement, total diclofenac and tramadol requirements, and occurrence of nausea and vomiting in 24 hours, postoperatively. The statistical analysis was done using Mann–Whitney U-test, Chi-square test, Fisher's exact test, and Kaplan Meier survival estimates. Results: More patients required rescue analgesia in 24 hours in group P (33%) than group D (10%, P = 0.04). The probability of a pain free-period was significantly higher in group D than group P (P = 0.03, log-rank test). Intra-operative fentanyl requirement and postoperative diclofenac and tramadol requirements were comparable in both the groups. The incidence of postoperative nausea and vomiting was significantly more in Group P than Group D. Conclusion: Addition of dexamethasone to ropivacaine for SAP block increases the time to first rescue analgesic in the postoperative period.

Background: Palliative care physicians in India have achieved access to methadone for pain relief in cancer patients. Despite being an effective drug in terms of analgesia, there are a number of reasons why this opioid medication is not as much as popular as morphine. We identified and tried to overcome a few such barriers in treating cancer pain with methadone. Methods: The clinical information of ten adult cancer patients (six males and four females), who voluntarily received methadone for their severe pain in the month of August 2019 were analysed retrospectively. We converted morphine to methadone in all ten patients under the supervision of an experienced practitioner. Results: During the methadone therapy, eight out of ten patients who were given methadone exclusively for their pain had adequate pain relief initially. The barriers identified included difficult titration methods due to distinct pharmacology, patient selection, clinical inertia, communication and co-ordination among physicians, communication among patient and physician, and patient and caregivers, and vigilant monitoring. Conclusion: Methadone is still finding its place in India for cancer pain management. As the drug is new to Indian practitioners, we have to overcome these barriers and facilitate its judicious use in cancer pain management.