Background: Acupuncture has been increasingly used as a complementary therapy in pain management. At Singapore General Hospital pain management center, approximately 40% of patients are referred for adjunctive onsite acupuncture. This number is increasing as acupuncture becomes a more readily accepted adjunct to conventional pain therapies. Materials and Methods: We conducted a two-part survey to look at patients’ perspectives before their acupuncture treatment regimen and the efficacy and effects of acupuncture after 5–10 sessions in the multidisciplinary management for their pain conditions. Results: A total of 80 people participated in the survey over 4 months. Sixty-one participants completed the two-part survey. 57.6% of participants had pain related to spine degeneration, of which 68.9% and 77% reported being affected in their sleep and mood, respectively. Follow-up survey after acupuncture sessions showed statistically significant improvement in pain scores. 79.5% reported improvements in mood and 90.9% in mobility. 93.2% said they would recommend acupuncture in the follow-up survey. Conclusion: Acupuncture was shown to have statistically significant effects on pain scores based on our pilot survey results. Majority of patients also reported improved mood and mobility which are part of the multidimensional effects of chronic pain that affect quality of life.

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Background: Confirmation of the position of the endotracheal tube is a crucial step in the management of critically ill patients. Confirmation by capnography is the gold standard but it is practically impossible in all situations. Ultrasound (USG) can be used as an effective alternative to confirm the endotracheal tube (ETT) position. We aimed to determine the sensitivity, specificity, positive and negative predictive values, and accuracy of real-time USG with capnography to determine the correct placement of the ETT. Patients and Methods: The study population consisted of a nonselected series of 65 consecutive patients aged above 18 years who required endotracheal intubation in the critical care unit. Outcomes measured were confirmation of ETT by USG and capnography and time taken to confirm ETT position by USG and capnography, ruling out endobronchial placement of the ETT. Results: The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of real-time USG of the upper airway to detect the ETT position were 98.36% (95% confidence interval [CI]: 91.20%–99.96%), 100% (95% CI: 39.76%–100%), 100%, 80% (95% CI: 36.41%–96.54%), and 98.46% (95% CI: 91.72%–99.96%), respectively. The mean time taken to detect the position of ETT by capnography (T2) was 15.91 ± 3.14 s, whereas that by real-time upper airway ultrasonogram (T1) was 11.85 ± 2.32 s, and the difference was statistically significant. Conclusion: Real-time tracheal USG is an alternative method to confirm the ETT position, which is not only sensitive and accurate but also faster than capnography.

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Background: Patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction experience significant postoperative pain, which could lead to a delay in recovery and discharge from an ambulatory surgical setting. Adductor canal block (ACB) has been used to offer effective postoperative analgesia after ACL repair. We compared the analgesic efficacy of alpha-2 agonists clonidine and dexmedetomidine as adjuvants to local anesthetics in ACB. Patients and Methods: Sixty subjects scheduled for elective arthroscopic ACL reconstruction were randomized into two groups of 30 patients each. Group 1 patients received US-guided ACB with 20 mL of 0.5% ropivacaine with 1 μg/kg clonidine as an adjuvant; group 2 patients received ACB with 20 mL of 0.5% ropivacaine with 1 μg/kg dexmedetomidine as an adjuvant. Demographic data, pain scores, motor and sensory block, postoperative tramadol consumption, time to rescue analgesia, and adverse events were compared. Results: The demographic data were comparable between both groups. The patients in group 2 when compared with group 1 had increased time for request to rescue analgesic (488.83 ± 67.934 min compared with 975.07 ± 90.251 min, P < 0.001), reduced tramadol consumption (179.33 ± 44.095 mg compared with 179.33 ± 44.095 mg, P < 0.001), and better pain scores at 12 and 18 h. Postoperative nausea and vomiting was less in group 2 compared with group 1. Conclusion: Dexmedetomidine, when added as an adjuvant to 0.5% ropivacaine in ACB, leads to increased time to first request of tramadol, reduced postoperative tramadol requirement, and decreased NRS scores when compared with clonidine.

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Background: Despite having various choices of labor analgesia in modern obstetric practice, there are limited appropriate instruments to measure labor pain comprehensively. The Angle Labor Pain Questionnaire (A-LPQ) is a new, condition-specific instrument that measures the multidimensional characteristics of labor pain and experiences, yet little information is available on its use in other countries and languages. This study aimed at developing a Chinese version of the A-LPQ questionnaire. Materials and Methods: Two independent certified translators translated the English version of the A-LPQ questionnaire, and reconciliation was performed by discussing the discrepancies with a local coordinator. A third translator performed the backward translation, followed by a review by six clinicians on the reconciled version. A cognitive debriefing was done in five pregnant women during the early stage of labor to collect their feedback. After the proofreading, the final version was tested in 50 pregnant women during their labor. Results: The A-LPQ questionnaire was forward translated and was adjusted to expressive and clinical relevance in a local setting. Minor changes were done after backward translation and clinicians’ review to enable a better understanding. No changes were required during cognitive debriefing, and the subsequent finalization showed that the Chinese version of the A-LPQ questionnaire could be well understood (Difficulty level: 2.3 (SD 3.1); with 0 being fully understand, and 10 being extremely difficult to understand). Conclusion: We successfully performed linguistic validation on the Chinese version of the A-LPQ questionnaire, which is appropriate in measuring the dynamic nature of labor pain in a local Chinese setting.

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Background: Behavioral management and carrying out surgical procedures for very young, uncooperative, anxious children can be challenging. It is usually encountered in children below the age of 6 years due to the following contributing factors such as immature reasoning, anxiety, fear, and inadequate coping skills. The goal of the study was to compare the efficacy of oral midazolam and oral triclofos sodium for conscious sedation in pediatric group of patients before elective surgeries. Materials and Methods: This prospective, single- blinded, randomized controlled, comparative study was conducted in 60 patients aged 2–8 years who were scheduled for elective surgery. The patients were randomly divided into two groups: M and T of 30 children each, where group M received 0.5 mg//kg midazolam and group T received 75 mg/kg triclofos sodium, orally, 60 min prior to anesthetic induction. The hemodynamics, acceptability of drugs, depth of sedation, and anxiety during separation from parents were assessed. Fisher’s exact test, chi-square test, and Student’s t test were applied to find significance. Results: The mean systolic and diastolic blood pressure, heart rate, respiration rate, and oxygen saturation at baseline to 60 min in groups M and T showed no significant difference between groups. Triclofos sodium has better acceptability over oral midazolam, whereas oral midazolam has better sedative properties over oral triclofos sodium. Conclusion: Oral midazolam was found to be more effective premedication and may be preferred over triclofos sodium due to the rapid and better sedative effect as well as good anxiolysis properties.

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Background: In addition to causing respiratory problems, patients with COVID-19 infection also present with neurological symptoms. We report neurological symptoms in a patient with severe COVID-19 infection admitted to the intensive care unit. Patients and Methods: We conducted a descriptive observational study from the patients treated in the intensive care unit (ICU) from October 2020 to September 2021 with neurological symptoms. Inclusion criteria for participants were patients who were confirmed positive for COVID-19 from the results of the nasopharyngeal polymerase chain reaction (PCR) swab, with neurological symptoms that appeared less ≤5 days before the results of the COVID-19 PCR swab were confirmed. Exclusion criteria were patients with negative PCR swab results, patients presenting with neurological symptoms >5 days before confirmed PCR, and patients with previously known neurological disorder. Results: A total of 160 COVID-19 patients were admitted to the ICU with neurological symptoms, consisting of 99 males (61.9%) and 61 females (38.1%). A total of 35 patients (21.9%) complained of headache, nine patients (5.6%) complained of vestibular disturbances, 23 patients (14.4%) with seizures, 88 patients (55%) with decreased consciousness (encephalopathy), nine patients with intracranial infection, 67 patients (41.9%) with stroke, and nine patients (5.6%) with movement disorders. Conclusion: The most common neurological symptom in severe COVID-19 patients treated in our ICU was decreased consciousness, followed by stroke and headache. Neurological symptoms found in patients with severe COVID-19 infection can be caused by direct viral infection or indirectly through the mechanism of severe hypoxia due to respiratory failure.

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Background: Spinal anesthesia (SA) has many advantages in lower segment caesarean section (LSCS), but hypotension is the main issue that can be managed in different ways. This study was conducted to know the effectiveness of three intravenous serotonin receptor antagonists (ramosetron, ondansetron, and granisetron) in the prevention of bradycardia and hypotension during LSCS under SA. Patients and Methods: A total of 160 parturients posted for LSCS under SA were enrolled in this study and divided equally into four groups. Five minutes before SA, Group R received intravenous (IV) 0.3 mg ramosetron, Group O received 4 mg ondansetron IV, Group G received 1 mg granisetron IV, and Group S received IV normal saline. All solutions were diluted with normal saline to 5 mL to blind the drugs. Heart rate (HR), systolic and diastolic blood pressure, and mean arterial pressure were recorded. The total consumption of vasopressor and side effects were recorded. Results: The decrease in mean arterial pressure and mean HR was significantly lower in group R than other groups at all intervals (P < 0.05). The incidence of hypotension was 25% in group R compared with 42.5%, 55%, and 72.5% in groups O, G, and S, respectively. Conclusion: Premedication with intravenous ramosetron significantly reduced hypotension, HR, and total vasopressor usage in LSCS parturients. Intravenous ondansetron and granisetron had lesser effects than ramosetron.

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Background: New biomarkers are urgently needed to predict the severity of patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Eosinophil count and neutrophil-to-lymphocyte ratio (NLR) are new biomarkers for the severity of viral infection. Pentraxin 3 (PTX3) is a natural humoral immune mediator that can bind to viruses, complement, and apoptotic cells, and can trigger T-helper type 1 (Th1) to produce pro-inflammatory cytokines and their levels increase depending on the severity of the disease. Materials and Methods: This was a case-control study consisting of 66 patients infected with SARS-CoV-2 who were divided into critical patients (Group C) and noncritical patients (Group N). We obtained lab samples from the subjects upon admission. We then analyzed the data using the Mann–Whitney U test, receiving operator characteristic (ROC) analysis, and chi-square test with odds ratio (OR) to test the hypothesis. Results: Median eosinophil count, NLR, and PTX3 levels in Group C were 0 ×10³/µL, 13.53 and 608.73 pg/mL, compared to 0.11 ×10³/µL, 1.94 and 28.50 pg/mL in Group N. The ROC analysis showed good predictive ability for eosinophil count, NLR, and PTX3 with area under the curve (AUC) of 0.913, 0.988, and 0.942 to predict coronavirus disease-2019 (COVID-19) severity. At the cutoff eosinophil count of 0.035 × 10³/µL, NLR 4.13 and PTX3 114.51 pg/mL, the OR values ​​were 17.5, 320, and 72.5 (P < 0.05) with a sensitivity of 84.8%, 97.0%, and 90.9% and specificity 75.8%, 90.9%, and 87.9%. Conclusions: Eosinophil count, NLR, and PTX3 levels can be used as predictors of clinical severity in SARS-CoV-2. Eosinophil count of <0.035 ×10³/µL, NLR >4.13, and PTX3 level >114.51 pg/mL are risk factors for critical conditions for COVID-19.

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Background: Anxiety associated with surgical stress can lead to high blood pressure (BP), which may end up with undue last minute cancellation of surgery. Relaxation therapy is now being widely used as a complementary therapy for stress and high BP. We conducted a randomized controlled study to compare the effect of relaxation therapy on pre-induction anxiety and BP in hypertensive patients. Materials and Methods: A randomized controlled study was conducted on hypertensive patients undergoing elective surgery. They were allocated into two groups (relaxation therapy and control) using simple randomization with allocation concealment. The relaxation therapy group received intervention by an audio clip an evening prior and 30 min before the scheduled surgery. Their anxiety score on numerical rating scale (0–10) and BP was recorded before and after each intervention. The control group received standard care only. Pre-induction BP and anxiety score were recorded in both groups. The outcome measures were difference in pre-induction anxiety and BP between relaxation and control groups and difference in pre- and post-relaxation anxiety and BP. Results: Out of 70 patients, 30 received relaxation therapy and 34 received standard pre-operative care. There was a significant reduction in BP and anxiety after relaxation therapy in the intervention group (P < 0.0001). The relaxation therapy group showed significantly lower pre-induction systolic BP (138.93 vs. 156.59, P < 0.0001) and anxiety score (2.5 vs. 5.5, P < 0.0001) than the control group. Requirement of anxiolytic drug was less in the relaxation therapy group. Conclusion: Relaxation therapy significantly reduces pre-induction BP and anxiety.

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Prediction of pediatric difficult endotracheal intubation is a challenge for anesthesiologists. Pediatric patient possess unique characteristics in relation with difficult intubation, especially their uncooperative nature which makes conventional anatomical criteria is not applicable. Acromioaxillo suprasternal notch index (AASI) is a new test that is more objective and does not require full cooperation from the patient. Twenty patients aged 1–6 years old underwent surgery under general anesthesia with endotracheal intubation were included in this case series. AASI seems positively correlated with Cormack–Lehane grade. It is a novel but useful examination to predict the difficulty of laryngoscopic visualization during tracheal intubation in children aged 1–6 years old. More samples and further study are needed to prove the correlation in this study.

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Introduction: Chloroprocaine is a local anesthetic with faster onset of action and short half-life, which results in short duration of analgesia limiting its use in surgeries. Researches proved that synergy with other drugs prolongs the duration of action and also the postoperative analgesia of chloroprocaine. Thus the present study was designed to compare the effectiveness of adding buprenorphine and fentanyl to intrathecal 1% 2-chloroprocaine for perianal surgeries. Materials and Methods: This prospective comparative study included 100 American Society of Anaesthesiologists physical class 1 and 2 patients of age 18–60 years, body mass index <35, scheduled for short duration perianal surgeries under spinal anesthesia. Patients were randomized into two groups: 30 mg 1% chloroprocaine was given along with 25 µg fentanyl in group F and 75 µg buprenorphine in group B. The time of onset, duration of sensory and motor block, two-segment and complete regression of spinal anesthesia, and duration of postoperative analgesia were studied. Results: Time for two-segment regression was 41.40 ± 7.82 and 44.80 ± 6.14 min in groups F and B, respectively, with P=0.43. In groups F and B, time to reach the modified Bromage score of 3 was 4.41 ± 0.48 and 4.17 ± 0.57 min, respectively. The time to void was insignificantly longer in group B than that in F of 300.96 ± 35.41 and155.86 ± 46.67 min without requirement of urinary catheterization. The time of first postoperative analgesic requirement was significantly longer in group B than that of group F of 715.82 ± 127.09 178.07 ± 453.13 min, respectively. Conclusion: The addition of intrathecal buprenorphine to chloroprocaine for spinal anesthesia significantly prolonged the postoperative analgesia compared with addition of fentanyl.

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Gastrostomy is needed to provide nutritional support in patients with head and neck cancer surgery. The incision in upper abdomen causes moderate pain. We usually encountered our postoperative patients complaining of significant discomfort that leads us to think about adding some regional anesthesia techniques with conventional pain management. Recently, the role of regional anesthetic techniques for involving anterior abdominal wall has been increased. Ten patients who underwent head and neck cancer surgery requiring open surgical gastrostomy for long-term nutritional support were taken into this descriptive case series. In addition to general anesthetic, intravenous nalbuphine, and paracetamol, ultrasound-guided subcostal transversus abdominal plane (TAP) block was performed 30 min prior to incision of gastrostomy to improve postoperative analgesia. All 10 patients had significant pain relief at gastrostomy incision site which is different from our experience in the same patient population before. The numerical rating score (NRS) was between 0 and 2, and average satisfaction score was 7–8 on a scale of 10. The patients reported a very low level of discomfort. No adverse events were recorded up to patient discharge from the hospital. Subcostal TAP block under ultrasound guidance is a valuable addition to improve postoperative pain management in open surgical gastrostomy. The available case series show encouraging analgesic results with no adverse events recorded. Formal prospective randomized trials are needed to provide further evidence on its efficacy, failure rate, and safety.

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Background: Acute respiratory failure is the main manifestation in patients with severe coronavirus disease (COVID-19), being hospitalized in an intensive care unit, and may even require invasive mechanical ventilation, which is associated with high mortality. The use of high-flow nasal oxygen (HFNO) for severe hypoxemic respiratory failure cases was limited in hospital setups. Its benefit to patients, compliance, complications, as well as comparison with non-invasive ventilation (NIV) mask were not studied. Patients and Methods: We included consecutive patients with COVID-19 acute respiratory failure who were categorized into three groups depending on admission oxygen saturation and respiratory rate for non-rebreather bag-mask (NRBM), HFNO, and NIV. All patients were observed for 2 weeks and defined parameters were noted. The mean and standard deviation were compared between the groups by using the ANOVA test; P-value <0.05 was considered as statistically significant. Results: The comparison of mean escalation of oxygen requirement on the 5th day showed a significant result (94.27 ± 1.7 vs. 92.16 ± 4.05 vs. 90.73 ± 2.49, respectively, P = 0.001). Similar findings were also found on the 10th day and 15th day of treatment. The NIV group showed a significant lack of compliance to oxygen therapy (P < 0.001) and also a significant incidence of complications (P < 0.001). Conclusion: NIV showed a significant amount of escalation in oxygen requirement, reduced therapy compliance, and associated complications in comparison to the NRBM and HFNO in COVID-19 settings.

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