Sublingual (SL) buprenorphine is approved for managing acute postoperative pain, characterized by easy administration, good pain relief and good patient compliance. We hypothesized that SL buprenorphine would be a better perioperative analgesic compared to intravenous (IV) opioids like tramadol in patients undergoing mastectomy surgery for breast cancer. After institutional ethics committee approval, we randomized 60 patients with breast cancer into 2 groups. In buprenorphine group, patients received 200 μg of SL buprenorphine thrice daily and in tramadol group patients received 100 mg of IV tramadol thrice daily. The analgesic efficacy of SL buprenorphine was comparable to that of IV tramadol. Visual Analogue Scale scores had no significant difference between the two groups at various time frames (0, 1, 3, 6, 12, 18 and 24 hours) at rest and movement except at 0 and 3 hours during movement when the score was lower in the tramadol group than the buprenorphine group. Four patients in the buprenorphine group received rescue analgesic (IV morphine 3 mg). Analgesic efficacy of SL buprenorphine appears comparable to IV tramadol for managing postoperative pain after mastectomy. SL buprenorphine can be administered sublingually, which is an advantage.

Postoperative acute pulmonary embolism (APE) can be a life-threatening emergency and is associated with very high mortality. Approximately two-thirds of patients, who died of pulmonary embolism, die within the first hour after the presentation. We report a case of APE following an emergency lower segment cesarean section (LSCS) because of severe fetal distress. This 37-year-old female with no previous medical or surgical history underwent LSCS under general anesthesia. The surgery was uneventful and she was extubated uneventfully at the end of surgery. Six hours after surgery, there was a sudden drop in oxygen saturation on pulse oximetry, tachypnea which raised the suspicion of APE. An urgent chest radiograph computed tomographic pulmonary angiography (CTPA) and transthoracic echocardiogram along a sample for D-dimer were ordered immediately. CTPA was consistent with APE involving the main pulmonary artery. Given immediate postoperative status, therapeutic anticoagulation was done using low-molecular-weight heparin. The patient was discharged 10 days later. APE is a potentially high-risk event that can be challenging in the postoperative period. A high index of suspicion and therapeutic anticoagulation with meticulous monitoring is required in such cases to reduce morbidity.