Indian Journal of Anesthesia and Analgesia

Background and objective: The axillary brachial plexus block is one of the entry level blocks suitable for novices. Studies about the minimum number of blocks required to achieve competency for neuraxial and epidural anaesthesia exist but data is astray for proficiency in an ultrasound-guided axillary brachial plexus block. The objective of this study was to quantify the number of blocks required by a novice to successfully perform an ultrasound-guided axillary brachial plexus block independently. In addition we aimed to identify the obstacles faced by novice during block performance which leads to its failure or the need for an intervention by an expert.

Methods: The novice trainee was given an introductory training on sono-anatomy of the axillary brachial plexus by an experienced anaesthetist. The trainee was instructed about criteria for failure and success at each procedure along with instruction to use the in-plane technique for axillary brachial plexus block. An ultrasound guided axillary brachial plexus block by multiple injection technique was performed. Whenever the expert anaesthesiologist realised any commitment error by the novice anaesthesiologist which could compromise the patient safety and could cause actual patient harm the procedure was taken over by the expert.

Results: A total of thirty-seven blocks were performed by single novice anaesthesiologist on patients who were scheduled to undergo axillary brachial plexus blocks for orthopaedic or plastic surgery of hand, wrist or forearm. Out of the thirty-seven cases 14 cases were categorized as failure since it required intervention by a supervisor whereas 23 cases were performed by novice independently. The trainee faced number of challenge such as (1) identification of sono-anatomy of brachial plexus at axilla, identification of radial nerve was reviewed to be the most difficult out of all structures with a difficulty of 16% in radial nerve, 10% in musculocutaneous nerve and 8% in both median and ulnar nerve. Other challenges include (2) needle guidance to the nerve, (3) difficulty in drug placement.

Conclusion: Attainment of proficiency in independently performing axillary brachial plexus blocks would require a minimum of 23 supervised blocks with main obstacle being identification of sono-anatomy of axilla.

Background: Caudal epidural analgesia is one of the most popular and commonly performed regional blocks in pediatric anaesthesia. When adjuvants are added to local anaesthetic agents, quality and duration of caudal analgesia are enhanced. This study was conducted to compare analgesic effects of adjuvants clonidine and dexmedetomidine when added to bupivacaine for caudal analgesia amongst children undergoing lower abdominal surgeries.

Material and Methods: It was a hospital based randomized double blinded prospective study, conducted among children aged between 1 and 10 years with ASA grade 1 and 2 who underwent elective infra umbilical surgery. Children were allocated into group three groups group B (received 0.25% bupivacaine 1 ml/ kg), group C (received clonidine 1 mcg/kg with 0.25% bupivacaine 1 ml/kg) and group D (received dexmedetomidine 1mcg/kg with 0.25% bupivacaine 1 ml/kg)

Results: The duration of postoperative analgesia was longest in group D (13.20 hours) when compared with group C (10.47hrs) and group B (6.73 hours) and the difference was statistically significant (p<0.001). There was a significant difference between the groups in the FLACC score measured second hourly in the post operative period. FLACC score was lowest in the group D and highest in the group B (p<0.001). This was because of the improved quality of analgesia provided by adding adjuvant dexmedetomidine to local anaesthetic solution.

Conclusion: This study showed that clonidine and particularly dexmedetomidine when combined with bupivacaine significantly improved the quality and duration of caudal analgesia.

Context: Residency training, particularly in anaesthesiology, is known for its high demands and stress, potentially leading to burnout. This study aimed to assess the levels of perceived stress and burnout among anaesthesiology residents in India.

Aims: This study aimed to assess the levels of perceived stress and burnout among anaesthesiology residents in tertiary care hospitals in India.

Settings and Design:

• Study Design: cross-sectional, observational study

•Study Participants: Indian Anaesthesiology residents working in tertiary care hospitals

•Sampling Method: convenience sampling

Methods and Material: A total of 109 anaesthesiology residents participated in this study. The Perceived Stress Scale (PSS-10) was used to assess perceived stress, while burnout was measured using the Maslach Burnout Inventory (MBI), focusing on emotional exhaustion, depersonalization, and personal accomplishment. Data were analysed to examine the relationship between stress and burnout with demographic variables such as age, gender, marital status, and year of residency.

Statistical analysis used: The sample size was determined using the formula proposed by Hulley et al. (2013), with parameters such as Z_α = 1.96 (Standard normal value at α = 0.05) and Z_β = 0.8416 (Standard normal value for β = 20%). The sample sizes for different correlation values were calculated, and 103 participants were determined to be the minimum required number for the study. A final of 109 participants were considered in this study. (Hulley SB, 2013) The collected data will be coded and entered into an Excel database for analysis. Qualitative variables will be expressed as frequencies and percentages, while quantitative variables will be reported as means and standard deviations. Spearman’s rank correlation will be used to assess the relationship between perceived stress and occupational burnout, with a significance level set at p<0.05.

Results: The majority of participants (58.7%) reported moderate stress, with 40.4% experiencing high stress. Nearly 89% of residents were categorized as having high burnout. A significant positive correlation was found between perceived stress and emotional exhaustion (r = 0.627, p < 0.001) and a moderate correlation with depersonalization (r = 0.345, p < 0.001). Married residents reported higher levels of stress and emotional exhaustion than unmarried residents (p = 0.002 and p = 0.005, respectively). No significant differences were observed between genders or across years of residency in terms of stress or burnout.

Conclusions: The findings indicate that anaesthesiology residents in India experience high levels of perceived stress and burnout, with married residents being more susceptible. This highlights the need for targeted interventions, such as mental health support and wellness programs, to address stress and burnout during residency training.

Introduction: Atrial fibrillation can be disturbing to the patient, may present as palpitations, syncope. When persistent and causing Haemodynamic disturbances to be treated, either pharmacologically when stable or with Cardioversion under sedation.

Case Report: Our patient aged 50 years male presented with pain abdomen, diagnosed as cholelithiasis. He also presented with palpitations, with an irregular heart rate, giddiness; when ECG was taken it showed a Heart rate of 130 to 150 and had no p waves and irregularly irregular. (Figure 1) (to add).

ECG Showed Atrial Fibrillation and Left Ventricular hypertrophy, Chest X-ray showed increased bronchovascular markings; 2D ECHO showed Mild Concentric LVH, Trivial MR and AR, Mild TR; EF:50%,HbA1c of 9.3%. Other Investigations within normal limits.

Patient was started on Tab. Metoprolol 50mg Twice daily and Tab Rivaxa 20mg once daily for one week and heart rate came down to 70bpm.Tab Rivaxa was stopped 12 hrs before surgery.

Premedicated with Inj.Fentanyl 100mcg, Inj.Loxicard 100mg, Induced with Inj. Propofol 100mg and Intubated with Inj Suxamethonium 100mg. Maintained with O2, N2O and Isoflurane and Inj Vecuronium. Monitored with HR, NIBP, SPO2, Temperature. IV fluids RL&NS were given. Analgesia with Fentanyl, IV Paracetamol. Was uneventful. Reversed with Inj Neostigmine & Inj Glycopyrrolate and extubated. Post-operative period was uneventful.

Conclusion: We successfully managed a patient with symptomatic Atrial Fibrillation with B blockers and without cardioversion.

Background: Neostigmine methyl sulfate, a quaternary ammonium compound with anticholinesterase activity, is routinely employed for the reversal of non depolarising neuromuscular blockade. Despite its favourable safety profile, cardiovascular complications, including bradycardia, atrioventricular block, and, in rare instances, ventricular arrhythmias, have been documented.

Case description: We describe the case of a 58-year-old female with diabetes mellitus, hypertension, bronchial asthma, and post-thyroidectomy status on thyroxine, who underwent Functional Endoscopic Sinus Surgery under general anaesthesia. Neuromuscular blockade with vecuronium was reversed postoperatively using neostigmine and glycopyrrolate; however, the patient subsequently developed stable monomorphic ventricular tachycardia. Pharmacologic intervention with lidocaine and amiodarone restored sinus rhythm.

Literature review Although neostigmine is more frequently associated with bradyarrhythmias, isolated cases of ventricular tachyarrhythmias have been reported. Beta-agonist and thyroxine use may upregulate myocardial β-receptors, thereby enhancing susceptibility to cholinergic-induced arrhythmogenesis, particularly in the perioperative setting.

Clinical relevance: This case highlights the importance of anticipating arrhythmic complications in patients receiving chronically administered sympathomimetic and thyroid replacement therapies. Perioperative vigilance and readiness to manage such adverse events are essential when reversing neuromuscular blockade with anticholinesterase agents

Anaesthetic management of patients with history of coronary artery bypass grafting(CABG) and acute pulmonary embolism (PE) presents a significant challenge to the Anaesthesiologist.

This report discusses the perioperative challenges in the management of a patient with a complex medical history who required urgent diversion colostomy for subacute intestinal obstruction. The patient was a case of carcinoma rectum with a history of systemic hypertension, diabetes mellitus, dyslipidaemia, chronic deep vein thrombosis (DVT), ischaemic heart disease (IHD) post- CABG and most notably, with added acute PE in the preoperative period. The anaesthetic management was focused on minimizing perioperative risks while managing the patient’s critical conditions. A multidisciplinary approach was employed for the optimisation of the cardiorespiratory function, placement of an Inferior venacava (IVC) filter to prevent further embolic events, anticoagulation therapy, and close monitoring of coagulation parameters. The report reviews the relevant literature and discusses strategies for managing such high-risk patients.

The advent of laparoscopy as a component of enhanced recovery after surgery (ERAS) has had astronomical repercussions from an anaesthetic viewpoint and management of the patient in the perioperative period. The creation of a pneumoperitoneum alters the milieu interieur of the patient in a way that is not quite well understood. Here, we present the case of a 13-year-old female patient ailing from pain abdomen and fever under evaluation posted for diagnostic laparoscopy under ASA IE The patient developed unforeseen ECG changes of sinus tachycardia with ST Depressions and T wave inversions in II, III, and aVF immediately post-insufflation of pneumoperitoneum. Despite extensive intraoperative and postoperative work-up the event remains an enigma underscoring the unpredictable repercussions of pneumoperitoneum on the physiology and the role of anaesthesiologists in diagnosing and treating these events in seconds to avoid catastrophic outcomes.

The lysosomal storage disease mucolipidosis presents formidable challenges for the pediatric anesthetist, not only due to progressive multi-system involvement but also because of intricate airway abnormalities. A two-year-old boy with mucolipidosis type II (GNPTAB mutation) presented with history of T.B under treatment and posted for flexible bronchoscopy with bronchoalveolar lavage (BAL). This report demonstrates the complexity of perioperative airway management in such children as guided by modern difficult airway algorithms, and the pivotal role of the I-gel® supraglottic airway device as both primary and rescue tool.