Indian Journal of Anesthesia and Analgesia

 Not Provided.

  The Takotsubo cardiomyopathy is a rare hemodynamic dysfunction, only recently reported . While the diagnostic criteria have been established and the outcome is known as favourable, the pathophysiological mechanisms are not entirely understood. Here we present the case of a patient scheduled for laparoscopic hysterectomy, who postoperatively developed a Takotsubo cardiomyopathy, supposedly triggered by an acute hypertensive crisis and emotional stress.

 Keywords: Takotsubo Cardiomyopathy; Transient LeftVentricular Apical Ballooning Syndrome; Stress­Induced Cardiomyopathy And Broken Heart Syndrome.

  Cardiac output (CO) monitoring is an integral part of management of patients during cardiac surgery, supramajor surgeries with large fluid shifts and critically ill patients in the ICU. It helps in early identification of insufficient tissue oxygenation and appropriate treatment can be instituted early. Traditionally, CO monitoring is done by thermodilution technique using pulmonary artery catheter. However, it is an invasive modality and several studies criticised and linked it to the increased mortality. This has lead into the development of newer minimally invasive methods most noticeably arterial pressure waveform derived cardiac output (APCO) monitoring system. It is an exciting technology based on normal population arterial waveform algorithm without any need of external calibration and can be attached to the pre­existing arterial line. However, thermodilution is still considered as a gold standard method of cardiac output monitoring. This article intends to highlight the pro and cons of these two techniques as well as other methods of CO monitoring. 

Keywords: Cardiac Output Monitor; Thermodilution; Pulmonary Artery Catheter; Flotrac; LiDCO; Echocardiograhy

  Cancer patients are at risk for several life threatening emergencies, including metabolic, cardiologic, neurologic, and infectious events. These oncologic emergencies can occur at any time during the course of a malignancy, from the presenting symptom to end­stage disease and may require an admission into the intensive care unit (ICU) at any time. Knowledge of such emergencies is critical to the understanding of these emergent syndromes in oncology patients. Each of these disease states requires careful evaluation of the patient’s symptoms, monitoring parameters for conditions and supportive care measures and interventions. Many of these high risk situations can be prevented and managed effectively if promptly recognized and timely treated. This review addresses the more commonly encountered emergencies and possible management in cancer patients. 

Key words: Hypercalcemia; SIADH; Superior Vena Cava; Leukostasis; Tumor Lysis; Intracranial Pressure.

  Background: This study was done to evaluate the efficacy of single bolus administration of Magnesium Sulphate epidurally as an adjuvant to epidural fentanyl citrate for post­operative analgesia with consideration of duration of analgesia and hemodynamic stability after abdominal surgeries and to compare the side effects of both groups. Method: One hundred patients received standard general anaesthesia with epidural anesthesia using 10 ml of 0.5% Bupivacaine. After the surgery, patients were randomized into Group­I [Epidural Fentanyl­ ï­g/ kg in 10 ml saline] and Group­ II [Epidural Magnesium­75 mg along with Fentanyl­1 g/ kg in 10 ml saline]. Supplementary analgesia was provided by Inj. Tramadol­ 50 mg when Verbal Rating Score (VRS) was > 4. Patient’s first analgesic requirement and duration of analgesia were recorded. Results: The duration of analgesia was significantly longer in Group II (290 ± 50 min) as compared to Group­ I (160± 30 min) (P­ 0.001). The frequency of rescue analgesics required in Group­ II (2.1±0.5) was significantly less than that in Group­I (3.3±0.5) (P­ 0.001). VRS was lower in GroupII up to 4 hours postoperatively (P­ 0.001). Conclusion: he Administration of Magnesium­ 75 mg as an adjuvant to Epidural Fentanyl­ 1 g/ kg significantly lowers the Verbal Rating Score (VRS) with prolonged duration of postoperative analgesia as compared with Epidural Fentanyl (1 g/ kg) alone. Concomitant administration of Magnesium also reduces the requirement of breakthrough analgesics without any significant side effects. 

Keywords: Epidural Adjuvants; Fentanyl; Magnesium; Postoperative Analgesia.

Introduction: Clonidine, the older drug is a selective ­2 adrenergic agonist with some ­1 agonist property. In clinical studies, the addition of clonidine to local anesthetic solutions has shown produce anti­nociception and enhance the effect of local anaesthetics. Methodology: This study was conducted on 80 patients undergoing upper limb surgeries aged between 20 to 60 years under ultrasound guided axillary brachial plexus block at Medical College Hospital. Informed written consent was taken. Results: Statistical analysis of sedation score by Chi­square test showed that the difference in sedation score was significant (P <0.05) at 30 and 60 min. The difference in sedation score at 15 min is not statistically significant though few subjects in both the groups were sedated (P >0.05). Conclusion: In conclusion, when compared to clonidine (1g/kg), dexmedetomidine (1g/kg) has a superior clinical profile as adjuvant to levobupivacaine (0.5%) in axillary brachial plexus block.  

Keywords : Clonidine ; Dexmedetomidine ; Levobupivacaine.
 

 Routinely, Subarachnoid block is practiced for performing operative procedures under general surgery, orthopaedic and obstetrics and gynecology below umbilicus. 100 patients ASA grade I ­ II of either sex were divided into 2 equal groups of 50 each pout which Group I were young adults (20­40 years age) and Group II were elderly patients above 60 years age. All patients were preoperatively evaluated for fitness of anaesthesia. In group I mean age was 32.42 ± 3.44 and in group II mean age was 66.40 ± 3.91 years. After intravenous access, preloading was done with 7 ml / kg Ringer lactate solution. The mean duration of operation in group I was 77.6 ± 14.6 mints and in group II was 81.0 ± 14.6 mints, there was no statistical significant difference. Mean preoperative pulse rate in group I was 87.12 ± 7.17 per min and 84.92 ± 14.6 min in group II patients. Mean arterial pressure was 90.0 ± 5.17 in group I and 91.2 ± 5.45 in group II patients with no significant difference. The maximum height of sensory blockade was significantly higher in elderly patients as compared to adult patients. Intraoperative fluid requirement was same in both groups. Intraoperative hypotension was noted in 22% of patients in group I and 34% of patients in group II and average number of patients requiring vasopressor was 2 patients in group I and 6 patients in group II. Thus incidence of intraoperative hypotension requiring immediate correction was more in elderly group as compared to adult patients. In recovery room, highest level of sensory blockade was more in group II as compared to adult group. In recovery room after application of orthostatic challenge, the changes mean pulse rate and MAP were noted at 0, 30, 60 and 90 minutes. At all time intervals percentage rise in mean pulse rate and percent fall in MAP was more significant in elderly (group II) patients at all time intervals as compared to group I patients and it was more significant at 0 and 30 minutes and even upto 90 minutes in elderly patients. The sensory level was higher and regression was slower in elderly patients as compared to adult patients. Thus orthostatic challenge test can be safely applied in elderly patients to assess its efficacy for discharging patients from recover to wards without harm to patients. 

Keywords: Spinal Anaesthesia; Differential Spread of Blockade; Higher Sensory Block In Elderly; Delayed Regression of Block; Orthostatic Challenge; Efficacy; Criteria for Early Shifting of Patients from Recovery to Wards; Curtails Load on Recovery Room.

 Background: Post­anesthetic shivering (PAS) is distressing for patients and may induce a variety of complications. The neurotransmitter pathways involved in the mechanism of post­anesthetic shivering are complex and poorly understood. We compared the effect of ondansetron ( 5­HT3 ntagonist) and butorphanol (agonist at “Kappa”­receptors and mixed agonist antagonist at mu opioid receptors) on intraoperative core and peripheral temperatures andPAS. Methods:After approval from institutional ethics committee and written informed consent 90 patients of age 18–60 years, ASA I­II, undergoing orthopedic, general or urological surgery were randomized into three groups.In this double­blinded, placebocontrolled, study: Group A(n = 30) received ondansetron 8 mg, Group B (n = 30) received Butorphanol, 25 gm / kg and Group C (n = 30) received saline 4 ml intravenous (IV) immediately before the anesthetic induction. Heart rate (HR), mean arterial pressure (MAP), oxygen saturation (SPO2), core (nasopharynx) and fingertip temperature (dorsum of middle finger) was recorded. Balanced general anaesthesia was induced by propofol 2.5 mg/kg and intubation was done with Vecuronium 0.1mg/kg. Anaesthesia was maintained with 70% N 2O in O2 and propofol infusion. PAS was documented by persons blinded to the study and included trainees in anesthesiology who were unaware of the group assignment. Results: PAS occurred in 19 of 30 (63.3%) patients in Group C (saline), compared with 6 of 30 (20%) in ondansetron group (P = 0.002) and 7 of 30 (23.3%) in butorphanol group (P = 0.004). Within each group, core temperature decreased and peripheral temperature increased significantly, but there were no significant differences among the groups A and B at any time interval. Conclusion: We conclude that both, ondansetron (8 mg) and butorphanol (25  gm / kg) IV given during the induction of anesthesia prevents PAS equally without affecting the core­to­peripheral redistribution of heat during general anesthesia. 

Keywords: Ondansetron; Butorphanol; Post­Anesthetic Shivering; General Anesthesia; Hypothermia.

Background: Various methods have been devised to prevent hypotension, a very common complication of subarachnoid block(SAB). This study was conducted to evaluate the efficacy of combined use of crystalloid preloading and vasoconstrictor for prevention of hypotension due to SAB, when compared to crystalloid preloading. Methods: 100 adult patients of physical status ASA I and II scheduled to undergo elective surgical procedure on lower abdomen under SAB were divided into two groups of 50 each. Crystalloid group: Preloaded with Ringer’s lactate: 15 ml/KBW over 20 min before SAB. Combination group: Preloaded with 7.5 ml/KBW of Ringer’s lactate over 10 min preceding SAB, followed by IV bolus of 2.5 mg of ephedrine in the first and second minute and 0.5mg ephedrine at the end of each minute for next 18 minutes after SAB. In each patient, pulse rate and systolic blood pressure were recorded. Subsequently, the recordings were done at 5th, 10th, 15th, 20th, 25th and 30th minute after SAB. Results: The incidence and severity of hypotension was maximum (18%) in the crystalloid group and less (2%) in the combination group. The difference in incidence of hypotension among two groups was statistically significant( P<0.05). The incidence of reactive hypertension was more in combination group (4%) than the crystalloid group (2%) and was statistically significant (P<0.05). The incidence of nausea (4 %) and vomiting (2%) was seen in combination group whereas there were no incidence of the same in crystalloid group. Conclusion: combination therapy with the reduced volume of crystalloid preloading and reduced dose of vasoconstrictor is an effective preventive measure against hypotension due to SAB and provides better haemodynamic stability when compared to the use of preloading alone. 

Keywords: Subarachnoid Block; Hypotension; Crystalloid Preloading; Vasoconstrictor; Ephedrine.

 The object of this study was to evaluate the effect ofgauze and type of spinal needle in causing post dural puncture headache (PDPH) in parturient undergoing LSCS. Seventy five parturient ASA grade I and grade II , age 20­35year with singleton uncomplicated pregnancy, who were randomized into three group I, II, and III received spinal anaesthesia using 25G quincke, 27G quincke and 25G whitacre needle respectively. Patients were interviewed on first, second, third and fourthday , after surgery, and were questioned with regard to incidence of headache, its severity, location, character, duration and associated symptoms like nausea, vomiting, auditory, ocular symptoms, and backache.The observations were analyzed by chi square and student t test. Statistical significance was assumed when p was <0.05. Incidence of PDPH was 20% in group I, 12% in group II and 4% in group III, which was not statistically significant. Among patients who developed headache, majority of patient had mild generalized headache. Most of patients develop PDPH on first postoperative day. Although the incidence of headache was statically similar among three groups, but clinically the headache was lesser in patients who received subarachnoid block with 25G whitacre spinal needle is compared to 25G quincke and 27G quincke spinal needle. 25G whitacre spinal needle is appropriate to minimize post dural puncture headache in cases of caesarean section. 

Keyword: PDPH; Spinal Anaesthesia; LSCS.

 Hypotension produced by the sympathetic blockade associated with spinal anesthesia has maternal and foetal adverse effects. Intravenous fluid expansion and vasopressors are used to prevent this hypotension. In this study we compared the effect of a combination of crystalloid co­load of lactated Ringer’s solution and a prophylactic phenylephrine infusion versus crystalloid coload alone in preventing predelivery hypotension in the mother following subarachnoid block for lower segment caesarean section. 100 ASA I or II term parturients posted for caesarean delivery were enrolled. They were randomly divided in to two groups: Group 1) a co­load of lactated Ringer’s solution at a volume of 15ml/kg body weight given over 10 minutes and a prophylactic phenylephrine infusion at rate of 50mcg/min. Group 2) a co­load of lactated Ringer’s solution at a volume of 15ml/kg body weight given over 10 minutes alone. Subarachanoid block was performed with 2 ml hyperbaric 0.5% bupivacaine (10 mg) at L3­4 interspace. Immediately after the injection of the intrathecal medication, the coload with or without infusion of phenylephrine was started depending on the group allocated. NIBP, heart rate and SpO2 were recorded every 1 minute until delivery, and thereafter every 3 minutes until the end of study. The incidence of pre­delivery hypotension was 2 % and 68 % respectively in group 1 and group 2. The lower incidence of pre­delivery hypotension in the group 1 was found to be statistically significant with a p value less than 0.01. The side effect profile of the two regimens was also comparable. In conclusion we found that prophylactic phenylephrine infusion at rate of 50mcg/min with a co­load of lactated Ringer’s solution at a volume of 15ml/kg body over 10 minutes significantly lowered predelivery hypotension in the mother. 

Keywords: Ringer Lactate Co­Load; Phenyephrine Infusion; Sub­Arachnoid Block; Hypotension.

 Background: Total Intravenous Anaesthesia using various drug combinations to produce adequate sedation and analgesia with rapid recovery for short surgical procedures is known for more than two decades. AIM: To compare the haemodynamic responses intra operatively and time to recovery in patients receiving Propofol­Ketamine and Propofol­Fentanyl in short surgical procedures. Design: Randomised controlled study. Material and Method: The study included 100 patients randomly selected into 2 Groups of 50 each. Group 1: received Propofol 1.5mg/kg and Ketamine 1mg/kg (PK group) Group 2: received Propofol 1.5mg/kg and Fentanyl 1 mcg/kg (PF group). Statistical Analysis: Using Chi­Square Test, Student ttest (paired and unpaired). Results and Coclusion: From the present study we concluded that both Propofol­Ketmine and Propofol­Fentanyl are equally safe and effective in Total Intra Venous Anaesthesia for patients undergoing short surgical procedures. Propofol­Ketamine combination has better haemodynamic stability than Propofol­Fentanyl combination. 

Keywords: Not Provided

 Background: Neuroedocrine stress response(NESR) to surgery is manifested by increase in circulating catabolic hormones (cortisol) leading to protein catabolism. This can be modified by providing adequate postoperative analgesia in children in the form of caudal block using ropivacaine and non opioid adjuvants like clonidine.There is paucity of literature comparing effects of 3µg/kg and 1.5µg/kg of clonidine with 0.2% ropivacaine in terms of neuroendocrine stress response to surgery in caudal block. Methods: 45 children aged 1­ 8 years, after premedication with oral midazolam and induction of anesthesia, caudal block was performed. Children were randomly allocated into 3 groups. Blood samples were obtained just after induction of anesthesia, 30 minutes after the start of surgery and 60 minutes after the end of surgery for measurement of serum levels of glucose and cortisol. Results: Mean blood glucose were within normal range and there was no statistically significant difference between the groups. There was a significant rise in serum cortisol levels from baseline values (T0) in group R in the post operative period. There was statistically significant fall from baseline levels in cortisol values postoperatively in the clonidine 1.5 µg/kg group(RC1.5) and clonidine 3µg/kg group (RC3) and this fall in cortisol values was greater in the clonidine 3µg/kg group when compared to the clonidine 1.5 µg/kg group. Conclusions: There was blunting of NESR to surgery when clonidine was used as adjuvant to ropivacaine in caudal block and this was maximum with clonidine dosage of 3µg/kg. 

Keywords: Neuroendocrine Stress Response; Clonidine; Ropivacaine; Caudal Block.

 Background: Fat embolism syndrome (FES) is a potentially lethal condition most commonly seen in polytrauma patients with multiple long­bone fractures. Treatment has centered on supportive care and early fracture fixation. Several small clinical trials have suggested corticosteroids benefit patients with FES, but this treatment remains controversial. Our objective was to determine the effect of corticosteroids on hemodynamic changes with respect to FES in patients with long­bone fractures. Methods: Forty four adults, who had sustained a tibia fracture, or a femoral fracture, were subjected to a double­blind randomized study to determine the effect of intra venous methylprednisolone in comparison with placebo on hemodynamic changes with respect to the development of the fat embolism syndrome. A Lindeque2 s criterion for the diagnosis of the fat embolism syndrome was used. Results: Post operatively there was significant decrease in the heart rate in methylprednisolone group of patients compared with placebo group. Other parameters like systolic blood pressure (SBP), diastolic blood pressure (DBP) did not show any significant results. Conclusion: Prophylactic corticosteroids can be used to prevent changes in vital parameters/ hemodynamic and to manage development of fat embolism syndrome. 

Keywords: Fat embolism syndrome; Hemodynamics; Polytrauma .

 Background: The antiemetic efficacy of metoclopramide and midazolam was shown before. The aim of the present study was to compare the efficacy and safety using intravenous metoclopramide and intrathecal midazolam for the prevention of nausea­vomiting in parturient undergoing cesarean section under spinal anesthesia. Methods: This prospective and randomized double blind study was conducted in 100 parturient aged between 21 and 30 years, ASA physical status É, scheduled to undergo elective cesarean section under spinal anesthesia. Parturient presenting for cesarean section with standardized 0.5% hyperbaric bupivacaine 2 ml spinal anesthesia were randomized to intravenous metoclopramide 10 mg (group I) or intrathecal midazolam 2mg ( group II). The incidence of nausea­vomiting and any other adverse effect were recorded during intraoperative and early postoperative period and compared between two groups by using chi­square test. Results: The incidence of nauseavomiting was 36% with intravenous metoclopramide and 10% with intrathecal midazolam. No clinically adverse events caused by study agents were observed in either group. Conclusion: Intrathecal midazolam 2mg significantly reduces the incidence of nausea­vomiting when administered with 0.5% hyperbaric bupivacaine for cesarean section under spinal anesthesia.

Keywords: Nausea; Vomiting; Cesarean Section; Spinal Anesthesia; Metoclopramide; Intrathecal Midazolam.

 Introduction: We designed a double blind randomized controlled trial to comparatively evaluate the efficacy of bupivacaine with two different doses of clonidine for pediatric caudal analgesia in infra umbilical surgeries. Methodology: 90 children, 2­10 years of age, weight < 20 kg of either sex, belonging to ASA grade I and scheduled for infra umbilical surgeries were taken up for the study. Patients were divided randomly into three groups of 30 each using the computer generated technique­ Group 1­ 0.75 ml/ kg of 0.25% bupivacaine and 1µg/ kg of clonidine; Group 2 ­ 0.75 ml/kg of 0.25% bupivacaine and 2µg/ kg of clonidine. Group 3: 0.75 ml/ kg of 0.25% bupivacaine. 0.75 ml/ kg of the study drug solution was injected after administration of anaesthesia. Post operative monitoring for heart rate, blood pressure, respiratory rate, SpO2; Post operative analgesia­ using Modified Objective Pain Score. Post operative sedation score using the Four Point Sedation Score was done at the interval of 0, ½, 1, 2,4,8,12,24 hours. results: Efficacy of Post operative analgesia assessed by MOPS score was found to be better in group 2 followed by group 1 and least in group 3. Also, post operative sedation score was highest in Group 2 as compared to group 1 & 3. Conclusion: We recommend a dose of 1µg/kg clonidine as an adjuvant to 0.25% bupivacaine (0.75ml/kg) for infra­umbilical surgeries to significantly prolong post­operative analgesia without causing significant sedation. Increasing the dose of clonidine to 2µg/kg didn’t significantly prolong postoperative analgesia but did produce significant sedation, which might interfere with discharge criteria for day care surgery. 

Keywords: Pediatric Caudal Analgesia; Infra Umbilical Surgeries; Clonidine; Bupivacaine.

  Dexmedetomidine is a highly selective á 2adrenoreceptor agonist recently introduced to anesthesia. It produces dose dependent sedation, anxiolysis and analgesia without respiratory depression. Methods: This prospective randomized doubleblind study was carried out on 100 patients, aged 20 to 70 years with American society of Anesthesiology (ASA) class I and II of either gender, for lower limb surgery, who met the inclusion criteria of spinal anesthesia. The randomly selected patients received Bupivacaine 0.5% 15 mg (3ml) + 0.5 ml of normal saline in group BS (n=50) and Bupivacaine 0.5% 15 mg (3ml) +Dexmedetomidine 10 mcg in 0.5ml NS in group BD(n=50). The onset time to reach sensory and motor level, the regression time of sensory and motor block, requirement of first rescue analgesic, hemodynamic changes and side­effects if any were recorded. Result: The onset time to reach T10 dermatome and modified bromage 3 motor blocks were not significantly different between the groups. Time to achieve sensory regression to L1 in Group BD (284.4±62.84 min) were prolonged as compare to Group BS (149.3±24.91min) (p=0.00). The regression time of motor block to reach modified bromage 0 was (379.5±75.42 min) and (231.6 ±44.55 min) in group BD and BS respectively (p=0.004). The first rescue analgesic was required at 200.90 ± 40.33 min and 327.60 ± 60.05 min in group BS and group BD respectively, were comparable (p=0.104). Conclusion: Intrathecal Dexmedetomidine as an adjuvant to intrathecal Bupivacaine prolong sensory and motor block with minimal side effects. So it is an attractive alternative choice for long duration surgery.

Keywords: Bupivacaine; Dexmedetomidine; Lower Limb Surgery; Spinal Anesthesia.

 The study design was a prospective, randomized, double blind. Ninety patients of either sex, ASA I and II were randomly divided into three groups according to the medium used for inflation of endotracheal tube cuff. The study was conducted to correlate the changes in intra­cuff pressure and post­operative incidence of tracheal morbidity in form of hoarseness, sore throat and dysphagia. We observed close relationship between rise in intracuff pressure and incidence of tracheal morbidity. The present study concluded that incidence of postoperative sore throat, hoarseness & dysphagia was significantly less (p 0.05) when Normal Saline & Lignocaine were used as medium for an endotracheal tube cuff inflation as compared to air.

Keywords: Lignocaine 2%; Endotracheal Tube (ETT) Cuff Inflating Medium; Intracuff Pressure of Endotracheal Tube; Post Intubation Tracheal Morbidity.

 Not Provided.