Indian Journal of Anesthesia and Analgesia

 Modified Radical Mastectomy, the surgical procedure for carcinoma of breast is routinely performed under general anaesthesia. Patient with lung metastasis and low serum albumin are at increased risk of perioperative morbidity and mortality. We report a case of carcinoma of breast with lung metastasis, right axillary vein thrombosis and low serum albumin (1.7 gm% with A/G ratio 0.61) managed successfully under sole thoracic epidural anaesthesia.

Keywords: Thoracic Epidural Anaesthesia; Modified Radical Mastectomy; Low Serum Albumin; DVT.

 Bilateral pleural effusion occurred after total parenteral nutrition was administered via a right subclavian venous line. The most likely explanation for the fluid passage into both pleural cavities was migration of the tip of the catheter from within the vein into the mediastinum. Fluid can pass into both pleural cavities via anatomical communications, yet to be described, which exist between the two pleural cavities1 Central venous catheterization can cause various complications, which are on the whole simple to explain with our current knowledge of anatomy. This case report, however, describes a complication occurring after subclavian venous catheterization, which is difficult to explain with our current knowledge of anatomy. Reports of ipsilateral pleural effusion following misplacement of a central venous catheter are not unusual. However, communications between the two pleural cavities are not known. A similar case of bilateral pleural effusion following a left internal jugular venous cannulation has been reported [1]. A second case of bilateral pleural effusions following an attempted right subclavian venous cannulation has also been reported [2]. No explanation was provided for the complication in either paper.

Keywords: Pleural Effusion; Subclavian Vein; Total Parentral Nutrition.

 Aims and Objectives: The present study was conducted to know the efficacy of dexmedetomedine infusion on perioperative hemodynamics and reduction in anesthetic requirement during general anesthesia in spine surgeries. Materials and Methods: After obtaining institutional ethical committee approval, the study was undertaken at Mahadevappa Rampure Medical College, Gulbarga. After obtaining informed written consent, 60 patients of ASA grade 1 & 2 were randomly allocated into two groups of 30 patients each,as Group C and Group D. The age group was 20­60 years of either sex undergoing elective spine surgery under GA. In group D, patients received dexmedetomidine as 1µg/kg over 10min before induction of anesthesia and maintained with 0.5­0.7µg /kg/hr infusion during anesthesia, and group C was taken as control. Hemodynamic changes and anesthetic requirement were recorded perioperatively. Results: Dexmedetomedine causes significant reduction in heart rate and mean arterial pressure, blunted tachycardia and hypertensive response to intubation and extubation (p<0.05), maintained better hemodynamic intraopertively. Also it reduced the requirement of fentanyl(50%), and inhalational agent isoflurane (29­33%) during general anesthesia. Conclusion: Dexmedetomedine reduces the requirement of opioids and inhalational agent during general anesthesia and provide stable hemodynamics intraoperatively.

Keywords:Dexmedetomedine; Fentanyl; General Anesthesia; Isoflurane.

 Background: Pain relief with minimal side effect in post operative surgical patients is essential for early mobility and recovery. Objective: This study was conducted to find out whether preoperatively oral pregabalin used as an adjunct in spinal anaesthesia has any effect in the prolongation of duration of dose of first rescue analgesic requirements, effect on anxiety, sedation scores and patient satisfaction level in the post operative period. Patients and Methods: This is a randomized double blind placebo controlled study conducted in 60 ASA 1&2 patients undergoing lower limb orthopaedic surgery under spinal anaesthesia. The patients are divided randomly into two groups. Group ­1 patients the control group where placebo drug is given one hour prior to surgery as an adjunct in spinal anaesthesia and Group­2 patients 75mg oral pregabalin is given similarly. VAS Scale was used for anxiety score and Ramsay Sedation Scale was used for sedation score, patient satisfaction level, duration of dose of first rescue analgesic requirements were measured. Results: Demographically there was no significant difference between both the groups. Comparison of time of first rescue analgesia there was statistically significant difference between Group­1 and Group­2 patients(p value >0.95) Sedation scores and anxiety scores are just significant between both the groups. No significant difference was found in the haemodynamic parameters between the groups.Patient satisfaction was better in the treated group as compared to the control group. Conclusion: From this study we concluded that oral pregabalin reduced the anxiety level and also prolonged the time period for the need of first dose of rescue analgesia. No side­effects of Pregabalin were noted and patient’s satisfaction was better in the treated group thanin the control group.

Keywords: Postoperative Pain; Calcium Channel Modulators; Spinal Anaesthesia; Rescue Analgesia; Sedation; Anxiety.

 Introduction: Ketamine a phencyclidine derivative with potent analgesic properties possesses few advantages over the other local anesthetics as it tends to stimulate the cardiovascular system and maintains the respiratory response to carbon dioxide. Methodology: On the eve of the surgery, all the patients were visited and a detailed examination including history, clinical examination, systemic examination of cardiovascular, respiratory and central nervous system and examination of spine for deformity, infection was carried out. Results: In the present study, the time taken to achieve maximum sensory blockade ranged from 2­8 minutes. In majority of the males (43 patients) it ranged from 4­6, while in females (26 patients) it ranged from 5.1­7 minutes. Conclusion: In the present study, the quality of motor blockade assessed by the Bromage scale was grade­III in all the patients.

Keywords: Ketamine; Spianal anaesthesia; Efficacy

 Introduction: Intrathecally administered ketamine is advantageous as its beneficial effects on the cardiovascular system and respiratory functions may be combined with the analgesic effects of spinal anesthesia. The primary mechanism of action of the spinal anesthetic ketamine is noncompetitive blocking of the NMDA ionophore. Methodology: 100 Patients were monitored continuously using sphygmo­manometer, pulse oximeter and electrocardiogram. After spinal anesthesia the patients pulse rate and blood pressure were recorded at 0, 5, 10, 20, 30, 45, 60, 90 and 120 minutes. Results: The most common complication was nystagmus, which was present in all males and females, followed by sedation, which occurred in 45 males and 25 females. Only 4 patients had delirium reaction. Conclusion: Intrathecal ketamine with adrenaline produces a reliable anesthesia, better operative conditions and patients comfort with minimal side effects.

Keywords: Ketamine; Complications; Blood Pressure.

 Background: The modified Mallampati (MMP) classification is a standard method of oropharyngeal evaluation for predicting difficult laryngoscopy. Previous studies have demonstrated that the predictive value of the MMP is improved when thepatient’s craniocervical junction is extended rather than neutral (Extended Mallampati Score, EMS). In the present study, we compared the predictive value of the MMP, EMS and thyromental score in the obese. Methods: We performed a prospective study of adult patients with a Body Mass Index (BMI) 40 comparing the MMP and EMS. The performance of the MMP, EMS, and thyromental distance was compared forthe ability to predict difficult laryngoscopy, defined as a Cormack­Lehane grade of 3 or 4. Positioning and direct laryngoscopic techniques were not standardized. Results: Hundred patients with a BMI >35 were evaluated withboth the MMP and EMS and received direct laryngoscopy. On average, craniocervical extension decreased the MMP class. Compared to the MMP, the EMS improved specificity and predictive value while maintaining sensitivity. Compared to the MMP and thyromental distance, an EMS thyromental distance, an EMS class of 3 or 4 were statistically significant predictors of difficultlaryngoscopy in the obese. There was no difference in the incidence ofdifficult laryngoscopy or intubation in the obese compared to patientswith a BMI >35. Conclusions: The EMS was Superior to the MMP in the Prediction of Difficult; Laryngoscopy in the Obese Population.

Keywords: Modified Mallampathi; Extended Mallampathi; Thyromental Distance; Cormac Lehane Grading; Obesity

 Introduction: The haemodynamic effects of alpha­2 adrenergic agonists are both central and peripheral. Stimulation of the peripheral subendothelial receptor causes vasoconstriction & the action is however transient. Methodology: Group LC: (N=40) received 25ml of 0.5 % of Levobupivacaine + 1 µg/ kg of Clonidine. [Total volume of drug­ 30 ml by adding sterile water for injection] Group LD: (N=40) received 25ml of 0.5% of Levobupivacaine + 1µg/ kg of Dexmedetomidine [Total volume of drug­ 30 ml by adding sterile water for injection. Results: In group LC, the mean SBP ranged from 117.15 ± 5.10 to 118.25 ± 6.93 mm of Hg, where as in group LD, the mean SBP ranged from 117.55 ± 5.44 to 119.10 ± 5.08 mm of Hg. Conclusion: No significant difference in haemodynamic variables i.e., pulse rate, SBP, DBP and oxygen saturation were found.

Keywords: Clonidine; Dexmedetomidine; Pulse Rate; Blood Pressure.

 Background: Post operative nausea and vomiting following laparoscopic cholecystectomy is a common complication. This study was designed to analyze and compare efficacy and adverse effect of ramosetron and granisetron in prevention of post operative nausea and vomiting following laparoscopic cholecystectomy. Method: 100 patients of American Society of Anesthesiologists class I­II, aged 25 to 55 years scheduled for laproscopic cholecystectomy were included in study. Patients with history of smoking, drug or alcohol abuse, known allergy to granisetron or ramosetron, impaired kidney or liver function, motion sickness and history of previous post­operative nausea and vomiting, or those who received antiemetics within 24 hours before scheduled surgery, menstruating, pregnant or lactating women, or those on whom laparoscopic cholecystectomy was converted into open cholecystectomy were excluded from the study. 100 patients were divided into 2 groups of group A and Group B of 50 patients each. Group A patients received 2 mg of granisetron diluted to make 4ml in normal saline and group B patients received 0.3 mg of ramosetron diluted to make 4ml in normal saline given at the end of surgery Results: No significant statistical difference seen immediately after extubation and 0 to 6 hrs and 6 to 12 hrs. but statistically significant result was observed 12 to 18 and 18 to 24 after surgery. Conclusion: Ramosetron provides prolonged relief from post operative nausea vomiting as compared to granisetron in laproscopic cholecystectomy .

Keywords: Granisetron; Ramosetron; Laproscopic Cholecystectomy; Nausea Vomiting

 Background & Objectives: Supraclavicular brachial plexus blocks have been performed effectively using local anaesthetic agents alone for upper limb surgeries. The Primary objective of this study is to determine whether the addition of fentanyl to a supraclavicular brachial plexus block improves the success rate, block time, duration and quality of postoperative analgesia. Secondary objective is can fentanyl be recommended as a safe adjuvant to local anaesthetic agents for peripheral blocks. Design & Methods: The study was conducted on ASA I­III patients who were randomly divided into Group I (Control) and Group II (Study). Patients in the control group received 20 ml 0.5% bupivacaine, 10 ml 2% lidocaine and 2 ml normal saline. The study group received 20 ml 0.5% bupivacaine, 10 ml 2% lidocaine and 2 ml fentanyl (100 g). Onset times for sensory and motor block were recorded. Post­operatively patients were followed over a 24 h period at 2hr interval for any breakthrough pain, and the intensity of pain was determined using Verbal Rating Score (VRS) system. Results: Fifty patients were studied with 25 in each group. The overall mean Verbal Rating Score for immediate postoperative pain in the fentanyl group was 2.6 compared to that of the control group which was 3.8 (p<0.001). 24 h post­operatively at 2hr intervals, the VRS ranged between 1 and 8; the mean VRS in control group was 5.7 while it was 3.8 in the study group (p<0.001). There was also a significant reduction in the incidence of breakthrough pain in the fentanyl group (p<0.0001) at the end of 24 hrs. Conclusions: The study found that the addition of 100 g fentanyl in supraclavicular brachial plexus block prolongs the duration of analgesia without any side effects. Fentanyl may be used as a safe adjuvant for supraclavicular brachial plexus blocks to improve the quality of analgesia.

Keywords: Fentanyl; Brachial Block; Ultrasound.

 Introduction: Epidural anaesthesia/analgesia with adjuvant is the preferred method for intra and postoperative pain relief in lower abdominal and lower limb surgeries but search for ideal adjuvant without any side effect goes on. Alpha (2 ) adrenergic agonists have both analgesic and sedative properties when used as an adjuvant in regional anesthesia. Aim: It is a comparative study of post operative analgesia with epidural Clonidine and epidural normal saline in patients undergoing lower abdominal and lower limb surgeries using combined spinal epidural technique. Materials and Methods: The present study was undertaken during the period of May 2015 to October 2016. 100 patients posted for elective major lower abdominal and lower limb surgeries were selected and allocated randomly into two groups. Each group has 50 patients. Group 1:­Patients received intrathecal 0.5% Hyperbaric Bupivacaine + epidural Clonidine 1µg/kg or 50µg whichever is lower, diluted to 10ml with normal saline. Group 2:­ Patients received intrathecal 0.5% Hyperbaric Bupivacaine + epidural 10ml normal saline. Quality of analgesia, duration of analgesia and duration of motor blockade between the two groups were compared. Patient vitals like pulse rate, blood pressure, respiratory rate, SPO2 and ECG were monitored during the study. During the study patients were observed for the side effects like nausea, vomiting, hypotension, bradycardia and dryness of mouth. Results: In present study majority of patients were in the age group between 31­50 yrs in both the groups and most of them weigh between 61­70 kgs. Total abdominal hysterectomy cases were majority cases observed in both groups. Quality of analgesia is excellent in both the groups and none of the patients complained of severe pain. Mild pain was observed in most of the cases in both the groups. The average time taken for 2 segment regression is more in Clonidine group compared to control group. The total duration of analgesia is more in Clonidine group compared to control group. The time taken for 1st movement i.e. beginning of motor recovery is more in Clonidine group compared to control group. Mean pulse rate, systolic BP and diastolic BP changes are statistically significant in Group 1. Complications observed in Group 1 were nausea & vomiting in 7 patients, hypotension in 7 patients, bradycardia in 1 patient, sedation in 1 patient, dry mouth in 2 patients. Hypoxia and bleeding were not reported. Conclusion: Quality of analgesia is excellent in patients receiving Clonidine when compared to placebo group. Total duration of analgesia and motor blockade is significantly prolonged in Clonidine group compared to placebo group. Minimal side effects like mild hypotension, mild sedation and dryness of mouth were seen in Clonidine group which does not require any active intervention.

Keywords: Epidural Analgesia; Bupivacaine; Clonidine.

 Context: The anxiety related to venepuncture can result in a hemodynamic stress response leading to increase in heart rate and blood pressure of the patient. Aims: To evaluate the efficacy of eutectic mixture of local anesthetic (EMLA) cream in attenuating the hemodynamic response to venous cannulation. Settings and Design: 200 patients undergoing elective operative procedures belonging to ASA grade I and II aged 18­60 years were selected and were divided into two groups. Methods and Material: EMLA cream was applied for 60 minutes in 100 group I patients with an occlusive dressing and in remaining 100 group II patients, normal saline was applied before cannulation. Heart rate and blood pressure was recorded prior and during cannulation. Statistical Analysis Used: Data analysis was done by Z­test. Results: There was no significant difference in heart rate, systolic blood pressure, diastolic blood pressure among group­I and group­II before cannulation. There was statistically significant difference in heart rate among group­I and group­II during cannulation (z=5.05, p<0.01). There is significant difference in systolic blood pressure among group­I and group­II during cannulation (z=5.28, p<0.01). Significant difference of diastolic blood pressure among group­I and group­II patients was noticed during cannulation (z=2.65, p<0.01). Conclusions: The hemodynamic stress response to venous cannulation was significantly low in patients with EMLA cream when compared to the control group. The effective time of application of EMLA cream in producing adequate analgesia to venous cannulation was found to be 60 minutes. No significant local side effects of EMLA cream were seen.

Keywords: Eutectic Mixture of Local Anaesthetic Cream; Hemodynamic Response; Venepuncture

 Purpose: Subarachnoid (spinal) block is a safe and effective alternative to general anesthesia when the surgical site is located on the lower extremities, perineum (eg, surgery on the genitalia or anus), or lower body wall (eg, inguinal herniorrhaphy).  In no other way, can an anaesthesiologist obtain so much of an effect for the introduction of a small quantity of the drug. Likewise a properly chosen adjuvant to local anaesthetic agent produces the best way to achieve a good quality regional block. Aim of Study: To compare the effect of intrathecal Clonidine 75 micrograms (µg) and Buprenorphine 150 µg with 2.5ml (12.5mg) of intrathecal 0.5% hyperbaric Bupivacaine. With regards to: 1) Sensory characteristics, 2) Motor characteristics, 3) Hemodynamic stability and 4) Side effects. Methodology: A prospective randomized experimental study were performed on 50 patients posted for lower abdominal surgery belonging to ASA I and aged between18­60 years after obtaining an informed consent and ethical clearance. Result: Addition of 150 µg Buprenorphine significantly enhances the onset of sensory block (90±15 secs) and motor block (150±15 secs) than compared to Clonidine onset of sensory block(150±20 secs) and motor block(210±20 secs) (p<0.05). Hemodynamic was well maintained with buprenorphine group. And addition of Buprenorphine 150µg to intrathecal Bupivacaine(0.5%) produces prolonged analgesia (526±96) than compared to the Clonidine group of 362±36mins (p<0.05) with no serious adverse effect noted perioperatively in either groups. Conclusion: The addition of Buprenorphine to intrathecal Bupivacaine (0.5%) prolongs the duration of post operative analgesia than compare to clonidine. Buprenorphine has faster onset of sensory and motor blockade than compare to clonidine.

Keywords: Clonidine; Buprenorphine; Hyperbaric; Lower Abdominal Surgery Analgesia; Bromage Scale [1].

 Background: Ultrasound guided oblique subcostal transversus abdominis plane block is associated with a wider area of spread (T7­L1). The aim of this study was to assess the efficacy of adding fentanyl to 0.25%bupivacaine in bilateral oblique subcostal transversus abdominis plane block preemptively in patients undergoing laproscopic cystectomy. Method: 100 patients posted for laproscopic ovarian cystectomy were randomly allocated in two equal groups. Group BF received preoperatively 20 ml of 0.25%bupivacaine and 1 mcg fentanyl(1ml) on each side oblique subcostal block and group B received 20 ml bupivacaine with 1ml normal saline. We assessed opioid requirement, the time of first demand of rescue analgesia and twenty four hour morphine requirement. Results: There is a statistically significant difference in the intraoperative fentanyl requirement between the two groups. Group BF required 16.4016.26mcg of intraoperative fentanyl while Group B required 59.8019.05mcg fentanyl (p<0.001). There is a significant difference in the mean VAS score in the two groups. The time of first demand of rescue analgesia was earlier in Group B; 5.961.09hrs compared to 11.182.28 hrs in Group BF (p<0.001). The total 24 hour morphine requirement in Group BF was significantly lower 0.581.01mg compared to Group B i.e. 4.621.63mg (p<0.001). Conclusion: 1mcg/kg fentanyl used as a supplement in bilateral TAP block reduced the need for systemic opioid intra and post operatively and prolonged analgesia in laproscopic ovarian cystectomy patients.

Keywords: Fentanyl; Bupivacaine; Ultrasound Guided Transversus Abdominis Plane Block; Laproscopic Surgeries.

 Context: Endo­tracheal intubation following laryngoscopy may cause sympathetic stimulation by releasing catecholamines and may result in complications like hypertension, tachycardia, cardiac arrhythmias, cerebrovascular accidents, which can be detrimental to the patient’s life. Many drugs and techniques are being tried to reduce the stressor responses to intubation over years, and Dexmedetomidine and esmolol are the newer drugs. Aims: This study was aimed at comparing dexmedetomidine versus esmolol in attenuating hemodynamic responses during and immediately after tracheal intubation. Settings and Design: This study was a randomised prospective double­blind controlled study. Subjects and Methods: Ninety patients posted for surgery under general anesthesia were divided into three groups, D and E and C with thirty patients in each group. Group­D patients received the first study drug dexmedetomidine 0.5 µg/kg, Group­E patients received the second study drug esmolol 1 mg/kg and Group­C patients received 0.9% 20ml saline as intravenous over 5 minutes before anaesthesia induction. The subject’s Systolic blood pressure, diastolic and mean arterial blood pressures with heart rate were measured at 1st, 3rd 5th, 7th, 10th minute post­ intubation. Statistical Analysis: The statistical methods employed were descriptive and inferential methods for the analysis of the obtained data. Results: A statistically significant differences were seen in the period between endotracheal intubation and at 3 minute post intubation in Group D. The heart rate, systolic, diastolic pressure and mean arterial pressures showed statistically significantly lesser increase in dexmedetomidine group (P<0.05) than compared to other two groups at immediate post intubation and till 3minutes thereafter. Conclusions: Dexmedetomidine is more efficient than esmolol in reducing the stressor responses to tracheal intubation and immediately (< 3minutes) thereafter.

Keywords:Dexmedetomidine; Esmolol; Hemodynamics; Intubation; Laryngoscopy.

 Background: 0.5% Bupivacaine used in subarachnoid block provides about 3 hours of analgesia. Opioids morphine and Fentanyl are used as adjuvant to produce extended postoperative analgesia. Nalbuphine is an agonist antagonist and does not require a narcotic license, which is a must for procuring other opiods. This study was carried out to evaluate the efficacy of Nalbuphine versus Fentanyl as intrathecal adjuvant. Material and Methods: Hundred ASA 1­3 patients posted for elective Total Abdominal Hysterectomy were included in this study and were randomly divided into two groups of fifty each. Group FB received 15mg of 0.5% Bupivacaine and 25 mcg of Fentanyl. Group NB received 15mg 0.5% Bupivacaine and 1mg Nalbuphine. Results: The onset of sensory blockade, time to attain peak sensory block and complete motor block was significantly faster in Group FB(p<0.001). The duration of motor block was comparable in both the groups. The time for sensory block to regress by two segments was significantly longer in Group NB, 97.72±9.50 minutes, than in Group FB, 88.88±9.48 minutes. The time to first analgesic requirement in Group NB was 460.78±77.98 minutes compared to 283.44±78.97 minutes in Group FB(p<0.001). No statistical difference was seen in terms of adverse effects. Conclusion: Time for sensory level to regress by two segments and the post operative analgesia time is longer with Nalbuphine. So, Nalbuphine is a good adjuvant in spinal anaesthesia especially in centres without narcotics license.

Keywords: Nalbuphine; Intrathecal Adjuvant; Fentanyl; Bupivacaine; Analgesia.

 Background: Hypotension is one of the common complications in patients undergoing surgeries under spinal anesthesia. This phenomenon is comparatively more in pregnant women undergoing caesarean section under spinal anesthesia due to anatomical variations in the spinal cord and physiological changes in pregnant women. Maternal position may influence the spread of the local anaesthetic drug. So, in this study we have aimed to compare incidence of hypotension and various other parameters like onset of sensory and motor blockade, total number of mephentermine incremental doses (5mg/dose) required in each group to correct hypotension after induction of spinal anesthesia in sitting and lateral position for caesarean sections. Methods: Seventy American Society of Anesthesiologists physical status I and II patients undergoing elective caesarean section were randomnly divided into two groups by closed envelope technique to receive spinal anaesthesia in the lateral position (Group L) or the sitting position (Group S). In Lumbar (L3­ 4) interspace, lumbar puncture was done after taking aseptic precautions, plain bupivacaine 0.5% heavy 10 or 12 mg according to the height was injected after confirming free flow of cerebrospinal fluid. After this, they were placed in the supine position immediately with right wedge providing for left lateral uterine displacement to avoid supine hypotension syndrome. Maternal blood pressure was measured every minute for 5 minutes, every two min for 10 min and 5­ minutely thereafter. Hypotension was defined as a fall in systolic blood pressure >20% of the baseline value or a value <90 mmHg. Results: Statistical studies showed that number of patients who received spinal anesthesia in lateral position had significantly more incidences of hypotension (19 incidences) compared to those who received in sitting position ( 10 incidences) with P value being (P= 0.048). And also there was faster onset (average time) of action (sensory and motor) in Group L (5 minutes for sensory and 6.2 minutes for motor) than compared to Group S ( 7 minutes for sensory and 7.4 minutes for motor) but not statistically significant ( P= 0.361 for sensory and 0.639 for motor). We also observed that, total number of incremental doses (5mg/dose) of mephentermine used were more in patients who received spinal anaesthesia in lateral position (n= 10 increments) than compared to those who received in sitting position( n=5 increments) but it was not statistically significant (P=0.145). Conclusion: Spinal anesthesia given in lateral position of the patients for caesarean section causes significantly more incidences of hypotension than that given in sitting position. And there were no significant differences with respect to onset of sensory and motor block and mephentermine requirement between the groups.

 Introduction: This question is asked invariably just like being asked during CPR’s correct method and right timing of practicing hand hygiene to avoid a loss of life to hospital acquired infection (HAI). Are we doing enough? Are we reminding others enough? Aim: This study is done to assess the level of knowledge; attitudes and practices among health care worker in ICU with regard to hand hygiene and to suggest documented and globally accepted recommendation for betterment in present practices and to improve compliance. Methodology: 100 nurses were selected by stratified random sampling technique and given a questionnaire consisted of standard precautions for hand hygiene. Next we intervene with an education module explaining all the measures that should be followed to control nosocomial infection and correct indications and methods for hand hygiene then we study the impact of education and measure any change in the level of compliance and attitude among different health care worker. Objectively we compared the result of skin swab culture from the dorsum of nurse’s hands for presence of endogenous microbial flora before and after the educational intervention. Statistical analysis: Descriptive statistics were used to summarize the data obtained. Result and conclusion: If the measures followed for hand hygiene are continuously pursued and upgraded, the infection level can be further reduced. This can be done by giving training, conducting awareness programme, providing asses of healthcare worker to standard requirements of hand hygiene and implementation of infection control programs.

Keywords: Hand Hygiene; ICU; Lifesaving Skill.

 In the present study pediatric patients of ASA g­1 & ASA­II were selected and divided in two groups each consisting of 30 patients. Induction done by Isoflurane is labelled as “GroupA” and sevoflurane as “Group­B”. The aim of study was to compare the induction and emergence from anaesthesia, complications during induction and post operative period and haemodynamic stability intraoperatively, In the present study, It was observed that mean pulse rate remain stable in sevoflurane and increased in isoflurane. The mean induction time for isoflurane was 130 seconds as compared to sevoflurane 106 seconds. The complications like bradycardia, hypotension were more with sevoflurane, whereas breathholding, coughing, laryngospasm and salivation were more in isoflurane. In sevoflurane mean recovery time was 84 seconds and in isoflurane it was 110 seconds. Postoperative pain and crying was same in both groups. In conclusion, induction and emergence from sevoflurane is rapid and pleasant than isoflurane.

Keywords: Anaesthesia; General Paediatrics; Induction Agent; Sevoflurane; Isoflurane.

 Background: Lower segment caesarean sections [LSCS] are the most common emergency or elective cases we come across. Majority of these cases are done under regional anaesthesia. Perioperative cardiac arrhythmias in these cases are common because of the altered physiology of pregnancy and anaesthesia. Significantly most of these arrhythmias are benign. However, some arrhythmias during spinal anaesthesia can cause sudden vascular collapse and lead to increased peri­partum morbidity and mortality. There are few case reports reported but the incidence of intraoperative arrhythmias is not well established. So this study on the incidence of arrhythmias during spinal anaesthesia in LSCS patients was undertaken. Methodology: We conducted this prospective study for a period of one year between august 2014 to august 2015. 957 patients underwent LSCS under spinal anaesthesia in this one year period. Out of which 68 patients were excluded as they had nonpregnancy related complications. 158 patients with pregnancy related complications like eclampsia, pre­eclampsia, gestational DM and gestational HT were also excluded. 10 cases got excluded as they had inadequate block so converted to GA. The study group included 721 patients.Results: 101 patients i,e 14% of them out of 721 patients developed arrhythmias perioperatively. Bradycardia was seen in 39[5.40%] patients followed by ventricular ectopics in 30 [4.16%] patients. Conclusion: Arrhythmias under anaesthesia are quite common. Most of these perioperative arrhythmias revert back spontaneously. Only few of them needs treatment and most of them have stable haemodynamics. The surgeons should be gentler and the anesthesiologists should be vigilant. Continuous, close monitoring of the patient is mandatory.

Keywords: Lower Segment Caesarean Sections [LSCS]; Perioperative Arrhythmias; Spinal Anaesthesia

 Introduction: Adequate postoperative pain relief after Caesarean delivery (CD) improves ambulation, breastfeeding and infant weight gain. The analgesic efficacy of the TAP block has been confirmed and used for postoperative analgesia following CD. We studied the analgesic efficacy and safety of TAP by using Loss of Resistance (LOR) technique, as part of a multimodel analgesic regimen, in the first 24 h after caesarean delivery. Materials and Methods: 60 patients of ASA physical status III, undergone Cesarean delivery under spinal anaesthesia were divided into two groups. Group T (n=30) patients received bilateral TAP block at the end of surgical procedure with 0.25% Bupivacaine (maximum dose of 2mg/kg). Group C patients received only conventional analgesic regime. Results: In Group T, patients who received TAP block required less analgesics and the time to require a first analgesic requirement was longer than the Group C. In Group C the patients required rescue analgesics much earlier than Group T. The mean VAS score in Group T was 1.54+0.41 Vs 4.02+0.24 in control group which was statistically significant (P <0.01). The TAP block significantly reduced the incidence of sedation (7% Vs 61%).Conclusion: We would like to conclude that administration of TAP block as a part of the multimodal analgesia provides effective analgesia and results in reduction of analgesic drugs requirement following Cesarean delivery.

Keywords: Cesarean Delivery; TAP Block; LOR Technique; Postoperative Analgesia.

 Bispectral Index (BIS) was introduced by Aspect Medical Systems, Inc in 1994 as a novel measure of level of consciousness by algorithmic analysis of patient’s encephalogram during anaesthesia. Besides providing an idea about the hypnotic state of the patient, it also enables titration of anaesthetic agents so as to avoid adverse effects as awareness and side effects of over doses. The ideal sedative medication should provide an early titrable level of sedation, predictable amnesia, decreased anxiety and a rapid recovery with minimal side effects. In the present study, 60 patients of either sex belonging to ASA grade I and II between age range of 20­60 years posted for elective operative procedures performed under spinal anaesthesia were selected. All these patients were preanaesthetically evaluated and written valid consent was obtained. All monitors were attached and baseline parameters as pulse rate, mean arterial pressure, respiratory rate and SpO2 were noted. These 60 patients were divided into 2 equal groups of 30 patients each. In Group M, Midazolam 1% intravenous infusion in 5% Dextrose was started in dose of 0.5mg/kg/hr till BIS value more than 75 was maintained with infusion via syringe pump at 65­85 range and In group P, Propofol 1% infusion in 5% Dextrose was started in dose of 6mg/kg/hr. Intraoperatively, mean pulse rate, mean arterial pressure, respiratory rate, SpO2 were monitored and noted at various time intervals. These patients were monitored intra and postoperatively for any side effects These patients were evaluated for time taken to reach required level of sedation, time taken for recovery, dose required for level of sedation, haemodynamic stability and Alderate score. It was observed that, there was no significant difference in groups M and P at various time intervals but there was statistically significant difference in mean pulse rate, mean arterial pressure amongst the groups at various time intervals, When compared to baseline readings. This difference was more significant in Propofol group as compared to Midazolam group. BIS value in both groups at various time intervals, there was significant difference. Mean time taken to reach required level of sedation was significantly greater in group M as compared to group P. Mean time taken for recovery in group M was significantly greater as compared to group P. The incidence of dreadful complications was comparatively less in both groups. Mean Alderate score on arrival in recovery room in both groups was significant and insignificant at 1 hour.

 Background: In comparison to open surgery laparoscopic cholecystectomy is beneficial. Nevertheless, pneumoperitoneum and the alteration because of patient position causing pathophysiological offers limitation in anaesthetic management. We designed a study to observe the changes on heart rate and blood pressure, intraocular pressure and end­tidal carbon dioxide pressure due to use of clonidine and nitroglycerin during laparoscopic cholecystectomy. Method: The study included 60 patients belonging to American Society of Anesthesiologists class I­II, planned for elective laparoscopic cholecystectomy were randomly divided into 2 groups: Clonidine infusion was given in group 1 at the rate of 1.5 µg/kg/hr and Group II received nitroglycerine infusion at the rate of 0.5 µg/kg/min (30µg/kg/hr). The parameters observed included mean arterial blood pressure, heart rate, end tidal CO2 , and intraocular pressure. Results: The groups were comparable with no significant differences in gender and age. Heart rate of the patients were observed at preinduction, at intubation and after intubation at at interval of 5 minutes onwards upto reversal. Heart rate comparison after 15 minutes onwards upto reversal between group I and II showed statistically significant difference. Mean arterial pressure comparison between group I and II showed insignificant difference. Mean IOP at the time of induction in group I and II was 16.27±3.06 and 18.13±2.80 respectively, which was significant statistically. ETCO2 difference between the groups was not statistically significant. Conclusion: The findings in our study suggested that clonidine surpass nitroglycerin in effectiveness with regard to prevent hemodynamic parameters changes and IOP induced by insufflations of CO2 in laparoscopic cholecystectomy. Also there is no significant hypotension requiring stopping of infusion or further treatment.

 Background and Aim: Studies and research are ongoing to find appropriate adjuvants tointrathecal local anaesthetic agents to make them more effective and economical. In view of the same we undertook a study with Levobupivacaine,being a newer agent with more cardiac stability and compared the outcomes with 3 adjuvants. Settings and Design: After approval from the hospital ethical committee, a randomized double blind study was conducted among 90 healthy, American Society of Anesthesiologists ASA I and II patients, scheduled forlower limb surgeries.The study wasdone over a period of one year. Materials and Methods: Spinal block was administered in L3 and L4 intervertebral space, using 0.5% Levobupivacaine 12mg. Adjuvants added in group 1­ Fentanyl 25 mcg, in group 2­ Dexmedetomidine 10mcg and in group 3 ­ Clonidine 30mcg. Anaesthetic level achieved was T10. Onset time to achieve sensory, motor blockade, and their regression time was noted. Hemodynamic changes and requirement for other analgesic drugs was also noted. Results: 90 patients were enrolled in our study. The data was recorded and analysed using statistical analysis.Conclusion: To conclude, Levobupivacaine with Dexmedetomidine, gavebetter result for intra and postoperativeregionalanaesthesia without any adverse effects.

Keywords: Adjuvants; Intrathecal; Levobupivacaine; Dexmedetomidine; Fentanyl; Clonidine.

 Background: Postoperative nausea and vomiting (PONV) remains one of the commonest causes of significant morbidity after tonsillectomy in children. A variety of prophylactic anti­emetic interventions have been reported, but there has only been a limited systematic review in this patient group. Aim: To find an efficient antiemetic agent for prevention of PONV in children undergoing tonsillectomy performed under G.A. Methods: We included 75 patients in the age group of 5­15 years undergoing Tonsillectomy. Patients were randomly divided into 3 groups of 25 patients each. The patients of Group I received Metoclopramide 0.25mg/kg, Group II Ondansetron 100 mcg/ kg and group III received Granisetron 40 mcg/kg intravenously just prior to induction of anesthesia. The following parameters were monitored during the study: Duration and quality of antiemesis, Pulse rate, Blood pressure, Modified Aldrete’s Score and Side effects if any. Results: Based on scoring system, it was found that the recovery score was 9. The patients were observed from 0–3 hrs and 3­24 hrs following Tonsillectomy for episodes of Nausea and / or Vomiting. Incidence of nausea and/or vomiting during 3­24 hrs after surgery is 44%, 20% and 8% in Groups I, II, and III respectively , with a statistically significant difference between Metoclopramide (Gr. I) and Granisetron (Gr. II ). Conclusion: Granisetron in a dose of 40 mcg/kg is more effective with very less side effects than Metoclopramide and Ondansetron in the long term prevention of PONV in the children undergoing tonsillectomy under GA.

 Background: Increased cough and restlessness during emergence from general anaesthesia in patients with hyperactive airway undergoing surgical procedures might result in adverse effects like hypertension, tachycardia or tachy arrhythmias, myocardial ischaemia, bronchospasm, and increased bleeding at the surgical site. Hence, in such patients, we sought to determine the benefits of filling the endotracheal tube cuff with either buffered lidocaine, saline or air, so as to prevent endotracheal tube­induced coughing during emergence from general anaesthesia. Aim and Objectives: To compare effects of ETT cuff inflation with buffered lidocaine 2%, saline and air for peri extubation period in patients with hyperactive airway for Initial & final ETT cuff pressure difference, Occurrence of cough in periextubation period & Incidence of sore throat post operatively. Method: 240 patients of ASA grade 1 & 2, of 15 to 60 years old, either with a history of chronic smoking or recently treated upper respiratory tract infections were randomly assigned into three groups (n = 80), based on the type of endotracheal tube cuff inflation, as follows: Group A (air), Group B (normal saline) and Group C (Buffered lidocaine). Cough in periextubation period was graded at extubation as: Grade 0 (no cough), Grade 1 (cough < 15s) and Grade 2 (cough > 15s). Result: Extubation was smooth in Group C compared with Groups B and A (p < 0.0001). Further, the incidence of sore throat was found to be lower in both liquid groups, B and C, compared with Group A at 1 h (p < 0.0001) and 24 h (p < 0.01) postoperatively.

Keywords: Buffered Lignocaine; Hyperactive Airway; Periextubation Period; Endotracheal Tube Cuff.

 Background: The racemic bupivacaine is commonly used local anaesthetic drug brachial plexus block in as it provides longer duration of action but has risk of cardiotoxicity .The use of levobupivacaine in brachial plexus block seems promising considering its lower toxicity and the need of large volumes in this block. However there is possibility of unsatisfactory motor blockade. Aim: To compare the efficacy and side effects of bupivacaine and levobupivacaine in brachial plexus block by supraclavicular approach. brachial plexus block Methods: This study included 60 patients belonging to ASA grade I and II, either sex, between age group of 18 to 65 years and above, undergoing hand, forearm and arm surgery under supraclavicular block. These patients were randomly divided into two groups. The patients received 30 ml 0.5% bupivacaine (Group B) or 30 ml 0.5% levobupivacaine (Group L). Motor and sensory blocks were evaluated. Sensory and motor block onset times, durations of sensory and motor block and duration of postoperative analgesia were recorded. Results: The two study groups were homogeneous with respect to age, sex, body weight and diagnosis type (type of fractures) and duration of surgery. The sensory and motor block onset times in Group B were significantly shorter than Group L (p < 0.05). The onset of sensory block was 9.33 + 3.27 min. in group B whereas, it was 16.13 + 2.83 min. in group L. The onset of motor block was 12.17 + 2.18 in group B, whereas it was 20.00 + 2.79 in group L. Sensory and motor block durations of Group B and L patients did not vary statistically significantly. In the present study, the mean duration of post operative analgesia was statistically insignificant between the two group (p= 0.766). It was 193.56 + 23.51 in group B and 192.83 + 23.54 in group L. Conclusion: 30 ml 0.5% bupivacaine and levobupivacaine was enough to achieve adequate supraclavicular block. Bupivacaine leads to faster sensory and motor block onset compared to levobupivacaine; however it has similar duration of postoperative analgesia.

Keywords: Supraclavicular Block; Bupivacaine; Levobupivacaine; Cardiotoxicity.

 Background: Endotracheal intubation is often associated with a hypertension and tachycardia. Intravenous MgSO4 is a popular method of blunting this response, because of its ability to depress sympathoadrenal response & catacholamine release. Objective: it was undertaken to compare the effects of 50mg/kg MgSO4 IV given 3 minutes before laryngoscopy and intubation. Methods: A sample size of 60 patients aged 18 to 60 yrs were included in the study and they were allocated into 2 groups of n=30 each. Group I served as control. Group II received 50 mg/ kg of IV magnesium sulphate 3 min before induction. HR, SBP were recorded pre­operatively, 30 sec, 1 min, 3min & 5min after intubation . Results: Patient receiving iv MgSO4 had a better intubating conditions (p<0.04) statistically significant than  in Group I. There was an increase in the HR at 1 minute after intubation compared to basal value (p < 0.01 ). Also, a decrease in SBP observed at 1 minute and 3 min after intubation when compared with basal value (p<0.001) and (p<0.001) respectively. The decrease in RPP at 1 minute & 3 minutte after intubation when compared with the basal value (p <0.001)& (p<0.01) respectively. Conclusion: Magnesium sulphate 50 mg/kg IV infusion 3 minutes before induction, is a simple, effective and practical method of blunting cardiovascular responses to tracheal intubation, not associated with any adverse effect.

Keywords: Laryngoscopy; Tachycardia; Hypertension; Catacholamine.

Introduction: Adjuncts to local anesthetics for brachial plexus blockmay enhance the quality and duration of analgesia. Buprenorphine and Fentanyl both are opioids, known to produce antinociception and enhance the effect of local anesthetics. The purpose of this study was to compare the effect of Buprenorphine and Fentanyl added to brachial plexus block by supraclavicular approach.