Indian Journal of Anesthesia and Analgesia

  Palliative care can be provided in acute care settings, hospices, patient’s own homes, ambulatory clinics, etc, and aims to provide dignity, respect, and humble care to the sick with the objective of managing pain, understanding their needs, and emotions, requiring careful understanding and observation skills. Patient’s needs are acknowledged and utmost holistic care is provided with an optimistic attitude and hope. Active listening is an important skill as it enables one to understand what the person is saying and to comprehend their feelings through empathy. Patients develop self­awareness and self­confidence by externalizing their feelings, thoughts, and emotions, thereby leading to a decrease in their emotional discomfort and suffering. This review article describes palliative medicine, narrative palliative medicine, empathic process, and compassion in brief. 

  Objective: The aim of the present study is to compare the effectiveness of intravenously administered Granisetron Metoclopramide and Droperidol in the prevention of postoperative nausea and vomiting in patients undergoing gynaecological Diagnostic laparoscopy under general anaesthesia. Design: The antiemetic efficacy of granisetron, and metoclopramide was assessed in postoperative nausea and vomiting for a period of 24 hours. Duration: December 2016 to November 2017. Setting: Department of Anesthesia, Bhaskar Medical College, Ranga Reddy, Telangana. Participants: A total number of 75 female cases between the age group of 18–35 years belonging to ASA grade I and ASA grade II with primary infertility coming for gynecological diagnostic laparoscopy. Methods: Patients were divided into 3 groups of 25 each. Group A received intravenous granisetron (40mcg/kg), Group B received Metoclopramide (0.2mg/kg) and Group C received droperidol (25mcg/kg) prophylactically for prevention of postoperative nausea and vomiting. The primary end point was the occurrence of PONV. The main outcomes were monitored for study period of 24hours postoperatively. Postoperatively the patients were observed in postoperative ward for 24hours for postoperative nausea, retching and vomiting, headache, sedation, dizziness, allergic reactions, extra pyramidal symptoms. Nausea and vomiting were evaluated on three point ordinal scale (0 = none, 1= nausea, 2 = vomiting/retching), with no distinction between vomiting and retching (i.e. retching was considered a vomiting event). Results: In the early postoperative period (0­4hrs), the incidence of nausea & vomiting was effectively controlled with use of granisetron & droperidol, it was significantly higher in metoclopramide group. In the late postoperative period (4­24hrs), PONV was significantly lower with granisetron and droperidol when compared to metoclopromide (p value <= 0.001). Conclusion: Administration of granisetron preoperatively is superior to metoclopramide and droperidol in long term prevention of PONV following gynecological diagnostic laparoscopy. 

  Objective: To compare the anesthetic efficacy and postoperative analgesia between 0.5% bupivacaine and 2mg dexamethasone and 0.5% bupivacaine alone in peribular block for small incision cataract surgery. Methods: 50 patients were randomized into 2 groups of 25 each to receive peribulbar anesthesia using 0.5% bupivacaine and 2mg dexamethasone in group I and 0.5% bupivacaine alone in group II. The patients were assessed for onset and duration of akinesia and postoperative analgesia. Results: Akinesia was achieved faster (6.32±1.11 mins) in group II when compared to group I (14.12±2.99 mins) which was statistically significant. The duration of akinesia was longer in group I (2.52±0.51 hrs) when compared to group II (1.36±0.40 hrs) which was also significant. The VAS scores were significantly lower at 0, 1, and 2 hrs in group I than in group II. Conclusion: The addition of dexamethasone to bupivacaine in the peribulbar block provided a prolonged duration of akinesia and analgesia with lower VAS scores postoperatively. 

  Context: Spinal anesthesia is considered safe over general anesthesia but has some side effects. To overcome its side effects, it can be given in sitting position and after two minutes patient can be kept in supine position. Aims: To compare the effect of positioning after induction of spinal anesthesia in orthopedic procedures. Settings and design: A Randomized controlled prospective double blind study was undertaken at Shadan Institute of Medical Sciences. Methods and material: 50 patients were divided into two groups of 25 each; group L and group S. Both the group patients were ASA 1 and 2 patients aged between 20 to 40 years, posted for lower limb orthopedic surgery. Group L patients were made supine immediately while group S patients were made supine after two minutes of giving anesthesia. Statistical analysis: Student’s t test was applied to compare the mean values. P value less than 0.05 was taken as statistically significant. Results: Both the groups were comparable in baseline characteristics like age, weight, MAP, SBP, DBP. The vasopressor requirement, lowest SBP and DBP were similar in two groups. Group L patients required more fluids, they had more mean fall of SBP, mean heart rate was more and lowest MAP was more compared to group S patients. These differences were statistically significant (p < 0.05). Conclusion: A 2 minute sitting post spinal anesthesia is a safe, reliable alternative for anesthetic management of orthopedic lower limb fracture surgeries. 

  Objective: To compare the anaesthetic efficacy and postoperative analgesia of 0.75% ropivacaine and 2mg dexamethasone with 0.5% bupivacaine and 2mg dexamethasone in peribulbar block for patients undergoing small incision cataract surgery. Methods: 50 patients were divided into 2 groups of 25 each and were randomized to receive peribulbar anaesthesia using 0.5% bupivacaine and 2mg dexamethasone in group I and 0.75% ropivacaine and 2mg dexamethasone in group II. The patients were compared for the duration of akinesia and postoperative analgesia. Results: Akinesia was achieved slower in group I (14.12±2.99 mins) when compared to group II (8.24± 1.05 mins) which was statistically significant. Group I showed significantly longer postoperative akinesia (2.52±0.51 hours) than group II (0.77±0.12 hours). Also the VAS scores were significantly lower at 1 hour in group I (2.94±0.54) when compared to group II (4.96±0.89). Conclusion: Ropivacaine and dexamethasone showed faster onset of akinesia but bupivacaine and dexamethasone showed prolonged postoperative akinesia, better postoperative analgesia and prolonged time to first recue analgesic. 

  Context: Endotracheal intubation is a routine since the discovery of general anesthesia. Passage of endotracheal tube is not without morbidity, dental damage and sore throat being the commonest and serious complications. An attempt to solve this problem lead to the invention of many oropharyngeal devices. For their successful placement in the larynx, the technique of insertion along with proper insertion conditions­ plane of anesthesia and no response from patient are required. Aims: To assess patients response for laryngeal mask airway insertion while maintaining hemodynamic stability using appropriate dose of induction agent. Settings and Design: A comparative randomised prospective double blind controlled study. Methods and Material: Sixty patients who underwent surgery under general anesthesia with laryngeal mask airway were randomized and divided into three groups (20 in each group): Group NS­patients receiving Etomidate plus normal saline, Group S1­patients receiving Etomidate plus 0.25mg/kg Suxamethonium, Group S2­ patients receiving Etomidate plus 0.5mg/kg Suxamethonium. We compared parameters like heart rate, mean arterial pressure and response from patient while inserting laryngeal mask airway ­ jaw relaxation, coughing, gagging, swallowing, movement of head and limbs, laryngospasm; among all three groups. Statistical analysis used: Pearson ChiSquare test to compare success rate between the groups for all the parameters assessed. Variables were analysed using One way ANNOVA test. Results: Low dose of Suxamethonium when combined with Etomidate provides better conditions for laryngeal mask airway insertion than etomidate alone. Conclusions: Intravenous 0.5mg/kg Suxamethonium produces better insertion conditions for Laryngeal Mask Airway than intravenous 0.25mg/kg Suxamethonium. 

  Background: Laparoscopy is now preferred because of various advantages such as reduced post operative pain, faster recovery and shorter hospital stays. It is associated with pneumoperitoneum, variations in patient positioning, and stress response leading to various haemodynamic changes. Various anaesthetic interventions like epidural, combined epidural and general anaesthesia, and pharmacologic interventions like nitroglycerine, esmolol have been used. Aims and objectives: To evaluate and compare the effects of oral clonidine v/s placebo in obtunding haemodynamic response to laryngoscopy, intubation and pneumoperitoneum in patients undergoing laparoscopic cholecystectomy. Postoperative sedation and other side effects were also observed. Materials and Methods: Patients were randomized into two groups­ Group C: 150 mcg of clonidine. Group P: Vitamin – C tablets 500mg, each receiving drugs orally 90 minutes before induction. Effect of oral clonidine in obtunding hemodynamic response and post operative sedation were monitored. Result: No significant difference was observed in mean age, gender and preoperative vital parameters (p>0.05). Significant difference in Heart rate, SBP, DBP, MAP after intubation, during incision, starting and release of pneumoperitoneum between the two Groups (p<0.05). Post­operatively patients in group C were sedated but aurosable as compared to Group P. Conclusion: Premedication with 150 mcg of oral clonidine is safe and improves perioperative haemodynamic stability and reduces postoperative sedation, nausea and vomiting in patients undergoing laparoscopic cholecystectomy. 

  Low back pain is a leading cause of disability and the commonest cause is intervertebral disc degeneration. We decide to compare the efficacy and safety of transforaminal epidural triamcinolone with or without local anaesthetic in the patients of Lumbar Disc Herniation for pain relief. Patients of low back pain with unilateral radiating pain not benefited by 6 weeks of conservative analgesia, having lumbar disc prolapse on X­ray and one­two level compression on MRI were included in the study. They divided into 2 groups; Group I receive fluoroscopic guided triamcinolone with bupivacaine, while Group II received Triamcinolone with normal saline. The patients were observed for improvement in VAS, ODI and at 3 weeks, 6 weeks and 9 weeks and analgesic intake after 9 weeks. The results showed improvement in VAS and ODI in both the groups but improvement was more in group I (p<0.05). Analgesic intake was also decrease in both the groups but more in Group I. We conclude fluoroscopic guided transforaminally injected triamcinolone is effective modality of treatment in lumbar disc degeneration patients. Its efficacy is improved by adding local anaesthetic with steroid. 

  Background: The pre anesthetic medication forms an integral part of anesthetic management. Some form of premedication is almost universally given before induction of anesthesia. In ancient days both wine and opium were given to lessen the fear of surgery. Objective: To assess the Compliance and Sedation Score of Intranasal Midazolam and dexmedetomedine Premedication among Children between 1 to 5 years of age. Methodology: A longitudinal study was conducted from June 2012 to December 2012 at Department of Anesthesiology of Shri M.P. Shah Medical College, Jamnagar, Gujarat. A total of 30 Cases were selected based on age sex matched with each group for the purpose of the study randomly as per the computer generated random Numbers. Group 1 received intranasal midazolam spray and Group 2 was given intranasal dexmedetomedine. Results: The sedation score was found to be statistically significant at 30 and 45 min post induction. Postoperative recovery score at 30 min was found to statistically highly significant with suggested that postoperative recovery score was better in group 1 as compared to group 2. Conclusion: Intranasal dexmedetomidine spray better sedative condition, response to IV cannulation, separation and induction as compared to intranasal midazolam in majority of patients. This study concludes that intranasal dexmedetomedine is better than intranasal midazolam as premedication in pediatric patients. 

  Objective: To compare the efficacy of dexmedetomidine as a hypotensive agent with esmolol in elective ENT Surgeries in ASA grade I­II patients. Methods: This study was a prospective, randomized, double blinded study that included 60 ASA grade I and II patients, undergoing ENT surgeries 30 patients in each group. They were allocated to receive either esmolol (Group E) or dexmedetomidine (Group D) to maintain mean arterial blood pressure (MAP) between (55­65 mmHg). Intraoperative analgesic and additional hypotensive agent requirements were recorded. Standard Average Category Scale (ACS) was used for assessment of blood loss intraoperatively. Hemodynamic variables, emergence time, postoperative recovery time and sedation score following tracheal extubation were recorded. Post­operative pain, nausea and vomiting score and time needed to first analgesic were also recorded. Independent student T test was used for comparision of continuous variables and Chi square test for categorical variables. A P value of < 0.05 was considered statistically significant. Result: There were no inter group differences in haemodynamics and ACS. Emergence time, postoperative recovery and sedation score were significantly higher in Group D. VAS score was significantly lower in Group D. Time to first analgesic request was significantly longer in Group D. No postoperative nausea or vomiting was observed in both groups. Conclusion: Both dexmedetomidine and esmolol were effective in providing ideal surgical field. Both were safe agents for controlled hypotension. Dexmedetomidine offers the advantage of analgesia, amnesia and sedation with better intraoperative and postoperative patient satisfaction as compared to esmolol. 

  Background and Aims: Supraglottic device can provide adequate ventilation for laparoscopic surgeries. This study was aimed to compare Proseal Laryngeal Mask Airway and I­Gel as airway device in laparoscopic hernioplasty. Methods: This was a prospective randomised study, conducted on 60 American Society of Anaesthesiology I­II adult patients posted for laparoscopic hernioplasty. Anaesthesia was induced with propofol and rocuronium. PLMA or I­Gel were introduced and fixed and Ryle’s tube was inserted. The attempts, ease of insertion, quality of airway sealing, haemodynamic changes, oxygenation, ventilation, respiratory mechanics and postoperative adverse event were noted. Statistical analysis was done with EPI 2000 software and
ease of insertion was the primary outcome variable. Results: Success rate of I­Gel insertion was 100% and that of PLMA was 96.67%. I­Gel was inserted at first attempt in 96.67% patients but for PLMA it was possible in 73.34% patients. Ease of insertion was more with I­Gel (score 3­93.33%) as compared to PLMA (score 3­ 70%). Difference between two device was statistically not significant in quality of airway sealing, haemodynamic parameters, attempts of Ryle’s tube insertion, oxygenation and ventilation (p>0.05). After capnoperitoneum, the peak airway pressure was 19±3.47 cmH2O, 21.03±3.77 cmH2O in I­Gel and PLMA group respectively. Insignificant adverse event were noted in both groups. Conclusion: Both I­Gel and PLMA can be used as airway
device in laparoscopic hernioplasty. Insertion of PLMA is more difficult than I­Gel but it provides effective ventilation similar to I­Gel, with minimum increase in peak airway pressure as compared to I­Gel.

  Background: There is significant postoperative pain in major gynecological cancer surgery patients. Ultrasound (USG) guided Transversus Abdominis Plane (TAP) block is a novel approach to provide analgesia to anterior abdominal wall. We evaluated the analgesic efficacy of the morphine added to bupivacaine in USG guided TAP block to patients undergoing major gynecologic cancer surgeries in a prospective randomized controlled clinical study. Method: After ethical committee approval, 60 ASA grade I and II adult female patients were included and randomly divided into 2 groups (30 each) to receive either 20ml 0.5% bupivacaine +morphine 0.1mg/kg diluted in 20ml saline (BM group) or 20ml 0.5% bupivacaine alone diluted in 20ml saline (B group) bilaterally in USG guided TAP block. Observation was done for time for first rescue analgesic requirement, total analgesic requirement, VAS score at rest and on movement, hemodynamics and drug related side effects for 24 hours in postoperative period. Results: Time for requirement of first rescue analgesic was significantly longer in BM group 11.20±3.16 hours in comparison to B group 8.10±2.13 hours (p<0.001) Total diclofenac sodium requirement in 24 hrs in BM group was 30.70±10.20mg and in B group was 93.20±20.36 mg (p<0.001). In BM group VAS score at 6, 8, 12hours were significantly lower compared to B group (p<0.001). No significant difference in hemodynamic changes and side effects. Conclusion: The USG guided TAP block using morphine with bupivacaine provided superior postoperative analgesia when compared to bupivacaine alone after major gynecological cancer surgeries without any significant side effects. 

  Adjuvant drugs are used to prolong the analgesic effects of local anesthetics in regional nerve blocks. This study was done to show the efficacy of Dexamethasone as a potent adjuvant in Supraclavicular Brachial plexus block. 60 patients who underwent upper limb surgeries were chosen for supra clavicular brachial plexus block and randomly allocated to two equal groups,one to receive Dexamethasone and the other to receive normal saline along with Lignocaine Bupivacaine mixture. Time of onset and duration of motor and sensory blockade were noted. The quality of Anesthesia and occurrence of complications was also observed.The mean onset time of sensory blockade in group A is 19.30, and in group B is 16.43 minutes. (p<0.005). The mean onset time of motor blockade in group A is 15.13 minutes, in group B is 13.33 minutes (p<0.005). In group A the quality of Anesthesia is 3 for 26 patients, 2 for 4 patients and in group B it is 3 for 29 patients and 2 for 1 patient. Statistical analysis shows the p value is 0.161, which is not significant. The mean duration of motor blockade in group A is 207.67 minutes, in group B is 374.93 minutes (p<0.005). The mean duration of sensory blockade in group A is 318.77 minutes, in group B is 642.33 minutes (p<0.005). There were no complications reported. We conclude that addition of dexamethasone to local anesthetic mixture fastens the onset of action of motor and sensory blockade, and prolongs the duration of motor blockade and analgesia significantly. 

  Context: Incidence of postoperative pulmonary complications is between 30­50% in patients undergoing abdominal surgery. Addressing pain at surgical site and improving respiratory mechanics , to reduce postoperative hypoxia have a key role in mitigating hospital stay and costs. Aims: To observe the changes in lung function tests and effect of different postures on postoperative oxygen saturations in patients undergoing upper abdominal surgery on the first, fourth and seventh postoperative days and to compare the respective pain scores. Settings and Design: Prospective observational study. Methods and Material: The study was done on 40 patients undergoing upper abdominal surgeries under general anaesthesia. Peripheral oxygen saturations (SpO2) was measured using pulse oximeter and lung function tests using Medispiror preoperatively and on postoperative day 1, 4 and 7. The SpO2 was measured in supine, sitting and standing positions. The FVC, FEV1 and PEFR was measured in the sitting position on all 4 days. Pain was recorded using Numeric Rating Scales. Statistical analysis used: The Statistical software
namely SPSS 18.0, and R environment ver. 3.2.2 were used for the analysis of the data and Microsoft word and Excel have been used to generate graphs, tables. Results: The improvement in oxygen saturation from supine (mean 95.95±1.77) to sitting (97.98±1.37) on the first postoperative was statistically significant with a p value of <0.001. Reductions in FVC from the preoperative (mean 2.35+0.48) value to the first post operative day (mean 1.29+0.39) was statistically significant with a p value of < 0.001. The FVC , PEFR and FEV1 were not at preoperative values even on the 7th postoperative day with a significant p value < 0.001 Conclusions: Postoperative oxygen saturations improve statistically in the sitting and standing position after upper abdominal surgery as compared to supine position. Simple maneuvers like change in position from supine to sitting and mobilization in the early postoperative period can improve the oxygen saturation and lung functions significantly and help in reducing lung atelectasis and resulting postoperative pulmonary complications. 

  Background: Phlebitis refers to the inflammation of a vein which can occur after repetitive intravenous injections through peripheral or central venous cannulation. Various preventive modalities are available but, none has been established Topical heparin drops have an edge over other therapeutic modalities being a non­aqueous, non­volatile, non­irritant and non­staining with significant penetration through the skin.

Aim: The present study aims to evaluate the efficacy of topical heparin for the prevention of phlebitis. Study design: A prospective, randomised and double blind study. Material and Methods: Two hundred patients were divided into two equal groups. Topical heparin sodium solution (1000IU/mL) was applied to one group following 3 hours of cannulation and was repeated every 8 hours for the next 72 hours. A placebo in the form of normal saline was applied to another. Statistical Analysis Used: It was done using SPSS 13. Values for pain and eight other variables associated with phlebitis were calculated before and after intervention in both the groups (Group A and Group B) where there were no signs of pain and phlebitis in the first place. The results were considered statistically significant if the p­value <0.05. Result: The redness around the cannula site and pain as assessed by VAS score was statistically significant between the two groups (p<0.05). Conclusion: The heparin sodium is effective as a prophylactic measure in reducing redness and pain following peripheral and central venous cannulation. 

  Background: Subarachnoid block is popular and commonly used worldwide. The advantage of an awake patient, minimal drug cost and rapid patient turnover has made this the method of choice for many surgical procedures. Among the popular drugs used for subarachnoid block are bupivacaine and and its enantiomer Levobupivacaine. Objectives: A clinical study to compare the effect of spinal anaesthesia with 0.5% hyperbaric levobupivacaine and 0.5% hyperbaric bupivacaine in patients undergoing elective below umbilical surgeries. Materials and Methods: 60 patients of American Society of Anaesthesiologists physical status class1 and 2 patients with 18 to 70 years of age posted for elective lower limb surgeries under subarachnoid block technique were randomly assigned into 2 equal groups. Group L received intrathecal hyperbaric 0.5% levo bupivacaine [total 3.5ml], Isobaric levobupivacaine made hyperbaric by adding 0.5ml of 50% dextrose to 3ml of levobupivacaine, Group B received intrathecal 15mg hyperbaric 0.5% bupivacaine with 0.5ml of normal saline.[total 3.5ml]. Results: Group L and Group B had similar onset of sensory blockade. Group L had delayed onset of motor blockade, lesser degree of motor blockade and lesser quality of intraoperative anaesthesia, similar level of sensory and maximum upper spread of sensory blockade, time  taken for two segment regression time and duration of motor blockade but shorter duration of analgesia when compared to Group B. Conclusion: Hyperbaric 0.5% bupivacaine remains effective choice than hyperbaric 0.5% levobupivacaine for spinal anaesthesia in elective surgeries, But hyperbaric levobupivacaine is also a better option for shorter procedures and outpatient spinal anaesthesia.

  Background: Relief of pain during operation is one of the mainstay of balanced anesthesia. So, any experience acquired in this field should be extended to the postoperative period also which could be done by use of suitable anesthesia. Objectives: To compare the effects of Clonidine and Low Dose Dexmedetomidine along with Bupivacaine on Pulse Rate, Blood Pressure and Respiratory Rate.). Materials and Methods: A Comparative study was carried out by the Department of Anesthesiology, G.R. Medical College and J.A. Group of Hospitals, Gwalior (M.P.). The study was done on 120 patients of ASA grade I & II of either sex with age group 18­60 years scheduled for elective lower limb surgeries. 40 Patients were allocated into different groups by randomization technique. Results: The demographic data of the three groups was comparable and the differences were not statistically significant (p>0.05).There was no statistically significant difference of (mean±SD) of Pulse Rate, Blood Pressure and Respiratory rate at different time intervals between three groups. Conclusion: We conclude that either, Intrathecal administration of clonidine (30µg) or dexmedetomidine (5µg) with hyperbaric bupivacaine 0.5% resulted without producing significant Hemodynamic or Respiratory Complication either during the time or surgery or post­surgery. Moreover, dexmedetomidine did not offer significant advantage over clonidine. 

  Background and AIMS: Subarachnoid blockade is widely used due to its simplicity, low cost and reduced complications due to general anaesthesia. Subarachnoid space can be approached from midline or paramedian approach (PMA). Accurate identification of the subarachnoid space is paramount as multiple attempts at needle insertion may cause patient discomfort, backache and Post Dural Puncture Headache (PDPH). The most commonly practiced technique is the midline approach. This approach is technically difficult in pregnant women due to inability to flex the spine adequately. The aim of the study is to compare the characteristics of midline approach (M) vs paramedian (P) for administration of spinal anaesthesia in patients posted for LSCS with respect to number of attempts, highest level of analgesia, duration of anaesthetic procedure and side effects such as blood tap, backache and PDPH after 48 hours. Materials and Method: 60 patients posted for caesarean section under spinal anaesthesia were divided into Group M: Spinal anaesthesia by Midline approach and Group P: Spinal Anaesthesia by Paramedian approach. The number of attempts, highest level of analgesia, duration of anaesthetic procedure and side effects such as blood tap, backache and PDPH after 48 hours were noted. Results: Paramedian group took fewer attempts and less time and a higher level of spinal block was achieved with the midline technique of spinal anaesthesia. Conclusion: Paramedian approach may be a better approach in the parturient as compared to the midline for administering spinal anaesthesia for LSCS. 

  Background: MAC is most common method of titration of volatile anesthetics and BIS is used to measure the hypnotic effect of anesthetics. This study was undertaken to evaluate and compare the BIS value produced by different inhalational agents at their 1 MAC end tidal concentration. Method: 200 patients of ASA I ­ II of either sex between 20­50 years , for laparoscopic cholecystectomy were divided into 4 groups of 50 each and received either halothane, isoflurane, sevoflurane or desflurane. General anesthesia was administered using fentanyl, propofol, inhalational agents and vecuronium and maintained with 67% nitrous in oxygen. After achieving and maintaining 1 MAC for 15 min, BIS value were recorded for next 15 min at an interval of 1 min .Collected data was analyzed using ANOVA test. Results: At 1 MAC end tidal concentration mean BIS value for halothane was 57.0±3.51, for isoflurane 51.57±3.84, for sevoflurane value was 49.621± 3.82, and for desflurane BIS value 42.11±4.68, and difference among groups were statistically significant. Conclusion: At 1MAC, BIS values are agent specific and BIS value of halothane > isoflurane > sevoflurane > desflurane. 

  Background: Opioid like Buprenorphine has been widely used as adjuvant intrathecally for providing prolonged post operative pain relief. Their advantages of neuraxial narcotics over systemic narcotics are well established. IntrathecalMidazolam, abenzodiazepine derivative apart from its own analgesic and sedative effect, it potentiate the analgesic effect of Bupivacaine. This study was conducted to compare the efficacy of intrathecal Buprenorphine (150µg) with intrathecal Midazolam (2.5mg) when used as an adjuvant to 0.5% Bupivacaine for lower abdominal surgeries and also to observe any side effects. Methods: After approval from hospital ethical committee, 90 patients between the age group of 20­60 years was taken. Informed consent from the patient was taken. All patients from ASA I and ASA II were allotted in three groups of 30 patients each. Group B was given 3.5 ml of 0.5% bupivacaine (heavy) with 150µg (0.5ml) buprenorphine intrathecally. Group M was given 3.5 ml of 0.5% Bupivacaine (heavy) with 2.5 mg (0.5ml) midazolam (preservative free) intrathecally. Group C was given 3.5 ml of 0.5% bupivacaine (heavy) with (0.5 ml) of Normal Saline intrathecally as controlled group Statistical analysis was performed using ANOVA test and T­test. p value < 0.05 was considered significant. Result: Onset of sensory and motor is fastest in Midazolam group while Buprenorphine provided prolonged duration of analgesia post­operatively (827.17+67.77 min.) as compared to Midazolam (297.5+33.21min.). Conclusion: Addition of Buprenorphine provides prolonged post­operative analgesia compared to other groups but sensory & motor onset is fastest with Midazolam. 

  Background: CMAC is a video laryngoscope with the unique advantage of having a blade design very similar to the most commonly used Macintosh laryngoscope. We conducted this study to compare the efficacy of intubation with the conventional Macintosh Laryngoscope and CMAC laryngoscope as measured by total time for successful intubation, number of attempts, laryngeal view, hemodynamic changes and airway morbidity. Material and Method: Seventy patients (n=35 in each group) were randomly allocated to be intubated with either CMAC or Macintosh laryngoscope (ML). Parameters measured were time taken for successful intubation, number of attempts, Cormack Lehane grading of laryngoscopic view, airway morbidity, blood pressure and heart rate at first, third and fifth minutes after Intubation. Results: The total intubation time was 26.6±3.71 seconds in CMAC group and 29.7±4.68 seconds in ML group. All the patients were intubated in first attempt. The increase in systolic blood pressure at first (121.43±9.71) and third minutes (116.60±9.53) following laryngoscopy was significantly lower in CMAC group as compared with Macintosh group (127.77±13.53 and 122.31±12.23 respectively) p=0.027 at minute 1 and p=0.021 at minute 3. Heart rate too showed a significantly lesser increase in CMAC group than in ML group (p =0.001, 0.02 and 0.009 at first, third and fifth minutes respectively). Conclusion: Intubation with CMAC is associated with shorter intubation time and better hemodynamic profile compared to conventional Macintosh laryngoscope in patients with no predicted airway difficulties. 

Background and Objectives: Inguinal hernia surgery is one of the commonest day care procedures and have very high incidence of moderate to severe postoperative pain which remains a great challenge for the anesthesiologist to treat it. Multimodal analgesic techniques like parenteral analgesics or regional analgesia are commonly practiced. Peripheral nerve block after surgical closure provide effective postoperative analgesia without any major side effects. This study was designed to compare the analgesic efficacy of Bupivacaine (B) and Ropivacaine (R). Materials and Methods: Fifty adult male patients scheduled for elective inguinal hernia repair were randomly allocated into two groups of 25 each. Group B ­ Bupivacaine, Group R ­ Ropivacaine respectively. General anaesthesia was given. Nerve block was administered at the end of surgery with 15 ml of the study drug. Visual Analog Score (VAS) was noted immediately at the end of surgery and hourly up to 8 hours and the time for rescue analgesia was noted. Independent ‘t’ test, SPSS version 16 was used for analysis. Results: We have found that both the drugs provided excellent postoperative pain relief for inguinal hernia repair with hemodynamic stability. Duration of analgesia was significantly longer in bupivacaine than ropivacaine. (389.96± 25.37mins Vs 301.24±20.72 mins with ‘p’ value < 0.01). Conclusion: At equal concentration, bupivacaine provided prolonged postoperative analgesia than ropivacaine. 

  Background: Ano­rectal malformation is a common anomaly seen in newborns and is associated with multiple anomalies like renal, vertebral, muscular and cardiac. Associated cardiac anomalies determine the morbidity and mortality of newborn. It is mandatory to properly evaluate the child for cardiac anomalies in children with ARM. Objective: The aim of the study is to evaluate the incidence of associated cardiac anomalies in thenew­borns with Ano­rectal malformation admitted ina tertiary care centre. Method: Total number of Ano­rectal Malformation admitted from June 2017 to May 2018 in our hospital was recorded. All cases after examination and evaluation were classified into Low ARM and High ARM. All cases after preoperative evaluations and basic haematological tests were taken for emergency colostomy or cut back anoplasty. Patients during postoperative period were performed echocardiogram for cardiac evaluation. Total number newborns with ARM having associated cardiac anomalies were determined. The incidence of cardiac anomalies in two types of ARM was determined. Results: Total number of newborns with ARM admitted for sugery in the period of June 2017 to May 2018 were 182. Out of which 21 cases were having congenital cardiac anomalies (11.53%). ASD is found to be commonest cardiac anomaly comprising 15 (60%). Other cardiac anomalies associated with ARM were VSD 7 (22%), Dextrocardia 2 (8%), Tetrology of Fallot 1 (4%). Newborns with High ARM have higher
incidence of cardiac anomalies when compared to Low ARM (18/7). All cases needed extra perioperative care like antibiotic prophylaxis, avoidance of air entry through ivcanula, avoidance of hypothermia and avoidance of fluid overload. Conclusion: The incidence of associated cardiac anomalies in newborns with ARM were found to 11.53%. High Type of ARM have grater incidence of associated cardiac anomalies. ASD was found to be commonest cardiac anomaly. Our study showed that cardiac evaluation during preoperative evaluation should be a pre­requisite for all cases of ARMs. 

Introduction: Intravenous regional anaesthesia (IVRA) also called as Bier’s block is a commonly used anaesthetic technique for surgical procedures on the upper extremities. Many adjuvants have been used to improve the quality of intravenous regional anaesthesia (IVRA). Aims and objectives: The aim of this study was to compare the use of dexmedetomidine and magnesium sulphate as adjuvants lidocaine for IVRA as regards to onset and duration of sensory and motor blocks, hemodynamic variables. Materials and Methods: This prospective, randomized, double-blinded trial was conducted in 60 ASA I and II patients scheduled for upper hand and forearm surgeries who were randomly divided into two groups, comprising 30 patients each. Group D received dexmedetomidine 1mic/kg and 0.5% lidocaine to a total volume of 40 ml, whereas group M received 25mg/kg of 50% magnesium sulphate and 0.5% lidocaine to a total volume of 40 ml. Onset and duration of sensory and motor block, hemodynamic variables were recorded and compared between the two groups. Results: There was statistically significant difference between both the groups as group D achieved rapid onset and prolonged duration of sensory and motor block compared to group M (p<0.0001). Group D showed significant difference in heart rate and mean arterial pressure compared to group M after the tourniquet deflation. (p<0.0001). Conclusion: Our study shows that Dexmedetomidine provides rapid onset and prolonged duration of sensory and motor block in Intravenous regional anaesthesia compared to magnesium sulphate.

Aim of Study: Many drugs are used for providing favorable intubation conditions during awake fiberoptic intubation (AFOI). However, most of them cause respiratory depression and airway obstruction leading to hypoxemia. The aim of this study was to compare intubation conditions, and incidence of desaturation between dexmedetomidine in combination with fentanyl and dexmedetomidine alone. Material and Methods: This randomized double-blind prospective study was conducted on a total of 60 patients scheduled for maxillo facial surgeries who were randomly allocated into two groups: Group DF received dexmedetomidine 1 mcg/kg along with fentanyl 2 mcg/kg and Group D received dexmedetomidine 1 mcg/kg over 10 min. Patients in both groups received glycopyrrolate 0.2 mg intravenous, nebulization with 2% lidocaine 4 ml over 15min and 10% lidocaine spray before undergoing AFOI. Adequacy of intubation condition was evaluated by Incidence of desaturation, cough score and post-intubation score, hemodynamic changes and sedation using Ramsay sedation scale (RSS) were noted and compared between two groups. Results: Cough score <2 was considered as favourable intubation condition, which was achieved in 27 out of 30 patients in Group DF, but only in 5 out of 30 patients in Group D which is statistically significant. (P < 0.0001) Better tolerance score (Score 1) was found in 21 patients of Group DF and only 4 patients in Group D. This difference was also statistically significant (P < 0.0001). higher RSS was achieved in Group DF(3.7±0.79)than in Group D (1.7±0.65) (P < 0.0001). We observed that 8 patients of Group DF and 28 patients in Group D were able to maintain SpO 2 (95%) (P < 0.0001) during the procedure Conclusion: Dexmedetomidine with fentanyl provides good intubation conditions than Dexmedetomidine alone during AFOI.

Background: Fractures of distal radius are common and there are different modes of anesthesia to obtain pain relief prior to closed reduction. The aim of this study was to prospectively compare hematoma block alone and general anesthesia for the reduction of distal radius fractures, with respect to pain perception before and after manipulation using a visual analogue scale (VAS), patients’ acceptance and surgeons’ acceptance. Methods: In this randomized, controlled study, 60 ASA-I and II patient were divided into HB group (n=30) who received Hematoma block, compared with GA group (n=30) who received general anesthesia. Pain was assessed preoperatively and postoperatively by VAS, and intraoperatively by change in heart rate and mean arterial blood pressure from the baseline levels. Patients’ and surgeons’ acceptance with the nature of procedure were assessed using patients score and surgeons score respectively. Results: Intraoperatively, HB group patients had better hemodynamic variables when compared to GA group. The mean of postoperative VAS of HB group and GA group were 2.1 and 3.83 respectively which was statistically significant. The difference of mean score between the two groups with respect to surgeons’ score (p<0.001) and patients’ score (p<0.001) were statistically significant. Post-manipulation pain was significantly greater in patients who received general anesthesia (VAS=3.83±0.64). Conclusion: Patient acceptance and surgeons’ satisfaction is greater with a correctly performed hematoma block and is a safe and effective alternative to general anesthesia. 

Objective: To compare the onset and duration of sensory and motor block, haemodynamic responses, side effects associated with administration of intrathecal isobaric levobupivacaine (0.5%) and isobaric ropivacaine(0.75%) for inguinal hernioplasty. Place and Duration of Study: Rajah Muthaih Medical College, Chidambaram, 2016-17. Methodology: After obtaining approval from institutional ethics committee and written informed consent from all patients, a randomized controlled double blinded clinical trial was conducted on 50 ASA 1 and 2 adult patients undergoing elective inguinal hernioplasty. Patients were randomly allocated into two groups, group L and group R of 25 each. Patients in group L were to receive isobaric levobupivacaine 0.5% and group R 0.75% ropivacaine. Haemodynamic variables (heart rate, systolic and diastolic BP) and onset and duration of sensory and motor block, sensory regression time were recorded and compared.

Title: Effect of administration of Magnesium sulphate, Clonidine or Dexmedetomidine on hemodynamics due to pneumoperitoneum in patients undergoing laparoscopic procedures under general anesthesia. Background: Pneumoperitoneum and the positioning during laparoscopy induce pathophysiological changes which potentially complicate anesthetic management and require some intervention. Aim: To compare the effects of Magnesium sulphate (MgSO4), clonidine, or dexmedetomidine on hemodynamic changes occurring after pneumoperitoneum in laparoscopic procedures. Material and Method: 60 adult, ASA Grade I & II, patients undergoing laparoscopies were randomly divided into three groups: Group M (magnesium sulphate), Group D (Dexmedetomidine) & Group C (Clonidine). In each group, boluses of study drugs were given before induction of anesthesia, followed by infusion prior to pneumoperitoneum. Heart rate, systolic/diastolic/mean blood pressure, end tidal CO2, sedation score, VAS score for pain were recorded. Mean and standard deviation for each parameter was calculated using ANOVA. Sedation and pain (VAS) Score were calculated by Kruskal Willis test, p value<0.05 was considered statistically significant’. Results: Intraoperative heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure were below baseline & comparable in all three groups (p<0.05) but minimally disturbed in dexmedetomidine group. Most of the patients were pleasantly sedated at the extubation with maximum patients responding to verbal commands quickly in clonidine group. VAS Pain score were minimal in dexmedetomidine group.

Background and aim: Difficult intubation is an important cause of mortality in surgical patients; even more so when it is unanticipated. Predicting difficult intubation with the help of different airway parameters has been the endeavor of all anesthesiologists. However, there are variations in the accuracy of these airway parameters due to differences in race and ethnicity. The present study was aimed to assess the efficacy of various airway parameters in predicting difficult intubation in the northeast Indian population. Methods: Four hundred adult American Society of Anesthesiologists physical status I and II patients scheduled for elective surgery under general anaesthesia requiring tracheal intubation were assessed preoperatively for different predicting factors of difficult laryngoscopy and intubation. Intubation difficulty was assessed by the Intubation Difficulty Scale. Sensitivity, specificity, positive predictive value and negative predictive value were calculated. The association between different variables and difficult intubation was evaluated using Fishers exact test; p-value < 0.05 was considered significant. Results: The mean age of the patients was 43.40±12.49 years; 60% patients were male. 23 (5.75%) patients were having difficult intubation. While all the parameters were strongly able to predict difficulty, thyromental distance < 6 cm and Cormack Lehane grade  3 were having the most strong relative risk (8 and 100.22 respectively; p < 0.0001 for both). Only Cormack Lehane grade  3 was having both good sensitivity and specificity (95.65% and 86.74% respectively). Conclusion: Difficult intubation rate is not different in northeastern Indian population. Thyromental distance , Modified Mallampati score and Cormack Lehane view were the strongest predictors of difficult intubation in the study population. 

Background: This study evaluated the prescribing pattern of analgesics in very terminal ill cancer patients who succumbed to their illness in a tertiary care hospital. Methods: This retrospective study was conducted in the Medical Records Department by observing for the type of cancer and previous treatment, details on recurrence/metastasis, co morbidities, pain when got admitted and the analgesics prescribed. The details were tabulated and subjected to frequency and percentage analysis. Results: In total, there were 173 deaths due to cancer during the study period (48% female, and 52% males). Most patients were in the age group of 41 to 50 and from town background (44.5%). Co morbidity was observed only in 24.6% of the patients and hypertension was the most commonly observed (13.3%). Most of the admission was due to complications of advanced cancer and metastasis. A range of analgesics were used to mitigate the pain. Tramadol alone (31.2%) was used in the maximum number of cases followed by morphine (26%). Combination of paracetamol and tramadol, tramadol and morphine and all the three were also used. Morphine alone (26%) and or in combination with other analgesics (7.4%) was also used. Morphine tables were the most prescribed over the injections. Conclusions: Analgesics have been increasingly prescribed in very terminally ill people with cancer. However, morphine was relatively under-prescribed. Relevant studies need to be carried out to determine the barriers for using morphine through prospective studies.

Background: International health care community is more worried about the rates of cesarean sections throughout the world. Cesarean sections are associated with temporary benefits but are associated with short and long term risks which can extend beyond many years after delivery and affect the health of the mother, child and future pregnancies. An ideal anesthetic technique, for minimizing the surgical morbidity among mothers and neonates has yet to be described in literature. Objectives: Hence our objective of the study was to compare the effects of spinal and general anesthesia on maternal hemodynamic status and foetal outcome by comparing the APGAR scores of the newborn. Materials and Methods: A prospective cross sectional study was conducted at ACSR tertiary care hospital for a period of one year.120 cases that fulfilled inclusion criteria were divided into two equal groups (50 each) and one group administered general anesthesia and other spinal. Maternal hemodynamic parameters were recorded and foetal outcome with regard to APGAR score at 1 and 5 minute interval was recorded. SPSS version 10 for windows was used for statistical analysis. P value <0.05 was considered significant. Results: In our study, statistically significant differences between the two groups were observed in relation to APGAR scores of the neonates at 1 and 5 minute intervals. APGAR score readings were higher in general anesthesia group. Significant differences were also observed in readings of HCO3 and PCO2 levels between the two groups and patients in general anesthesia group were more tachycardic than patients in spinal anesthesia group. Discussion: To conclude in our study, we observed that umbilical artery pH and APGAR scores of neonates who received general anesthesia were lower than the neonates born under regional anesthesia. Spinal anesthesia is effective than general anesthesia, foetal outcome is favorable in cases of spinal than general anesthesia. This study can be further evaluated in cases of emergency cases of cesarean section which covers all the risk factors.

Introduction: Airway management is must during delivery of general anaesthesia. Previously, laryngoscopy and endotracheal tube (ETT) insertion has been the mainstay in providing adequate airway management and delivering anaesthesia. The laryngeal mask airway (LMA) offers a much less invasive way of maintaining the airway as it does not pass through the glottis but is placed over the glottis. It does not require the use of the laryngoscope. Objective: To determine the haemodynamic response elicited by laryngoscopy and endotracheal intubation and compare it with that elicited by laryngeal mask insertion in ASA I and ASA II patients, undergoing elective general surgeries. Methods: A hospital based prospective randomized comparative study was conducted to determine the haemodynamic response, elicited by laryngoscopy and endotracheal intubation and compare it with that elicited by laryngeal mask airway insertion in ASA I and ASA II patients, undergoing elective general surgeries. After induction of anaesthesia either an ETT or LMA was inserted. Evaluations included measurement of blood pressure and heart rates before insertion, and 1 minute, 3 minutes and 5 minutes after insertion. Results: There was an increase in HR, SBP and DBP seen after laryngoscopy and ETT insertion as well as after laryngeal mask airway insertion. The change in haemodynamic parameters after laryngoscopy and ETT insertion were significantly greater than those elicited by LMA insertion. Conclusion: A significant haemodynamic response consisting of an increase in HR, SBP and DBP was seen after the insertion of both the LMA and ETT in this study. It was also concluded that the haemodynamic response to laryngoscopy and ETT insertion is significantly greater than that to LMA insertion.

Background: Ultrasound guided (USG) supraclavicular brachial plexus (SPB) block can be performed either by a single injection (SI) technique, injecting the entire volume of drug in the corner pocket or by a double injection (DI) technique, whereby half the volume of the drug is injected in the corner pocket and remaining half directly into the neural cluster. We conducted this study to compare thesuccess rates of the two techniques. Methods: A comparative two group study was carried out in 120 patients who underwent elective upper limbsurgeries (excluding the shoulder) under USG guided SPB in M.S. Ramaiah Hospital, Bangalore. Patients were randomly allocated in two groups (SI & DI). Both the groups received 30 ml 0.5% ropivacaine. SI group received the entire volume in the corner pocket, whereas DIgroup received 15 ml in corner pocket and the remaining 15 ml in the neural cluster. The blocks were assessed every 5 mins upto 30 mins forboth sensory and motor blockade using cold test and motor movements respectively, in the musculocutaneous, median, radial and ulnar nerves distribution. Each nerve was allocated a maximum of 2 points for complete blockade. Hence a maximum composite score of 16 could be achieved. To label a block successful a minimum of 14 points were required. We compared the success rate of blockade and total anaesthesia related time between the two groups. Results: The success rate of the blockade in the SI and DI group was 96.7% and 91.7% respectively at 30 min of performing the block which was not statistically significant. All the seven patients who had failure in both the groups had ulnar nerve sparing. The mean total anaesthesia related times in the two groups were 21.42±3.29 and25.17±2.45 in DI and SI groups respectively with P<0.001. During the first 25 minutes, the DI group displayed a higher proportion of patients with minimal composite score of 14 points. Fifty eight patients(96.7%) in DI achieved a composite score of 14 points and above within the first 25 minutes. The mean onset times were 17.25±2.83 and 22.72±2.47 in DI and SI group respectively. No adverse events were seen in both the groups. Conclusions: The success rates in both the SI and DI techniques were comparable. The DI technique results in a faster onset and hence a shorter total anaesthesia related time, which however may not be clinically relevant.

Introduction: Management of both intraoperative anaesthesia and post operative pain by neuraxial block demands addition of additives which gives good and prolonged postoperative analgesia with minimal side effects. Among various choices of additives, alpha 2 agonists are one among the preferred drugs. Aim of the Study: To compare the efficacy of a mixture of 0.5% bupivacaine and clonidine 150 micrograms with 0.5% bupivacaine used alone in lumbar epidural anaesthesia for lower abdominal surgeries. Materials and Methods: Fifty patients belonging to ASA I or ASA II category were selected for the study. All patients were randomly divided into two groups of 25 each. Group I, the control group received 10-15 ml 0.5%of bupivacaine and 1 ml of normal saline and Group II. Clonidine group received 10-15 ml of 0.5% bupivacaine and 150µgm of clonidine. Onset and duration of sensory and motor block and duration of post-operative analgesia along with adverse effect were studied. Statistical analysis was performed using student unpaired t –test and chi- square test. Results: Epidural clonidine in the dose of 150 µgm combined with 0.5% bupivacaine produced an effective anaesthesia with rapid onset, intensified and prolong blockade and an extended duration of post operative analgesia with minimum side effects.

Introduction: Inadequate pain relief after caesarean section delivery impairs mother’s ability to optimally care for her infant and to breastfeed in the immediate postoperative period. Pre-emptive analgesia is an antinociceptive treatment that prevents the establishment of altered processing of afferent input which amplifies postoperative pain. The lower dose of ketamine is not associated with neonatal depression and complication is minimal with high patient acceptance. Aim and Objectives: To assess the pre-emptive analgesic efficacy of pre-incisional i.v. low dose ketamine in patients posted for L.S.C.S under spinal anaesthesia. Material and Methods: The present clinical prospective study was carried out in Department of Anesthesiology, during Dec. 2011 to Oct. 2013. Sixty parturients of ASA Grade I and II were randomly divided into two groups of 30 each, every even number patient received IV ketamine (group K) and every odd patient received normal saline (group B). Results: Highest level of sensory block reached in group B was T2 in 7% of patients and 10% of patients in group K. All patients had excellent sensory analgesia. Mean time of total duration of sensory block was 234.27±24.23min in group B and 230±28.8min in group K. Mean time of effective analgesia was 126±17.6 min in group B and 161.6±24.2 min in group K. Hypotension was noted in 12 (40%) in group B and in 9 (30%) in group K. Shivering was observed in 3 patients in group B. Conclusion: The pre-incisional administration of low dose intravenous ketamine delayed the time to first analgesic request in parturients. The study could not substantially demonstrate the preemptive analgesic property of ketamine.

Background: Sedation is a necessity for MRI (Magnetic Resonance Imaging) procedures in children for alleviating anxiety and to avoid movements during the procedure. Dexmedetomidine a selective alpha-2 adrenoreceptor agonist is very useful for such procedures. Aims and Objectives: To analyze and compare the sedative, hemodynamic and respiratory effect of Intravenous (IV) dexmedetomidine with IV dexmedetomidine and midazolam combination in children undergoing magnetic resonance imaging (MRI) examination. Material and Methods: Total of 60 patients were studied, 30 in each group, group D and group DM. Group D received inj. Dexmedetomidine 2mcg/kg, Group DM received dexmedetomidine 2mcg/kg and inj. Midazolam 0.03 mg/kg intravenously. The level of sedation was assessed by the Ramsay sedation scale and quality of MRI was assessed using the 3 point scale. During the procedure, respiratory rate, heart rate, oxygen saturation and blood pressure were continuously monitored and recorded using MRI compatible monitors. The data were analysed using SPSS version 24.0. Results: There was significant difference in onset of sedation; the mean values ranged 6.3±2.28 minutes (mins) and 3.23±3.02 minutes for D and DM group respectively (p < 0.05). There was significant difference in the Level of sedation; the mean values ranged 4.57±0.57 and 5.27±0.52 for D and DM group (p < 0.05). There was no significant difference in blood pressure values at various time periods between the two groups. The quality of MRI is better in Group DM than group D. There was no significant difference in heart rate, respiratory rate, oxygen saturation values at various time periods between the two groups. 4 patients in Group D received supplementation, whereas none in group DM received supplementation. Conclusion: Addition of midazolam to dexmedetomidine for sedation helped in decreasing the onset of sedation and also offered a better quality of MRI study without any haemodynamic or respiratory disturbances.

Background: Morphine is an opioid and its intrathecal use for postoperative pain relief is well documented. Nausea and vomiting are the common adverse effects with intrathecal morphine and might be distressing in patients undergoing abdominal surgeries limiting its usage. Ondansetron is helpful in treating of nausea and vomiting but would be of greater help when administered pre-emptively. Aims and Objectives: Primary aim of study was to study the effect of pre-emptive ondansetron in controlling intrathecal morphine induced nausea and vomiting. Secondary aims was to assess its effectiveness in controlling pruritus. Methods and Materials: In this prospective, randomized study ninety patients undergoing abdominal hysterectomy were categorized into 3 equal groups receiving 15mg hyperbaric Inj.bupivacaine, in addition 0.5ml saline in Group-I, and 100µg and 200µg of intrathecal morphine diluted to 0.5ml respectively in Group-II and Group-III. All patients received 4mg of Inj.ondansetron intravenously 10 minutes before administering spinal drug preparation. Patients were assessed for duration of analgesia, nausea, vomiting, pruritus and other adverse effects of intrathecal morphine. Results: There was statistical significant difference with respect to age, body mass index and duration of surgery between three groups. Intrathecal morphine resulted in significantly longer duration of analgesia in patients receiving intrathecal morphine (p<0.001). Pre-emptive ondansetron effectively controlled intrathecal morphine induced nausea (p=0.809) and vomiting (p=0.199) and it was statistically insignificant when compared to control group, but did not decrease incidence of pruritus (p=0.027). Conclusion: Pre-emptive intravenous Inj.ondansetron (4mg) effectively controls intrathecal morphine induced nausea and vomiting but not pruritus.

Introduction: Administration of local anesthetics into the pleural space provides rapid onset and long duration of analgesia upper abdomen surgeries without respiratory depression as seen with opioids.in this study we attempt to find the efficacy of interpleural analgesia in reducing post operative pain and parenteral analgesic requirement in patients undergoing upper abdominal surgery. Aim: To analyze the efficacy of interpleural analgesia in reducing post operative pain and parenteral analgesic requirement in patients undergoing upper abdominal surgery. Materials and Methods: After ethics committee approval and written informed consent 36 patients undergoing elective upper abdominal surgeries were selected randomly based on computer generated random numbers. General anaesthesia administered as per routine in our hospital. When the surgery was over the patients divided into two trearment groups of 18 patients. 1. Pleural analgesia (bupivacaine) combined with Parenteral analgesics (Pentazocine). Forty milliliters of Injection bupivacaine 0.25%via intrapleural catheter. 2. Parenteral analgesics alone. (Pentazocine). Results: Consumption of pentazocine were higher in control group than in pleural group, for Day 1(P < 0.001), Day 2 (P < 0.01) and Day1 + 2 (P <0.001) Mean pain scores were significantly reduced 30 min after IP instillation of bupivacaine 0.25 % compared to control group. Conclusion: It is concluded from this study that intermittent interpleural analgesia with bupivacaine was more effective than intermittent intramuscular administration of pentazocine alone. 

Context: Epidural analgesia is an effective mode of labour analgesia. Few studies have shown that epidural analgesia is associated with an increase in maternal body temperature. The greatest impact of this increase in maternal body temperature lies in the need to eliminate the possibility of infection and subsequent use of antibiotics. This study was done to determine the relationship between epidural labour analgesia and maternal body temperature in Indian population. Aims: To determine the relationship between epidural labour analgesia and increased maternal intrapartum temperature. Settings and Design: A prospective randomised study in our institution. Methods and Material: Sixty ASA 1 or 2 consenting parturients scheduled for normal delivery were randomly allocated to 2 groups of 30 each to receive inj Fentanyl 50 mg intravenous or epidural boluses of 0.125% ropivacaine with 2 mg/cc of fentanyl after ethical committee approval. Baseline maternal and fetal vital parameters including maternal body temperature were recorded. Statistical analysis used: Data was analysed using student’s unpaired t-test, Mann Whitney’s U test and one-way ANOVA wherever indicated Results: Significant difference (p< 0.05) in the maternal body temperature between the groups at all intervals were noted. There was a significant rise in the temperature from baseline within the group as well (p< 0.05). Conclusion: The present study shows that maternal body temperature increases during labour and epidural labour analgesia only exaggerates it, albeit, without any apparent repercussions on the mother or infant.

Introduction: Laryngoscopy and intubation is associated with a reflex sympathetic pressor response resulting in elevated heart rate (HR) and blood pressures (BP). This may prove detrimental in high risk patients and may be in normal patients also. Several drugs Nitroglycerine (NTG), Lignocaine, Beta-blockers, Opioids, Calcium Channel blockers and Adrenergic agonists, have been used for attenuating the stress response. NTG sublingual spray is a new introduction to attenuate the stress response to intubation. Aims: Aim of this study was to compare the effects of sublingual NTG spray and intravenous (iv) Lignocaine on the haemodynamic response following laryngoscopy and intubation. Patients and Methods: Randomised control study involving sixty ASA I and II patients who are aged between 20 to 40 years posted for elective surgery were divided randomly into two groups of thirty each. ‘Z’ test was used for statistical analysis. All patients received premedication with Glycopyrrolate (0.01mg/ kg), Midazolam (0.02 mg/kg)iv. Patients were induced with Thiopentone 5 mg/kg iv and muscle relaxant was used in the form of Vecuronium (0.1 mg/kg)iv. First group received iv Lignocaine 1.5 mg/kg, 5 min before intubation and second group received two puffs of NTG sub lingual spray, 400mcg/spray. HR and BP were recorded noninvasively before induction, post-induction, at intubation (0 min), 1,3,5,7 and 10 min from the onset of laryngoscopy. Pair wise comparison between the groups was done by `z’ test. For all tests a `z’ value of 1.96 was considered significant and a `p’ value of 0.05 was considered significant. Results: In group N, the rise in systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) was not significant at 1, 3 and 5 min after laryngoscopy, the attenuation was statistically highly significant with p values of < 0.001. Where as in group L, there was significant increase in SBP, DBP and MAP till 7 min post laryngoscopy, after which the values reached the pre induction values. Conclusions: Pre-treatment with sublingual NTG spray provides a consistent and reliable attenuation of pressure response to laryngoscopy and intubation when compared to iv Lignocaine.

Aim: To compare 0.5% Bupivacaine and 0.75% Ropivacaine in patients for brachial plexus block through axillary approach. Materials and Methods: A prospective randomized study patients aged between 20 to 60 years with ASA class I and II posted for elective upper limb surgeries were included in the study. The study population was randomly divided using computer generated numbers into 2 groups with 30 patients in each group. Group B (n = 30) received 0.5% Bupivacaine, Group R (n = 30) received 0.75% Ropivacaine. Results: There is no statistically significant difference in the demographic profile of the patients in either groups. There is significant difference in the onset of sensory block in the dermatomes C5 to T1. The duration of sensory block was prolonged in group B with difference is statistically and clinically significant with a P value of <0.0001. Onset of motor block is faster in group R compared to group B with a p value of <0.0001 which is highly statistically significant. The duration of motor block in group B is longer than the duration of motor block in group R. It is a significant statistical difference in these values with a p value <0.0001. There is no statistical significant in the quality of sensory block in both the groups with a P value of 0.56. There is no significant difference in quality of motor block in both the groups with p value of 0.13. There is no significant statistical difference in changes in in the hemodynamic parameters. There was no occurrence of any dysrhythmias or any changes in the pattern of ECG during this study, all the patients had normal sinus rhythm. There were no adverse effects in this study. Conclusion: Faster onset of sensory and motor block and less cardiotoxic effects combined with the above said characteristics of Ropivacaine makes it a better choice than Bupivacaine for brachial plexus block through axillary approach for fore arm surgeries.

Background and Aims: For the achievement of clear bloodless surgical field, local infiltration of adrenaline is used routinely in Ear, Nose and Throat (ENT) surgeries. The present study was intended to study effectiveness of the addition of dexmedetomidine to local infiltration solution of lignocaine and adrenaline and any adverse effect associated with it. Methods: We recruited 80 patients in the age group of 18-65years by randomization posted for tympanoplasty or septoplasty under general anesthesia and divided into two groups of 40 each. Group A received local infiltration of 11.5ml of 2% lignocaine with adrenaline (1:200000) dilution with 0.5ml normal saline while Group D received local infiltration of 11.5 ml of 2% lignocaine with adrenaline (1:200000) dilution with 0.5ml (50µg) of dexmedetomidine. Monitoring involved-Heart rate, Blood pressure, Intraoperative surgical bleeding and Surgeon’s satisfaction score. Intraoperative isoflurane and fentanyl requirement was calculated. Student’s t-test was used for analysing statistical significance in time related variables. Results: Intraoperative tachycardia and hypertension which was seen after infiltration of solution of lignocaine and adrenaline was found to be abolished by addition of dexmedetomidine. Also dexmedetomidine containing solution significantly decreased intraoperative bleeding and thus increased surgeon’s satisfaction. Isoflurane and fentanyl requirement was significantly reduced in study group. Conclusion: Addition of dexmedetomidine to local infiltration solution of lignocaine and adrenaline in ear and nose surgeries provides a good quality surgical field with stable haemodynamics with decreased requirement of other agents for the purpose of clear field, enhancing safety of the procedure and patient and cost effectiveness.

Background and Aims: Induced hypotension reduces blood loss during functional endoscopic sinus surgery (FESS), provides better surgical field visibility and minimizes the incidence of major complications. We aimed at comparing nitroglycerine (NTG) and dexmedetomidine for inducing controlled hypotension in patients undergoing FESS. Material and Methods: Sixty adult patients of ASA physical status I or II, undergoing FESS under general anaesthesia were randomly allocated to two groups of 30 patients each. Group N received NTG infusion at the rate of 0.5-5 mcg/kg/min while Group D patients received a loading dose of Dexmedetomidine 1mcg/kg/min followed by an infusion at the rate of 0.2-0.7 mcg/kg/hr. The infusions were titrated to maintain mean arterial pressure (MAP) in the range of 65-75 mm Hg in both the groups. The visibility of surgical field was assessed by the surgeon using Average Category Scale (ACS) scores. The haemodynamic parameters, rescue fentanyl usage, emergence time and time to first postoperative analgesic request were recorded. Results: The desired MAP (65- 75mm Hg) could be achieved in both the groups. No significant intergroup differences were observed in ACS scores. The mean heart rate was significantly lower in Group D at various time intervals (P<0.05). Rescue fentanyl usage was significantly lower in Group D. Emergence time was significantly lower in Group N. Time to first analgesic request was significantly longer in Group D. Conclusion: Dexmedetomidine is comparable to Nitroglycerine for inducing controlled hypotension in FESS and provides good operative field visibility. Dexmedetomidine has the added advantage of reducing perioperative analgesic requirements.

Background: In regional anaesthesia and analgesia, maintaining better hemodynamic stability and minimal side effects is very much essential. A number of adjuvants have been combined with local anaesthesia’s (LA) to improve the effectiveness of LA. Therefore, in the present study, the efficacy of Bupivacaine with dexmedetomidine or Fentanyl as adjuvant in maintaining better hemodynamic stability was studied. Materials and Methods: 60 patients of ASA group-I and II aged between 18-60 years undergoing elective lower abdominal, urologic, lower limb surgeries were selected and divided into two groups of 30 each. Group “BP” received intrathecally 12.5mg 0.5% of Bupivacaine +5 µg of dexmeditomidine while group “BF” received 0.5% Bupivacaine +12.5µg of Fentanyl. Result: Group-BD and in Group-BF did not differ significantly (p>0.05) with respect to heart rate, SBP and DBP at any interval of time. There was an insignificant variation in the side effects of anaesthesia.VAS was 0.03± 0.18 in group BD and 0.10 ± 0.31 in group BF, which was statistically in- significant. Whereas, VAS of patients anesthetized by Bupivacaine with Dexmeditomedine or Fentanyl as adjuvantwas statistically significant at 3 hours and 12 hours (p<0.05). Conclusion: Bupivacaine with dexmeditomidine provided good quality of intraoperative analgesia with minimal side effectsandbetter hemodynamic stability.

Aims: To compare Platelet indices with SOFA scores of patients with sepsis in order to assess the relationship between platelet indices like MPV and PDW and the severity of sepsis. Settings and Design: A total of 100 patients with sepsis or septic shock as cases and 95 patients as controls (with out sepsis) were considered for this study. Patients and Methods: The SOFA scoring of the patients (both cases and controls) was done at the time of admission. The relationship between platelet indices and severity of sepsis obtained by prognosis of the patient using admission SOFA score was assessed. Statistical Analysis: Statistical analysis was performed using SPSS for Windows version 17.0. Results: In patients with sepsis, there was a significant difference (P<0.05) between the baseline values of platelet counts as well as platelet indices amongst the two groups. Conclusion: The findings of this study suggest that platelet indices are significant indicators of severity of sepsis. Intense supervision and aggressive treatment of sepsis patients with higher baseline platelet indices may prevent progression of disease.

Introduction: The sympathoadrenal response to laryngoscopy and intubation is hazardous in patients with hypertension, coronary artery disease, cerebrovascular disease and intracranial pathology. Various drugs are used to attenuate this stress response. Aim and Objectives: This study compares the efficacy of Esmolol and Magnesium Sulphate in attenuating the hemodynamic stress response to laryngoscopy and intubation. Methodology: Randomized prospective single blinded study was designed. Ninety patients of ASA PS I and II were randomly allocated into three groups of thirty each. P—received normal saline, E—Esmolol 1.5mg/kg, M—Magnesium Sulphate 50mg/kg. Statistical Analysis: ANOVA and Pearson chi square test were used. A p value <0.05 was considered as statistically significant. Tukey’s HSD was used to compare between groups. Observations and Results: The following observations were made. 1. Group E showed maximum attenuation of heart rate and blood pressure. 2. Group M also showed significant attenuation of blood pressure response but produced tachycardia on infusion of the drug. Heart rate response was not statistically significant compared to group E. 3. All patients recovered well. 4. Incidence of side effects was not significant between the groups. Conclusion: Esmolol is effective in blunting the intubation response followed by Magnesium Sulphate which blunts the hypertensive response but produces tachycardia during infusion of the drug. Placebo was ineffective in blunting hemodynamic stress response.

Background: Brachial plexus block is widely employed regional nerve block technique for upper extremity surgeries. Supraclavicular approach is most preferred as it is easy and gives consistency in results with minimal side effects. Various adjuvants have been added to local anesthetics to Prolong the duration of anesthesia. In our study, Dexamethasone has been added to ropivacaine to evaluate its effect on duration of analgesia. Aim: Evaluating the effect of adding dexamethasone to ropivacaine in supraclavicular brachial plexus block compared with ropivacaine alone. Materials and Methods: A Randomised prospective and double blinded clinical study. Seventy patients of ASA I and II of either sex, aged 20-65 years, undergoing various elective upper limb surgeries were equally divided into two groups and given supraclavicular brachial plexus block. Group A patients (n = 35) received 30 ml of 0.5% ropivacaine with distilled water (2 ml)control group whereas Group B patients (n = 35) received 30 ml of 0.5% ropivacaine with 8 mg dexamethasone (2 ml) made study group. The primary outcome measures were the onset of sensory and motor block, duration of analgesia and pain scores. Results: The onset of sensory and motor block was seen to be faster in Group B than Group A. Patients in group A required first rescue analgesia earlier (410.28± 38.70 min) thanthose of Group Bpatients (996.60 ± 56.60 min), which was found statistically significant (P < 0.002). The total dose of rescue analgesia was higher in Group A as compared to Group B, which was statistically significant (P < 0.00). Conclusion: Addition of dexamethasone (8 mg) to ropivacaine in supraclavicular brachial plexus approach significantly and safely prolongs sensory, motor blockade and postoperative analgesia more than that produced by ropivacaine alone.

Background: Clonidine, an 2-agonist, has been used intrathecally as an adjuvant to bupivacaine in spinal anaesthesia, for prolonging anaesthesia and postoperative analgesia. This study was designed to compare efficacy of two doses of intrathecal clonidine (15µg versus 30µg) for prolongation of anaesthesia, with maintainance of heamodynamic parameters, to find out lowest possible effective dose. Methods: Sixty patients, scheduled to undergo lower abdominal surgery, were enrolled. They were randomly divided into two groups, of 30patients in each group. Group BC15 received 15mg (3ml) of hyperbaric bupivacaine plus 15µg clonidine plus 0.1ml of normal saline and Group BC30 received 15 mg hyperbaric bupivacaine plus 30 µg (0.2ml) clonidine, thus keeping volume of injectable solution constant to 3.2 ml, in both groups. Results: Highest level of sensory block achieved, was recorded which was almost similar in both groups. Time taken to achieve highest level of sensory block , time to achieve two segment regression, time to achieve regression to L1 dermatome , time to first analgesic request , time to achieve maximum Bromage scale 4, time to achieve regression back to minimum Bromage scale 1 and haemodynamic changes, showed no stastically significant difference amongst both groups (P value >0.05). Conclusion: Both doses of intrathecal clonidine i.e.15µg and 30µg with bupivacaine, produce equal prolongation of sensory and motor block alongwith time to first analgesic request.So, clonidine15µg intrathecally with bupivacaine is preferred over 30µg or higher dose to achieve prolongation of desired sensory and motor block alongwith postoperative analgesia with clinically insignificant haemodynamic effects.

Introduction: Popliteal block is one of the rarely performed regional anaesthetic techniques because it requires great expertise in anatomical land marks and is often very technically challenging. Recent introduction of ultrasound technique for nerve blocks has gained popularity when comparing to the standard nerve stimulation technique. In this study, we have compared the success rate, duration of block procedureand complications between nerve stimulation and ultra sound guidance of popliteal block. Methods: 120 patients undergoing foot and ankle surgery were randomized to receive the block using either the nerve stimulation (n = 60) or the ultra sound technique (n = 60). Ropivacaine 0.25% (30 mL)was injected for both the groups. Results: Duration of the block procedure and block failure rate were significantly higher in nerve stimulation technique than the ultra sound technique (P value < 0.05). There were no differences in onset and duration of block between two techniques. The nerve stimulation guidance was associated with significant incidence of vascular puncture (13.3%) but ultrasound technique was safer with nil incidence of vascular puncture. Conclusions: Ultrasound guidance technique was better in lesser block procedure time and a good success rate (P value < 0.05) and was safer, with no incidence of vascular puncture.

Background and Aims: Propofol is widely used for induction of anaesthesia, although the pain during its injection remains a concern for all anaesthesiologists. A number of techniques have been adopted to minimise propofol induced pain. Various 5 hydroxytryptamine 3 antagonists have shown to reduce propofol induced pain. Hence, this placebo controlled study was conducted to compare the efficacy of ramosetron and lignocaine in terms of attenuation of propofol induced pain during induction of anaesthesia. Methods: Hundred adult patients, aged 18–60 years, posted for various elective surgical procedures under general anaesthesia were randomly assigned to two groups of 50 each. Group R received 0.3 mg of ramosetron, Group L received 0.5 mg/kg of 2% lignocaine. After intravenous (IV) pre treatment of study drug, manual occlusion of venous drainage was done at mid arm with the help of an assistant for 1 min. This was followed by administration of propofol LCT after release of venous occlusion. Pain was assessed with a four point scale. Unpaired Student’s t test and Chi square test/ Fisher’s exact test were used to analyse results. Results: In our study out of 50 patients of each study group, 54% in lignocaine group and 60% in ramosetron group did not have pain, 34% in lignocaine group and 24% in ramosetron group had mild pain, 10% in both groups had moderate pain, 2% in lignocaine group and 6% in ramosetron group had severe pain. Conclusion: Pre treatment with IV ramosetron 0.3 mg is equally effective as 0.5mg/kg of 2% lignocaine in preventing propofol induced pain.

Introduction: Chemically induced tranquillity improves acceptance of Regional Anaesthetic techniques. Intravenous sedative medications are useful for the same as positioning for surgery can be uncomfortable and spontaneous movements by an inadequately sedated patient can cause interference with the surgical procedure. To allay this problem, sedation remains as inevitable modality. Objectives: Comparison of the sedation properties and efficacy of Dexmedetomidine with Midazolam when used for intraoperative sedation during Regional Anaesthesia. Methods: Prospective, randomized study was carried out in 100 patients of ASA grade 2 & 3, above 60 years of age, weighing 40 to 90 Kg, of both genders, scheduled for elective procedures. In our study, patients were divided into 2 groups of 50 each with the help of a computer generated table of random numbers. They received either Dexmedetomidine or Midazolam intravenously during Sedation for Regional Anesthesia. Accordingly patients receiving dexmedetomidine were classified as group X1 and those receiving Midazolam as group X0. HR, MAP recorded in all patients and compared. Result: HR and MAP in Dexmeditomidine group is significantly low than Midazolam group. Conclusion: Dexmedetomidine can be considered superior than Midazolam as a sedative agent for sedation under Regional Anaesthesia in Elderly patients.