Indian Journal of Anesthesia and Analgesia

The trait is Autosomal recessive. Primary ciliary dyskinesia is the major patho-physiology with Sinusitis, Bronchiectasis and Situs Invertsus as the characteristic features. Preoperatively Respiratory and Cardiovascular system require special optimisation because of the presence of ciliary dysfunction, the management should be customised to avoid problems in the perioperative period. In present case few pre-emptive efforts like avoiding high FiO2, anticholinergics and thorough endobronchial suctioning utilizing fiberoptic bronchoscope before extubation helped us to avoid anticipated complications. Features important from anaesthetic view point include bronchiectasis and pan sinusitis causing airwayobstruction, gas trapping and arterial hypoxemia that can later proceedto acute respiratory failure.

There are special concerns in ophthalmic surgeries, as most of these patients are elderly patients with multiple systemic diseases, pediatric patients, often premature with congenital syndromes, some of them may have limited access to airway, there are concerns regarding oculo cardiac reflex, intraocular pressure and anesthetic interaction and systemic effects of ophthalmic medications.

Awake fibreoptic intubation (AFOI) is often the preferred method for airway management in patients with difficult intubation. The success of AFOI is highly dependent on use of various sedatives, in addition to adequate preparation of airway. Although various pharmacological agents like fentanyl, ramifentanyl, midazolam, ketamine, propofol have been used for conscious sedation during AFOI, most of them have respiratory depressant effect in higher doses. Hence there is a need for an ideal sedative agent for AFOI that will not cause respiratory depression, also minimize undue discomfort and anxiety. The purpose of this study was to compare the effectiveness of Dexmeditomidine with propofol for conscious sedation during awakefibreopticnasotracheal intubation. 

Methods: Eighty patients with ASA (American society of anaesthesiology) physical status I and II, with age group between 18 to 55 years, were randomly divided into Dexmeditomidine (D) and Propofol (P)group. Patients with Group D were given intravenous Dexmeditomidine (n=40) 1µg /kg infusion over 10 mins. Group P were given propofol (n=40) 70 µg /kg min over 10 mins. Airway prepared by topical anaesthetic and airway blocks. Effectiveness of Dexmeditomidine and Propofol for patient’s intubating conditions , patient’s tolerance as graded by a scoring system, and hemodynamic changes were evaluated . Results: AFOI was successful in all patients. The patient’s comfort score was better in dexmditomodine group. The dexmeditomidine group experienced fewer airway events and less heart rate response to intubation than the propofol group. 

Conclusion: Dexmeditomidine group allows better tolerance, more stable hemodynamic status and preserves a patent airway. 

Objective: To assess the analgesic effect of bilateral ultrasound-guided transversus abdominis plane- block (TAP) with bupivacaine compared with ropivacaine among pregnant woman undergoing a cesarean section. 

Methods: In this study, 60 parturient scheduled for cesarean section randomly received either 20 ml of 0.25% bupivacaine (n=21) or ropivacaine 0.375 % (n=39) in the transversus abdominis plane on each side at the end of surgery. The clinical endpoints such as pain intensity, time to the first analgesic requirement, number of pain medication used and nausea, vomiting, were measured at 2, 8, 12, 24, and 48 h following TAP block. 

Results: Both 0.375% ropivacaine and 0.25% bupivacaine showed a significant reduction in pain intensity. However, there was no statistically significant difference between the groups in pain intensity. Time for first rescue analgesia was seen first in patients under bupivacaine group than ropivacaine group. There was no significant difference in a number of analgesic doses between both the groups. Side effects like nausea and vomiting were comparable. 

Conclusion: Both 0.375% ropivacaine and 0.25% bupivacaine were safe and efficient in TAP blocks in parturients undergoing caesarian section. Time for first rescue analgesia was shorter in bupivacaine group compared to ropivacaine group. 

The haemodynamic response associated with laryngoscopy and tracheal intubation may be harmful to certain patients. The laryngeal mask airway (LMA) avoids the need for laryngoscopy and allows positive pressure ventilation of the lungs in appropriate patients. This study compared the haemodynamic response, ease of insertion and adequacy of ventilation, of tracheal intubation with that of LMA-Classic insertion in patients undergoing short surgical procedures. Sixty patients undergoing short surgical procedures between 18-60 years of ASA grade I and II were randomly allotted to one of the two groups of 30 each (group ETT vs group LMA). Laryngoscopic tracheal intubation or LMA-classic insertion was performed after induction of anaesthesia with fentanyl and propofol, and muscle relaxation with succinylcholine. Anaesthesia was maintained with halothane and nitrous oxide in oxygen. Haemodynamic response, ease of insertion and adequacy of ventilation was observed and compared. The increase in HR, SBP, DBP and MAP in the laryngeal mask airway group was significantly less than that in ETT group. Also the observed haemodynamic variables returned to baseline earlier in LMA group than in ETT group. There was no statistical difference observed in oxygenation and adequacy of ventilation between the two groups with no significant difference in periopertive adverse events in both the groups. Our study supports the usefulness of laryngeal mask airway as an alternative to endotracheal tube in airway management during general anaesthesia (with muscle relaxation) in appropriate patients for short surgical procedures.

Opioids and local anaesthetics administered together intra-thecally have potent synergistic analgesia. 

Aims and Objectives: To compare the efficacy of premixed versus sequential administration of fentanyl as an adjuvant to intrathecal hyperbaric bupivacaine following spinal anaesthesia in infra-umbilical surgeries. 

Methodology: This study was carried out in a tertiary care center where 140 orthopaedic, urology and general surgery patients scheduled for elective infra umbilical surgery under spinal anaesthesia were enrolled. All the patients were randomly divided into two groups with 70 patients in each group. Patients in group A received intrathecal hyperbaric bupivacaine 12.5 mg premixed with fentanyl 25 mcg. The drugs were mixed together in a single syringe just before intrathecal injection. Those in group B received fentanyl 25mcg followed by sequential administration of hyperbaric bupivacaine 12.5mg in a separate syringe intrathecally. The vitals were monitored and recorded, progression of spinal block was assessed and all data collected were analysed using appropriate statistical methods. 

Results: More patients in group A achieved a higher level of intrathecal block than in group B. However, time to regress L1 spinal level was significantly less in group B compared with group A (p-value 0.001). Also, patients in group B achieved maximum sensory level earlier than group A. Time to regression of motor block to Modified Bromage I was also significantly more in group B than in group A. Haemodynamically, there was no significant difference in the baseline heart rate and blood pressure between both the groups. After spinal anesthesia, heart rate and blood pressure (both systolic and diastolic) decreased in both groups minimally without statistical significance. Postoperatively, in both the groups very few patients required rescue analgesics. The incidence of adverse effects was comparable in both the groups without statistical significance. 

Conclusions: Fentanyl given sequentially in a separate syringe as adjuvant to intrathecal hyperbaric bupivacaine can result in faster onset of both sensory and motor block and prolongs the duration of spinal anaesthesia. Also, it minimises clinically significant side effects and reduces the postoperative analgesic requirements.

Context: Propofol is the commonly used intravenous drug to maintain adequate depth of anaesthesia in brachial plexus repair surgery under general anaesthesia without muscle relaxant. It has rapid onset of action, antiemetic effect and rapid emergence but causes respiratory and cardiac depression. Dexmedetomidine, an adrenergic agonist, with sedative, analgesic andanaesthetic sparing effects is an alternative intravenous drug to maintain depth of anaesthesia.

Aims: We designed a prospective study to see the effect of intravenous infusion of dexmedetomidine and propofol on haemodynamics, ionic balance and postop sedation in brachial plexus repair surgery under the guidance of entropy.

Methods: Fifty patients undergoing brachial plexus repair surgery were randomly divided into two groups of twenty five each. Group D group patients received 1μg/kg dexmedetomidine iv loading  dose for 10 min followed by infusion of 0.2 to 0.6 μg/kg/hr. Group P patients received propofol 1 mg/kg iv loading dose followed by infusion of 2 to 3 mg/kg/hr to maintain intraoperative entropy range from 40 to 60. Haemodynamics was noted at baseline, 1minute, 5 minutes, 10 minutes, 15 minutes, 30 minutes after intubation and later every 30 minutes till the end of the surgery. ABG was analysed at baseline, 2 hours after intubation and half hour before exbutaion Postop sedation score was noted immediate after extubation, 30 minutes and 60 minutes post extubation. Results: D group had significant lesser heart rate from the baseline. than P group. Systolic blood pressure, Diastolic blood pressure and Mean arterial pressure at 1 minute and 5 minutes after intubation, intraoperative state and response entropy were significantly lower than the baseline in P group than D group. P group also had more postop sedation score at extubation and 30 minutes post extubation than D group. ABG was maintained in the normal range, but P group had less pH, less Serum bicarbonate, and less base excess before extubation and less serum potassium 2 hours after intubation than D group. Other parameters of demographics, pO2, serum lactate, sodium, potassium and chloride were similar in both the groups. Conclusion: Intravenous Dexmedetomidine is an alternative adjuvant to propofol to maintain depth of anaesthesia for brachial plexus repair surgery with stable haemodynamics, blood gas towards normal range and low postop sedation scores.

Background: Brachial plexus block is a popular and widely employed regional nerve block of upper extremity which avoids the unwanted effect of anesthetic drugs. It has been proved in numerous studies that dexmedetomidine is harmless and effecient  in several spinal, epidural and regional anaesthesia in humans. Less exploration of dexmedetomidine in regional blocks was the reason for study. Objectives: To determine efficacy of anesthesia and analgesia between dexmedetomidine-bupivacaine and bupivacaine-alone in brachial block. Methods: After institutional ethics committee approval and patient consent, 70 Upper limb surgery patients, aged 18-60 years; ASA physical statuses 1 and 2were randomized into 2 groups. Group I and II received bupivacaine 0.5%+ 1ml Normal saline, bupivacaine 0.5% 15ml+ 100 mcg dexmedetomidine+ 15ml lignocaine+adrenaline, respectively. A pre-anesthetic checkup was done for all patients, which will include a detailed history, general physical and systemic examination. Results: There was no statistical difference in the heart rate and BP at the start of the procedure. Mean heart rate recorded in study group at 15minutes, 30minutes, 45minutes, 60minutes and 90minutes was statistically significant compared to control group. Mean BP recorded was significantly lower in study group at 15 min, 45 min, 60 min durations in comparison to control group, however it was similar in both the groups at the end of the procedure. Conclusion: In conclusion, dexmedetomidine added to 0.5% bupivacaine and 2% lignocaine + adrenaline is an attractive and safe option for improving the duration and quality of supraclavicular brachial plexus block in upper limb surgeries.

Introduction /Context: High incidence of difficult or failed intubation in pregnant patients is still a major challenge for anaesthesiologists. To evaluate airway changes in pregnant patients we used mallampatti grade and image J software at various intervals. 

Aims: To assess the upper airway changes in pregnant women at the onset of labour, following delivery and after 48 hours and to identify any predictive factors. 

Settings and Design: Methods and Material: 77 ASA II parturients admitted to the labour and delivery suite (early active labour, cervical dilatation 2-3 cm) were included in the study. Initial airway examination was graded according to the Samsoon modiûcation of the Mallampatti classiûcation(T1).Airway photographs were taken. The images were studied under Image J software and the area of opening of the oropharynx were calculated. 

Statistical analysis used: Mc Nemar Bowkar test, Wilcoxan signed ranks test and chi-square test. Results: Significant differences were seen in percentage of parturients in whom mallampatti grading changed more than 1, equal to 1 or more grade at T1-T2 (24.6%, P<0.05) T2-T3 (37.6%, P=0.036) T1-T3 (55.8%, P=0.00008). Mean area of opening of oropharynx with MPG grade 3 or less than 3 at T1 (59.38%) T2 (64.5%) T3 (80%). Significant changes were also seen in mean area change in parturients with MPG 3 or less than 3 at T2-T3 (29.5%) T3-T2 (37.75%) T3-T1 (54.04%). 

Conclusions: There is significant change in the airway of pregnant women undergoing labour and delivery and these changes are fully reversed by 48 hours after delivery. Our study conûrms the absolute necessity of examining the airway before anaesthetic management in obstetric patients

Background and Aim: The I-gel is the innovative second generation supraglottic airway device from Intersurgical. I-gel offers  unique advantages of easy insertion, reduced trauma, superior sealing pressure, and gastric access. Drugs such as propofol, sevoflurane are commonly used for supraglottic device insertion. The pharmacokinetic characteristics of Propofol allows for rapid onset and offset of drug effect with better blunting of airway reflexes compared to thiopentone. Midazolam is a wellestablished anaesthetic pre-medicant for short surgical procedures. The aim of the study is to compare propofol and propofolmidazolam for ease of I-gel insertion. 

Methods: Eighty patients, aged 18-45, were divided into two groups group P and Group PM. They received anaesthesia induction with propofol and propofol–midazolam after pre-medicating with Inj.Fentanyl 2micrograms/kg respectively. Patients in (group P) received IV normal saline 2ml followed by Propofol 2.5mg/kg for induction. Patients in (group PM) received IV Midazolam 0.04mg/kg three minutes before induction with propofol. The following conditions were assessed for ease of I-gel insertion such as number of insertion attempts, Jaw relaxation, coughing and gagging. The total dose of propofol, hemodynamic changes during induction were the other parameters recorded. 

Results: I-gel was successfully inserted at first attempt in 33 patient’s (80%) in group PM and 24 patients (60%) group P and it was statistically significant (p £0.03). The total dose of propofol consumed in group P (45.5±8.165) was more compared to group PM (44.65±6.483)
(p£ 0.002). Conclusion: I-gel insertion was swifter with better hemodynamic stability in propofol-midazolam than propofol alone for day care surgeries. 

Background: This prospective randomized double-blind study was designed to compare the analgesic efficacy and safety of intrathecal midazolam versus fentanyl as an adjunct to levobupivacaine for total abdominal hysterectomy. 

Methods: Sixty ASA grade I–II female patients undergoing total abdominal hysterectomy were randomly allocated into two groups. Group 1 (LM)– 3 ml of 0.5% isobaric levobupivacaine+2mg(0.4ml) of preservative free midazolam was given and in Group 2 (LF)- 3ml of 0.5% isobaric levobupivbacaine+12.5ug fentanyl(.25ml)+0.15ml of normal saline was given. The onset and duration of sensory and motor blockade, postoperative pain and the time to 1st rescue analgesia was noted. Patients were observed for hypotension, bradycardia, sedation, respiratory depression, pruritus, nausea and shivering. 

Results: The onset of sensory blockade was early in LM group(p- value <0.01). while duration of sensory blockade was comparable between the two groups(p-value >0.05). Onset of motor blockade was again early in LM group as compared to LF group (p value=0.007). The duration of rescue analgesia was significantly prolonged in group LM as compared with group LF (p-value <0.001). The incidence of pruritis was more in group LF while respiratory depression was more in LM group. 

Conclusions: Addition of midazolam to intrathecal levobupivacaine provides early sensory and motor blockade and also prolonged time for rescue analgesia when compared to LF group. The incidence of pruritis was less in LM group while sedation and respiratory depression was more as compared to LF group.
 

Laryngoscopy and endotracheal intubation are powerful stimuli which can increase the sympathetic activity leading to tachycardia, hypertension and dysrhythmias. These hemodynamic changes are associated with the release of catecholamine (cortisol, epinephrine and nor-epinephrine). To compare the effect of oral Pregabalin and Clonidine for attenuation of hemodynamic responses to laryngoscopy and tracheal intubation
 

Background: Pneumoperitoneum required for laparoscopy causes cardiovascular and pulmonary stress responses. Various pharmacological interventions have been used to attenuate those  sympathetic  response. N-methyl-D-aspartate(NMDA) receptor antagonists like ketamine have received great attention. We used low dose of ketamine 0.3mg/kg for attenuation of pressor response. 

Method: Patients scheduled for laparoscopic cholecystectomy were divided in group K (ketamine0.3 mg/kg)and group N(normal saline).Ten minutes before creation of pneumoperitoneum, the (group K) received ketamine 0.3 mg/kg diluted in normal saline intravenously whereas group N received same amount of normal saline. Hemodynamicparameters were monitored and results observed. 

Results: Heart Rate,Systolic Blood Pressure, Diastolic Blood Pressure, Mean Arterial Pressure were significantly attenuated in group K (p<0.001) as compared to group N. 

Conclusion: Low dose ketamine attenuates hemodynamic response in pneumoperitonium in laparoscopic cholecystectomy.
 

 Introduction: This study was conducted to assess the accuracy of ultrasound for estimation of appropriate sized endotracheal tube. 

Methods: Patients underwent preoperative ultrasound examination during pre-anesthetic check up by an Anaesthesia Resident under guidance of an experienced ultra-sonologist. Ultrasound assessment of various diameters of trachea was done and the size of endotracheal tube inserted during surgery was noted. The data was compared with clinically used endotracheal tube size to assess the sensitivity and specificity of ultrasound. Patients were monitored post-operatively over 24 hours for the post-operative complications such as sore throat, laryngeal edema, laryngospasm, nerve injury and aspiration of gastric contents. 

Results: A significantly higher tracheal diameter and ETT size was observed for males than females. The complications reported were Sore throat (8%) and Hoarseness of voice (4%). 

Conclusion: Ultrasonography, is trusted, non-invasive method for preanesthetic estimation of the subglottic tracheal diameter selection for clinical use and validated the reliability of ultrasound for subglottic diameter avoiding complications of either trauma or inefficient ventilation.

Aims & Objectives: To study the effect of Dexmedetomidine on hemodynamic parameters in cases of OPCAB during 

• Intubation,
• Intraoperatively during grafting and
• Postoperatively till extubation.
Methods: A prospective randomized double blind study involving 60 patients of either sex undergoing elective OPCAB was conducted; patients were randomly divided into two groups of 30 each. Patients received either Dexmedetomidine as loading dose of 1µg/kg over 10 min followed by a maintenance dose of 0.5µg/kg/hr (group A) or a placebo infusion of normal saline (Group B). The hemodynamic response during intubation, intraoperative hemodynamic variations, the heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure were recorded before extubation, during extubation, at 1, 3 minutes and every 5 minutes thereafter. Extubation quality was assessed on a 5 point scale and sedation by Richmond Agitation–  Sedation Scale. 

Results: In Dexmedetomidine group (group A) heart rate, BIS value was on the lower side compared to the placebo group (group B). The increase in heart rate in group A was significant only at 1 min after intubation whereas in group B it extended during 3rd & 5th min after intubation. The intraoperative variations in heart rate, mean arterial pressure (MAP), mean pulmonary arterial pressure (MPAP) were minimal in group A as compared to group B. There was significant increase in heart rate and mean arterial pressure (p<0.001) during extubation in group B. Ninety percent of patients in group A and 16.7% in group B could be extubated smoothly. The average time to extubate was 292.50±45.3 min and 255±56min minutes in groups A, and B respectively (P value 0.13). 

Conclusion: Dexmedetomidine is a good adjuvant to general anaesthesia, reduces the stress response to intubation and provides minimal variations in hemodynamic intraoperatively. Dexmedetomidine continued postoperatively provides adequate sedation and reduces the stress response to extubation without prolonging the time to extubation.

  Aim: To evaluate the time of onset, duration of sensory blockade & motor blockade, haemodynamic effects, time duration of post-operative analgesia as well as complications of intrathecal Bupivacaine 0.5% and intrathecal Bupivacaine 0.5% with Inj. Fentanyl 20 mcg in pre-eclamptic parturients opting for elective lower segment caesarean section. 

Material & Methods: A total number of 60 pre-eclamptic parturients with mild to moderate preeclampsia opting for elective lower segment caesarean section were included in a prospective randomized double-blinded control study. Parturients were assigned to receive spinal anaesthesia (SAB) randomly with hyperbaric Inj. Bupivacaine 0.5% 1.8 ml (Group B) or hyperbaric Inj. Bupivacaine 0.5% 1.4 ml along with Inj. Fentanyl 20mcg (0.4ml) (Group F), total of 1.8 ml. The onset, duration, and recovery from sensory blockade and motor blockade, time required to obtain maximum sensory blockade and duration of spinal anaesthesia were noted. The statistical analysis was done by Chi-square test and student’s t-test. 

Results: The onset of both sensory and motor blockade was slower in group B. The durations of sensory block (150±20.24 min) and motor block (135±18.06 min) were significantly long enough in the group F. Haemodynamic parameters were significantly stable in Fentanyl group. 

Conclusion: The addition of Fentanyl 20 mcg to subarachnoid block in mild to moderate pre-eclamptic parturients opting for elective lower segment caesarean section, increased the duration of analgesia, with less side effects and without adverse neonatal outcome. Thus, intrathecal Fentanyl is advantageous in pre-eclamptic parturients with minimal side effects. 

  Background: Epidural placement in lumbar spine is used to provide anaesthesia for surgeries below umbilicus. However the success depends on correct identification of epidural space taking into consideration anatomic variations. Studies have found that ultrasound is an useful tool to help in identification of the epidural space. Hence we used ultrasound to study the variability of skin to epidural space depth at various lumbar spinal levels. 

Study Method: We conducted a prospective observational study of 100 patients in age group of 40 to 60 years to compare the skin to epidural space depth (SED) at L1-L2,L2-L3 and L3-L4 space. We also compared the variation at these levels with respectto sex and BMI. 

Results and Conclusion: We found that the SED was highest at L3-L4 space with a mean distance of 4.15 +/-0.21cm from skin followed by L2-L3 (4.12 +/-0.22 cm) and least distance in L1-L2 space (4.1 +/-0.22cm). Age and sex had no correlation to the SED. However the SED had a significant correlation with the BMI (kg/m2) from which we could compute a formula. Mean (cm)=0.074(BMI)+2.534 where 0.074 is regression coefficient and 2.534 is a constant.

Introduction:  Fracture femur, a painful condition is common in the elderly patients with associated co-morbidities. Systemic NSAIDS increase the chances of epigastric pain, coagulation abnormalities where as opioids increases chances of delirium, altered sensorium, especially in this population [1]. Administration of block to overcome pain avoids the side effects of these analgesics. Proper patient positioning for regional anaesthesia is a challenge for the anaesthesiologists.  In this study our aim is  to compare perioperative analgesia and ease of patient positioning using fascia iliaca compartment block (FICB) and IV fentanyl. 

Objective: To compare the efficacy of FICB and IV fentanyl for perioperative analgesia, ease of positioning for spinal anaesthesia in patients with fracture femur, compare haemodynamic parameters. 

Method:  A prospective double blind study was conducted  on 60 ASA 1, 2 and 3 patients for 1 years in SRMS IMS, which were divided into 2 groups 30 patients in each group Group 1: Received the Fascia Iliaca compartment block with 20 ml of 0.2% Ropivacaine 15 minutes before the Subarachnoid block. Group 2: Received Intravenous fentanyl at 1 mcg/kg intravenously single dose15 minutes before the Subarachnoid block. VAS score, sitting quality and hemodynamic parameters were noted at regular time interval and were statistically analyzed. 

Discussion and Conclusion: FICB provides better positioning of the patient for spinal anaesthesia as compared to IV fentanyl and it also prolongs the duration of first postoperative analgesia.

Keywords: Fascia Iliaca Compartment Block; IV Fentanyl; Positioning; Fracture Femur.

  Background and Aims: Different additives have been used to prolong Brachial plexus block. We evaluated the effect of adding Dexmedetomidine to Ropivacaine for Ultrasound guided Supraclavicular Brachial plexus blockade. The primary endpoints were the onset and duration of sensory and motor block and duration of analgesia. Materials and Methods: A total of 60 patients (18-60 years) satisfying inclusion and exclusion criteria posted for elective upper limb surgeries under supraclavicular Brachial plexus block were divided into two equal groups (Group R and RD) in a randomized, double-blind fashion. In group RD(n= 30) 30 ml 0.5% Ropivacaine plus 2 ml (50 micrograms diluted to 2ml ) of Dexmedetomidine and group R (n = 30) 30 ml 0.5%  Ropivacaine plus 2 ml normal saline were administered in Ultrasound guided supraclavicular block. Sensory and motor block onset times and block durations, duration of analgesia, and side effects if any were recorded for each patient. Results: Demographic parameters were comparable in both groups. Onset time of sensory and motor block were shorter in Group RD (6.1±3.4 min and 8.9±3.08 min respectively)than in Group R (8.3±4.4 min and 13.0 ± 5.6 min respectively) (p = 0.001). Duration of sensory and motor blockade were longer in Group RD (630.50±208.2 min and 545.9±224.0 min respectively) than in Group R (400.8± 86.6 min and 346.9±76.9 min) (p = 0.001). Duration of analgesia was longer in Group RD (805.7±205.9 min) than in Group R (411.0±91.2 min) (p = 0.001). Intra-operative hemodynamics were significantly lower in group RD (P < 0.05) without any adverse sideeffects. Conclusions: Dexmedetomidine when added to Ropivacaine for Brachial plexus block shortens the onset time and prolongs the duration of the block and the duration of post-operative analgesia.

As bariatric surgeries is being accepted as safe procedure in India, it demands anesthesiologists to spruce up their knowledge and expertise as they play a vital role in safe perioperative patient management. This would require a thorough understanding of the pathophysiologic changes, surgical procedures and anesthesia case management for morbidly obese patients. The anesthetic management may be complicated by various comorbidities associated with obesity. Intubation, maintenance of oxygenation, fluid and pain management may be particularly challenging. In our experience, with proper perioperative care and vigilant monitoring, the incidence of intraoperative and postoperative morbidities and mortalities can be reduced. This study describes the anaesthetic experience in 103 consecutive patients of either sex with average body mass index (BMI) of more than 46.5kg/m2 who underwent laparoscopic bariatric surgery in the form of gastric bypass, sleeve gastrectomy and mini-gastric bypass at our institution. Data analyzed included demographic profile, comparison of BMI and ASA classification and associated medical problems. There were no incidences of life threatening complications. We conclude  that with proper perioperative care and monitoring the outcome of bariatric patients is excellent.

Background: Airtraq and Mc Coy laryngoscopes have been commonly used in difficult airway scenarios. In the present study, the study aims to evaluate the comparison of Airtraq from McCoy Laryngoscope in view of laryngoscopic time and ease of insertion in elective surgical patients. 

Methods: A prospective randomized prospective study was undertaken in 60 ASA I and II patients, 18-60 years of age scheduled for elective surgical procedures. Patients were randomly divided into two group Group M (30 patients) and Group A (30 patients). Following induction and adequate muscle relaxation, they were intubated using either of the techniques first, followed by the other. Laryngoscopy time, haemodynamic parameters, maneuvers required were recorded between Airtraq and Mc Coy group. 

Results: The mean intubation time of laryngoscopy in Airtraq group was 19.20 seconds whereas in McCoy group was 35.33 seconds. There was statistically significant difference between both the group on basis of number of attempts required for intubation (p-value=0.019). However there was no difference between two groups on the basis of ease of intubation, maneuvers required and complication. 

Conclusion: In terms of visualization of glottic area Airtraq laryngoscope is better in comparison to McCoy laryngoscope.

  Background: a2-agonist prolongs the duration of intrathecally administered local anaesthetics. This study was planned to investigate the effects of 45 µg and 90µg clonidine added to 0.5% intrathecal hyperbaric bupivacaine for postoperative analgesia. 

Materials and Methods: This prospective study was conducted in 90 patients of ASA grade I and II, both sex and aged between 20-60years. Patients were randomly allocated to Group A receiving normal saline+bupivacaine, Group B receiving a combination of 45µg clonidine+bupivacaine and Group C receiving combination of 90µg clonidine+bupivacaine. Sensory block, Motor block, sedation score and hemodynamic parameters were recorded. 

Results: Time for onset of sensory block (2.9±0.78 min) and motor block (6.27±0.98 min) was significantly lowest in group C (2.9±0.78 min). (p<0.01) The duration of analgesia was significantly higher in group C (495.33±34.2 min) (p<0.05). The motor block was most prolonged and intense in group C (2.0±0.0 score at 1.5 hr). Maximum sedation was seen at the end of 3 hrs with mean score of 2.1±0.37 in group C as compared to 2.1±0.3 in group B and 1.06±0.2 in Group A. There was no significance difference between the groups for fall of blood pressure. Hypotension and bradycardia were significantly higher in group B and group C as compared to group A, but was within acceptable limits. 

Conclusion: Intrathecal 90 µg clonidine seems to be the optimum safe dose because it significantly prolongs postoperative analgesia and markedly decreases supplementary analgesic demand with minimum hemodynamic changes.

Introduction: Lower limb surgeries were performed under popliteal block. Over the years Sciatic nerve has been blocked pre bifurcation by using peripheral nerve stimulator and blind techniques. But thanks to the Ultrasound which allowed us to visualize the branches of Sciatic nerve post bifurcation like tibial and common peroneal nerves in the popliteal fossa. 

Aims and Objectives: To compare onset of action of sensory and motor blockade between pre birfurcation sciatic nerve block with post bifurcation common peroneal nerve and tibial nerve block. 

Materials and Methods: This prospective randomized observational double blind study was conducted in 102 ASA I and II patients scheduled for surgeries on ankle and foot who were randomized into two groups A and B. Group A received 20ml 0.375% ropivacaine for tibial nerve and 10ml of 0.375% for common peroneal nerve post bifurcation whereas in Group B 30 ml of 0.375% ropivacaine was given pre bifurcation. Grade of Sensory and motor blockade were assessed every 5 minutes till complete surgical blockade and Block onset time were measured. 

Results: The Mean Onset of Block in group A was 18.5±4.1 min whereas in group B was 21.5 ±2.7 min (p <0.0001) which was statistically significant. Rate of complete sensory and motor block was also faster in group A compared to group B. 

Conclusion: Sciatic nerve block post bifurcation provides rapid onset of block and faster complete sensory and motor block compared to blocking the sciatic nerve before bifurcation.

 Background: In the present scenario there is an increased demand by the mothers for painless deliveries. Therefore the number of babies delivered by C Sections has increased. However it also necessitates one to study the effects of various agents and anesthetics used during such operations that may have immediate or long-term undesirable effects on physiological processes of newborns. With this background we tried to evaluate the newborns delivered by C section under general anesthesia using Scanlon’s scoring system. 

Methods: A total of 66 females were selected for the study based on including and excluding criteria. They were divided into two groups Group I (n=35) included females evaluated to have normal vaginal deliveries. Group II (n=31) included females for Caesarean section both elective and emergency. They were pre-anesthetically evaluated thoroughly. Both the groups were comparable in respect of maternal age, parity, birth weight, gestational age and duration of labor of each other. 

Results: Various assessments and scorings of Scanlon’s neurobiological behavioral scoring system collectively assessed as one more response called overall response. It signifies the integrity and commencement with response of central nervous system as, muscle tone, pinprick, sound, placing, alertness and decrement. Up to 24 hours of delivery overall response with low scores was noted in maximum no. of neonates in Group II as compared to Group I. Lastly, even at 48 hours of life, Group II with low scores was noted in more number of neonates as compared to neonates of Group I who has reached better scores. 

Conclusion: Assessment by Apgar scoring and application of Scanlon’s scoring system is different as far as clinical importance. Scanlon’s scoring system is highly recommended and sensitive evaluation of overall newborns  when central nervous system functioning is concerned.

Introduction: Intrathecal opioids potentiate the analgesic property of local anaesthetics. Hence, this study was conducted to evaluate the efficacy and safety of intrathecal Fentanyl (25mg) with hyperbaric Bupivacaine in lower limb orthopaedic surgery. 

Methods: 100 participants, aged 18 to 60 years, of ASA Physical status I and II, scheduled for lower limb orthopaedic surgery under subarachnoid block, were randomly divided into two groups (n=50 each); Group C received 3.0 ml (15 mg) 0.5% hyperbaric Bupivacaine + 0.5 ml Normal Saline (0.9%) and Group F received 3.0 ml (15 mg) 0.5% hyperbaric Bupivacaine + 0.5ml Fentanyl (25mg). Degree of sensory and motor block, quality of intraoperative anaesthesia, postoperative analgesia (VAS score), time of 1st  rescue analgesia (effective analgesia), hemodynamic variables and side effects were evaluated and compared. At VAS ³ 4, rescue analgesic Inj. Diclofenac Sodium intravenous was given. 

Results: Participants in Group F had faster onset and peak, with prolonged duration of sensory block (p<0.0001). Motor characteristics were comparable in both groups. Duration of analgesia was longer in Group F (179±12.08 min) than Group C (135±12.57 min) (p<0.0001). Effective analgesia was longer in Group F (350.1±34.02 min) than in Group C (292.5±31.94 min) (p<0.0001). Incidence of side effects was less in Group F. 

Conclusion: It is concluded that addition of 25mg Fentanyl with 0.5% hyperbaric Bupivacaine, in subarachnoid block, fastens and prolongs sensory block; also improves postoperative analgesia, with fewer side effects. 

Introduction: Pain in the postoperative period produces many physiological and psychological effects. Opioids when combined with local anesthetics for epidural analgesia provide effective pain relief by acting on spinal opiate receptors. They enhance the effect of pain relief and prolong the duration of analgesia. 

Aims and objectives: To compare the effects of Buprenorphine and Butorphanol when added to Bupivacaine for postoperative epidural analgesia with regards to onset and duration of analgesia, hemodynamic variables and sedation scores. 

Materials and Methods: This prospective randomized and double blind observational study was conducted in 100 ASA I and II patients scheduled for lower limb orthopedic surgeries and were randomized into two groups A and B. group A Patients received 8ml of 0.125% Bupivacaine+ 2mcg/ kg of buprenorphine Whereas group B received 8ml of 0.125% of Bupivacaine + 3mcg/kg of butorphanol. Onset and duration of analgesia, sedation, hemodynamic variables and side effects were recorded and compared between the two groups. 

Results: The mean onset of analgesia in groupA was 5.28 min compared to Group-B which was 8.8 min which is statistically significant (p<0.05). Duration of analgesia in
Group-A was 491.7 min compared to Group- B, which was 338.7min and statistically significant (P<0.05). Conclusion: We conclude that Buprenorphine added to Bupivacaine provides early onset and prolonged postoperative epidural analgesia compared to epidural butorphanol.

Context: Considering the potential difficulties associated with conventional laryngoscopy in difficult incubating conditions, airway devices that increase the ease of performing can have a profound clinical impact.

Aim: The current study compared the efficacy and safety of AirTraq (AirTraqR, Prodol Meditec, Vizcaya, Spain)l aryngoscope with Macintosh laryngoscope.

Settings and Design: The current study was aProspective, Randomized, single-blind controlled trial, conducted in Govt. Mohan Kumaramangalam Medical College Hospital, Salem, between May 2015 and January 2016. Total of 60 subjects requiring endotracheal anesthesia were randomly allocated to AirTraqR or Macintosh laryngoscope groups. Cormack-Lehane and Intubation Difficulty Score, intubating time, hemodynamic parameters and complication rate were compared.

Statistical methods used: Independent sample t-test. chi Square test/Fisher’s exact test and two way repeated measures ANOVA were used appropriately.

Results: Both groups were comparable in all the baseline parameters. The intubation difficulty score (1.47 Vs 0.17, p value < 0.001) and duration of intubation (17.2 Vs 11.03, p value < 0.001) were significantly higher in Macintosh group as compared to AirTraqR. AirTraqRgroup had a higher proportion of subjects in CL grade 1 (93% vs 43.3%, P value < 0.001). The proportion of subjects with airway trauma was also higher in Macintosh group (6.67% vs 10%, P value 0.64) as compared to AirTraqR group. A higher proportion of subjects in AirTraqR group were in Operator Grade I (93.3% Vs 66.7%). The hemodynamic parameters were comparable between the two groups.

Conclusions: AirTraqR laryngoscope shall be considered ahead of Macintosh laryngoscope, where ever feasible.

Introduction: Infraclavicular brachial plexus can be blocked by various approaches like classical infraclavicular(CIB), retroclavicular (RCB), parasagittal and pericoracoid. In our study we compared novel RCB approach with CIB approach using dual guidance of ultrasound and peripheral nerve locator.

Methodology: In this prospective, randomised trial, 60 patients were randomly allocated in to two groups CIB (n=30) and RCB (n=30). In the CIB approach, the needle is inserted 2 cm medial and 2 cm inferior to the coracoid process and directed from ventral to dorsal. In RCB approach, the needle insertion point was found  by palpating the supraclavicular fossa, just medial to the shoulder at a point sufficiently posterior to the clavicle and the needle was advanced from cephalad to caudal and block was given with 0.5% ropivacaine injection in the both groups. The primary aim of our study was to compare needle visualization and needling time and secondary outcomes studied were clinical success  rate of block, onset and duration of sensory block and motor block, and patient satisfaction between CIB and RCB groups.

Results: Needle visibility score in RCB was 4.8276 and in CIB 3.0714 which was significantly better in retroclavicular group (p=0.0453) and needling time in RCB was 2.8 mins and in CIB 4.67 which was lesser when compared to classical approach group (p=0.030). There were no statistically significant differences between the two groups in terms of sensory or motor block success, surgical success, patient satisfaction and complication rate.

Conclusion: The flat needle angle, needle visibility, and needling time was better in RCB in comparison with CIB. Hence we conclude that RCB can be considered as a better alternative to CIB approach. Further study in a larger patient population is needed to evaluate if utilizing the retroclavicular approach results in improved efficacy, increased safety, and more rapid acquisition of skill for novice regional anaesthetists.

Aim: This study was conducted with the aim of determining the optimal depth of ET placement in Indian adult population and its relation with vertebral column, height, weight, arm span length.

Materials and Methods: This was a prospective study which was carried out in 100 ASA grade I and II adult patients who were planning to undergo elective surgery which required orotracheal intubation during general anaesthesia.

Results: The airway distance from lip to carina was 22.38±2.59 cms in males and 20.92±3.55 cms in females; airway distance from lip to cricotracheal membrane was 13.67 ±0.59 cms in males and 11.99±1.66 cms in females; airway distance from cricotracheal membrane to carina was 9.10±6.58cms in males and 9.37±0.22cms in females; airway distance from endotracheal tube tip-carina was 3.21±1.11 cms in males and 2.22±2.58 cms in females; airway  distance from lip to endotracheal tube tip was 21.29±1.08 cms in males and 18.39 ±3.33 cms in females. The various airway distances in males and females were correlated with patient factors separately. The total airway length (L-C), lower airway length (CT-C) were significantly correlated with height, arm span, vertebral column length (P<0.05), but the correlation with upper airway length (L-CT) was not statistically significant. In females, both total and upper airway length was significantly correlated with height, arm span, vertebral column length. In case of BMI and airway distances, it was statistically insignificant in both males and females. It was found that the total and upper airway length correlated significantly with height, arm span and vertebral column length (P<0.01), when the various patient factors were correlated with airway lengths in all patients (males and females together). The coefficient of correlation was much less suggesting a poor correlation, the lower airway length was also found to have a statistically significant correlation with height, arm span and vertebral column length. BMI and airway distances were not found to be correlated.

Conclusion: The patient’s height correlates the best with the length of the airway. In Indian population, the mean airway distances were smaller so that the average depth of fixation was easier from right angle of mouth.