Indian Journal of Anesthesia and Analgesia

It is known that patients with pulmonary hypertension are at high risk for anaesthesia and surgery. Primary pulmonary hypertension (PPH) has now been replaced byidiopathic pulmonary hypertension or pulmonary artery hypertension (PAH). PAH is arareform of progressive fatal disease. Occasionally these patients may be posted for non cardiac surgeries.Ideal anaesthetic technique involves maintaining of stable pulmonary and hemodynamicparameters for a possible good outcome. Here we present a 31 year old female with severe pulmonary artery hypertension who underwent successful excision of a hugevulvalmass.

Background and Aim: Laparoscopic procedures are conventionally done under general anaesthesia for avoiding patient discomforts and shoulder pain due to pneumoperitoneum that occur during laparoscopy under spinal anaesthesia. Here a study was designed to look for the possibility of using right superficial cervical plexus block and intravenous dexmedetomidine infusion to reduce shoulder pain in patients undergoing laparoscopic surgery under spinal anaesthesia.

Materials and Methods: 50 patients of age between 18-60years with ASA grade I/II undergoing elective laparoscopic surgeries were given spinal anaesthesia with 0.5% hyperbaric bupivacaine and grouped as technique used. Group S (n=25) received right superficial cervical plexus block. Group D(n=25) received Dexmedetomidine  intravenously.

Result: No patients required conversion to general anaesthesia. VDS score for referred shoulder pain was statistically lower in group S compared to group D. Injection dexmedetomidine was associated with lower heart rate and blood pressure.

Conclusion: Right superficial cervical plexus block is more effective than dexmedetomidine for reduction of referred shoulder pain during laparoscopic surgery under spinal anaesthesia.

Background: Transversus abdominis plane block (TAPB) has emerged as a safe and effective regional anaesthesia technique for providing postoperative analgesia following lower abdominal surgeries. Complications associated with ultrasound guided TAPB are rare and pose a lower overall risk to the patient receiving TAPB versus caudal block (CEB), which is considered as gold standard for paediatric lower abdominal surgeries. Our study hypothesis was that TAPB would initially be equivalent to caudal block in providing postoperative pain control but would also show improved pain relief beyond the anticipated caudal duration.

Methods: This was a randomised controlled trial involving 80 children, 1-7yrs old, randomly allocated into one of the two equal groups; TAPB group (T-group) and CEB group (C group). Children underwent lower abdominal surgeries. All children received general anaesthesia using ketamine 2mg/kg and 1% sevoflurane. Group T received  0.5ml/kg of 0.25% bupivacine and group C received 0.75ml/kg of 0.25% bupivacaine under ultrasound guidance. Primary outcome measures were pain scores and duration of analgesia. Pain scores were assessed using Wong Baker FACES scale and FLACC scale. Secondary outcome measured were time taken for instilling the block, hemodynamics, and parent satisfaction and any other adverse events.

Results: TAPB patients had significantly longer duration of analgesia compared to CEB patients (p<0.001). Regarding pain scores, after 6hrs, there was a significant difference in the pain scores (p=0.02) between two groups with group T having low pain scores. There was no statistically significant difference in the time taken for instilling the block  (p=0.139). There was statistically significant increase in HR and MAP intra-operatively in group T patients (p<0.001) at 10 and 15min post block time. There was no statistically significant difference between two groups regarding parent’s satisfaction. (p=0.136).Thus pain scores were significantly lower in group T and duration of analgesia also lasted longer. None of our patients had any complications postoperatively nor did we have any exclusions.

Conclusion: Both CEB and TAPB give adequate analgesia during the early Post-operative period. However, TAPB results in prolonged analgesia beyond the anticipated CEB duration. Considering the safety profile of TAPB and avoiding the narcotics related side effects, this should be considered a preferred regional technique over CEB for lower abdominal surgeries whenever possible.

Aim: The aim of this study is to evaluate the effect of the low doses of ketamine and midazolam with bupivacaine intrathecally in terms of duration of analgesia and haemodynamic parameters.

Materials and Methods: This prospective randomized double blind study conducted in patients posted for Infra umbilical surgeries. Patients with physical status ASA I and ASA II with Infra umbilical surgeries like herniorrhaphy, varicose vein surgery, orthopaedic surgeries with less than 3 hr duration were taken up for the study.

Results: All demographic details are not significant. With addition of midazolam and ketamine the mean onset of sensory block is quicker compared to other two groups. with addition of midazolam and ketamine the mean onset of motor block is quicker compared to other two groups. With addition of Midazolam and ketamine the maximum sensory level and reached in higher compared to other two groups. With addition of midazolam and ketamine the duration of sensory block and motor block is prolonged compared to other two groups. With addition of ketamine and Midazolam the mean duration of  pain free interval is prolonged and rescue analgesics required are less compared to other two groups. In all three groups the mean systolic blood pressure was comparable and they are not statistically significant. The Vasopressors required in Group A and C were compared and they are not statistically significant. In Group B and Group C the sedation score was higher compared to Group A.

Conclusion: Low doses of preservative free ketamine (0.1mg/kg) and midazolam (0.02mg/kg) when added to bupivacaine intrathecally provides prolonged post operative analgesia without any significant side effects.

Background: Spinal anaesthesia has many advantages for elective surgeries, but the undesired effect of hypotension is to be managed by different interventions. Induction of the Bezold Jarisch reflex in the setting of decreased blood volume, mediated through serotonin is hypothesised to be one of the factors contributing to hypotension. Recent studies suggested that ondansetron, a 5-hydroxytryptamine subtype 3 receptor antagonist, given prior to spinal anaesthesia may reduce the hemodynamic changes.

Aims: To evaluate the effects of two serotonin receptor antagonists, ondansetron and granisetron in the spinal anaesthesia induced hypotension, bradycardia, sensory and motor blockade using hyperbaric bupivacaine in patients undergoing elective surgeries.

Methods: A prospective observational study on 300 patients scheduled for elective surgery under spinal anaesthesia was donedividing them into 3 with 100 in each group, receiving intravenous ondansetron 4mg granisetron 1mg and saline 2mL respectively. Spinal anaesthesia was given using 3 ml 0.5% heavy bupivacaine. Mean arterial pressure, heart rate, vasopressor use, sensory and motor blockade, their regression were assessed. Chi-square test was used for analysing incidence of hypotension, ANOVA test for changes in mean arterial pressure, vasopressor use, motor and sensory blockade characteristics. p value<0.05 was considered statistically significant.

Results: The ondansetron group, compared to granisetron and control groups showed a lower incidence of fall in mean arterial pressure, and vasopressor use [p< 0.05] No significant changes in heart rate, onset and regression ofsensory and motor blockade were noted among three groups.

Conclusion: Intravenous ondansetron 4mg given before spinal anaesthesia in elective surgeries significantly decreased hypotension and vasopressor usage. There were no significant inter group differences in incidence of bradycardia, motor and sensory blockade.

Introduction: Pain relief is important for reduction of postoperative morbidity necessitating continuing search for safe and efficient method in pediatric patients due to difficulty in pain assessment and concern of potential side effects. Single dose caudal epidural block is simple, effective and easy technique to perform due to anatomy of sacrum of child. There are reports of ropivacaine/bupivacaine being used routinely for  caudal anaesthesia (Bramwell, Kapsten) and the extension of its analgesic action in the postoperative period.

Aims & Objectives: To study and compare the effects of caudal ropivacaine and caudal bupivacaine for postoperative analgesia in pediatric patients w.r.t. duration and quality of postoperative analgesia, duration of motor blockade, hemodynamic effects and adverse  effects if any.

Methods: Comparative double blind prospective study included 100 patients of ASA grade I/II in age group of 2 years to 12 years posted for elective surgeries ( circumcision, herniotomy, hydrocoele repair etc). General anesthesia was given followed by a single shot caudal epidural in the left lateral position after completion of surgery. They were  randomly divided into two groups of 50 each, Group B – 0.2% ropivacaine 0.75 ml/kg. Group A – 0.125% bupivacaine 0.75 ml/kg.

Results: The mean duration of analgesia using caudal ropivacaine was 5.43 hrs and caudal bupivacaine was 5.38 hrs. The mean duration of motor blockade with caudal bupivacaine was prolonged 6.10 hrs and caudal ropivacaine was 3.16 hrs. No hemodynamic instability and adverse effects.

Conclusion: 1. caudal ropivacaine showed quality and duration of postoperative analgesia comparable to that of caudal bupivacaine. 2. The duration of motor blockade with caudal ropivacaine was short as compared to that of caudal bupivacaine 3.  Hemodynamic parameters were stable. 4. No any adverse effects.

Background: Regional anaesthesia is an established method to provide analgesia for patients in the operating room and during postoperative phase. Ultrasound (USG) guided femoral nerve block offers advantage over intravenous anaesthesia in the acute phase of traumatized patients and during the initial transport of injured patients.The primary objective was to evaluate the pain relief in fracture femur patients using USG guided femoral nerve blocks on arrival in the emergency department. The secondary objective was to compare requirement of supplementation of analgesic and complications in both groups.

Methods: This prospective interventional study enrolled a sample of 60 patients with fracture femur, 30 in each group. Control group includes patient with conventional  analgesia while, in study group ultrasound-guided femoral nerve block was given with inj. bupivacaine 0.25% 10ml in plane approach. Pain score on movement and rest were assessed at baseline and 1 hourly after the procedure for 24 hours.

Results: All procedures required one attempt, no complications and there was 66% pain relief in study group as compared to control where only 44% relative decrease in pain scores was observed,(P<.005) 1hr to 24hr after procedure.

Conclusions: USG guided femoral nerve blocks are feasible to perform in the emergency department. Significant and sustained decreases in pain scores were achieved with this technique.

Introduction: Ventilator Associated Pneumonia (VAP) is reported to be one of the most common nosocomial infection among patients who are mechanically ventilated in the Intensive Care Unit (ICU). The aim of the present study was to evaluate the effectiveness of implementation of VAP prevention bundle on the incidence of VAP and also to assess the microbiological profile of VAP infection.

Material and Methods: This thirteen-month study was conducted in the ICU of a tertiary care hospital in Northern India. First month was used for introducing the VAP bundle in the unit through education sessions and the remaining 12 months were used for assessing the effect of the VAP bundle on the rates of VAP infections. VAP bundle included head-ofbed elevation (between 30° to 45°), daily sedation interruptions and assessment of readiness to wean, maintenance of endotracheal cuff pressures of 20-30 cm of H2O, daily oral care with Chlorhexidine 2%, use of endotracheal tubes with subglottic suctioning system, peptic ulcer prophylaxis and deep vein thrombosis prophylaxis. VAP bundle compliance chart had to be filled daily. Patients aged more than 18 years and who were mechanically ventilated for more than 48 hours in the ICU were enrolled in the study. Patients who were intubated or on mechanical ventilation for more than twelve hours in areas outside the ICU, prior to admission, were excluded from the study. VAP was diagnosed by Clinical Pulmonary Infection Score (CPIS) and microbiological study of their sterile endotracheal aspirates.

Results: The overall incidence of VAP was found to be 23.2 VAP episodes per 1000 ventilator days which was low as compared to the VAP incidence before VAP prevention bundle implementation. The most predominant pathogen was found to be Acinetobacter species (48.21%). 48.21% isolates were Multi Drug Resistant (MDR) with Acinetobacter being the most common isolate.

Conclusion: Education and compliance with VAP bundle implementation helps to decrease the rate of VAP incidence. VAP with MDR organisms affects a significant proportion of patients who are mechanically ventilated in the ICU.

Background: Anaesthesia in dilatation and curettage (D & C) is administered with the dual goals of rapidly and safety establishing satisfactory procedural condition for the performance of therapeutic or diagnostic procedures while ensuring rapid predictable recovery with minimal post operative sequel.Therefore, we decided to use  Dexmedetomidine in 2 doses (1µg/ kg and 0.6µg/kg) with Ketamine (1 mg/kg) to provide procedural sedation in D&C and compare the efficacy and safety of dexmedetomidine 1µg/kg + 1mg/kg ketamine versus dexmedetomidine 0.6µg/kg + 1mg/kg ketamine for the procedure.

Material & Methods: This prospective randomized double blind study was conducted in department of Anaesthesiology of a Tertiary care hospital. In this study 80 patients scheduled for elective Dilatation and Curettage were included and divided equally in two groups.Group A- In this group 1µg/kg lnj. Dexmedetomidine was given, along with 1mg/kg lnj. ketamine IV and group B- Inthis group 0.6µg/kg lnj. Dexmedetomidine was given, along with 1mg/kg lnj. Ketamine IV.

Results: In our studythe mean age of patients in group A (41.5007 years) and group B (4 1.1008 years) differed insignificantly with p-value of 0.8254. The comparison of mean between two groups after giving dexmedetomedine was statistically significant in heart rate, DBP and SBP but respiratory rate & SpO2 was statistically not significant.

Conclusion: We have concluded that the comparison of baseline, intraoperative (after Ketamine) and post operative values of heart rate, systolic BP and diastolic BP showed that the values were better maintained in group A as compared to group B. Hence both the combination were comparable in safety but since the vital parameters were better maintained in group A, 1 µg/kg Dexmedetomidine + 1 mg/ kg Ketamine is better than 0.6 µ/kg.

Introduction: The comparison was made between the clonidine 200 ug and midazolam 15 mg to check the clinical efficacy in respect to the sedative, attenuation of hemodynamics, anxiolytic and antisialogogue response in adult patient undergoing general anesthesia.

Material and Methods: Total of 100 patients were included in the study, included patient belong ASA 1-2 physcial status and the age group of 20 – 50 years. Males and females, both genders were included in the study. Of the total 100 patients; they were randomly divided into two groups with 50 patients in each group. Patients included in the group 1 were given Oral clonidine 200 ug, 90 mins prior to the surgery. Patients included in the group 2 were given oral midazolam 15 mg, 90 mins prior to the surgery. General  anesthesia with thiopentone sodium, vecuronium, fentanyl, oxygen, nitrous oxide and sevoflurane were given to all the patients. Five point sedation score was used to assess the patient’s level of sedation. We recorded the baseline values before medication and 90 mins after medication. After intubation period of 1, 5 and 10 mins the hemodynamic parameters were recorded.

Results: The extent of sedation was seen in the patient given Midazolam as compared to the clonidine pretreated patients. In the clonidine group we see the antisialogogue effect. In the clonidine group all the haemodynamic parameters were well maintained throughout the period of study.

Conclusion: There was significant attenuation of pressor response to laryngoscopy and intubation in the clonidine group as compared to midazolam therefore drug of choice for premedication.

Introduction: Opioids when added to local anaesthetics in sub-arachnoid block decreases the dose of local anaesthetics and offers stable hemodynamics. Nalbuphine is an agonist-antagonist act on kappa receptors providing analgesia. Buprenorphine is a mixed agonist-antagonist narcotic with high affinity at both m and kappa opiate receptors.

 Aim: In this study we have compared the analgesic efficacy of buprenorphine and nalbuphine when added with bupivacaine in spinal anaesthesia.

Material and Methods: A randomized, double blinded, prospective study on 60 patients of ASA I and II undergoing lower abdomen and lower limb surgery under subarachnoid block was done. Patients were randomly allocated into two groups (n=30). Each group received 15 mg of 0.5% of injection bupivacaine heavy along with either 60ìg of buprenorphine (Group B) or 0.8 mg nalbuphine (Group N). Characteristics of sensory and motor blocks, haemodynamic changes, duration and quality of analgesia, adverse effects, sedation, visual analog score (VAS) score and analgesic requirement were studied at different time intervals.

Results: Onset of sensory block for Group N is 1.519±0.367 and Group B is 2.665±0.462. Onset of motor block for Group N is 4.639±0.976 and Group B is 3.686±0.373. Duration of sensory block in Group N is 170.60±24.42 and Group B is 237.93±16.43. Duration of motor block in Group N is 257.17±27.74 and Group B is 410.93±17.79. The duration of analgesia (in minute) was 295.60±18.95 in N Group and 566.43±42.19 in Group B. There was no significant difference regarding block characteristics and haemodynamic parameters. The adverse effects were less in N Group.

Conclusion: Onset of sensory and motor block was faster in Group N compared to Group B. The VAS scores showed that post operative analgesia lasted significantly longer in patients in group B than in group N. No significant side effects were observed in either of the two groups. Sub-arachnoid buprenorphine provides longer duration of post-operative analgesia compared to nalbuphine.

Context: The use of Brachial plexus block under Ultrasound guidance for Anesthesia has increased recently. Various adjuvants are added to enhance the analgesic effect of local anesthetic agents namely opioids, alpha 2 agonist,  dexamethasone, etc.

Aim: The aim of this study was to evaluate the effect of analgesic efficacy of nalbuphine as an adjuvant to 0.5% bupivacaine for interscalene brachial plexus block.

Settings and Design: This is a prospective randomized double blind control study conducted in Melmaruvathur Adhiparasakthi Institute of Medical Science & Research over a period of one year from June 2016 to June 2017.

Methods and  Material: Sixty patients of ASA I and II undergoing elective  shoulder surgery under Ultrasound guided Interscalene brachial plexus block were randomly allocated into two groups of thirty patients each to receive either 20mL of 0.5% bupivacaine with 1 mL normal saline ( Group I-Bupivacaine with control group) or 20mL of 0.5% bupivacaine with 1 mL of Nalbuphine 10mg (Group II- Bupivacaine with Nalbuphine). Onset and duration of sensory and motor block and duration of postoperative analgesia were observed.

Statistical analysis used: Statistical analysis was performed using appropriate test with Graphic prism 5.0 software.

Results: Addition of Nalbuphine with bupivacaine has faster onset of sensory and motor block and enhanced duration of sensory motor block compared to  bupivacaine alone with statistically significant difference (p<0.0001). Nalbuphine prolongs the duration of analgesia significantly (p<0.0001). None of the patients experienced any adverse hemodynamic changes and complications.

Conclusion: The present study explains that Nalbuphine 10 mg added to 0.5% bupivacaine in interscalene brachial plexus
block has significant increase in the duration of analgesia with no adverse effects.

Context: The critical period for a patient who was given general anaesthesia is the time during immediate recovery from anaesthesia. The PACU is a dynamic entity that greatly benefits the delayed recovery patients from research directed  interventions to guide the next level of care for post-operative health status.

Aim: The aim of this study is to determine peri-operative risk factors, morbidity and mortality of delayed recovery cases and correlate the outcomes of these patients with ASA physical status and Modified Aldrete’s recovery scores in the Post Anaesthesia Care unit (PACU) .

Methodology: After institutional ethics committee approval and written, informed consent, 434 adult patients belonging to both genders posted for general surgical elective procedures were included in this observational study. Delayed recovery patients were identified at the end of surgery using Modified Aldrete’s Recovery Score and shifted to PACU for further follow up until their discharge and  morbidity and mortality was recorded.

Results: Mean intra-operative blood loss and mean duration of surgery were proportionally increased as the ASA physical status is high = 0.000, statistically significant. As the pre-operative ASA physical status grading is increased the percentage of patients that had more than 48 hrs PACU stay also increased and it was statistically significant with p = 0.029. As the ASA grade increases the recovery scores were inversely proportional, p=0.029 statistically significant.

Conclusion: Preoperative co-morbid conditions, ASA physical status and Modified Aldrete’s Recovery Scores are good predictors of postoperative outcomes for patients given general anaesthesia.

Background: Succinylcholine is a depolarizing muscle relaxant, provides ideal muscle relaxation for surgical procedures along with anesthetics. Which is extensively used short acting muscle relaxant, with several undesirable side effects. These side effects are muscular fasciculations, postoperative muscle pains, rise in serum potassium, rise in intraocular tension and intragastric pressure. Nondepolarizing muscle relaxants like Atracurium and Rocuronium are better in reducing the fasciculation and myalgia in comparison with other drugs. Hence,our main aim of this study to compare the effect of  Rocuronium and Atracurium on Succinylcholine induced myalgia.

Methodology: We compared the incidence of  postoperative myalgia (POM) with Atracurium (ATR) and Rocuronium (ROC) in different groups prior to Succinylcholine for tracheal intubation by using ASA class 1 or 11 in all patients posted for surgery under general anesthesia.The subjects were assigned to one of three groups: group 1 received Normal saline 5ml; group 2 received 0.05 mg/kg Rocuronium; and group 3 Atracurium 0.05mg/kg. Thiopentone was administered 1min 45 sec after pretreatment to induce anesthesia. Three minutes after, Succinylcholine 2 mg/kg was given, and fasciculations were recorded on a scale of 03. Postoperative myalgia was assessed at 6,12 and 24hrs by questionnaire and graded 03.

Results: Patient demographic profile and baseline parameters were comparable and there were no differences between these groups. Post operative myalgia though it is seen more with NS and Atracurium than Rocuronium. There was no statistical differences seen at 6, 12 and 24 hrs after surgery.

Conclusion: The severity of Succinylcholine induced Post operative myalgia was reduced significantly with Rocuronium than Atracurium.

Background: Several general and local anesthetic techniques have been employed to try and prevent increase in intraocular pressure during surgery. Interest in general anesthesia for intraocular surgery is relatively recent. Many surgeons now prefer full anesthesia and indeed the increasing scope of ophthalmic surgery demands it. This study was therefore undertaken to know the changes in intraocular pressure, during various steps of general anesthesia using thiopentone sodium or ketamine for induction and suxamethonium (succinylcholine) for neuromuscular blockade.

Material and Methods: Sixty patients between the age group of 1-75 years were selected for this study. These patients were divided into two groups –I and II. The patients in groups were given general anesthesia and were operated for either ophthalmic or non – ophthalmic indications. A detailed general examination (including measurement of blood pressure) and systemic examination was done to rule out any systemic disorder which would directly or indirectly affect the measurement of intraocular pressure during the course of the study. Routine blood and urine investigations were done.

Results: The mean fall in intraocular pressure after induction as compared to mean baseline intraocular pressure was 2.48±1.32 in group – I. The mean rise in intraocular pressure after induction as compared to mean baseline intraocular pressure was 2.67±2.08 in group-II. This difference in the intraocular pressure after induction in group -I was statistically highly significant as compared to group -II (p<0.01).

Conclusions: Thiopentone sodium can be safely used as an inducing agent in any intraocular surgery done under general anesthesia. Ketamine, as far as possible, should be restricted to extraocular ophthalmic surgeries.

Background: A number of adjuvants to local anesthetics have been used intrathecally to prolong analgesia. So, the present study was planned to study the effect of intrathecal bupivacaine with neostigmine versus clonidine as an  adjuvants in lower abdominal surgeries.

Material & Methods: 128 patients of ASA physical status grade I and II, aged 30- 50 years, scheduled for lower abdominal surgeries under spinal anesthesia of a tertiary care teaching hospital were randomly selected in two groups of 64 each; Group BN:12.5 mg (2.5 ml) of 0.5% bupivacaine + 25 µg neostigmine with total volume made up to 3.0 ml with normal saline and Group BC:12.5 mg (2.5 ml) of 0.5% bupivacaine + 50 µg clonidine with total volume made up to 3.0 ml with normal saline. Sensory block characteristics, motor block characteristics, time to first rescue analgesic were recorded. Any adverse effects were also noted.

Results: Time to reach T10 sensory level was 2.53±0.58 min in Group BC and 2.33±0.60 min in Group BN which was statistically comparable (p= 0.06). But time to reach peak sensory level was 8.14±0.77 min in Group BC as compared to 6.38±0.79 min in Group BN (p<0.01). The mean duration of sensory block was 321.72±8.32 min in Group BC and 301.72±27.6 min in Group BN (p<0.01). All patients of both groups achieved Bromage score of 3 signifying complete motor block. Duration of motor block was significantly longer in group BC  (223.36±14.39 min) as compared to group BN (204.53±10.64 min) (p<0.01).

Conclusion: Clonidine as adjuvant to bupivacaine results in significant prolongation of duration of sensory blockade and analgesia as compared
to intrathecal neostigmine.

Background: Introduction-Intravenous regional anesthesia (IVRA) is a simple,reliable and cost effective technique for surgeries involving the distal arm.It has the advantage of speed of onset,rapid recovery, reliability of blockade and cost effectiveness. Various adjuvants have been added to local anesthetics to increase the speed of onset and duration of post operative analgesia.The aim of the present study is to compare the effects of adding fentanyl versus dexmedetomidine to lignocaine during IVR.

Materials and Methods: This study included 60 patients of ASA class 1 and 2 of either sex aged between 20-50 years scheduled for various  upper limb  surgeries.Patients were randomly divided in to two groups of 30 each.Group LF received 40ml of 0.5% lignocaine with fentanyl 2µg/kg and group LD received 40ml of 0.5% lignocaine with dexmedetomidine 1µg/kg. Postoperative pain score was recorded using Visual Analogue Scale (VAS). Injection paracetamol 1gram intravenous infusion was given as rescue analgesic when VAS score reached >4. Duration of postoperative analgesia was noted from deflation of torniquet to VAS score of 4. Patients were observed for adverse effects like skin rash,bradycardia and sedation intraoperatively and postoperatively following torniquet deflation in both the groups.

Result: Earlier onset time of both sensory block  (4.80±0.60min)and motor block (8.60±3.20min)were noted in group LD compared to sensory block(6.82±1.50min)and motor block (10.80±1.20min)in group LF.Postoperative analgesia was also considerably prolonged in group LD(350.52±42.5min)compared to group LF(204.42±32.5min). Adverse effects like bradycardia and sedation were noted in two and four number of patients respectively in group LD.

Conclusion: The addition of 1µg/kg dexmedetomidine to lignocaine when compared to 2µg/kg fentanyl in IVRA  reduces the time for onset of block, increases the duration of block. Improves quality of anarsthesia prolonged post operative analgesia and reduced rescue analgesia requirement.

Aim: To evaluate the efficacy of Ropivacaine and Bupivacaine in spinal  naesthesia in children for infraumblical surgeries as regional anaesthesia in children and ambulatory setup is gaining popularity.

Materials and Methods: This is a randomized controlled study involving 60 children of age between 7 and 12 years posted for elective infraumblical surgeries under spinal anaeshesia. They are allotted into two groups, Group R receiving 0.5% ropivacaine and Group B receiving 0.5% bupivcaine. The onset of sensory block, maximum height of sensory block, time taken to reach the maximum height of sensory block, two segment regression time, onset of motor block, mean duration of sensory & motor block and quality of block were noted. The  hemodynamic parameters noted are pulse rate, systolic and diastolic blood pressure, oxygen saturation with pulse oximeters.
Statistical Analysis used: Chi- Square test.

Results: There was significant delay in onset of sensory and motor block in ropivacaine group. There was earlier two segment regression time, earlier offset of sensory and motor block and time taken for micturition was earlier in ropivacaine group. The quality of block was adequate in both groups. The hemodynamic parameters were well  maintained in both groups.

Conclusion: Ropivacaine provides a good alternative to bupivacaine in case of short duration of surgeries. It is more suitable in cases of ambulatory surgeries where the patients meet the discharge criteria earlier and can be discharged from the hospital.

Background: Many anesthetic drug combinations have been used in patients to improve regional anesthesia. This study was planned to compare the analgesic and sedative effects of dexmedetomidine and clonidine as an adjuvant to bupivacaine in patients undergoing lower limb surgeries.

Material and Methods: This prospective study was conducted in 50 patients of ASA grade I and II, aged between 18-65 years. Patients were randomly allocated to Group BC receiving 30ml of 0.5% bupivacaine + 2 mg/kg of clonidine and group BD receiving 30 ml solution of 0.5% bupivacaine + 1.5 mg/kg of dexmedetomidine. Onset and  duration of sensory and motor blocks, duration of analgesia, sedation, and complication if any were recorded.

Results: Group BD resulted in an earlier onset (8.52±2.36 min) of sensory analgesia at T10 as compared to Group BC (9.76±3.44 min). (p<0.05) Time to onset of motor block was significantly shorter in group BD (17.42±5.16 min) as compared to group BC  (19.76±4.06). (p<0.05) Time for rescue analgesia was comparatively shorter in group BC (310.76±23.75 min) as compared to group BD (344.88±28.16). (p<0.05) Mean sedation score 3 was significantly higher in group BD (40%) as compared to group BC (16%). (p<0.0001) The incidence of dry mouth was higher in both the groups but it was statistically non-significant in both the groups (p>0.05).

Conclusion: Dexmedetomidine was found to be better adjuvant than clonidine with bupivacaine because of better analgesia effect, sedative effect and also hemodynamically stable during the surgical procedures under anaesthesia.

Background: In major surgeries, anesthesia plan requires modification as per patient’s need for safe outcome. Orthopedic and gynecological surgeries require excellent surgical conditions and prolonged and effective postoperative analgesia.

Objective: To compare the safety measures of combined spinal epidural anesthesia verses epidural anesthesia.

Materials and Methods: The randomized prospective study was conducted on 20 to 60 years old ASA grade (I and II) patients posted for orthopedic and gynecological surgeries. Sixty patients were divided into two groups of 30 each such as group A (combined spinal epidural) and group B (epidural anesthesia). Various parameters were studied to compare safety parameters of combined spinal epidural  anesthesia and epidural anesthesia in terms of quality of analgesia, hemodynamic changes and opinion feedback (patient’s opinion regarding comfort and acceptance of  technique, surgeon’s opinion regarding quality of relaxation and preference of technique). Data was analyzed using unpaired t test and chi square test with the help of MS Excel and SPSS software.

Results: The quality of analgesia was excellent in group A (CSE) as compared to group B (EA). Hemodynamic changes during anesthesia and surgery were comparable in both the groups. Surgeon’s opinion regarding motor blockade and preference of technique was in favor of group A compared to group B. Patient’s acceptance revealed equivocal in both groups.

Conclusion: Our study concludes that CSE anesthesia is more safe technique over EA for patients as well as surgeons.

Context: Carbon dioxide is most commonly used to insufflate the abdominal cavity to facilitate short laparoscopic surgeries, where the real challenge lies in management of pathophysiological changes due to hypercarbia.

Aim: To study the effects of hypercarbia on respiration in short laparoscopic procedures such on diagnostic laparoscopy and laparoscopic sterilization.

Settings and Design: An observational study on 60 female subjects aged between 25-45 years presenting for diagnostic laparoscopy forinfertility, laparoscopic sterilization of ASA I & II category.

Methods and Material: Anaesthesia was given by ketofol Intravenous induction and sevoflurane 1% with CO 2/N2O insufflation of abdomen. The pre, intra, postoperative pulse, BP, O2 saturation, Respiratory rate, EtCO2 were noted with special reference to preinsufflation, during insufflation & deflation of abdomen.

Statistical analysis used: Descriptive analysis was carried out by mean and standard deviation and presented in trend line diagram, error  bar diagram for quantitative variables, frequency and proportion for categorical variables.

Results: Pre anesthesia Respiratory rate was 13.13±1.09. A1.75 time rise was noted in Respiratory rate (24.43±3.42) to maintainnormocarbia during insufflation.

Conclusions: Spontaneous Ventilation is effective in maintaining normocarbia during short laparoscopic procedures. Endotrachal intubation and paralysis to maintain normocarbia could be avoided.

Introduction: Proseal LMA produce very less sorethroat and cough when compared to the endotracheal tube in paediatric patients for short duration surgeries.

Aim: To compare the pediatric proseal LMA with endotracheal tube for intubation in pediatric patients undergoing elective surgeries short duration under general anesthesia with respect to ease of insertion, hemodynamic response and complications.

Methodology: After getting consent and Ethical committee approval eighty patients were selected based on the inclusion and exclusion criteria and randomly allocated into one of the 2 equal groups GROUP P-Proseal laryngeal mask group and GROUP T-Endotracheal group. General anaesthesia given as per routine in our hospital. Group P Proseal LMA of 2 size inserted. GROUP T: Appropriate sized Endo tracheal tube inserted. Maintained with nitrous oxide 66% and oxygen 33% with sevoflurane 0.2-0.4%. Hemodynamics, number of attempts and failure of insertion noted.

Results: Using endotracheal tube 92.5% patients were intubated in the first attempt, 3 (7.5%) required a second intubation attempt. In the proseal laryngeal mask airway group, the first attempt success rate was 82.7% (31 patients). A second attempt was required in 17.3% (9 patients). Heart rate was significantly higher in ETT group during the first Ten minutes of insertion than the Group P. More incidence of cough with ETT while more incidence of blood on the device with proseal LMA. Data analysed using chi square and student t test.

Conclusion: we concluded that the proseal laryngeal mask airway could be an effective alternative to endotracheal intubation in children undergoing short duration elective procedures under general anaesthesia.

Central venous access has become a mandatory part for clinical management of critically ill patients, both in acute care setting and chronic long term care. However, anatomical landmark guided technique for IJV cannualation is not devoid of complication like carotid arterial puncture and pneumothorax. In this prospective, randomized, controlled, clinical trial, we compared and assess the anatomical landmark guided technique for IJV cannulation with USG guided technique in terms of success rate, no. of attempts and complications. Sixty four patients of either sex, between age group of 18 –70 years requiring either elective or emergency CVC placement, were randomly divided to 2 groups, Group USG: USG guided technique and Group ALG: Conventional or anatomical landmark guided technique. Venous access time and catheterization time both were found to be statistically significantly less in USG group compared to ALG group (p<0.0001). Successful cannulation in 1st attempt could be done in more no. of patients in USG group (26 patients) compared to ALG group (6 patients) (p<0.00001). Success Rate was 87.5% in Group ALG while it was 100% in Group USG. Which was statistically highly significant (p<0.05). Overall Complications rate was 25% versus 3.125% in Group ALG and group USG respectively which was statistically significant.(p<0.05).Ultrasound guided central venous catheter placement is easy, safer and prudent approach than anatomical landmark guided technique hence should be encouraged to improve patient’s safety and quality care.

Background: Paramedical staff is the cornerstone of health care system. Knowledge of paramedical staff regarding different specialty is of paramount importance for the  efficient delivery of healthcare services. As anesthetist are frequently involved in the emergency care of a patient, knowledge of paramedical staff regarding anesthesia and the role played by anaesthetist can help in the efficient and timely delivery of health care needs of patient which ultimately results in the better patient outcome.

Aim: To assess paramedical staff’s knowledge regarding anesthesia and anesthetist.

Method: 100 paramedical staff posted in the different department were selected for the study. They were administered a set of questionnaire face to face orally by an investigator and responses from individual participant were recorded. The data collected were subjected to simple statistical analysis.

Results: 75% of paramedical staff knew that anesthetist is a specialist doctor. 40% of participant knew that anesthetist are concerned with the post-operative care of a patient and only 25% of candidates were aware of role of anesthetist in ICU. Very few participants knew about the role of anesthetist in providing trauma care and labor analgesia.

Conclusion: Every paramedical staff should be made aware of the different roles played by the anesthetist apart from providing anesthesia to surgical patients. This will finally result in the better utilization of anesthesia services, better patient satisfaction, and better patient outcome.

Objective: To evaluate the intubating conditions with rocuronium at. 6mg/kg (2*ED95) and 0.9mg/kg (3*ED95) at 60 seconds using the timing principle.

Methods: 60 patients were divided into 2 groups of 30 each. Group A received 0.9mg/kg and group B received 0.6mg/kg of rocuronium. Intubation was done at 60 s. The Train of four monitoring was done at the adductor pollicis muscle. The TOF count at intubation and time to loss of TOF were noted and compared.

Results: Intubating conditions were excellent 13 (65%) in group A compared to 9 (45%) in group B and was statistically significant. The TOF count at  intubation was not statistically significant (p=0.677) between the groups where as time to loss of TOF (p=0.03) were significant between the groups.

Conclusion: Intubating conditions were better in group A in comparision with group B but both the groups provided clinically acceptable conditions for intubation. The use of train of four count at the adductor pollicis as a guide for laryngeal muscle paralysis is questionable.

Introduction: Propofol (2,6 di-isopropyl phenol) is widely used agent for induction of anesthesia, although the pain during its injection remains a concern for all anesthesiologists. The incidence of Propofol injection pain (PIP) varies between 28% to 90% in adults. Despite several interventions and pretreatment with drugs to alleviate pain, the failure rate is 13-32%. The aim of this study was to find the most efficacious method of alleviating PIP by combining  intervention of venous occlusion along with Lignocaine, Dexamethasone or Ondansetron pretreatment.

Methods: This is a double blinded randomized prospective clinical study on adult patients between the age group of 18-59 years scheduled for elective general surgical procedures. 150 patients were randomly allocated through computer generated table into three groups scheduled to receive 2ml of Lignocaine (20mg), Ondansetron (4mg) or Dexamethasone (6mg). Drugs were administered after tourniquet application inflated to 40mm Hg and occlusion was released after 30 seconds and then 0.5mg/kg of propofol was administered at the rate of 0.5ml / sec. The blinded investigator evaluated the pain score using the four point scale at 15 second interval. Statistical analysis was made by SPSS version 16.

Results: The incidence and intensity of pain in patients receiving Lidocaine and Dexamethasone were significantly lower than those receiving Ondansetron (p<0.001).

Conclusion: Pretreatment with intravenous Dexamethasone and Lidocaine along with venous occlusion for 30 seconds was found to be equally effective in reducing Propofol injection pain. Both these drugs were found to be superior to Ondansetron in achieving this goal.

Background: Spinal blockade provides excellent anesthesia for patients undergoing lower segment cesarean section (LSCS). However hypotension after spinal anesthesia is a common adverse effect that is commonly experienced in patients undergoing cesarean section. So our aim is to analyze a simple technique like leg elevation for decreasing the incidence of post spinal hypotension and vasopressor requirement in parturients undergoing cesarean section under spinal anesthesia.

Materials and Methods: Sixty full term patients posted for elective cesarean section belonging to ASAI and II were divided into two groups. Patients preloaded with Ringer lactate at 10 ml/ kg prior to the spinal anesthesia. Spinal anesthesia was given with 0.5% Bupivacaine heavy 2ml. Patients in Group C lower limbs will not be raised and in Group LE will have their legs elevated at 30° with two pillows underneath the calf muscles after spinal anesthesia. The hemodynamic parameters were monitored every 3 minutes until the delivery of the baby and every 5 minutes till the end of surgery. If hypotension occurred, then along with crystalloid loading a bolus dose of inj. Mephentermine 6 mg was given.

Result: Incidence of hypotension in Group C (46.6 %) was significantly more compared to group LE (23.3%). Dose requirement of vasopressor was also significantly less in Group LE.

Conclusion: Legs elevated with two pillows underneath the calf muscles was the simple ,easiest and effective method of controlling post spinal hypotension in caesarean patients and needs to be practiced routinely.

Introduction: Critical events under anesthesia can cause sudden and dramatic complications. Recognition and analysis of such events helps to improve OR practices (in order to prevent recurrence of the same); thereby improving the overall quality of anesthetic practice. Unlike other countries which have national registries to capture such incidents, India relies on a voluntary and non-standard reporting of critical incidents under anesthesia. None of these papers have studied anesthesia-related complications in patients who have predominant renal dysfunction.

Materials and Methods: A retrospective audit was performed of all critical incident reports filed in our department from 01/01/2015 to 31/12/2015. The data was analyzed to identify the incidence, causes and outcomes of these events.

Results: Of 1217 anaesthetics administered, 2.54% of patients had reported adverse events during surgery. Most complications occurred in the elderly patients (41.9%) and those who were ASA grade III or above (45.1%). More than half (54.8%) of the complications involved the cardiovascular system. There were two deaths during  this period (mortality=0.16%).

Conclusions: Though anesthesia related complications have declined dramatically with the use of advanced monitoring and safer drugs, there is still potential for improvement. Use of checklists and standard protocols can help mitigate much of the human error associated with these critical events. The larger proportion of cardiovascular complications in our patients is probably a reflection of the higher incidence of cardiovascular complications in patients who have renal dysfunction.

Keywords: Critical Events; Critical Incident Reporting; Anaesthesia; Anaesthesia Mortality; Critical Incident Reporting Form;
Renal Insufficiency Chronic.

Background: Anesthetist most of the time feel that they have not been given the credit they deserve. They have been treated as behind the screen specialist. Their role has never been appreciated by the patient. Most of the time patient’s knowledge about anesthesia andanesthetist is limited.

Aim: To assess patient awareness regarding anesthesia and anesthetist  

Method: After approval from the institutional ethical committee, 200 participants cheduled for various surgical procedures were randomly selected. After obtaining informed written consent, they were administered a set of questionnaire face to face orally by an investigator and their responses were recorded separately. The data collected were subjected to simple statistical analysis.  

Result: Out of 200 patients, only 40% knew that anesthetist alleviate the pain of surgical procedure by putting the patient to sleep. Only 30% of participants said that anesthetist is a specialist doctor. Hardly very few patients knew about the role of anesthetist outside the operation theatre.

Conclusion: Awareness of patients about anesthesia and anesthetist is very much limited. Lack of recognition and appreciation of the role of anesthetist by the patients contributes to the frustration of anesthetist. Hence, every opportunity to spread awareness about  anesthesia and anesthetist among patients must be utilized for the benefit of both patient and the anesthetist.