Indian Journal of Anesthesia and Analgesia

Context: SAB is safe and effective technique for TURP, offers advantage of easy identification of TURP syndrome, bladder perforations but, associated with hemodynamic changes like hypotension and bradycardia in geriatric patients with coexisting cardiac and respiratory diseases. Hence the study had been undertaken with low dose bupivacaine in combination with tramadol. Aims: To evaluate the efficacy of very low dose bupivacaine with tramadol as an alternative to conventional dose of bupivacaine in TURP surgeries. Settings and Design: Randomised double blind prospective study. Methods and Material: 64 patients scheduled for TURP surgeries, aged 55-75 years with ASA-PS I and II were recruited and randomly divided into 2 groups. Group I-injection bupivacaine 0.5 ml (2.5 mg)+ preservative free tramadol 1 ml (50 mg) diluted with 0.5 ml NS intrathecally. Group II-injection bupivacaine 2 ml (10 mg) intrathecally. Statistical analysis used: Data analysis: SPSS 22 version software; Categorical data: frequencies and proportions; Continuous data:mean+ SD. Tests of significance: Chisquare test and independent t test. p value < 0.05: statistically significant. Results: Attainment of sensory blockade in group I was slow ie., 8.44 ± 2.35 min compared to that in group II ie., 6.53 ± 1.65 min and the two segment regression is faster in group I ie., 65.38 ± 20.52 min compared that of group II ie., 86.78 ± 36.88 min which were statistically significant. The time for rescue analgesia was significantly higher in group I ie., 312.56 ± 137.42 min compared to group II ie., 256.97 ± 130.46 min. The degree of motor blockade was less in group I. There were no significant changes in heart rate and SpO2, but the fall in MAP in group II was significant compared to that in group I. Conclusions: 50 mg preservative free Tramadol added to intrathecal bupivacaine 2.5 mg offers adequate anaesthesia, stable hemodynamics, early ambulation and prolongs analgesia.

Background: Emergence Agitation is a very common phenomenon seen after nasal surgeries, can be due to the nasal packing done and feeling of shortness of breath. We did this study to investigate the efficacy of Inj. Dexmedetomidine infusion to reduce the incidence of emergence agitation in adults undergoing nasal surgeries. Methods: 60 adult patients undergoing nasal surgeries were randomized into two groups. The Group-D (n=30) receive dexmedetomidine infusion at rate of 0.5 mcg/kg/hour from starting of induction of anesthesia and stopped before extubation while Group-P (n=30) received normal saline infusion as placebo. Induction of anesthesia was done with Inj. Propofol (2-2.5 mg/kg) & fentanyl (1 mcg/kg) and sevofluarane used for maintainance of anesthesia. The incidence of Emergence Agitation (EA) evaluated by Ricker’s Agitation sedation scale (RSAS) and intraoperative haemodynamic stability were evaluated in study. Results: Incidence of Emergence agitation was lower in Group-D than Group-P. Mean arterial blood pressure & heart rate were stable intra operatively and during emergence agitation in Group-D as compared to Group-P. There was no delay in extubation observed with no residual sedation in group D. Conclusion: Emergence agitation in the early post extubation phase following general anesthesia is a prevelantphenomenon seen during nasal surgery patients in adults. Intra operative dexmedetomidine infusion reduces postoperative Emergence Agitation (EA) and provides good intra operative haemodynamic stability in adults undergoing nasal surgeries without any respiratory depression and delayed extubation.

Background: Laryngoscopy and endotracheal intubation is often associated with hypertension and tachycardia because of sympatho-adrenal stimulation which is usually transient. In patients with cardiovascular and cerebrovascular diseases, the sudden hemodynamic response can produce deleterious effects in the form of myocardial ischaemia or infarction, arrhythmias, cardiac failure, raised ICP and cerebral haemorrhage. In view of this, the present study was undertaken to evaluate and compare the effects of 2% Lignocaine 2 mg/kg nebulization given 10 minutes and 2% Lignocaine 2 mg/kg iv given 90 seconds before induction for attenuation of intubation response. Materials & methods: Sixty ASA Grade I & II patients in the age group 20-60 years of either sex scheduled for elective surgeries under general anaesthesia were allocated into Group A and Group B with the sample size of 30 in each. Group A received nebulization with 2% lignocaine 2 mg/kg 10 minutes and Group B received 2% lignocaine 2 mg/kg intravenous 90 sec before induction. Heart rate, systolic and diastolic blood pressure and mean arterial pressure and SpO2 were recorded, basal values and subsequently at 1st, 3rd, 5th, 7th and 10th minute after intubation. Results: It was noted that, Group A, the rise of HR, SBP, DBP, MAP at 1 min after intubation were found to be 24.86 bpm, 9.6 mm Hg, 20.44 mm Hg, 22.30 mm Hg respectively. In Group B, the rise of HR, SBP, DBP, MAP were found to be 11.7 bpm, 3 mm Hg, 2.61 mm Hg, 4.77 mm Hg respectively. Conclusion: It was seen that use of lignocaine has suppressed heart rate and blood pressure changes to laryngoscopy and endotracheal intubation. In fact intravenous lignocaine has better suppressing property than nebulization of lignocaine.

Background: Pain is an integral part of all surgery and is the biggest cause of apprehension amongst patients. This apprehensive behavior creates a feeling of dissatisfaction with the pain relief methods used conventionally. Easy availability, ease administration and economical makes a method of analgesia successful (Lehmann et al.). Inj. Tramadol is a synthetic agonist opioid analgesic without any preference for any particular type of opioid receptor. Its presence in the central neuraxial system mediates the nociceptive action when given either intra thecally or epidurally. Aim: The present study was designated to compare postoperative analgesic efficacy and safety of epidural tramadol vs. intrathecal tramadol along with its physiological side effects. Study Design: Prospective, randomized-controlled, blinded trial. Methodology: 60 patients of either sex, ASA status I or II and posted for abdominal surgeries, gynecological surgeries, orthopedic surgeries were studied in two groups to receive either Inj. Tramadol intra thecally (Group II) along with spinal anesthesia or Epidurally (Group I) along with single shot epidural anesthesia. Duration and quality of analgesia (visual analog scale [VAS] scores), hemodynamic parameters, and adverse event were recorded and statistically analyzed using Chi square test and a p value of <0.05 was considered significant. Results: Mean duration of analgesia after epidural bolus of opioid tramadol was 9.86 ± 2.19 hours as compared to intrathecal tramadol which was significantly higher 14.23 ± 1.76. VAS score was always lower in Group I in comparison to other group during the study at various intervals. Hemodynamic parameter remained stable in both the groups. Conclusion: We conclude that tramadol 0.5 mg/kg with bupivacaine 0.5% intrathecally provides more effective and longer-duration analgesia than tramadol 1 mg/kg with bupivacaine 0.05% when given epidurally.

Introduction: Shivering can be defined as a physiological response to core hypothermia. Occurrence of shivering is common in patients of regional anesthesia as well as general anesthesia. Shivering cause some serious health consequences so efforts should be taken to prevent or treat at earliest. Aim: To compare efficacy and safety of butorphanol over tramadol as anti-shivering agent under spinal anesthesia and to watch for any side effects. Material and Methods: A prospective randomized comparative study was conducted in 80 patients who developed shivering under spinal anesthesia posted for lower limb orthopedic surgeries. At onset of shivering, patients were randomly allocated in two study groups and study drug was given as slow intravenous injection. Group B - Injection butorphanol (1 mg) 1 ml slow iv. Group T - Injection tramadol (50 mg) 1 ml slow iv. Time taken to complete control of shivering, failure rate, recurrence rate, hemodynamic changes and side effects (nausea, vomiting, itching and sedation) were recorded during study period. Data were collected and analysed using statistical methods. Result: Response rate is similar in both groups. At 1 min post treatment, butorphanol group had more patients with complete control of shivering. There was significantly less chance of reccurence in butorphanol group. Hemodynamic parameters were comparable in both study groups through entire study. Butorphanol treated patients had mild to moderate degree of sedation than tramadol group. Conclusion: Both butorphanol and tramadol are effective in control of shivering under spinal anesthesia. Butorphanol has advantage of faster onset and lesser recurrence rate, only disadvantage being mild to moderate sedation which may warrant observation of respiration.

Context: Role of anesthesia for total abdominal hysterectomies is concerned with relieving pain during both intraoperative and the postoperative period. Several adjuvants are used to enhance the quality and duration of epidural anesthesia. Aims: We compared clonidine and dexmedetomidine as additives to levobupivacaine for epidural analgesia with emphasis on onset and duration of sensory block, duration of analgesia, and adverse effects. Settings and design: It is a randomized, double blind and prospective study conducted in tertiary care center. Subject and Methods: Sixty patients of American Society of Anesthesiologists (ASA) physical status Classes I and II who underwent total abdominal hysterectomies were randomly allocated into two equal groups. Group LC received 10 ml of 0.125% levobupivacaine + 1 µg.kg-1 of clonidine and Group LD received 10 ml of 0.125% levobupivacaine + 1 µg.kg-1 of dexmedetomidine through the epidural catheter. We evaluated onset of analgesia, time of peak effect, duration of analgesia, cardiorespiratory vitals, adverse effects, and need of rescue analgesics. Statistical analysis: Student’s t-test and chi-square test. Results: Group LD demonstrated early onset, fast peak effect, prolonged postoperative analgesia, and stable cardiorespiratory vitals when compared with Group LC. There was a statistically significant reduction in analgesic requirement in group LD as compared to group LC. There were no major adverse effects in either group. Conclusion: As compared to clonidine, dexmedetomidine is a better neuraxial adjuvant to levobupivacaine, since it provides early onset, prolonged postoperative analgesia and stable cardiorespiratory vital parameters, without increasing adverse effects.

In today’s era, multimodal analgesia is the main strategy used for providing postoperative analgesia in patients undergoing knee surgeries yet 25-40% patients experience severe postoperative pain [1]. Intravenous opioids, epidural analgesia and non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used analgesics but have many systemic side-effects [2]. Peripheral nerve blocks have minimal systemic sideeffects and ultrasonography guided peripheral nerve block isa preferred method for providing pain relief. The femoral nerve block (FNB) was widely used for knee surgeries but it had the disadvantage of prolonged quadriceps muscle weakness which can be minimized by Adductor canal block (ACB). Therefore ACB has been introduced recently for knee surgeries. Thus, we decided to compare the efficacy of USG guided femoral nerve block and adductor canal block for postoperative analgesia in knee surgeries. Our study included adult patients undergoing knee surgeries. Fifty patients were randomly divided in two groups – group A: (n=25) received adductor canal block; group F: (n=25) received femoral nerve block, postoperatively. Both blocks were performed under USG guidance after complete wearing off of central neuraxial blockade. The average duration of sensory blockade for group F was 6.53 hours ± 4.64 while for group A was 5.77 hours ± 1.30 which was statistically not significant (p value >0.05). However, we found statistically significant difference in motor blockade in group A as compared to group F (p value <0.05). Thus we conclude that USG guided Adductor canal block effectively provides comparable postoperative analgesia to femoral nerve block while preserving the quadriceps muscle strength.

Background: Now days, more and more patients with cardiovascular disorders are presenting themselves for surgery so anaesthesiologists are in search of safe and efficient drugs and techniques which can prevent cardiovascular responses due to laryngoscopy and intubation. Clonidine possesses beneficial effects on haemodynamics during stressful conditions like laryngoscopy and endotracheal intubation. We undertook this study to compare the effect of different doses of clonidine in attenuating the presser response to laryngoscopy and intubation in patients posted for elective surgery under general anaesthesia. Materials and Methods: This prospective randomized double blind controlled study was conducted on ASA Physical Status I and II patients in the age group of 20–60 years of either sex, scheduled for elective noncardiac surgeries under general anaesthesia requiring endotracheal intubation. Group A received 20 ml normal saline IV as infusion over 15 min whereas Group B, C and D received IV Clonidine 1, 2 and 3 µg/kg respectively, diluted to 20 ml with normal saline as infusion over 15 min. The parameters recorded were HR, SBP, DBP and MAP at 1,2,3,5,10 and 20 min after intubation. Postoperatively, heart rate, blood pressure, oxygen saturation (SpO2) and sedation level were noted at 1 hour interval for 6 hours. Results were compiled and statistically analysed. Results: After laryngoscopy and intubation, the mean heart rate and blood pressure (SBP, DBP and MAP) showed a much lesser increase in clonidine treated groups B and C as compared to control group A and this was dose related. In clonidine treated group D, the mean pulse rate and blood pressure even did not show any rise despite the stimulus of laryngoscopy and intubation and remained near the basal value throughout the study period but this was clinically not worrisome and did not required any therapeutic intervention. The heart rate and blood pressure (SBP, DBP and MAP) returned to baseline values much earlier at 5 and 2 minutes in clonidine treated groups B and C respectively. Patients in all the three clonidine treated groups showed a dose related higher level of sedation as compared to control group. Conclusion: Clonidine at all the three different doses not only attenuated the intensity of haemodynamic responses to laryngoscopy and endotracheal intubation but also decreased the duration of the response. The effect of clonidine was clearly protective and was dose related.

Objectives: The study was designed to compare the respiratory mechanics of the patients with either I-Gel or ProSeal LMA as airway device during positive pressure ventilation while undergoing laparoscopic hernia repair surgeries. The other parameters compared are ease of insertion and airway trauma. Methodology: This randomized control study was conducted in our tertiary care hospital. 110 patients of ASA PS class 1-2 were randomly divided into 2 groups of 55 each. Premedication and anesthesia technique were standardized in both the groups. One group had PLMA as their airway device and the other group had I-gel as their airway device. We compared the respiratory mechanics (dynamic compliance, airway resistance and peak airway pressure) of these patients during positive pressure ventilation. The other parameters compared were ease of insertion and airway trauma. Results: I-Gel is a better device compared to PLMA in terms of dynamic compliance, peak airway pressure, airway resistance and ease of insertion was higher with PLMA. There was no significant difference in blood staining after removal of the device or trauma to lips, tongue and teeth between two groups. Conclusion: From our study, we concluded that I-Gel is a better device compared to PLMA in terms of dynamic compliance, peak airway pressure, airway resistance and ease of insertion. There was no significant difference in blood staining after removal of the device or trauma to lips, tongue and teeth between two groups.

Background:Hip fractures in elderly is a common occurrence around the world and is associated with increased morbidity and mortality. Adding to this burden is the inadvertent pain management occurring frequently in the Emergency Department due to the fear of adverse effects of the administered pharmacotherapy. Hence, newly developed, safer Ultrasound guided nerve block modality is the cornerstone in the management of pain in these special populations attending the Emergency Department. Objectives: To determine the efficacy of Ultrasound (US)-guided three-in-one femoral nerve block as compared to intravenous opioids alone for analgesia in the elderly patients presenting to the Emergency Department (ED) with hip fractures. Methods: This was a single centre, pragmatic randomised controlled open-label trial. Older adults (age>55 yrs) with radiologically confirmed hip fractures were randomized into either of the two treatment arms: US-guided three-in-one Femoral Nerve Block plus Intravenous Morphine (FNB group) vs Intravenous Morphine alone Standard Care (SC group). Pain relief was measured with a 11-point numerical rating scale (NRS). Secondary outcome measures included the amount of rescue analgesia received and occurrence of adverse events (respiratory depression, hypotension, nausea/vomiting). Results: Thirty patients in each arm completed the study. There was no significant difference between the two groups with respect to baseline characteristics. There was a significant decrease in pain intensity over time in FNB group (p<0.001). The primary outcome measure, SPID over 1 hour was significantly greater in the FNB group [292.0(225-330) vs 106.5(45-195), p<0.001]. With regard to second outcome measure, parenteral opioid use, FNB group received significantly less parenteral opioid than those in the SC group [0.8 mg vs 9.5 mg, p<0.001]. Conclusion: US-guided femoral nerve block as an adjunct to intravenous opioids resulted in: 1) Significantly reduced pain intensity; 2) Decreased amount of rescue analgesia received; 3) Significantly reduced adverse events due to opioids. Hence, our study supports the routine use of US-guided three-in-one femoral nerve block for pain management in hip fractures in the ED.

Context: Emergence agitation is a post anesthetic phenomenon commonly associated with ENT surgeries. We studied the effects of maintenance infusion of Dexmedetomidine on prevention of Emergence agitation in adult patients undergoing FESS. Aims: To see the effects of intraoperative dexmedetomidine infusion on incidence of emergence agitation and recovery characteristics in terms of cough, pain and nausea vomiting scores. Settings and Design: A prospective, randomized, controlled, double blinded comparative study done at our institute. Methods and Material: One hundred patients undergoing FESS surgery were randomized into two groups. Group D (n=50) received dexmedetomidine infusion at a rate of 0.5 μg kg−1 hr−1 from induction of anesthesia until extubation, while group C (n=50) received volume-matched normal saline infusion. The incidence of agitation and recovery characteristics in terms of Cough score, Nausea vomiting score and Pain scores were evaluated in both groups. Statistical analysis used: Parametric data were analyzed using oneway ANOVA and the Student’s paired t-test where appropriate. Non parametric data were analyzed using Chi-square test. A value of p < 0.05 was considered statistically signicant. Results: The incidence of Emergence Agitation (Ricker sedation agitation score ≥ 5) was higher in group C compared to group D (p <0.001). Recovery characteristics in terms of Cough score (p=0.118) and Nausea vomiting score (p=0.589) were similar in both groups, while Pain score was higher in Group C compared to Group D (p<0.001). Increase in Heart rate and MAP at emergence was more in Group C compared to Group D. Conclusions: Dexmedetomidine as an adjuvant to general anesthesia for FESS is an excellent drug to reduce Emergence agitation, provide better postoperative pain relief and also maintains stable hemodynamics at emergence.

Low back pain is a symptom and not a disease which can lead to suffering, sadness and sleeplessness and hence physical limitation and disability. It’s a universal problem the etiology of it can be viscerogenic, neurogenic, vascular, psychogenic, spondylogenic, ergonomic, obesity. The major pitfall is to miss a treatable cause in the rush to treat the symptoms. Kelly et al. 1956 postulated that inflammation of nerve root from the compression causes pain and neurological changes. Various modalities of treatment are available including injection therapy, current therapy and surgery with a conservative approach before going for definitive treatment. Epidural injection of local anesthetics (Viner 1925), steroids (Kepes and Duncalf 1960), interferential current therapy (Tidy 1968) were the various modes tried for treatment of symptoms – the aim being to reduce the inflammatory response, restore the electric equilibrium of the affected cell membranes. This present study was undertaken to break the cycle of pain and thus providing better life style to the patient which in turn helps early mobility relieving the muscle spasm and further reducing the pain. Patients with low backache of neurogenic and spondylogenic in nature were taken in consideration. Those patients who didn’t respond to conservative approach were subjected to receive either epidural steroids (Methyl prednisolone) or Interferential Current therapy. Epidural Methyl Prednisolone 80 mg with Inj. Bupivacaine 0.125% and Inj. Buprenorphine 0.1 mg was used followed by NSAIDS orally for whole duration of treatment of 30 days. The other group received interferential therapy at a dose of 30 mv medium frequency at the maximum point of tenderness followed by physiotherapy and NSAIDS for a period of 90 days. The patients were observed for the effectiveness of both modalities of treatment in terms of symptom free life style, early rehabilitation and psychological well being using General Health Questionnaire both pre and post procedure.

Background: Successful Cardio Pulmonary Resuscitation for a good patient outcome requires teamwork and appropriate knowledge amongst health professional is necessary. Uniform protocols can be put in place only if hospital personnel have sound knowledge of Basic Life Support, which is achievable with regular training alone. We conducted this study to assess the knowledge and attitude among medical faculties, interns and students regarding BLS at our institute. Methods: An observational study was conducted at a tertiary care hospital from Gujarat, India. A self-prepared questionnaire was distributed to the participants and based on their responses; the percentage of knowledge and attitude regarding BLS was assessed. Results: Total 230 participants (94 faculties/senior residents, 36 junior residents/medical officers and 100 students/interns) were included in the study. For the purpose of analysis the faculty/SRs were divided in two groups based on their involvement in emergency services. The mean score (out of 15) for Faculty/ SR (Emergency) was 7.3, Faculty/ SR (Non- emergency) was 6.5, JR/ Mo was 8.1 and Student/ Intern was 8.0., indicating that Faculty/ SR (Non-emergency) scored significantly lower. Only one participant scored between 91-100%, five between 81-90%, 20 (8.7%) between 71-80%, 89 (38.69%) scored 51-70% and 115 (50%) scored less than 50%. Trained participants scored better versus those who were untrained (p = 0.0012). Years of clinical experience did not affect the knowledge scores (p = 0.3905). Conclusion: Overall knowledge of the doctors and students of our Institute was not satisfactory which warrants an Institutional policy for regular BLS training.

Background and Objective: Transversus abdominis plane (TAP) block is a recently introduced regional technique that blocks abdominal wall neural afferents between T6 and L1 and thus can relieve pain associated with an abdominal incision of lower segment cesarean section. This study was conducted in 60 female patients to assess visual analogue scale (VAS) for pain score, requirements of rescue analgesics, patient’s and surgeon’s satisfaction score, side effects and complications if any. Method: After institutional review board approval and informed written consent from patients, Patients were randomly allocated to one of the two groups of 30 patients each. In Group T (TAP block with 15 ml of 0.25% Bupivacaine bilateral + Diclofenac Sodium 75 mg intravenous 8 hourly) given and in Group C (Diclofenac Sodium 75 mg Intravenous 8 hourly) given. The assessment of presence and severity of pain was done for 24 hours. At any point of time if VAS is ≥ 4, intravenously Paracetamol 1 gm was given to the patient as a rescue analgesic. Result: The mean VAS pain Score was comparable in each group and difference was significant statistically at 6, 8, 10, 12 hours (p<0.05). Requirement of rescue analgesia was reduced in patients of group T as compared to patients of group C. Hemodynamics remained stable in both the groups. Conclusion: TAP block as a part of multimodal analgesic regimen for post cesarean delivery provided reliable and effective analgesia in this study, and no complications due to the TAP block were detected.

Introduction: Caudal analgesia is reliable, safe and has become most popular and commomly performed regional blocks in pediatric infraumbilical surgeries but has a short duration of action without adjuvants. Dexmedetomidine a potent alpha 2 adernergic agonist, provides better hemodynamic stability and longer post operative analgesia than many other adjuvants. Ropivacaine a amide local anaesthetic, provides pain relief with less motor blockage with reduced central and cardiotoxic effects than bupivacaine. Hence study conducted with 2 groups ropivacaine alone (R) and ropivacine plus dexmedetomidine (RD) an adjuvant. Aims: Primary objective is to compare post operative analgesia between two groups, secondarily sedation. Methods: prospective, randomized study was carried out in 60 patients of ASA grade 1 and 2, aged between 2 and 8 yrs weighing <20 kg, scheduled in elective infraumbilical surgeries. In our study patients were divided into two groups of 30 each with the help of computer generated table of random numbers. Group R received 0.2% ropivacaine 1 ml/kg and Group RD received ropivacaine 0.2% 1 ml/kg plus dexmedetomidine 1 mcg/kg. Mean duration of caudal analgesia, mean duration of sedation and any other side effects were recorded in both the groups and compared. Result: The mean duration of caudal analgesia in group RD was 10.41 hrs while group R was 5.89 hrs and difference is statistically significant (p<0.001) and quality of sleep was better in group RD. Conclusion: Addition of dexmedetomidine to caudal blocks significantly prolongs post operative analgesia with arousable sedation without significant side effects.

Background: Ultrasound (US)-guided Interscalene or Shoulder blocks are commonly used for Shoulder arthroscopic surgeries. Aim: The aim of this randomized study were to compare the block performance and onset times, effectiveness, incidence of adverse events and patient’s acceptance of US-guided Interscalene or Shoulder blocks. Methods: 68 patients were randomized to two equal groups: Shoulder block (SB) and Interscalene group (ISN). Each patient received a mixture containing 0.75% Ropivacaine. The block performance and latency times, surgical effectiveness, adverse events and patient’s acceptance were recorded. Results: The mean block performance time was 5.529 ± 1.022 mins in the ISN group and 8.559 ± 1.260 mins in the SB group. Onset of sensory block and motor block was early in ISN group. However, duration of sensory and motor block was higher in SB group. The total requirement of analgesic was higher in SB group and patients’ satisfaction was slightly more in ISN group. Also, ISN group had more complications than SB group. The haemodynamic parameters (H.R, systolic BP, diastolic BP, RR and SpO2) were recorded at 0, 4, 6, 12 & 24 hours. These parameters were all comparable in both the groups, thus statistically insignificant. Conclusion: Shoulder block can be considered in patients with Acute or Chronic respiratory distress, decreased pulmonary reserve, elderly patients, COPD patients and in patients with absolute contraindication to any degree of phrenic nerve block which almost always occurs in Interscalene nerve block.

Background and Aim: Supraclavicular approach to subclavian vein catheterization has become one of the forgotten techniques in anaesthesia practice. The aim of this study is to compare supraclavicular approach with infraclavicular approach to subclavian vein cannulation, with respect to time taken to identify and cannulate vein, number of attempts taken to cannulate, success rate and complications. Method: In this study, 60 patients were enrolled and their right subclavian veins were catheterized by either Supraclavicular approach (Group-A, n=30) or infraclavicular approach (Group-B, n=30). Parameters including time to locate the subclavian vein, number of attempts needed to successfully cannulate the vein, success rate, total access time and complications were recorded. Results: The mean time to identify Right Subclavican Vein in first attempt in Group A was 10.652 ± 3.926 seconds as compared to 15.550 ± 8.325 seconds in Group B. In Group A, 23 out of 30 patients (76.7%) were successful in first attempt compared to 20 out of 30 patients (66.7%) in Group B. The average number of attempts needed to successfully identify the right subclavian vein in Group-A was 1.24 ± 0.511 and in Group-B was 1.37 ± 0.688. The total access time for Group A was 197.069 ± 35.12 seconds and for Group B was 227.481 ± 61.22 seconds. Arterial puncture is more common in Group-A (3 out of 30) whereas malposition of the catheter was more common in Group-B (3 out of 30). Conclusion: Supraclavicular approach can be used as an effective alternate to infraclavicular approach for Subclavian Vein cannulation

Background: Intranasal midazolam is a novel technique for administering premedication in children. It has been shown to be more effective than parental presence or placebo in reducing anxiety and improving patient’s compliance at induction of anesthesia. Dexmedetomidine is selective 2 agonist with sedative, anxiolytic and analgesic properties with favorable pharmacokinetics. We designed this prospective randomized double-blinded study to compare the safety and efficacy of midazolam and dexmedetomidine administered intranasally as premedication in children undergoing cardiac surgery for CHD. Method: Sixty-two children belonging to the American Society of Anaesthesiologists (ASA) class I and II, scheduled for elective cardiac surgery were divided into two groups by standard randomization technique. Patients belonging to group M received intranasal midazolam 0.2 mg/kg whereas patients in group D received intranasal dexmedetomidine 1 µgm/kg 30 min prior to surgery in an adequately monitored condition. Patient’s sedation score, behaviour scores, attitude, heart rate, respiratory rate, oxygen saturation, intravenous cannula acceptance and face mask acceptance at the time of induction were studied by an observer till induction of anesthesia. Results: There was no significant difference in sedation score in both the groups except at 20 minutes, when it was significantly lower in patients belonging to Group D as compared to those of Group M. There was no significant difference inheart rate, respiratory rate, SpO2, behavior score, parental separation acceptance, behavior at separation and level of sedation atinduction of anaesthesia between the two groups. There was a significant difference in the number of patients with a change of behaviour (6.4% v/s 34.4%) and change of sedation (7.1% v/s 37.5%) in Group M and Group D respectively. Patients inGroup M were calmer and allowed face mask application at the time of induction of anesthesia. Conclusion: Intranasal route is safe and effective for administering both, midazolam and dexmedetomidine as premedication in children undergoing corrective surgery for congenital heart disease. However, we observed better behaviour with midazolam at induction of anesthesia.

Background: Dexmedetomidine is a newer α2 agonist with sedative, sympatholytic and analgesic properties. This study was carried out to evaluate the effect of two different concentrations of intravenous dexmedetomidine infusion on haemodynamic response to critical incidents like laryngoscopy, endotracheal intubation, creation of pneumoperitoneum and extubation in patients undergoing laparoscopic cholecystectomy. Methods: The study was conducted at our institute in 60 ASA grade I & II patients undergoing laparoscopic cholecystectomy. They were randomly allocated into two groups of 30 patients each ‘Group Dex 0.25’ and ‘Group Dex 0.5’. The patients received dexmedetomidine infusion at the rate of 0.25 /kg/hr and 0.5 mcg/kg/hr respectively, starting 15 minutes before induction and continued till the end of surgery. Standard anaesthesia technique was used. Comparison of the effect of infusion on haemodynamic changes seen in laparoscopic cholecystectomy was done. Results: Haemodynamic response to laryngoscopy and creation of pneumoperitoneum was blunted more in group Dex 0.5 as compared to group Dex 0.25. The intraoperative and post operative analgesic requirement was also reduced in group Dex 0.5. The time to first analgesic demand was later in the group Dex 0.5 as against group Dex 0.25. No significant side effects were noted in either group. Conclusion: Dexmedetomidine infusion at the rate of 0.5 mcg/kg/hr given perioperatively can serve as a very useful anaesthetic adjunct for premedication, maintenance of haemodynamic stability and postoperative analgesia without any significant adverse effects.

Objective: This study is conducted to assess the analgesic effects of intravenous magnesium sulphate (50 mg/kg) in hip surgeries under spinal anaesthesia. Methods: This prospective, randomised, double blinded control study was done on 60 patients posted for hip surgeries (Dynamic hip screw fixation, Proximal femur nailing and Hemiarthroplasty) under spinal anaesthesia. The patients were randomly divided into two groups with 30 patients each. Group S (Study) received magnesium sulphate 50 mg/kg intravenously in 250 ml Normal saline, 15 minutes before spinal anaesthesia and group C (Control) received same volume of normal saline. Hemodynamic variability, duration of analgesia and analgesic requirements were evaluated upto 12 hours after surgery. (30 minutes, 2, 4, 8 and at 12 hours). Results: Postoperative pain scores were significantly lower in Group S (p<0.05) at 2nd hour after surgery and was not significant at other time intervals. Time to first analgesic requirement was significant (p=<0.005) between two groups. Rescue analgesic requirement was lower in Study group compared to Control group, and was statistically significant (p=0.009). The two groups had no significant differences with regards to hemodynamic variability and had no side effects. Conclusion: Intravenous magnesium sulphate 50 mg/kg when given as a bolus reduced the postoperative pain and decreased the need of rescue analgesics after spinal anaesthesia for hip surgeries.

Abolishing the pain conduction in sensory nerves – this idea would have definitely come from progressive physicians. Various local anesthetic agents since 1860 have been isolated and synthesized till dates which have their action mediated through nerve conduction blockade. But there are other agents who can inhibit conduction to varying degrees, in a nerve and other excitable tissues – like H1 – blockers, Antihistaminics, Anti convulsants, opioids, Marine Biotoxins. Phenothiazine derivative of H1 – blocking agents viz. Promethazine and Diphenhydremine have potent local anesthetic activity as compared to procaine (a amide local anesthetic) when injected locally. Promethazine is widely used as anti emetic, anti histaminic and hypnotic agent by oral, introa muscular, intra venous and trans rectal route but its local anesthetic property has not been fully utilized and advocated in clinical practice. A careful search to literature was done and this study was undertaken to study the use of promethazine in aspect to onset of action, intra operative analgesia, post operative analgesia, sedation along with other complications as compared to Bupivacaine. Sixty patients of ASA status I & II, undergoing elective surgery like Hydrocelectomy, circumcision and others to be operated under regional blocks were randomly divided in two groups: Group I to receive Inj. Promethazine hydrochloride (2 mg/kg) diluted to make a volume of 15 ml, Group II to receive Inj. Bupivacaine 0.25% (2 mg/kg) to a maximum of 15 ml and patients were observed for onset of analgesia, duration, requirement of rescue analgesic using 4 point pain score and post operative sedation using Cook’s Sedation Score along with hemodynamic stability and any other known complications. It was found that there was good analgesia in both the groups per operatively with good hemodynamic stability all throughout the surgery and surgery accomplished satisfactorily with no side effects except drowsiness seen in Group I specially of age > 45 years. Hence, promethazine can be considered as a safe alternative to standard local anesthetics for superficial surface surgeries where sensitivity to local anesthetics is a problem.

Shivering is one of the most common complications of a central neuraxial blockade. Shivering is defined as involuntary, spontaneous, oscillatory mechanical activity of skeletal muscle associated with increased oxygen consumption. Shivering can be thermo regulatory or non thermo regulatory. Its mere presence per operatively is very unpleasant and even physiologically stressful. It is managed per operative either by non pharmacological means such as warm blankets, drapes, warm intravenous fluids or by pharmacological means using various drugs like intravenous opioids, HT3 antagonists, Dexmedetomidine (α-2 agonist). Our study was planned to study the efficacy of Dexmedetomidine with that of Tramadol for control of shivering after spinal anesthesia given in patients for various surgical indications. 60 Patients of age group 15-70 years of ASA grade I & II were divided in two groups Group D (to receive Inj. Dexmedetomidine 0.5 µg/kg intravenously slowly) and Group T (to receive Inj. Tramadol 1 mg/kg intravenously slowly) intra operatively who developed shivering of the Grade 3 and 4. We found that Dexmedetomidine in the dose of 0.5 µg/kg intravenously controls shivering faster than Tramadol 1 mg/kg, reduces patient discomfort experience time, and also induces sedation without any nausea and vomiting. Hence Dexmedetomidine seems to be a better alternative to Tramadol for per operative and post operative shivering during central neuraxial blockade.

Background: Shivering is one of the complications of central neuraxial blockade due to impairment of thermoregulatory control. Control of post spinal anesthesia shivering is essential for optimal peri-operative care which can be achieved by non-pharmacological and pharmacological means. Aim: The present study was designed to evaluate and compare the efficacy of intravenous Butorphanol and Tramadol for control of intraoperative shivering under spinal anesthesia. Material & Methods: In this prospective, interventional double blind, randomized study, 60 ASA I/II patients, aged 18–60 years, undergoing elective lower abdominal, urological and lower limb surgeries under spinal anesthesia, who subsequently developed shivering of grade 3 or 4, were randomized into two groups, to receive Tramadol 1 mg/kg or Butorphanol 0.03 mg/kg. Time taken to control shivering, response rate, recurrence rate and side effects such as nausea, vomiting, dry mouth, respiratory depression and sedation were observed. Results: Butorphanol had rapid onset of action for control of shivering as compared to Tramadol (p<0.05). The incidence of recurrence was significantly higher with Tramadol compared to Butorphanol while as sedation was found to be significantly higher with Butorphanol as compared to Tramadol. Side effects such as nausea, vomiting was significantly higher with Tramadol. Conclusion: Both Intravenous Butorphanol and Tramadol are effective treatment for control of shivering following spinal anaesthesia. Butorphanol is superior to Tramadol for control of shivering post spinal anaesthesia in several respects like rapid onset of action, lesser recurrence and lesser incidence of nausea and vomiting.

Background: Hypotension is the commonest side effect after giving spinal anaesthesia in lower segment caesarean section (LSCS). Various drugs are being used to prevent hypotension due to spinal anaesthesia. Aim: The present study was planned to compare role of preemptive (used just after giving spinal anaesthesia) Phenylephrine and Ephedrine intramuscularly (IM) in reducing spinal anaesthesia induced hypotension and other adverse effects in LSCS. Settings and design: After approval from ethical committee (Reference No: SGRR/IEC/16/18) a prospective, double blind randomized control clinical study was conducted. Material and method: Total 90 pregnant females with single pregnancy, term gestation and aged between 18-45 years and American Society of Anaesthesiologist (ASA) class І, posted for LSCS were selected and randomly divided by using envelope technique into three groups each having 30 patients. In Group A Phenylephrine 4 mg, in Group B Ephedrine 30 mg and in Group C normal saline was given by intramuscular route. Statistical Analysis: One way ANOVA test was used to compare means of different groups whereas Chi- square test was used to compare proportions of different group. p value <0.05 was considered statistically significant. Results: Mean blood pressure values were found maximum in Phenylephrine group followed by Ephedrine group and least in control group. Incidence of hypotension and nausea/vomiting was seen least in Phenylephrine group in comparison to other groups. Conclusion: Phenylephrine and Ephedrine both were effective in maintaining mean blood pressure, lowering incidence of hypotension and associated adverse effects related to spinal anaesthesia however Phenylephrine was found more effective.

Background: Laparascopic surgery is a routinely performed surgery and it is desirable to have a stable intraoperative haemodynamic states by avoiding hypertension and tachycardia. Aim: The present study has been conducted to compare the beneficial effect of alpha2 adrenergic receptor agoinist dexmedetomidine versus placebo in maintaining the perioperative haemodynamic parameters during laparoscopic cholecystectomy. Materials and Methods: The present Randomized double blind comparative study was conducted in the Department of Anaesthesiology. A total of 60 patients randomly allocated in two groups, to Group D (Dexmedetomidine) & Group P (Placebo) of 30 each undergoing elective laparoscopic cholecystectomy, under GA were studied. The patients recieved preloaded and coded study drug as infusion (Dexmedetomidine 0.5 mcg/kg & NS 10 ml) before induction. Results: Sex, age, and weight were comparable in the two groups. The study drug dexmedetomidine maintained cardiovascular stability during laparoscopic cholecystectomy. Mean arterial pressure and heart rate in Group D (Dexmedetomidine) were significantly less after intubation and throughout the period of pneumoperitoneum. In addition, other drugs requirement in placebo group was found to be considerably high when compared to dexmedetomidine group. Conclusion: Dexmedetomidine improves intraoperative and postoperative haemodynamic stability during laparoscopic surgery without prolongation of recovery. Dexmedetomidine was more effective in attenuating hemodynamic response to intubation and pneumoperitoneum when compared with placebo.

Introduction: Rapid smooth induction, rapid recovery, perioperative hemodynamic stability, minimum post-operative pulmonary complications and effective analgesia intra-operatively and post-operatively are the main aspects of general anesthesia. Aim: To compare the attenuation of the pressor response to laryngoscopy and intubation with intravenous Fentanyl 2 mcg/kg and intravenous Butorphanol 40 mcg/kg. Materials and Methods: It is a randomized prospective comparative study comparing the two opioiddrugs. The patients were then randomly assigned into two groups of 30 each in Group F and Group B received Inj. Fentanyl 2 mcg/kg IV and Inj. Butorphanol 40 mcg/kg respectively. Results: There was no statistical significance between the Two groups (B / F) when the demographic parameters like age distribution (36.03 ± 7.73/36.23 ± 6.80), sex distribution (15/15 vs 16/14), weight (65.5 ± 7.72/66.63 ± 5.81) were compared. The comparison of parameters like pre operative pulse rate, systolic blood pressure, diastolic pressure, mean arterial pressure, rate pressure product, respiratory rate and sedation score was also found to be statistically insignificant between the two groups. Both the Butorphanol group and the Fentanyl group was comparable with respect to events of intra operative hypotension and intra operative Bradycardia. There was no significantly respiratory depression post extubation in both the groups. We observed that the post extubation sedation score was significantly higher with the Butorphanol group than with the Fentanyl group. A favourable side effect profile was observed with the Butorphanol group than with Fentanyl group with respect to the occurrence of post-operative shivering whilethe incidence of post-operative nausea and vomiting was similar between the groups. Conclusion: Intravenous Butorphanol prior to induction of anaesthesia helps in better attenuation of the hemodynamic response to laryngoscopy and intubation than intravenous Fentanyl. We conclude that Butorphanol could be an effective alternative to Fentanyl for attenuation of the hemodynamic stress response to laryngoscopy and intubation.

 Context: Maintaining hemodynamic stability, reducing pain on injection with Propofol and preventing PONV, in TIVA technique is a contentious subject and there is no perfect method to reduce it. Aims: To compare propofol with ketamine and propofol with butorphanol for total intravenous anesthesia in short surgical procedures. Settings and design: Hospital based study was carried out at SVS Medical College, Mahabubnagar. Methods: Total of 60 patients was studied. They were of either sex and the age ranged from 18-60 years. They had ASA-I & ASA-II grade. Two groups of patients were created randomly. Group K, received PropofolKetamine and Group B, Propofol Butorphanol. Both the groups were induced with Propofol 1.5 mg/kg IV and maintained with Propofol 9 mg/kg/hr IV. Statistical analysis: Chi square test and student’s t test were used. Results: The SBP and DBP fell in both groups of patients after induction. SBP & DBP differed significantly during various intervals in patients who belonged to Group B. Such a significant difference was not found in group K. Pain on injection with Propofol was not attenuated by Butorphanol pre-treatment rather than Ketamine. Post-operative sedation was more in Group B (Propofol-Butorphanol) than in Group K (Propofol –Ketamine). Both the groups were found to be comparable in terms of post operative nausea and vomiting. Conclusion: “Propofol-Ketamine (Group K) combination” has been found to be more effective than the other group of patients who belonged to Group B in terms of stability of the hemodynamic parameters as well as sedation was lesser after surgery.

Background: To minimize patient discomfort, anxiety and pain and to improve patient cooperation throughout the procedure and ease the performance of the procedure by the endoscopists conscious sedation is required. The main objective of this study is to explore and compare the safety and efficacy of dexmedetomidine versus midazolam in providing sedation aimed at endoscopy. Materials & Methods: A randomized, prospective study was directed in Pushpagiri institute of medical sciences Thirunalla Totally 60 patients were enrolled in this study & they were separated in two groups: Group M: Inj.Fentanyl 1 mcg/kg + Inj.Midazolam 0.04 mcg/kg. Group D: Inj.Fentanyl 1 mcg/kg + Inj. Dexmedetomidine 1 mcg/kg. Participants of either sex, aged 18-60 years of age undergoing diagnostic and therapeutic Endoscopy, with American Society of Anaesthesiologist (ASA) Grade I and II. Results: The mean arterial pressure was significantly lower at time-points 2 and 3 compared with time-point 1 in participants of midazolam group (p < 0.05). SpO2 and RSS scores were significantly higher in the dexmedetomidine group as compared to midazolam group at time-points 2 and 3. Participants in the dexmedetomidine group rated their overall satisfaction with the procedure higher as compared to midazolam group (p < 0.05). A total of 6 patients (dexmedetomidine group n = 1; midazolam group n = 5) believed that they required either more or less sedation than they acknowledged. No patient reported feeling any severe pain during the process. The amnesic effect was corresponding in both groups, with no patient reporting any recall of intra-procedure events. There were no clinically significant complications in either group. Conclusion: Our results are suggestive of that dexmedetomidine has a good safety outline and is an effective sedative for use in endoscopy. We conclude that Dexemeditamedine has Good, Effective, Safety, Awake analgesia but satisfactory throughout procedure due to hypotension and bradycardia due to alpha 2 agonist action compared to midazolam group.

 Introduction: The incidence of femoral neck fractures, one of the most common traumatic injuries in elderly patients increases continuously among the ageing population. Anaesthetic management of NOF is either spinal or general anaesthesia. One of the modalities for postoperative pain control is lower limb peripheral nerve blocks. Opioids like fentanyl, tramadol, midazolam, neostigmine, clonidine and dexmedetomidine are being used. Dexmedetomidine has been used as an adjuvant in local anaesthetic solutions at a dose of 1 µg/kg in lumbar plexus block and has convincingly shown to prolong the duration of anaesthesia and post-operative analgesia. Despite these assumptions, an understanding of the mechanism and site of the action of dexmedetomidine used as an adjuvant to lumbar plexus block is unknown. Hence, this study was conducted with Aim of: (1) The effectivity of dexmedetomedine as an adjuvant to Ropivacaine 0.75% in lumbar plexus block. (2) To study the adverse effects of dexmedetomidine in lumbar plexus block. Methods: This is a prospective, double blind randomised systemic control trial. It comprises of three groups. Lumbar plexus block was given using Inmed (R) nerve stimulator using a 100-mm-long stimulating needle. Capdevila is the current technique of choice. Results: The mean age and sex in Group A (d) (Study Group), Group B (ivd) (Control Group) and Group C (r) (Placebo Group) are similar. Surgery lasted for 40 to 60 minutes. All three groups were statistically comparable. Mean duration of sensory block was 586 ± 37.77 min (group A), 390 ± 24.91 min in (group B) and 376.83 ± 26.79 min (group C). The prolongation of sensory block was highly significant in group A when compared to group B and C. Mean VAS score at 6 hrs in Group A was 1.37 ± 0.60, Group B 1.67 ± 0.76 and in Group C 1.87 ± 0.82. No complications due to the block or drugs used. Conclusion: Dexmedetomidine at the dose of 1 mcg/kg can be added to 0.75% ropivacaine, perineurally in lumbar plexus block effectively and safely.

 Background: Anaesthesia alleviates human sufferings during the surgical procedures. It may be either General anaesthesia or Regional anaesthesia depending upon surgery. General anaesthesia imparts total sensory loss. It also entails poly pharmacy, that is, use of multiple drugs for achieving “Balanced Anaesthesia”. But then, loss of consciousness requires maintenance of airway, even an artificial airway like endotracheal intubation. Use of multiple drugs have their inherent side effects. Hence, general anaesthesia is always stratified in respect to its risk-benefit in individual case scenario. Materials & Methods: The present study was undertaken at Pushpagiri institute of medical sciences Thirunalla Patients posted for sub-umbilical surgeries under intra dural anaesthesia were included in the study. Among 150, Patients were randomly divided into three groups, each group containing 50. Group I (Q) - Patients who received SAB with Quincke 27G needle n=50. Group II (S) - Patients who received SAB with Sprotte 27G needle n=50. Group III (W) - Patients who received SAB with Whitacre 27G needle n=50. Descriptive statistical analysis has been carried out in the present study. Results: There is no statistically significant difference in body height and age group among the study groups p>0.05. This indicates that there is no statistical difference in the inter space selected for lumbar puncture p=0.22. This implies that, there is no statistically significant difference for the number of attempts taken to perform Lumber puncture. p=0.92.This signifies that, there is no statistical difference with respect to Bromage scale among the study groups. p>0.05. Conclusion: Thus, pencil point Whitacre needle is better choice in view of early onset, more height achieved, low incidence of PDPH and less failure rates. However, cost factor should be weighed against the complication.

 Background: As the day care surgery becomes popular, caudal epidural block has become routine intervention in children and infants. But the major limitation with this technique is duration of analgesia after single injection, which is limited by the pharmacology of local anaesthetic agent used. To prolong the duration of caudal analgesia various adjuvants such as opioids, ketamine midazolam and α2 agonists are used with single shot technique.We have deigned this study to elucidate the efficacy and safety of dexmedetomidine as an adjuvant to caudal Levobupivacaine versus Levobupivacaine alone in paediatric patient. Material and Method: Present study is a randomized, prospective comparative study conducted at department of anaesthesia.Based on exclusion and inclusion criteria 80 patients were enrolled for this study. The patients were randomly allocated into two groups.Group L:- 0.75 ml/kg Levobupivacaine 0.25%, diluted in normal saline 0.9% Group LD: - 0.75 ml/kg Levobupivacaine 0.25% with Dexmedetomidine 1 µg/kg. Various parameters like cardiovascular parameter, duration of analgesia, FLACC score and adverse drug reaction was recorded and compared. Result: Both groups were comparable to each other with respect to age, sex, weight, duration of surgery and ASA scare, The P value was more than 0.05 which was statistically insignificant.After induction at 5 min, heart rate was 105.26 + 11.61 /min in group L and 106.52 + 15.22/min in group LD. The P value was 0.2162. After 15min of induction the heart rate was 107.27 + 14.41 in group L and 108.36 + 14.24/min in group LD. The P value was 0.2019 which is not significant. The time of analgesia was 342.8 + 12.4 mins in group L and in group LD it was 486.40 + 14.6 mins. Duration of analgesia was longer in group LD and is significant statistically. Discussion and Conclusion: From present study we can conclude that caudal administration of 1 µg /kg dexmedetomidine along with 0.75 ml/kg Levobupivacaine is resulted in prolongation of the duration of analgesia, less postoperative analgesic requirement as compared with 0.75ml/kg Levobupivacaine alone. There is no significant difference in hemodynamic parameters and increase incidence of adverse drug reaction.

Background: Ropivacaine is a local anaesthetic agent which is a long acting amide, a pure S (-) enantiomer of propivacaine. It has reduced potential for neuro and cardiotoxicity and safer than bupivacaine. This drug is less lipid soluble and blocks sensory neurones to greater extent than motor nerves. Mother undergoing caesarean section will be mobile early, so that breastfeeding and other things will be easy for mother. We have designed present study to evaluate the sensory and motor characteristic and the advice effect of spinal 0.75% isobaric ropivacaine 15 mg compared to 0.5% bupivacaine 8 mg for caesarean section. Material and Method: Based on exclusion and inclusion criteria 80 parturients were enrolled for this study. The parturients were randomly allocated into two groups. We have used computer generated randomization table for randomization. Each group consists of forty parturients. Parturients who have received Bupivacaine were allocated in Group B and parturients who have received Ropivacaine were allocated in Group R. Result: Motor block characterisation in two groups, the mean time for onset of grade III block was 7.54 + 1.2 min in Group R and 3.34 + 2.86 min in Group B, This difference was statistically significant. Total duration of block in Group R was 98.67 + 12.38 and 121.74 + 17.38 min in Group B. This finding is significant statistically. Mean of total duration of analgesia was 164.66 + 19.68 min in Group R and 149.86 + 21.72 min in Group B. The value p value was 0.001. Conclusion: Based on our observation we can conclude that onset of sensory block was faster with bupivacaine, time to repression of sensory block was shorter with ropivacaine. The total duration of sensory block was little higher in bupivacaine but duration of analgesia were compared in two groups. Onset of motor block was late and duration of motor block was significant early in ropivacaine group. Haemodynamic parameter was comparison in both groups.

 Background: Pain poses a unique challenge to anesthesiologist. Continuous unrelieved pain activates the pituitary adrenal axis which can suppress the immune system resulting in postsurgical infection and poor wound healing. Opioids have been added as adjuvants to local anesthetics in spinal anesthesia to alleviate pain. Fentanyl is a phenylpiperidine derivative synthetic opioid agonist. As an analgesic fentanyl is 75-125 times more potent than morphine. Buprenorphine is an agonist antagonist derived from the opium alkaloid the baine. It is estimated that affinity of buprenorphine for mu receptors is 50 times greater than that of morphine. This study was carried out to evaluate the effects of Intrathecal Fentanyl with bupivacaine compared to intrathecal buprenorphine with bupivacaine on duration of post operative analgesia in lower abdominal surgeries. Methods: A double blinded randomised study was carried out with one hundred and thirty two patients of ASA grade I and II aged between 20 and 70 years undergoing lower abdominal and lower limb surgeries under spinal anaesthesia. The patients were given 3 ml of hyperbaric bupivacaine premixed with either 10 mcg Fentanyl (Group F), Buprenorphine 60 mcg (Group B) or 0.2 ml normal saline (Group S). Postoperatively VAS score for pain, time to first dose of analgesic required, total analgesic required and adverse effects with in 24 hours post operative period were noted. Results: Prolonged post operative analgesia was observed in Group BB (623.11 ± 98.86) compared to Group BF (536.56 ± 69.31) and BS (296.88 ± 36.32). Post operative rescue analgesic requirement was significantly less in group buprenorphine. Conclusion: Addition of Fentanyl and Buprenorphine as adjuvants to intrathecal 0.5% hyperbaric bupivacaine prolongs post operative analgesia. Intrathecal buprenorphine 60mcg as an adjunct to bupivacaine for subarachnoid block showed a longer duration of action and less postoperative rescue analgesic requirement in comparison to Intrathecal Fentanyl 10 mcg.

 Background and Aim: This study aims to compare the topographical method and formula method for assessing the depth of central venous catheter (CVC) insertion in internal jugular vein (IJV) and subclavian vein (SCV) on both sides. Methods: Total of 496 patients were randomly assigned to eight groups; formula method right IJV, topographic method right IJV, formula left IJV, topographic left IJV, formula right SCV, topographic right SCV, formula left SCV, and topographic left SCV with 124 in each. The formula method involves mathematical calculations as described by Peres [3,14] and Kim et al. [2] to calculate the depth of catheter insertion. If the catheter tip was up to 1 cm above and below the carina as seen in post procedural chest x- ray it was considered to be in a satisfactory position. Results: The CVC's inserted via the IJV route on both the right and left sides were within the acceptable range when the depth of insertion was determined by the topographic method compared to the formula method {statistically significant for both right and left IJV (p< 0.001)}. The CVCs inserted via the subclavian route on both right and left sides by both topographic and formula methods were not in the acceptable range in majority of the patients and required repositioning. Conclusion: The topographic method was far superior then formula method in assessing the depth of CVC insertion in internal jugular vein on both right and left side whereas neither formula method nor topographic method was accurate in establishing optimal depth of CVC insertion by subclavian route in either right and left side.

 Introduction: Previous studies have hypothesized that in routine patients undergoing surgery, the conventional C-MAC video laryngoscope compared to direct laryngoscopy can improve the rate of glottis view significantly. The C-MAC platform is to our knowledge the only Video Laryngoscope that allows the clinician to perform both direct and indirect laryngoscopy with the same blade and can be used as its own control. Aim: To compare laryngoscopic view by direct and indirect laryngoscope. Materials and Methods: Following ethical approval and sample size estimates 65 consecutive patients undergoing surgery under general anaesthesia were studied. First direct laryngoscopy was performed using conventional C-MAC and the best view obtained was graded by the first anaesthesiologist without looking at the video monitor. A second anaesthesiologist blinded to the laryngeal view obtained under direct laryngoscopy graded the laryngeal view on the video monitor, this was considered as indirect view. Parameters observed were modified Cormack Lehane grading of which grade 1 and 2a were defined easy views, grade 2b and 3a as restricted views and grade 3b and 4 were graded as difficult views. BURP (Backward Upward Right Pressure) mannevour and intubating aids wereused when required and were noted down. Results and Discussion: Easy views were 20 (30.8%) in direct and 47 (72.3%) in indirect. Restricted views were 41 (63%) in direct and 18 (27.7%) in indirect. Difficult views were 4 (6%) in direct and nil in indirect. These were statistically significant with p value <0.01. Indirect view coincided well with Mallampatti grading than direct view. BURP was applied more in direct view than indirect view. Conclusions: C-MAC by improving laryngoscopic view becomes an important tool in both anticipated and unanticipated difficult airway. It serves as both an innovation for difficult airway management and as a powerful teaching tool.

 Background: Though laparoscopy is associated with lesser postoperative pain, it is not completely a pain free procedure. Given the expanding role of ambulatory surgery and need to facilitate an earlier hospital discharge, improving postoperative pain control has become an important issue for anesthesiologists. Objective: To analyze the analgesic effect of intraperitoneal instillation of 1 μg/kg dexmedetomidine with 0.25% bupivacaine to that of 0.25% bupivacaine alone in patients undergoing laparoscopic surgeries. Methods: Sixty patients posted for elective laparoscopic surgeries were randomized into two groups - Group B: received 30 ml Bupivacaine 0.25%, Group BD: received 30 ml of mixture of Bupivacaine 0.25% with Dexmedetomidine (1 μg/kg), intraperitoneally before removing the trocar. The intensity of the pain was assessed using Visual Analog scale (VAS) at 30 min, 1 hour, 2 hours, 6 hours, 12 hours, and 24 hours. The duration of analgesia, demand for rescue analgesics and side effects, if any were noted. Results: The demographic variables were comparable. There was a significantly prolonged duration of post-operative analgesia, a significant reduction in VAS scores and analgesia requirement rate over the 24-hour period in Group BD. Though the heart rate decreased significantly in patients of dexmedetomidine group, they were hemodynamically stable. There was no significant difference in the incidence of adverse effects. Conclusion: The intraperitoneal instillation of Bupivacaine with 1 μg/kg of dexmedetomidine in laparoscopic surgeries is a better choice for postoperative analgesia with minimal side effects.

 Introduction: Preoperative anxiety in children leading to postoperative negative changes and long-term behavioral problems needs better preanesthetic sedation. Across the world, midazolam is the most commonly used premedicant in pediatric patients. The fact that no single route has achieved universal acceptance for its administration suggests that each route has its own merits and demerits. Aim of the Study: This study compares oral midazolam syrup and intranasal midazolam spray as painless and needleless systems of drug administration for preanesthetic sedation in children. Materials and Methods: The study was in Government Stanley hospital Chennai. Period of the study was between 2012-2013. Seventy pediatric patients belonging to ASA physical status I & II scheduled for elective minor surgical procedures were included in the study. Children belonged to the age group of 2 to 8 years of both sexes. The children were randomly allocated into 2 groups with 35 patients in each group. (Group N & Group O). Demographic data including age, weight, and sex of the children were recorded. The children were given premedication 30 minutes before surgery orally or nasally. The reaction of the children to the premedication was noted. Group – N – received intranasal midazolam at a dose of 0.2 mg/kg using. Insideatomizer midazolam Nasal spray containing 100 microliters/ metered dose which delivers 0.5 mg/dose. Results: The median behavior score and sedation score were further analyzed with the children divided into different age groups age 2–5 and age 7–9yr. The median behavior scores at baseline, at separation from a parent, and at induction were not different among the children from groups N and 0 in all age groups. The median sedation scores of group D were significantly different from group M at separation from parent and at induction in children of age 2–5 yr. In age Group 2–5 yr, the median sedation scores at separation from the parent were 6 and 2 from group N and 0 respectively (p - 0.001). For the same age group, the median sedation scores at induction of anesthesia were 6 and 2 for group N and 0, respectively (p - 0.001). Conclusion: In conclusion, Intranasal midazolam when used as premedication in children, in a dose of 0.2 mg/kg hasa more rapid onset of action with satisfactory sedation and anxiolysis than oral midazolam. The rapid onset of action of nasal midazolam makes it an ideal route for premedication in children.

 Background: Laparoscopic cholecystectomy is one of the most common ambulatory elective procedures. Surgical pain derives significantly from the incisions made in the anterior abdominal wall. Nerve supplying the anterior abdominal wall are derived from T6-L1 afferent nerve which course through the neurofascial plane between the internal oblique and transversus abdominis muscle. The subcostal transverse abdominis plane (TAP) block is better suited for upper abdominal surgery [T7-T11] in relieving postoperative pain. Materials and Methods: 60 patients were randomly allocated into any one of two groups of 30 patients each, by means of computer-generated randomization. Group A patients received bilateral subcoastal TAP block with Ropivacaine 0.25% 40 ml injected under ultrasound guidance. Group B patients received intraperitoneal installation of Ropivacaine 0.25% 40 ml through laparoscopic instrument before laparoscopic port closure. Results: Resting VAS scores were significantly lower in group A than B at 4 hr (p=0.003), 8 hr (p=0.001), 12 hr (p=0.001) and 24 hr (0.001) after the operation. Deep inspiration VAS scores were significantly lower in group A than B at 4 hr (p=0.003), 8 hr (p=0.001), 12 hr (p=0.001) and 24 hr (<0.001) after the operation. Both static and dynamic pain were accompanied by lower analgesic requirement in the subcostal TAP block. Conclusion: Ultrasound guided subcostal TAP block is one of the most effective supplemental techniques as part of the multimodal post-operative analgesic regimen.

 Background: Various adjuvants are co-administrated with local anaesthetic agent to improve the speed of onset of block, duration of analgesia and can decrease the dose of local anaesthetic agent. As the dose of local anaesthetic decreases, its adverse drug reaction also used to decrease specifically Bupivacaine. Present study has been designed to evaluate the, efficacy and safety of dexmedetomidine as an adjuvant to bupivacaine in spinal anaesthesia. Method: This is a randomised, double blind, prospective comparative study conducted in the department of anaesthesia, Based on inclusion and exclusion criteria 72 patients were enrolled for this study. These patients were randomly allocated in to two groups Group B and Group BD. Sensory parameters like, onset of sensory block; total duration of sensory block was recorded using pin prick method. Motor block was assessed with modified Bromage score. Time for onset and duration of motor block was recorded. Result: Mean time required for the onset of sensory block in group B was 3.24 + 1.34min and in Group B, it was 2.42 + 0.84 min. This difference is statistically significant. The P value was 0.006. The mean duration of sensory block was 181.07 + 20.8 min in group B and 263.6+38.8 min in group BD. This difference was significant statically (p=0.00001). The mean time for onset of motor block was 8.31 + 1.84 min in group B and 7.94 + 32.0 in group BD. This difference is not significant statistically. The p value was 0.1428. Discussion and Conclusion: From present study we conclude that 5 microgram dexmedetomidine as an adjuvant to hyperbaric bupivacaine prolong the duration of sensory and motor block. It provides good quality of analgesia, haemodynamic stability and prolongs post-operative analgesia.

 In spite of arthroscopic surgeries being minimally invasive, they cause significant post-op pain. Intraarticular administration of local anaesthetics with or without adjuvants or opioids alone are known to produce post-op analgesia of varying degrees and duration. The purpose of this study was to compare the effects of intra-articular bupivacaine, neostigmine and fentanyl after arthroscopic surgeries. 45 patients were randomized to receive intra-articular bupivacaine, neostigmine and fentanyl after arthroscopic surgery under spinal anaesthesia. Visual analog pain scores (VAS), duration of analgesia as defined as time for first demand for parenteral analgesics and the total subsequent consumption of analgesics was evaluated. There was significant difference of duration of analgesia between the three groups being estimated from Time Zero to the time when the VAS score was greater than 6 and medication for pain was administered. Duration of analgesia was more prolonged in Group III (Fentanyl) as compared to Group I (Bupivacaine) and Group II (Neostigmine). Also, duration of analgesia in Group I was significantly prolonged as compared to Group II. These changes were statistically highly significant when compared to each other (p<0.05). Among all the groups, no significant side-effects were observed.

Objectives: To evaluate the response of dexmedetomidine and magnesium sulphate for attenuating stress response in laparoscopic abdominal surgeries. Material and methods: Patients of ASA grade I and II aged between 20 and 60 years, either gender and who underwent elective laparoscopic abdominal surgeries were included in the study and divided into two groups, group D (n=52) and group M (n=52). Group D patients received Inj dexmedetomidine 1 µg/kg bolus for 15 min followed by 0.2-0.4 µg/kg /hr infusion and group M patients received inj magnesium sulphate 2g bolus for 15 min followed by 12-15 mg/kg/hr infusion. Intraoperative hemodynamic parameters like Heart rate, mean arterial pressure were recorded and emergence time, extubation time and sedation scores were assessed. Results: Heart rate and Mean arterial pressure were significantly low in group D compared to group M. Recovery time and sedation score was significantly higher in group M compared to group D. Time to reach Aldrete score ≥ 9 was significantly more in group M compared to group D. Conclusion: Dexmedetomidine and Magnesium sulphate attenuated stress response to surgery and pneumoperitoneum. Dexmedetomidine had better hemodynamic stability compared to Magnesium sulphate. Early post operative recovery was found in dexmedetomidine group.

 Aim and objectives: This prospective, randomised, single blinded controlled study evaluated and compared the efficacy of Bilateral subcostal USG- guided Transversus Abdominis muscle plane block to the Conventional Port site Infiltration in patients who undergo elective Lap- cholecystectomy in Rajiv Gandhi Government General hospital – Madras medical college. Sixty patients belonging to ASA1 and 2, between 18 to 60 years of either sex, satisfying inclusion criteria were randomised into two groups containing 30 patients each. Group 1– TAP block. Group 2 – Port site infiltration. At the end of surgery USG guided TAP block or port site infiltration were given, before extubation. The block was performed under ultrasound guidance. Results: Two groups were similar with respect to demography. Hemodynamics response was similar without any statistical difference between the two groups. Post operative VAS scoring was significantly low in the TAP block with less amount of recue analgesic requirement. Conclusion: We conclude that bilateral USG guided sub costal Transversus abdominis plane block is a better and more efficient alternative method to conventional port site infiltration in Laparoscopic cholecystectomy to provide analgesia in the postoperative period.

Background and Aim: Point of care (POC) glucometry is most widely used method for monitoring blood sugar levels in the Intensive care unit (ICU). But, the accuracy of bedside glucometry using capillary blood is controversial in patients with shock. We aimed to compare the accuracy of POC glucometry with laboratory blood glucose measurements in patients with shock and requiring Noradrenaline infusion. Methods: This is Prospective, Observational study done on 100 consecutive patients admitted to ICU with shock categorized into two groups of 50 each, requiring two different doses of Noradrenaline infusion (Group A: 5 mcg/min and Group B: 10 mcg/min). POC capillary, POC venous and laboratory venous blood sugar measurements were simultaneously done in each patient. Results: ANOVA test was performed which showed that there was no statistical significance between the blood samples and also between the two groups (F value 0.022, p value 0.978). In Group A, stronger correlation was found between POC venous and lab venous blood sugar measurements (r=0.886, p<0.01) whereas in Group B, stronger correlation was found between POC capillary and lab venous blood sugar measurements (r=0.897, p<0.01) Conclusion: POC glucometer blood sugar estimation using capillary blood quite accurately correlates with the POC glucometry using venous blood and the laboratory values, even in patients with Noradrenaline infusion, provided all the confounding factors are eliminated before measuring blood sugar levels.

 Objectives: To compare direct conventional laryngoscopy (DCL) and video laryngoscopy (VL) in patients with difficult airway and to assess whether video laryngoscopy is superior to direct conventional laryngoscopy in difficult situations. Methodology: It was a randomised controlled study. Preoperative assessment of difficult airway was done. Among the patients coming for elective surgery, the patients with difficult airway were chosen. Hundred such patients were selected as per the inclusion criteria. They were divided into two groups with fifty patients in each group. Group A was direct conventional laryngoscopy, the control group. Group B was video laryngoscopy, the study group. During intubation, several parameters were noted. Cormack Lehane view, number of intubation attempts, time for intubation, oral trauma etc were noted. Result: Cormack Lehane view was better in VL. Number of attempts was lesser in VL than in DCL. Time for intubation was lesser in DCL. Conclusion: For successful intubation, the number of attempts was lesser in VL. Hence VL could be a better tool in difficult airway management.

 Context: Controlled hypotension is required for middle ear surgery to achieve a bloodless operative field which is achieved by dexmedetomidine. Aims: To study and assess the efficacy of dexmedetomidine infusion in lower doses i.e., 0.25 mcg/kg/hr to lower systolic blood pressure below 30% of baseline values, quality of oligaemic surgical field to achieve the targeted SBP in patients undergoing middle ear surgery. Settings and Design: Double blinded Randomised Control Prospective Study. Methods and Material: After obtaining ethical committee permission and patient consent, the study was conducted on 50 patients aged 18 to 60 years belonging to ASA-PS I and II undergoing middle ear surgery, were randomly divided into 2 groups. Group A received dexmedetomidine 0.25 μg/kg/hr as continuous IV infusion. Group B received dexmedetomidine 0.5 μg/kg/hr as continuous IV infusion. Exclusion criteria included cardiovascular disease, hypovolemia, bradycardia, hepatic impairment, pregnancy and lactating mothers, on sedatives and hypnotics, known allergy to dexmedetomidine. Statistical analysis used: Data analyzed- SPSS 22.0 software. Categorical data: frequencies, proportions. Test of significance: Chi-square test. Continuous data: Mean standard deviation. Test of significance: Independent t test. p value: < 0.05- statistically significant. Results: There was insignificant difference in mean HR, mean SBP, mean DBP among both groups. Both groups had excellent surgical field favourable to operating surgeons with similar grading of surgical bleed. Conclusions: Dexmedetomidine at lower doses i.e., 0.25 μg/kg/hr can be used safely to yield blood less surgical field in middle ear surgeries by allowing the hemodynamic variations within the physiological range.

Context: Endotracheal intubation and laryngoscopy are basic and fundamental tools of anaesthesiologists to take care of the airway. It is important to find an effective means of attenuating sympathetic response to laryngoscopy and intubation. Aims: Our aim was to compare and assess the efficacy of i.v esmolol and fentanyl before laryngoscopy and tracheal intubation and to observe the variations in sympathetic response to laryngoscopy and intubation. Methods and Materials: This study was a prospective randomized doubleblind study on patients undergoing ENT, orthopaedics, gynaecological, general surgical, neurological and laparoscopic procedures. A clinical comparative study of attenuation of the sympathetic response to laryngoscopy and intubation was done in 60 patients of American Society of Anesthesiologist (ASA) grade I or II, age between 20 to 50 years of both the sexes and Mallampati airway assessment of grade I, posted for elective surgeries selected randomly. In study group I (n=30) patients receive 2 mg/kg esmolol IV, 3 minutes before laryngoscopy and intubation. In study group II (n=30) patients in this group receive 2 µg/kg of fentanyl IV, 5 minutes before laryngoscopy and intubation. Statistical analysis used: The statistical analysis was done by STATA 11.2 (College Station TX USA). Students independent sample t-test and Chi-square test were used. p < 0.05 considered as statistically significance. Results: Maximum rise in systolic blood pressure was observed at the post-intubation first minute, i.e., 133.73 ± 10.36 and 144.43 ± 10.92 in the Group I and II from the baseline, respectively but maximum rise of heart rate (103.43 ± 7.50) was during the first minute in group I but maximum rise of heart rate (87.83 ± 5.45) was in group I. The diastolic blood pressure and mean arterial pressure changes was significant between fentanyl and esmolol groups at 1 and 3 minute and post-induction, 1 and 5 minute respectively. Group I showed better control of heart rate during laryngoscopy and intubation at the first, 3 and 10 min after intubation compared to other groups (p < 0.05). Conclusions: Esmolol is more effective than fentanyl in attenuation of the sympathetic response to laryngoscopy and intubation.

Context: Spinal anesthesia induced hypotension in parturients undergoing Cesarean section can be detrimental to both foetus and mother. Prophylactic administration of vasopressors helps in preventing hypotension thereby maintaining the uteroplacental blood flow. Aims: The main objective of this study is to determine whether prophylactic intramuscular Glycopyrrolate administration reduces the incidence and severity of hypotension associated with spinal anesthesia in parturients. Settings and Design: Randomized double blinded prospective study. Methods and Material: Sixty parturients scheduled for elective LSCS under spinal anesthesia were randomly allocated into two groups of 30 each, Group G who received intramuscular glycopyrrolate 0.2 mg (1 ml) and Group S who received intramuscular saline (1 ml), 15 minutes prior to subarachnoid block. Incidence and severity of hypotension, heart rate and blood pressure changes, incidence of nausea and vomiting were observed. Statistical analysis used: Chi-square test was used for qualitative data and for Continuous data, mean and standard deviation. SPSS 22 software was used. Results: Thirteen out of thirty parturients (43.3%) had hypotension in glycopyrrolate group whereas 22 out of 30 parturients (73%) developed hypotension in saline group with a p value of 0.018. The median dose of vasopressor requirement was less in glycopyrrolate group when compared to saline group (0 vs 6 mg). Conclusions: Pre-emptive treatment with intramuscular glycopyrrolate reduces the incidence and severity of hypotension in parturients undergoing Cesarean sections under spinal anesthesia.

Background: Propofol is a widely accepted medication for the  uccessful insertion of laryngeal mask airway, but as a sole induction agent, it has a very low success rate. A number of co-induction agents have been  used with propofol to increase the success rate of LMA insertion. Aim and Objectives: To evaluate the efficacy of two different doses of midazolam i.e. 0.05 mg/kg and 0.08 mg/kg intravenously when used with propofol versus propofol alone for LMA insertion. To find the appropriate dose of midazolam that provides ideal condition and maximum haemodynamic stability. Material & Methods: 75 adult patients of ASA I & II grade randomly divided into 3 groups. Group P: Propofol + Saline Group PM1: Midazolam 0.05 mg/kg 3 minutes before propofol + Propofol Group PM2: Midazolam 0.08 mg/kg 3 minutes before propofol + Propofol. LMA insertion attempted 1 minute after the administration of Propofol. Total dose of propofol used, the insertion conditions and haemodynamic changes were noted. Results: There was no statistical difference in demographic profile. Haemodynamically patients were more stable in group PM1 & PM2 than in group P. Dose of propofol used in PM2 (2.05+0.21 in mg/kg) & PM1 (2.38+0.21) was less than in Group P (2.84 mg/kg). 100% success rate in LMA insertion was  observed in group PM1 & PM2 in first attempt whereas it was 80% in group P. 88% in group PM2, 60% in group PM1 & only 32% patients in group P had excellent insertion conditions. Conclusion: Propofol as a sole agent does not provide LMA insertion conditions. Midazolam when used with propofol provides adequate conditions for LMA insertion in a dose dependent manner.