Indian Journal of Anesthesia and Analgesia

Meningomyelocele surgeries are common in pediatric anesthesia and forms a congenital neural tube defect (herniation of meninges and neural elements through a skull defect). One of the main problems which occur during induction of these children is the difficulty in positioning for airway management and the need to prevent sac compression or rupture. We hereby describe a novel way of positioning of these children over an elevated platform, with the occipital meningomyelocele resting in the padded hollow of an adult soft silicon
head rest (used during prone positioning surgeries). After successful induction and airway securing over this, the same elevated platform was used for the definitive surgical procedure. This innovative positioning adjunct not only supports the herniated sac in supine position, but also eases the intubation process in these difficult airway cases and obviates the risk of latex allergy.

Aim: To compare the efficacy of butorphanol and tramadol in mitigating postoperative pain as rescue analgesia while observing its effect on hemodynamic stability. Setting and Design: This prospective, doubleblinded randomized controlled study was conducted at the postoperative recovery area. Materials and Methods: Hundred patients of 18–60 years of age, American Society of Anesthesiologists physical status Class I and II of both sex who underwent elective laparoscopic cholecystectomy, were enrolled in this study after approval from the Institutional Ethics Committee. Patients were randomly allocated into two groups (50 patients each); Group B received injection butorphanol 1 mg and Group T received injection tramadol 100 mg intravenously in the postoperative recovery room when patient complains of pain and Visual Analog Scale (VAS) more than 4. Parameters assessed were pain intensity by Visual analog score at 10, 20, 30, 40 and 60 minutes, relief of pain is described as VAS less than 4 after 30 minutes, sedation score after 30 minutes and side-effects. Statistical Analysis Used: Student’s t-test and Chi-square test were used for statistical analysis. Results: Pain intensity was also significantly low with butorphanol than tramadol upto 40 minutes. Relief of pain is 100% with injection butorphanol. More patients were found to be alert in tramadol group as compared
with butorphanol. Conclusions: Intravenous butorphanol (1 mg) provides superior pain relief than intravenous tramadol (100 mg) when used as rescue analgesia for postoperative pain with lesser incidence of nausea and vomiting.

Background: Many adjuvants have been tried to improve the duration of spinal anesthesia and quality of analgesia both intraoperatively and postoperatively to overcome the disadvantages of spinal anesthesia. Aims: The aim of this study was to evaluate the onset and duration of sensory and motor block, hemodynamic effect, postoperative analgesia and adverse effects of dexmeditomedine or fentanyl given with hyperbaric bupivacaine for spinal anesthesia. Materials and Methods: 120 patients were divided into two groups of sixty each undergoing
lower limb and lower abdominal surgeries with ASA Grade 1 and 2. Patients were randomly allocated to receive either Group BD: 0.5% Hyperbaric Bupivacaine 15 mg + 5 g Dexmedetomidine; Group BF: 0.5% Hyperbaric Bupivacaine 15 mg + 25 g Fentanyl intrathecally. Results: Patients in dexmedetomidine group showed a significantly prolonged duration of motor and sensory block than patients in fentanyl group. Conclusions: Addition of dexmedetomidine potentiates bupivacaine spinal anesthesia by increasing significantly the duration of motor and sensory blockage with hemodynamic stability and reduced rescue analgesics as compared to fentanyl.

Background: Laparoscopic cholecystectomy is one of the most common practiced surgeries for gall bladder disease. Dexmedetomidine is a α2 agonist with sedative, sympatholytic and analgesic properties and hence, it can be a very useful adjuvant in anaesthesia as stress response buster, sedative and analgesic. Materials and Methods: The present study was conducted on 90 patients with American Society of Anesthesiologists physical status I to III scheduled for laparoscopic cholecystectomy of both genders. Patients were divided into 3 Group.
Group I (Control) patients received normal saline 0.9% infusion, Group II patients received dexmedetomidine infusion 1 mcg/kg/h and Group III patients received dexmedetomidine infusion 0.4 mcg/kg/h. parameters
such as duration of anesthesia, duration of surgery, change in heart rate, MAP etc. was compared in both groups. Results: ASA I was 25 in Group I, 26 in Group II and 23 in Group III, ASA Grade II was 5 in Group I, 4 in Group II and 7 in Group III. The difference was nonsignificant (p > 0.05). Mean duration of anesthesia in Group I was 92.1 minute, in Group II was 98.4 minutes and in Group III was 85.2 minutes, mean duration of surgery in Group I was 77.4 minutes, in Group II was 92.3 minutes and in Group III was 75.1 minutes. The difference was nonsignificant (p > 0.05). The mean PR (beats/min) before starting in Group I was 88.3, in Group II was 91.4 and in Group III was 90.3. After 15 minutes was 87.2 in Group I, 82.3 in Group II and 80.4 in Group III. 1 minute after induction was 87.3, 82.5 and 80.6 in groups. MAP before staring was 99.3 mm Hg, 99.2 and 101.4 mm Hg in all groups, after 15 minutes was 98.4, 95.2 and 98.9 in all groups, 1 minute after induction
was 98.2, 89.5 and 89.9 in all groups respectively. The difference was nonsignificant (p > 0.05). Conclusion: Low dose dexmedetomidine infusion in the dose of 0.4 mcg/kg/h effectively attenuates haemodynamic stress response without any adverse events.

Context: Propofol due to its favorable pharmacokinetic profile is widely used in TIVA. Propofol, when used alone causes decrease in cardiac index and mean arterial pressure and lacks analgesic property. To
overcome these disadvantages, many adjuvant drugs are added. Aim: To compare two drug regimens: Propofol-ketamine and propofol-butorphanol in surgical procedures less than 60 minutes. Settings and Design: Hospital based comparative study was carried out at Department of Anesthesiology, SVS Medical College, Mahabubnagar. Methods: Sixty patients aged 18–60 years of both sexes belonging to ASA I and ASA II Grades were randomly allotted to one of two groups of 30 each. Group K received ketamine 1 mg/kg and propofol
1.5 mg/kg as inducing agent and Group B received butorphanol 20 μg/kg and propofol 1.5 mg/kg. In both the groups, anesthesia was maintained with propofol 9 mg/kg/hr via infusion pump. Heart rate, SBP, DBP were monitored as baseline, induction and in postinduction period after 10, 20, 30, 40 minutes. Occurrence of pain on injection with propofol was noted. Postoperative sedation was assessed using Ramsay Hunt sedation score and incidence of PONV was noted in both groups. Statistical Analysis: The data was analyzed using t-test and p - value of < 0.05 was considered statistically significant. Results: In Group B, there was significant variation in heart rate, SBP and DBP at everytime interval from baseline to end of surgery whereas there was
no statistically significant change in hemodynamic parameter throughout surgery in Group K. The incidence of sedation postoperatively in Group K was 36.7% whereas in group B it was 46.7%. It was found that in
Group B patients 23.3% of them had pain as compared with 56.7% in Group K showing pain. There was no statistically significant difference in two groups regarding incidence of PONV. Conclusion: Data and their
analysis suggest that combination of Propofol-ketamine, offered better hemodynamic stability over propofolbutorphanol.

Context: Adjuvants and hyperbaric bupivacaine are mixed in a single syringe before injecting the drugs intrathecally. Their densities may be altered by mixing them in a single syringe, thus affecting their spread.
Administering local anesthetic and the adjuvant separately minimizes the effect of changes in densities. Aims: To compare efficacy of intrathecal clonidine with hyperbaric bupivacaine administered as a mixture and sequentially and to assess the onset and duration of sensory and motor blockade and postoperative analgesia.
Settings and Design: Group M received mixture of clonidine (75 mcg) and hyperbaric bupivacaine 0.5% (10 mg) and Group S received clonidine (75 mcg) followed by hyperbaric bupivacaine 0.5% (10 mg) through separate syringes. Materials and Methods: 60 full term parturients of elective cesarean section were divided into two
groups based on the technique of intrathecal drug administration. Statistical analysis used: Quantitative data was analyzed by student’s ‘t’ test and qualitative data was analyzed by Chi-square test. Results: Duration of analgesia was significantly longer in Group S (474.33 ± 20.79 min) than in Group M (337 ± 18.22 min). The time to achieve highest sensory block and complete motor block was significantly less in Group S. Conclusions: When clonidine and hyperbaric bupivacaine were administered in a sequential manner, block characteristics improved significantly compared to the administration of the mixture of the two drugs.

Background: Brachial plexus block is the widely-used nerve block in anesthesia for upperlimb surgeries. Ropivacaine, a newer local anesthetic with less cardiotoxicity used frequently now-a-days. Adding adjuvants increases the quality of the block and duration of analgesia. Aims of the study: Aim of the study is to compare the effects of adding 100 mg Tramadol and 10 mg Nalbuphine to 0.5% Ropivacaine in Supraclavicular brachial plexus block in patients undergoing upperlimb orthopedic surgeries. Also, study the block characteristics and complications during the study. Materials and Methods: A prospective randomized control study was conducted on, 60 ASA I/II patients of either sex at 20–50 years of age, undergoing upperlimb orthopedic
surgeries. Group RT received 32 ml of drug mixture (30 ml 0.5% Ropivacaine plus 2 ml of Tramadol), whereas Group RN received 32 ml of the mixture (30 ml of 0.5% Ropivacaine plus 10 mg of Nalbuphine). Time of onset and duration of sensory and motor blocks, duration of analgesia, time for first rescue analgesia and a total number of doses of rescue analgesia were monitored and recorded. Results: Onset of sensory block, motor block in Group RT (8.82 ± 2.2 and 9.45 ± 0.5) was statistically faster than Group RN (11.45 ± 2.1 and 12.23 ± 1.2)
respectively. The total duration of sensory and motor block was significantly more in Group RN than Group RT. The time of first rescue analgesia was significantly longer in Group RN (18.12 ± 1.2) than RT (14.32 ± 3.3). The total dose of rescue analgesia was statistically insignificant among the groups (2 vs 2). 5 patients in Group RT developed nausea and vomiting. Conclusion: The addition of Tramadol fastens the onset of sensory and motor blocks but the addition of Nalbuphine produces a longer duration of sensory and motor blocks with negligible complications.

Aims: Evaluation of airway blocks vs general anesthesia for diagnostic direct laryngoscopy & biopsy for carcinoma larynx it is a comparative study. Materials and Methods: A total of 60 patients between the age
group 50–70 years were included in the study. They were ASA Grade 3 or 4 and scheduled for Laryngeal biopsy under anesthesia. Patients were randomized in two groups, Group A received airway blocks with
2% lignocaine and Group B received general anesthesia. Group A patients received bilateral superior laryngeal nerve block, glossopharyngeal nerve block and transtracheal block. Group B patients received general anesthesia. Patients were monitored during anesthesia using continuous ECG, NIBP and Pulseoximetry.
Intraoperative IV fluids were given according to the protocols. Vital data was recorded preoperatively and during direct laryngoscopy at every 5 minutes interval. Results: Preoperative vitals were same in both
groups and statistically there was no significant difference in the data. Mean arterial pressures were raised during postoperative period. The postop analgesia was significantly higher in Group A and lasted longer as compared to Group B and patients were less agitated and calm. In Group B patients, most of them required postop nebulization as compared to Group A where no patient needed nebulization. Conclusion: Laryngeal biopsies done under regional airway blocks have less of hemodynamic changes and good analgesia in postop period, compared to cases done under general anesthesia.

Aims: Study aimed at comparison of recent addition Supra Glottic Airway Devices I-gel and Baska mask during general anesthesia in patients undergoing elective laparoscopic pelvic surgery. Settings and Design: Prospective, randomized, single blind study. Materials and Methods: After institutional review board approval and written informed consent, 50 patients aged 18–60 years scheduled for elective laparoscopic pelvic surgery were randomly assigned into two groups either I-gel or Baska mask. After premedication and preoxygenation,
patients were induced with Inj. fentanyl 2 mcg/kg and Inj. propofol 2- 2.5 mg/kg IV. Insertion of SGA was done according to group assigned. The insertion characteristics were recorded in form of number of attempt,
time of insertion, manipulation required and failed insertions. Success of orogastric tube insertion was noted in both the groups. Working performance was compared in form of hemodynamic stability, oropharyngeal leak pressure, mean tidal expiratory volume and postoperative complications. Statistical analysis used: Data were
analyzed by using unpaired t-test, Chi-square test. Results: Shorter insertion time was found with I-gel (16.80 ± 02.23) as compared to Baska mask (21.56 ± 04.20). Oropharyngeal leak pressure and mean tidal expiration volume were higher for Baska mask (25 ± 02.50;679 ± 98.17) as compared to I-gel (22.72 ± 02.13;600.08 ± 88.06). Hemodynamic parameters and postoperative complications were comparable among both the groups. Conclusion: Baska mask has a better working performance with higher oropharyngeal leak pressure and mean tidal expiratory volume while I-gel has lesser insertion time.

Context: Achieving satisfactory postoperative analgesia with epidural opioids has been the subject of research many times. Aims: To evaluate postoperative pain relief in patients administered with epidural nalbuphine or tramadol for lower-limb surgery under combined spinal-epidural anesthesia. Settings: Tertiary hospital, Kanchipuram Dist, Tamil Nadu. Design:Prospective observational study. Materials and Methods: The study was done on patients undergoing lower-limb orthopedic procedures. The patients were assigned to either epidural nalbuphine (N) Group or epidural tramadol (T) Group. The convenience sampling technique was used until each group had 40 subjects. Group N received epidural 0.125 % bupivacaine with nalbuphine 0.2 mg/ml infusion@6ml/hr and Group T with epidural 0.125 % bupivacaine with tramadol2mg/ml infusion@6ml/hr started at sensory regression to T10 for postop analgesia. The pain severity was assessed using Visual Analog Scale (VAS) and sedation was assessed using Pasero Opioid-induced Sedation Scale (POSS). Intravenous paracetamol was used as rescue medication. Statistical analysis used: Chi-square test and unpaired t-test. Results: The mean sedation at 2 hrs was 1.65 ± 0.8 in tramadol and 2.8 ± 0.41 in the nalbuphine group. The difference was statistically significant (p - value < 0.001). The mean VAS at 12 hrs was 1.06 ± 0.4 in tramadol and 1.26 ± 0.44 in nalbuphine. At 24 hrs it was 0.86 ± 0.41 in tramadol and 1.05 ± 0.34 in nalbuphine group, with statistically significant differences (p - value < 0.05). In the tramadol group, 5 (12.5%) had vomiting and 6 (15%) were administered with IV
paracetamol. Conclusions: Nalbuphine was more effective in providing postoperative pain relief compared to Tramadol. Tramadol was associated with a higher incidence of nausea and vomiting.

Induction: and maintenance of general anesthesia in pediatric patients is often managed with an inhaled anesthetic agent, with various inhalational anesthetic agents available having their pros and cons. In this study, we evaluated and compared sevoflurane with halothane in pediatric patients for induction characteristics and hemodyanamic effects. Sixty patients, aged between 2 and 10 years undergoing various surgeries were randomly divided into two groups of 30 each to receive either sevoflurane or halothane anesthesia, induced by using
equipotent incremental doses of either of the inhalational agent upto 3 MAC. Anesthesia was then maintained with either of the inhalational agents at 0.5 MAC with nitrous oxide (60%) in oxygen (40%). Induction time, induction scoring and hemodynamic parameters were recorded and analyzed using appropriate statistical method. Results: of our study showed that the induction time of sevoflurane was significantly faster than that of halothane (184 ± 56 secs vs 302 ± 62 secs) without any major airway problem (salivation, breath-holding and coughing). Excitement and restlessness during induction was found to be more common with sevoflurane than with halothane but this difference was not statistically and did not interfere with the induction. Heart rate
and blood pressure were better maintained during sevoflurane anesthesia than the halothane anesthesia. We did not find any significant incidence of cardiac arrhythmias with either of the agents.

Background: Supraclavicular brachial plexus block is preferable to general anesthesia in upper limb surgeries. Various adjuvants have been added to improve the quality of the block and prolong postoperative analgesia. Alpha-2 agonists are used as adjuants to local anesthetics to extend the duration of neuraxial and peripheral nerve blocks. We compared clonidine and dexmedetomidine as an adjuvant to bupivacaine in supraclavicular brachial plexus block. Aims: To compare the effects of Clonidine and Dexmedetomidine when added as adjuvant to Bupivacaine on onset and duration of sensory & motor block, duration of analgesia and quality of block for Supraclavicular brachial plexus block. Methods: In this prospective, double-blinded study 60 ASA I–II patients were randomly divided into two groups of 30 each. First group received 30 ml bupivacaine 0.325% with Clonidine 1 mcg/kg (Group C) and second group received 30 ml bupivacaine 0.325% with dexmedetomidine 1 mcg/kg (Group D) in Supraclavicular brachial plexus. The characteristics for anesthesia and analgesia were assessed for the two groups. Results: Onset of sensory block was faster
in Group D than in Group C, while onset of motor block was faster in Group C than in Group D, but the difference was not statistically significant. Duration of sensory block and motor block was 234.17 ± 24.11 min and 296.30 ± 25.78 min in Group C as compared with 445.07 ± 67.79 min and 503.10 ± 75.67 min in Group D. Statistically significant longer duration of sensory and motor block was observed in Group D (p < 0.001). There was significant increase in duration of analgesia in Group D (477.27 ± 70.11 min) as compared with Group C (285.43 ± 26.88 min). In Group D, 83.3% of the patients achieved Grade IV quality of block as opposed to 43.3% in Group C (p = 0.006). Conclusion: To conclude, dexmedetomidine prolongs the duration of sensory and motor block and enhances the quality of block as compared with clonidine when used as an adjuvant to Bupivacaine. The added advantage of conscious sedation, hemodynamic stability, and minimal side-effects makes it a potential adjuvant for nerve blocks.

Background and Aims: ProSeal Laryngeal Mask Airway (PLMA) has been proven to cause minimal hemodynamic fluctuations and postoperative complications when compared to cuffed Endotracheal Tubes (ETT) in laparoscopic surgeries. Hence, present study was done to compare ABG analysis and hemodynamic parameters in patients undergoing laparoscopic cholecystectomy. Materials and Methods: Present study included fifty American Society of Anesthesiologist Class I patients weighing 30–70 kg within age group of 20–60 years posted for elective laparoscopy cholecystectomy after the ethical committee clearance and were randomly allocated to either PLMA (Group I) or ETT (Group II) group with 25 in each group. Hemodynamicr esponses, ABG analysis and postoperative complications were noted and compared. Results: There was no demographic difference. When we analyzed heart rate, systolic and diastolic blood pressure, mean arterial
pressure values, they were found to be comparable throughout except for those after insertion (p < 0.05). The ABG analysis and EtCO2 before pneumoperitoneum and one hour after pneumoperitoneum showed no
significant difference (p > 0.05) with either of the device. No case of regurgitation or aspiration found in either group. Postoperative complications were mainly seen with ETT Group. Conclusion: Metabolic effects of either PLMA and ETT during laparoscopy cholecystectomy were similar but PLMA affects the hemodynamic parameters to a lesser degree making it a better choice.

Context: Postoperative patients requiring mechanical ventilation in surgical ICU’s require adequate sedation and analgesia in order to modulate physiological response to stress and pain, hence reducing morbidity and mortality in the ICU. The consequences of inadequate sedation and analgesia can be sustained, including selfremoval of intraluminal tubes and vascular catheters, aggressive behavior by patients against care providers, and poor patient-ventilator synchrony. Oversedation can lead to prolonged duration of mechanical ventilation,
more prolonged ICU, and hospital stays. Aims: To evaluate the effects of dexmedetomidine and midazolam for sedation in postoperative mechanically ventilated patients. Study Design: Arandomized prospective study. Methods: 100 patients aged above 18 years after major abdominal or pelvic surgeries requiring a minimum of 6 hours of artificial ventilation admitted to intensive care units were included as subjects, and they were randomly divided into two groups of fifty each. Group D received Dexmedetomidine, a loading dose of 2.5 μg/kg, and a maintenance dose of 0.5 g/kg/hr, and Group M received Midazolam a loading dose of 0.05 mg/kg and a maintenance dose of 0.025 mg/kg/hr. Both groups were compared for the level of sedation using Ramsay sedation score, hemodynamic variables, safety profile. Statistical analysis used: Chi-square test and Student’s unpaired t-test. Results: Ramsay sedation score was within the desired level (2–4) in both
dexmedetomidine and midazolam group (p > 0.05). Patients who received dexmedetomidine infusion had significantly lower heart rates compared to patients who received midazolam infusion (p < 0.00), there
were no significant differences in SBP, DBP, MAP and oxygen saturation between two groups. Conclusion: Dexmedetomidine and midazolam are safe sedative drugs for postoperative mechanically ventilated patients.
Patients were easily aroused to cooperate without signs of irritation within the dexmedetomidine group.

Introduction: Surgeries like direct and indirect inguinal hernia repair, lower limb surgeries, urological surgeries and gynecological surgeries are commonly done under spinal anesthesia. It is a selective 2-
adrenoceptor agonist and is currently used for its sedative, analgesic and sympatholytic properties. Intravenous Dexmedetomidine decreases the inhalational anesthesia and opioid requirements during general
anesthesia. Aims: To compare the postoperative effect of intravenous dexmedetomidine in comparison with intravenous midazolam on intrathecal bupivacaine in patients undergoing gynecological surgeries under spinal anesthesia. Materials and Methods: Prospective randomized study between March 2017 and August 2018. This study was conducted in 100 patients belonging American Society of Anesthesiologists (ASA) physical status classification class 1 & 2 and undergoing gynecological surgeries under spinal anesthesia were included. Results: Postoperative analgesia was significantly prolonged with the use of intravenous dexmedetomidine premedication than with intravenous midazolam. Heart rates were lesser in dexmedetomidine Group A when compared to midazolam Group B, but overall requirement of anticholinergics was similar in both groups. Mean
arterial pressures were lower with dexmedetomidine Group A when compared with midazolam Group B. Conclusion: Intravenous dexmedetomidine premedication prolongs the duration of sensory and motor blockade during the spinal anesthesia with Bupivacaine with good sedation and postoperative analgesia than with intravenous midazolam premedication in patients undergoing gynecological surgeries under spinal anesthesia.

Aims: To study the use of surgical plethysmographic index in assessing the effects of dexmedetomidine in attenuating the hemodynamic stress response. Materials and Methods: A two group comparative study was
done on 60 patients of ASA I and II patients undergoing elective laproscopic cholecystectomy under general anesthesia in a tertiary referral hospital setting. Group F received 100 ml of normal saline while Group D received 0.5 g/kg of dexmedetomidine in 100 ml normal saline. Results: We found that rise in Heart Rate, Systolic and Diastolic BP and Mean Arterial Pressure was significantly attenuated in the dexmedetomidine group. The Surgical plethysmographic index (SPI) was also reduced. The SPI changed earlier than heart rate
and blood pressure in response to stimulation. Opioid and propofol need was also significantly reduced. Endocrine stress response was also attenuated as noted by the lower readings of blood sugar during the
surgery in the dexmedtomidine group. Conclusion: Surgical Plethysmographic Index is an effective indicator of analgesic depth. Dexmedetomidine attenuates the hemodynamic and neuroendocrine stress response to intubation and surgery and has opioid and anesthetic sparing effects.

Background: The transversus abdominus plane block is a regional anesthesia technique first described in 2001. It is useful in procedures requiring nerve block in the anterior abdominal wall region from T6-L1. It was first used as a blind landmark technique. But more recently it has been performed under ultrasound guidance. TAP blocks are important because they can be used as an alternative analgesic solution in surgery. The purpose of our study was to evaluate effectiveness of TAP block to provide effective postoperative analgesia in patients undergoing inguinal hernia repair surgery. Materials and Methods: Our study was conducted in our institution under ultrasound guidance. Total 40 patients
undergoing unilateral inguinal hernioplasty surgery under spinal anesthesia were included in the study. Patients were divided into 2 groups of 20 each. Group B - Patients receiving USG-TAP block at
the end of surgery with 20 ml Inj. Bupivacaine 0.50% - 20 patients. Group R - Patients receiving USGTAP block at the end of surgery with 20 ml Inj. Ropivacaine 0.75% - 20 patients. Patient monitored every
two hours upto 24 hours postoperatively for pulse rate, BP, pain by VAS score and complications if any. Pain was assessed by visual analog score from 0 to 10. Recession of motor block noted by movement
of ankle and knee joint. Results: The mean pain score on VAS in Group B and Group R was 4.75 and 4.89 respectively, 24 hours after surgery. The difference in the two groups was statistically insignificant
(p - value > 0.05). VAS score was the same in both the groups at all the time in first 24 hours. Conclusion: About 15 ml of 0.5 % bupivacaine or 15 ml of 0.75 % ropivacaine for transverse abdominis plane block
produces satisfactory and comparable sensory block, related to duration, analgesia and VAS score. The hemodynamics were stable in both the groups. The lower CNS and cardio toxicity of ropivacaine
may help in reducing the risk to the patients. There was no much clinical difference in duration, dose of analgesia and VAS score among both the groups, when injected in equal volume for TAP block under ultrasound guidance. Ropivacaine has a potentially improved safety profile when compared with Bupivacaine.

Unanticipated difficult tracheal intubation is a significant source of morbidity and mortality in anesthesia practice. Identifying situations and patients at risk for airway management problems is a key to optimal care. This study compares the parameters described to identify a difficult intubation to look for the best predictors or combinations thereof. Materials and Methods: The preoperative airway assessment used multiple parameters like Mallampati test, Thyromental Distance, Head and neck Movement, Interincisor Gap, Lahey & McCormick Scale. The results were evaluated on the basis of sensitivity, specificity, positive and negative predictive value of these tests. During intubation a cumulative Intubation Difficulty Scale rating greater than 5 was used to
classify a patient as a difficult intubation to validate the scores. Results: Amongst all the parameters studied individually, the Upper lip bite test was found to have the highest sensitivity of 48.48% and specificity of
97.3%. When multiple parameters were taken into consideration, the combination of Mallampati score, Upper lip bite test and Neck circumference to thyromental distance ratio was found to have the highest sensitivity of 75.76% and specificity 91.12%. Conclusion: Application of multiple predictors can reduce the frequency of unanticipated difficulty and also unnecessary interventions related to over prediction of airway difficulty.

Background: Labor pain is very painful. Parturients struggle with agony of pain due to lack of awareness and knowledge. These is significant decrease in acceptance also. Aims: Aims to evaluate awareness & to educate for acceptance of labor analgesia in pregnant women. Methods: A sample size of 240 pregnant women were included in our study. Each parturient will be counselled and after obtaining a written informed consent the questionnaires will be given which contains questions related to awareness, acceptance, utilization of most
common pain relief methods available in the hospital. Results obtained are analyzed by descriptive statistics. Chi-square, Fisher exact test, student t-test. SPSS version 21.0 used for calculation. p < 0.05 is considered significant. Results: Most of the parturients (81%) were not aware of labor pain relief techniques and only 18% were aware. Around 45% did not utlise labor analgesia because of lack of knowledg. Now, after awareness 69% were ready to accept labor analagesia and 39% were not ready to accept. Postcounseling we saw around 13% increase in acceptance. Hence, we found that by creating awareness, there was increase in acceptance for labor analgesia and utilization of labor analgesia techniques. Conclusion: Awareness among parturients
attending our hospital is found to be less. By providing education and counseling, awareness and acceptance can be increased. Obstetricians and anesthesiologist should work as a team and should ensure utilization of labor analgesia services.

Background: Pain arising from fracture of femur is of severe nature, and any degree of movement can worsen the pain. Surgery for fixation of femoral fractures may be done under spinal anesthesia. Fascia Iliaca
Compartment Block (FICB) produces a simultaneous block of the femoral and of the lateral femoral cutaneous nerves, provides good pain relief for patients with fracture femur and even intravenous fentanyl can also be used to relieve the pain. Aims: We conducted this study to compare the analgesic efficacy of Intravenous Fentanyl (IVF) and Ultrasonography (USG) Fascia Iliaca Compartment Block (FICB) for preoperative pain relief and while positioning for subarachnoid blockand also to assess the duration and quality of postoperative analgesia in the first 12 hrs. Materials and Methods: Sixty patients aged 18 to 65 years, with American Society of Anesthesiologists status I to II, undergoing surgery for femur fracture were chosen for the study and randomized into 2 groups. Group A (n = 30) received 1 mcg/kg fentanyl Intravenously and Group B (n = 30) underwent ultrasonography (USG) guided FICB with 0.5% Bupivacaine of 20 ml volume, 20 minutes prior to positioning for subarachnoid block. Preprocedural and postprocedural parameters such as hemodynamic parameters, visual analog scale (VAS) scores for 12 hours and quality of positioning and request of first rescue analgesia were recorded. Results: Preprocedural VAS scores were similar in both groups. Postprocedure VAS score in Group B was significantly less compared to Group A. Patients in Group B had
better quality of positioning for subarachnoid block. Requirement of first rescue analgesia was prolonged in Group B compared to Group A. Conclusion: FICB group patients had better quality of positioning subarachnoid block and prolonged postoperative analgesia. This suggests USG guided FICB is an effective way to reduce patient discomfort during positioning for subarachnoid block in femoral fractures and prolong postoperative analgesia.

Background: Nausea and vomiting are common complications of anesthesia and surgery. Patients undergoing middle ear surgeries are exposed to a higher-risk of Postoperative Nausea Vomiting (PONV).
These complications may alter the results of reconstruction and anatomical alignments. Numerous antiemetics have been studied to prevent and treat PONV in patients undergoing middle ear surgeries. The aim of this study is to compare the effect of ramosetron and dexamethasone for prophylaxis of postoperative nausea and
vomiting in patients undergoing middle ear surgeries. Methods: In a randomized controlled clinical trial, 60 patients were divided into two groups, one receiving ramosetron, one receiving dexamethazone, all patients were subjected to middle ear surgeries. The patients in the Group R received ramosetron (0.3 mg IV) and the patients in Group D received dexamethasone (8 mg IV), Using Bellivelle’s scoring system, the incidence of PONV and its severity during the 24-hour period after surgery were measured and compared. Result: The incidence rates of PONV in dexamethasone group is 89.9%, and with ramosetron group is 29.9%, which showed statistically significance (p - value < 0.0001). The incidence rate of postoperative nausea and vomiting in dexamethasone group is significantly higher than that of ramosetron group. Conclusion: Ramosetron 0.3 mg IV given before induction of anesthesia is an effective means of reducing PONV in middle ear surgeries. Compaed to dexamethasone 8 mg IV ramosetron 0.3 mg IV significantly reduces PONV in the immediate postoperative period. Ramosetron is suitable alternative to dexamethasone in controlling PONV

Context: Dexmetedomidine is  2 agonist used as adjuvant to spinal anesthesia for prolongation of sensory, motor block, postoperative analgesia. Aims: To study the effect of single-dose IV dexmetedomidine
on hemodynamic profile, sensory-motor block prolongation, sedation. Methods and Material: 100 adult patients of ASA 1 and 2 posted for elective infraumbilical surgery were included. They were randomly divided into 2 groups. Group D received intravenous dexmtedomidine 0.5 g/kg over 10 min slowly. Group M - 0.5 mg/kg over 10 mins. Both drugs were administered 15 min after spinal anaesthesia with 15 mg 0.5% intrathecal bupivacaine heavy. Vital data, duration of sensory and motor block, sensory regression, Ramsay Sedation score and side effects were evaluated. Results: Duration of sensory block
in Group D was 308 ± 20 min prolonged than Group M 200 ± 15 min. Duration of two segment regression time in Group D – 140 ± 8 min more than Group M 120 ± 6 min. Ramsay sedation score was slightly more for Group D without any respiratory depression. Patients of both groups remained hemodynamically stable through out with minimal side-effects. Conclusions: Intravenous dexmetedomidine significantly augments the sensory and motor block of intrathecal bupivacaine providing excellent sedation.

Background: Various anatomical measurements & noninvasive clinical tests, singly or in various combinations can be performed to predict difficult laryngoscopy & intubation in apparently normal patients. Recently introduced “Upper Lip Bite Test (ULBT)” & “Ratio of Height to Thyromental Distance (RHTMD)” are claimed to have high predictability in comparison to commonly used Mallampatti Grading (MPG). Materials and Methods: We conducted a prospective single blinded observational study of 150 adult patients of ASA Grade I & II, assessed them for MPG, ULBT & RHTMD according to standard methods & correlated with the Cormack & Lehane grade. The Data analysis was done using Graphpad Software. Result: ULBT & RHTMD had more sensitivity, specificity, positive predictive value & negative predictive value, i.e., 83%, 85%, 69%, 89%, 56%, 78%, 89%, 92% respectively as compared to MPG 28%, 85%, 48%, 73%. P - value for both the tests were < 0.01
in comparison with MPG. Conclusion: Amongst the three methods used, RHTMD is best predictive test for difficult laryngoscopy in apparently normal patients, but ULBT can also be used as an acceptable alternative which is less cumbersome than RHTMD.

The primary aim is to compare postoperative analgesia by intraperitoneal infiltration of bupivacaine versus bupivacaine with dexmedetomidine in laparoscopic surgery. The secondary objective to assess postoperative pain relief, rescue analgesic drug requirement and side-effects in both groups. The study was approved by the University’s institutional ethics committee (Reg No. ECR 518/Inst/MH/2014/RR-17) and written informed consent was obtained from all subjects participating in the trial. The  study  was conducted prior to patient enrollment at Bharati Vidyapeeth Medical College institutional ethics committee (REF: BVDUMC/IEC/62, Principal investigator: Hemadip Tavethiya, Date of registration: 7th September, 2018). This  prospective  comparative study enrolled a sample of 52 patients, 26 in each group. Group B received only Bupivacaine intraperitoneally and Group BD received Bupivacaine with adjuvant Dexmedetomidine intraperitoneally. VAS score was seen at 1, 2, 4, 6, 12, 24 hours postsurgery and VAS score > 3 was given IV paracetamol or IV diclofenac sodium as rescue drug. Results: VAS at different time intervals, overall VAS in 24 h was significantly lower (2.34 ± 0.84, 3.65 
± 0.47), total analgesic consumption was low in Group BD than Group B. Conclusion: Intraperitoneal instillation of bupivacaine in combination with dexmedetomidine is superior to bupivacaine alone.

Background: Recovery from general anesthesia and tracheal extubation is associated with increased hemodynamic response due to reflex sympathoadrenal activity and can be dangerous in susceptible patients. Many pharmacological methods were used to attenuate hemodynamic response but none were ideal. Aims: The aim of this study was to compare the effects of intravenous Esmolol and sublingual Nitroglycerine spray on hemodynamic response following tracheal extubation in patients undergoing general anesthesia for various surgeries. Methods: 60 patients of ASA 1 and 2 of either sex undergoing elective surgeries under general anesthesia were placed randomly in either Group A (n = 30) or Group B (n = 30). Group A received intravenous Esmolol 1.5 mg/kg and Group B received Sublingual 0.8 mg NTG spray. Either of the study drug was administered after 1 minute of the reversal agents being given. Hemodynamic variables HR, SBP, DBP and MAP were monitored and noted during tracheal extubation. Results: Intravenous Esmolol group had better control over heart rate when compared to Sublingual NTG spray group during tracheal extubation. Sublingual NTG spray group had modest increase in heart rate (Mean of 122 bpm). With respect to Systolic, Diastolic and Mean arterial blood pressure both the groups were found to be statisticaly insignificant and had clinically significant control over hemodynamic response during tracheal extubation. Conclusion: Intravenously administered Esmolol in dose of 1.5 mg/kg attenuates tracheal extubation response by having better control on heart rate and blood pressure with minimal complications when compared to sublingual 0.8 mg NTG spray group.

Introduction: Regional anesthesia is particularly indicated for patients undergoing peripheral limb surgery because it provides effective intraoperative anesthesia and postoperative pain control. Supraclavicular approach of brachial plexus block is the most commonly used approach and provides the most complete and reliable anesthesia for upper limb surgery. The concurrent injection of α2 adrenergic agonist drugs has been suggested to improve the nerve block characteristic of LA solutions. Objectives: To assess the time of onset and duration of action of Ropivacaine with MgSO4 and Ropivacaine with dexmeditomidine. Materials and Methods: Patients with American Society of Anesthesiologists physical status (ASA) Grade 1 or 2 posted for  elective upper limb orthopedic surgeries were included in the study. The study patients were randomly divided into 2 Groups with 25 patients in each group namely Group A (n = 25): 20 ml 0.75% ropivacaine (150 mg) +2.5 ml (250 mg) MgSO4 and Group B (n = 25): 20 ml 0.75% ropivacaine (150 mg) + 2.5 ml dexmedetomidine (1 mcg/kg + normal saline). Brachial plexus block through supraclavicular approach was performed. The primary outcome measure was the onset of sensory and motor blockade, while secondary was the duration of sensory and motor blockade. The adverse reactions during the perioperative period were recorded. Results: Overall, the onset of motor and sensory blockade in Group B was faster than Group A and the duration of motor and sensory blockade in Group B was longer than Group A, which was statistically significant with p - value < 0.001. Conclusion: Dexmedetomidine as an adjuvant to Ropivacaine in the supraclavicular brachial plexus block for upper limb surgery significantly shortens the onset time for sensory and motor block and prolongs the duration of sensory and motor blocks with the use of ultrasound guidance for the peripheral nerve blocks.

Background: Pain after thoracotomy is probably the most severe pain experienced by the patient and opioid are one of the most commonly used analgesics for postoperative pain. Hence, the present study was undertaken to compare the efficacy and safety of 25 mcg/hour of fentanyl patch with 20 mcg/hour of buprenorphine patch for postoperative pain management in postthoracotomy patients. Methods: Total sixty patients of ASA Grade I, II and III, age between 20 and 60 years, who have undergone thoracotomy surgeries were enrolled in the study and randomly divided into two groups of 30 patients each. Group A received 25 mcg/hour of fentanyl patch and Group B received 20 mcg/hour of buprenorphine patch immediately after patient was received in critical care unit postsurgery. Patients were followed for three days. Results: Demographic profile and baseline characteristics were comparable between two groups. Group A had significantly higher level of mean VAS score as compared to Group B at Day 2 and 3. In the same follow up period, both the groups were comparable in regards to mean level of sedation score and hemodynamic variables (HR, SBP and DBP). In Group A 11 (36.66%) patients and in Group B, 8 (26.66%) patients required single dose of rescue analgesic, (p - value > 0.05). The incidence of nausea and vomiting were 13.33% in Group A and 23.33% in Group B. Conclusion: Both the fentanyl and buprenorphine patch are effective and safe in controlling postoperative pain but buprenorphine is better than fentanyl in this respects, as it have longer duration of action and require less rescue analgesic for pain relief. 

Aims and Objectives: To compare the effects of crystalloid preload and crystalloid coload on hemodynamic parameters in patients undergoing elective cesarean section under spinal anesthesia. Materials and Methods: One hundred patients with American Society of Anesthesiologists Physical Status I and II scheduled for elective cesarean section under spinal anesthesia were randomly allocated into two groups with fifty patients each. Group P: Received 15 ml/kg of Ringer‘s lactate solution over 20 minutes prior to spinal anesthesia. Group C: Received 15 ml/kg of Ringer‘s lactate solution over 20 minutes as soon as Cerebrospinal fluid (CSF) was tapped. Patients were assessed for hemodynamic changes, mean and total dose of vasopressor consumption in the intraoperative period. Results: The incidence of Hypotension was high in Group P (66%) when compared to Group C (36%) with p - value of 0.0027 which is statistically significant. Hypotension appeared early in Group P (6.85 ± 0.83) when compared to Group C (15.83 ± 0.92) minutes with significant 
p - value of < 0.001. Group P also had higher incidence of nausea and vomiting (48% and 34%) when compared to Group C (18% and 12%) respectively with statistically significant difference. (p - value 0.0027 and 0.0014 respectively). The incidence of bradycardia and shivering was also high in Group P as compared to Group C though the difference is statistically insignificant. Conclusion: Crystalloid coload in the dose of 15 ml/kg is more effective than the crystalloid preload in the same dose for prevention of spinal hypotension in patients undergoing elective cesarean section.

Context: Oral premedication is commonly used in pediatric anesthesia to provide preoperative anxiolytics and to ensure smooth induction. Midazolam is currently the most commonly used premedication, but newer drugs such as dexmedetomidine have emerged as alternatives for premedication in the pediatric population. Aims: The aim of the study is to compare the clinical effects of oral dexmedetomidine and oral midazolam on preoperative sedation and postoperative recovery profile in children. Materials and Methods: We performed a prospective, randomized, double-blinded controlled study in 106 children, 2–10 years of age undergoing elective surgeries under general anesthesia. Patients were randomly assigned to receive either oral dexmedetomidine 4 mcg/kg (Group D, n = 53) or oral midazolam 0.5 mg/kg (Group D, n = 53) 40 minutes prior to mask induction. Preoperative sedation and anxiolytics, the response of the child during separation from the parent, quality of mask acceptance and recovery profile were compared for the two groups. Statistical Analysis: Results were analyzed using an unpaired Student’s t-test and Chi-squared test. p < 0.05 was considered statistically significant. Results: The level of preoperative sedation at the end of 40 minutes was significantly higher in the dexmedetomidine group (3.74 ± 0.07) than the midazolam group (3.17 ± 0.10). Response to parental separation and quality of mask acceptance was significantly better in group dexmedetomidine compared to group midazolam (p > 0.05). Intraoperative Heart rate and Mean Arterial Pressure (MAP) was lower in the dexmedetomidine group compared to midazolam group. The incidence of postoperative agitation was significantly less in the dexmedetomidine group (p < 0.05). Conclusion: In this study, we concluded that the premedication with oral dexmedetomidine produced better preoperative sedation and recovery from anesthesia in pediatric population compared to premedication with oral midazolam.