Indian Journal of Anesthesia and Analgesia

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Retrograde intubation is one of many techniques that can be used in those cases where oral or nasal tracheal intubation may be extremely difficult or impossible. Retrograde intubation is a reliable and easily learned technique that offers an alternative to more invasive surgical solutions for securing the airway. Submental intubation provides intraoperative airway control, avoids use of oral and nasal route, with minimal complications. Submental intubation is an acceptable option, especially when long-term post-operative ventilation is not planned. We hereby report a case of a 55-year-old woman with a recurrent history of a pleomorphic adenoma of palate which required tumour excision under General Anaesthesia for which Awake Retrograde Submental Intubation was done.

Giant mediastinal mass tumors have been associated with perioperative respiratory and circulatory life- threatening complications during induction of general anaesthesia and initiation of positive pressure ventilation leading to sudden cardiac arrest known as MMS, ‘Mediastinal mass syndrome’ (4, 5,6). A detailed meticulous preanaesthetic evaluation and a well thought out anaesthetic plan can avoid life-threatening events during management of these patients. We report a successful anaesthetic management of a 12 yrs old pediatric patient with a left sided giant mediastinal germ cell tumor, posted for complete surgical resection. We followed the guiding principles for anaesthetic management of such cases, maintaining propped up position, avoiding muscle relaxants, maintaining spontaneous breathing, keeping cardiac team and perfusion team ready to cannulate and institute CPB in case of sudden cardiorespiratory collapse, adapting to low volume ventilation and titrated and step wise induction of anaesthesia.

The Classic Fontan has been abandoned these days due to occurrence of rapid and incessant complications. Presence of complications like, morbid obesity, obstructive apnoea, chronic atrial flutter, elevated Fontan pressures as seen in our patient, increases the risk of Anaesthesia manifold times. We report a case of 32 year old male patient with failing modified Fontan and aforementioned complications, posted for radiofrequency ablation under general Anaesthesia.

Brachial plexus is a complex bundle of nerves, extending from the neck to the axilla, which supplies both motor and sensory fibres to the upper extremity. So clear understanding of anatomy and distribution of nerves is effective for regional anaesthesia. The introduction of ultrasound guidance techniques not only reduces the possible risk of pneumothorax but also allows a faster onset time of the block, with a reduction of the volume of local anaesthetic mixture,that has to be injected for a successful peripheral nerve blocks Also detects vascular structures and pleura, needle tip control, and monitoring of distribution of local anaesthetic (LA). After obtaining the approval of institutional ethical committee of hospital, a retrospective review of anaesthesia register from January 2015 until January 2020 (60 months) was done. All the adult patients who underwent upper limb surgeries underwent peripheral nerve stimulator guided injections for supraclavicular brachial block and paediatric patients under axillary block by landmark technique from January 2015 to July 2017, will be allocated to PreUS group and after availability of portable ultrasonography as Post-US with ultrasonography being available since July 2017 and outcome will be recorded. As it is a retrospective study, all possible data will be included and analysed. As it is a retrospective study, nothing could be excluded.So comparision for 30 months of pre ultrasound and 30 months of post ultrasound period. Conclusions: In adults ultra sound increased 26 % rise in no of surgeries under regional anaesthesia which is quite significant.The reduction in mean effective volume(MEV) in adults was about 51% by the application of ultrasound. In children, there was a definitive rise of 60 % increase in no of cases under Axillary approach of brachial block and 43% reduction in the mean effective volume(MEV).

Background: Baska mask has been chosen to secure airway for surgeries under general anesthesia in view of its adaptability during positive pressure ventilation as it moulds accordingly. Aims: Our aim was to compare BASKA mask with Endotracheal tube primarily for hemodynamic changes, and also ease of insertion in terms of number of attempts and time taken for insertion, airway trauma, intraoperative and postoperative laryngopharyngeal morbidity (LPM) occurring in patients undergoing laparoscopic cholecystectomies under general Anesthesia. Methods: A hospital based prospective, randomised comparative clinical study involving60 ASA I and II patients undergoing laparoscopic surgeries under general Anesthesia were randomly divided into 2 groups of 30 each (n=30), either using BASKA mask or ETT. Hemodynamic changes in both the groups were compared, along with number of attempts and time for insertion and laryngopharyngeal morbidities. Results: Hemodynamic fluctuations are less in patients who received Baska mask for their airway management than with endotracheal tube insertion. The number of attempts of insertion and time duration of insertion of Baska Mask (Mean ±SD=13.50±5.49) for airway management were less and with negligible postoperative laryngopharyngeal comorbidities when compared with endotracheal intubation in adult patients undergoing elective laparoscopic cholecystectomy under general anaesthesia with positive pressure ventilation. Conclusion: Baska Mask with its unique anatomy and features is a good alternative to endotracheal tube for airway management in elective laparoscopic cholecystectomies under general anaesthesia with positive pressure ventilation in terms of negligible hemodynamic changes, less number of attempts and reduced mean time duration of insertion, and less laryngopharyngeal morbidities.

Background: Recently there has been an interest to explore the efficacy of nalbuphine as' an adjuvant to local anaesthetic agents. This study was designed to compare its analgesic efficacy when added to levobupivacaine in patients undergoing inguinal hernia surgeries under subarachnoid block. Methods: Fifty patients belonging to ASA I/II, between 18-65 years of age undergoing inguinal hernia repair were randomly allocated to receive subarachnoid block with either 12.5 mg of 0.5% isobaric levobupivacaine (2.5 ml)+ normal saline (0.5 ml) (Group-LS) or 12.5 mg of 0.5% isobaric levobupivacaine (2.5 ml)+ 1 mg nalbuphine (0.1 ml) + normal saline (0.4 ml) (Group-LN). Onset of sensory block, two segment regression time, time of regression to T12, duration of effective analgesia and intensity of motor block were assessed. Results: Onset of sensory block was comparable in the two groups (P=0.774). Time of regression of sensory block to T12 dermatome was 161.09 ± 40.50 min in group LS and 167.50 ± 50.17 min in group LN (P=0.633).The duration of effective analgesia was 177.39 ± 43.53 min in group LS and 183.75 ± 56.69 min in group LN (P=0.669).Motor block parameters were also comparable.More number of patients in group LN had a sedation score of one as compared to group LS.No major side effects were seen. Conclusion: 12.5 mg levobupivacaine with or without nalbuphine is sufficient for conducting inguinal hernia surgeries. Intrathecal nalbuphine 1 mg did not affect the sensory and motor block characteristics of levobupivacaine.

Context: Patients undergoing percutaneous nephrolithotomy (PCNL) experience considerable post-operative pain. Perioperative pain control for PCNL using regional anaesthesia techniques like erector spinae plane block (ESPB) helpsin better outcome in terms of pain, fentanyl requirement. It also indirectly helps in faster recovery and early discharge from hospital. Aims: To assess and compare perioperative pain control provided by ESPB with 0.5% bupivacaine and dexmedetomidine as adjuvant to it. Settings and Design: This randomized case control study was undertaken in a tertiary care centre. 60 patientsplanned for elective unilateral PCNL over a period of 15 months. Patients were randomized into two groups (Group B and group D) using envelope method. Patients were compared for fentanyl consumption, duration and effectiveness of analgesia obtained. Methods and Materials: ESPB was administered pre operatively under ultrasound guidance at the level of 10th thoracic vertebrae. Needle tip was visualised above transverse process of 10th thoracic vertebra. Position was confirmed by hydro dissection on injecting normal saline under ultrasound and drug was injected.Patients were assessed for painat specific time intervals. Total opioid consumption was noted. Data obtained was recorded and analysed. Statistical analysis used: Statistical analysis was performed by SPSS software v.23.0. Oneway analysis of variance, Bonferroni correction, Chi square test was used. P value of <0.05 was considered statistically significant. Results: Dexmedetomidine as adjuvant to local anaesthetic agent improves the quality and prolongs the duration of analgesia. It also decreases total fentanyl consumption. Conclusion: ESPB provides adequate analgesia for PCNL. Addition of dexmedetomidine decreases fentanyl and sevoflurane consumption meanwhile increasing duration of analgesia.

Background and need for study: One of the challenge faced by paediatric anaesthesiologist is the allaying of fear of a child in the preoperative period. Among the commonly used premedicant in children, midazolam is the front runner. A combination low dose of ketamine and midazolam have been tried to overcome the deficiencies of ketamine and midazolam alone. Aims: This research was planned to compare the effectiveness of combination of low dose midzolam–ketamine with oral midazolam alone as a premedicant in paediatric patients in terms of degree of sedation, separation from parents, mask acceptance, and postoperative recovery Design: Prospective, randomised, double blind controlled study. Methods: Sixty children of ASA physical status I or II, aged between 1 and 12 years, who were scheduled to undergo elective minor surgery were randomised into two groups M and MK of thirty children each. Children in group M were administered with oral midazolam 0.5 mg.kg-1 mixed with 2 ml of honey and group MK were administered with combination of low dose oral midzolam (0.25 mg.kg-1) & oral ketamine (3 mg.kg-1) for premedication mixed with 2 ml of honey. Patient was assessed for parental separation anxiety, mask acceptance, level of sedation and emergence delirium. Statistical Analysis: Difference with respect to anxiety at separation from parents and tolerance to mask between the two groups was analysed using chi-square test . Difference with respect to incidence and severity of emergence delirium between the two groups was analysed using an independent sample t test . The P <0.05 was considered significant. Results: Parental separation was acceptable in 23 patients (76.7%) in group M and 28 patients in (93.3%) in group MK (Table 2, 3). Mask acceptance was satisfactory in 13 (43.3%) in group M and 19(63.3%) in group MK. Post-operative delirium was noted in one patient in each group. Conclusion: The low dose mixture of ketamine and midazolam provides better parental separation and mask acceptance with better cooperation during induction of anaesthesia.

Background and Objectives: Nasal Fibreoptic intubation (NFI) is the recommended technique in patients with difficult airway like facial defects, limited mouth-opening and cervical instability but it requires the patient to be awake. The usage of an ideal sedative agent and stabilizing the intubating condition was essential for this. In this study we compare efficacy of different doses of dexmedetomidine for conscious sedation facilitating NFI. Materials and Methods: This is a prospective, blinded-randomized-trial to correlate the effectiveness of different loading and maintenance doses of dexmedetomidine during NFI on 60 patients, 30 in each group, aged between 20 and 60 years with ASA grade I or II enrolled for elective surgery. All patients received 2 mg Midazolam as premedication before transferring to operating room. Group A patients received Dexmedetomidine 1 mcg/kg I.V bolus slowly over 10 minutes then 0.8 mcg/kg/h as maintenance throughout the procedure. Group B patients received Dexmedetomidine 0.8 mcg/kg I.V. as bolus and 0.2 mcg/kg/h as maintenance dose. Primary outcomes were assessment of sedation level and comfort of each patient by Total Comfort Scale (TCS). The difference in quantitative measures was done using student ‘t’ test and difference in proportions by ‘Chi’ square test. P<0.05 was considered statistically significant. Results: With respect to comfort scores and optimal conditions during NFI, Group A people showed significantly lower scores when compared to Group B. Conclusion: Dexmedetomidine with loading 1μg/kg and higher maintenance dose 0.8μg/ kg/h were better for NFI with better patient tolerance, patient comfort, patient satisfaction, good sedation and preserved upper airway with spontaneous breathing.

Background and aims: Inferior venacaval compression during pregnancy causes extradural venous engorgement which may reduce the lumbar cerebrospinal fluid volume. A subsequent greater cephalad spread of sensory block is observed. We hypothesized that maternal abdominal circumference measurement can reflect the compressive effect of uterus and investigated the relationship between maternal abdominal circumference and the level of sensory block, the maximum level of sensory block, incidence of hypotension, nausea, vomiting, requirement of ephedrine in term parturients undergoing cesarean section under spinal anasethesia. Methods: Abdominal circumference of 40 term parturientswere measured before performing subarachnoid block. 0.5% hyperbaric bupivacaine (2ml, 2.2ml, 2.4ml) was injected into L3-L4 subarachnoid space according to parturients height .The level of sensory block was assessed at various time intervals. The statistical tests applied were Onewayanova, product moment correlation and independent sampleT Test. Results: The correlation coefficient between abdominal circumference and the level of sensory block was significantly positive at various time intervals (p<0.05) following spinal anesthesia. There was a positive correlation between abdominal circumference and highest level of sensory block. No significant correlation was found between abdominal circumference and incidence of hypotension, requirement of ephedrine, nausea and vomiting after spinal anaesthesia (p>0.05).There was a significant positive correlation between BMI and the level of sensory block (p<0.05). Conclusion: Parturients with greater abdominal circumference value have a higher level of sensory blockade after spinal anaesthesia. Abdominal circumference cannot predict the incidence of hypotension, nausea, vomiting and the dose of ephedrine required.

The aim of this prospective randomized study is to compare intubating laryngeal mask airway (ILMA) with Macintosh laryngoscope (ML) in patients with simulated cervical spine injury, to compare the hemodynamic variables and to see any complications associated with their use in the peri-operative period. Methods: We selected 60 ASA physical status 1 and 2 patients posted for elective surgeries under general anaesthesia. These patients were randomly allocated into two groups of 30 each: Group ML was intubated using Macintosh laryngoscope and Group ILMA was intubated using ILMA. Baseline hemodynamic parameters (BP, HR), 3 min and 5 min post intubation readings and number of attempts taken for successful intubation were recorded. Results: The mean duration of intubation was more in Group ILMA (28.93 +/-8.98 seconds in Group ML vs 74.83 +/-16.03 seconds in Group ILMA) with a P value of <0.01. The rise in hemodynamic parameters was comparatively higher in Group ILMA than in Group ML but it was statistically insignificant. Conclusion: Macintosh laryngoscope is a faster method to secure tracheal intubation than Intubating Laryngeal Mask in patients with cervical collar. The success rate of intubation through Intubating Laryngeal Mask is similar to that of Macintosh laryngoscope.

Background: Ropivacaine has been used for brachial plexus block because of its safety profile. Dexmedetomidine is one of the adjuvants added to Ropivacaine as it is known to potentiate sensory and motor blockade. Aim: Our aim was to compare and assess the effectiveness of adding Dexmedetomidine as an adjuvant to 0.75% ropivacaine in supraclavicular brachial plexus block using parasagittal approach for duration of analgesia primarily. Onset and duration of sensory and motor blockade were also the variables compared. Materials and methods: A prospective single blinded randomized comparative clinical study was carried out among in eighty patients of ASA Grade I and II between the ages of 20-60yrs, scheduled for elective upper limb orthopedic surgeries involving the forearm under supraclavicular brachial plexus block using parasagittal approach. Group R received 20ml of 0.75% ropivacaine along with 1ml of normal saline while Group RD received 20ml of 0.75% ropivacaine along with 0.5mcg/kg dexmedetomidine constituted to 1ml. Sensory, motor blockade & analgesic efficacy was determined. Statistical Analysis: Student t-test was used for demographic and hemodynamic data analysis. Unpaired t-test was used for evaluation of data which consisted of onset, duration of sensory and motor blockade along with duration of analgesia. The results were statistically significant if p-value <0.05. P-value <0.001 was considered highly significant. Results: Duration of analgesia lasted longer in Group RD (991.09 ± 16.34) when compared to Group R (542.57 ± 18.37). Onset time for sensory and motor blockade were rapid in Group RD (7.71 ± 1.23, 13.66± 1.03) when compared to Group R (10.14 ± 1.00, 18.60 ± 1.54). Duration of sensory blockade was prolonged in Group RD (780.26 ± 31.43) when compared to Group R (455.57± 20.28). Duration of motor blockade was also enhanced in Group RD (725.57 ± 25.18) when compared to Group R (397.74 ± 24.92). Conclusion: Addition of Dexmedetomidine to Ropivacaine provided superior analgesia along with faster onset and longer duration of sensory and motor blockade.

Background: Juvenile nasopharyngeal angiofibroma(JNA) is a locally invasive benign vascular tumor, controlled hypotension is used to facilitate endoscopic resection. Nitroglycerine and Dexmedetomidine were compared as hypotensive agents in this study. Methods : Ethics Committee has approved the study which was conducted at Government ENT hospital, Hyderabad during 2016 – 2018.Study included 40 patients divided into two groups, Group D (Dexmedetomidine) n=20,1µg/kg over 15 min followed by a maintenance infusion at 0.5µg/kg/hr,GroupN(Nitroglycerine) n=20- Nitroglycerine @ 0.5µg/kg/min and titrated in doses 0.5-5µg/kg/min for target blood pressure respectively. Results : A statistically significant difference was observed in the study in mean pulse rate between two groups Group D-66.09±2.83, Group N-86.59±4.24, p value 0.0001. Blood loss was lower in Group D-310.71±140.58 compared to Group N 482.61±141.42 , and is statistically significant (p value 0.0004). SBP, DBPand MAP were comparatively lower in Group D throughout the surgery. Conclusions: Dexmedetomidine is a better hypotensive agent with favourablehemodynamics and significantly less blood loss when compared to Nitroglycerine.

Background: Various adjuvants have been added to bupivacaine to shorten the onset of block and prolong the duration of block. Present study was undertaken to compare the efficacy of intrathecal fentanyl or buprenorphine with bupivacaine for all infraumbilical surgeries. Materials and Methods: 60 ASA I and II patients posted for various infraumbilical surgeries were chosen for the study and the patients were divided into two groups of 30 each. Group F received 3ml of 0.5% bupivacaine with 25µg of fentanyl and group B received 3ml of 0.5% bupivacaine with 60µg of buprenorphine.Sensory block was tested with pinprick method and motor block was assessed by onset of Bromage scale 3. Results: Patient in Buprenorphine group showed a significantly prolonged duration of motor and sensory block than patients in fentanyl groyp and also postoperative VAS scores were significantly low for the buprenorphine group when compared with fentanyl. Conclusion: To summarise, buprenorphine has higher efficacy with intrathecal bupivacaine with prolonged duration of sensory and motor blockade with decreased incidence of side effects, better haemodynamic stability and also analgesic sparing effect in the postoperative period when compared to fentanyl.

This study was conducted to compare the effects of hyperbaric bupivacaine 0.5% alone versus hyperbaric bupivacaine 0.5% + fentanyl 25mcg in spinal anaesthesia in patients undergoing LSCS. Objective: A prospective randomised comparative study, conducted to compare the onset and duration of analgesia and hemodynamic changes, side effects like nausea, vomiting, respiratory depression, shivering, pruritis, etc. if any. Method: After institutional committee approval and obtaining written informed consent. 64 patients posted for LSCS were randomly divided into two groups with 32 patients in each group. All patients were examined before the surgery and thoroughly investigated as per institution protocol and counselled about the anaesthesia and procedure. Patients were instructed to fast for 6-8 hours before surgery. Baseline blood pressure, heart rate and oxygen saturation were recorded. Lumbar subarachnoid block was performed. After confirming free flow of CSF the drug was injected. Features assessed :The time of onset of sensory analgesia at T10 segment, maximum level of analgesia, degree of motor blockade, duration of effective analgesia, hemodynamic parameters and complications. Results: Addition of fentanyl to bupivacaine can be safely administered in patients undergoing caesarean section without significant hemodynamic changes and adverse effects. It markedly improves intraoperative anaesthesia and significantly reduces need for postoperative analgesia. Total duration of analgesia with bupivacaine alone was 176.6 +/-31.9 mins versus 276.7+/- 31.4 mins with added fentanyl. Conclusion: The addition of 25 micro gram of fentanyl to 2ml (10mg) of hyperbaric bupivacaine intensified and prolonged the duration of bupivacaine induced sensory block without affecting motor blockade.

Background: Cataract surgery are usually done in elderly patients. Dexmedetomidine is a potent non-opiod sedative and analgesic devoid of respiratory depression. Midazolam is the most commonly used sedative which is commonly associated with respiratory depression specially in elderly patients. Objectives: To compare the effects of intravenous dexmedetomidine and midazolam on the haemodynamic stability, sedation and intraocular pressure and to study the safety profile of the drug Methodology: After obtaining permission from institutional ethical committee and patient informed consent, study was conducted at BMCRI from November 2016 to May 2018 in ASA Grade 1 and 2 patients of 40 to 70 year age undergoing cataract surgery. Patients were randomly allocated to two Group D and M of 32 each. Group D received inj. dexmedetomidine 0.25mcg/kg, Group M received inj. midazolam 0.02mg/kg diluted to 10ml over 10 minutes as intravenous injection. Peribulbar block was given with 8-10ml of injection 2% lignocaine with adrenaline with hyaluronidase. Haemodynamic parameters like Heart Rate, Mean Arterial Pressure and SpO2, Intra Ocular Pressure in non-operating eye, Ramsay Sedation Score, Visual Analogue Score and Modified Aldrete Score were recorded. Results: We concluded that in our study demographic data were comparable. Patients of Dexmedetomidine group had reduction of IOP after drug injection (p=0.001) and at post bulbar block (p=0.002) which is statistically significant compared to Group M patients and also there was statistically significant difference in RSS Score between two groups. Conclusions: Dexmedetomidine provides same conscious sedation as Midazolam. Dexmedetomidine reduces intraocular pressure and maintains SpO2 when compared to Midazolam in cataract surgery.

Context: Subarachnoid block (SAB) is a safe anesthestic technique commonly practiced worldwide. It is associated with hypotension (33%), bradycardia (13%), and shivering due to hypovolemia, sympathetic blockade, and Bezold- zarisch reflex. Hypotension is managed with vasopressors and crystalloids, while drugs and physical methods are useful to control shivering. Aims: The study aims to evaluate the efficacy of ondansetron versus low dose ketamine to prevent hypotension and shivering during SAB. Settings and Design: A prospective, randomized comparative study. Methods: The studywas conducted on 120 patients undergoing elective lower abdominal surgeries under SAB. Patients were randomly allocated into two groups of 60 each. Group K received 0.25 mg/kg ketamine, while Group O received 4 mg of ondansetron as a slow intravenous infusion (IV) 5 min before SAB. Mean arterial pressure (MAP) and Heart rate (HR) were studied at 2 min intervals for the first ten minutes and once in 5 minutes for the next thirty minutes. Shivering scores were measured at 5 min interval for 40 min. Statistical Analysis: Mean Arterial pressure and heart rate were compared and analyzed using unpaired t-tests. Shivering was compared using contingency tests. Results: A decrease in HR is significantly lower in group K than in group O after 2 min (p < 0.001), 8 min (p < 0.001), 15 min (p < 0.0031), 25 min (p < 0.0115) and 40 min (p < 0.0037) of SAB. MAP was increased at 2 min time interval in the Ketamine group comparative with the Ondansetron group with a p-value <0.05 showing a high statistical significance. Group K had grade I (p < 0.001) shivering in 70% (42) of the patients compared with 36.7% (22) of patients in group O. Conclusion: Administration of IV ondansetron and ketamine prevents SAB induced hypotension and shivering effectively.

Caudal epidural block is one of the most common regional techniques in pediatric anaesthesia. Epidural route of dexamethasone prolongs analgesic effect. Bupivacaine acts mainly by blockade of voltage gated NA+channel in the axonal membrane. Dexamethasone have a local anesthetic effect on nerve by direct membrane action.

Methodology: A randomized, prospective, interventional study.80 paediatric patients were allocated into two equal groups. BD group received 1.0 ml/kg of 0.25% bupivacaine with 0.1mg/kg of dexamethasone and B group received 1.0ml/kg of 0.25% bupivacaine. Patients more than 6 years were excluded from the study.

Results: In our study FLACC scores in group BD was reduced as compared to group B. Mean duration of analgesia was 279.8±11.54 minutes in group B was increased by adding Dexamethasone to 486.07±3.72 minutes in group BD.

Conclusion: The study was conducted in 80 children, aged 6months to 6 years of ASA I AND II undergoing elective Genitourinary surgeries under general anaesthesia. It is found that addition of Dexamethasone to Bupivacaine in caudal analgesia significantly increases the duration of postoperative analgesia without much side effects.