Indian Journal of Anesthesia and Analgesia

Context: Available evidence on efficacy of adjuvants to local anesthetics (LAs) in supraclavicular BPB is of varying strengths and levels. Several studies have been conducted in which Magnesium Sulphate (MgSO4) was administered (with placebos and other drugs) as adjunct to LAs in supraclavicular BPB, and they revealed varying degrees of efficacy with or without side effects

Aim: To study efficacy of 20ml 0.5% ropivacaine with 250mg MgSO4 and 20ml 0.5% Ropivacaine with 500mg of MgSO4 in supraclavicular approach to brachial plexus block under ultrasound guidance

Settings and design: Prospective Randomized Controlled Comparative Interventional study was conducted at KIMS Hospital, Kondapur, Hyderabad.

Methods: 80 patients undergoing upper limb surgeries were included. They were randomly assigned in two groups of 40 each; with one group receiving MgSO4 250mg and the other MgSO4 500mg. two groups were compared for different parameters.

Statistical Analysis: Chi Square Test was applied for categorical data and t test for the continuous data.

Results: Baseline parameters, pre-anesthesia vital parameters were comparable in two groups (p>0.05). Duration of onset of sensory and motor block and completeness of block was similar in two groups (p>0.05). But duration of block was significantly more both for sensory and motor in Mg-500 compared to Mg-250 group (p<0.05). Heart rate, Mean Arterial Pressure (mmHg) were comparable in two group at all durations from pre-operative to 24 hours (p>0.05).

Conclusion: Duration of sensory and motor blockade is prolonged by addition of MgSO4 in two doses (500mg and 250mg) to Ropivacaine in USG-guided supraclavicular BPB. Action of MgSO4 is dependent on the dose, more the dose longer the action.

Key messages: 20ml of 0.5% ropivacaine with 500mg of magnesium sulphate in supraclavicular approach to brachial plexus block under ultrasound guidance can be used instead of 250mg magnesium sulphate.
 

Background: Electroconvulsive therapy formerly known as electroshock is a psychiatric treatment in which seizures were electrically induced to provide relief from psychiatric disorder. The most common technique of anaesthesia used during ECT is General Anaesthesia with bag and mask ventilation which is being used for a long time. However, there are case reports of pulmonary edema, bronchospasm, hemodynamic changes during this technique, so we want to compare the effectiveness of I-gel over bag and mask ventilation in ECT.

Methods: In our study 50 patients were randomized and 25 of them were ventilated with bag and mask. The other 25 patients were ventilated with I-gel. Vital parameters were monitored intra-operatively and postoperatively we observed nausea, vomiting, bronchospasm, sore throat, laryngospasm.

Results: Statistically significant difference were found in mean heart rate and blood pressure values in both the groups. Also we noticed 2 cases of nausea, 1 case of vomiting 2 cases of sore throat in bag and mask group whereas 2 cases of bronchospasm in I-gel group.

Conclusion: Hemodynamic variables were better controlled in I-gel group. Also the post operative complications were less in I-gel group.

Background: Arterial hypertension and diabetes mellitus are prevalent co-morbidities in surgical patients, and they might have an impact on perioperative care. Many times, the healthcare team will conduct a preoperative test for diabetes that has gone unnoticed. However, it is rarely assessed how much these disorders affect perioperative anaesthetic care.

Aim: The aim of the study was to determine the prevalence of new, managed, and uncontrolled hypertension, diabetes mellitus, and their perioperative sequelae in adult surgical patients.

Methods: This prospective observational study was conducted in a tertiary care teaching hospital. Total 186 adults of both sexes, planned for elective non-cardiac surgery were included. Arterial hypertension (AHTN) and Diabetes Mellitus (DM) was defined as per JNC-7 and ADA definition. The prevalence of new, controlled, uncontrolled AHTN and DM and their perioperative anaesthetic were assessed.

Results: Total 186 patients’ 98 (53% )cases posted were evaluated were with hypertension, 67(36%) cases with diabetes mellitus followed by 21 (11%) cases with both HTN and DM. The prevalence of these co morbidities was found to be highest in 6th decade.

The prevalence of DM was also higher in male than female , but the differences were statistically insignificant for AHTN, DM and for both . The prevalence of renal failure and coronary artery diseases, mean age in the patients with both the comorbidity were higher than either of hypertensive and diabetic group and both the differences were statistically significant.12 (12.2% ) hypertensive and 2 (3%) diabetic and patients were in the range of postponement of elective surgery.

Conclusion: Adults have a high prevalence of AHTN and DM, which increases dramatically with age. Both men and women are affected in the same way. The prevalence of uncontrolled AHTN and DM is concerning, demanding immediate action to treat these serious noncommunicable diseases.

Background and Aim: Brachial plexus blocks when administered adroitly offer numerous benefits over general anaesthesia for upper limb surgeries. It is especially beneficial in patients with substantial comorbid conditions such as diseases involving the respiratory and cardiovascular system, life-threatening obesity, and those with an anticipated difficult airway. Out of its many approaches, we aim to compare and assess the Supraclavicular and Infraclavicular techniques utilising ultrasonography.

Methods: Sixty consenting ASA I–II patients, aged 18–65 years, scheduled for elective upper limb surgery were randomly divided into two groups of 30 each: Supraclavicular (S) and Infraclavicular block Groups (I). Blocks were performed under ultrasound-guidance. The quality of the block intra-operatively, patient satisfaction post-operatively, duration of the sensory & motor block, and complications were observed.

Results: Demographics, number of attempts, mean pain score felt during the administration of the block, mean duration of motor and sensory blockade and incidence of complications were all comparable between the two groups & statistically not significant. However, at 5 and 10 minutes after the execution of the block, the Infraclavicular group showed a higher level of blockade, indicating that the onset of action of the block was significantly quicker.

Conclusion: Time taken to perform & rapidity of onset were more in the Infraclavicular block with no difference in adequacy of both blocks at 30 minutes.

Aims: Sympathetic system gets stimulated ondirect laryngoscopy and intubationand catecholamines are released. This response though of short duration, is hazardous to compromised subjects with brain and cardiac dysfunction. Vagus nerve also can be stimulated during laryngoscopy and intubation.

Ourstudy is to find out the effects of Nalbuphine Hcl 5mgm and Dexmedetomidine 25mgm on hemodynamic variables SBP, DBP, MAP and HR at the time of laryngoscopy and intubation. Study was carried out in Pushpagiri Institute of Medical Sciences. Consecutive sampling technique was used to select study population.

Methodology: We selected 100 subjects, ASA1 and 2, were randomly grouped into 2 groups of 50 each. All our subjects received 500ml crystalloid solution. Allsubjects were induced on Propofol and intubated on succinylcholine. The stress response was assessed by observing hemodynamic variables SBP, DBP, MAP and HR.

Statistical Analysis: Data was digitized and analyzed using SPSS22.0. Independent sample test was used to assess the difference in parameters. Data was stratified on the basis of age and weight of 2 groups. P-value of less than 0.05 was considered statistically significant.

Conclusions: Dexmedetomidine influences HR and the effect is more as age advances. In subjects heavier than 80kg, mean HR was higher. The effect of Dexmedetomidine on heart rate was statistically significant at a P value less than 0.05. Nalbuphine, according to studies, increases BP and HR. In our study, this rise in MAP was observed in subjects heavier than 70kg. But this finding was not statistically significant.

Geriatric patients (age 65 years and above) are more prone to POCD who undergo general anesthesia. Also the geriatric patients with co morbidities and substance abuse have higher chances for POCD.

Objective: To compare Post-operative cognitive status and recovery (time specific) in geriatric patients undergoing general anesthesia with sevoflurane or desflurane, by MMSE score. Also to compare other side effects and recovery.

Materials and Methods: This is prospective, randomized, interventional, single blind study. A study of 70 patients of either sex, ASA-I/II/III in the age group of above 65 years who were operated under general anesthesia and randomly allocated in two equal groups. Group S consisted of 35 patients who were given sevoflurane. Group D consisted of 35 patients who were given desflurane. MMSE score was taken pre-operatively and patients with score more than 27 were selected for this study.

Results: Statistically significant immediate recovery from general anesthesia was noted in group D compared to group S. But difference in post-operative MMSE score at 1 hour, 3 hours and 6 hours between group S and group D was statistically insignificant.

Conclusion: Patients given General Anesthesia with Desflurane showed early recovery signs, i.e. eye opening, following of verbal commands and extubation compared to patients given sevoflurane which is statistically proven. But MMSE score was lesser in desflurane than sevoflurane, which was insignificant.

Introduction: Early mobilization is the primary goal after operation of hip fracture in the elderly wherein the main impediment despite adequate fixation being surgical site pain. Prolonged post-operative recumbency due to pain could lead to various complications like venous thrombosis and cardio-pulmonary compromise. Over enthusiastic use of NSAIDs or opioids on the other hand can have its own set of complications. Hence this study was carried out to evaluate effectivity and safety profile of a commonly used drug, diclofenac via transdermal route in comparison to iv diclofenac.

Methods: 30 patients meeting the study criteria were alternatively allocated to either groups of IV diclofenac and TD diclofenac. All patients were informed how to monitor post-operative pain on a VAS scale at 2,4,6 and 12 hour intervals. Group TD was applied Trans Dermal Diclofenac 100 mg patch, 1 hour prior to surgery and repeated at 12 hourly intervals. Group IV was given intravenous diclofenac 75 mg 1 hour prior to end of surgery and repeated at 12 hourly intervals. First rescue analgesic used was Intra Venous (IV) Paracetamol, if VAS was more than 6, if administered Its dosage and timing of administration was noted. IV tramadol was kept as a standby rescue analgesic.

Results: both the groups were comparable with regards to age and ASA scores. Time to first rescue analgesia, IV Paracetamol, in group TD was 10.23±2.42 hours while that in group IV was 8.15±2.48 hours. It was statistically significant(p<0.05). None of our patients required IV tramadol. The mean VAS scores at 2, 4, 6 and 12 hours were lower in group TD in comparison to group IV. There were no significant side effects noted. Conclusion: We can conclude that transdermal diclofenac patch group patients had lower VAS scores at all measured intervals compared to IV diclofenac group and a significantly longer time of rescue analgesic use. Thus, it seems a safe and effective choice for post-operative analgesia in orthopaedic patients.><0.05) None of our patients required IV tramadol. The mean VAS scores at 2, 4, 6 and 12 hours were lower in group TD in comparison to group IV. There were no significant side effects noted.

Conclusion: We can conclude that transdermal diclofenac patch group patients had lower VAS scores at all measured intervals compared to IV diclofenac group and a significantly longer time of rescue analgesic use. Thus, it seems a safe and effective choice for post-operative analgesia in orthopaedic patients.

Key Message: Pre-emptive application of transdermal diclofenac patch in geriatric intertrochanteric fractures provides good analgesia in post-operative period and can reduce requirements of opioids with minimal side effects.
 

Objective: Intravenous dexamethasone prolongs the duration of analgesia and motor block provided by brachial plexus block with plain 0.5% bupivacaine.

Material and Methods: After obtaining Ethical Committee’s approval, informed consent was taken from the patients involved in the study. The 60 patients included in the study were divided randomly into two groups with 30 patients in each. In group P, ultrasound guided supraclavicular brachial plexus block was given with 30 ml of plain 0.5% bupivacaine without any additive followed by 2 ml of normal saline intravenously. In group D, ultrasound guided supraclavicular brachial plexus block was given with 30 ml plain 0.5% bupivacaine followed by 8 milligrams (2 ml) dexamethasone intravenously, injected after giving the block. Following this, duration of analgesia and duration of motor block was calculated for both the groups.

Results: The mean duration of analgesia in group P (plain bupivacaine 0.5% in block with 2 ml normal saline iv) was 365±20 minutes (approx 6 hours) while the mean duration of analgesia in group D (plain bupivacaine 0.5% in block with 8 mg dexamethasone iv) was 902±30 minutes (approx 15 hours). The duration of motor block noted in group P was 253±32 minutes (approximately 4 hours) and that in group D was 572±36 minutes (approximately 9.5 hours). Both these results were highly significant. (p<0.001). Conclusion: Intravenous (IV) administration of dexamethasone along with supraclavicular brachial plexus block with 0.5% bupivacaine significantly prolongs analgesia as well as motor block provided by the block. As dexamethsone is still not approved for perineural use by the various drug regulatory authorities around the world including FDA and long term effects of perineural dexamethasone are still under study, IV administration of dexamethasone should be preferred over perineural use in contemporary practice of anaesthesia.><0.001)

Conclusion: Intravenous (IV) administration of dexamethasone along with supraclavicular brachial plexus block with 0.5% bupivacaine significantly prolongs analgesia as well as motor block provided by the block. As dexamethsone is still not approved for perineural use by the various drug regulatory authorities around the world including FDA and long term effects of perineural dexamethasone are still under study, IV administration of dexamethasone should be preferred over perineural use in contemporary practice of anaesthesia.

Background: Shivering is an unpleasant and stressful symptom for the patient undergoing surgery. It occurs as a thermoregulatory response to hypothermia. Shivering obscures intraoperative monitoring. It can be detrimental to patients with low cardiorespiratory reserve as it increases oxygen demand, produces arterial hypoxemia and lactic acidosis. This study aimed to evaluate the relative efficacy of intravenously administered Inj. Dexmedetomidine 0.5µg/kg in 100 ml NS and Tramadol 0.5 mg/kg in 100 ml NS and 100 ml NS as a placebo group in controlling shivering posted for lower abdominal surgeries and lower limb general surgeries under spinal anaesthesia.

Method: 120 participants, aged 18 to 65 years, of ASA Physical status I and II, scheduled for lower abdominal surgeries and lower limbgeneral surgeries under spinal anaesthesia. The patients were randomly allocated into 3 groups of 40 each and were named as group D (Dexmedetomidine 0.5µg/kg), group T (Tramadol 0.5mg/kg) and group N (100ml Normal Saline) as aplacebo. Vital parameters of the patients such as heart rate, blood pressure, spo2, temperature and shivering score, sedation score were monitored at regular intervals as per protocol. Statistical tests like Chi square test, Student’s t test (unpaired and paired) were applied to the data collected.

Results: Both the dexmedetomidine and tramadol were effective in the prevention of postspinal shivering. Dexmedetomidine had better sedation profile (P value<0.00001) without any respiratory depression and had fewer incidences of nausea and vomiting when compared to Tramadol. Thus, it can be used as a better alternate for shivering prophylaxis for patients undergoing surgeries under regional anesthesia.

Conclusion: Dexmedetomidine is more effective in the prevention of shivering when compared with tramadol and placebo (normal saline). Dexmedetomidine has an added advantage of adequate reliable sedation. Hence we conclude that Dexmedetomidine at 0.5µg/ kg is most effective in the prevention of shivering when compared with tramadol.

Background and aims: To study the analgesic efficacy of preventive rectal Diclofenac in comparison to post-operative rectal Diclofenac in elective caesarean section surgeries.

Methodology: After obtaining approval from institution ethics committee, patients undergoing elective caesarean section under spinal anesthesia were included in the study and divided into two groups ED(Early Diclofenac) & LD(Late Diclofenac), differing in the time of administration of first dose of 100mg rectal Diclofenac. Pain scores were noted at 12 & 24 hours post administration of first dose of rectal Diclofenac, using the numerical rating score. Rescue analgesia was given in form of Tramadol infusion. Time to first rescue analgesia, postoperative pain scores at 12& 24 hours, cumulative opioid requirements and side effects if any were noted.

Results: We observed a statistically significant difference in the time to first rescue analgesia between the two groups. There was no statistically significant difference in the average pain scores, cumulative opioid requirements and side effects between the two groups.

Conclusion: Rectal Diclofenac is an effective modality for treatment of postoperative pain after caesarean section. Preventive rectal Diclofenac, in comparison to postoperative Diclofenac significantly prolongs the duration to first rescue analgesia. The two groups did not differ significantly in the cumulative opioid consumption at 24 hours. There was no statistically significant difference in pain scores at 12 and 24 hours between the two groups. The average pain scores in both groups were around 3/10.

Objective: To compare sensitivity, specificity, positive and negative predictive values of upper lip bite test and modified mallampatti test to predict difficulty in endotracheal intubation in patients between 16 to 55 years of age.

Methods: One hundred ASA1/2 patients admitted for elective surgical procedure requiring endotracheal intubation were prospectively studied to predict difficult intubation in age group 16-55 years of age after obtaining an informed consent. Preoperative Airway assessment was done with modified mallampatti test and upper lip bite test.

Results: In our study, eighty four had Upper lip bite test (ULBT) class I and II and sixteen patients had class III. Of these two ofthe ULBT class Iand II and five of the ULBTclassIII had Cormack Lehane grade III . There were one hundred patients predicted to be easy for intubation by MMT (i.e. patients who had ULBT class I and II) out of whom however, we encountered difficult intubation in 6 patients. One in MMT class III also had difficult intubation. None of the patients had class IV MMT.Of the entire one hundred patients, a total of seven patients had difficult intubation, all of whom had Cormack Lehane class III on laryngoscopy.

Conclusion: Upper Lip Bite Test (ULBT)is a better test at predicting difficult endotracheal intubation when compared toModified Mallampati Test (MMT). Upper lip bite test and modified mallampatti classification are good predictors of easy intubation rather than difficult intubation. Upper lip bite test should be used in combination with other airway assessment methods viz. Thyromental distance, hyomental distance, inter incisor distance to predict difficult intubation.