Indian Journal of Anesthesia and Analgesia

Introduction:Dilated cardiomyopathy(DCM) is one of the most common types of non ischemic heart muscle disease among the adult population, and it is associated with a high perioperative mortality. Case Report: A 33-year-old female, G2P1L1+1 at 37 weeks of gestation admitted electively for cesarean section who is a known case of DCM with an ejection fraction of 40%. In the preoperative evaluation, patient has a history of shortness of breath on mild to moderate physical exercise, 12-lead electrocardiography (ECG) showed sinus rhythm with occasional premature ventricular complexes and other parameters are normal. Echocardiogram (Echo) showed severely dilated left ventricle with moderately to severely reduced systolic function due to global hypokinesia and indeterminate filling pressures, and no thrombi were present. All monitoring parameters were connected and an awake arterial line was inserted first followed by epidural in the sitting position. Inj. bupivacaine 0.25% 20 mL + 40 μgn fentanyl was given into the epidural space. The depth of the epidural space was 9.5 cm, while the depth of the catheter was 5.5 cm. The epidural was uneventful, and we changed the patient position into a supine position. Intravenous fluids were maintained at 60–80 mL/h. Intra operative vitals are stable and baby was extracted and blood loss around 700ml.Patient shifted to ICU for close monitoring. Conclusion: Dilated cardiomyopathy is associated with high mortality and persistewnt decrease in quality of mother. Careful selection of drugs and best anesthetic techniques is important for good maternal and fetal outcome.

Introduction: The drug metabolising enzyme pseudocholinesterase (butyrylcholinesterase) is responsible for the breakdown of the muscle relaxant medicines mivacurium and succinylcholine. Following infusion of mivacurium and succinylcholine, a deficiency of any kind might produce protracted paralysis and apnoea. Case presentation: It's a case study of a patient who developed long-term apnea after taking mivacurium. Conclusion: Prolonged blocks may be encountered due to mivacurium use. The diagnosis of pseudocholinesterase enzyme deficiency can be given after a careful clinic supervision and peripheral nerve stimulator monitoring. A decrease in the activity of pseudocholinesterase enzyme and improvement in neuromuscular function will help verifying our diagnosis. Instead of pharmacological applications that may further complicate the situation, what should be done in such patients is to wait until the block-effect goes down by the help of sedation and mechanical ventilation.

Introduction: ALPA is an autoimmune hypercoagulable state caused by antiphospholipid antibodies. It is characterized by thrombotic episodes in arteries, veins and pregnancy related complications like still birth, preterm delivery, miscarriage and severe preeclampsia. We report a case of APLA syndrome due to its rarity. Case Report: A 28 year old woman with a history of two previous abortions and positive serology for APLAs with 9 months gestation came to our hospital for safe confinement. She was diagnosed as primary APLA syndrome in view of bad obstetric history and positive lupus anticoagulant. She is a known hypothyroidism. She was on Injection Enoxaparin 0.6 ml OD for 1 year which was changed to unfractionated heparin 14000 units OD subcutaneously after admitting to our hospital. In view of bad obstetric history, an elective caesarean section was planned. Unfractionated heparin was stopped 24 hours before surgery. Preoperative investigations revealed a normal APTT, PT, INR. Spinal anesthesia given in L3–L4 inter-spinal space with 25G needle after preloading with 500 ml crystalloids and a sensory block up to T6 was attained. She delivered a single live male child with APGAR score 9. Injection Oxytocin 15 units was given intraoperatively. The further perioperative course was uneventful. She was restarted on Injection Enoxaparin 0.6ml OD for 6 weeks. 

Introduction: Anesthesiologists face a difficult task in managing pain in trauma patients with acute rib and spine fractures, and attaining appropriate analgesia is critical in minimizing pulmonary consequences. Erector spinae plane (ESP) blocks are a type of localized anaesthetic that can be used to treat pain. Case Report: After falling off his bike, a 42-year-old man suffered several rib and spine fractures. His injuries included fractures of the D4, D5, D8, D11, and D12 vertebral bodies, as well as fractures of the pedicle and spinous process of the D7 and D9 vertebrae, as well as comminuted fractures of the D7 and D10 vertebral bodies. The decision to proceed with bilateral ESP block was made. A right-sided ESP block was conducted. On presentation, the patient was in excruciating pain due to multiple rib and spine fractures, and was experiencing pain-related decreased respiratory effort. After receiving an ESP block, the patient's pain gradually subsided, and his respiratory effort improved, and he was managed conservatively in the hospital until he was taken for surgical intervention. Conclusion: A novel myofascial plane block for thoracic analgesia is the ultrasound-guided erector spinae plane block (ESP). It allows patients to cough and breathe deeply while also reducing the length of time they are on mechanical ventilation.

Introduction: Dynamic valvular insufficiency and LVOT blockage are also possible outcomes of hypertrophic obstructive cardiomyopathy (HOCM). Furthermore, attempting to replace an inadequate mitral valve surgically can result in iatrogenic LVOT blockage. In the general population, it affects one out of every 500 adults, with a male to female ratio of 2:1. Among the general population, the prevalence is around 0.2 percent, and the incidence in pregnant women is around 0.1–0.5 percent. Case Report: 21 year old female patient presented with 9 months of amenorrhea posted for elective lower segment caesarean section. Her previous documents revealed that she was a diagnosed case of hypertrophic obstructive cardiomyopathy during her last pregnancy 1 year ago. History of previous surgery that is induced abortion at two and half months of gestation age a year back operated under spinal anaesthesia. ECG showed ST elevation present in V2 , V3, V4 , V5 leads and features of left ventricular hypertrophy (LVH) , Her echocardiography report revealed features of hypertrophic obstructive cardiomyopathy with severe LVOT obstruction. Left ventricular ejection fraction (LVEF) was 20-25%. Conclusion: HOCM is normally well tolerated during pregnancy, although those who have had previous symptoms or arrhythmias may experience an exacerbation of symptoms. The majority of these people, on the other hand, can be effectively controlled medically. This case report showed that patients with HOCM can be safely managed under general anaesthesia with muscle relaxants and inhalational volatile anaesthetics, as well as an erector spinae block for analgesia

Introduction: Case series helps us to evaluate management and safety of spinal anesthesia for caesarean delivery in pregnant women with COVID-19 infection. Case Series: We hereby report the management of three COVID-19 positive pregnant women undergoing caesarean section in our hospital. Patients presented with mild symptoms of COVID 19. Routine investigations and COVID -19 markers were evaluated. Anesthesia and operation went uneventfully. Conclusion: Health care providers and babies were not infected with virus. Precautionary measures and strategies were of utmost importance to lower virus contagion risk. Spinal anesthesia was preferred over GA.

Background: Separation anxiety among children is common and normal.Children undergoing radiological imaging studies often require sedation to avoid panic episodes & severe anxiety for induction of Anaesthesia. It is important for the child to lie still during the scanning procedure & mostly we find it difficult for the children to keep still during a CT scan, which is usually about 10–15 minutes. This study aimed at comparing and evaluating the efficacy of use of intranasally administered Dexmedetomidine Vs intranasal midazolam for paediatric sedation undergoing diagnostic CT scan studies.

Methods: 100 paediatric patients within age group 1-10 years were divided into 2 groups of 50 patients each, Group I & II respectively, were given either intranasal Dexmedetomidine or Intranasal Midazolam. The depth of sedation was assessed by using University of Michigan sedation scale.

Results: This study concluded that Intranasal Dexmedetomidine is superior & more effective than Midazolam for pediatric sedation.

Relief of operative as well as post operative pain should be the prime responsibility of an anesthesiologists. The most common treatment for post operative pain remains conventional intramuscular injection of narcoticswhich are associated with several side effects like nausea, vomiting, itching, hypotension, bradycardia,urinary retention, dysphoria,respiratory depression, early and later. Pregnancy induced hypertension is a major cause of morbidity and mortality in obstetrics, complicating 3-8% of pregnancies. Severe preeclampsia poses a dilemma for anesthesiologists, and there is some controversy about the best anaesthetic technique for caesarean delivery in such cases. Though spinal anasthesia reduces the risk of airway instrumentation in high risk patients of preeclampsia, there are still limitations about its limited duration of analgesia. In present study we intend to compare dexmedetomidine and clonidine used with hyperbaric bupivacaine for spinal anaersthesiain patients with preeclampsia undergoing LSCS.

Primary Objective: To compare the clinical efficacy of intra the caldexmedetomidine vs Clonidine on: (a) Onset and duration of sensory block (b) Onset and duration of motor block (c) Duration of analgesia (d) Side effects if any.

Secondary Objective: to compare the haemodynamic profile among patients of the two group.

Methodology: All eligible patients were randomly assigned into two groups of 50 each by chit and envelope method: Group A: SAB was given with 2ml, 0.5 % Bupivacaine(H) + 45 µg Clonidine. Group B: SAB to be given with 2ml, 0.5% Bupivacaine (H) + 5µg dexmedetomidine. Results: Regression of sensory block was prolonged in group B as compared to group A.(p value <0.0001). There was regression of motor block in group B as compared to group A. p value<0.0001Heart rate remained stable and comparable at different time points in 2 groups. Except three patients in group A and one patient in group B, no other patient in either group developed bradycardia. Three patients in group A and in group B developed hypotension which responded to intravenous fluid therapy. Sedation score decreased to 0 within 5 hours. At no time, sedation score exceeded 2 and no patient developed signs of respiratory depression.

Conclusion: Dexmedetomidine in the dose of 5µg added to 10 mg 0.5% Hyperbaric Bupivacaine in SAB for LSCS surgery in parturients with preeclampsia provides comparable onset for sensory and motor blockade but significantly prolonged duration as compared to 45µg of clonidine. Longer duration of postoperative analgesia with 5µg Dexmedetomidine makes it superior to clonidine in respect to postoperative analgesia. Both the drugs produce desirable level of intraoperative and postoperative sedation, stable hemodynamics and minimal side effects.