Indian Journal of Anesthesia and Analgesia

Background: Dexmedetomidine is a highly selective α2 adrenoreceptor agonist with sedative, anxiolytic and analgesic Properties without any respiratory depression. It decreases the requirement of volatile anaesthetics with better hemodynamic stability in surgical patients. We avoided the risk of awareness under anaesthesia by using Bispectral index. Aims: To evaluate the efficacy of Dexmedetomidine pre-medication on Sevoflurane requirement and to assess the haemodynamic stability during elective laparoscopic cholecystectomy surgeries. Methods: Randomized double- blind control study. Design: Forty eight patients were randomly allocated into two groups. Group A received saline infusion and Group 2 received Dexmedetomidine infusion in a dose of 1ug/kg over 15 min before induction. Vital parameters and bispectral index were noted throughout the surgery. Patients were induced and intubated as per the standard protocol and maintained with Oxygen & Nitrous oxide (1 litre Oxygen + 2 litre Nitrous oxide) with Sevoflurane concentration adjusted to achieve BIS values of 45-55. Demographic profile, hemodynamic parameters total Sevoflurane consumption were noted. Statistical Analysis: Statistical analysis was performed using SPSS software version 22.0. Percentage analysis was done for qualitative data. Parametric data were compared using an unpaired t-test. Nonparametric data were compared with Fisher’s exact test or Chi square test. Results: Mean Sevoflurane consumption in Group A and Group B were 0.379 ± 0.10 , 0.169 ± 0.05 ml/min respectively with P<0.001 which was statistically significant. A 55.4% reduction in Sevoflurane consumption was found in patients receiving Dexmedetomidine premedication. Conclusions: Dexmedetomidine premedication is useful to reducing Sevoflurane consumption during general anesthesia and it provides better haemodynamic stability.

Introduction: A perinephric abscess is usually a complication of urologic infection which results from fat necrosis. Before the era of antibiotics, perinephric abscesses were due to prolonged bacteremia. More than 3/4 of perinephric abscesses are now due to complications of urinary tract infections. Case Report: We present a 71 year old female case with Right Emphysematous Pyelonephritis Grade I Hydroureteronephrosis with left perinephric abscess, left lobar pneumonia posted for bilateral DJ stenting with perinephric drain placement under continuous spinal anesthesia. Presented with H/o lower back pain, associated with fever since 3 days and H/o burning micturition, since 6 months. She is known case of Type 2 DM since 23 years and on Inj. Biphasic Insulin, Tablet vildagliptin, Tablet Dapaglifazone, known case of hypothyroidism and on tablet Thyroxin 50 mg OD in morning. H/o stroke 20 years back right side Upper & lower limb affected. H/o previous appendectomy 20 years back, CT–KKUB suggestive of Emphysematous Pyelonephritis, right side with grade I HUN, left perinephric fat with ill diffused hypodense area in upper lobe of left kidney. Non obstructive left renal calculus 4.0mm. ECG shows RBBB, Saturation was 92% on Roomair, On ABG analysis severe metabolic acidosis found. We planned to administer continuous spinal anesthesia. Patient was explained about the continuous spinal anesthesia & written informed consent was taken. Tablet Alprazolam 0.25 mg, and tablet Rantac, 15 was given previous night and in morning on the day of surgery. Nil per oral is maintained 8 hours before surgery. A 18 Gauge IV cannula was secured, a 5 lead Electrocardiogram, Pulse Oximeter, NIBP and ETCo2 monitoring was done. Under strict aseptic precautions, L3 L4 space was identified and using 18G tuhoy needle, Lumbar puncture is done. Injection Bupivacaine 0.8cc given, block is achieved till T8 level. Surgery was lasted for one and half hour. Vitals were stable. Patient shifted to recovery room and was under observation for an hour, patient was shifted to post operative ward. Conclusion: This is an Original case report, which provide a successful management of anesthesia, of bilateral DJ stenting with perinephric drain placement under continuous spinal anesthesia. Anesthesia Management for Right Emphysematous Pylonephritis with grade I HUN. With perinephric abscess with left lobar Pneumonia.

Wilhelm Ebstein first described the clinical and anatomical features of an anomaly of the tricuspid valve in 1866, which occurs in 1 percent of congenital heart defects (1 in 110,000 of the general population). It is characterized by dysplastic abnormalities of both basal and free attachments of the tricuspid valve leaflets, with downward displacement and elongation of the septal and anterior cusp, with resulting tricuspid regurgitation. Congestive heart failure and sudden collapse are the most common causes of death. Case Report: A 21 year old primi with 37 wks gestation was referred to our hospital for complicated pregnancy management. She complained of occasional palpitations, and dyspnoea on severe exertion. She had no history of recurrent chest infections, cyanosis or heart failure in the past. On examination she had pansystolic and mid-diastolic murmurs with right parasternal thrill, along with widely split second heart sound. The ECG showed sinus rhythm with right bundle branch block. Chest X-ray showed enlarged right atrium with cardiomegaly, while echocardiogram showed the presence of moderately enlarged right atrium, tricuspid regurgitation with downwardly displaced tricuspid valves, confirming diagnosis of Ebstein’s anomaly. Her blood reports were within normal limits. We kept ready all routine and emergency drugs and equipments. Subsequently she was shifted into the OT, monitors were attached, and given antibiotics for bacterial endocarditis prophylaxis. A sitting epidural was tried at L3-4 interspace. INJ bupivacaine 0.5% 15cc given in graded doses of 5 cc every 5 minutes by monitoring hemodynamic response. Level achieved till T6. Thereafter left lateral tilt and oxygen were continuously administered to the patient. Intraoperatively her vitals were stable and duration of operation was 60 minutes and a female baby of birth weight 2.4kg was extracted. Postoperatively the patient vitals were stable. Conclusion: In conclusion, women with Ebstein’s anomaly may present with a multitude of problems and, should be considered as high risk and cared for in tertiary centres by a multidisciplinary team including obstetricians, cardiologists and obstetric anaesthetists in pregnancy and during delivery. Epidural anaesthesia in a fractionated or ‘graded’ manner provides a haemodynamically stable patient with adequate analgesia, and may be preferred to general anaesthesia in these patients.

Background: Shoulder pain due to adhesive capsulitis is a prevalent musculoskeletal condition, necessitating innovative treatments. Radiofrequency ablation (RFA) offers an effective approach to alleviate chronic shoulder pain. This case report focuses on Cooled Radiofrequency ablation of articular branches of the glenohumeral joint, performed with hybrid technique using fluoroscopy and ultrasonography, while the patient remains in a lateral position. Case Presentation: A 56-year-old female presented with chronic right shoulder pain and restricted motion diagnosed with right shoulder adhesive capsulitis. Diagnostic blocks of sensory articular nerves provided significant pain relief, leading to Glenohumeral joint sensory articular nerve denervation via Cooled Radiofrequency Ablation. The procedure was performed with the patient in a lateral position, as lying prone was intolerable due to pain. The patient showed substantial pain relief and improved range of motion post-procedure. Discussion: Cooled radiofrequency ablation (CRFA) has shown promise in treating Adhesive Capsulitis and Glenohumeral joint osteoarthritis. While the traditional approach involves changing the patient's position from prone to supine, this case report introduces a novel lateral position technique. Benefits include improved patient comfort, strict asepsis maintenance, reduced procedure time, and decreased radiation exposure. However, challenges in C-arm positioning were encountered. Additionally, hydrodilatation of the glenohumeral joint was performed, resulting in further pain reduction and range of motion improvement. Conclusion: This case report demonstrates the efficacy and safety of Cooled Radiofrequency Ablation for the Glenohumeral joint, utilizing a lateral position approach. The findings support its potential advantages over traditional methods, offering a valuable addition to the management of chronic shoulder pain. Further research and clinical experience will refine its role in addressing this common and debilitating condition.

Introduction: Lower limb ischemia, peripheral arterial disease, and diabetes mellitus are considered the major cause for limb amputations in more than 50% of cases. These patients have increased risk of perioperative mortality and morbidity due to additional comorbidities, such as cardiac diseases. Continuous spinal anaesthesia (CSA) provides better cardiovascular stability, less local anaesthetic requirement, better control of anaesthesia level and lower risk of local anaesthetic toxicity were reported in the CSA technique compared with a single-dose spinal anaesthesia technique. We reported a high-risk patient who underwent below knee amputation surgery under CSA. Case Report: This is a 50-year-old male, American Society of Anaesthesiologists (ASA) III, dilated cardiomyopathy admitted for below knee amputation surgery. Preop vitals are stable. Blood investigations are normal. Chest radiography showed cardiomegaly, and echocardiography revealed sinus tachycardia with poor R wave progression and low ejection fraction (EF) of 20%. Continuous spinal anaesthesia was planned for the procedure, during the surgery total amount of fluid given was 40 mL of crystalloids at the rate of 20ml/hr. Intraop vitals stable. The patient was transferred to post op ward following the removal of spinal catheter. No anaesthetic complications noted. Conclusion: We reported the successful anaesthetic management of a patient with coronary artery disease and low ejection fraction undergoing below knee amputation surgery. CSA technique with low dose hyperbaric bupivacaine provided safe and effective ananaesthesia with minimal haemodynamic changes for this case.

Incidence of back pain related to disc prolapse is higher in morbid obesepatients. Treatment options including epidural injections and surgery is difficult in such patients. Here we are discussing a case of successful Hybrid technique for caudal epidural steroid injection in a morbidly obese patient.

Introduction: Partial anomalous pulmonary venous connection is the type of cyanotic disease defined as one or more, but not all pulmonary veins drain directly either into a systemic vein or into the right atrium. Subarachnoid block in the form of spinal anesthesia is given as it minimizes SVR changes, and provides sufficient anesthesia of perineum/pelvic organs, sensory and motor blockade of lower limbs, allowing early ambulation, voiding, and hospital discharge. Case Report: A 29-year-old female, G2P1L1, BMI of 25 with 32 weeks 5 days gestational age with 8 months of amenorrhea posted for emergency lower segment cesarean section (LSCS). Preanaesthetic evaluation was done and the patient underwent LSCS under spinal anesthesia without any intraoperative difficulty or complications. On POD-9, the patient developed breathlessness with a fall in oxygen saturation and required Intensive care unit (ICU) support. A 64-slice CT pulmonary angiogram was done and showed changes suggestive of Partial Anomalous Pulmonary Vein Connection (PAPVC). The patient was worked up, diagnosed with PAPVC, and symptomatic treatment initiated. Once symptomatically better, prophylactic management is advised and the patient is discharged. Conclusion: Patients with PAPVC with stable hemodynamics can be managed successfully with spinal anesthesia as the mode of anesthesia for surgical procedures.

Rapid advances in Artificial Intelligence (AI) have led to diagnostic, therapeutic, and intervention based applications in the field of medicine. Today, there is a deep chasm between AI based research articles and their translation to clinical anaesthesia, which needs to be addressed. Machine learning (ML), the most widely applied arm of AI in medicine, confers the ability to analyse large volumes of data, find associations, and predict outcomes with ongoing learning by the computer. It involves algorithm creation, testing and analyses with the ability to perform cognitive functions including association between variables, pattern recognition, and prediction of outcomes. AI supported closed loops have been designed for pharmacological maintenance of anaesthesia and hemodynamic management. Mechanical robots can perform dexterity and skill based tasks such as intubation and regional blocks with precision, whereas clinical decision support systems in crisis situations may augment the role of the clinician. The possibilities are boundless, yet widespread adoption of AI is still far from the ground reality. Patient related “Big Data” collection, validation, transfer, and testing are under ethical scrutiny. For this narrative review, we conducted a PubMed search in 2020-21 and retrieved articles related to AI and anaesthesia. After careful consideration of the content, we prepared the review to highlight the growing importance of AI in anaesthesia. Awareness and understanding of the basics of AI are the first steps to be undertaken by clinicians. In this narrative review, we have discussed salient features of ongoing AI research related to anaesthesia and perioperative care.

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