Indian Journal of Anesthesia and Analgesia

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Background and Aim: Lower abdominal surgeries today are done preferentially under subarachnoid block. The relatively short duration of analgesia is a limiting factor which is overcome by adding an adjuvant to intrathecal bupivacaine.Adjuvants have been helpful in induction of early ambulation but at the cost of their associated adverse effects. We aimed to compare two different doses of dexmedetomidine as adjuvant to 0.5% hyperbaric Bupivacaine in abdominal hysterectomy. Material and Methods: It was a prospective, double-blind study among 60 patients posted for abdominal hysterectomy under spinal anaesthesia. The patients were randomly allocated to 2 groups (Group D1 and Group D2) of 30 each. Group D1 received hyperbaric Bupivacaine (15 mg) with Dexmedetomidine (5 µg). Group D2 received hyperbaric bupivacaine (15 mg) with Dexmedetomidine (10 µg). The onset time of sensory and motor block, regression time of sensory and motor block, duration of analgesia, hemodynamic parameters were recorded both intra and postoperatively. The primary efficacy parameters were to determine the onset and duration of sensory block, motor block and duration of postoperative analgesia. Secondarily any associated hemodynamic changes and adverse effects of Dexmedetomidine were also recorded. Results: Onset of sensory block was 3.16 ± 0.37 minutes in Group D2 as compared to 4.80 ± 0.74 minutes in Group D1 with total duration of sensory block as 355.35 ± 11.83 minutes in Group D2 and 257.77 ± 18.43 minutes in Group D1. Similarly, the onset of motor block was 4.12 ± 0.34 minutes and 4.74 ± 0.71 minutes, with total duration of motor block as 324.67 ± 22.15 minutes and 225.41 ± 17.20 minutes in Group D2 and in Group D1 respectively. Duration of analgesia was360.19 ± 16.38 minutes with Dexmedetomidine 10 µg but 302.06 ± 17.36 minutes in Dexmedetomidine 5 µg group. Conclusions: Addition of 10 µg of Dexmedetomidine to 0.5% hyperbaric Bupivacaine 15mg (3 mL) in spinal anaesthesia significantly decreases the onset time, prolongs the duration of both sensory and motor blockade, improves the quality of postoperative analgesia with better hemodynamic stability as compared to bupivacaine with 5 µg Dexmedetomidine

Background: The research aimed to assess how fentanyl and dexmedetomidine impact Ropivacaine in supraclavicular brachial plexus blocks regarding pain relief, motor block duration, and onset times for sensory and motor blocks. Methods: This prospective comparative study involved 70 patients (aged 18-60, ASA 1 or 2) undergoing upper limb orthopaedic surgeries at the Department of Anesthesiology, Dr. M.K. Shah Medical College, Ahmedabad, Gujarat, India. It was conducted from January 2023 to December 2023 after participant consent. Results: Significant differences were observed in sensory block onset times: 6.42 ± 1.21 min for dexmedetomidine vs. 10.04 ± 1.24 min for fentanyl. Motor block onset times were also significant: 9.8 ± 0.96 min (dexmedetomidine) vs. 12.90 ± 1.80 min (fentanyl). Duration of motor block was longer with dexmedetomidine (527 ± 48.01 min) than fentanyl (459 ± 34.73 min). Sensory block duration was also longer with dexmedetomidine (538.66 ± 48.5 min) compared to fentanyl (487.32 ± 48.27 min). Dexmedetomidine provided prolonged analgesia (734.1 ± 34.30 min) compared to fentanyl (650.1 ± 23.33 min). Conclusion: The addition of dexmedetomidine to 0.5% Ropivacaine in supraclavicular brachial plexus block significantly hastens the onset of sensory and motor blocks, prolongs their duration, and extends analgesia compared to fentanyl combined with 0.5% Ropivacaine.

Overview The study aimed to investigate the impact of Epidural Volume Extension (EVE) on sensory block height following intrathecal injections with reduced doses of bupivacaine. It was designed as a randomized, controlled, double-blind trial involving 80 adult male patients with ASA status I or II scheduled for orthopedic lower limb surgery under combined spinal epidural anaesthesia. Patients were randomly assigned to receive either a reduced intrathecal dose of bupivacaine (5 or 8 mg) with or without EVE, based on group allocation. The study aimed to compare the maximum sensory level (Smax) achieved with and without EVE application across the two different intrathecal doses. Further research is warranted to better understand the relationship between intrathecal dose and EVE efficacy, considering various factors such as instillation technique, timing, and patient characteristics. Results: The study revealed that applying Epidural Volume Extension (EVE) alongside a 5 mg intrathecal bupivacaine dose significantly decreased the maximum sensory block height (Smax) compared to not using EVE However, there was no significant difference in Smax when EVE was applied alongside an 8 mg intrathecal bupivacaine dose compared to without it. Conclusion: Avoiding the application of Epidural Volume Extension (EVE) to 5 mg plain bupivacaine during a combined spinal epidural block in patients undergoing lower limb orthopedic surgery is advisable. This caution stems from the observation that implementing EVE alongside this particular dosage of bupivacaine could lead to a reduction in the maximum sensory level.

Background: Postoperative pain management plays a key role in perioperative anaesthesia care. Postoperative analgesia can be achieved by the use of oral or parenteral analgesics like NSAIDS and opiods. However, opioids are associated with dose dependent side effects including nausea, vomiting, pruritis, sedation and respiratory depression. Techniques that reduce opioid requirements such as peripheral nerve blocks, neuraxial blocks with local anaesthetics, intrathecal opioids and adjunctive techniques may be beneficial to the patient. Transversus abdominis plane block has recently been described as an addition or alternative to the other analgesic regimes. TAP block has been shown to reduce postoperative opioid use in elective abdominal surgery, including open appendicectomy, laparotomy, Caesarean section and laparoscopic cholecystectomy.1 Aim: The purpose of this study was to compare the efficacy of Ultrasound guided Transversus abdominis plane (TAP) blocks with local site infiltration using 0.2% Ropivacaine in providing postoperative analgesia in patients undergoing elective caesarean section surgeries. Objectives: To study the time taken for first dose administration of rescue analgesic. To study the total amount of analgesic consumed and the assessment of patient satisfaction. Material: After obtaining approval from the ethical committee and obtaining informed consent, 60 pregnant women aged 20-40 years posted for elective caesarean section surgeries were randomly divided into Group T and Group L. Bilateral TAP block was performed in Group T after the completion of surgery, under ultrasonography guidance with a Sonosite M Turbo portable ultrasound unit with a linear 5-10 MHz probe. A 100mm long, 22G short bevel needle (Stimuplex, B. Braun Melsungen AG, Germany) was used to administer a total of 40ml (20ml for each side) of 0.2 % Ropivacaine for the TAP block. In group L, post-operatively a total of 40ml of 0.2% Ropivacaine was used for subcutaneous wound site infiltration. The Srikanth Reddy Karkala, Pradeep Uday Kiran Boddu, Anuradha Suresh Deolalkar et al. Comparison of Ultrasonography Guided Bilateral Transverse Abdominis Plane (TAP) Block And Local Site Infiltration With 0.2% Ropivacaine for Post Operative Analgesia Following Caesarean Section. parameters recorded were intraoperative haemodynamics, postoperative pain scores and the need for rescue analgesia in the first 24 hours postoperatively. Results: A total of 60 patients were analyzed. Duration of analgesia was significantly longer 5.5±2.8 hours in group T compared to group L 2.5±1.36 hours (p<000.1), mean consumption of diclofenac was 107.5±37.8 mg and 162.5±34.585 mg in group T and L respectively (p<0.001). Conclusion: Post-operative analgesia and patient satisfaction is better with ultrasound guided TAP block than with local site infilteration.

Background: Periarthritis shoulder is a common cause of chronic shoulder pain. Conventionally, Intraarticular Platelet Rich Plasma (PRP) injection has been used for its treatment. Rotator cuff interval is involved in pathogenesis of adhesive capsulitis, so PRP injection at rotator interval can become an alternative to conventional intra-articular approach. Aims: This randomised controlled trial was done to comparethe efficacy of PRP injection by intra-articular and rotator interval methods for management of periarthritis shoulder. Methods: The study was carried out by randomising 60 patients, aged>18 years into two groups; group A (n=30, intraarticular) and group B (n=30, rotator interval). They were given 3-4 ml of freshly prepared PRP intra-articularly and at rotator interval under ultrasound guidance. The Shoulder Pain and Disability Index (SPADI), Numerical Rating Scale (NRS) score and post injection complications were assessed at 0, 1st and 3rd month in both the groups. Results: The median NRS and SPADI scores were equivalent in both the groups at baseline. At 1st and 3rd month post injection, the median SPADI and NRS scores in group B were significantly lower than group A(p<0.05). There were no reported complications from both the groups. Conclusion: Both intra-articular and rotator interval methods of PRP injection were efficacious in pain reduction as well as in improving the shoulder functions, but rotator interval approach was more effective than intra-articular for management of periarthritis shoulder.

Introduction Post-operative sore throat (POST) is a common complication after endotracheal intubation, influenced by various factors. Dexamethasone, an anti-inflammatory, and dexmedetomidine, an alpha-2 adrenergic agonist, have both been studied for POST prevention. This trial compared their efficacy in patients undergoing laparoscopic cholecystectomy. Materials and Methods In this two-year, double-blind, randomized trial, 60 adults undergoing elective laparoscopic cholecystectomy were divided into two groups: Group 1 received dexamethasone (0.2 mg/kg, max 8 mg), and Group 2 received dexmedetomidine (1 µg/kg). POST incidence and severity were assessed, with statistical significance set at p<0.05. Results No significant differences were found in age, gender, or BMI between the groups. Group 2 showed lower heart rates and MAP post-intubation. POST incidence was 33.33% in Group 1 and 46.66% in Group 2 (p=0.354), with comparable POST severity and complications. Conclusion: The incidence and severity of post-operative sore throat and hoarseness were similar while using dexamethasone and dexmedetomidine in patients undergoing elective laparoscopic cholecystectomy under general anaesthesia.

Context: Brain computer interface devices like Neuralink implants will pose a significant challenge in the present understanding and learning curve for Neuromonitoring techniques during neurosurgery and Neurocritical care. Aims: We hereby enlist our concern with regards to electroencephalography, trans-cranial doppler and cerebral oxygenation monitoring in patients with such implants for neurosurgical procedures. Settings and Design: Short communications Conclusions: There exists minimal published research with regards to EEG monitoring, cerebral oxygenation monitoring and cerebral blood flow monitoring in patients coming for neurosurgeries for brain tumors with these kind of brain computer interfaces implanted in their cerebral cortex. This brief communication will help in generating research interest in this upcoming evolution in medical care.

Introduction: This case report details the anaesthetic management of a pregnant patient with supraventricular tachycardia (SVT) undergoing an emergency caesarean section. SVT, a common arrhythmia in pregnancy, is initially treated with adenosine. When adenosine fails, calcium channel blockers like diltiazem are used, and amiodarone is considered as a third-line option before electrical cardioversion. Case Report: In this case, a 19-year-old primigravida at 40 weeks 4 days presented with palpitations and SVT with a heart rate of 201 bpm despite adenosine and diltiazem. Amiodarone was successfully administered, reducing the heart rate to 143 bpm with visible P waves on ECG. Subsequently, she underwent an emergency caesarean section under spinal anaesthesia with 0.5% bupivacaine and fentanyl. Hypotension following the spinal anaesthesia was managed using phenylephrine and IV fluids, maintaining a stable intraoperative heart rate of 120-130 bpm. Throughout the surgery, phenylephrine was used to prevent hypotension associated sympathetic stimulation, which could exacerbate SVT. Post-operatively, the patient maintained normal sinus rhythm, and after evaluation by a cardiologist and echocardiogram, no significant abnormalities were found. She was discharged after 7 days of postnatal care without recurrence of SVT or other arrhythmias. This case highlights the complexity of managing SVT during pregnancy, necessitating a multidisciplinary approach involving anaesthesiologists and cardiologists. The choice of spinal anaesthesia over general anaesthesia was made based on its minimal cardiovascular impact and effective management of hemodynamic stability with vasoactive medications. Careful consideration of pharmacological interventions and their potential effects on both maternal and fetal health is crucial in such cases. Conclusion: effective management of SVT during pregnancy involves tailored anaesthetic techniques and vigilant monitoring to ensure optimal maternal and fetal outcomes while addressing the arrhythmia and its associated hemodynamic challenges.

Background: Vallecular cysts are a rare cause of difficult tracheal intubation. We report a case of difficult endotracheal intubation in an adult with symptomatic vallecular mass for surgical resection. The anesthetic plan was to carry out awake intubation under airway blocks and sedation with adequate maintenance of spontaneous respiration and also keeping tracheostomy as a standby option. Case description: In this case, laryngoscopy was challenging due to the size and extent of the vallecular mass to the lingual surface of epiglottis, thus necessitating gentle laryngoscopy to prevent catastrophic cyst rupture and pulmonary aspiration. The glottis was not visualized using flexible fiberoptic bronchoscope and video laryngoscope, which made intubation difficult. Endotracheal intubation was finally obtained by the help of an ENT surgeon using ENT rigid laryngoscope. At the end of surgery, the surgeon decided to proceed with tracheostomy due to risk of airway edema, bleeding and aspiration. Histopathology of epiglottic mass revealed that of a pleomorphic adenoma. Clinical relevance: Patients with vallecular or epiglottic mass are more likely to have difficult airways after induction of anesthesia. Anaesthesiologist should give paramount importance to pre-operative airway assessment, anticipating and handling difficult airway and intubation failure, and making prompt and correct choices in ensuring patient safety.

Introduction: Poliomyelitis, caused by an enterovirus, is a neuromuscular disorder that has been largely eradicated but remains a challenge in some tropical regions. It primarily spreads via the fecal-oral route and damages the motor and autonomic nervous systems. Kyphoscoliosis, characterized by abnormal spinal curvature and rotation in both sagittal and coronal planes, complicates neuraxial anaesthesia and presents significant anaesthetic challenges. Case Report: A 36-year-old female at 39 weeks 4 days gestation was scheduled for an elective caesarean section. She had a history of poliomyelitis with progressive spinal deformity and was short in stature (146 cm, 56 kg) with thoracolumbar scoliosis and a mediastinal shift. Neurologically, she had complete motor paralysis in both lower limbs but no sensory deficits. Her airway was Mallampati grade 4, and lab parameters were normal. High-risk consent was obtained. Due to her spinal deformity, lumbar puncture was challenging. A paramedian approach at L3-L4 with a 25G Quincke needle was used to administer 1.8 ml of 0.5% hyperbaric Bupivacaine and 0.2 ml of 15 mcg Fentanyl. The sensory block initially reached T8 on the right and T12 on the left. After 15 minutes with no improvement, a repeat block with 1 ml of 0.5% hyperbaric Bupivacaine was given. With a left lateral tilt, the block level improved to T6 bilaterally. The caesarean section proceeded without complications, and a healthy baby was delivered. The patient had an uneventful 24-hour postoperative period. Conclusion: In managing anaesthesia for a patient with kyphoscoliosis and poliomyelitis, meticulous preoperative evaluation for skeletal, respiratory, and cardiovascular abnormalities is crucial. In this case, the patient’s stable maternal and fetal condition allowed for a successful spinal anaesthesia despite initial difficulty. Literature supports that a repeat block after 15-20 minutes can be a safer alternative to general anaesthesia in such cases.

Vagal Schwannomas are extremely rare, benign, slow growing tumours. Perioperative management in these cases differs from those of other neck swellings due to its close proximity to vital neurovascular structures. Surgical resection of vagal schwannoma involves various anaesthetic challenges like difficult intubation, intraoperative hypotension, bradycardia, cardiac arrest, torrential bleeding, vocal cord paralysis, possibility of ventilatory support and prolonged post op ICU stay. Here we present a case of a 29 year old male, posted for surgical resection of a benign neck swelling (4.9×3.7×6.3 cm) originating from the vagus nerve. Knowledge about anticipated complications, vigilance in prevention and prompt management of hemodynamic alterations can prevent devastating complications. This case report aims to pen down the course of perioperative management from our experience and from existing literature.

Introduction: The varicella zoster virus (VZV), a DNA virus in the herpes family, causes chickenpox, a generally mild but contagious illness. About 5–10% of pregnant women lack VZV antibodies and can contract varicella during pregnancy. The impact of primary VZV infection varies with the gestational period: maternal complications are highest in the third trimester, while fetal risks are greatest in the first and second trimesters. Mitral stenosis from rheumatic fever is the most common valvular heart disease in pregnancy, usually emerging due to cardiovascular changes. Improved care has reduced related mortality and morbidity. Case Report: A 25-year-old female diagnosed with G2P1L1 with 36 weeks 4 days gestation with active varicella infection with rheumatic heart disease in latent labour, posted for emergency LSCS. Thorough pre-anaesthetic evaluation was done to assess patient’s ability to respond to physiological challenges encountered intraoperatively. Patient presented to the hospital with complaints of breathlessness and active varicella infection for 2 days. Patient had not been diagnosed with any other co-morbidities prior to this. In view of breathlessness, ECG, chest X-ray and 2D echo was done and patient was found to have RHD with sever MS, sever TR, sever PAH with preserved EF of 60%. General anaesthesia was performed and patient was induced with thiopentone and fentanyl, patient was intubated with endotracheal tube, maintained with isoflurane, vecuronium. Patient was started on inj. Furosemide 0.5ml/hr intra op. Blood gas analyses done intraoperatively to correct metabolic, electrolyte disturbances, blood sugars monitored for glycemic control, adequate volume replacement was done with crystalloids. Post-operatively patient was shifted to ICU with endotracheal tube for postoperative elective ventilation, extubated the following day. Conclusion: Numerous hemodynamic factors must be evaluated to determine the suitable anaesthesia for caesarean section in sever RHD patients. Both regional and general anaesthesia have been administered for caesarean sections in parturients with varicella. When selecting anaesthesia technique, its essential to thoroughly weigh the risk and benefits of general anaesthesia and central neuraxial block.

Tracheostomy is a surgical procedure in which both the surgeon and anaesthetist share responsibility for managing the airway. Although rare, airway fire is a serious complication of tracheostomy with the potential for devastating patient morbidity and mortality. This article discusses a case of airway fire during tracheostomy and explores the factors contributing to this risk

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