Indian Journal of Clinical Anaesthesia

324-328

Authors: Alka Kewalramani (Chhabra), Savita Choudhary, Rakesh Kushwaha, Nagendra Prasad Sharma, Sourabh Bhate.

Background and Aims: Etomidate is frequently used nowadays as an inducing agent in patients with compromised cardiovascular function, but it leads to undesirable side effect like myoclonus and pain on injection during induction in unpre-medicated patients. Several drugs are considered alone and in combination, before induction to reduce the incidence of myoclonus. This prospective, randomized study was aimed to compare butorphanol and fentanyl administered before the induction of etomidate to reduce the myoclonic movements. Material and Methods: Sixty patients of ASA I-II, aged 18-50 years undergoing surgeries in general anaesthesia were divided into two groups and pretreated either with intravenous butorphanol 0.02mg/kg and iv midazolam 1mg(Group BM) or intravenous fentanyl 1mcg/kg and iv midzolam(Group FM) followed by induction with etomidate until loss of eyelash reflex. Incidence and severity of myoclonus, pain on injection, apnoea and postoperative nausea and vomiting were noted. Induction dose of etomidate and induction time were observed and compared between the two groups. Results: Study results showed the incidence of myoclonus of grade 1 were 6.7% and 10% in group BM and group FM respectively(p=1.000). The mean dose of etomidate for induction and induction time were found to be 10.00±1.5mg and 32±4.50 seconds in group BM as compared to 12.00±1.8mg and 40±5.00seconds respectively in group FM.(p<0.001) Conclusion: The incidence and severity of etomidate induced myoclonus is reduced by combination of midazolam with butorphanol or fentanyl if administered before induction. Also the dose of etomidate for induction is decreased by butorphanol in combination with midazolam.

335-341

Authors: Aparna G. Kulkarni, Omshubham Asai, Abhimanyu S. Tarkase.

Aims and Objectives: The aim of the present study was to study the effectiveness of co-loading of crystalloid over preloading of crystalloid in prevention of maternal hypotension during spinal anaesthesia for elective caesarean section. Material and Methods: Hundred parturients aged 18-35 yrs undergoing elective caesarean section were randomly allocated in two groups of fifty each. Group P received preload of 20ml/kg of ringer’s lactate solution over a period of 20 minutes before spinal anaesthesia, while Group C received co-load of 20ml/Kg of ringer’s lactate solution at the maximal possible rate by pressurized giving set at the time of administration of spinal anaesthesia. Both the groups received spinal anaesthesia using 2ml of 0.5% hyperbaric bupivacaine at L3-4 level with 23G Quinke’s spinal needle. Blood pressure measurements were recorded in both the groups at 2min interval from the start of the regional block for the first 10 min and then at 5min interval till 30min and thereafter every 15min till the end of surgery. Similarly other parameters like heart rate, SPO2, maximum level of sensory block and APGAR scores were also recorded. Statistical Analysis: Chi-square test was used to find the significance of study parameters on categorical scale between groups. Z test was used to find the significance of study parameters on continuous scale between two groups (intergroup analysis) on metric parameters. Significance was assessed at 5 % level of significance. Any p – value less than 0.05 (p<0.05) and 0.01 (p<0.01) is considered as significant and highly significant respectively. Results: Demographic data was comparable in both the groups. The baseline systolic blood pressure was comparable in both the groups and the difference was not statistically significant. The fall in blood pressure was more in Gr. P than in Gr. C at 5 to 30 min after administration of spinal anaesthesia and this difference was statistically significant. (P <0.05) Similarly the incidence of hypotension was more in Gr. P (72%) than Gr. C (23%) and this difference was also statistically significant. There was no statistically significant difference in the other parameters like heart rate, SPO2 and APGAR score in both the groups. Conclusion: Co-loading of crystalloids lowers the incidence of hypotension than preloading after spinal anaesthesia for elective caesarean section.

347-352

Authors: Jawaharlal Narayansa Irkal, Siddareddy Velayudha Reddy, Venkatayogi Harsha Vardhan, Sama Madhavi.

Context: Despite of prophylaxis, nausea or vomiting is most common in the postoperative period, may leads to unanticipated readmission, prolonged hospital stay and patient’s frustration. Earlier studies have reported conflicting results of dextrose on postoperative nausea and vomiting hence we designed this study. Aim: Testing the role of intravenous 5% dextrose on reducing the frequency of postoperative nausea and vomiting. Study design: A prospective, randomized, double-blind, placebo-controlled study. Methods: In this study, we allocated 90 healthy patients scheduled for tympanoplasty under general anesthesia. The participants were randomized into two groups (n=45) to receive either Ringer’s lactate solution (group C) or 5% dextrose in Ringer’s lactate solution (group D) intravenously following surgery. A standard technique was applied for general anesthesia in all patients and single dose of ondansetron 4 mg was given intravenously half-hour before recovery from anesthesia. Postoperative nausea and vomiting scores, antiemetic doses were recorded at 0, 30, 60, 90, 120 min and 24 hours. The duration of stay in post-anesthesia care unit was also noted. The data recorded were analyzed using student t-test and chi-square test. A value of P <0.05 was considered as significant and 0.0001 was considered as extremely significant. Results: Postoperative nausea and vomiting scores were not different between the groups and non-significant statistically (P >0.05). Conversely, patients in group D consumed less antiemetic doses (P = 0.004), and had a short duration of stay in the post-anesthesia care unit (P<0.0001) when compared with patients in group C. Conclusion: In this study, postoperative dextrose 5% intravenous infusion resulted in improved postoperative emesis management as explained by decrease in rescue antiemetic consumption and post-anesthesia care unit duration of stay.

358-363

Authors: Lalitha Jeenger, Jitendra Jeenger, Suresh Chandra Dulara, Adhokshaj Joshi.

Background Post-operative cognitive dysfunction (POCD) is the subtle cerebral complication temporally seen following surgery. Objectives: To compare the influence of general anesthesia (GA) and of combined spinal-epidural anesthesia (CSEA) upon the early post-operative neurocognitive outcome in elderly (60-70 years) subjects undergoing hip surgery. To measure the impacts of preoperatively hospital stay on POCD. Methods: Total 60, patients were recruited in a prospective, randomized, parallel-group study. They were enrolled and randomized to receive either GA (N= 30) or CSEA (N = 30). All of them were evaluated on the Mini Mental State Examination (MMSE) for their cognitive function and Clock Drawing Test (CDT) for visuospatial function prior to the surgery. The operated patients were re-evaluated 3 days after the surgery on same scales. The data collected were analyzed to assess statistical significance. Results: We observed no statistically significant difference in cognitive and visuospatial function in both the group pre-operatively, which were comparable with respect to age, sex. We found significant cognitive impairment in patients exposed with GA postoperatively 23.33% whereas in CSEA only 6.66%. Visuospatial function was also significantly affected by GA (26.66%) in comparison to CSEA (13.33%). Duration of preoperative hospital stay didn’t affect the neurocongitive functions postoperatively. Conclusions: We observed a positive difference in cognitive outcome with CSEA as compared to GA. Certain aspects of the cognition were affected to a greater extent like visuospatial functioning with exposure to GA undergoing hip surgery.

370-375

Authors: Prashanth Gowtham Raj SK, Bhagyashree Amingad.

Background: The concept of preemptive analgesia had evolved in the recent years. Present days multimodal approach is the most preferred practice for perioperative pain relief, as no single agent is effective in inhibition of nociception without its side effects. Pregabalin originally a spasmolytic, now used as a newer anti-epileptic drug, in the management of generalized and partial epileptic seizures. Its use as a preemptive analgesic in many surgical procedures had proved promising results. Hence the aim of our study was to evaluate efficacy of preemptive pregabalin for prolonging post-operative analgesia, reducing post-operative opioid analgesic requirement and haemodynamic stability. Material and Methods: 80 patients of ASA grade I and II physical status posted for elective modified radical mastectomy were divided into 2 groups of 40 each. Group T –received pregabalin 150 mg orally 1 hour before general anaesthesia. Group C – received identical empty capsules as placebo 1 hour before general anaesthesia. Results: The postoperative VAS scores were significantly lower and duration of analgesia was longer in pregabalin group as to control group. The total analgesic consumption, PONV scores were also lower in pregabalin group. Ramsay sedation scores were slightly higher in pregabalin group but were acceptable clinically. The side effects were similar in both groups. Conclusion: Preemptive 150mg oral pregabalin reduces post-operative pain scores(VAS)significantly, provides longer duration and better quality of post-operative analgesia, reduces opioid analgesic requirement and attenuates haemodynamic response to laryngoscopy, endotracheal intubation and also extubation without increase the side effects when used in optimal doses.

389-399

Authors: Vijay Narayanan S, Mohamed Mubarack A, Iniya R, Rajalekshmi M.

Background: Hypotension after spinal anaesthesia is preventable by adequate pre-loading with colloids or crystalloids. Women posted for emergency caesarean section are more vulnerable for hypotension as they are not preloaded adequately due to time constraints. The idea of the study is to maintain haemodynamics by administering preload solution without any delay. Here 6% Hydoxyethyl starch (HES) is compared with Ringer lactate (RL) as a preloading solution. Materials and Methods: 50 pregnant women posted for emergency caesarean section were randomly allocated into 2 groups – Group H of 25 women received 500 ml of 6% HES and Group R of 25 women received 500 ml of RL intravenously as preload prior to spinal anaesthesia. The requirement of ephedrine to counter hypotension and the changes in the haemodynamic parameters were noted. Statistical analysis was done using Student’s ‘t’ test, Fisher’s test and Chi square test, and p <0.05 was considered statistically significant. Results: The requirement of ephedrine was less in 6% HES group (p <0.001). The haemodynamical parameters were more stable in 6% HES group where there was minimal fall in blood pressure (p < 0.001) and minimal rise in heart rate (p <0.01) compared to RL group. Conclusion: The administration of 6% HES as a preloading solution before spinal anaesthesia in pregnant women undergoing Emergency Caesarean section is superior to Ringer lactate as it causes less incidence of hypotension and requires less ephedrine and intra-operative intravenous fluids.

407-418

Authors: Ramakrishna Reddy Mudiganti, Swathi K, Aruna Subhash T.

Background: Spinal anaesthesia is a popular technique for lower abdominal surgeries for more than a century. Choice of local anaesthetics depends mainly onset, duration, intensity of sensory and motor block and side effects. With time newer local anaesthetics were invented and used to get better analgesia and less side effects. Aim: To study and compare the effects of 0.5% Levobupivacaine with 0.5% Bupivacaine in spinal anaesthesia. Design: Randomised Controlled study. Material & Method: The study includes 100 patients randomly divided into 2 groups of 50 each. Group L patients received 3ml of 0.5% Levobupivacaine (15mg) 5mg/ml.Group B patients received 3ml of 0.5% Bupivacaine (15mg) 5mg/ml. Statistical Analysis: by using SPSS version 20 (Statistical Package for Social Studies), Chi square test, F table, Mean and standard deviation were used. Results & Conclusion: Duration of sensory block and time for first requirement of post-operative analgesia was longer in patients who received 0.5% Levobupivacaine intrathecally when compared to 0.5% Bupivacaine intrathecally. Though there was no statistical significance in terms of onset of sensory and motor block, duration of motor block was less in Levobupivacaine group. Stable haemodynamics and less side effects were observed with Levobupicaine. Hence, Levobupivacaine is a better alternative to Bupivacaine for spinal anaesthes

427-431

Authors: Sambhunath Das, Suruchi Ladha.

Introduction: Laryngoscopy and tracheal intubation is associated with profound adverse hemodynamic changes. Coronary artery disease patients have compromised myocardial blood flow and usually have associated hypertension. If the stress response to tracheal intubation is not controlled, it may lead to severe hypertension, arrhythmias and myocardial ischemia. Dexmedetomidine is a new alpha agonist with high potency to control the stress response, pain and tachyarrhythmia. Hence, impact of dexmedetomidine on hemodynamic parameters during tracheal intubation in coronary artery bypass grafting (CABG) surgery patients was evaluated in the study. Methods: Sixty patients undergoing CABG were enrolled in the study. They were divided into 3 groups. Group 1 received thiopentone 3-5mg/kg, group 2 received thiopentone plus lignocaine 1mg/kg and group 3 received thiopentone plus dexmedetomidine 0.5µg/kg prior to laryngoscopy and tracheal intubation. Heart rate (HR), mean arterial pressure (MAP) and cardiac index (CI) were measured before induction, after anaesthetic induction, at laryngoscopy, and 1min, 3min, 6min and 10min after tracheal intubation. The extra amount of fentanyl and thiopentone required controlling hypertension to laryngoscopy and intubation was noted. The values were analyzed with SPSS 20 software with a P value of <0.05 considered as significant difference. Result: Demography variables of patients were similar among the groups. The values of MAP, HR and cardiac index were similar at base line in all three groups. The increase in the heart rate and cardiac index was less in dexmedetomidine group compared to thiopentone only group (p<0.05) at all-time points. Dexmedetomidine group also had lower rise in MAP after base line in comparison to group 1 and significantly less at laryngoscopy (p< 0.0001). Lignocaine group had better control on hemodynamic changes during intubation compared to group 1, but less attenuation compared to dexmedetomidine group. Group 3 patients required less thiopentone (23.2±27mg vs 52.5±29.1mg vs 107.5±53.8mg, p=0.0001) and fentanyl (26.2±30.8µg vs 58.7±39.9µg vs 108.7±35.6µg, p=0.0001) in comparison to group 1 and group 2. Conclusion: Dexmedetomidine is an effective drug in attenuating the hemodynamic response to tracheal intubation in patients undergoing CABG. Dexmedetomidine reduced the requirement of rescue doses of thiopentone and fentanyl.

439-441

Authors: Sanjeev Bhimashankar Birajdar, Deepa Nijalingappa Allolli, Mujahed Javed.

Introduction: Postdural puncture headache is commonly experienced by parturients especially after caesarean delivery under spinal anaesthesia. The objective of our study was to study the incidence of PDPH in pregnant women with low and high body mass index. Methods: Our study comprised of Group A and Group B of 30 patients each with BMI < 30kg/m2 and > 30kg/m2 respectively undergoing elective caesarean section under spinal anaesthesia. Results: The study was a prospective randomized study in which incidence of PDPH was higher in patients with low body mass index compared to those with high body mass index. Conclusion: Incidence of PDPH was higher in patients with low body mass index compared to high body mass index and the difference was statistically significan

447-450

Authors: K. Hemnath Babu, Shashikanth G. Somani, Sonali Somani, Venugopalan VM.

Objective: To compare efficacy of subarachnoid block with bupivacaine alone and low dose bupivacaine with fentanyl as adjuvant in terms of, onset and duration of anaesthesia and post-operative analgesia. Materials and Methods: Present prospective randomized case control study was conducted in 60 patients undergoing elective caesarean section. They were randomly divided into two groups of 30 each. Subarchnoid block was standardized. Haemodynamic parameters, onset and duration of sensory and motor blockade, post-operative analgesia and side effects (if any) were compared. Data was analysed using student’s unpaired t-test. Results: Onset of analgesia was earlier in Group BF (1.36±1.30min) compared to Group B (1.81±1.61min) which was statistically significant(p<0.05). Duration of two segment regression in Group BF (81.21±9.40min) was significantly prolonged then Group B (62.4±14.81min) which was statistically significant(p<0.05). Duration of sensory blockade in Group BF (124±9.36min) was significantly more than Group B (104.7±6.40min) which was statistically significant(p<0.05). In Group BF, onset of motor blockade was delayed and duration of motor blockade was less as compared to Group B, which was statistically not significant (p>0.05). Postoperative analgesia in Group BF (194±16.82min) was significantly prolonged then Group B (108.57±7.90 min) which was statistically significant(p<0.05). Conclusion: Addition of fentanyl to bupivacaine resulted in faster onset of action and effective spinal anaesthesia with a lower dose of bupivacaine.

455-459

Authors: Suman Chattopadhyay, Ananya Biswas, SK Samim Ferdows, Dilip Kumar Bhowmik, Swagata Dey, Biswanath Bi.

Introduction: Laparoscopic cholecystectomy is associated with an appreciably high rate of postoperative nausea & vomiting (PONV) which is considered as a reason of patient’s delay in discharge and disability aggravation. This study was designed to compare the effectiveness of Ondansetron, Dexamethason and Ondansetron plus Dexamethasone as an antiemetic prophylaxis for preventing PONV in patients after laparoscopic cholecystectomy. Methods: In this randomised double blind study, 153 patients of both sexes of ASA I and II aged between 16 to 60 yrs received 4 mg Ondansetron (Group O, n = 50), 8 mg Dexamethason (Group D, n =51) or Ondansetron 4 mg plus Dexamethasone 8 mg (Group OD, n=52) intravenously immediately before induction of anaesthesia. Perioperative care was standardised in all patients. Patient was then observed for 24 hours postoperatively for any episode of PONV and any adverse effects of the study drugs. Results: A complete response (defined as no PONV and no need for another antiemetic) was achieved in 62% of the patients receiving Ondansetron, 64.7% of the patient receiving Dexamethasone and in 84.6% of patients receiving Ondansetron plus Dexamethasone (P<0.05). The overall cumulative incidences (0-24 hrs) of PONV were 40% in Ondansetron group, 37.3% in the Dexamethasone group and 15.4% in combination group (P<0.05). No difference in adverse events was observed in between group. Conclusion: We concluded that combination of Ondansetron plus Dexamethasone is better than each drug alone as an antiemetic prophylaxis against PONV following laparoscopic cholecystectomy.

468-473

Authors: Swarnalingam Thangavelu, Shankar Anand Radhakrishnan, Nazir Ahmed Mallick.

Background: The pain experienced after upper abdominal surgery leads to a reduction in 70-75% of vital capacity which leads to postoperative pulmonary complications. The ideal adjuvant for epidural analgesia in patients undergoing upper abdominal surgery seems to be every effective for better outcome and early immobilization in the immediate postoperative period. With this background we planned to conduct a study on epidural analgesia by comparing two alpha 2 agonists. Methods: 50 patients who have planned for elective upper abdominal surgery under general anaesthesia were enrolled in our study. Before induction of general anaesthesia, epidural catheterization was done. The surgical procedure was carried out under routine general anaesthesia with endotracheal controlled ventilation. The patients were given either Dexmedetomidine or Clonidine in the dosage of 2mcg/Kg with 0.125% Bupivacaine via epidural catheter after extubation. Patients were shifted to Post Anaesthesia Care Unit for observation. Sedation and pain were assessed with monitoring of vital parameters. The side effects were also noted. Results: Statistical analysis showed that the duration of analgesia was prolonged in the patients who received Dexmedetomidine as an adjuvant with local anaesthetic agent (417.32±67.36 minutes, p value < 0.05). The time to first rescue analgesia was comparatively delayed in Dexmedetomidine group while comparing with Clonidine group (425.6±64.27 minutes, p value < 0.05). The incidence of hypotension and bradycardia was greater in Clonidine group. There was no significant statistical difference with respect to side effects in both groups. Conclusion: From our study we concluded that Dexmedetomidine provides both analgesia and sedation with better hemodynamic status while compared to Clonidine used as adjuvants in epidural analgesia. But needs further study to optimize the dosage of these two adjuvants while giving via epidural route along with local anaesthetic agen

488-491

Authors: Madhuri S. Kurdi, Ashwini H. Ramaswamy.

Research is essential for the growth and development of any medical science. The status of research in developing nations is very primitive mainly because of lack of funds and lack of motivation. India is doing good academic progress and the situation of clinical research in India is nowadays improving rapidly. Training programmes on research methodology are being conducted and multidisciplinary research units are being set up in several medical colleges in India. Several organizations have sponsored the development of short duration modules of mobile research workshops in India. Research publications are a desirable qualification nowadays, for promotion amongst faculty members. This has led to a great enthusiasm amongst faculty members to get their research studies published. This article describes the current status of clinical research in developing nations and discusses the measures undertaken to improve research activities in India.

144-147

Authors: Anil Shetty, Vinaybabu Kurian, Anand Bangera, Nikil M.P.

Background & Objectives: Drugs administered before anaesthesia to decrease anxiety and to obtain a smoother induction, maintenance and emergence from anaesthesia is a part of preanaesthetic medication. Clonidine, a central α2 agonist and Midazolam, a benzodiazepine, are among drugs used as preanaesthetic medication which plays a vital role in producing sedation and reducing anxiety especially in children. Hence, the aim of this study was to evaluate the role of oral Clonidine and oral Midazolam as an ideal preanaesthetic medication in children to produce sedation and reduce anxiety. Methods: A prospective randomised double blind study was done involving 70 children (2-10) years scheduled for elective surgery between the period of January 2014 to July 2015 in Department of Anaesthesia, K.S. Hegde Medical College and Hospital, K.S.Hegde Medical (Affiliated to NITTE university), Deralakatte, Mangalore, Karnataka, India. They were randomly divided in to two groups as group A (Oral Midazolam, 0.5mg/kg) and group B (Oral Clonidine, 4mcg/kg). The drugs were administered to the subjects 45 minutes before induction of anaesthesia and evaluated for sedation and anxiety based on scores as per protocol. Results: Anxiety scores showed a decrease in both Midazolam and Clonidine group with a value of 3.35(p<0.001) and 4.12(p<0.00) respectively. Similarly, sedation scores showed an increase in both Midazolam and Clonidine group with a value of 4.25(p<0.001) and 5.51(p<0.000) respectively. Interpretation & conclusions: Oral Clonidine (4mcg/kg) is a potent and efficacious preanaesthetic medication in children when juxtaposed with oral Midazolam (0.5mg/kg) in producing sedation and reducing anxiety along with analgesic sparing effect.

155-159

Authors: Debaprasad Mohanty, Mahendra Kumar Nayak, Sidharth Sraban Routray, Debasis Mishra.

Postoperative cognitive dysfunction (POCD) is one of the major complications after operation in elderly patients. In various studies it was shown that perioperative blood transfusion was an independent risk factor for development of POCD in aged patients. So, the current study was a comparative study to assess and analyze the effect of liberal transfusion and restrictive transfusion in orthopedic surgery patients. Material & Methods: In a prospective randomized study 80 patients with the age more than 65 years undergoing lower limb orthopedic surgery from November 2013 to October 2015 were included. After all investigations the patients were given combined spinal and epidural anaesthesia. They were divided into two groups – Restrictive group and Liberal group and were given blood transfusion accordingly. The incident of POCD, MMSE score were noted and compared. Observation: We observed that no statistical difference was observed in the groups with respect to age, sex, body weight, ASA grade, level of education, preoperative MMSE scores, length of surgery, preoperative haemoglobin levels, intraoperative blood loss. There was no significant difference for MMSE score at preoperative examination. 17.5% patients in restrictive transfusion group and 20% patients in liberal transfusion group developed POCD. Conclusion: Lliberal transfusion strategy was not superior to restrictive transfusion strategy in terms of a better postoperative cognitive functioning.

165-169

Authors: Dnyaneshwar Ramaji Fating, Ashwini K. Dandekar, N.G. Tirpude.

Background: Laryngoscopy and endotracheal intubation evoke a haemodynamic response leading to increased heart rate and blood pressure. Purpose of present study was to evaluate the efficacy of Nalbuphine for attenuation of haemodynamic response to laryngoscopy and intubation. Methods: 120 patients belonging to ASA Grade I and II, posted for elective laparoscopic surgery under general anaesthesia were included in this double blind prospective randomised study. Patients were randomly allocated in two groups to receive either injection Nalbuphine IV 0.2mg/kg diluted to 5 ml with normal saline (Group N) or 5 ml normal saline (Group C), five minutes before induction. Monitoring of heart rate, systolic blood pressure, diastolic blood pressure and mean arterial blood pressure was done at laryngoscopy and endotracheal intubation and 1, 3, 5, 7 and 10 minutes after laryngoscopy and endotracheal intubation. Results: Increase in heart rate, systolic blood pressure, diastolic blood pressure, mean arterial blood pressure in Group N was lower than in Group C. Conclusion: Intravenous Nalbuphine in the dose of 0.2 mg/kg appears to be a promising drug which can be used to attenuate the haemodynamic response to laryngoscopy and intubation.

179-183

Authors: Leena Goel, Megha Goel.

Introduction: Monitored Anesthesia Care (MAC) is proposed to be a suitable technique for middle ear surgery. Aim: In present study we compared the efficiency of dexmedetomidine and propofol as an adjunct to local anesthesia for in producing analgesia, sedation, variation in respiratory and hemodynamic responses, along with patients and surgeons satisfaction. Materials and Methods: Fifty patients were enrolled in this prospective, single blinded, randomized study. The patients were allotted randomly into two groups: dexmedetomidine (Group D) or propofol (Group D). Sedation was assessed with Ramsay Sedation Scale (RSS) value of 3. Different parameters observed included changes in hemodynamic and respiratory values, post-surgical recovery time, sedation analgesia, surgeons’ and patients’ satisfaction about quality of anaesthesia. Results: Both the drugs i.e. dexmedetomidine and propofol were found to be providing adequate sedation but propofol was related with increased need for rescue analgesia and less patient satisfaction. These results propose that dexmedetomidine provide sufficient sedation with analgesia with good surgeon and patient ease without any adverse effect for patients being operated for middle ear surgery under local anesthesia.

191-195

Authors: “Light wand- guided nasotracheal intubation in patients with limited mouth opening: a comparison with blind nasal intubation”

Background and objectives: Approximately 1–3% of surgical patients have difficult airways, which accounts for the most important cause of anaesthesia-related morbidity and mortality. The fibreoptic bronchoscope is considered the gold standard for the management of difficult airways. However, blind nasal intubation remains a basic technique in developing countries, especially in remote areas where a Fiberoptic bronchoscope is not always available. The light wand is a simple, cost effective device, and has become a tool widely accepted in airway management under various clinical scenarios, including difficult airways. The study was conducted to evaluate the efficacy of light wand-guided nasotracheal intubation over blind nasal intubation. Methods: A total of 60 ASA Grade I & II patients of age 18-60 yrs of Body mass index between 18-25 kg/m2 with limited mouth opening (distance between upper and lower central incisors < 3.0 cm) posted for elective surgeries were divided into two equal groups in a randomized, double-blind fashion. Blind nasal group 30 patients Light wand Group: 30 patients Results: The first attempt and overall success rate of light wand guided nasotracheal intubation was 80% and 90% respectively, significantly higher than blind nasal intubation i.e. 50% and 66.66% respectively (p<0.05). The mean intubation time in light wand group was 103±61 seconds and was 155±73 seconds in blind nasal group (p<0.05). There was significantly better haemodynamic stability and a lower incidence of pharyngalgia in lightwand group. Interpretation & Conclusions: The study shows nasotracheal intubation using the light wand to be a more effective and simple approach than blind nasal intubation, with a higher success rate, better haemodynamic stability, and fewer postoperative complications in patients with a known or anticipated difficult airway.

207-213

Authors: Prashanth Kumar C, Chaitra U, Sathyajith Karanth A.

Background: Prolonged post-operative analgesic effect of intrathecal morphine is often limited by its adverse effects. This study was conducted to know the effect of three different doses of intrathecal nalbuphine in reducing adverse effects related with intrathecal morphine. Methods: The study was performed in a prospective, randomized, observer-blind manner. Total of 120 patients were divided randomly into four groups (n=30) to receive 100 micrograms of morphine alone (Group A), 0.5mg(Group B), 1.0mg(Group C), 1.5mg(Group D) of nalbuphine with 100 micrograms morphine. Post operatively patients were monitored for vital signs, SpO2, sedation, pain (VAS), presence of pruritus, nausea and vomiting, respiratory depression and urinary retention for 24 hours. Results: Addition of nalbuphine decreases pruritus, nausea and vomiting in dose dependent manner with maximum effect at 1.5mg. No significant differences observed in vital signs, SpO2, sedation score, pain (VAS) score, duration of analgesia and total dose of analgesia required. None of the patients developed respiratory depression and urinary retention. Conclusion: Present study provides evidence that addition of 1.5mg of intrathecal nalbuphine with 100micrograms of intrathecal morphine completely abolishes opioid induced pruritus and significantly reduces nausea and vomiting without reducing analgesic effect of morphine.

219-223

Authors: Rajneendra Sharma, Seema Partani, Saurabh Bhateja.

Background: Intrathecal neostigmine produces analgesia but its utility is limited by increased incidences of nausea and vomiting. However, epidural neostigmine has been investigated to produce postoperative analgesia without nausea and vomiting. The purpose of the current study was to define the dose range for analgesic effectiveness of epidural neostigmine co-administered with levobupivacaine and side effects in patients after lower limb orthopedic procedures. Patients & Methods: After Institutional Ethical committee approval and informed written consent, 120 patients (n = 30) undergoing lower limb orthopedic surgery were randomly allocated to one of four groups and studied in a prospective way. Patients were randomized to receive either saline or 50, 100, or 150 µg neostigmine in 1ml as adjuvant to Levobupivacaine 0.5%, 20 ml (n = 30 per group), epidurally. Onset and duration of analgesia and motor block was assessed using pin prick, visual analogue scale (VAS) and bromage scale for 22 hrs. peri-operatively. Any side effects were also observed. Results: Groups were demographically the same and did not differ in intraoperative vital characteristics (heart rate and respiratory rate), however there was some protection from hypotension observed in neostigmine 100 and 150 µg group. Addition of neostigmine resulted in significant longer duration of analgesia in group III (490±105.2 mins) and group IV (542±133.6 mins) than control group I (335±101.3 mins). The time of onset of analgesia (7.2 mins versus 9.2 mins in control) and motor block (12.4 and 11.5 mins versus 17 mins in control) was also decreased significantly. Two patients in control and one patient in group III developed nausea/vomiting which was statistically insignificant. There was no other incidence of increased side effects in any group. Conclusion: Co-administration of epidural neostigmine and levobupivacaine appears to be a useful technique for perioperative analgesia as it increases duration of analgesia without increasing side effects.

233-237

Authors: Rakesh Kushwala, Savita Choudhary, Shashank Gupta.

Background: Post-operative pain poses special problems in children. The use of caudal epidural analgesia for post-operative pain relief, either completely eliminates or appreciably reduces the hazards of narcotic analgesics. So, this study was planned to clinically evaluate the efficacy, safety and duration of pain relief following caudal epidural analgesia in children. Materials & Methods: This prospective study was conducted in children from age group 0 to 12 years undergoing perianal and genital surgery after taking permission from institutional ethics committee. Patients with sacral anomalies, skin infection, poor bony land marks, movements and previous operation were not included in study. 1% lignocaine hydrochloride was used with adrenaline in concentration of 1:2000000 for caudal analgesia Children were observed for pain as well as for any untoward effects in post-operative period. Results: In this study caudal block was successful in 48 (96%) cases out of total 50 surgical patients who were recruited during the study period. The duration of pain relief ranged from 265 minutes to 500 minutes. The average duration was 394 minutes. Haematoma and Blood in epidural tap were observed in 4% and 8% cases respectively. Retention of urine was recorded in 4% cases. Pain at injection site was complained by 12% cases. Nausea and vomiting was recorded in 20% cases. Conclusion: It is concluded that caudal block is an efficient and safe method for achieving pain relief of reasonable duration during post-operative period in children.

243-250

Authors: Venkatesan K, Vijay Narayanan S, Iniya R, Rajalekshmi M.

Background: Adequate analgesia following caesarean section decreases morbidity, ambulation, improves patient outcome and facilitates care of the newborn baby. Intrathecal Magnesium, an NMDA antagonist has been shown to prolong analgesia without significant side effect in healthy parturients. We therefore studied the effect of adding intrathecal Magnesium sulphate to Bupivacaine, Fentanyl in patient with mild pregnancy induced hypertension undergoing caesarean section. Aim: To study and compare the effect of added Fentanyl 0.5cc (25 mcg) & Magnesium sulphate 0.1cc 50% (50mg) to 0.5% 2cc (10mg) Bupivacaine, in patients with pregnancy induced hypertension (PIH) undergoing elective Caesarean section under spinal anesthesia. Materials and Methods: 60 patients undergoing elective caesarean section under spinal anaesthesia were randomly divided into three groups. Control group (N=20) received 0.5% 2cc (10mg) Inj.bupivacaine+0.6cc normal saline. Fentanyl group (N=20) received 0.5% 2cc (10mg) Inj.bupivacaine+0.5cc (25micgm) Inj.fentanyl+0.1cc normal saline. Magnesium sulphate group (N=20) received 0.5% 2cc (10mg) Inj.bupivacaine+0.5cc (25mcg) Inj.fentanyl+0.1cc 50% (50mg) magnesium sulphate. Onset, duration and recovery of sensory and motor block, duration of spinal anaesthesia, APGAR score and post operative analgesia duration were studied. Statistical analysis was done using univariate analysis, ANOVA and two group ‘T’ test. p<0.05 was taken as statistically signicant. Results: Onset of sensory and motor blockade were delayed in the magnesium sulphate group which was significant. Duration of spinal anesthesia, motor block duration and post-operative analgesia were also significantly prolonged in Magnesium sulphate group. Conclusion: Addition of magnesium sulphate to intrathecal bupivacaine is beneficial in antenatal women undergoing caesarean section, as it prolongs the motor blockade and duration of analgesia.

257-260

Authors: Rajkumar Ahirwal, Yashwant Dhayjale.

Background: Caesarean deliveries done under spinal anesthesia are associated with higher incidence of post-operative nausea and vomiting (PONV). Aims and Objectives: Present study was performed to find the efficacy of subhypnotic dose of propofol compared to ondansetron and placebo in controlling nausea and vomiting during caesarean delivery under spinal anesthesia. Material and Methods: A randomized placebo controlled study was done on 90 parturient patients at GMC and Hamidia Hospital, Bhopal between May 2013 and December 2013. All the study patients were randomly divided into three groups: Group I (Placebo treated), Group II (1 mg/kg/hr infusion of propofol) and Group III (4 mg of Ondansetron). Emetic episodes (nausea and vomiting) were evaluated using linear numerical scale ranging from 0 (No nausea and vomiting) to 2 (Vomiting). Results: In present study we found that on administration of study drugs incidence of PONV was low (13.33%) in propofol group as compared to ondansetron group (16.66%) (p >0.05). Incidence of PONV was significantly more in placebo treated group (53.33%). Conclusion: Propofol and ondansetron, both were highly effective as compared to placebo in preventing the emetic episodes during caesarean delivery under spinal anesthesia. Moreover subhypnotic dose of propofol was more effective than ondansetron in the prevention of PONV

271-277

Authors: Manoj Kumar N. Gajbhare, Neha P. Kamble.

Background: Spinal anaesthesia for cesarean section has been the preferred technique for majority of anaesthesiologist. Maternal hypotension following spinal anaesthesia remains common place in cesarean delivery. The combination of reduced dose of local anaesthetics with intrathecal opioids makes it possible to achieve adequate spinal anaesthesia with minimum hypotension. Objectives: The aim of our study was to compare the effectiveness of plain bupivacaine with low dose bupivacaine plus fentanyl with respect to sensory and motor blockade, hemodynamic changes, side effect profile and post-operative analgesia after spinal anaesthesia. Material and methods: 60 patients undergoing elective cesarean section under spinal anaesthesia were randomly allocated to two equal groups; Group B patients received 10 mg (2 mL) of 0.5% hyperbaric bupivacaine and Group B + F received 8mg (1.6 mL) of 0.5% hyperbaric bupivacaine plus 20 ug (0.4 mL) preservative free fentanyl. The clinical profile of subarachnoid block in two groups and its effect on maternal and neonatal outcome was studied. Results: The mean time required to reach peak sensory level was earlier in Group B + F. Mean time of two segment regression of sensory analgesia and complete sensory recovery was significantly earlier in Group B. Duration of motor recovery was earlier in Group B +F. Mean maximal heart rate was significantly more in Group B. Mean minimal systolic arterial pressure was significantly less in Group B compared to Group B + F. The duration of effective analgesia was significantly more in Group B + F (235.33+29.15) compared to Group B (120.33+10.98). The incidence of side effects was less in Group B + F than Group B. Conclusion: We can conclude that the addition of low dose fentanyl to 0.5% hyperbaric bupivacaine for spinal anaesthesia in cesarean section provides satisfactory sensory and motor blockade, better hemodynamic stability, less side effects and effective post-operative analgesia.

283-286

Authors: Seema Partani, Rakesh Kushwaha, Rajnindra Sharma.

In this era of modern scientific advancement where automobile industries are reaching new heights and roads are jammed-up with all types of vehicles; accidents form a bulk of cases admitted to trauma ward. Majority of these cases have fascio-maxillary injuries where a proper airway assessment is the most important part of treatment. In this content a retrospective study was done analyzing the case records of sixty patient with fascio-maxillary injuries admitted to our institute over a period of six months. The aim of this study was to find out the difficulties found during management. Majority of patients were in age group of 20-30 yrs and ten patients had some degree of airway compromised and five had associated head injuries. Out of these ten compromised airway, five were managed with change of position, oral suction & use of oropharyngeal airway; while four needed endotracheal intubation in casualty (Fig. 1) and only one required tracheostomy in casualty. 20 patients were intubated via nasal route. Blood transfusion was done for three patients.

292-299

Authors: "Preanaesthetic sedation with intranasal midazolam atomizer versus oral midazolam in paediatric patients” – a randomized comparative study

Background: Separation from the parents and unfamiliar operation theatre environment adds severe anxiety and apprehension to children. Therefore, an effective preanaesthetic medication for use in children undergoing surgery is required. In spite of plethora of research activities, premedication in children remains a controversial subject as various premedication and delivery systems have developed using different routes of administration. Aims and objectives: To compare the safety, efficacy, ease of administration, acceptability, degree of sedation, anxiolysis and parental separation of midazolam by oral and intranasal spray for preanaesthetic sedation. Materials and Methods: Sixty six ASA-I and ASA-II paediatric patients of age group one to ten years, scheduled for elective surgical procedures were divided into Nasal(N) group and Oral(O) who were randomised to receive either intranasal midazolam atomizer spray (0.4mg/kg) or oral midazolam syrup (0.5mg/kg). The demographic details, vital parameters, sedation score, anxiolytic score, separation score and drug acceptability were noted before administering the drug and at 10,20,30 minutes interval till parenteral separation was done. Results: There was statistically significant increase in mean pulse rate at 10 minutes interval in group-N (P< 0.05). Though statistically significant increase in systolic blood pressure(SBP) was noted at all 3 intervals(P<0.05)in group O, statistically significant increase in diastolic blood pressure(DBP) was noted in group O only at 10 minutes of interval (P-value<0.05). Drug acceptability was good in group-O which was statistically significant(P- value <0.001). Sedation and anxiolysis were good in group-N compared to group-O but statistically significant scores were noted at 20 minutes interval (P<0.001, P<0.01 respectively). Parental separation in group-N was better compared to group-O which was not statistically significant. Conclusion: Both the oral and nasal routes were equally safe. The transnasal route achieved faster sedation, anxiolytic and separation scores, virtually complete absorption as compared to oral syrup. Hence it may be preferred as a good alternative to oral midazolam. The oral route was better accepted by children.

316-323

Authors: R. Venkatraman, C.R. Saravanan, P. Ayyanar Sakthivel, Ajay Haridas Poonath.

Background: The cataract surgeries are usually done in elderly patients under monitored anaesthesia care with or without sedation. Dexmedetomidine is a non-opioid sedative and analgesic and is devoid of respiratory depression. The objective of this present study is to evaluate the sedative effects of low dose dexmedetomidine infusion for unilateral cataract surgery. The patient and surgeon satisfaction scores were also recorded. Methods: Sixty patients scheduled for unilateral cataract surgery were randomly assigned to two groups: Group 1 receiving dexmedetomidine 0.5mcg/kg diluted in 100ml normal saline infusion over 15min while group 2 received normal saline. The patients in both the groups received premedication with alprazolam 0.5mg two hours prior to surgery. The hemodynamics, sedation score, patient and surgeon satisfaction scores and any adverse effects were recorded. Ramsay sedation score (RSS) of 3 was kept as a satisfactory sedation for the patient. Results: All the patients in group 1 achieved RSS of 3 while in group 2 only 47% of patients reached the target score. The patient and surgeon satisfaction scores were better with group 1. There was a significant fall in heart rate and blood pressure between 15 and 25 min after dexmedetomidine infusion. In group 1, two patients had bradycardia and four patients developed hypotension which was easily manageable. Conclusion: Dexmedetomidine, when administered as a low dose infusion provides reliable sedation and is a useful anaesthetic adjuvant for monitored anaesthesia care in cataract surgery. The patient and surgeon satisfaction scores were also better with dexmedetomidine infusion.

4-11

Authors: Abhishek Bhuava, Akshaya N Shetti, Vinod Kharde, VK Badhe, Das Divekar

Introduction: Preanesthetic medication forms an integral part of anaesthetic management. Pharmacological and non-pharmacological techniques are tried to achieve anxiolysis and better hemodynamic stability. Clonidine is alpha 2 agonist and acts on central nervous sytem. It is adminstered in various route and oral route is one of them. This study has been designed to study the effect of oral clonidine on perioperative hemodynamics. Aims: To evaluate beneficial effects of oral clonidine in attenuating the haemodynamic responses and comparing with placebo in patients undergoing surgeries under general anaesthesia. Settings and Design: Randomized double blind study. Methods and Material: Two hundred patients were enrolled in this study and studied for 2 years. Randomization was carried out. Four groups, including 50 patients per group were created. Group I (Placebo) received oral tablet ranitidine 150 mg, Group II C2, C3 and C4received oral clonidine 2 µg/kg, 3µg/kg and 4µg/kg body weight respectively. Sedation, anxiolysis and hemodynamic changes were recorded. Statistical analysis used: The statistical significance for categorical variables was determined by chi-square test. For continuous variables two sample t-test was applied. For intra group comparison paired t- test and for inter group comparison unpaired t-test was used. Results were expressed as Mean ± SD (standard deviation). A P value < 0.05 was considered statistically significant. Results: No statistically significant differences concerning demographic data between the groups of patients computed. A significant difference observed with respect to sedation and anxiolysis between all the four groups. The HR response between clonidine (2 µg/kg, 3µg/kg and 4µg/kg) and placebo was very significant at all times (p<0.001) showing a favorable response towards attenuation of HR. The SBP, MAP and DBP response between clonidine and placebo is significant at all times. When compared to clonidine (2 µg/kg, 3µg/kg and 4µg/kg) group the requirement of MAC of Isoflurane in placebo group is higher. Conclusion: Administration of oral clonidine preferably 4µg/kg, as pre-medicant results in improved perioperative haemodynamic stability and Isoflurane sparing effect.

16-19

Authors: Madhavi Ravindra Nishtala, Bhargavi Sanket, Chandrika Yabagodu Ramavakoda

Anaesthesia for laparoscopic pyloromyotomy poses multiple challenges. We have analysed our experience of anaesthetizing these infants by describing the perioperative events statistically in order to improve our anaesthetic technique. Pre-operative records, demographic details, intraoperative and post operative records of all cases of laparoscopic pyloromyotomy performed over a period of 5 years in a tertiary care unit were collected and reviewed. A statistical analysis of demographic details, preoperative clinical features with emphasis on metabolic derangements, adverse events during surgery and in the post operative period was done. We observed a combined intraoperative and post operative complication rate of 20% with no occurrence of mortality. Maximum morbidity post operatively was due to the development of emesis seen in 8 children (7.3%).

27-32

Authors: Sidharth Sraban Routray, Deba Prasad Mohanty, Laxmidhar Dash, Debasis Mishra, Avijit Prusty

Background: There are various ICU scoring systems like APACHE and SAPS II to predict mortality which are done at 24 hours of admission during which precious time is lost in administering therapy. In various studies microalbuminuria has shown promise not only as a predictor of organ failure and vasopressor requirement but also of mortality. Aim: To evaluate the relation between microalbuminuria (urine micro albumin creatinine ratio) and SAPS II score in patients with sepsis and whether it could predict mortality in critically ill patients and the risk of developing multiorgan failure. Methods: In was a prospective, non-interventional study conducted on 64 patients admitted to ICU. Spot urine samples were collected at 6 and 24 hours of admission and were tested for urine microalbumin by immunoturbidometric method and for urine creatinine by Jaffe method and urine microalbumin: creatinine (Urine ACR) ratio was calculated. The urine ACR was co-related with SAPS II score and mortality of the patients. Results: SAPS II score ranged from 13 to 87. Median SAPS II score among survivors were 42.0 and among non survivors were 63.5. Non survivors had a higher SAPS II score compared to survivors (P value=0.0001).Urine ACR 1(urine micro albumin creatinine ratio at 6 hour) was 66.4 μg/mg among survivors and 166.5 μg/mg among non survivors and ACR 2 (urine micro albumin creatinine ratio at 24 hour) was 34.6 among survivors and 151.4 among non survivors (p value = 0.0001). Urine ACR 1 and Urine ACR 2 were correlated with SAPS II score and found statistically significance. Conclusion: The degree of microalbuminuria was more among patients with organ dysfunction than among patients with no organ dysfunction. Significant microalbuminuria is also predictive of organ dysfunction.

36-38

Authors: Vibhuti A. Shah, Vidhi A. Gujjar

Objective: Purpose of the study, is to find out if Non Invasive Ventilation (NIV) failure can be predicted, on the basis of the information available at initial point of a contact with patient. Methods: This is the retrospective study of patients which were admitted to AMC MET Medical College, ShethL.G.General Hospital, Ahmedabad during the years 2014-2015.Patients were assign, to one of the two groups covering the successful NIV treatment & NIV failure. Results: 90 patients were incorporated in the study& two groups were compare on the variables accessible at initial point of contact with patient. Patients in which NIV treatment failed did had elevated levels of the C-reactive protein (p=0.04). Multivariate analysis showed that an odds ratio, of 1.13 for NIV failure; associated with increased respiratory rate. NIV was less likely to fall short in patients with the recognized Chronic Obstructive Pulmonary Disease (p=0.05). Conclusion: In this current study NIV failure, was found to be associated with the elevated levels of the C-reactive protein tended to have the elevated respiratory rates.

44-47

Authors: Manjula Sarkar, Pushkar Desai, Shantaram Pawaskar, Shubhra Sarkar

Background: Acute pain in the perioperative setting is detrimental to post operative outcome and adequate analgesia leads to better outcome. Methods: Sixty ASA I/II patients between 18- 65 years undergoing laparoscopic cholecystectomy and appendicectomy were included and randomly divided into 2 groups. ASA III/IV patients, previous opioid and alpha 2 agonist treatment and patients requiring extensive surgical dissection were excluded. Group D received IV Dexmedetomidine 1μg/kg over 10 min followed by 0.2-0.7 μg /kg/hr and Group P received IV Paracetamol 15 mg/kg prior to extubation. Patients were monitored for hemodynamics and VAS score was assessed after extubation till 24 hours. Rescue analgesia (IV tramadol 1 mg/kg) was given and the time interval till the requirement of first dose of rescue analgesia was recorded. Results: In group D, 12 patients required rescue analgesia as compared to 4 Patients in group P (40% vs13.3%; P=0.02). VAS scores were similar in both groups with group P showing trend towards low score. Median time at which the first dose of rescue analgesia was administered in group P was longer (134.42 + 12.67 vs 82.76 + 9.38 min; P=0.001). Incidence of bradycardia and hypotension was higher in group D (20% vs 3.3%; P=0.04). Conclusion: Paracetamol is a superior to Dexmedetomidine for analgesia in short surgical procedures and should form a part of multimodal analgesia.

52-55

Authors: GV Rao, Jyothsna M

Introduction: Organophosphorus compounds are anti acetylcholinesterases which exert their toxicity by interfering with the normal function of zetylcholine, an essential neuro - transmitter throughout the autonomic and central nervous system. Methodology: The study was conducted at the Respiratory Intensive Care Unit of Department of Anaesthesiology. Prior approval for the study and the protocol was obtained from the institution ethical committee. After explaining the possible prognosis in the course of organophosphorus poisoning, consent from a responsible attendant / informant of the patient was obtained before the actual study was initiated. Results: It’s evident from the above table that maximum number of patients presented with mild poisoning based on the SCE levels (77%) and about 23% had moderate to severe poisoning levels. Conclusion: There was a significant correlation between SCH levels and duration of consumption of OP.

62-68

Authors: Anuradha Ganigara, Chandrika Y Ramavakoda, Bindu, Bhargavi Sanket, Vinay Jadhav, Jayalaxmi Sripathi

Background: Biliary atresia (BA) is a progressive and fatal obliterative cholangiopathy affecting 1 in 10,000 infants resulting in biliary cirrhosis and eventually death within the first two years of life. The first line of treatment is a surgical procedure known as Kasai’s portoenterostomy which aims to restore the forward flow of bile into the intestines. There is paucity of literature regarding perioperative anesthetic management of BA and its outcome. This review was thus specifically done to fill in the dearth with regard to anesthetic challenges and complications met during management of infants with BA undergoing Kasai’s procedure. Materials and methods: Retrospective data of all infants diagnosed and operated for EHBA in our institute from 2011 to 2014 was collected. Perioperative data, anesthetic and surgical details including post operative course of these children were collected and analyzed. Results: The highlights of our series were the delayed presentation of infants with BA at an average age of 85 days which indirectly prolonged the operative time. These infants in early stages of cirrhosis had higher requirements of crystalloid and blood component therapy. Intraoperatively, a decrease in blood pressure was also reflected in the R wave amplitude of ECG which signals further research in the direction of non invasive hemodynamic monitoring in infants. Of significance was the finding of normal intraoperative blood glucose values in infants with EHBA and thus inadvertent dextrose supplementation in all infants with liver dysfunction needs to be avoided. Multimodal analgesia in the form of intravenous opioids, paracetamol, tramadol and judicious local anesthetic infiltration can be used to tackle perioperative pain. Conclusions: In conclusion, when faced with anesthetizing infants with EHBA, the anesthesiologist needs to pay attention to the preoperative assessment like age of presentation, severity of the liver dysfunction and associated congenital and co morbid conditions like anemia and coagulopathy. Goals of anesthetic management would include meticulous maintenance of euvolemia, euthermia, euglycemia and provision of adequate perioperative analgesia and anesthesia.

74-79

Authors: Rajesh Subhedar, Shakuntala Shelke, Rupali Patil, Ajay Subhedar, Vishal Ambre

Introduction: Up till now almost all studies used either single intravenous dose of dexamethasone in perioperative period for post operative pain relief or perineurally in regional anesthesia along with local anesthetic agent to prolong the regional anesthesia. The recent animal studies shown the neurotoxicity of perineurally used injection dexamethasone. This study was planned to evaluate the effect of single dose of dexamethasone in infiltration with local anesthetic agent in day care surgical procedure. Methodology: Cases selection is from ASA – grade I & II patients posted for day care surgical procedure be done under local infiltration anesthesia. The patients are randomly allocated into two groups. Dexamethasone group-GD —25 patients. Control group- GC -26 patients patients were observed for symptoms of perineal itching, effect at the site of local infiltration and PONV. Post operative pain was evaluated half hourly after end of surgical procedure. Pain score is noted by numeric rating scale (NRS) at first pain, after one hour of analgesic and at the time of discharge from the hospital. They were followed up to 7 to 8 days for wound healing and stitch removal. Observation: The average time of first pain was 259.1 min and 120 min in Group D & C respectively. NRS pain score after rescue analgesic in group D was significantly lower than Group C. Amongst Group D four patients did not required any analgesic till the time of discharge on the same day. From Group C four patients needed additional analgesic Itching at the site of local infiltration perineal itching and PONV was not significant. Conclusion-We conclude that addition of injection dexamethasone with injection lignocaine for local infiltration anesthesia delays the requirement of first analgesic significantly. In addition to this the analgesic effect of injection dexamethasone along with injection diclofinac is highly promising.

85-95

Authors: Vijayanand kannabiran, Pushpa rani anand

Introduction: Ropivacaine has a reduced risk of cardiotoxicity, neurotoxicity, and rapid recovery of motor function. Postoperative pain relief is an important issue with Ropivacaine. Dexmedetomidine which is a highly selective α-2 adrenergic agonist with eight times greater affinity for receptors than clonidine decrease the requirements of analgesics and augment the effects of local anaesthetics. Aim and Objective: Compare the analgesic efficacy of intrathecal isobaric 0.75% Ropivacaine with the combination of isobaric 0.75% Ropivacaine and Dexmedetomidine. Study design: A prospective randomized double-blinded study. Sample size: 100 patients were selected and allocated in two groups randomly. Inclusion criteria · ASAI & II · Either sex · 18-60 years for lower limb Orthopaedic surgery Exclusion criteria: · Patient refusal · Patients who had contraindications for spinal anaesthesia · Allergy to local anaesthetics · Cardiac disease · Hypertension Patients were divided into two following groups randomly by lot method. · Group R: Received 3ml volume of 0.75% isobaric ropivacaine and 0.5ml normal saline. · Group D: Received 3ml volume of 0.75% isobaric ropivacaine and 5µg dexmedetomidine in 0.5ml normal saline Observations: Ropivacaine vs. plain 0.75% isobaric Ropivacaine given intrathecally in patients who underwent lower limb orthopedic surgeries.The following observations were made: 1. The addition of 5ug Dexmedetomidine to 0.75% Ropivacaine significantly prolonged the duration of analgesia and the time to demand analgesia. 2. The addition of dexmedetomidine intrathecally produced sedation that was arousable for many hours compared to plain ropivacaine group 3. The incidence of side effects such as hypotension and bradycardia were more in patients who received dexmedetomidine But shivering was greatly reduced in dexmedetomidine. 4. No episode of respiratory depression was noted in both the study groups which are more common with opioids.

102-107

Authors: Megha G H, Kamala G R, Sanjeev G M

Introduction: Alpha-2 agonists are mixed with local anaesthetic agents to extend the duration of spinal, extradural and peripheral nerve blocks. We studied the effect of dexmeditomidine as an adjuvant to bupivacaine in brachial plexus block on onset and duration of sensory and motor block, duration of analgesia, level of sedation, perioperative hemodynamic parameters and complications. Methods: Forty patients of ASA Ι and ASA ΙΙ scheduled for upper limb surgery were included in double blind randomised comparison of inj. Dexmeditomidine and inj. Normal saline. We divided patients in two groups. Group A patients were given inj dexmeditomidine 50 microgm (0.5ml) and group B patients were given inj normal saline in brachial plexus block as adjuvant to 30 ml of local anaesthesic solution containing 14 ml of lidocaine with adrenaline and 16ml bupivacaine. We recorded time of onset and duration of sensory and motor block, level of sedation, duration of analgesia, hemodynamic changes and side effects in both groups. Results: mean time to onset of sensory block was 5.42±1.39 min in group A and 8.34± 1.35 min group B and that of motor block was 11.1± 2.6min in group A and 18.0± 2.9min in group B. Total duration of sensory block was 730.15±78.27min in group A and 360.62±61.7min in group B and that of motor block was 616.2± 54.46min in group A and 288.4± 54.26min in group B. Duration of analgesia was 970.36 ± 80.7 min in group A and 300±40.31 min in group B. Conclusion: addition of 50 microgm of inj dexmeditomidine to bupivacaine in brachial plexus block shortens onset and prolongs duration of sensory and motor block, prolongs duration of analgesia and decreases intraoperative requirement of sedatives.

115-120

Authors: Khaja Ali Hassan, Ahsan Mustafa

Introduction: The descriptive study is to compare this new device, the Laryngeal tube airway with the Laryngeal mask airway in securing the upper airway during short surgical procedures under general anesthesia. Methodology: After obtaining Institutional approval and written informed consent from all patients, 60 patients ASA I/II, aged 20-50 in this study. They were randomly classified into two groups, Group I (LT) and Group II (LMA). Results: The first attempt success rate in securing the airway with LT was 80.0% and the success rate with LMA was 86.6%. The time taken for securing the airway with LT was 37.76 + 5.27 and with LMA was 29.26 + 4.22 sec. Conclusion: Laryngeal tube is superior to LMA in providing a better airway seal.

129-130

Authors: M.P. Nath, Tejwant Rajkhowa, R.K. Bhattacharyya

During general anesthesia polypharmacy is used and all drugs have the tendency to produce allergic reactions leading to anaphylaxis, although rare. Sometimes typical clinical picture of anaphylaxis may not be manifested producing the scenario complicated and if not timely intervened, may be lethal. Propofol (2, 6 di-isopropyl phenol) is commonly used as induction agent in modern anesthesia practice and its anaphylactic incidences being reported1. Here we report a case of Propofol anaphylaxis who underwent functional endoscopic sinus surgery (FESS) didn’t show typical features of anaphylaxis and timely resuscitation lead to complete recovery.

134-136

Authors: Mrunalini Parasa,, Nagendranath Vemuri, Shaik Mastan Saheb, Divya Nayak L, Vidyasagar Ramakrishnan

Temporo mandibular joint ankylosis is an anticipated difficult intubation scenario. Awake fibre optic intubation is the safest approach to secure the airway. Availability of an adequate sized flexible fibreoptic bronchoscope is a prerequisite for successful endotracheal intubation. We report the use of a flexible urethroscope to facilitate nasotracheal intubation in a four years child.

196-203

Authors: Kamala GR, Leela GR

Introduction: Sedation has been shown to increase patient satisfaction during regional anesthesia and may be considered as a means to increase the patient’s acceptance of regional anesthetic techniques. For surgery under regional anesthesia, sedation is a valuable tool to make it more convenient for the patient, the anesthetist, and the surgeon. This study focuses sedative property of Dexmedetomidine in regional anesthesia. Material and Method: This study was conducted in the Department of anaesthesiology, Banaras Hindu University. A randomized prospective study was conducted on 60ASA grade I and II patients of age 20 to 60 years undergoing elective gynaecological surgery. Dexmeditomidine was administered intravenously for sedation. Group A sedation was monitored by BIS and Group B by Ramsay sedation score (RSS). Results: The induction, maintenance and total dose of Dexmedetomidine in group A was significantly less than in group B (28.77±4.44 vs 35.43±6.90, 12.24±2.70 vs 18.57±4.74, and 41.01±5.97 vs 54.00±9.62 mcg p< 0.001). Recovery time was prolonged in group B in comparison to group A (37.87±3.35 vs 22.17±3.19 mins p<0.001). Vitals like heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure were significantly less than baseline in both groups. Respiratory rate and SPO2 did not change significantly from baseline in both groups. Conclusions: Dexmedetomidine provides effective sedation. Use of BIS during Dexmedetomidine infusion reduces the dose required for sedation.

209-212

Authors: Ilango Ganesan, Saravanan Ravi, Karthik Krishnamoorthy

Background and Objectives: Conventional management of post-operative pain using routine analgesics in orthopaedic surgeries results in undesirable side effects especially in elderly population. Hence this study was designed to assess the effectiveness of Fascia iliaca compartment block in postoperative analgesia using Ropivacaine. Methods: We performed Fascia iliaca compartment block with 30 ml of 0.5% Ropivacaine in 20 patients postoperatively, who underwent lowerlimborthopaedic procedures under General anaesthesia. Results: The Verbal pain score(VPS) considerably decreased 1 hr after the block and the mean duration of analgesia was 4.85 ± 2.86 hrs. Conclusion: Fascia iliaca compartment block is very useful method of postoperative analgesia in lower limb orthopaedic procedures.

217-221

Authors: Leena Patel, Kinna Shah, Vimalkumar Padhiyar, Keval Patel, Bipin Patel

Background: Post-operative pain relief after lumbar laminectomy and stabilization surgery is related to soft tissue and muscle dissection, manipulation and removal at the operating site. Aims & Objectives: The present study is designed to evaluate the pre-emptive effect of 0.5% Ropivacaine infiltration in patients undergoing lumbar laminectomy. Materials and Methods: In this prospective, randomized study, seventy five patients belonging to ASA I and ASA II were randomly allocated to three groups as group A, group B and group C. After conventional general anesthesia, patients were kept in prone position. Patients belonging to group Areceived 2 mg/kg of 0.5% ropivacaine before incision and patients belonging to Group B received the same as wound infiltration before closure and group C patients received 10 ml saline infiltration at closure. Injection diclofenac sodium intravenous was given as a rescue analgesia when required. We observed pain intensity with Visual Analogue Scale (VAS) at 0, 30 minutes and 1,3,6,12,16 hrs, time for first analgesic requirement, total diclofenac sodium consumption and incidence of nausea and vomiting. Results: Mean VAS score immedietly after the surgery for group A was (2.3±1.8) significantly lower than group B(5.0±1.9, P=0.0001) and group C(6.6±2.3,P=0.0001). First analgesic dose requirement time was longer in group A (120±21min) than group B(60.3±20.1min,P=0.0001) and group C(10±19.3min,P=0.0001). Total amount of diclofenac sodium required in group A(65.8±20.8mg) was less than group B(110±25.8mg,P=0.0001) and group C(141±22.1mg,P=0.0001). Incidence of nausea and vomiting were equal in all the groups. Conclusion: Infiltration with 0.5% Ropivacaine significantly decreses post-operative pain intensity and diclofenacsodium consumption. Infiltration has better effect when given pre-emtively.

227-234

Authors: Ashwini G S, Kamala G R, Ramesh.K

Background: Intraoperative hypertension and tachycardia are common hemodynamic disturbances in patients undergoing laparoscopic assisted vaginal hysterectomy. In addition there is increase in systemic vascular resistance, and is associated with a decrease in cardiac index and metabolic changes. Dexmedetomidine a centrally acting α-2 agonist has been particularly effective in blunting the haemodynamic response to tracheal intubation and pneumoperitoneum. Methodology: Sixty patients, scheduled for elective laparoscopic assisted vaginal hysterectomy belonging to ASA class I and II, in the age group 38 to 55 years were included in the study and they were assigned randomly into two groups.Group D (n=30): received dexmedetomidine as a bolus of 0.6 μg/kg body weight (0.3 ml/kg body weight) over 10 min intravenously, 10 min before induction, followed by infusion at a rate of 0.2 μg/kg/hr(0.1 ml/kg/hr) throughout the surgery. Group C (n=30): received bolus of normal saline at a rate of 0.3 ml/kg body weight in 50 ml syringe over 10 min intravenously, 10 min before induction followed by infusion at a rate of 0.1 ml/kg/hrthroughout the surgery. Results: It was noted that HR, SBP, DBP and MAP in group D were significantly decreased after intubation, throughout the period of pneumoperitoneum and after extubation. In addition dexmedetomidine produced arousable sedation after extubation, decreased the incidence of post operative nausea and vomiting without significant side effects like bradycardia and hypotension. Conclusion: Dexmedetomidine as a single bolus dose of 0.6 μg/kg body weight and continuous infusion at a rate of 0.2 μg/kg/hr was seen to effectively attenuate the haemodynamic response to laryngoscopy and tracheal intubation and also to pneumoperitoneum without any side effects.

240-245

Authors: Pushpa Rani, K.Vijayanand M

Background: Laparoscopy requires creation of a pneumoperitoneum which produces a significant rise in heart rate, mean arterial pressure, reduction in venous return and systemic vascular resistance. Various pharmacologic agents are used to control hemodynamic changes associated with pneumoperitoneum. Aim: To compare the effects of Clonidine administered intravenously (group IV) and intraperitoneally (group IP) on hemodynamics,recovery and post-operative pain in patients undergoing elective laparoscopic gynaecological surgeries. Study design: Randomized controlled trial. Methodology: Sixty patients undergoing elective laparoscopic gynaecological surgeries were selected. General anaesthesia was administrered in all cases.After inserting ports Group IV: received Clonidine 1µg/kg i.v along with Ropivacaine 0.25% 20cc intraperitoneally using a ryles tube introduced and directed towards hepatophrenic recess Group IP: received Clonidine 1µg/kg along with Ropivacaine 0.25% 20cc.intraperitoneally Vitals weremonitored every 30min during the procedure. Postoperatively oxygen saturation,heart rate, and blood pressure weremonitored.Aldrete recovery scoring system was used to assessreadiness for discharge. When the score was>8, and pain was monitored using VAS scoring in lying and sitting posture next 12hours. Statistical Analysis: Continous data was analysed using student t-test while categorical data was analysed using fisher’s exact test and chi square test. Results: Intravenous Clonidine significantly reduced the MAP (group IP: 80.5±6.7,group IV: 67.44±5.6) during intraoperative period while intraperitoneal group showed reduced MAP in postoperative period (group IP: 75.98±7.35, group IV: 83.36±17.05). Heart rate both during intraoperativeperiod (group IP: 63.2±6.35, group IV: 77.6±9.35) and postoperative period (group IP: 75.6±7.35, group IV: 83.36±17.05) showed significant decrease in intraperitoeal group. Intraperitoneal Clonidine showed better hemodynamic control by maintaining heart rate and MAP postoperatively and better recovery profile in the form of VAS Scoring(2.0±0.618 p value <0.05) and time to request first rescue analgesia(6.567±0.9 p value <0.05). Conclusion: Clonidine when added to ropivacaine (0.25%) intraperitoneally provide better hemodynamic control and prolonged analgesia with less side effects than intravenous clonidine.

251-255

Authors: Neha P. Kamble, Manojkumar N. Gajbhare

Background: Postoperative sore throat is a common and disturbing complication after endotracheal intubation, leading to patient discomfort and dissatisfaction. Objective: To find out the efficacy of ketamine gargles in reducing the incidence and severity of postoperative sore throat after endotracheal intubation. Material and method: We studied the role of pre-operative ketamine gargles for reducing postoperative sore throat. Patients undergoing elective abdominal and pelvic surgery under general anaesthesia with endotracheal tube were included in the study. They were randomly allocated in two groups, each group comprising of 30 patients. Group 1(K) received preservative free ketamine 50mg in 29 ml distilled water. Group 2(C) gargled with 30 ml distilled water. Patients were asked to gargle for 30 seconds, 5minutes before induction of anaesthesia. Postoperatively sore throat was assessed at 0, 4, 8 and 24 hours after extubation. The severity of sore throat was assessed from mild to severe. Results: Immediately after extubation, 90% patients in group C had sore throat compared to 66.7% in group K. 24 hours after extubation, the incidence decreased to 50% in group C and 13.3% in group K. Similar decrease incidence was noted at 4 and 8 hours post extubation in group K. No patient in group K complained of change in voice or hoarseness of voice. Conclusion: We found that preoperative gargling with ketamine is a simple and cost effective way to reduce the incidence and severity of postoperative sore throat.

262-268

Authors: Suhail Sidiq, Umar Qadir Bacha, Abdul Waheed Mir, Rayees Najib, Mohammad Akbar Shah

Background: Tramadol hydrochloride is a centrally acting analgesic with a combination of opioid and non-opioid receptor mechanisms and a benign side effect profile. The epidural route appears to be a logical choice because of the direct effect in the transmission and processing of pain. The purpose of this study was to find out the effective dose of epidurally administered tramadol for postoperative analgesia in urological surgical patients. Method: 60 healthy patients of American Society of Anesthesiologists(ASA) physical status classification I and II, with age ranging from 20-60 years, scheduled to undergo elective surgeries were equally divided into 3 groups(I,II & III) receiving 1mg/kg, 2mg/kg and 3mg/kg of tramadol hydrochloride epidurally respectively post-operatively in PACU. Time to first request for analgesia and side effects like nausea, vomiting, dizziness and pruritus were also noted. Results: There was a statistically significant difference in the period of postoperative pain relief in Group-I (6.8±2.3 hours), Group-II(14±8 hours) and Group-III(21.4±3.7 hours). There was significant increase in postoperative nausea and vomiting in group III (40%) as compared to group I (10%) and group II (5%). Conclusion: These findings suggest that 2mg/kg body weight of epidural tramadol is an optimum dose for postoperative analgesia without increase in side effects. 3mg/kg dose can also be used with appropriate anti emetics to decrease the incidence of PONV with this dose.

277-280

Authors: Priya Sachin Sadawarte, Anjali Rakesh Bhure, Sumita Vivek Bhargava

Preoperative evaluation forms an important part of perioperative management. Missed diagnosis can increase perioperative morbidity as a chance of preoperative optimisation is missed. Though obstructive sleep apnoea is common and can be easily diagnosed, it remains undiagnosed due to lack of awareness. If identified preoperatively, we can confirm and quantify the diagnosis with a sleep study and prepare an appropriate perioperative management plan, thus reducing perioperative morbidity and mortality. Hence all the anaesthesiologists should have adequate knowledge of the clinical presentation of OSA. Here we describe diagnosis and anaesthesia management of OSA.

126-130

Authors: Hina Khurshid, Khawer Muneer, Mohammad Sadiq Malla

Emergence agitation is a short lived phenomenon occurring commonly after nasal surgery. In this study we used dexmedetomidine infusion in that intraoperative period to decrease the incidence of emergence agitation in adult patients posted for nasal surgery. Methods: 100 adult patients (ASA I-II, 20-60 years posted for nasal surgery were randomly divided into two groups. Group D received infusion of dexmedetomidine 0.4mcg/kf/hr during the intraoperative period, and Group C received normal saline infusion as placebo. All patients were induced with fentanyl (1mcg/kg) and propofol (1.5mcg/kg) and maintained with isoflurane. Incidence of agitation, hemodynamics, pain scores, time to verbal commands and extubation were evaluated. Results: Incidence of emergence agitation was lower in Group D (26%) than Group C (50%). Group I showed more stable hemodynamics than Group II. Time to verbal response and extubation was more for Group D than Group C (p < 0.05) though it was not clinically significant. Conclusion: The use of dexmedetomidine as intraoperative infusion resulted in smooth emergence with more stable hemodynamics.

137-140

Authors: Saravanan Ravi, Karthik Krishnamoorthy, Ilango Ganesan

Laryngeal mask airway(LMA) is a supraglottic airway device extensively used in children for day care surgeries. Propofol is the gold standard drug for LMA insertion, but Sevoflurane is a recent volatile agent emerging as an effective alternative. Objective: The objective of this study is to compare Sevoflurane and Propofol for insertion of Laryngeal mask airway in children. Methods: We conducted a prospective randomized study involving 60 paediatric patients posted for below umbilicus surgeries aged between 4 and 12 years of ASA physical status 1&2. 30 patients in group S were induced with sevoflurane 7% and 30 patients in group P were induced with propofol 3mg/kg i.v. The time to induction, time to jaw relaxation, time to LMA insertion were recorded. The hemodynamic parameters and any complications associated during the procedure were recorded. Results: Patients in group S had shorter induction time(39.1±6.30 s Vs 41.4±4.17 s in group P) whereas time to jaw relaxation(107.3±17.51 s in group S Vs 49.4±5.69 s in group P) and time to LMA insertion(117.9±19.2 s in group S Vs 59.3±6.8 s in group P) were shorter in group P. Both the groups were comparable in successful insertion in the first attempt as well as hemodynamic stability. Conclusion: Propofol and Sevoflurane are equally effective for LMA insertion in children

147-150

Authors: Sapna Bansal, Sachin Bansal, Shruti Saini, Dhanwant Kaur, Apoorva Kaul, Jaggy

Peritoneal insufflation of intra-abdominal pressure >10 mmHg induces a significant alteration of hemodynamics. Use of α-2 adrenergic agonists Dexmedetomidine significantly reduces hemodynamic changes and anesthetic requirements as it has sedative, analgesic, and anxiolytic properties. Methods: 100 patients of ASA I- II undergoing laparoscopic cholecystectomy were randomly allocated into two groups of 50 patients each. Group I patients received dexmedetomidine infusion at 0.2μg/kg/hr and Group II patients received normal saline infusion at 0.2μg/kg/h starting after intubation and continued till peritoneal deflation. Parameters noted were pulse rate, mean arterial pressure, oxygen saturation, EtCO2 and isoflurane requirement. Results: In dexmedetomidine group, the haemodynamic response was significantly attenuated. The anaesthetic requirement was also less with dexmedetomidine group without any desaturation. Conclusion: Dexmedetomidine infusion in the dose of 0.2μg/kg/h effectively attenuates haemodynamic stress response to pneumoperitoneum during laparoscopic surgery.

156-160

Authors: Kshitija Bhagavan Sawant1, Harsha Patel

We compared the characteristics of spinal anesthesia with plain and hyperbaric ropivacaine for LSCS. Method:- In this prospective randomized double blind study 60 pregnant patient of ASA physical status1&2 were given 15mg of either isobaric ropivacaine(n=30) or hyperbaric ropivacaine(n=30) in glucose 8% along with fentanyl 25mcg intrathecally for LSCS. The characteristics of spinal anesthesia, hemodynamic parameters, quality of anesthesia and muscle relaxation as well as duration of post-operative analgesia were compared. RESULT: - There were no significant difference in median time to onset of sensory block at T6 (plain6.33±4.62 vs. hyperbaric 4.52±2.84 minutes; p>0.05), maximum sensory level achieved (plain 8.10±3.92 vs. Hyperbaric 6.63±2.47 min, p>0.05) and onset of grade 3 motor block (plain 8.20±5.38 vs. hyperbaric 6.10±2.38 minutes; p>0.05). Median maximum extent achieved was also comparable, but in group H duration of sensory (plain 206.23±24.42 vs. hyperbaric164.50±30.29 min., p<0.001) and motor blockade (plain170.50±39.19vs hyperbaric 133.33±30.17min; p<0.001) and duration of post-operative analgesia were significantly shorter. Incidences of hypotension were more in the group H (43.33%) compared with group I (23.33%). Quality of anesthesia and muscle relaxation was satisfactory in most patients in either group. Total duration of analgesia was 218.37±28.74min in group H and 239.30±28.28min. In group I(p<0.05). CONCLUSION: - 15mg of (0.75%) hyperbaric ropivacaine provides similar, reliable and effective quality of spinal anesthesia with shorter duration of sensory and motor block, when compared with 15mg of (0.75%) isobaric ropivacaine.

169-172

Authors: Sarvesh Pal Singh1, Minati Choudhury, Milind P Hote, Palleti Rajasekhar

Indian Journal of Clinical Anaesthesia (IJCA) publishes definitive, peer-reviewed articles devoted to the clinical practice of anaesthesia. IJCA publishes a wide range of articles in the discipline of anesthesiology including basic science, translational medicine, education, and clinical research to create a platform for the authors to make their contribution towards the field without restrictions/barriers of subscription and language. IJCA addresses all aspects of anaesthesia practice, including anesthetic administration, pharmacokinetics, preoperative and postoperative considerations, coexisting disease and other complicating factors, cost issues, and similar concerns anesthesiologists contend with daily. Exceptionally high standards of presentation and accuracy are maintained. This Journal is an Open Access journal and aims to publish research articles, reviews, case studies, commentaries, short communications, and letters to the editor on various aspects of anesthesiology and perioperative medicine and making them freely available worldwide. The core of the journal is original contributions on subjects relevant to clinical practice, and rigorously peer-reviewed. Highly respected international experts have joined together to form the Editorial Board, sharing their years of experience and clinical expertise. Specialized section editors cover the various subspecialties within the field. To keep your practical clinical skills current, the journal bridges the gap between the laboratory and the clinical practice of anesthesiology and critical care to clarify how new insights can improve daily practice

180-181

Authors: Sukriti Atram1, Surbhi Dinesh Mundada

Afibrinogenemia is a rare bleeding disorder with an estimated prevalence of 1:1,000,000. It is an autosomal recessive disease resulting from mutations in any of the 3 genes that encode the 3 polypeptide chains of fibrinogen. Spontaneous bleeding, bleeding after minor trauma and excessive bleeding during interventional procedures are the principal manifestations. Replacement therapy is the mainstay of treatment of bleeding episodes in these patients and plasma-derived fibrinogen concentrate is the agent of choice. Cryoprecipitate and fresh frozen plasma are alternative treatments that should be used only when fibrinogen concentrate is not available. We report a case of congenital afibrinogenemia, a 3 years old child, posted for emergency intracranial hematoma evacuation who was successfully managed by fresh frozen plasma as other alternatives were unavailable.

184-187

Authors: Umar Qadir Bacha, Hina Bashir, Rafia Hassan, Khawer Muneer, Masarat Ara

Pneumothorax is the commonest complication of brachial plexus block using the supraclavicular approach. The onset of pneumothorax is usually delayed. In this case, we report the immediate onset of pneumothorax after an attempted supraclavicular block using the ‘Classical’ technique. This report highlights the importance of maintaining a high index of suspicion of pneumothorax even in the immediate post block period.