Indian Journal of Clinical Anaesthesia

1-5

Authors: Mukesh Somvanshi, Archana Tripathi, Anil Rajoriya

Background: Midazolam is often used for premedication in children. We investigated the efficacy of different doses of intranasal midazolam for premedication in 75 children, ASA physical status I and II, aged 3 to 10 years of either sex undergoing various elective surgical procedures. Methods: In a randomized, double blind, placebo controlled design, all children were allocated to one of the three groups of 25 each. Group – A received 0.2 mg/kg intranasal midazolam (5mg/ml). Group – B received 0.3 mg/kg intranasal midazolam (5mg/ml). While Group – C received intranasal normal saline. After 20 minutes of premedication, sedation scores and ease of separation from parents were noted. Children’s response at the time of intravenous cannulation and face mask application was also measured. Results: Sedation scores in group A and B were excellent (3.64 ±0.5 & 3.76 ±0.7 respectively) compared to group C (1.24 ±0.4). Separation of children from their parents was easier in group A & B than in Group C. In group A & B, children were calm on intravenous cannulation and face mask application. Conclusion: We conclude that intranasal midazolam is effective and very well accepted premedication drug in children.

15-18

Authors: Alpa patel, N. Desai

The present study was carried out to evaluate the efficacy of epidural midazolam in relieving post –operative pain compared to epidural Buprenorphine. Thirty patients of ASA Grade I & II, of both sexes were randomly selected for study. Half of them received Inj. Buprenorphine 4μg/kg (Group A) and rest of the patients received Inj. Midazolam 30μg/kg (Group B) epiduraly on complain of pain. Pain score was determined by subjective method that is visual analogue scale. Mild sedation with epidural midazolam was favorable in decreasing agitation & apprehension in post-operative period. The duration of analgesia lasted for 5-24 hrs in Group A & 16-48 hrs in Group B. Patients were stable as far as vitals were concerned.

27-31

Authors: Shrinivas.T.R, Ravi kumar

Background: Venous cannulation is the most commonly performed invasive procedure in hospital patients. It is painful and associated with a high incidence of vasovagal reactions and pressor responses in patients. Objectives: The aim of the study is to evaluate the efficacy of eutectic mixture of local anesthetic cream in producing dermal analgesia for venous cannulation. Material and Method: 200 patients were selected randomly of either sex, and divided into two groups. In group-I EMLA cream was applied and in group-II normal saline (placebo) was applied. Pain for intravenous cannulation was assessed by VAS scale. Results: The mean pain score for venous cannulation in patients with EMLA cream was very less when compared to the placebo group. Conclusion: EMLA cream is effective in producing dermal analgesia in response to venous cannulation.

36-40

Authors: Nita D Gosai, Dipika P Patel, Dr Rekha N Solanki, Maharshi B Pandya, Deven B Gohel, Bipin M Patel

Aim: To study ease of location of epidural space, distance of epidural space from skin, difficulties encountered during location of space and insertion of catheter. Material & Method: 60 patients posted for gynecological surgery under ASA grade I/II were randomly allocated in 4 groups. 15 patients in each receives midline epidural by hanging drop technique, midline epidural by loss of resistance technique, paramedian epidural by hanging drop technique and paramedian epidural by loss of resistance technique. Epidural depth by sterile marking ink and difficulties during insertion of needle and catheter were recorded. Observation & Results: We observed that epidural space encountered comparatively more deeper in paramedian approach. Difficulties were less encountered during paramedian approach. Ease of location was better with loss of resistance technique. Conclusion: We found no difference between the hanging drop and loss of resistance technique for identifying the lumber epidural space. But efficacy is better with the loss of resistance technique compared with hanging drop technique.

48-56

Authors: Shikha Soni, Ankit Soni, Manjula Bapugol, Sadik Mohammed, Rakesh Karnawat, K. L. Tulsiani

Objective: Despite advances in medical treatment, surgical intervention is often associated with postoperative pain, nausea, and vomiting. While epidural analgesia is considered the gold standard for post- thoracic surgery pain relief even Paravertebral nerve block (PVB) has the potential to offer equal postoperative pain relief and fewer side effects when used for breast surgery. Method: We compared thoracic PVB with epidural block in a double-blinded, prospective, randomized study of 60 women scheduled for unilateral breast surgery. Patients were divided into two groups of 30 each, Group E (Thoracic epidural group), Group P (Thoracic paravertebral group), each who received 15ml of 0.5% Ropivacaine either in the thoracic epidural region or thoracic paravertebral region. Results: Patients receiving epidural showed a fall in mean arterial pressure leading to significant p-value at 10, 20, 30, 40, 50 min, 1hr, 1 hr PO. The fall was soon addressed with fluid bolus and if not responding vasopressors were given in form of 6 mg mephentermine. In Group E 33% (10/30) patients required vasopressors as compared to 0% (0/30) in Group P. The analgesic profile of the two regional technique were similar in both groups. In Group E (20%) patient experienced Nausea and Vomiting which was more than Group P (7%) Conclusion: We conclude that Paravertebral nerve block has the potential to offer equivalent surgical condition and analgesia along with good patient satisfaction as compared to epidural anesthesia but better patient profile and tolerance and fewer postoperative side effects when used for breast surgery.

63-69

Authors: Prashanth N, Neeta PN, Amit RU, Shilpa K

Background: Fat embolism syndrome is commonly associated with long bone fractures and the mortality associated with it is due to cerebral and pulmonary involvement. Recently experimental and clinical data have suggested that the benefit of corticosteroid therapy may be maximized if the treatment is given early as a prophylaxis for the development of the fat embolism syndrome in high risk patients. The aim of our study was to test the efficacy of single dose methyl prednisolone as prophylaxis to prevent Fat embolism syndrome in patients with single long bone fracture of lower limb. Methods: We conducted a double blinded randomized control among 44 patients, who showed signs and symptoms of sub clinical fat embolism and fulfilled our inclusion and exclusion criteria over 2years period in a tertiary trauma care centre, Bangalore, Karnataka. These 44 patients were randomly selected and assigned 1 envelope and segregated to respective group. The nursing staffs who were educated about the division of groups administered the drug methyl prednisolone or normal saline accordingly. We were blinded to this allocation of groups and drug administration. The patients were followed up by us in the ICU and wards. At the end of study, the group allocation was disclosed. Among these patients were divided into Control Group A (21 patients), who were given placebo treatment with normal saline and Study Group B (23 patients), who were given a single dose of methyl prednisolone 30mg/kg over one hour. Results: Among the 44 patients analyzed, 33.3% of group A and 8.7% of group B patients developed clinical Fat Embolism Syndrome (FES). The mean duration of ventilator support in group A (9.25 days) was higher than in the group B (7.33days). There was significant increase in the vital parameters like heart rate and respiratory rate as well as significant fall of Spo2, in control group than the study group postoperatively. There is no change in the PaCO2, systolic and diastolic blood pressure. Conclusion: A Single prophylactic dose of Methyl Prednisolone 30 mg/kg significantly reduces the incidence of Fat Embolism Syndrome. Hence use of Methyl Prednisolone as a Prophylaxisfor Fat Embolism Syndrome in long bone fractures of lower limbs is beneficial.

74-77

Authors: Nandita Mehta, Shikha Sharma

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.

82-85

Authors: Alpana Arya, Shilpi Jain, S. C. Dulara, Loveleena Gupta

Background: Post-operative nausea and vomiting (PONV) is commonly seen in female patients undergoing abdominal surgeries under general anaesthesia. In this randomized double blind prospective study, efficacy of ondansetron and palonosetron for prevention of PONV following abdominal surgeries under general anaesthesia was compared. Methods: 60 female patients undergoing elective abdominal surgery were randomly allocated to one of the two groups of 30 patients each. Group O patients received injection Ondansetron 4mg and Group P patients received injection Palonosetron 75mcg intravenously 15 minutes before induction. All episodes of PONV within 72 hours after induction of anaesthesia were recorded. Statistical Analysis: Statistical analysis was done using two sample t test. Results: The incidence of complete response (no PONV, no rescue medication required) during 0-6 hours in post-operative period was 93.33% in patients of group O and 86.67% in patients of group P. But the incidence of complete response during 6-24 hrs of post-operative period was only 73.33% in patients of group O while it was 93.33% in patients of group P. During 24-48 hours in postoperative period incidence of complete response was only 66.67% in group O while it was 96.67 % in group P. And during 48-72 hrs in postoperative period incidence of complete response was 86.67% in patients of group O and 96.67% in patients of group P. Rescue antiemetic in the form of inj. Metoclopramide was given in the patients who had vomiting. Conclusion: Single dose of Palonosetron was more effective for prevention of nausea and vomiting in comparison to Ondansetron after 6 hrs in post-operative period in abdominal surgeries.

92-96

Authors: Borse Y M, Thorat S A , Dighe J P , Patil P J

Introduction: Pain is a unique emotional experience, which is associated with actual or potential tissue damage. Postoperative pain management is necessary. The most effective preemptive analgesic regimens are those that are capable of limiting sensitization of the nervous system throughout the entire perioperative period. Material & Methods: Radomly patients were assigned in two groups of 60 patients who underwent lower limb orthopedic surgery. The clinical effects of intrathecally administered Inj Bupivacaine 0.5% hyperbaric 2.5 ml (group B) with Inj Buprenorphine preservative free 150 mcg additional to the hyperbaric bupivacaine 0.5% 2.5 ml (group B) for lower limb orthopedic surgeries were studied . Results: Surgery had mean duration of 87.3(16.7) min for group B and 96.3(17.1) min for group BN. There was statistically no significant (P>0.05) difference of time of onset, maximum level and time required reaching maximum level of sensory block in between the groups. All patients in both groups had complete motor blockade. There was statistically no significant (P>0.05) difference in preoperative, during surgery and postoperative hemodynamic parameters in between two groups. Sensory recovery was significantly (P<0.01) delayed in BN group compared to B group. Mean duration of effective analgesic was markedly raised (P<0.001) to 909 (216.9) min in group BN from 158(17.3) min in group B. Complication of nausea, vomiting and shivering was noted in both the groups with no significant difference(P>0.05). Conclusion: Buprenorphine added to Bupivacaine hyperbaric have effective and considerably prolonged postoperative analgesia.

102-106

Authors: Ravi Kumar, Sreedevi K. P

Background: This study was designed to evaluate the efficacy, onset and duration of sensory and motor blockade, occurrence of delirium reaction and other complications of Ketamine with Adrenaline given intrathecally. Methods: 100 patients belonging to ASA grade-I & II of both sexes scheduled for lower abdominal surgery were randomly selected for the study. 7All the patients received injection Ketamine 75mg with Adrenaline 100 microgram intrathecally. The onset of sensory and motor blockade, maximum level and time taken for sensory level, quality and duration of sensory and motor blockade, intra-operative complications were assessed. Results: The onset of sensory and motor blockade was in 2.60±0.64 minutes, 4.33±0.60 minutes respectively. The duration of sensory and motor blockade was 85.48±11.68 minutes, 108.36±11.78 minutes respectively. The maximum level achieved ranged from T6-T10. The time taken to achieve maximum sensory blockade ranged from 2-8 minutes. There were no significant changes in mean systolic and diastolic arterial blood pressure or pulse rate. Intra-operatively, nystagmus was seen in all patients. Sedation and delirium was seen in 70 patients and 4 patients respectively. Conclusion: Ketamine with adrenaline produced a quicker onset of sensory blockade with good muscle relaxation. Ketamine stimulated the cardiovascular and respiratory systems, which may be an advantageous in maintaining stable haemodynamics over local anaesthetics during perioperative period for lower abdominal surgeries.

111-113

Authors: Lalit Gupta, Gaurav Dwivedi, Poonam Bhadoria

Non cardiogenic pulmonary oedema (NCPE) continues to represent an important cause of morbidity and mortality with a large human and financial cost. Because of the resemblance of the clinical picture to that seen with respiratory distress of the neonate, NCPE has been referred to as the Adult Respiratory Distress Syndrome (ARDS). In spite of the great improvement in supportive therapy, mortality continues to exceed 50%. The diagnosis of drug-related NCPE relies upon documented exclusion of other causes of NCPE like gastric aspiration, sepsis, trauma, negative pressure pulmonary oedema, etc. We describe cases of 55-year old male who underwent an elective surgery under general anaesthesia and developed NCPE after administration of ‘neostigmine-glycopyrrolate’ used to reverse residual neuromuscular blockade. The patient was treated successfully with mechanical ventilatory support, and adjuvant therapy. This report emphasizes that this fatal complication may be seen with neostigmine, the pathogenic mechanism remains unknown, and it probably is a drug-related NCPE.

117-118

Authors: Chetan Shukla, Mukesh Somvanshi, Lata Sharma, Somank Gupta

Transurethral resection of prostate (TURP) is a very common surgical procedure in urological practice worldwide. Bladder rupture due to explosion is a very rare complication of this surgery. We report a case of 64 year old diabetic patient who underwent TURP for benign prostatic hyperplasia (BPH). Procedure was uneventful for 40 min. After that a loud thump was heard and sudden fall in blood pressure (BP) was noticed, despite aggressive management BP was not maintained. Then intraabdominal exploration revealed bladder rupture, which was repaired by surgeon. Blood pressure was gradually maintained towards normal. Then patient was shifted to intensive care unit (ICU) and then discharged uneventfully.

1-3

Authors: Dr. Rakesh Sadhu

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 anaesthesiology 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 anaesthetic administration, pharmacokinetics, preoperative and postoperative considerations, coexisting disease and other complicating factors, cost issues, and similar concerns anaesthesiologists 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 anaesthesiology and perioperative medicine and making them freely available worldwide.

13-22

Authors: Sarvesh Pal Singh2,*, Minati Choudhury1, Ujjwal Kumar Chowdhury3, Sandeep Chauhan1

Background: Cerebral protection has always been an important concern during cardiac surgery. Near infrared spectroscopy (NIRS) can continuously monitor cerebral oxygenation and is increasingly being used as a surrogate measure to ensure the wellbeing of brain. This prospective observational study was designed to observe the changes in cerebral oxygenation in patients undergoing coronary artery bypass surgery (CABG) with the aid of cardiopulmonary bypass (CPB) during hypothermia and normothermia, and to determine if there was any correlation between the cerebral oximetry values and variables like hematocrit (Hct), mean arterial pressure (MAP), partial pressure of oxygen in blood (PaO2), CPB flows and temperature. Methods: Forty patients scheduled to undergo elective CABG with the aid of CPB were enrolled in this study. The regional cerebral oxygen saturation (rso2), haematocrit, (MAP), PaO2, temperature and pump flows during CPB were measured at following time points during the surgery -T1:Baseline before induction of anaesthesia (on room air), T2:After induction of anaesthesia with a FiO2 of 100% , T3:After induction of anaesthesia with a FiO2 of 50% , T4:At the initiation of CPB (the lowest value of rso2 at the time of initiation of CPB), T5:On CPB at 35°C , T6:On CPB at 32°C, T7:On CPB after rewarming at 36°C , T8:After weaning from CPB with a FiO2 of 100% (after protamine administration) and T9:After weaning from CPB with a FiO2 of 50% (just before sternal closure). During CPB, pump flows were also recorded to find any deviation from the standard protocol. Results: The mean baseline rso2 values were 64.35 and 64.97 for right and left frontal lobes, respectively and there was a relative increase in rso2 values with increase in PaO2 levels in the preCPB period. There was a maximum relative decrease of 12% in rso2 values with the initiation of CPB and the values remained below baseline throughout the hypothermic CPB. An insignificant decrease in rso2 values occurred with hypothermia which reversed at rewarming. The rso2 values reached baseline values in the post-CPB period. Based on post hoc analysis we observed that rso2 values could be predicted as 0.329 X per unit change in haematocrit; 0.133 X per unit change in MAP and 0.005 X per unit change in PaO2. Conclusion: In patients undergoing cardiac surgery with CPB cerebral oximetry values were well maintained with maximal decrease of 12% at the time of initiation of CPB. Mild decrease in rso2 occurred with institution of CPB which reversed by the end of rewarming. The rso2 values differ insignificantly during hypothermic CPB. Cerebral oxygenation appears to be influenced by haematocrit, mean arterial pressure and partial pressure of oxygen in blood in pre, during and post CPB period.

30-37

Authors: Dr. Ram Badan Singh1,*, Dr. Richa Prabhakae2, Rajiv Kumar Dubey3, Prof. TB Singh4

Aim of Study: To find out effect of clonidine on fentanyl and Ropivacaine requirement to produce Epidural Anesthesia. Material and Method: After Institute ethical clearance and consent from patient, 60 patients of ASA I and II were studied in 3 groups. All patients were premedicated with ranitidine and metoclopramide. In operation room epidural catheter was placed. After recording base line hemodynamic parameters, drugs were mixed in 20ml syringe according to 3 different groups and given through epidural catheter. Observation and Result: All patients were monitored for hemodynamic changes and recorded at different time interval. Data were analyzed using different tests. Patients of all 3 group have similar level of anesthesia with lower adverse effects hypotension which was more in clonidine, fentanyl and ropivacaine group. Conclusion: With this study we concluded that adition of clonidine in fentanyl and ropivacaine significantly reduces the amount of ropivacaine and fentanyl required to produce epidural anesthesia.

46-51

Authors: Dr. Bharat Paliwal, Dr. Manoj Kamal, Dr. Anamika Purohit, Dr. Geeta Singaniya

Central venous catheterization (CVC) has become an integral part for management of patients in intensive care units. It enables invasive monitoring, facilitate atrial pacing and permit delivery of parenteral alimentations and medications. Notwithstanding, CVCs are associated with numerous complications such as mechanical complications, infections and thrombotic complications. We presented a case of 17-year-old male patient who developed massive central venous thrombosis causing superior vena cava (SVC) syndrome after sequential placement of a right and left subclavian vein central venous catheter. Colour Doppler and Computed tomography (CT) angiography showed thrombosis of bilateral subclavian, internal jugular and axillary veins with minimal blood flow. Patient was treated with low molecular weight heparin (LMWH) and warfarin with partial recanalization of veins and resolution of symptoms.

56-59

Authors: Dr. Lalit Gupta, Dr. Gaurav Dwivedi

Seldinger's technique is widely used to place central venous and arterial catheters and is generally considered safe. This technique does have multiple potential risks. Guidewire-related complications are rare but potentially serious. We describe a case of an entrapped guidewire during central venous catheter insertion followed by a review of the literature on this topic. Measures which can be taken to prevent such complications are explained in detail as well as recommended steps to remedy errors should they occur.