Indian Journal of Clinical Anaesthesia

Page No. 502-506

Authors: Anita Kumari, Lakshmi Mahajan, Deepika Madaan, Pankaj Sarangal, Ruchi Gupta.

Proseal LMA(PLMA) and LMA supreme(SLMA) are improved versions of classic LMA and offer additional safety features such as provision of better glottis seal at low mucosal pressure, presence of a drain tube which prevents gastric insufflation and thus protects against aspiration. In the present study we compared the efficacy and aspiration risk of proseal LMA and LMA supreme with LMA classic in adult anaesthetized paralysed patients. Methods: We conducted a randomised prospective study in 60 adult anaesthetized paralysed patients. The proseal LMA and LMA supreme were compared with LMA classic in terms of ease of insertion, number of attempts, insertion time & hemodynamic parameters as primary outcome. The incidence of aspiration with these LMA devices using pH paper readings from LMA tips and comparing it with gastric content pH obtained through ryle’s tube, perioperative complications and cost effectiveness of the device used were evaluated as secondary outcome. Results: Ease of insertion was although more in PLMA and SLMA than CLMA but statistically comparable in all three groups. First attempt insertion was 15/20 in group 1, 18/20 in group 2 and 3 each. Second attempt insertion was 5 patients in CLMA; 2 patients in PLMA & one patient in SLMA. Median insertion time was (22.6±3.8 sec, 20.7±3.9 and in 18.9±4.2 sec) in group 1, 2 and 3 respectively. There was no case of aspiration as evidenced by LMA tip pH which remained in the range of 6-7. The cost of SLMA was found to be more in comparison to PLMA and CLMA. Incidences of intra and post-operative complications were similar in all the three groups. Conclusion: Clinically PLMA and SLMA are easier to insert than CLMA, but overall the three groups were comparable with respect to insertion characteristics, airway manipulation required, hemodynamics, risk of aspiration and perioperative complications but cost effectiveness along with clinical benefit was seen more with PLMA.

page No. 512-517

Authors: Alka Kewalramani(Chhabra), Seema Partani, Nagendra Prasad Sharma, Venus Sharma.

Background and aims: During general anaesthesia, maneuver of laryngoscopy and tracheal intubation is accompanied by varying degree of sympathetic stimulation. This may prove detrimental in patients with compromised cardiac and cerebrovascular reserve and hence many approaches have been tried to prevent the potentially adverse circulatory responses. In the present study, we compared dexmedetomidine with labetalol to assess and evaluate the haemodynamic responses to laryngoscopy and endotracheal intubation during induction of general anaesthesia and during extubation. Material and methods: This study was carried out in ninety patients who were posted for various surgeries requiring general anaesthesia with orotracheal intubation. They were allocated into three groups. Group D patients received 0.5mcg/kg dexmedetomidine, diluted to 5ml of 0.9% normal saline, group L received 0.25mg/kg labetalol diluted to 5 ml normal saline and group C received 5ml 0.9%normal saline. All study drugs were administered over 5 minutes followed by induction with IV Propofol 2mg/kg and suxamethonium 1.5 mg/kg. Maintenance of anaesthesia was done with 100% oxygen, sevoflurane and IV Atracurium. Haemodynamic monitoring of systolic and diastolic blood pressure, heart rate(HR), mean arterial pressure(MAP) were done. Calculation of rate pressure product( RPP) were done and all parameters were compared at intubation(I0), 1(I1), 3(I3), 5(I5), 10(I10) and 15(I15) minutes postintubation, intraoperatively and at extubation. Results: Group D and group L showed statistically significant fall in HR,SBP, DBP, MAP RPP at induction, at intubation(I0), I1, I3, I5, I10, I15 than group C(p<0.001). There were decrease in HR, SBP, RPP in group D than in group L (p<0.001), while at I10 and I15 fall in MAP was significant in group D(p<0.001). Group C showed incidence of tachycardia and hypertension to be 83% and 77% respectively. Group D showed bradycardia in three patients and hypotension in four out of thirty patients which were statistically insignificant when compared to group L.(p>0.05). Conclusion: The haemodynamic responses to laryngoscopy, endotracheal intubation and extubation are better controlled with dexmedetomidine than labetalol.

Page No. 525-528

Authors: Bhavani Vaidiyanathan, S. Saravanakumar, Gomathi Karmegam

Background and Aim: Supraglottic airway devices (SGA) offer certain advantages over endotracheal intubation, making them appropriate for outpatient anesthesia. The I-gel® is the innovative second generation supraglottic airway device from Intersurgical. I-gel offers unique advantages of easy insertion, reduced trauma, superior sealing pressure, and gastric access. Drugs such as propofol, sevoflurane are commonly used for supraglottic device insertion. The pharmacokinetic characteristics of Propofol allows for rapid onset and offset of drug effect with better blunting of airway reflexes compared to thiopentone. Midazolam is a well-established anaesthetic pre-medicant for short surgical procedures. There are innumerable studies on insertion of classic LMA with propofol but only few with I-gel. This prompted us to inspect the efficacy of propofol, and propofol–midazolam co-induction for I-gel insertion in spontaneously breathing patients for elective day care procedures. The primary aim of the study is to compare propofol and propofol-midazolam for ease of I-gel insertion. Methods: Eighty patients, aged 18-45, were divided into two groups group P and Group PM. They received anaesthesia induction with propofol and propofol –midazolam after pre-medicating with Inj.Fentanyl 2micrograms/kg respectively. Patients in (group P) received IV normal saline 2ml followed by Propofol 2.5mg/kg for induction. Patients in (group PM) received IV Midazolam 0.04mg/kg three minutes before induction with propofol. The following conditions were assessed for ease of I-gel insertion such as number of insertion attempts, Jaw relaxation, coughing and gagging. The total dose of propofol, hemodynamic changes during induction were the other parameters recorded. Results: I-gel was successfully inserted at first attempt in 33 patient’s(80%) in group PM and 24 patients(60%) group P and it was statistically significant(p ≤0.03). The total dose of propofol consumed in group P(45.5±8.165) was more compared to group PM(44.65±6.483)(p≤0.002). Conclusion: I-gel insertion was swifter with better hemodynamic stability in propofol-midazolam than propofol alone for day care surgeries.

Page No. 534-539

Authors: Ilango Ganesan, R. Vasanthageethan, Arunachalam R

Background and Objectives: Supraclavicular block is one of the most common techniques of regional anaesthesia employed for upper limb surgeries. The practice of combining additives to local anaesthetics used in peripheral nerve blocks carries lot of advantages. Hence this study was designed to evaluate the effect of addition of Clonidine to Bupivacaine in Supraclavicular brachial plexus block. Materials and Methods: We studied the addition of 100 µg of Clonidine to 0.375% bupivacaine compared with saline placebo in place of clonidine for nerve locator guided supraclavicular block using sublavian perivascular technique. Forty patients fulfilling inclusion criteria were divided into two groups, group B (Bupivacaine only group) and group BC (Bupivacaine and Clonidine group) and supraclavicular block was performed in them accordingly. Results: The onset of motor and sensory blocks were quicker in group BC (4.25±0.72 min, 8.40±0.82 min respectively) compared to group B (6.40±1.14 min, 12.00±1.97 min respectively). The duration of motor and sensory block in group BC were longer (396.30±14.92 min, 466.75±13.91 min respectively) compared to group B (299.00±23.32 min, 328.95±34.13 min respectively). These were found to be statistically significant (p value < 0.05). Conclusion: Adding clonidine to bupivacaine resulted in faster onset and longer duration of sensory and motor blockade. Intensity of postoperative analgesia also improved with mild intraoperative sedation and decreased heart rate without major haemodynamic instabilities.

Page No. 546-550

Authors: Madhavi Sanjay Chaudhari, Sanket Bharat Shah, Hemlata Vithal Kamat

Introduction: Central venous cannulation is commonly performed procedure on critically ill patients. Of the two methods, landmark technique and ultrasound (USG) guided latter increases success rate and decreases complications associated with the procedure. Ultrasound guided cannulation can be done in short or long axis approach. In the short axis approach, both artery and vein can be simultaneously viewed and hence would have less chances of arterial puncture. In the long axis approach only one vessel and the entire length of the needle is visualized and therefore there would be less chances of posterior wall puncture. In this prospective randomized observational study USG guided internal jugular vein (IJV) cannulation was done by trainees (post graduate students). The aim of this study was to find the incidence of successful cannulation and incidence of complications by short and long axis approach. Materials and Method: Fifty patients were randomly allocated into two groups, short axis and long axis. All the patients were cannulated by Seldinger technique and free flow of blood was confirmed through all the ports. Results: Demographic variables were comparable between the two groups. On first attempt 92% of patients in long axis and 76% of patients in short axis were cannulated. In both the groups, remaining patients were cannulated on second attempt and large number of patients had arrhythmias. Four patients had arterial puncture in short axis group but none was seen in long axis group. Conclusion: All patients were successfully cannulated. Higher first attempt successful cannulation and overall less complication were seen in long axis approach but the difference was not statistically significant

Page No. 556-561

Authors: Namrata Ranganath, Arathi BH

Introduction: There are studies which infer that spinal anaesthesia can be prolonged after adding adjuvants to local anaesthetics or by oral premedication before the block is performed. Aim of our study: To prolong the duration of spinal anaesthesia after the block has been performed. The study was done to compare the effects of intrathecal and intravenous clonidine on duration of spinal anaesthesia and to evaluate any advantages or disadvantages of intravenous over intrathecal clonidine in terms of analgesia, sedation, post–operative shivering and hemodynamic stability. Methodology: A prospective randomized double blind controlled comparative clinical study, was conducted on 60 patients, aged 20-60 years belonging to ASA I and II scheduled for elective infraumbilical procedures. Patient were divided into three groups of 20 each randomly, Group A- intrathecal bupivacaine (0.5% heavy) 3ml (15mg) + 75mcg of intrathecal clonidine, Group B- intrathecal bupivacaine (0.5% heavy) 3ml (15mg) + 3 mcg/Kg of intravenous clonidine over 10min, Group C – (control group) - intrathecal bupivacaine (0.5% heavy) 3ml (15mg) + 0.5ml of normal saline, intrathecally in L3-L4 interspace with a 25G Quinke’s needle. Intraoperatively the parameters noted were; Sensory characteristics- Time of onset of analgesia (T10), Maximum level of analgesia achieved, Time taken for maximum level of analgesia, Time for sensory block to regress to T10, Total duration of analgesia(rescue analgesic on patient demand). Motor characteristics- Time of onset of motor blockade (grade 1 bromage), Maximum grade of motor blockage achieved, Total duration of motor blockade (regression to Bromage-I), Hemodynamic monitoring, Sedation levels (OAA/Sscale) and Shivering episodes. Statistical software: The Statistical software namely SAS 9.2, SPSS 15.0, Stata 10.1, MedCalc 9.0.1, Systat 12.0 and R environment ver.2.11.1 were used for the analysis of the data and Microsoft word and Excel have been used to generate graphs, tables. Results: Intravenous clonidine after bupivacaine spinal anaesthesia has characterstics similar to and comparable with intrathecal clonidine with bupivacaine with an added advantage of significant. Intraoperative and post-operative sedation, Protection against postoperative shivering and Beneficial in prolonged surgeries.

Page No. 568-571

Authors: Prashant Raosaheb Ginimuge.

Background: Many techniques of pre-oxygenation have been proposed and followed world-wide. 3–5 minutes of tidal volume pre-oxygenation is the most preferred technique of choice for pre-oxygenation. This technique may not be feasible in emergency situations. Hence this study was conducted to evaluate the efficacy and utility of four vital capacity breath pre-oxygenation technique, as its less time consuming. Methods: Fifty American Society of Anesthesiologists grade I and II patients in the age group of 20–40 years were studied under two groups of 25 each. Group I did not receive any pre-oxygenation and group II received pre-oxygenation in the form of four vital capacity breaths in 30 seconds. Rescue breaths with 100% oxygen were administered to all those patients whose oxygen saturation dropped below 75%. Results: It was observed that after one minute of post induction apnea, patients in group I had a reduction in oxygen saturation to a mean of 79.92±3.328%, in comparison to 87.24±2.368% in group II. It was also observed that vital parameters at the end of 1 min of apnea were close to baseline values in group II. The results were analysed using the "Analysis of Variance" (ANOVA) method. Conclusions: Pre-oxygenation with four vital capacity breaths does prolong the onset of desaturation and thus can be useful in emergency situations where time is precious.

Page No. 576-582

Authors: Priti M. Patel, Rakesh D. Panchal, Bipin M. Patel

Background: Pre-incisional analgesia has been shown to be more effective in control of postoperative pain by protecting central nervous system from deleterious effects of noxious stimulus and resulting allodynia and increased pain. Anti-hyperalgesic and antiallodynic properties of pregabalin improve postoperative pain by preventing the development of central sensitization. This study was designed to compare the efficacy of two different doses of Pregabalin with that of placebo in reducing post-operative pain, analgesic requirement, prolongation of analgesia and side effects. Method: Ninety female patients of ASA grade Ι & ΙΙ undergoing gynaecological surgeries were randomly divided in three groups of thirty each. Patients received Pregabalin 150 mg (P1), Pregabalin 300 mg (P2) and placebo (P0) one hour before surgery. Post-operatively parameters observed were visual analogue score (VAS) and sedation score, time to first analgesic requirement, total analgesic consumption and side effects for first 24 hours. Result: VAS score were lower in the Pregabalin group as compared to placebo group. Sedation score was highest with Pregabalin 300 mg as compared to other two groups. Time to first rescue analgesia was 6.97±1.351 hours in group P1, 8.47±1.408 hours in group P2 as compared to 3.1±1.604 in placebo group. Mean number of total doses of rescue analgesics in first 24 was 1.67±0.711 hours in group P1, 1.2±0.407 in group P2 as compared to 2.97±0.668 in group P0. Side effects like visual disturbance and dizziness were higher in group P2 as compared to other two groups. Conclusion: Pre-emptive pregabalin provide batter analgesia post operatively than placebo group. While 300mg pregabalin produces longer analgesia and require less number of doses of rescue analgesics than 150 mg Pregabalin, this dose produces more side effects like dizziness, sedation, visual disturbance and headache post operatively.

Page No. 588-592

Authors: Sangeetha Balakrishnan, Kevin Koshy Jacob

Background: It is recommended to maintain endotracheal tube cuff pressure within a range of 20 to 30 cm H2O to prevent complications. Objective: To assess the ability of experienced anesthesiologists to inflate endotracheal tube cuffs to optimal range of cuff pressure by subjective assessment alone. Methodology: An observational study was conducted to assess the ability of experienced anesthesiologists to inflate endotracheal tube cuffs to optimal range of cuff pressure by subjective assessment alone. 150 adult patients of either sex posted for elective surgeries were intubated and cuffs were inflated guided by subjective assessment alone. The pressure in these cuffs were then measured using a cuff pressure manometer and recorded. Statistical analysis was done using SSPS 18 (trial version). The primary outcome studied was the distribution of cuff pressures whether it was within or out of normal range (20 to 30 cmH2O). The relation of cuff pressure with age, sex, height, weight and nutritional status was looked for using Chi-square, Fischer Exact and Correlation tests. Results: The anesthesiologists were able to inflate the cuff to an optimal cuff pressure only in 64% of cases. The cuff pressures were recorded as low in 17.3% while in 18.7% of cases the cuff pressure reached above the optimal range. No relation was established between cuff pressure and age, gender, height, weight or nutritional status. Conclusions: Even experienced anesthesiologists are not able to inflate the endotracheal tube cuff up to optimal cuff pressure by using subjective assessment alone in all cases.

Page No. 599-603

Authors: Senthil Marappan, Prabhu Thilaak, Aparna Sukumaran, Sabapathy Vadugapalayampudur Appavoo, Shankar Ra

Background: An ideal intravenous anaesthetic agent to be considered for day-care surgery should provide rapid recovery with very less side effects and available at a reasonable cost. Both ketamine & propofol has all these characteristics but however cause significantly opposing hemodynamic effects which can be detrimental in patients with high risk, if used as sole induction agent. Aim: To assess and compare the efficacy of three different proportions of intravenous propofol-ketamine combination in minor gynaecological procedures. Materials and methods: A prospective comparative study was done on 120 patients at Vinayaka Missions Medical College Hospital by the anaesthesia department among the females who had been posted for minor gynaecological procedures. The study subjects were classified into 3 groups of 40 each. The anaesthetic drug administered for each group is as follows Group I – Propofol 1.5mg/kg + Ketamine 0.5mg/kg; Group II - Propofol 1.5mg/kg + Ketamine 1.0mg/kg and Group III - Propofol 1.5mg/kg + Ketamine 1.5mg/kg. The vital parameters were measured immediately(1 min.) after the drug (Propofol-Ketamine combination) administration and then after every 5 minutes upto half an hour. Adequacy of depth of anesthesia will be analysed by using EVANs(1987) scoring system. Requirement of airway intervention by means of bag and mask ventilation were recorded. Untoward events like vomiting or emergence phenomena during recovery were carefully watched and recorded. Results: The systolic BP and the mean heart rate was much lower in group 1 and it was highest among group 3. The mean time of maintaining the adequate depth of anaesthesia without giving supplement dosage, which was assessed by using EVANS scoring had shown that among the group I patients it was much lower when compared with group II and III and the difference was found to be statistically significant (P<.05). The air way intervention in the form of bag and mask ventilation was required by 82.7% of the patients in group III when compared to 7.5% in group I and the difference was found to be statistically significant. The recovery from anaesthesia by taking into consideration of the supplemental dose, was found to be very high in group III patients than that of group I and II and the difference was found to be statistically significant. Conclusion: Of the three different doses of ketamine with a fixed dose of propofol (1.5mg/kg), ketamine 1mg/kg was found to be a better dose when compared to 0.5mg/kg and 1.5mg/kg for day care gynaecological procedures.

Page No. 607-610

Authors: Soumya Samal, Shaswat Kumar Pattnaik, Ankita Mohta, Saubhagya Kumar Jena

Introduction: Postoperative analgesia is very essential for the postpartum women as it enables faster rehabilitation and initiation of breastfeeding. Spinal anaesthesia is most commonly used anaesthetic technique. So, we tried to compare the efficacy of dexmedetomidine and morphine as adjuvant to bupivacaine in lower segment caesarean section. Methods: This prospective comparative study was conducted on sixty parturients of ASA grade I and II scheduled for elective lower segment caesarean section under spinal anaesthesia. Cases were randomly divide into two groups: Group D received 12.5 mg of 0.5% hyperbaric bupivacaine with 5 µgdexmedetomidine and Group M received 12.5 mg of 0.5% hyperbaric bupivacaine with 125 µg morphine. Parameters recorded were the duration of time to achieve T8 sensory blockade, the time to S1 level sensory regression, the time of motor regression to Bromage 0, the time to first rescue analgesia and incidence of side effects. Results: The mean time of sensory block to reach T8 dermatome was significantly faster in group D (p=0.00004). The mean time of sensory regression to S1 and motor regression to reach modified Bromage 0 was significantly longer in group D (p<0.05). Both 1 & 5 min APGAR were similar in both the groups. Although the time to first rescue analgesia was longer in group D, it was statistically not significant. Side effects were more in group M.

Page No. 616-620

Authors: Sunder Paneerselvam, MN Nandakumar

Background: The laryngeal mask airway is a popular supraglottic airway device, with intravenous propofol being the agent of choice for its insertion. Sevoflurane is a volatile anaesthetic agent, which combines rapid, smooth inhalational induction of anaesthesia with rapid recovery, making it ideal for day care anaesthesia. Objective: To compare conditions for LMA insertion following induction with intravenous propofol and inhalational induction with sevoflurane (viz., jaw opening, ease of insertion, coughing, gagging, laryngospasm and patient movement) and number of attempts for insertion of Laryngeal Mask Airway. Study design: A randomized single blinded clinical trial. Methods: After obtaining the institutional ethical committee approval, fifty adults patients were allocated randomly into two groups of 25 each; group P (Propofol group) and group S (Sevoflurane group). Patients in group P were induced with 2.5 mg/kg intravenous Propofol. In group S, after priming the Bain’s circuit with Sevoflurane 8% in 50% N2O and O2 (flow rate – 8 litre/minute) for 30 seconds, patients were asked to take vital capacity breaths via the face mask connected to primed circuit. The LMA insertion was attempted afterloss of eyelash reflex and assessing the jaw relaxation. Scoring system was used to grade the conditions for the LMA insertion. Results: The mean time required for induction with propofol was 34.08 secs and with sevoflurane it was 46.96 secs. The mean time required for LMA insertion with propofol was 63.04±3.75ssecs and in sevoflurane group it was 87.48±15.14ssecs. In both the groups excellent conditions for LMA insertion were obtained. Complications while inserting LMA were not significant in both the groups. Conclusion: The observation of this study shows that propofol produces a much faster induction and good jaw relaxation for insertion of LMA than induction with sevoflurane. The insertional characteristics like coughing, gagging, laryngospasm, ease of insertion, patient movements and haemodynamic stability are comparable between the two groups. Prolonged time to jaw relaxation with Sevoflurane when compared to Propofol may delay laryngeal mask airway insertion.

Page No. 626-630

Authors: Radha Korumbil Raghavan, Ushakumary Reghunathan, Bindu Meleveethil, Anis Jassir Meleveettil

Background and Aims: Postoperative analgesia after intrathecal bupivacaine is limited to a few hours. The aim of this study was to assess the effects of intrathecal Neostigmine added to hyperbaric bupivacaine on the onset and duration of spinal anaesthesia and in prolonging postoperative analgesia. Methods: A prospective, randomized double blind study was conducted in 90 patients of ASA grades I and II, in three groups of 30 each, scheduled for lower limb surgeries under subarachnoid block. Patients in Group 1 received 0.5% hyperbaric Bupivacaine 2.5ml (12.5mg) + 0.1ml of sterile normal saline, Group 2 received 0.5% hyperbaric Bupivacaine 2.5ml (12.5mg) + 0.05ml Neostigmine (25mg) + 0.05 ml sterile normal saline and Group 3 received 0.5% hyperbaric Bupivacaine 2.5ml + 0.1ml Neostigmine (50mg). The onset and duration of sensory and motor block, time of two segment regression of sensory block, postoperative analgesia and side effects were studied. Results: The mean onset time of sensory and motor block were comparable in the three groups. The sensory and motor block were prolonged by the addition of Neostigmine, of which adding 50mg Neostigmine was found to be statistically significant (p value <0.001). The visual analog scale (VAS) scores were significantly lower compared to control group upto 4 hours postoperatively in the 50mg Neostigmine group. Conclusions: 50mg Neostigmine is needed to produce significant prolongation of analgesia without significantly increasing the adverse effects, and it reduces the VAS score and analgesic consumption postoperatively.

Page No. 635-639

Authors: Neha Sharma, Nandita Mehta, Shikha Sharma

Background: Transversus Abdomin is Plane (TAP) Block is a regional analgesic technique. It provides analgesia after abdominal surgery particularly where parietal wall pain forms major component of pain. It allows sensory blockade of abdominal wall skin and muscles via local anaesthetic deposition above Transversus Abdominis muscle(TAM). We evaluated efficacy of Bupivacaine and Ropivacaine in Ultrasound guided TAP Block for post-operative analgesia in abdominal surgeries like hernia repair, open cholecystectomy in a hospital based, double blind, prospective, randomized clinical trial. Method: 60 adult patients undergoing elective abdominal surgery under general anaesthesia were included in this study and were randomly divided into two groups according to computer generated table of randomization. After induction of anaesthesia, TAP Block unilateral or bilateral(depending upon nature of incision of surgery) was performed using 15 ml of 0.5% Ropivacaine or 0.25% Bupivacaine each side. Each patient was assessed intra-operatively for haemodynamic parameters like HR, SBP, DBP, MBP and SPO2 at 0, 5, 10, 20 minutes (m) and then after every 10m till the end of surgery. Post-operatively patients were assessed for pain with VAS score at 0m, 30 m, 4, 8, 12, 18 and 24 hours (h) by a blinded investigator. Results: Intra-operatively haemodynamic parameters remained stable and comparable in both the groups. Mean duration of analgesia in Ropivacaine group and Bupivacaine group was 12.61±5.13hrs and 9.92±4.81h respectively, the difference was found to be statistically significant. Conclusion: 0.5% Ropivacaine provided longer duration of analgesia than 0.25% Bupivacaine when used in Ultrasound guided TAP Block on patients undergoing abdominal surgeries. TAP Block via lumbar approach using Ultrasonography provides better pain relief especially in lower abdominal surgeries as compared to upper abdominal surgeries. There were no complications attributable to TAP Block or drugs under study.