Indian Journal of Clinical Anaesthesia

287-290

Authors: Vasantha Kumar KR, Aditi Prabhu, Bhavya P, Tasneem Kauser, Karna Venkata Siva

Introduction: Interscalene brachial plexus block is one of the commonly performed techniques for upper limb regional anaesthesia which can be performed by paraesthesia, nerve stimulator, or ultrasound guided technique. The present study compares ultrasound and electrical nerve stimulator guided techniques in terms of their efficacy and safety when used for administering interscalene brachial plexus blocks. Materials and Method: 60 patients belonging to ASA physical status I or II, aged between 18 to 65 years, undergoing elective clavicle surgeries were randomized into two groups of 30 each. They received an interscalene brachial plexus block with 25ml of 0.75% ropivacaine + 1.5ml (75mcg) of fentanyl, with either nerve stimulator (group N) or ultrasound guidance (group U). The time taken to complete the block, onset of sensory and motor block and the number of inadvertent vascular punctures were noted. Post block haemodynamic parameters and adverse events were also noted. The observations were statistically analyzed using the student’s t test and chi square test. P value of less than 0.05 was considered statistically significant. Results: The procedural time in group U (5.93+1.11min) was significantly shorter when compared to that in group N (10.46+2.81min) (p=0.0001). The onset of sensory and motor blocks was similar in both the groups with a P value of 0.91 and 0.89 respectively. Accidental aspiration of blood was seen in 1 patient in Group N (3.33%) but not in Group U. The haemodynamic parameters were in the normal range and there were no adverse events in either group. Conclusion: Though the block onset times are similar with both ultrasound guidance and nerve stimulator, the use of ultrasound is advocated as it has a better utility (shorter procedural time) and safety profile.

298-303

Authors: Selvakumar Rajasekaran, Suresh Murugaiah, Asha Anandan, Ayshvarya Ramalingam.

Introduction: Levobupivacaine is less cardio toxic and has a longer duration of analgesia compared to bupivacaine. There are limited studies comparing the effects of addition of fentanyl with levobupivacaine. To compare the characteristics of sensory and motor blockade, associated haemodynamic changes and side effects following intrathecal levobupivacaine and levobupivacaine with fentanyl in patients undergoing elective caesarean section. Materials and Method: A prospective, double blind, randomised control study. 80 patients belonging to age group 18 to 35 years, ASA I & II posted for elective LSCS in a tertiary care centre were randomly allocated into two groups, Group L (n=40) received injection levobupivacaine 0.5%, Group LF (n=40) received 0.5% levobupivacaine with 15 mcg fentanyl. Intra-operative and post-operative haemodynamic parameters, sensory and motor block characteristics along with incidence of side effects in the two groups were noted. The observed data’s were analysed by SPSS version 21.0 software. Result: The haemodynamic parameters were comparable in both the groups. The mean onset time of sensory block in group L was 4.38±.490 mins and 2.28±.452 mins in group LF. Effective analgesia period is longer in group LF with a mean value of 179.90±6.953 mins, when compared to 132.70±8.058 mins in Group L. The mean onset time for motor block was 5.75±0.840 mins in group L while in group LF it was 2.70±0.464. Complete reversal of motor blockade occurred in 152.75 minutes in group L while it took 116.33 minutes in group LF. APGAR scores were comparable in both the groups. The incidence of nausea and vomiting was found to be 20% in Group LF and only 7.5% in Group L. 15% of patients among group LF complained of pruritus while there was no incidence of pruritus among patients in group L. Conclusion: Addition of intrathecal fentanyl 15µg to 10 mg of 0.5% levobupivacaine in caesarean section shortens the onset of sensory and motor block, prolongs the duration of postoperative analgesia with rapid motor recovery with increased incidence of pruritus, nausea and vomiting.

310-315

Authors: NV Madhavakrishna, A. Niranjan Kumar, S. Mahalakshmi, VJ Karthik.

Introduction: We evaluated the efficacy of inj.Metoprolol 50 µgms/kg. i.v. given 5 minutes before induction of anesthesia in attenuating the hemodynamic response to intubation and CO2 pneumoperitoneum. Materials and Method: We conducted a randomized double-blind controlled study on 60 patients. Five minutes before induction of anesthesia, either inj. Metoprolol 50µgm/kg diluted to 10 ml or 10ml normal saline given intravenously. Heart Rate(HR) and MAP recorded at basal, one, five minutes after Intubation, 15 minutes after establishing pneumoperitoneum, before and after extubation were analyzed with Descriptive statistics. Results: In Both the groups no significant increase was observed in HR at 1 minute and 5 minutes after intubation compared to the basal HR. But the MAP at 1 and 5 minutes after intubation increased significantly in control group, whereas no significant increase occurred in Metoprolol group. HR and MAP recorded at 15 minutes after pneumoperitoneum showed significant increase from both basal and pre pneumoperitoneum values in control group but no significant increase was observed in Metoprolol group. During Extubation also no significant increase in HR and MAP observed in Metoprolol group compared to pre extubation values whereas Control group showed significant increase in HR and MAP after extubation compared to pre extubation values. Conclusion: Intravenous Metoprolol 50 µgms/kg. i.v. given 5 minutes before induction of anesthesia reduces adverse hemodynamic changes during intubation and pneumoperitoneum during laparoscopic surgeries. There are no significant adverse effects during surgery or 8 hours post operatively.

320-323

Authors: K. Senthil Kumar, J. Suresh, T. Murugan.

Introduction: Various techniques and drugs have been adopted to prolong postoperative analgesia. Epidural steroids have been used successfully for long time for chronic pain syndrome. The safety of epidural steroids is well established. Based on the above evidences and concepts we used dexamethasone and opiod as adjuvant to local anesthetic agent in our study. Aim and Objective: To compare the efficacy of epidural dexamethasone versus fentanyl on post operative analgesia. Materials and Method: After getting Ethical committee approval and written informed consent the study was conducted in 60adult male patients aged between 25 –45 years belonging to ASA Physical status I and II undergoing elective hernioplasty under epidural anesthesia were randomly allocated into one of the three groups (20 patients per group) by lotting method. Method of blinding: Patients and the person performing the epidural technique was unaware of the epidural drug composition. The drug solution was prepared by an anaesthesiologist assistant in the operating room and was labelled accordingly. Study period: From onset of epidural blockade to onset of postoperative pain with VAS > 5. Group 1: Patients receiving 11 cc of 0.5% bupivacaine plus normal saline 1 cc epidurally. Group 2: Patients receiving 11 cc of 0.5% bupivacaine plus 50 µg fentanyl epidurally. Group 3: Patients receiving 11 cc of 0.5% bupivacaine plus 4 mg preservative free dexamethasone epidurally. All patients received a total volume of 15 ml of study drug including 3 ml of test dose plus 1 ml of adjuvant. All patients were monitored for 24hrs postoperative period for complications, hemodynamics and pain. Results: Group 2 patients with fentanyl as adjuvants showed early onset of anesthesia 5.075 min when compared with their two groups(group 1 -5.3min and group 3 6.252 min) v but group 3 patients with dexamethasone showed prolonged duration 373 min(group 1 -256.05 min and group2- 347.25min). Conclusion: We conclude that epidural dexamethasone resulted in prolonged postoperative analgesia without any side effects like nausea, vomiting, pruritus, sedation except hypotension in few patients. Dexamethasone can be used as adjuvant in single dose epidural techniques with adequate monitoring.

329-332

Authors: Narendra Rathore, Lalit Raigar, Arvind K. Shukla, Abhay K. Jain, Vikram Raj Purohit.

Purpose: To know the complications of conscious sedation in cervical cancer patients treated with cobalt (CO60) based Intracavitary brachytherapy (ICRT) and to assess pain on visual analogue scale (VAS). Materials and Method: Cobalt intracavitary brachytherapy application was performed with conscious sedation in 40 carcinoma cervix patients and post-procedural pain was assessed with VAS at every 30 minutes interval for six hours along with other complications. Result: Pain was well controlled (mean VAS 4.5) in all patients with maximum VAS 10 and tramodol was received as rescue analgesic. Common complication was grade 1 & 2 bradycardia in 8 patients; and grade 1 hypertension in 6 applications; no patients found Gr 3 or 4 hypertension, Hypotension in 11 Patients (Gr1 in 7). Conclusions: Conscious sedation is a fast and safe option to perform intracavitary brachytherapy applications (Cobalt 60) in the patients of cervix cancer.

338-344

Authors: Prabhavathi R, G. Anand ISAAC, P. Narasimha Reddy, P. Umanageshwarah.

Intrathecal anesthesia is used commonly for surgical procedures and local anesthetics are associated with relatively short duration of action. A number of adjuvants have been used to prolong the postoperative analgesia. Objectives: This study is to investigate the effects of intrathecal Magnesium sulfate 100 mg, added to hyperbaric Bupivacaine 0.5% on the Spread, duration, regression of spinal block, and duration of postoperative analgesia in patients undergoing lower limb surgeries. Materials and Method: Sixty selected patients were randomized to Group B (n=30) patients who received 0.5% heavy Bupivacaine 3ml (15 mg) + Normal saline 0.2 ml and Group M (n=30) patients who received 0.5% heavy Bupivacaine 3ml(15mg)+50%MgSO4 0.2 ml(100mg) intrathecally for lower limb surgeries. Block characteristics, hemodynamic changes and adverse effects were compared. Results: Efficacy of both the drugs when given intrathecally was studied. Mean time needed for sensory blockade at T10 was 3.3±0.7 min in group B and 4.33±0.9 min in group M and p value (<0.001). The mean of total duration of the sensory block in group B was 171.5±18.76 min while it was 218.5±22.52 min in group M (p value <0.001). Time taken for onset of motor block was 4.96±1.2 min in group B and 7.66±1.26 min in group M (p value <0.001). The mean of total duration of motor block in group B was152.5±11.87 mins while it was190.66±21.2 min in group M (p value <0.001). The total duration of effective analgesia in group B was 168.5±16.56 min and in group M was 225.76±24.81 min (p value <0.001). There was no clinical significance in occurrence of side effects in both the groups. Conclusion: Magnesium sulphate at a dose of 100mg added to 3ml of bupivacaine provided better and extended duration of sensory, motor blockade and total duration of effective analgesia for patients under intrathecal anaesthesia for lower limb surgeries with no sedation.

352-357

Authors: Shruthijayaram, Bhagyashree Amingad.

Introduction: Ropivacaine is the single enantiomer specific local anaesthetic having reduced potential for cardiotoxicity and neurotoxicity. Its characteristics of slow onset, shorter duration of sensory analgesia and rapid motor recovery will nesseciates for early analgesic intervention. Adding adjuvants to ropivacaine improves the efficacy of subarachnoid block. Drugs like dexmedetomidine, a highly selective alpha 2 adrenergic agonist and buprenorphine an opioid agonist and antagonist have been used as effective adjuvants. Aim: To evaluate and compare whether the small dose of adjuvants buprenorphine and dexmedetomidine added to isobaric spinal ropivacaine prolongs the duration of sensory and motor block as well as the duration of postoperative analgesia. The adverse effects and hemodynamic variable were also studied. Materials and Method: The study included 90 patients aged between 20-60 years belonging to either American Society of Anesthesiologists (ASA) Physical Status I/II scheduled for elective lower limb surgeries. The patients were randomly allotted to three groups. Group RS -received intrathecal 3ml of 0.75% ropivacaine with 0.5ml of normal saline. Group RB received 3ml of 0.75% ropivacaine with 60µg of buprenorphine. Group RD -received 3ml of 0.75% ropivacaine with 5µg of dexmedetomidine. The onset time to peak sensory level, onset of complete motor block (modified Bromage 3), duration of sensory and motor block, hemodynamic variables, and adverse effects if any were noted. Results: There was no difference between groups regarding demographic data and duration of surgery. Duration of sensory and motor block was significantly prolonged with Dexmeditomidine when compared with buprenorphine or saline (P<0.001). Dexmeditomidine delayed the time for first analgesic requirement postoperatively (P<0.001). No significant side effects were observed. Hemodynamic parameters were stable. Conclusion: Intrathecal dexmeditomidine as adjuvant to ropivacaine has shorter sensory onset time and is associated with prolonged duration of sensory and motor block and prolonged the time for first analgesic demand when compared with buprenorphine or plain ropivacaine with good hemodynamic stability and no significant side effects.

363-367

Authors: Sarala C. Baria, Venkatraman V, Kamla Mehta, Kirti Patel.

Introduction: Gas Man is a commercial product which allows anaesthesiologist to simulate and experiment with anaesthesia delivery systems. This type of virtual anaesthesia machine is an animated gas machine illustration on computer screen, which is modifiable when the user selects different gas flows, vapour concentration etc. Attaining and maintaining steady state of depth of anaesthesia is very essential during maintenance phase of anaesthesia which can be accomplished by monitoring the depth of anaesthesia. Aims: This study was conducted to evaluate two methods (Conventional and Simulated) of delivering inhalational anaesthetic agent (Sevoflurane) with the help of end tidal anaesthetic concentration and correlate it with BIS monitoring. Materials and Method: Sixty adults patients undergoing elective laparoscopic cholecystectomy were randomly distributed to two groups. Group - C: Low flow anaesthesia technique based on conventional dosing strategy (n=30) and Group -S: Low flow anaesthesia technique by utilizing dosing strategy developed by computer simulation studies using Gas Man software (n=30). The study was to compare two methods of anaesthesia delivery system during maintenance of anaesthesia and hence observations were made after 20 minutes of intubation. Results: In Group S, all the cases BIS value remained less than 60 and end tidal concentration of Sevoflurane was found >1.5 MAC. Conclusion: FGF and dial setting of Sevoflurane according to Gas Man software maintains the end tidal concentration of anaesthetic agents in the predicted therapeutic window without awareness during maintenance phase of anaesthesia.

375-381

Authors: Anurag Yadava, Chandan K. Jaiswal.

Introduction and Aims: The pain after major abdominal surgeries, if treated inadequately, may lead to increased postoperative morbidity and delayed recovery. The present study aims to compare continuous epidural infusion of ropivacaine-fentanyl with bupivacaine-fentanyl for postoperative analgesia in major abdominal surgeries. Materials and Method: This prospective, randomised, double blind study was conducted in 112 patients undergoing major abdominal surgeries. The patients were divided into two groups: each involving 56 patients. One group received 0.125% bupivacaine + 1µg/ml of fentanyl and the other received 0.2 % ropivacaine + 1 µg/ml of fentanyl. Both the infusions were started at a constant rate of 5 ml/h at the end of surgery. The Visual analogue scale (VAS) to assess pain, heart rate, systolic blood pressure, diastolic blood pressure, duration of surgery and anaesthesia, amount of crystalloids used and side effects were noted and compared at different time intervals. The data was analysed using SPSS 20.0 (trial version). Results: The mean of VAS pain score after 1,2,4,6,8,12 and 24 hours of surgery was less in RF group as compared to BF group and the total rescue analgesia consumption in 24 hours after surgery was 2.4 g (mean) in BF group and 1.3 g(mean) in RF group and the difference was statistically significant (P < 0.0001). There were no statistically significant differences in haemodynamic or physiologic variables when compared with both the groups. Conclusion: Analgesic potency and motor sparing effect of ropivacaine-fentanyl is better than bupivacaine-fentanyl at doses used in our study.

388-392

Authors: Kavita Udaykumar Adate, Kalyani Nilesh Patil, Adnan Qamar Ali Sarkar.

Introduction and Aims: Peripheral nerve block techniques have evolved over time with the advent of peripheral nerve stimulator and ultrasonography. We intend to compare these two techniques in this study with respect to their efficacy, reliability and safety. Materials and Method: Prospective, randomized, observer-blinded study was conducted on 60 ASA I-II patients posted for surgery of shoulder, clavicle or proximal humerus. They were randomly allocated in to two groups to receive either ultrasound guided (USG group) or peripheral nerve stimulator guided (PNS group) interscalene brachial plexus block with 20 ml of local anaesthetic solution (2% lignocaine with adrenaline 10ml + 0.5% bupivacaine 10 ml). We compared the procedure time, time for adequate sensory and motor block, duration of block, block failure rate, complications and patient satisfaction. Result: Ultrasound significantly reduces the time to conduct the block as compared to PNS. The onset of block was earlier and duration was significantly prolonged (p=0.0001) in USG group. The success rate was 100% and patient satisfaction was significantly better in USG group compared to PNS group. Conclusion: Ultrasound guided technique for interscalene brachial plexus block provides a block which is faster in onset, has prolonged duration, higher success rate and better patient satisfaction compared to PNS guided nerve block.

400-405

Authors: Pratibha SD, Vidya Patil, Basvaraj Patil, Vijaya Sorganvi.

Introduction and Aims: Supraglottic airway devices are safe and efficient in airway management. I-gelTM and ProsealTM laryngeal mask airway are supraglottic airway devices which are used to secure and maintain airway during anaesthesia with additional gastric channel. Aim of our study is to compare the efficacy of both the supraglottic airway devices, I-gel and Proseal LMA(PLMA) in patients under general anaesthesia with controlled ventilation. Materials and Method: A total of 126 patients of ASA Grade I and II who underwent short surgical procedures were included and were randomly allocated to I-gel or PLMA group. Patients were induced with standard doses of propofol airway was secured with either of the supraglottic airway devices. We compared ease, duration of insertion, insertion attempts, mean pulse rate, mean arterial pressure (MAP), ease of gastric tube insertion and adverse events. Data was compiled and analyzed statistically by Mann –Whitney U test and Student t- test, the means and Chi- square test was compared for categorical variables. Results: There was no significant change in demographic data and hemodynamics before premedication, after premedication, at induction and insertion in mean pulse rate and MAP. Mean time for insertion was significantly less in I-gel compared to PLMA. There was significant change in mean pulse rates and MAP in both groups at1, 3, 5, 10 and 15mins with mean pulse rate and MAP being higher in PLMA than I-gel. Gastric tube insertion was easier in I-gel group and sore throat was significant in PLMA. Conclusion: I-gel is a better supraglottic airway device with higher first attempt success rate, was easy to insert, had better hemodynamic stability, with less incidence of sore throat compared to PLMA for controlled ventilation.

412-415

Authors: Bhavna Kakkar, Nishtha Kachru, Mallika Boishya, Lalit Gupta.

Sepsis is a major cause of morbidity and mortality in pediatric age group, mainly because of hemodynamic compromise and multi-organ dysfunction. Septic patients have impaired tissue perfusion, threatening functions of vital organs and situation becomes more challenging if the child has concomitant pericardial and pleural effusions. Anesthesiologists are involved in preoperative resuscitation with judicious use of fluids, vasopressors and inotropes and timely administration of appropriate intravenous antibiotics. Perioperative management requires careful selection of induction and maintenance anesthesia agents, optimizing intravascular volume status, avoiding any lung injury during mechanical ventilation, monitoring investigations and post-operative management of patients in post- anesthesia care unit (PACU) or intensive care unit (ICU). We report successful management of a five year old boy with sepsis with moderate pericardial and pleural effusions for emergency hip joint aspiration and drainage, to the best of our knowledge there is no previously reported case in literature.