Indian Journal of Clinical Anaesthesia

Page No. 3-7

Authors: Sadhana Sudhir Kulkarni , Savani Sameer Futane

Postoperative delirium is a common but often a missed complication following major surgery in elderly patients. Early diagnosis, treatment with non-pharmacological means, and drug treatment reduces complications, so also hospitalization cost. Awareness about common precipitating factors, preventive measures, treatment & training of healthcare workers is essential regarding this problem as it can be prevented in about 40% patients.

Page No. 13-15

Authors: Amit Bhardwaj , Balwinder Singh , Arwinder Pal Singh

Objective: Comparison between thoracic epidural and general anesthesia for breast surgeries. Aim: The aim was to compare general anesthesia and thoracic epidural anesthesia in patients undergoing breast cancer surgeries on the basis of intra operative hemodynamic parameters, post-operative analgesic requirement and side effects such as nausea, vomiting, sedation and hemodynamic variability. Method: A randomized double blind study was conducted on 60 ASA grade I, II and III females who received thoracic epidural anesthesia in group I (N=30) and general anesthesia in group II (N=30). Assessment of the block, vital monitoring and complications were noted. Results: No significant differences were observed in both the groups. Hypotension and pruritus was more frequent in patients who underwent epidural anesthesia while hyper-tension was more common in patients with general anesthesia. Degree of patient satisfaction was similar in both the groups. Conclusion: Thoracic epidural anesthesia is safe and reliable alternative to general anesthesia in women undergoing modified radical breast surgeries.

Page No. 21-25

Authors: Ankur Gandhi, Kalpeshkumar Mistry

Background: Lumber plexus block is technically difficult but with availability of nerve locator, it is relatively easy and reliable technique of anaesthesia. This study was planned to compare lumber plexus block with spinal anaesthesia for postoperative analgesia Methods: After obtaining permission from institutional ethical committee total 50 patients of either sex with fracture neck femur belonging to physical status ASA group I to III; posted for routine orthopaedic surgery were selected randomly. Group I (SA) received spinal anaesthesia and Group II (LPB) received posterior lumbar plexus block. Time of onset and level of sensory and motor block were noted. Intraoperative vitals were noted at every 15 minute intervals. Patients were observed for 2 hrs at interval of 30 minutes for postoperative pain using visual analogue scale (VAS), vitals and for complications. Results: Time required for sensory blockade was more 17.32±2.61 in Group II as compared to 3.76±0.91 in Group I (p<0.05) and time required for motor blockade was higher in Group II (22.76±2.67) as compared to Group I (8.64±0.91) (p<0.05). Hypotension was observed in 15 patients in Group I as compared to 2 patients in Group II. VAS score at interval of 30 min was statistically significant in Group I (3.16±1.11) compared to Group II (1.5±0.51). Conclusion: LPB provides good sensory and motor block with feasibility to extend block, better haemodynamic stability with less side effects so it is a valuable option as compared to SA with supplementation of sedation in case of insufficient analgesia.

Page No. 30-36

Authors: Bidyut Borah, Mukesh I Shukla, Nirali K. Joshi, Parasmani

Introduction: The stress responses to laryngoscopy comprising of elevation in heart rate and rise in systolic and diastolic pressure are well known. The potential for life threatening complications associated with these responses is also well documented. Therefore, it has become very much necessary to discover a drug which can abolish this response. The present study is designed to study the effectiveness of dexmedetomidine (D), clonidine (C) and magnesium sulfate (M) in attenuating the hemodynamic response to laryngoscopy in patients undergoing surgeries. Methods: This study was carried out on 120 ASA grade I & II patients aged 18 to 55 years scheduled for elective surgical procedures under general anesthesia lasting for more than 2 hours. Patients were divided randomly into 3 groups, group D received 1mcg/kg of dexmedetomidine, group C received 1 mcg/kg of clonidine and group M received 30 mg/kg of magnesium sulfate. Data were entered in excel sheet and analysed by SPSS software. Qualitative data were expressed by number and percentage. Quantitative data were presented by mean +/- SD. Results: Comparison of three groups reveals that hemodynamic variables were similar within the groups at baseline and at 5min before intubation while there were significant difference between them starting from just after the intubation, 30 sec after intubation then 1 min, 2min, 3min, 4min, 5 min, 10min after intubation. Conclusions: Dexmedetomidine (1mcg/kg) in comparison to magnesium sulfate (30mg/kg) and clonidine (1 mcg/kg) is far more effective in blunting the hemodynamic response to laryngoscopy.

Page No. 41-45

Authors: Kaushal Kabir, Gaurav Acharya, Manish Banjare, KK Arora, Sachin Kumbhare

Context: Etomidate is having more stable cardiovascular response as compared to propofol during laryngoscopy and intubation. Aims: The present study compares the effect of propofol and etomidate on cardiovascular response to laryngoscopy and intubation. Settings and Design: This prospective comparative study was conducted at a tertiary care hospital in central India. Methods and Material: Hundred healthy patients of both sex aged between 18 to 45 years, ASA physical status I & II, scheduled for elective surgery under general anaesthesia were selected. Patients in group P (n=48) were induced with propofol 2.5 mg/kg i.v. and group E (n=47) were induced with etomidate 0.3 mg/kg i.v. Patients’ haemodynamic and cardiovascular parameters were recorded before induction (T1), before intubation (T2) and 1, 3, 5 and 10 minutes afterwards. The haemodynamic parameters before induction i.e. T1 was taken as baseline. Statistical analysis used: The data was collected using Microsoft Excel software and was analysed using SPSS software version17.0. Results: There was significant difference regarding systolic blood pressure, diastolic blood pressure and mean arterial pressure among two groups. Hypotension was seen in 18.8% patients in group P after induction while there was none in group E. Conclusions: Etomidate is having more stable cardiovascular response as compared to propofol during laryngoscopy and intubation.

Page No. 51-55

Authors: Kalpeshkumar Mistry, Ankur Gandhi

Background: Intrathecal opioids are synergistic with local anaesthetics and intensify the sensory block without increasing the motor block and offer haemodynamic stability. This study was planned to compare the effects of low doses and high dose bupivacaine along with fentanyl citrate. Methods: This study was carried out in patients presenting for short surface surgical procedures below umbilicus from physical state ASA grade I and II. 60 Patients were randomly allocated in to Group BF 5 [Inj. Bupivacaine Hydrochloride 5 mg + Inj. Fentanyl citrate 25 μg] and Group BF 7.5 [Inj. Bupivacaine Hydrochloride 7.5 mg + Inj. Fentanyl citrate 25 μg] of 30 each. Sensory and motor block were assessed. Patients were observed for both intraoperative and postoperative complications. Results: Mean levels of sensory blockade to pinprick were T10 in group BF5 and T8 in group BF7.5. Total duration of sensory blockade (175.3+14.56 min) and motor blockade (129.5+19.09 min) were significantly higher in group BF7.5. Hypotension was seen in 7 patients of BF7.5 as compared to just 2 patients in group BF5. None of the patients from either group had bradycardia and respiratory depression. Incidences of shivering, pruritus and headache were similar in both groups. Conclusion: Both doses of bupivacaine hydrochloride 5 mg and 7.5 mg with fentanyl citrate 25 μg intrathecally provide successful anaesthesia below T10 spinal segment. However, 7.5 mg dose is associated with denser block, increased incidence of hypotension, delay in achieving highest sensory blockade and delayed recovery which delayed ambulation and discharge time following short surgical procedures.

Page No. 64-68

Authors: Kalyani Nilesh Patil, Kavita Udaykumar Adate, Shalini Pravin Saredesai

Context: Alpha-2 agonists improve the block characteristics in regional anesthesia, when added to local anesthetics. Aim: To evaluate and compare efficacy of dexmedetomidine and clonidine, as an intravenous adjuvant to intrathecal bupivacaine. Settings and Design: Prospective, randomized, double-blind placebo-controlled study. Methods and Material: 75 patients of American Society of Anaesthesiologists status I or II, scheduled for orthopaedic lower limb surgery under spinal anaesthesia, were randomly allocated into three groups of 25 each. Patients in group D received dexmedetomidine 1μg/kg; group C received clonidine 2μg/kg and group PL received physiological saline, each premixed to 20 ml intravenously over 20 min, starting 20 min after the subarachnoid block with 15 mg of 0.5% hyperbaric bupivacaine. Duration of sensory and motor blockade, postoperative analgesia, sedation scores and side effects were recorded. Statistical analysis used: Parametric testing done using one-way analysis of variance (ANOVA), intergroup comparison with post-hoc analysis Tukey’s test. Categorical data analyzed using Chi-square test. P< 0.05 was statistically significant. Results: Duration of sensory block was significantly prolonged by dexmedetomidine (231.20+24.84 min) and clonidine (200+23.67 min) than placebo (171+12.25 min) (p<0.001). Duration of motor block was 135.20+12.87 min with placebo, 180.40+24.70 min with clonidine and 205.20+25.56 min with dexmedetomidine (p<0.001). Postoperative analgesia was significantly prolonged by dexmedetomidine (255+23.14 min) than by clonidine (221.40+ 24.30 min) and placebo (202.60+14.08 min) (p<0.001). The mean sedation score was significantly higher in dexmedetomidine group. Conclusion: Single-dose intravenous dexmedetomidine and clonidine given after spinal anaesthesia prolong duration of sensory and motor block and postoperative analgesia.

Page No. 74-79

Authors: Shetty Guruprasad, Bhat Manjunath Timmappa, Torgal SV

Background: In spite of repeated use of oxytocin, the minimum effective dose oxytocin is not clear. Oxytocin when administered in excess dose may cause unwanted cardiovascular effects like tachycardia and hypotension and when the dose is inadequate it can result in uterine atony and increased uterine bleeding. We compared three different regimes of oxytocin in patients undergoing elective caesarean delivery, to compare haemodynamic changes and uterine contraction. Methods: Ninety patients undergoing elective caesarean delivery were administered an i.v bolus of either 3U or 5U and without bolus of oxytocin after delivery, followed by an oxytocin infusion of 20 U/h. Spinal anaesthesia was administered to all patients and with MAP more than 60 mmHg received respective oxytocin doses. We compared changes in MAP, heart rate, uterine tone, blood loss, the need for additional uterotonic and antiemetic drugs. Results: In our study maximum hypotension was in 5U oxytocin bolus with infusion group i.e. twenty three patients (76%) when compared with three patients (10%) in 3U bolus with infusion group and five patients (16%) in only infusion group. The pulse rate was increased to a greater extent in 5U bolus group than 3U and without bolus groups. Uterine tone was very good in patients who received 5U, good in 3U and inadequate to adequate in without bolus. Eleven patients (37%) in 20U infusion group were required additional uterotonic drugs when compared to two patients (7%) in 5U and 3U with infusion groups. The antiemetics used were highest after 5U (63%) than 3U (10%) and without bolus (3%). Conclusion: Lower dose of oxytocin bolus is better than higher bolus dose and without bolus dose based on the oxytocin effect on haemodynamic changes and uterine contraction.

Page No. 84-87

Authors: Prachi Kar, Shibani Padhy, R. Gopinath

Background and Aims: The risk of blood loss in lung surgeries is significant and depends on the nature of surgery. The literature on the pattern of intraoperative requirement of blood transfusion in various types of lung surgeries is scarce. In the absence of clear evidence, often inappropriate amount of blood is cross matched, ordered and transfused. Excessive cross matching of blood can increase the burden on the blood bank. The aim of the study was to analyze the blood transfusion practice in patients undergoing major lung surgery at our center and propose a maximum blood ordering schedule (MSBOS) for optimizing blood ordering. Methods: Retrospective review of electronic database of medical records and anesthesia charts was done for patients who underwent thoracotomy and major lung surgery between July 2014 and June 2016. All the patients were studied under 5 surgical categories. Upper lobectomy, lower lobectomy, pneumonectomy, decortication and others (Hydatid cyst excision/lung abscess drainage/ Bullectomy/wedge resection). Under each category amount of blood cross matched and transfused intraoperatively were noted. Cross match to transfusion ratio(C: T ratio), Transfusion probability (T%), and Transfusion Index(TI) were calculated and Maximum surgical blood ordering schedule (MSBOS) was proposed in each surgical category. Results: A total of 229 patients with mean age of 40 years were studied. Four hundred seventy eight units of blood were cross matched and 162 units were transfused in 90 patients. C:T ratio, TI and T% were 2.95, 0.7 and 39% respectively in the total cohort. All the three indices showed significant usage of blood in upper lobectomy and pneumonectomy group whereas all the indices showed low requirement of blood in patients undergoing decortication, Bullectomy, hydatid cyst excision, lung abscess drainage and wedge resection. MSBOS suggested crossmatch and reserve of 2 blood units for upper lobectomy and pneumonectomy, and 1unit for lower lobectomy. Decortication, Bullectomy, hydatid cyst excision, lung abscess drainage and wedge resection were suitable for Type and Screen (T&S) Conclusion: Blood ordering based on surgical category can provide a rational and efficient way of blood ordering and management of resources in patients undergoing lung surgeries.

Page No. 94-98

Authors: Jayesh Shakeet, Rakhi Bansal, Mridul Janweja, Sarita Janweja

Background: Oxytocin is considered the drug of choice for managing post-partum hemorrhage resulting from uterine atony, but optimum regimen of oxytocin is yet to be uncovered. Here our primary aim was to compare the uterotonic effects (uterine tone, use of rescue drugs, and intra-operative blood loss) of three low dose different regimens of oxytocin. Methods and Material: It was a double blind randomized control trial conducted in tertiary care teaching hospital. One hundred and twenty primi/second gravida mothers, age group 18-40 years, ASA grade II and height between 1.52 to 1.72 meters, scheduled to undergo elective caesarean section under spinal anesthesia were randomized in to three groups based on oxytocin regimen administered; group A- 3 IU bolus plus 5 IU infusion, group B- 3 IU bolus and group C -5 IU infusion. Fishers exact test was used to compare the proportion between the groups and quantitative data were compared by using Kruskal-Wallis test. Results: At 2 minutes the percentage of subjects having adequate uterine tone (uterine tone score ≥3) was higher in group A (95%) and B (90%) in comparison to group C (70%) (Fisher exact test, p=0.006). Overall median uterine tone score remained low in group C in comparison to group A and B. Frequency of use of additional uterotonic drugs was equivalent (Fisher exact test, p-0.09) in all the groups but blood loss in group B and C was higher in comparison to group A (P<0.001). Hemodynamic derangements and drug side effects were again proportionate in all the groups (P>0.05). Conclusions: Bolus plus continuous infusion (3IU plus 5IU) of oxytocin is better uterotonic than either infusion or bolus alone.

Page No. 103-105

Authors: Savita Choudhary, Alka Kewalramani (Chhabra), Pooja Gandhi

Background: Increase use of laryngeal masks like I-gel in recent years is growing because of its single use, non-inflatable and other advantages. Methods: This prospective observational study was conducted in female patients who came for laparoscopic surgeries in IVF unit of a tertiary care teaching institute during study period of 6 months in whom I-gel supraglottic airway device was used. Age, weight, type of surgery, I-gel size, number of insertion attempts ease of insertion, oropharyngeal leak pressure were recored. Any complications occurring during insertion and adverse events in post-operative period were noted. Results: A total of sixty women were included with in a study period of six month. Mean age of the patients were 30.55 years. Duration of anaesthesia ranged from 25 to 50 min. Most of the surgeries (60%) were performed as diagnostic laparoscopy. The overall insertion success rate was 96.67%. Size 3 was used comfortably in every case and it was judged as easy in every case. Mean insertion time of I-gel was 6.5 seconds (range 4-8 seconds). Oropharyngeal leak pressure was 26 cm of water (range 23- 40). No complication or adverse event was noted during peri and post-operative period. Conclusion: I-gel is a simple, reliable, fast, effective and easy to use supraglottic airway device with high leak pressure and without significant complications in patients requiring shorter duration surgery like gynaecological laparoscopic surgeries.

Page No. 112-117

Authors: Placid Siroraj, Sunder Panneerselvam, CR Saravannan

Background: Assessment of intravascular volume status is an essential parameter for the diagnosis and management of critically-ill patients. In order to assess the intravascular volume status noninvasively, we conducted a study to to find the correlation, if any, between sonographic IVC collapsibility index and Central Venous Pressure to assess the volume status in ICU patients. Methods: The Institutional Ethics Committee approval was obtained. 60 spontaneously breathing post-operative patients with a functioning central venous catheter were recruited for this study. The distal port of the catheter was connected to a pressure transducer and the pressure displayed on the monitor in mmHg was noted. Simultaneously the IVC diameters during end inspiration and end expiration were measured in the longitudinal and transverse orientations using the M-mode of the ultrasound machine. The Collapsibility Index was calculated from the IVC diameters. Collapsibility Index? 50% suggested hypovolemia and Collapsibility Index <50% suggested euvolemia or hypervolemia. This was compared with the measured Central Venous Pressure to find the correlation between the two. Additionally the change in IVC diameter with Central Venous Pressure was observed. The IVC Collapsibility Index for longitudinal and transverse orientations were calculated separately and they were compared with each other to find which among them correlated the best with the Central Venous Pressure. Results: In our study the IVC Collapsibility Index correlated well with the Central Venous Pressure. The sensitivity and specificity of IVC Collapsibility to Central Venous Pressure were also found to be statistically significant. The change in IVC diameters were also found to be statistically significant when compared to Central Venous Pressure. The sensitivity of the IVC Collapsibility Index in the longitudinal orientation was much better than that of the transverse orientation to detect low CVP. Conclusion: IVC Collapsibility Index can be used as an alternative to CVP measurement to guide us in the fluid management of patients in the ICU.

Page No. 122-127

Authors: Swati Bisht, Sadanand Gopal

Background: Endoscopic retrograde pancreaticogram (ERCP) requires patient to be sedated and pain free in prone position. Propofol sedation may cause cardiorespiratory depression. Etomidate is a good alternative with stable hemodynamic and respiratory parameters. We have compared these two drugs on their cardiorespiratory, induction time and recovery profiles. Methods: A total of 100 patients undergoing ERCP were randomly distributed to etomidate or propofol groups. Patients in the etomidate group received etomidate induction and maintenance, while propofol group received propofol anaesthesia. Cardiorespiratory parameters, time for induction and recovery along with adverse effects were noted. Results: The induction time was longer in the etomidate group than the propofol group.(p<0.001) The time for attaining Modified Aldrette score 9 was longer in the etomidate group(p<0.001). The percentage of fall in MAP and HR was higher in propofol group(p<0.001). SpO2 fall was also significant in propofol group. One patient in etomidate group developed myoclonus. Adverse effects like bradycardia, hypotension, hypoxia were significantly more in the propofol group. Conclusion: Etomidate is a safe and cardiostable induction agent in patients with obstructive jaundice undergoing ERCP.

Page No. 132-137

Authors: Tejesh CA, Shashikala TK, Viswanathan PN

Introduction: Halothane has been the inhalational induction agent most often used in paediatric anaesthesia as it provides smooth induction with good intubating conditions. However, it is associated with disadvantages like myocardial depression and arrhythmias. Sevoflurane having low blood-gas solubility allows for rapid induction, has less myocardial depression and its pleasant odour may make it a suitable agent of inhalational induction in children. Hence, the present study was undertaken to compare the induction and intubation characteristics of sevoflurane and halothane. Methods: The study population consisted of 200 children aged 1-12yrs, who were randomly assigned into two groups. Group H received incremental concentrations of halothane 0.5-5% and Group S received incremental concentrations of sevoflurane 1-7%. Induction and intubation times, induction and intubation characteristics, and haemodynamics were studied. Results: The induction and intubation times were shorter with sevoflurane compared with halothane (Group H v/s Group S; induction time 108.6 sec ± 13.3 v/s 64.2 sec ±12.7, intubation time 282.8sec ±34.1 v/s 213sec ±42.6 (P<0.05)). The induction related side effects were minimal with both agents and did not come in the way of smooth induction. 93% children with halothane and 88% children with sevoflurane had acceptable intubating conditions. Halothane was associated with slight decrease in heart rate and mean arterial pressure, whereas sevoflurane was not associated with any significant haemodyamic changes. Conclusion: Sevoflurane produces rapid induction than halothane and intubation time is achieved faster with sevoflurane than halothane. Induction with both agents is associated with minimal induction complications and acceptable intubating conditions are obtained with both agents in majority of children.

Page No. 143-146

Authors: Mukkavilli Lakshmi Narasimham, B. Dinakar Rao

Introduction: This study was conducted to evaluate the effect of Intraperitoneal Bupivacaine alone or with dexmedetomidine or tramadol for relief of pain after laparoscopic cholecystectomy. Material and Methods: The patients were divided into 3 Groups of 50 each, Group A was given 50 ml 0.25% bupivacaine and 5 ml normal saline, Group B 50ml 0.25% bupivacaine plus tramadol 1mg/kg wt and Group C, 50ml 0.25% bupivacaine plus dexmedetomidine 1ug/kg. The duration of analgesic effect was noted based on the time difference between the disappearance of pain after the analgesic injection and reappearance of pain was recorded and assessed by using VAS scale. Results: The number of females were slightly more than the male. The age group of the patients predominantly ranged between 31-40 years. Pain was significantly lower in Group C i.e. patients given bupivacaine plus dexmedetomidine compared to the patients in Group A and Group B. Patients in Group A i.e. with bupivacaine alone had the highest VAS score. Post-surgery, minor complications were seen in a few patients, with nausea being most common, followed by vomiting and pruritis. Conclusion: Bupivacaine plus dexmedetomidine given to patients who underwent laparoscopic cholecystectomies was more effective as an analgesic compared to Bupivacaine alone or in combination with Tramadol

Page No. 150-152

Authors: Rupali N. Gorgile, Sunita Shende, Sanyogita V. Naik

To avoid fetal exposure to polypharmacy and protection of maternal airway, regional anesthesia is usually preferred in pregnancy. Here, we report a case of 20 year old primigravida with 13±2weeks of gestation, diagnosed as a case of left ovarian cyst posted for emergency laprotomy done under combined spinal epidural anesthesia.