Indian Journal of Clinical Anaesthesia

9-12

Authors: Anuja Agrawal, Mridul M. Panditrao, Smita Joshi.

Introduction: The recommended approach for postoperative pain management is to initiate the treatment with analgesics such as paracetamol, NSAIDS, and aspirin followed by adjunctive use of opioids to treat more acute pain symptoms. However, the adverse effects associated with opioids and NSAIDS are well established. Aim: To study the efficacy of paracetamol in comparison to Tramadol when used as analgesic component of balanced anesthesia, pre-emptively for intraoperative and postoperative purpose. To study their side effects. To find out which of these two drugs is better in providing intraoperative and postoperative analgesia with minimum side effects. Materials and Methods: 60 patients of either sex, divided using computer generated random number table into 2 equal groups. Group T: (n 30): Tramadol hydrochloride group, Group P: (n 30): Paracetamol group. The dose of paracetamol and tramadol hydrochloride was 15mg/kg and 2mg/ kg body weight respectively. Statistical analysis: analysis was done by SPSS software version 11 by using Z test, chi-square test, proportion test (Z). P value less than 0.05 was considered as significant and less than 0.0001 as highly significant. Results: Both the groups were comparable with respect to their demographic profile, ASA status, and surgical procedures. Both paracetamol and tramadol have a good analgesic action and fewer side effects. The mean score of VAS Scale in group P (1.86  2.40) and group T (3.03  2.42) was similar and difference was not statistically significant. Also the side effects were comparable in both groups. Total number of rescue analgesics required by the group P (1.6) was significantly less as compared to the group T (3.7) with Z value = 4.00, p < 0.0001. Conclusion: Paracetamol has a better efficacy than tramadol hydrochloride in providing intra-operative and post-operative analgesia, when used pre-emptively with reduced number of doses of analgesic and almost no side effects.

17-24

Authors: Avinash Prakash, Anita Yadav, Habib Md. Reazaul Karim, Anil Kumar Narayan, Kumar Aman.

Introduction and Aim: Anaesthesia as speciality has evolved very much but the services are yet very much under recognized. This may be partly because of low knowledge of anaesthesia and anaesthesiologists. School education level of patients may also affect this. This study was conducted to assess the patient’s knowledge and perception about the role of anaesthesiologists, anaesthesia and their relationship with different educational level of patients and previous anaesthesia exposure Materials and Methods: The present cross sectional study was conducted with 150 participants aged > 15 years of either sex posted for elective surgery. A questionnaire was used as data collection tool. Data of entire cohort as well as in different subgroups based on education level and previous exposure were calculated and compared using INSTAT software and p < 0.05 was considered significant. Results: All the participants (56.67% female; mean age 39.36 + 12.63 years) completed the questionnaire. Their knowledge and awareness of anaesthesia and anaesthesiologists was very poor. Even patients with previous anaesthesia exposure were having poor knowledge (3 to 41 % in different aspects). No difference in knowledge and awareness was noted with different educational level (p > 0.05). Previously exposed patients had significantly more knowledge regarding ‘who makes you unconscious’, ‘types of anaesthesia’ and routes of ‘general anaesthesia administration’ but it failed to show difference in other aspects. Conclusion: Knowledge about anaesthesia and anaesthesiologists are still very poor. School education has no positive impact and previous anaesthesia exposure increases the knowledge in limited aspects.

30-33

Authors: Karthik Jain M., Bindu George, Fonseca Alex Jude, Deleema D., Ann Mary.

Introduction: Postoperative visual loss (POVL) after posterior approach to spine surgeries is a devastating complication necessitating a prospective study. The primary aim was to identify ophthalmological changes contributing to POVL (visual acuity, anterior segment, intraocular pressure (IOP), fundus, field of vision, external ocular examination). Secondary objectives was to evaluate the relationship between ophthalmological changes and various perioperative data including patient comorbidities, positioning and other intraoperative details. Materials and Methods: After getting necessary approvals and consent, thirty patients posted for the posterior spine surgeries were assessed preoperatively. Ophthalmological examination was conducted preoperatively, the day before surgery and postoperatively twice (first within an hour of completion of surgery and second at twenty four hours). Perioperatively, data including type of surgical frame, headrest used, duration of prone positioning, total blood loss, total intravenous fluids administered, lowest mean arterial pressure for more than ten minutes, blood transfusion details and use of hypotensive anaesthesia were noted. Data were analyzed using chi-square test, paired t test, and correlation coefficient. Results: There were no changes in visual acuity, anterior segment, fundus and field of vision postoperatively. But 12 patients had a rise in IOP and six developed lid edema and chemosis. There was a minimal increase in IOP at one hour post operatively (right eye- 2.8 mm Hg (p=0.001, and left eye- 3 mmHg(p<0.001). The analysis of perioperative data revealed no relationship with ophthalmological changes noted. Conclusion: There were no clinically significant ophthalmological changes contributing to POVL in spine surgeries in prone position. Observed ophthalmological changes did not have any correlation with patient comorbidities, positioning and other intraoperative details.

43-49

Authors: Ravindra Kumar Gehlot, Shekhar Suman Saxena, Lalit Kumar Raiger.

Introduction: The major responsibility of the anesthesiologist is to provide adequate ventilation to the patient because airway related problems are still the most common cause of anaesthesia related morbidity and mortality. The use of I-gel has been reported in laparoscopic surgeries and was found equally effective ventilatory device as PLMA. Therefore, we planned this study to compare I-gel and PLMA with ET tube in patients undergoing laparoscopic cholecystectomy. Materials and Methods: This prospective study was conducted on 90 patients of both sex, 18-60 years age, ASA grade I-II, scheduled for elective laproscopic surgery under general anaesthesia. All patients were randomised into three groups of 30 patients each; Group I (I-gel), Group P (PLMA), Group E (ET Tube). Attempts of insertion of devices, effective airway time and easiness of gastric tube; hemodynamic parameters (HR, MAP, SpO2 and EtCO2) were recorded. Results: There was significantly less 2nd attempt required in I-gel group(10%) as compared with ET tube (36.7%) and PLMA (13.3%),(p=0.019). Laryngopharyngeal morbidity were significantly more in Group E as compared to Group P and I (p<0.05). Hemodynamic changes were significantly higher in Group E immediately after intubation which persisted for 3 minutes and immediately after extubation (p= 0.00). Conclusion: Supraglottic Airway Devices (PLMA and I-gel) were as effective as ET tube in establishing airway and the haemodynamic stability is better then ET tube in laparoscopic cholecystectomy.

56-61

Authors: Shivanand Y. Hulakund, Archana R. Endigeri, Navya C. N., Prakashappa D. S..

Introduction and Aim: The cardiovascular changes to airway manipulation like tachycardia and hypertension occur secondary to catecholamine secretion. These changes make less effects on normal patients but can be hazardous in cardiac compromised patients. Various pharmacological measures are tried to lessen these ill effects. As a result we made an effort to compare the usefulness of two drugs, highly specific α2 agonist Dexmedetomidine at a dosage of 1µg/kg versus Esmolol 1mg/kg; in reducing these effects during induction of G.A. Materials and Methods: In this randomized clinical trial 102 patients, of age group 18-65 years and American Society of Anesthesiology classification I/ II, undergoing various surgeries under G.A. requiring intubation were distributed into 2 groups of 51 patients each. Group D patients were given Dexmeditomedine1µg/kg in diluted form over a time period of 10 minutes and Group E patients were given Esmolol 1mg/kg diluted to 10 ml and given over 1 min .Induction of anesthesia was done with volatile agent sevoflurane. Maintenance was done with O2 and N2O 30:60 along with vecuronium. Monitoring was done and hemodynamic parameters were recorded at particular intervals during laryngoscopy and intubation of trachea. Results: All observations were expressed as mean and standard deviation. Based on statistical analysis the Baseline heart rate, and baseline mean arterial pressure were comparable in both the groups. The decrease in mean HR observed at, 3, 5 and 10minutes after intubation in Group D was statistically highly significant compared to mean HR in group E (p<0.000).(table 2). The mean fall in SBP in group D at 1, 3, 5 and 10 minutes after intubation was statistically highly significant (p=0.000) compared to the Esmolol group E The fall in mean DBP value at 1,3, 5 and 10 minutes of intubation were statistically highly significant (p=0.000)in group D compared to the latter group. The mean basal MAP, 2min after drug administration and 1min after induction are comparable in both groups (p>0.05).The fall in mean MAP values in group D at 1, 3, 5 and 10 minutes of intubation were statistically highly significant (p<0.0000001) compared to group E. 1min after induction fall in mean RPP value in D group is statistically higher than in E Group (P=0.0243). We also noticed hypotension in 5 patients and a fall in heart rate in 3 patients of study group in group D which did not need any medication. However no patients in the latter group had these side effects, we attribute this to the lesser dosage of esmolol used. Conclusion: This study shows that dexmeditomedine 1µg/kg is better than esmolol 1mg/kg for lessening the stress response to airway manipulation.

68-74

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

Introduction: Spinal anaesthesia is the most commonly employed technique for Caesarean section. Many drugs such as opioids as intrathecal additives such have been widely studied found to be associated with respiratory depression, pruritis, etc. Upcoming studies on alpha-2 agonists as intrathecal additives have been found promising and will replace opioids soon. Knowledge on the efficacy of the individual a2 agonists over one another is lacking. So the aim of the study is to compare the spinal additive effect of dexmedetomidine and clonidine in pregnant patients for caesarean section. Materials and Methods: Ninety patients belonging to ASA group I and II of age group of 20 – 40 years were included in the study. Patients with PIH, Diabetes, Body weight above 100kg, Height less than 145 cm, Post spinal surgeries, spinal deformity, and known history of Coagulopathy and allergic to study drugs, documented IUGR, intrauterine anomaly and patients those who are not willing for spinal anaesthesia were excluded from the study. They were randomly allocated into three groups of 30 patients each, Group D where the patients received dexmedetomidine 5µg with bupivacaine 10mg, Group C where the patients received clonidine 15µg with bupivacaine 10mg and Group B where the patient received bupivacaine 10mg with 0.9% saline 0.5ml. The duration of the sensory and the motor blockade, two segment regression times, duration of the postoperative analgesia, sedation and neonatal wellbeing with maternal hemodynamic changes were studied. Results: Demographic characteristics and hemodynamic parameters were comparable between the three groups. The onset and maximal sensory block was faster in Dxm and clonidine groups (162±41.40;166±37.57) than control group (254.67±28.73) which was statistically significant. The two segment regression time was significantly shorter in control group (67.53±5.94) than Dxm and clonidine group (103.47±8.08;108±6.90). Dxm and clonidine group showed shorter time (3.40±0.84; 3.13±0.50) to reach Bromage grade 3 motor block than control group (4.52±1.78). The maximum sedation score recorded in both Dxm and clonidine group was 2.The time of onset (minutes) of sedation between Dxm and clonidine groups which was (8.9±2.85;7.43±2.27 ) were statistically insignificant. Conclusion: Addition of intrathecal clonidine 15µg/ dexmedetomidine 5µg to 10mg of bupivacaine in LSCS patients increase the duration of motor and sensory blockade, with little changes in maternal hemodynamics without any changes in neonatal outcome.

80-85

Authors: Shubhendu Bajpal, Nanda Upadhyaya, Rina Gadhavi.

Introduction: Regional anesthesia has lots of advantages compared to general anesthesia for Vaginal hysterectomy. Intrathecal anesthesia and Epidural anaesthesia are regional anaesthesia techniques used for Vaginal Hysterectomy. Aim and Objectives: 1.To study the adjuvant effect of alpha 2 agonist DEXMEDETOMIDINE with local anesthetic (ROPIVACAINE 0.75%) in lumbar epidural anesthesia in form of onset and lasting period of sensory and motor blockade, variation in hemodynamic parameter, post-operative analgesia. Materials and Methods: The study population was randomly divided into, 25 patients in each group. 1. Group R (n=25) -20ml of 0.75% ropivacaine; 2. Group RD (n=25) -20ml of 0.75% ropivacaine + 1µg/kg of dexmedetomidine. With the patients in sitting position, epidural space was identified by hanging drop method and confirmed by loss of resistance technique to air using 18G Tuohy needle via the midline approach at either L2-3 or L3-4 inter spinous space. An epidural catheter was fixed at 3 cms inside the epidural space. Result and Interpretation: result shows the prolonged sensory and motor blockage in RD group. Onset of sensory and motor blockade is stastaticaly significant. Sedation score is higher in RD group. Difference in heamodynamic parameters were statistically not significant. Parameters and side effects between two groups. Conclusion: Dexmedetomidine given epidurally with ropivacaine produces synergistic effect of profound and prolonged motor blockade and sensory blockade with better sedation and hemodynamic stability. Ropivacaine and dexmedetomidine can be a safe and effective alternate for epidural blockade in vaginal hysterectomies.

92-101

Authors: V. S. Senthil Kumar, V. Arun Pothan Raj.

Whenever the conventional laryngoscopy fails, insertion of supraglottic airway device may be indicated. The I-Gel and LMA-Supreme are both novel supraglottic airway devices which are disposable, cheap and aids the passage of gastric tube which helps in gastric drainage. Both the devices can be used as an adjunct to endotracheal intubation in patient with difficult airway. This prospective randomized, single blind study was designed to compare the supraglottic airway devices I-Gel and LMA-Supreme in patients undergoing general anaesthesia for elective surgeries. After obtaining the institutional ethical committee approval, 60 adult patients of ASA I and II physical status of either sex undergoing elective surgical procedures under general anaesthesia were randomly allocated into 2 groups. Group A I-Gel group (n=30) and Group B LMA-Supreme (n=30). The study showed no significant difference between the two groups based on demographic variables. The mean insertion time for LMA-Supreme is significantly lower than I-Gel (P<0.05). The airway leak pressure was comparable between the two devices. The first attempt success rate and the ease of insertion was significantly better in LMA-Supreme than I-Gel (P<0.05). There was no significant variation in the hemodynamic response in both the groups. Post-operative sore throat was noted in LMA-Supreme and blood staining was noted in I-Gel group. When compared with I-Gel LMA-Supreme has a higher first attempt success rate and also a lower insertion time.

110-113

Authors: Madhavi R. Godbole, Girish Saundattikar.

Introduction: As is well described laryngoscopy and intubation produce significant hemodynamic response. It is shown in previous studies that type of laryngoscope blade used affects the degree of hemodynamic response to endotracheal intubation. In our study we have attempted to compare hemodynamic response to laryngoscopy and intubation using Macintosh and McCoy blade. Aim: Our aim was to perform comparative study of hemodynamic response to laryngoscopy and intubation using Macintosh versus McCoy blade. Materials and Methods: A prospective randomized controlled study comparing hemodynamic response to laryngoscopy and intubation using Macintosh and McCoy blade was conducted. A total no. of Sixty patients, either male or female, between age group of 20 -50yrs, belonging to American Society of Anaesthesiology physical status I and II requiring General anaesthesia were randomly allocated to either group A (Macintosh group) or group B (McCoy group) In both the groups, standard methods were used. Comparison of hemodynamic parameters i.e. Heart rate (HR), systolic (SBP) diastolic (DBP) and mean blood pressure (MAP) was done at induction, during laryngoscopy and intubation, till 5 mins after intubation. Statistical Analysis: Hemodynamic changes in between the two groups were compared statistically using Unpaired “t” tests. Results: Significant rise in all HR, SBP, DBP, MAP was seen in both the groups after laryngoscopy and intubation. In group A the rise was found to be statistically significant as compared to group B. Conclusion: This study helped us to conclude that McCoy blade produces reduced hemodynamic response to laryngoscopy and intubation as compared to Macintosh blade

120-124

Authors: Dinesh Govindarao, Lakshmi Priya, Sunitha G. E..

Introduction and Objectives: Levobupivacaine and Ropivacaine, the two S enantiomers of Bupivacaine can be safer alternatives to racemic bupivacaine due to claims of cardiovascular safety profile. Hence, this study was conducted to assess the clinical efficacy of Levobupivacaine and Ropivacaine for spinal anaesthesia for orthopaedic surgeries of lower limbs. Methods and Materials: For this study, 60 adult ASA class I and II patients admitted for elective lower limb orthopaedic surgeries were randomised to 2 groups of n=30 each after approval from ethical committee and informed written consent. Spinal anaesthesia was given with 3ml Levobupivacaine 0.5% (15 mg) to patients in Group L and with 3ml Ropivacaine 0.5% (15 mg) to patients in Group R. Characteristics of spinal anesthesia in the two subsets like analgesia, motor blockade and hemodynamic parameters were observed and adverse effects, if any, were recorded. Data obtained were compiled and analysed with suitable statistical tests. A p-value of 0.05 was considered significant. Results: Onset of sensory and motor block were significantly faster in Group L (7 and 1.87 min) compared to Group R (9.43 min and 3.10 min). The maximum level of analgesia was attained faster in Group L (12.67 mins) compared to Group R (16.67 mins). The two segment regression time and the duration of analgesia were significantly shorter in Group R (72.63 min, 213.93 min) compared to Group L (103.6 min, 251.33 mins) Higher grade of motor blockade was achieved rapidly in Group L (9.03 mins) when compared to Group R (12.63 min). The mean duration of motor blockade was prolonged in Group L (263.67 mins) whereas recovery from motor blockade was earlier in Group R (151.17 mins). Both the groups had stable hemodynamics and adverse effects were not observed in both the groups. Conclusion: Intrathecal isobaric Levobupivacaine 15mg and Ropivacaine 15mg are effective in lower limb orthopaedic surgeries without significant haemodynamic changes. However, Levobupivacaine produced faster onset, prolonged and higher level of sensory block, prolonged motor blockade compared to Ropivacaine.

129-133

Authors: Dhaval Kumar C. Patel, Neeta Abhay Kavishvar.

Introduction: For pain relief during labor, regional analgesia is considered the most preferred technique; nevertheless the best method is yet to be determined. We carried out a randomized study to assess efficacy, safety & maternal satisfaction with standard epidural and combined spinal epidural (CSE) analgesia technique among 40 primigarvida. Materials and Methods: Healthy primigarvida in labor having cervical dilatation between 3 to 5 cm were assigned randomly to receive either epidural or CSE for labor analgesia. Analgesia was established in Epidural group with 12ml of 0.0625% bupivacaine added with 2µg/ml fentanyl & in CSE group with intrathecal injection of 2.5mg 0.5% heavy bupivacaine plus fentanyl 25µg (total 2 ml). In both groups whenever patient’s VAS>3, 2nd dose was given in form of epidural bolus 10ml 0.0625% bupivacaine + 2µg/ml fentanyl, followed by infusion of same concentration at 8 ml/h. Results: The onset of labor analgesia was significantly faster in CSE group (5.5±1.9 vs. 13±5.9 minutes, p<0.001) compared to epidural group. More than 75% patients in both groups didn’t developed any motor blockade. The total dose of bupivacaine used in Epidural group was 20.5±6.6mg whereas it was only 8.5±7.7mg in CSE group which was significant low than epidural group; same was for fentanyl (65.1±21.6µg in epidural and 44.4±24.6µg in CSE group). In CSE group 35% patients had pruritus and 10% had nausea and vomiting, but none had in epidural group. Mothers have labeled quality of analgesia comparable. Conclusions: Both techniques were equally effective in relieving the pain during labor, but the onset of analgesia with CSE technique was faster than epidural group. The LSCS rate was comparable and complications were minor. Thus CSE can be safe and effective alternative to standard epidural technique for labor analgesia.

141-146

Authors: Prerana Jogdand, Prasad M. Sule.

Aim and Objectives: Aim of the present study was to compare the efficacy of the block, hemodynamic effects, postoperative analgesia and side effects of combined psoas compartment sciatic nerve block with continuous spinal anaesthesia in adult patients undergoing lower extremity surgeries. Materials and Methods: Sixty patients of either sex, ASA grade I, II and III, age between 18-70 years, were randomly allocated into two groups. In group A, psoas compartment block was performed by posterior approach using 30cc of 0.25% bupivacaine and sciatic nerve block by classical posterior approach using the 20cc of 0.25% bupivacaine. In group B, continuous spinal anaesthesia was performed in the L3-L4 interspaced with the patient in lateral decubitus position using 3cc (15 mg) of 0.5% heavy bupivacaine. We studied various parameters of block, hemodynamic effects, duration of postoperative analgesia and any complications. Results: Group B had earlier onset of sensory and motor block as compare to group A. The mean duration of sensory and motor block was significantly prolonged in group A than in group B. The efficacy of sensory blockade was comparable in both the groups while in group A 90% patients and in group B 97% of patients had complete motor blockade. The incidence of hypotension was more with group B as compared to group A. The duration of post-operative analgesia was longer in group A than in group B. No major complications were observed in both the groups. Conclusions: It was concluded that combined psoas compartment block and sciatic nerve block is a beneficial alternative to existing anaesthesia techniques for lower extremities surgeries.

152-155

Authors: Yi Lin. Lee, Shah Shitalkumar Sharad, Keng Tiong Jerry Tan, Kothandan Harikrishnan.

Congenital heart disease affects approximately 1% of the population and is the leading cause of birth defect associated infant illness and death. The most common cyanotic heart disease is tetralogy of Fallot (TOF) which is characterized by overriding of aorta, ventricular septal defect (VSD), pulmonary stenosis and right ventricular hypertrophy. TOF are repaired early in infancy and involves closure of the VSD and repair or replacement of the pulmonary valve to improve right ventricular outflow. A potential and significant complication is stenosis of the pulmonary homograft. We discuss a young patient with previous sternotomies for repair of TOF presenting for his 4th redo-sternotomy for an infective abscess near his old pulmonary homograft. This case presents to us multiple challenges such as a septic patient, previous sternotomies and a potential for intraoperatively massive blood loss.

159-161

Authors: Mohandeep Kaur, Michell Gulabani, Vinod Bala Dhir, Rao Pal Singh.

Subacute Sclerosing panencephalitis (SSPE), also known as Dawson’s disease or measles encephalitis, is an extremely rare and fatal subacute infection caused by a persistent defective measles virus (MV). It mostly develops 7-10 years after initial MV infection and is fatal within 3 years from onset of symptoms.1 Measles virus infection before 2 years of age has 16 times higher risk of developing SSPE as compared to infection occurring after five years of age.2 SSPE is a progressive, degenerative disease of the central nervous system that occurs several years after measles infection. Saha et al reported an annual incidence of 21 per million population in India3 as compared to 2.4 per million population in the middle east.4-5 By this case report, we aim to stress on the certitude that the only definitive prevention against SSPE is timely measles vaccination.