Indian Journal of Clinical Anaesthesia

165-169

Authors: Shilpa Masur, Anilkumar Ganeshnavar, Preetika Hiremath, Dinesh Naik

One of the commonly used regional anaesthesia technique for postoperative pain relief in paediatric surgery is caudal block. By increasing the volume of local anaesthetics, a higher initial level of blockade might extend the analgesic duration. Our aim was to compare analgesic durations between higher volume lower concentration and lower volume higher concentration levobupivacaine administered to children undergoing infraumbilical day care surgery. Materials and Methods: After obtaining ethical clearance and informed consent from guardian we performed randomized, prospective, observer-blinded study. Sample size calculated was 24 in each group. Caudal block was performed after induction and securing airway with appropriate size LMA. Children aged 6months to 5yr ASA I-II, received Levobupivacaine either 0.8 mL/kg of 0.375% (lower volume/ higher concentration [Group L], n 24) or 1.5 mL/kg of 0.1% solution (higher volume/ lower concentration [Group H], n 24) with radioopaque dye. Duration of analgesia and time for the 1st dose of oral acetaminophen was noted. Results: Fluoroscopic examination showed the spread levels of Levobupivacaine to T12(T12–L2) in Group L and T6 (T4–T8) in Group H. The mean duration of analgesia in Group H was significant than in Group L, i.e., 639.091 ± 89.8628 min and 587.028 ± 87.7387 (P < 0> Conclusions: Caudal analgesia with higher volume lower concentration of levobupivacaine (0.1%) provides longer duration of analgesia than lower volume higher concentration levobupivacaine (0.375%) in children undergoing day-care infraumbilical surgery.

175-181

Authors: Anuradha Suryaprakash Karande, Sangeeta Shrikant Page

Introduction: Laryngoscopy and intubation result in stimulation of larynx, pharynx, epipharynx and trachea, which are extensively innervated by autonomic nervous system. The parasympathetic supply is via the vagus and sympathetic supply via superior cervical ganglion. To diminish hemodynamic responses to tracheal intubation, Fentanyl along with hypnotic agents commonly used. Keeping in mind, an attempt has been made to assess the efficacy of injection fentanyl for attenuation of sympathetic response to intubation. Aims and objective: To assess efficacy of 2microgram/kg body weight fentanyl and 3 microgram/kg body weight fentanyl administered before laryngoscopy and endotracheal intubation for attenuation of hemodynamicresponse. Materials and Methods: 90 normotensive adult patients, belonging to ASA physical status I, of either sex, age group of 18-65 years, free from inter current cardiovascular and neurological disease, were posted for elective surgical procedures under general anaesthesia requiring orotracheal intubation were selected. All were elective cases. Three groups were made. Group I-Control group-10 cc normal saline IV. Group II- 2microgram/kg body weight fentanyl IV diluted to 10 cc with Distillate Water (DW). Group III- 3 microgram/kg body weight fentanyl IV diluted to 10 cc with D.W. Each group comprised of 30 patients. Result: The rise in pulse rate in both the fentanyl groups, was less and statistically significant than control group (p<0> Conclusion: Use of intravenous fentanyl in both doses, i.e. 2 mcg/kg as well as 3 mcg/kg is safe and effective for attenuation of hemodynamic response to laryngoscopy and intubation.

185-189

Authors: Renuka R., Radhika D. Dhandal

Postoperative nausea and vomiting (PONV) is a common complication after anaesthesia. Although self limiting and non fatal, it can cause significant morbidity and delay discharge. The intention of doing this study was, to evaluate the accuracy of three risk scores in predicting PONV and to evaluate the efficacy of different therapeutic regimens based on the risk score in the reduction of PONV. Materials and Methods: In this prospective, randomized, double blinded study, 180 patients between 18-60 years age group, belonging to ASA 1 and ASA 2 categories coming for elective surgeries under general anaesthesia of 1-4hrs duration irrespective of the type of surgery were scored preoperatively for postoperative nausea and vomiting using APFEL, KOIVURANTA, PALAZZO and EVANS scoring systems into low risk and high risk groups. Low risk group (i.e., Group O) consisting of 60 patients - inj. ondansetron 4mg was given intravenously 30 minutes before administration of reversal agent. High risk group was further categorized into Group M and Group D consisting of 60 patients each, based on the intervention to assess the efficacy of the drugs used in these two groups. Group M patient received inj.ondansetron 4mg+inj.metoclopramide 10mg intravenously (IV) 30 minutes before administration of reversal agent. Group D patient received inj. dexamethasone 4mg IV at induction and inj.ondansetron 4mg IV 30 minutes before administration of reversal agent. After the procedure, patients were observed for any retching, nausea or vomiting in postanaesthesia care unit and up to 24 hours. Rescue treatment from a drug of different pharmacological group was administered if required. Results: Area under the curve (AUC) and the corresponding 95% confidence intervals for the scores drawn from Receiver operator characteristic (ROC) curves were: Apfel: 0.6154 (0.50470-0.72618); Koivuranta: 0.6154 (0.50470-0.72618); Palazzo & Evans: 0.6443 (0.54096-0.74764). And, a complete response of 71.67% was observed in Group O, 76.67% in Group M and 90% in Group D. Thus we concluded that, all the three scores had moderate accuracy in predicting the risk of PONV and ondansetron-dexamethasone combination was found to be superior to ondansetron- metoclopramide combination in high risk patients.

195-198

Authors: Hachio William M. Yanthan, Tridip Jyoti Borah, Subrata Pahari, Tirtha Ratan Ghosh, Jaideep Sonowal

Introduction: Prime objective of anaesthesiologist is to minimize adverse psychological and physiological effects of anaesthetic technique. Premedication causes sedation and reduction of anxiety during separation from parents. It also provides a calm and cooperative child for smooth induction of anesthesia. We evaluated the differences in quality of premedication with orally administered midazolam and ketamine in the paediatric population undergoing elective surgical procedures and tried to ascertain the minimum interval required between premedication and parental separation. Objective: This study was undertaken to compare the efficacy and safety of oral midazolam and oral ketamine as a preanaesthetic medication for paediatric patients undergoing elective surgery. Materials and Methods: In this prospective, randomized, double blind study a total of 60 children aged 1-6 years, belonging to ASA grade 1 and 2, scheduled for elective surgery were randomized into two groups of 30 each to receive either midazolam 0.5 mg/kg (Group A) or ketamine 5 mg/kg (Group B) orally. Parameters to be assessed were quality of sedation and anxiolysis, ease of parent-child separation and ease of venepuncture. Results: Overall success rate of midazolam for sedation and anxiolysis was higher than ketamine in all the time frames. Successful separation from parents was easy in 25 patients (83.33%) in group A and 13 patients (43.33%) in group B. Successful venepuncture was obtained in 93.33% and 90% of patients in group A and group B respectively. This higher rate of success during venepuncture was probably due to use of EMLA cream prior to venepuncture. Conclusion: We concluded that premedication with oral midazolam 0.5mg/kg provides better sedation and anxiolysis, easy parent child separation than oral ketamine 5mg/kg.

205-209

Authors: Devaraj I. C., Manjunath Timmappa Bhat, Shrirang V. Torgal

Aims and Objectives: Propofol and etomidate are most frequently used intravenous induction agents, with very similar onset of action and duration of action, few advantages over each other and few unwanted effects. Recent studies and reintroduction of etomidate has paved way for its routine use in haemodynamically unstable patients. Materials and Methods: One hundred patients belonging to American Society of Anaesthesiologists (ASA) class I and II, aged between 18 to 60 years scheduled to undergo elective surgical procedure under general anaesthesia were selected. All the patients received tablet diazepam 0.2 mg/kg as premedication and fentanyl 2 mcg/kg body weight before induction. Patients were be randomly allocated to group P ((n = 50), who received propofol 2 mg/kg or group E (n = 50) who received, Etomidate 0.3 mg/kg as induction agent for general anaesthesia. Endotracheal intubation was facilitated by vecuronium 0.1mg/kg body weight. Heart rate (HR), Systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial blood pressure (MAP) were recorded at basal, after fentanyl, 1, 3, 5 and 10 min following induction. Results: There was no significant change in the heart rate at and after the induction, intubation in either group P or group E. There was significant decrease in SBP, DBP and MAP in group P following induction, whereas there was less decrease in Group E. There was increase in the SBP, DBP and MAP after intubation in both the groups, but in group P it did not increase above the basal and remained below the basal levels at 5 and 10 minutes following intubation. Conclusion: Etomidate provides stable haemodynamics at induction of general anaesthesia. But it does not attenuate the haemodynamic response to laryngoscopy and intubation. Propofol causes significant hypotension at induction and attenuates the pressor response to laryngoscopy and intubation.

216-221

Authors: Lalit Gupta, Bhavna Gupta, Poonam Bhadoria, U. C. Verma

Objectives: The ProSeal Laryngeal Mask Airway (PLMA) mostly inserted by finger technique and by an introducer tool method. Recently a newer Suction Catheter Guided (SC) insertion technique has been successfully used in children. We performed a study in children with aims and objective to compare the ease of PLMA insertion using SC and conventional techniques. Methods: 126 American Society of Anaesthesiologist’s class I and II children in age group of 1-12 years weighing 10-50 kg, admitted in our hospital, undergoing an elective surgery in under general anaesthesia in supine position were included in our study. An appropriate size PLMA was inserted using Suction Catheter, introducer tool or digital technique in Groups SC, I and D respectively (n=42) after induction of general anaesthesia. Correct placement of the PLMA was confirmed by using appropriate clinical tests. Ease of PLMA insertion with hemodynamic response was done by time to insertion, number of insertion attempts to achieve effective ventilation and number of cases which required lateral approach of insertion. Results: In Group SC, PLMA device was inserted after a single attempt in 41 (97.6%) patients, but PLMA insertion was failed in 5 patients in Group I (11.9%) and 6 patients in Group D (14.3%) even after two attempts, and the difference was statistically significant (p=0.044). Time taken for successful placement was statistically shorter in the SC-guided group (SC 22.5±4.021 seconds, I 31.4± 17.57 seconds, D 27.10±12.9 seconds, p value <0> Conclusion: Suction Catheter guided ProSeal LMA insertion was an easier, faster, more successful and a relatively atraumatic technique which also ensures correct placement of the PLMA in the hypopharynx as compared to the routine conventional PLMA insertion techniques with no hemodynamic pressor response to PLMA insertion using any of the three techniques.

228-232

Authors: Amol Singam, Arpita Jaiswal, Rashmi Deshpande Tapan Dhumey

Introduction: Relevant incidences of nausea-vomiting during and immediately after cesarean section in spinal anesthesia are found to be high. Effectiveness of intrathecal midazolam (2 mg) as an adjuvant to bupivacaine on the incidence and severity of intraoperative and immediate postoperative nausea and vomiting was investigated in the present study. Materials and Methods: A randomized, controlled, double-blind study was conducted in 120 healthy women (ASA Physical status I and II) scheduled for elective cesarean section under spinal anesthesia. Parturients were randomly divided into two equal groups of 60 each. Group M(study group) -Patients received 10 mg (2.0ml) of 0.5% hyperbaric bupivacaine combined with 2 mg (0.4 ml) midazolam intrathecally and Group C (control group)- 10 mg (2.0ml) of 0.5% hyperbaric bupivacaine combined with 0.4 ml normal saline intrathecally. Assessment of the patients were done for incidence of nausea-vomiting, hemodynamic effects and occurrence of adverse effects during cesarean section and during first 6 hours after the operation. Results: Incidence of emetic symptoms in Group M were significantly lower than Group C (15% vs 63.34%, p< 0>). There were no clinically serious adverse events observed in any of the groups. All neonates had APGAR scores more than 8 at one and five minutes. Conclusion: Intrathecal midazolam as an adjuvant to Bupivacaine is associated with lower incidence of nausea and vomiting with no neonatal adverse effects.

237-243

Authors: Sudarshan M. Boregowda, Basavanna P. Linganna, Santosh K. Raju

Objectives: The objectives of our study were to compare the efficacy and safety of 0.2% Levobupivacaine with 25 mcg Fentanyl and 0.2% Ropivacaine with 25 mcg Fentanyl given epidurally for post-operative analgesia in patients who were operated electively for lower limb orthopaedic conditions under spinal anaesthesia. Materials and Methods: Sixty patients belonging to American Society of Anaesthesiologists (ASA) Class I and II of both sexes, of age within 20 - 60 years were included in the study after obtaining institutional ethical committee clearance. Patients were divided randomly into 2 groups: Group - LF which received 8 ml of 0.2% Levobupivacaine with 25 mcg Fentanyl and Group - RF which received 8 ml of 0.2% Ropivacaine with 25 mcg Fentanyl. Surgery was conducted under spinal anaesthesia. Later 8 ml of the test drug combination was given epidurally in the post-operative period when the patient complained of pain (VAS score > 4) and the parameters were recorded periodically until pain reappeared (VAS score > 4). Results: In both the groups mean duration of surgery, changes in haemodynamics and demographic profiles were comparable. However the total duration of post-operative analgesia in Levobupivacaine group was 325 +/- 63.06 minutes and in Ropivacaine group was 210 +/- 24.91 minutes respectively and this appeared to be statistically significant. Conclusion: Compared to 0.2% Ropivacine with 25 mcg Fentanyl, 0.2% Levobupivacaine with 25 mcg Fentanyl provides intense and longer duration of post-operative analgesia with similar haemodynamic stability.

249-254

Authors: Chiteshwar Walia, Pankaj, Manjunath Prabhu, Daniel Thomas

Introduction: Premedication with sedative drugs is often used in paediatric practice as one of the modalities to reduce preoperative anxiety in children undergoing surgery. It reduces both patient and parental anxiety and improves overall satisfaction. Also, provides anterograde amnesia and reduces postoperative behavioral changes and adverse outcomes in children. The ideal premedication in children should be readily acceptable and should have speedy and reliable onset with negligible side effects. Materials and Methods: After obtaining institutional medical ethics committee approval, sixty ASA physical status I or II children, aged 1-8 years scheduled for elective surgery were randomly allocated into one of the two groups. Group M (n=30): received preservative free oral midazolam 0.5mg/kg (1ml=5mg) + acetaminophen based syrup (5ml=120mg) upto maximum value of 0.4ml/kg. Group MK (n=30): received preservative free oral midazolam 0.25 mg/kg (1ml=5mg)with 3mg/kg oral ketamine(1ml=50mg) + acetaminophen based syrup (5ml=120mg) upto maximum value of 0.4ml/kg. Results: Combination of midazolam0.25mg/kg and ketamine3mg/kg provided faster onset and higher degree of sedation, comparable incidence of satisfactory parental separation and mask acceptance without any added side effects in comparison to midazolam 0.5mg/kg. Conclusion: Addition of low dose ketamine to midazolam as a premedication provides adequate sedation.

261-265

Authors: Ranjan Ramakrishna, Hemanth KJ, Sunil BV, Neeta S, Sonal Bhat

Introduction: Premedication is widely used in pediatric anesthesia in order to provide sedation and anxiolysis. Aim of the study was to compare the effectiveness of combination of low dose oral midazolam and ketamine with oral midazolam or oral ketamine as premedication. Materials and Methods: 150 childrens between ages 2 and 10 were divided into 3 groups of 50 members each. They received either combination of oral midazolam 0.5 mg/kg and oral ketamine 3mg/kg or oral midazolam 0.5 mg/kg or oral ketamine 6 mg /kg as pre medication. Premedication was given 30 minutes before the induction of anesthesia. Patients also received oral atropine 0.02mg/kg along with the study drug. Sedation and anxiolysis were assessed before giving premedication and at an interval of 10 minutes, 20 minutes and 30 minutes after premedication. Behavior at separation from parents and acceptance or response to venipuncture was also assessed at the end of 30 minutes. Statistical analysis was performed using SSPE computer software version 16. Groups are compared using chi square tests. Result: We found that oral combination of midazolam 0.5 mg/kg and ketamine 3 mg/kg with atropine 0.02mg/kg offered better sedation [96% children], anxiolysis [76% children], acceptance of parentral separation [80% children] and comfortable venous cannulation [84% children]. We conclude that Combination of oral ketamine, midazolam and atropine is a superior premedicating agent than using these drugs individually.

272-276

Authors: Suruchi Ambasta, Swagat Mahapatra

Introduction: This was a prospective, randomized, double blind, comparative, clinical study to assess the efficacy of Esmolol and Labetalol, in low doses, for attenuation of sympathomimetic response to laryngoscopy and intubation. Materials and Methods: This study was conducted on 50 ASA 1 patients of either sex undergoing elective surgeries under general anaesthesia. Patients were randomized into two groups; group E who received intravenous Esmolol (0.5 mg/kg) or group L who received intravenous Labetalol (0.25 mg /kg) prior to induction and hemodynamic parameters were recorded as per designed protocol to assess stress response to laryngoscopy and intubation. Results: Both the study groups had similar demographic profile. Instat version 3.10 was used for statistical calculations. The study data were analyzed using statistical methods of mean, standard deviation. Esmolol (0.5 mg/kg), abetalol (0.25 mg/kg) significantly attenuated the rise in heart rate, systolic blood pressure, and RPP during laryngoscopy and intubation. However, the difference was not statistically significant among the values for DBP and MAP. Conclusion: From our clinical study it can be concluded that in lower doses, intravenous Labetalol (0.25 mg/kg) is a better agent than intravenous Esmolol (0.5 mg/kg) in attenuating the sympathomimetic response to laryngoscopy and intubation. Usual dose of esmolol used to obtund intubation response is 2-4mg/kg, while labetalol has been tried in all doses ranging from 0.25, 0.5, 0.75, and 1 mg/kg.17

282-286

Authors: Sarika M. Shetty, Vyshnavi S., Dharanindra M., Archana KN

Introduction and Aims: Currently wide arrays of video laryngoscopes are available to facilitate laryngoscopy and endotracheal intubation in routine and difficult airway patients, intensive care units (ICU) and emergency settings. This study is undertaken to compare the efficacy of C-MAC and King Vision video laryngoscope for easy laryngoscopy and endotracheal intubation in patients with no predictors of difficult airway. Materials and Methods: 60 adult patients undergoing elective surgery were randomly allocated into 2 groups for intubation using either King Vision laryngoscope (KVL group) or C-MAC video laryngoscope (C-MAC group). The parameters recorded were need for external laryngeal manipulation, percentage of glottis opening (POGO score), Cormack Lehane grading, number of attempts and time taken for successful endotracheal intubation and the airway morbidity. Systolic, diastolic, mean blood pressure and heart rate were measured preoperatively and at 1 and 2 min following endotracheal intubation in both the groups. The obtained data were analysed using chi-square test and Student’s t-test using SPSS software. Results: The use of Kings Vision laryngoscope or CMAC video laryngoscope did not differ significantly with respect to good laryngoscopy and intubating conditions. But airway morbidity was significantly lower in the KVL group (10%) when compared with the C-MAC group (40%) p<0> Conclusions: The use of C-MAC or KVL provided excellent laryngoscopy and intubating conditions except for the airway morbidity and haemodynamic stability which were better with the use of KVL.

289-291

Authors: Urmila Palaria, Arpita Das, Charul Jakhund

Introduction of epidural catheters has increased the benefits of epidural block by several folds, permitting extension of neuraxial blockade for extended period of time. Although, it’s insertion is safe, but removal may be associated with breakage of fragment of catheter in the epidural space. This is rare but troublesome both for anaesthesiologists and patients. Many a times the fragment is not visualized with available radiological imaging techniques even after being radioopaque. Usually broken fragment lies in the space as an inert foreign body but it’s surgical removal becomes mandatory once neurological symptoms develop

294-296

Authors: Charuta Gadkari, Priyanka Pravin Deshmukh, Megha Tajne, Ankush Wasnik

A patient with post burn contracture of neck and Marjolin’s ulcer on anterior chest wall was posted for wide local excision and skin grafting. Skin graft was taken from lower limb under unilateral subarachnoid block and wide local excision of ulcer was performed under thoracic epidural anaesthesia. In the background of pre-formulated strategy in view of anticipated difficult airway, regional anaesthesia is a well established and safe alternative in expert hands.