Indian Journal of Clinical Anaesthesia

306-310

Authors: Harpreet Kaur,Veena Shukla*,Ranjana Khetarpal,Magila Muthuramalinga Pandian

Modern medicine involves highly specific and sophisticated techniques and equipments. However, human errors as well as equipment failure may lead to fatal accidents an increase in the cost of health care. Using checklist as tool for surgical safety involves safe anaesthesia, maintenance of open airway, correct surgical site, infection control and efficient communications and team work. Although no checklist is universal or guarantees absolute safety, an effective checklist has a patient centered approach and keeps patient safety and comfort a priority.

321-326

Authors: R Anitha Preethi,A Pushparani*

Introduction: Hemodynamic instability during pregnancy may compromise the blood flow to the uteroplacental bed which may lead fetal acidosis. We compared ephedrine and phenylephrine on fetal outcome and hypotension during elective cesarean section. Aim: To compare the effectiveness of ephedrine versus phenylephrine in fetal outcome and the treatment of fall in blood pressure during subarachnoid block for elective cesarean section. Materials and Methods: Study Design: Prospective, randomized, double blind. Based on inclusion and exclusion criteria 50 patients were selected and divided into two equal groups. All patients were done under subarachnoid block as per routine in our hospital. Group E received Ephedrine 6mg if >20% fall in the heart rate and systolic blood pressure from the baseline. Group P received phenylephrine 20mcg as increments if>20% fall in the heart rate and systolic blood pressure from the baseline. Results: Both the groups were comparable with regard to the fetal outcome (Apgar score and fetal umbilical vein ABG). Nylephrine group showed statistically significant fall in heart rate and systolic blood pressure when compared to the Ephedrine group during the first 20minutes. After 25th minute both the drugs were comparable. Conclusion: Both the drugs were comparable with respect to the fetal outcome and maternal hemodynamics in patients undergoing elective cesarean section under subarachnoid block.

327-333

Authors: Chhaya M Suryawanshi,Rajan Kumar*,Rachna Wadhwa

Introduction: Laryngoscopy and endotracheal intubation are noxious stimuli capable of producing tachycardia, arrhythmias and hypertension. This study was being done to compare the effectiveness of a pre-induction dose of clonidine with dexmedetomidine administered by intravenous infusion inattenuating the haemodynamic stress responses resulting from laryngoscopy and endotracheal intubation. Materials and Methods: Sixty adult patients included in this study were randomly divided into two groups, namely, Group A (Clonidine 4 mcg/kg) & Group B (Dexmedetomidine 1 mcg/kg) using computer generated random allocation chart and haemodynamic parameters were analyzed and recorded quantitatively from preoperative period to 30 mins post – intubation period. In the immediate post operative period and 2 hours after surgery, patient’s recovery was assessed with ALDRETE recovery score and BRUSSEL’S sedation score. Results: Mean heart rate showed fall following dexmedetomidine or clonidine infusion (19% and 23% respectively from the baseline) which was clinically significant in clonidine group but was statistically not significant in both the groups (p>0.05), while the increase in Mean heart rate following intubation was 8% and 10% respectively. In the current study, there was fall in blood pressure following infusion of study drug which was clinically not significant.Following tracheal intubation, maximal average increase was 5% in systolic and 3% in diastolic blood pressure in dexmedetomidine group, as compared to clonidine group in which, it was 6% and 4%, respectively. Isoflurane consumption, propofol requirement and opioid requirement throughout the intraoperative period was reduced in both the Groups. Aldrete recovery score and Brussels sedation score were calculated and found better in group B as compared to group A. Patients were sedated but arousable. Conclusion: Based on our study we conclude that both clonidine and dexmedetomidine are equally effective in attenuating the pressor response caused by laryngoscopy and tracheal intubation.q

341-347

Authors: Ashwini H,Seema Kumari K*,Lavanya R

Introduction: Post-operative sore throat is one of the most common complications following endotracheal intubation. Though considered minor complication, it may cause significant patient dis-satisfaction. Various non-pharmacological and pharmacological trials have been used with variable results. Objectives: To compare the efficacy of nebulised dexamethasone with that of nebulised magnesium sulphate in decreasing the incidence and severity of postoperative sore throat (POST). Materials and Methods: In this prospective double blind study 90 patients undergoing surgery under general anaesthesia with endotracheal intubation lasting <3hr> Results: Compared to group M, significantly lesser number of patients in group D had post-operative sore throat at 0hr (p= 0.0262), 4th hr (p=0.00022), 8th hr (p=0.00039) and 12hr (p=0.000657). None of the patients in group D had any hoarseness of voice at 0hr, 4th hr, 8th hr of assessment (p= <0> Conclusion: Preoperative dexamethasone nebulisation just before induction of anaesthesia is an effective method of reducing the incidence and severity of POST following endotracheal intubation. Dexamethasone nebulisation reduces the severity of sore throat more effectively than magnesium sulphate nebulisation.

354-360

Authors: Soma Ganesh Raja*,Gowri Shankar Sarate

Use of an effective sedative premedicant significantly minimizes the emotional trauma associated with perioperative anxiety and its sequelae. Currently, oral midazolam is the most commonly used premedicant in most of the countries followed by oral ketamine. Aims and Objectives: To compare the efficacy and safety of oral ketamine and oral midazolam as premedicant for paediatric cardiac catheterization. Materials and Methods: This study was carried out in the tertiary care centre in sixty patients randomly assigned into two groups of thirty patients each, to compare the efficacy of oral ketamine and oral midazolam pre medication as sedative for paediatric patients undergoing cardiac catheterization using various parametes and observation scale of response and Visual Analogue scale. Data collected was analysed and the statistical significance of these intra-group and inter-group observations thus made was determined using either a ‘Chi Square test’ or an ‘Unpaired T-test’ or Mann whitney test. Results: The demographic trends in all the groups were comparable. The type of procedure performed were also comparable in both the groups. The mean heart rate, mean systolic and diastolic blood pressures, mean arterial blood pressure were higher in the ketamine group than in the midazolam group. Though there was fall in oxygen saturation in both the groups the ketamine group required oxygen supplementation more than midazolam group though it was statistically insignificant. The mean onset of sedation was earlier for midazolam than for ketamine. Also the parental separation was smoother and calmer in patients who had oral midazolam than oral ketamine. Similarly while positioning the children for cath study also patients medicated with midazolam showed better response than those medicated with ketamine. The response to local anaesthetic injection during femoral vessels cannulation also showed midazolam with better results. The adverse effects such as secretions, nystagmus, nausea, vomiting, delirium were more common with ketamine. The mean time spent in recovery was 53.33 minutes with ketamine group and also parental satisfaction in terms of VAS score is better and favours midazolam than ketamine. Conclusions: Oral midazolam is a better premedication of choice than ketamine for paediatric patients undergoing cardiac catheterization.

368-372

Authors: Rashmi H D,Hanumanthappa V. Airani*

Introduction: Among the depolarizing muscle relaxants, Succinylcholine is the widely used depolarizing agent until today in anaesthesia practice. Side effects like hyperkalemia, fasciculations, myalgia, increased intracranial pressure and intraocular pressure are common with the use of this drug. Pretreatment with various drugs have been proven to lessen these side effects. In our study, low dose of oral pregabalin was used as a premedication to assess its effects on the incidence and severity of fasciculations and postoperative myalgia caused by Succinylcholine administration. Materials and Methods: 60 patients of either gender undergoing elective ENT surgeries under general anaesthesia were randomly allocated to two groups of 30 each. Patients in Group PG (pregabalin group) received 75 mg of pregabalin orally 1 h prior to surgery and patients in Group CG (control group) received matching placebo. Fasciculations and myalgia grading was done by a blinded observer. Haemodynamic variables were measured at regular intervals. Results: Both groups were comparable in regard to Demographic data (p > 0.05). We didn’t find any significant difference in the fasciculations incidence (p=0.702) and myalgia incidence (p=0.081) between the two groups. But the severity of fasciculations is statistically significant between the groups (< 0>P < 0> Conclusion: Low dose oral pregabalin- 75 mg decreases the severity of succinylcholine-induced fasciculations and myalgia. There is not much effect on the incidence of fasciculations and myalgia in patients undergoing elective ENT surgeries.

378-382

Authors: Shipra Singh,Suruchi Ambasta*

Introduction: Critically ill patients are prone to develop malnutrition which is a major contributory factor to the already existing burden of morbidity and mortality. Early nutrition support is an effective therapy to prevent malnutrition when patients are unable to take oral nutrition. Aim: To determine the effectiveness of a nutrition support protocol versus non-protocol management on initiating nutrition support in ICU patients. Materials and Methods: This randomized controlled study was conducted on fifty critically ill patients on mechanical ventilation with twenty five patients in each group. Nutrition protocols were followed in Group I patients and group II comprised of nonprotocolised patients. Results: Hospital stay for group I patients was 22.7 days while group II patients stayed for 31.9 days (p-value <0> Conclusion: Patients in whom nutrition support protocols were followed received enteral nutrition earlier, had early weaning from ventilator, spent less time in ICU as well as hospital and had lesser complications with low mortality.

389-393

Authors: B Sanjeev Kumar,Pratheeba N*,Remadevi R,Ravindra Bhat R,Senthilnathan M

Introduction: The potential long-term complication of intraoperative awareness needs to be addressed. These complications range from mild auditory perceptions to being fully awake. Studies with prospective patient interviews that specifically inquire about awareness have noted an incidence of 0.1 to 0.2 percent in the general population and approximately 1 percent in high-risk populations. Aims and Objectives: Comparative evaluation of two dose regimens of propofol to assess the depth of anesthesia during total intravenou anesthesia using Bispectral index monitor. The objectives were to find the average Bispectral index during propofol anaesthesia, compare and determine, in two groups, the amount of additional bolus or reduction in the infusion rates of propofol in two dose regimens and to correlate the Bispectral indices with hemodynamic monitoring and to assess incidence of postoperative awareness in the two groups. Materials and Methods: This study was conducted as a prospective randomized double-blind study in a teaching hospital. After the approval from the Ethics committee of the institution, 50 ASA I-II patients were randomly divided into two groups (GI and GII). The patients were induced with a standard regimen of 2 mg kg-1 of propofol and 0.1 mg kg-1 of vecuronium and intubated using appropriate sized endotracheal tube. Following intubation, propofol was infused according to the group the patients was allotted. GI received propofol infusion maintenance dose of 10 mg kg-1 hour for the first 10 minutes following intubation, 8 mg. kg-1 hour for the next 10 minutes and thereafter 6 mg kg-1 hour for the entire length of the surgery. GII received propofol infusion maintenance dose of 8 mg kg -1hour for the first 10 minutes following intubation, 6 mg kg -1hour for the next 10 minutes and thereafter 4 mg kg-1 hour for the entire length of the surgery. The Bispectral index, blood pressure and heart rate were monitored during intubation and thereafter every five minutes for the entire length of the surgery. And the propofol dose was adjusted to maintain the Bispectral index between 40 and 60. Results: Additional doses of propofol were required in the GII 8/6/4 mg kg-1 hour regimen when compared to GI 10/8/6 mg kg-1 hour dose regimen. The average Bispectral index was comparable in the two groups. Conclusion: Patients were hemodynamically stable when the Bispectral index was maintained between 40 and 60. Intraoperative awareness was not detected during this study.

399-402

Authors: Shivanand L. Karigar*,D G. Talikoti,Basavaraj Patil

Introduction: After the birth of the baby if the placenta is not expulsed within 30 minutes of the delivery, it is termed as retained placenta. The incidence of retained placenta is 2% of deliveries world-wide and is an important cause for maternal mortality and morbidity. Nitroglycerine (NTG) is an organic nitrate that relaxes smooth muscles and produces a generalized vasodilatation. As it relaxes the smooth muscle, it is also used as a uterine relaxant for manual placental removal. Aims and Objectives: To know the efficacy and safety of intravenous NTG in manual removal of placenta and to know the hemodynamic effects during the procedure. Materials and Methods: Total number of patients included in this study were 40. Patients were divided in two groups, each group having 20 patients each. Group 1 patients were administered with 100 microgm of NTG and group 2 patients with 150 microgm of NTG. Clinical parameters and complications were studied and compared between the two groups. Placenta was observed for separation and graded as easily separated, separated with assistance, difficult to separate, failed to separate. The clinical parameters like hypotension, tachycardia, headache after awakening, palpitation after awakening were compared between the two groups. Results: In group 1, we observed that placenta was easily separatedin 12 patients (60%), separated with assistance in 3 patients (15%), difficult to separate in 3 patients (15%) and in 2 patients (10%) placenta was not separated. In group 2, we observed that, placenta was easily separated in 14 patients (70%), separated with assistance in 2 patients (10%), difficult to separate in 2 patients (10%) and in 2 patients (10%) placenta was not separated. Conclusion: Intravenous NTG is an effective and safe method for manual removal of placenta with a dose of 100 microgram.

407-414

Authors: Pradeep Hosagoudar*,K R Vimala,Uday Bhaskar,Vallur Swetha Redd,L Krishna,Pradeep Hosagoudar*,K R Vimala,Obstetrics and Gynecology Obstetrics and Gynecology,Vallur Swetha Reddy,L Krishna

Introduction: Labor pain is the most severe pain a women would experience and several treatment modalities have been adopted since decades. Labor analgesia using epidural technique is considered as the efficient and effective treatment options available. Parturients in India especially rural areas are less aware regarding labor analgesia using epidural technique. Aim: To study the effects of labor analgesia using epidural technique in nulliparous women. Materials and Methods: Sixty full term nulliparous women with singleton vertex pregnancy were made aware of labor analgesia using epidural technique and included, those willing were grouped epidural(n=30), those not keen were grouped control(n=30). In 1st stage labor, parturients in epidural group received bupivacaine and fentanyl, whereas in control group received intramuscular Inj. tramadol, and Inj. pethidine if needed. Duration of 1st and 2nd stage labor, pain relief, maternal satisfaction, adverse effects, instrumental deliveries, 1st and 5th minute Apgar score and NICU admission were recorded. Results: The mean duration of first stage labor was shorter (p=0.071) in epidural group (250.17±106.33 minutes) compared with control group (302.0±111.99 minutes) and statistically insignificant prolongation (p=0.892) (18.73±6.82 minutes) of 2nd stage labor as compared to control (18.33±14.53 minutes). Pain relief in epidural group was statistically significant (p<0 p=1.00).>st (p=0.306) and 5th minutes (p=1.00), NICU admission rate were statistically insignificant (p=0.143) between groups. Conclusion: Labor epidural analgesia using Inj.bupivacaine and Inj.fentanyl provides good pain relief, safe for mother and baby. It does not affect labor duration, instrumental delivery rate or neonatal outcome.

423-430

Authors: Ruma Thakuria,Tridip Jyoti Borah*,Jaideep Sonowal,Dipika Choudhury

Introduction and Aim: Dexmedetomidine, a neuraxial adjuvant, when given intrathecally with hyperbaric bupivacaine provides stable hemodynamic conditions, good quality of intraoperative and prolonged postoperative analgesia with minimal side effects. When intravenous dexmedetomidine is used in conjunction with neuraxial anesthesia, few studies have shown that it prolongs the sensory-motor blockade and provides better intraoperative and postoperative analgesia. We formulated this hypothesis that intravenous (IV) dexmedetomidine bolus followed by infusion would prolong the duration of subarachnoid block (SAB) with 0.5% heavy bupivacaine. Our aim was to assess the onset and duration of sensory and motor blockade following IV dexmedetomidine supplementation after SAB. Materials and Methods: Sixty American Society of Anesthesiologists Grade I and II patients undergoing elective surgeries under spinal anesthesia were randomized into two groups of 30 each. Immediately after subarachnoid block with 3 ml of 0.5% hyperbaric bupivacaine, patients in group II received a loading dose of 1 µg/kg of dexmedetomidine intravenously by infusion pump over 10 min followed by a maintenance dose of 0.5 µg/kg/hr till the end of surgery, whereas patients in group I received an equivalent quantity of normal saline. The time to reach peak sensory block level, time taken for two segment regression and maximum motor block, total duration of sensory and motor blockade, Ramsay sedation score and modified Bromage score were statistically analyzed using Statistical Package for Social Sciences (SPSS Inc. Chicago, IL, USA) Windows-based version 16.0. Results: Two segment regression time of sensory blockade was more in the dexmedetomidine group (130.33±14.49 mins) as compared to the normal saline group (94.67±15.02 mins) which was statistically significant (P< 0> Conclusion: The results of the present study shows that, intravenous dexmedetomidine given as a loading dose followed by maintenance dose prolonged the duration of sensory and motor blockade of bupivacaine-induced spinal anesthesia. It also provided conscious sedation without respiratory depression while maintaining good hemodynamic stability.

437-439

Authors: Gunaseelan S,Arun Kumar. J*

Introduction: Axillary block with Bupivacaine mixed with adjuvants like dexmedetomidine, a more selectivealpha2 adrenoreceptor agonist, induces faster onset of blockade, delays the absorption of local anaesthetic and prolongs its action. Steroid adjuvants like dexamethasone can decrease inflammation at the same time demonstrated prolonged analgesic effect. The study aimed at comparing the efficacy of these adjuvants in affecting regional block onset and duration. Materials and Methods: This Randomized, uncontrolled, single blinded, two-arm, concurrent parallel trial was conducted during January to March 2017 among 60 participants posted for forearm and hand surgeries randomly allocated into two groups viz: Group A: 30 subjects given a mixture (30ml) of Bupivacaine (0.25%) and Dexamethasone (8mg) and Group B: 30 subjects given 30ml a mixture (30ml) of Bupivacaine (0.25%) and 1 ml of dexmedotomidine (100µg). The intra and post-operative outcomes of the two groups were compared statistically. Results: The onset of motor and sensory blockade was significantly (p<0> Conclusion: Dexmedotomidine when compared with Dexamethasone used as an adjuvant to Bupivacaine in axillary block for forearm and hand surgeries showed marked efficacy in terms of earlier onset of action, prolonged blockade and longer duration of post-operative analgesia.

445-450

Authors: Viji S Pillai*,Bhagyalakshmi Ramesh,Silvy Anna Varughese

This study compares the safety and efficacy of multiple level thoracic paravertebral block and modified Pecs block for postoperative pain relief after Modified Radical Mastectomies. After Institutional Review Board [IRB] and Human Ethics Committee [HEC approval, the study was conducted on 41 patients who were scheduled to undergo modified radical mastectomy. Written informed consent was taken. Female patients in the age group of 18-75 years who were ASA grade I and II were randomly allocated to two groups to either receive Ultrasound guided Thoracic paravertebral block TPVB at T2 and T4 levels (Group 2) or an ultrasound guided modified PECS block (Group 1) preoperatively in the block room. Paravertebral block was given at two vertebral levels T2 (10 ml) and T4 level (10 ml) under ultrasound guidance utilising the parasagital in-plane technique. Modified PEC block was administered to patients in the PEC group.10 ml of 0.5% Ropivacaine for Pec1 and 20ml for Pec 2. In all patients surgery was done under GA. Pain was assessed with Numerical Rating Scale (NRS) on a 0 to 10 scale, for 24 hours after surgery, at 0,0.5,1,1.5,2,4,6,12 and 24 hours after surgery by a blinded observer. Rescue opioid and Paracetamol requirement was recorded. The patients were also monitored for any specific block related complications. Primary outcome measures were the numerical rating scores for pain and rescue analgesic requirement. Secondary outcome measures was looking for any block related complications. Demographic categorical variables were expressed in frequency and percentage, and the continuous variables were reported in terms of mean and standard deviation. The comparison of pain scores between the thoracic paravertebral nerve block and modified pectoral nerve block was done using Mann-Whitney U test. Mean duration of analgesia and mean 24 hour Morphine, Paracetamol consumption was compared using Student's t test. There was no statistically significant difference between the two groups with respect to the pain scores at 0,0.5,1,1.5,2,4,6,12,and 24 hours at rest or with movement of the ipsilateral arm. The 24 hour Morphine consumption was not also statistically significant. [pec gp,mean 2.17, SD 1.09, tpvb gp mean 2 SD 0.77, p value 0.752.] Paracetamol consumption in the initial 24 hours after surgery was also not statistically significant between the two groups (pec gp. 36.8% and tpvb gp. 50% patients received paracetamol with a p value of 0.523). We found both the blocks, modified Pecs and multiple level paravertebral block were equally effective in treating postoperative pain.

453-456

Authors: Nitin Choudhary*,Abhijit Kumar,Sonia Wadhawan,Poonam Bhadoria,Vishnu Panwar

Large retrosternal goitre is a challenge to the anaesthesiologist and the surgeon. We describe the successful anaesthetic management of a 44 year old male patient with extensive retrosternal goitre with severe tracheal compression, operated for total thyroidectomy under general anaesthesia by combined cervical approach and sternotomy. A multidisciplinary team approach with surgical colleagues allowed successful management of the patient.

459-460

Authors: Rashmi Patil,*,Madhuri Kurdi

Tonsillectomy is a commonly performed procedure in children. Disseminated sepsis is a rare complication of tonsillectomy. Patients usually present with hypotension, reduced oxygen saturation, tachycardia with high total count and reduced urine output. Our patient also required NIV (non-invasive ventilation), ionotropes and antibiotics with serial blood examinations. Early diagnosis and prompt treatment will help in better outcome. The tonsils contain T lymphocytes and macrophages as they serve immune defense mechanisms. Tonsillitis is most commonly caused by viral infection, 40% of cases are caused by bacterial infection. Immunological functions like antigen transport and antibody production are altered in diseased tonsils. The presence of various micro organisms in the open tonsillar bed during and after tonsillectomy acts as foci of infection. The tissue reaction and presence of micro-organisms is also due to different surgical techniques involved.