Clinical Anaesthesia

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.
Keywords: Epidural block, Epidural catheter, Breakage, Radiological imaging, Neurological symptoms.

A comparative study of intrathecal low dose bupivacaine with fentanyl and low dose levobupivacaine with fentanyl in transurethral resection of prostate: Randomized, double blind, prospective study Abstract Objective: Isobaric levobupivacaine has been recently introduced for intrathecal use and there are very few studies comparing it with widely used hyperbaric bupivacaine. So this randomized trial was planned to study the effectiveness of intrathecal low dose isobaric levobupivacaine with fentanyl and compare it with low dose hyperbaric bupivacaine with fentanyl in transurethral resection of prostate. Materials and Methods: This prospective, randomized, double blinded study was conducted in 60 ASA physical status I and II patients, aged between 50-80 years and posted for transurethral resection of prostate under subarachnoid block. Enrolled patients were divided into two groups of 30 each. Patients in Group B received 7.5mg, 0.5% hyperbaric bupivacaine with 25mcg fentanyl intrathecally while patients in Group L received 7.5mg, 0.5% isobaric levobupivacaine with 25mcg fentanyl intrathecally. Time to achieve sensory block to T10 level, max spread of sensory block, time to two-segment regression and time to S1 regression were recorded. Motor blockade was assessed at every 2 minute for 20 minute, at the end of the surgery and in recovery room. Onset time of motor block, maximum motor block and duration of motor block were also recorded. Results: A total of 60 subjects were enrolled. Baseline parameters were comparable. Onset of sensory block was significantly faster in group B compared to group L. The mean time of onset in Group B was 4.75±0.79 min. and in Group L was 6.60±0.61 min. Both group had statistically significant difference in onset and duration of motor block. The mean time of onset of motor block in Group B was 6.4±1.6 min and in Group L was 9.9±2.3 min. The mean duration of motor block in Group B was 164.17±22.8min and in Group L was 138.27±23.5min. Group B had statistically significant dense block compared to group L. The median MBS in Group B was 1(95% C.I. 1.18-1.68) and in Group L was 2 (95% CI 2.13-2.86). In group B, 20 patients had complete motor block while in group L number of patient with complete motor block was only 4. Conclusion: Our results, suggest that subarachnoid low-dose isobaric levobupivacaine fentanyl provides lesser degree of motor block & for short duration when compared with heavy bupivacaine.

Supraglottic airway devices have a special niche for themselves with regards to airway management in modern anaesthesia practice. They have become a very good alternative to mask ventilation and tracheal intubation in elective surgeries and have an important place in the emergency settings. The single-use supraglottic airway devices I-gel™ and LMA-Supreme™ have been developed with the aim to overcome the limitations and improve the efficacy of currently available supraglottic airway devices like there airway sealing pressure, ease of placement but with discordant results with regards to airway sealing pressure, ease and success of placement and airway morbidity. The aim of this prospective, randomized trial was to evaluate these two airway devices in routine clinical practice. Materials and Methods: 80 patients (ASA grade1-2) were randomly allocated to two groups; Group I (I-gel TM ; n=40) and Group S (LMA-Supreme TM ; n=40). A size 3 or 4 (I-gel TM and LMA-Supreme TM) was used in patients and inserted by experienced anaesthesiologists who had 3 years' experience and had performed 20 successful insertions with each device. First attempt success rate, time for insertion and airway sealing pressure of each device was measured. Airway sealing pressure with LMA-Supreme TM was measured at an intracuff pressure of 60cmH2O. Patients were enquired after surgery for the presence of any dysphagia, sore-throat or hoarseness of voice. Data were analyzed statistically using unpaired 't' test and Chi-square test. A p value of < 0.05 was considered to be statistically significant. Results: The first attempt success rate for I-gel TM was 92.5% and for LMA-Supreme TM was 87.5%. Ventilation was established in 19.7 seconds (range 14-24 seconds) in the I-gel TM group and in 24.2 seconds (range 19-29seconds) in LMA-Supreme TM group (p<0.001). There was no failure in either of the groups. Mean airway sealing pressure was comparable between both the devices (I-gel TM 23.2 cmH2O; LMA-Supreme TM 22.4 cmH2O; p>0.001). Conclusion: Both I-gel TM and LMA Supreme TM are disposable, latex-free devices which do not need any digital or introducer tool for insertion. They have good airway sealing pressures, ease of insertion and low airway morbidity especially with I-gel, so they can be a good choice in patients undergoing elective surgeries.
Keywords: I-gel, LMA supreme, Airway sealing pressure.

Knowledge of 2015 basic life support (BLS) guidelines among doctors and nursing staff of a rural based tertiary care hospital, in western India: Current status and requirement Abstract Background & Aim: The chances of return of spontaneous circulation and survival to hospital discharge increase after cardiac arrest with high quality cardiopulmonary resuscitation (CPR). In the era of evidence based medicine and as a requirement of National accreditation board for Hospitals and healthcare providers (NABH), basic life support (BLS) should be practiced as per latest guidelines. The aim of this study was to evaluate the knowledge of recent BLS guidelines with emphasis on high quality chest compressions, among doctors and nursing staff of our center. Method: This cross-sectional study was conducted in a tertiary care hospital in Western India. The awareness about recent guidelines of American heart association (AHA), BLS, and factors associated which include profession, age, gender, current primary posting, previous BLS training and updated with Highlights of 2015 was assessed by using a MCQ based questionnaire. Statistical Analysis: The descriptive analysis was run to find the proportions of various parameters and Chi-square test was applied to find association between different qualitative variables. Significant result was considered at 5% level of significance. Results: Among 213 participants, 92 were doctors and 121 were nursing staff. Only 10.3% had acceptable score (>16 correct answers out of 20 MCQs). Relation between acceptable score and responders having updated with 2015 guidelines and previous BLS training was found to be statistically insignificant. Conclusion: Knowledge about BLS is very poor among health care providers in a tertiary care hospital.

Aim: This study aims to evaluate the effects of prophylactic use of oral esomeprazole, pantoprazole and Placebo on Gastric pH and Gastric volume at the time of induction (post-induction) and at recovery (pre-extubation), in fasting patients undergoing surgical procedure under general anaesthesia. Material and methods: This prospective, randomized, double blind, placebo controlled study was done in sixty patients of ASA physical status 1or 2, aged between 18 – 65 years, of either sex, scheduled for elective surgery under general anaesthesia, were enrolled for the study. Results: There was no statistically significant difference between the groups with respect to age and weight and also between the groups when compared to premedication to intubation time, premedication to extubation time and duration of surgery. When compared with placebo, the reduction in gastric volume was statistically (P<0.01) and clinically significant in both pantoprazole and esmoprazole group during post induction (V1) and pre extubation(V2) time. However, when comparing with esomeprazole and pantoprazole there was no significant difference between the two groups. In V1 (post-induction) the maximum volume obtained in placebo, pantoprazole and esomeprazole groups were 25ml, 15ml, and 15ml, respectively whereas in V2(pre-extubation) the maximum volume for placebo, pantoprazole and esomeprazole were 20ml, 15ml and 10 ml respectively. In fact we failed to obtain any gastric aspirate in one patient in each groups. Both post-induction(pH1) and pre-extubation (pH2) pH in esomeprazole group, the increase in gastric pH was statistically(P<0.001) and clinically significant when compared with placebo. In pantoprazole group also, the increase in gastric pH was statistically and clinically very highly significant when compared with placebo. Also when comparing esomeprazole and pantoprazole, esomeprazole was more effective in increasing gastric pH which was statistically significant (P<0.01). Conclusion: Both esomeprazole and pantoprazole when administered orally are effective in reducing gastric volume and increasing pH as compared to placebo. Tablet esomeprazole and pantoprazole are comparable with respect to reduction in gastric volume but esomeprazole increase the gastric pH more effectively than pantoprazole.

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

The central nervous system (CNS) deserves special consideration in the perioperative setting for several reasons for an anesthetist. An understanding of neuroanatomy is essential because neuro anesthesia continues to develop and evolution of neurosurgical practice is accompanied by new challenges for the anesthetist. Basic knowledge and expertise of the neuro-anesthetist can directly influence patient outcome. With the recent advancement in functional and minimally invasive procedures, there is an increased emphasis on the provision of optimal operative conditions, preservation of neurocognitive function, minimizing interference with electrophysiological monitoring, and a rapid, high-quality recovery. So, during neuro anesthesia, anesthesiologist needs to know physiology of CNS including cerebral metabolism and cerebral blood flow. Neuro anesthesia can be challenging, because sometimes apparently contradictory demands must be managed, for example, achieving optimal conditions for neurophysiological monitoring while maintaining sufficient anesthetic depth, or maintaining oxygen delivery to neuronal tissue and simultaneously preventing high blood pressures that might induce local bleeding. One of the peculiarities of neuro anesthesia has always been that as much importance is attached to wakening the patient as sending them to sleep. We have included the anesthesia for neurosurgery in two parts. In the first part, we had discussed cerebral anatomy, physiology and intracranial pressure, in the second part we have included anesthesia considerations for surgery for brain tumor, aneurysmal surgery, temporal lobe surgery, trans sphenoidal surgery and traumatic brain injury.
Keywords: Anesthesia, Neurosurgery.

The central nervous system (CNS) deserves special consideration in the perioperative setting for several reasons for an anesthetist. An understanding of neuroanatomy is essential because neuro anesthesia continues to develop and evolution of neurosurgical practice is accompanied by new challenges for the anesthetist. Basic knowledge and expertise of the neuro-anesthetist can directly influence patient outcome. With the recent advancement in functional and minimally invasive procedures, there is an increased emphasis on the provision of optimal operative conditions, preservation of neurocognitive function, minimizing interference with electrophysiological monitoring, and a rapid, high-quality recovery. So, during neuro anesthesia, anesthesiologist needs to know physiology of CNS including cerebral metabolism and cerebral blood flow. Neuro anesthesia can be challenging, because sometimes apparently contradictory demands must be managed, for example, achieving optimal conditions for neurophysiological monitoring while maintaining sufficient anesthetic depth, or maintaining oxygen delivery to neuronal tissue and simultaneously preventing high blood pressures that might induce local bleeding. One of the peculiarities of neuro anesthesia has always been that as much importance is attached to wakening the patient as sending them to sleep.

Trauma has been a widely studied subject in western world in past decade. Many international organizations
have formulated guidelines regarding the management of victims who have threatened airway due to any
kind of trauma. Indian subcontinent is following the western world in such situations but incidence and
nature of trauma is different, moreover the availability of resources varies. This review article will highlight
the topics like need for pre-hospital intubations, status of rapid sequence intubation, cricoid pressure,
adjuncts for intubation and airway management of victims with trauma of special nature.
“My heart and soul were wrecked; I was not sure whether my windpipe is going to make it or not”- Joshua
Graham

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.
Keywords: Modified pectoral nerve block, Multiple level thoracic paravertebral block, Postoperative analgesia, Modified radical mastectomy.

Introduction: Regional blocks are increasingly the preferred for a wide range of lower limb surgical procedures over spinal and epidural anesthesia. Various local anesthetic agents in different concentrations have been used for combined femoral and sciatic nerve block. But the existing evidence is inconclusive on the ideal anesthetic agent and its concentration. The available evidence on relative merits of different anesthetic agents in Indian Population is even limited. Objectives: To compare the safety, efficacy and hemodynamic parameters of 0.5% Bupivacaine and 0.5% Ropivacaine during combined femoral and sciatic nerve block. Materials and Method: The study was a randomized double-blind controlled trial of 36 subjects, randomly assigned to 0.5% Bupivacaine and 0.5% Ropivacaine groups. Subjects between 18 to 60 years belonging to ASA grade I and II, posted for various below knee lower limb procedure were included. Time is taken for onset of sensory and motor block, duration of sensory and motor block was compared across the study groups using independent sample t-test. The occurrence of complications and hemodynamic parameters also were compared. Results: In the current study, no statistically significant difference was observed in the time taken for onset of sensory block in either femoral nerve (13.39 and 13.69 minutes in Bupivacaine and Ropivacaine groups respectively, p value 0.39) or sciatic nerve (17.19 and 17.14 minutes, p value 0.89) The motor blockade took 21.28 and 21.64 minutes respectively in both the study groups (P value 0.53). In the current study, the duration of sensory block was slightly longer in Bupivacaine group, as compared to Ropivacaine group (933.67Vs 924.22, p value 0.19), but this difference was statistically not significant. The duration of motor block was significantly longer in Bupivacaine group (243.78 Vs 189.11, p value 0.001), as compared to Ropivacaine group. None of the study subjects in both the groups have reported any complications. There were no significant differences in hemodynamic parameters across the groups. Conclusions 1. Both sensory and Motor block onset time were similar with 0.5% Bupivacaine and Ropivacaine in combined femoral and sciatic nerve block. The duration of sensory block also was comparable across the two groups 2. Bupivacaine had comparatively longer duration of motor block, as compared to Ropivacaine group 3. There were no clinically or statistically significant differences in hemodynamic parameters

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.
Keywords: Video laryngoscopes, Endotracheal intubation, Airway morbidity, Haemodynamic changes

Introduction: Equilibration point of an inhalational agent is the transition point when ratio of expired (Fe) to inspired (Fi) concentration of inhalational anaesthetic agent (Fe/Fi) reaches 0.8 or when uptake of volatile agent reaches 80%. It helps in reducing the duration of initial high gas flows before switching over to low flows.
Aim: To compare Desflurane with Isoflurane for equilibration time, intraoperative hemodynamic parameters and post extubation recovery parameters.
Materials and Methods: Depending on the volatile anesthetic agent being used patients were randomly allocated into two groups. Group I (n =25) received Desflurane and Group II (n=25) received Isoflurane as inhalational anesthetic agent. In all patients low flow anaesthesia was given after achieving equilibration time and that time was noted. Other parameters measured were intraoperative heart rate, mean blood pressure, mean EtN2O, mean EtFe (End tidal volatile anesthetic agent concentration), recovery parameters (recovery time, recovery score and vitals) and any complications if any.
Statistics: Analysis was performed on SPSS (Statistical package for social sciences) version 17.0 Statistical Analysis Software.
Result: The equilibration point for group I was achieved in 2.18 ± 0.84 min and for group II was achieved in 10.08 ± 2.36 min and this difference was statistically significant. The intraoperative heart rate and MAP did not differ significantly (p>0.05) between the two groups at all time periods. On comparing, post extubation vitals i.e. HR (8.1%) and recovery time (69.9%) they were found significantly (p<0> Conclusion: Desflurane use results in shorter equilibrium time and earlier reduction of FGF with early and better recovery than Isoflurane.
Keywords: Desflurane, Isoflurane, Low flow Anaesthesia, Equilibration time.

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

Background: In paediatric airway management, uncuffed Endo tracheal tubes(UETT) were always thought to be safe for practice. Cuffed ETT(CETT) were found to cause airway edema and increased resistance to airflow in the post extubation period. With the advent of Microcuff paediatric tracheal tube (MPTT), the airway management protocol has led to tremendous change. The goal of our study was to compare TT exchange rates and post extubation stridor between MPTT and uncuffed TTs in paediatrics. Methods: 140 paediatric patients aged 1 to 6 yrs., requiring general anesthesia were divided into group 'MPTT' (Microcuff Paediatric Tracheal Tube) and group 'U' (Uncuffed ETT) randomly. Patients were intubated orally following which incidence of number of tube exchange rates and post-extubation stridor for both MPTT and uncuffed tubes was noted. In addition, airway sealing pressure was noted for MPTT. Results: We found that, there was less tracheal tube exchange rate with MPTT and post extubation stridor was comparable with uncuffed ETT. Conclusion: This clinical study shows that the MPTT are safe for use as they have fewer incidence of airway morbidity namely tube exchange rates and post extubation stridor.

The prevention of ventilator-induced lung injury and diaphragmatic dysfunction is now a key aspect in the management of mechanical ventilation, since these complications may lead to higher mortality and prolonged length of stay in intensive care units. Different physiological measurements, such as esophageal pressure, electrical activity of the diaphragm, and volumetric capnography, may be useful objective tools to help guide ventilator assistance.

A randomized clinical comparative trial to study the efficacy of adding Clonidine or Dexamethasone to Bupivacaine(0.5%) in prolonging the duration of post operative analgesia with ultrasound guided TAP block in cesarean delivery Abstract Introduction: With dramatic rise in the rate of cesarean deliveries in the last two decades, post-operative pain management of these patients has become a major medical challenge. We studied the efficacy of adding dexamethasone and Clonidine as adjuvants to bupivacaine using USG guided TAP block. Material and Methods: 60 patients posted for elective cesarean delivery under spinal anesthesia were selected for the study. Patients received 20ml of 0.125% Bupivacaine with Dexamethasone (4mg), Clonidine(25µg), Saline(2ml) on each side, in groups D,C and B respectively. Post-operatively pain scores using VAS score, time to first rescue analgesic, and 48hr analgesic consumption were studied. Results: VAS scores were comparable in all the three groups in the first 12hr, it was higher in group B in the next 36hrs. Time to first resque analgesic was prolonged by 2hrs in all three groups. Tramadol requirement was significantly lower in the group C and group D after 12hrs. Conclusion: We conclude that USG guided TAP block using either clonidine or dexamethasone as adjuvants to bupivacaine will equally help in alleviating the somatic pain for extended period of time thereby providing substantial improvement in quality of pain care and breast feeding experiences.

Introduction: The combined spinal epidural anesthesia (CSE) plays a unique role in management of
perioperative analgesia. It is associated with early postoperative mobilization and rehabilitation with
minimally associated pain and discomfort, which is the most desirable feature in modern surgery.We
designed this study for comparative evaluation of dexmedetomidine and ketamine for epidural analgesia
in lower limb orthopedic surgeries in patients operated under CSE.
Materials and Methods: The study included 50 patients divided into two groups (25 each). Group D:
Patient received bolus dose of dexmedetomidine 1 mg/kg after spinal anesthesia followed by bupivacaine
0.125% with dexmedetomidine 1 mg/ml epidurally using 240 ml elastomeric pump at 5ml/ hr till 48 hours.
Group K: Patient received bolus dose of ketamine 0.5 mg/kg after spinal anesthesia followed bupivacaine
0.125% with ketamine 0.5mg/ml epidurally using elastomeric pump at 5ml/hr till 48 hours.
Results: There was no significant difference between the two groups (p>0.05) in terms of highest sensory
level achieved and time for complete motor block. The patients in both the groups were hemodynamicaly
stable throughout the study. The duration of analgesia was longer with dexmedetomidine however, none
of the patients in both the groups required rescue analgesic. The time to regression of sensory level to L5
in Group D was found to be 594  63.04 minutes as compared to 362.4  45.76 minutes in Group K (p
< 0.001) while, the time to regression of motor block to Bromage scale 1 in Group D was 488.4  42.88
minutes whereas, in Group K it was 303.6  36.04 minutes (p < 0.001). The incidence of sedation, nausea,
vomiting and other side effects were comparable.
Conclusion: We conclude that continuous epidural infusion with dexmedetomidine and ketamine
effectively reduced the postoperative rescue analgesics requirements and provided good patient satisfaction
in patients undergoing lower limb orthopedic surgery.

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.
Keywords: Tonsillectomy, Sepsis, Hypotension, Inflammation.

Objectives: This study is to know the efficacy of 5µg and 10µg of Dexmedetomidine adding to 0.5% bupivacaine (heavy) under spinal anaesthesia for urological procedures. The purpose of our study is to know sensory onset, motor onset, sensory blockade duration, motor blockade duration, effective analgesia duration, rescue analgesia duration, VAS score, haemodynamic factors like heart rate and blood pressure and also untowards adverse effects. Materials and Method: In a prospective randomized study, 120 patients of ASA grade I/II aged between 20-60 years undergoing urological surgeries were divided randomly into three groups of 40 each. Group D5-0.5% hyperbaric bupivacaine 12.5 mg (2.5ml) + 5 µg Dexmedetomidine, Group D10-0.5% hyperbaric bupivacaine 12.5 mg (2.5ml) + 10 µg Dexmedetomidine, Group BS-0.5% hyperbaric bupivacaine 12.5mg + normal saline 0.5ml. Results was analysed using one way ANOVA and Kruskal wallis test. p<0.05 considered statistically significant. Results: In Dexmedetomidine groups sensory and motor blockade onset was early (Group D10>Group D5). Sensory blockade duration and motor blockade duration was increased. Effective and rescue analgesia duration was also increased in the order of GroupD10>Group D5>Group BS. There was no clinically significant haemodynamic parameters alteration without any adverse effects/complication among three groups. Conclusion: 10µg dexmedetomidine enhances the duration of analgesia and patients remained pain free for a longer period of duration in post-operative period compared to plain bupivacaine or 5µg dexmedetomidine with better haemodynamic stability with minimal or no adverse effects.

Introduction: Postoperative pain is a common complaint following laparoscopic nephrectomies and in
these patients transverse abdominis (TAP) block is a useful an effective analgesic modality in controlling
pain compared to other techniques. This prospective randomized comparative study is to compare the
analgesic efficacy of unilateral TAP block versus bilateral TAP block for better analgesia postoperatively.
Materials and Methods: A total of 60 ASA I-II patients undergoing lapararoscopic nephrectomies (18-
60 years) were included and divided into two groups A(n=30) and B(n=30). Group A: Lateral ultrasound
guided(USG) unilateral TAP block with 20ml of 0.25% isobaric bupivacaine. Group B: Lateral USG guided
bilateral TAP block with 20ml of 0.25% isobaric bupivacaine at the end of surgery before extubation.
Statistical Design: the statistical testing conducted using statistical package for the social science system.
For all statistical tests, a p value less than 0.05 was taken to indicate a significant difference.
Results: We found that total mean analgesic duration of the block was significantly longer in bilateral
(B) group (14.3h2.48h rs) as compared to group A(6.22.14hrs) with p value of 0.000000017564. VAS
scores were significantly higher in the group A with p value of 0.00000000124575. The mean number of
doses of additional rescue analgesia (i.e fentanyl) in Group A was 3.12  0.72 as compared to 1.04  0.73
in Group B (given at 18 hrs.), the p value comes out to be 0.0000000125 which is statistically significant.
Conclusion: Bilateral USG guided TAP block is of more benefit than unilateral TAP block in reducing
postoperative pain and also reduced overall use of opioids in laparoscopic nephrectomies.

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.
Keywords: Levobupivacaine, Ropivacaine, Fentanyl, Post-operative analgesia, Local anaesthetics.

Introduction and Aims: ultrasound had revolutionized the nerve block by, increasing the reliability with less complications. This study evaluates the block characteristics and efficacy between perivascular and perineural ultrasound guided axillary brachial plexus block for upper limb surgeries.
Materials and Methods: 100 patients in the age group of 18-60 years belonging to ASA I,II physical status undergoing axillary block in upper limb surgeries were randomly allocated into Group PN- perineural (n=50) and Group PV- perivascular (n=50). In both the groups Musculocutaneous nerve block done with 6ml of local anaesthetic mixture. In perineural group, radial nerve, median nerve and the ulnar nerve were anaesthetized separately with 8ml of local anaesthetic mixture respectively. In perivascular group, the needle tip was then advanced dorsal to the artery, corresponding to 6’o clock position. 24ml of local anaesthetic mixture was incremently injected. The primary objective was to assess the success rate of blockade for surgery. The secondary objectives were to assess the onset and duration of sensory and motor block and to study the incidence of adverse effects.
Results: There was no statistical significance in the success rate of blockade between the techniques (PN-98% and PV 96% with P value is 0.362).The sensory and motor onset time in PN group(6.98 min,10.22 min) is faster than PV group(10.96 min,13.50) with P value was<0> Conclusion: we conclude that the USG guided perineural technique as more reliable than the USG guided perivascular technique of axillary block.
Keywords: Perivascular, Perineural, Ultrasound guided, Axillary brachial plexus block.

Introduction: Endobronchial Ultrasound Guided Trans bronchial needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic modality for evaluating intra thoracic lymph nodes, becoming one of the important tool in the armamentarium of pulmonologists. The size of the fiberscope and sharing of the airway with the bronchoscopist poses unique challenges to the anesthesiologist. In light of these developments it is important to develop an office based anesthesia technique for this relatively new procedure. Hence we did this descriptive cohort study.
Aim: To describe the accuracy and anaesthetic management of EBUS-TBNA as a day care procedure, done with general anesthesia (GA).
Materials and Methods: Data was collected from January 2017 to December 2017 at our institute from patients who underwent EBUS-TBNA under GA using second generation laryngeal mask airway (LMA). Specifically, hemodynamic status, Oxygen saturation, duration of the procedure, diagnostic yield and complications of the procedure were recorded.
Results: 23 patients underwent EBUS-TBNA under GA. All patients were found to be hemodynamically stable with fluctuations in blood pressure and heart rate being less than 20% from the baseline with no episodes of desaturation .The average number of biopsies taken is 3.3, with average duration of the procedure being 67.0±17.6 (mean±SD) minutes. The incidence of post procedural complications like cough and sore throat were minimal. Successful diagnostic yield was found in all cases with no incidence of recall of the procedure.
Conclusion: The performance of EBUS-TBNA under general anesthesia with LMA provides great hemodynamic stability and adequate ventilation in a shared airway. It demonstrates excellent diagnostic accuracy. It provides comfort to the patient and the good examination conditions to the bronchoscopist.
Clinical Significance: Use of P-LMA solves the dilemma of managing ventilation during EBUS TBNA without affecting the diagnostic yield of the procedure.
Keywords: Endobronchial ultrasound, Trans bronchial needle aspiration, LMA, Propofol.

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.
Keywords: Dexmedetomidine, Clonidine, Laryngoscopy, Aldrete score, Brussels score.

Introduction: Low flow anaesthesia, a technique introduced by Foldes in 1952 has resurged in clinical practice due to easy availability of low solubility inhalational agents. Being economical, ecological and clinically advantageous, it has initiated a renaissance in the field of anaesthesia. This study tested the safety and efficacy of LFA technique using Sevoflurane and its cost effectiveness. Materials and Method: A prospective observational study including 100 patients (ASA I/II,18-65 years) was conducted with the permission of institutional ethical committee and patient's consent. Selected patients were assigned into two groups by computer generated chit with fresh gas flow 3L and 0.5L in high and low flow group respectively. Chi square test and t test were used for stastical analysis. Primary objectives were to assess the economic efficacy of low flow technique and to compare the recovery characteristics of patients. Secondary objectives were to compare haemodynamic stability of patients in between two techniques. Result: Demographic data in both the groups were comparable. Both the techniques were comparable in terms of patient's haemodyanamic stability. Recovery was earlier in low flow group(p<0.05) with complete return of all reflexes. Consumption of sevoflurane was almost 2.5 times less in LFA group (p<0.001) as compared to high flow group. Conclusion: Low flow technique is a safe, economic & efficient technique of general anaesthesia.

Background: Nitrous oxide (N2O) is a gas, which provides good analgesia without many side effects for short procedures outside the operating room.It is combined with 50% oxygen and is available in premixed cylinders as Entonox. In our quest to find a safer alternative we decided to compare fentanyl with Entonox for acute pain and for small painful procedures in the casualty. Aim: To assess the effectiveness, feasibility and acceptance of Entonox in providing pain relief for patients who present with acute pain and for providing pain relief in short procedures in the casuality in comparison with fentanyl. Materials and Methods: A prospective single blinded randomized comparative study was conducted in Vinayaka Missions superspeciality hospital a unit of VinayakaMissions KirupanandaVariyar Medical College, Salem during the period between March 2014 and Feb 2015. The patients with pre-treatment score more than six (Pre VAS > 6) or planned for painful procedures were taken up for the study.. Group A was considered as the control group where all the patients received injection Fentanyl 2 micrograms per kg and group B was considered as the study group where all the patients received entonox.Fifty patients were done under each group. Results: The pain score of the patients were measured after giving the drugs at the interval of 10mins, 20mins and 30mins. The mean score of the patients in the entonox group at the end of 10mins was 3.16 and in fentanyl group it was 3.91 and similarly at the end of 20mins it was 2.98 in the entonox group and 3.42 in fentanyl group and there was a statistically significant difference between the two groups. The mean pain score at the end of 30mins was 1.48 and 1.78 in entonox and fentanyl group respectively and there was no statistical significant difference between the two groups. The adverse events like drowsiness and hypotension was more common in fentanyl group than that of entonox group and the difference was statistically significant (p<.05). In fentanyl group four patients developed respiratory failure and required assisted ventilation for 30mins,whereas no such incident had occurred in entonox group. Conclusion: Entonox is a safe and effective analgesic for minor procedures and in alleviating acute pain. It is cost effective and poses no significant risk to the patients in the form of hemodynamic changes or respiratory depression.

Minimal surgical access techniques have become a gold standard of patient care in present era, laparoscopic cholecystectomy is preffered treatment of choice for gall stones. Along with advantages, it is also associated with severe sympathoadrenal stress response, a cause for morbidity and mortality. Dexmedetomidine is an highly selective alpha2 adrenoceptor (?2-AR) agonist, seems to control this sympathetic response and provide a stable perioperative haemodynamics.
Aim of the Study: To investigate effects of preoperative single bolus dose of Dexmedetomidine on hemodynamic parameters in patients posted for Elective Laparoscopic Cholecystectomy.
Design: Randomised Prospective Double-Blind Study.
Materials and Methods: 50 ASA Gr I & II patients belonging to both sex in age group of 20 to 50yrs scheduled for Elective Laparoscopic Cholecystectomy were randomly divided into two groups of 25 each Group-D (Dexmedetomidine) and Group – S (Placebo (0.9% Saline)) A Balanced General Anaesthesia technique included Propofol, Vecuronium IPPV & Isoflurane 0.5%. Perioperatively SBP, DBP, MAP, HR were recorded at predetermined intervals - Pre-op, After Induction, After Intubation & 15 mins interval and extubation data was analysed statistically.
Results: In Group D - HR, MAP, SBP, DBP were significantly less in comparison to Group S.
Conclusion: A single bolus dose of Dexmedetomidine preoperatively effectively attenuates sympathoadrenal stress responses to laparoscopy results in stable perioperative hemodynamics.
Keywords: CO2 insufflation, Stress response, Dexmedetomidine, ?2- adrenoceptor agonist.

Introduction: Tramadol is atypical opioid having central as well as peripheral analgesic action. It acts on opioid receptors as well as having effect on neuronal reuptake of nor epinephrine and serotonin. In this study, the effects of tramadol given by two different routes, intravenous and rectal, were compared in terms of analgesic efficacy and duration as well as its side effects in appendectomy patients. Material and Methods: Forty patients of acute appendicitis undergone appendectomy under spinal anesthesia between age group of 20 to 50 years, of either sex having weight of 40 to 70 kg and ASA 1 or 2 physical status were included in the study to receive either Tramadol 100mg intravenously (Group A) or 100 mg rectal suppository (Group B) at the end of surgery. First onset of pain, VAS score, rescue analgesic requirement and side effects noted. Results: Demographic parameters were comparable in both groups. Mean duration of first onset of pain in group B (417.5±128.22min) was longer than group A (304±86.16 min) and it was statistically significant (tailed significance value of 0.0010). Rescue analgesic requirement was significantly prolonged in group B than group A. Also incidence of postoperative vomiting was less in group B than group A (5% Vs 20%). Conclusion: We conclude that rectal tramadol can be better alternative to intravenous tramadol for postoperative analgesia in appendectomy.

Aims: 1.To study and compare efficiency of clonidine and dexmedetomidine to reduce haemodynamic response i.e. attenuation of pressor response to laryngoscopy and tracheal intubation with single premedication dose.
2. To evaluate dose sparing effect of clonidine and dexmedetomidine on induction agent.
Materials and Methods: 60 patients physical status ASA grade I and II were randomized into two groups: C and D (n = 30 in each group). Group C received 1µg/kg of clonidine while group D received 1µg/kg of dexmedetomidine preoperatively over 10 minutes before induction through syringe infusion pump. Each patient was induced with injection Thiopentone sodium until loss of eyelash reflex. After check ventilation succinylcholine 2 mg/kg was given followed by tracheal intubation. Anaesthesia was maintained with O2+ N2O(50:50) and Vecuronium supplemented with isoflurane. Hemodynamic parameters were recorded.
Results: We observed no statistical difference in heart rate, blood pressure (systolic, diastolic and mean arterial pressure) between the two groups from baseline up to induction between two groups. Group C had higher readings of HR, SBP, DBP and MAP compared to group D after intubation upto 3 min which was statistically significant. Induction dose of thiopentone was lower in dexmedetomidine group and was statistically significant.
Conclusion: Dexmedetomidine attenuated the hemodynamic pressor response and also reduces the dose requirement of thiopentone sodium and was superior to clonidine.
Keywords: Clonidine, Dexmedetomidine, Premedication, Pressor response.

Introduction: Conventional laryngoscopy using the traditional Macintosh blade remains the commonest method of tracheal intubation in the routine clinical scenario. Video laryngoscopes have taken over this position in many scenarios as they have been proved successful over conventional laryngoscope. There are several types of video laryngoscopes available with multiple advantages over one another. We aimed to compare the performance of the Airtraq and McGrath when performing tracheal intubation in routine anaesthesia practice.
Materials and Methods: Sixty patients posted for surgery requiring endotracheal intubation were randomized to undergo intubation using an Airtraq (n=30) or McGrath (n=30) video laryngoscope. Primary end points were total duration of intubation, overall success rate of tracheal intubation, number of optimization manoeuvres used and ease of intubation between the two groups.
Results: We observed that the duration of successful intubation was shorter in Airtraq 19.18 (±2.86) secs) than in the McGrath laryngoscope.27 (±5.09) secs)* P < 0>A significantly better Cormack lehane view was obtained with the Airtraq. Grade I in 73.3% with the Airtraq group versus 50% in the McGrath group, p<0> Conclusion: We conclude that the Airtraq laryngoscope facilitates a more rapid and successful intubation as compared to McGrath in routine clinical practice.
Keywords: Airtraq, McGrath, Intubation.

Introduction: Use of endotracheal tube (ETT) has many limitations. There is a need for an airway device with similar safety and good side effect profile. In this prospective observational study, the oxygenation and ventilation parameters between patients who were inserted Proseal laryngeal mask airway (PLMA) or ETT for laparoscopic surgeries were compared.
Materials and Methods: After ethical committee approval, informed consent was obtained from sixty patients (thirty in each group) posted for elective laparoscopic surgery. Following induction of general anaesthesia and paralysis, PLMA or ETT was inserted and pressure control mode was used for ventilation. The following parameters were measured: a. Oxygen saturation and changes in FiO2 needed to ensure a target SpO2> 95%, EtCO2 and changes in respiratory rate and inspiratory pressure needed to ensure a target EtCO2 between 35-45 mmHg. b. Insertion characteristics of airway device and gastric tube, hemodynamic responses, incidence of complications. Statistical Analysis: Chi-square test was used to analyze qualitative data. Independent t test was used to assess quantitative variables. Repeated measures ANOVA was used to compare the outcome measures over time adjusted for duration of surgery and anaesthesia. P values<0>
Results: Both groups were comparable with respect to age, gender and weight. Oxygenation and ventilation parameters achieved with both ETT and PLMA were comparable and satisfactory. Haemodynamic parameters increased significantly in ETT group compared to PLMA group during airway insertion and removal. Also, postoperative sore throat was comparatively less in the PLMA group.
Conclusion: Hence we conclude that PLMA may be considered as an alternative to ETT in airway management of patients undergoing laparoscopic surgeries with comparable oxygenation and ventilation parameters and improved side effect profile.
Keywords: Endotracheal tube, Proseal laryngeal mask airway, Laryngoscopy, Pneumoperitoneum.

Introduction: The hemodynamic responses to endotracheal intubation (EI) may impose myocardial ischemia, infarction (MI); arrhythmias or precipitate cardiac failure. Dexmedetomidine, which is a D-isomer of medetomidine is more specific for alpha 2 adrenergic receptor and shorter acting than clonidine. As studies to explore the property of dexmedetomodine for attenuation of haemodynamic responses to EI are only few, this study was an attempt to assess the efficacy and safety of dexmedetomidine for the same. Aim and Objectives: To assess the efficacy of a single preoperative dose of intravenous dexmedetomidine in attenuating the haemodynamic responses to EI. Materials and Method: The study design was prospective, interventional randomised placebo controlled clinical trial. Each and every patient who fulfilled the eligibility criteria was randomly assigned to one of the two groups, Group C (Control) or Group D (Dexmedetomidine), using a computer generated random number table. Participants of group C received 20 ml of normal saline over 15 minutes and of group D received dexmedetomidine 0.5µg/kg diluted in normal saline to make 20 ml over 15 minutes through a syringe pump. Results: There was statistically significant rise in the mean heart rate in Group C‚ during EI from 82.82 ± 13.37 to 115.86 ± 13.12 (p<0.001). In Group D‚ there was a decrease in mean heart rate at preinduction from basal value of 86.74 ± 15.37 to 76.00 ± 14.77 (p<0.001). The mean heart rate during EI (I) and also at one minute after intubation came to near basal level 87.82 ± 15.41 (p>0.05). Similar results were for systolic arterial pressure, diastolic arterial pressure, mean arterial pressure and rate pressure product. Conclusion: From the present study‚ it is concluded that pretreatment with dexmedetomidine 0.5µg/kg attenuated the sympathoadrenal response to laryngoscopy and endotracheal intubation effectively‚ but could not obtund it completely. It was also inferred that tachycardiac response was better attenuated than pressure response.