Clinical Anaesthesia

Introduction: Major complex intraabdominal surgeries which have prolonged intraoperative surgical duration and wide hemodynamic fluctuations so they required an elective mechanical ventilation in view of large fluid shift and massive blood loss. So such large group of patients for providing conscious sedation two most popular agents dexmedetomidine and propofol are being used because their mechanisms of action and pharmacokinetic properties are different.
Aims and Objectives: Primary aim of our study is to assess the duration of mechanical ventilation in both study group (D or P) following major intraabdominal surgery. The secondary aim was to evaluate total duration of intensive care unit as well as hospital stay, incidence of delirium and any additional sedative agent.
Materials and Methods: All patients on arrival to the ICU and after fulfilling the inclusion and exclusion criteria following completion of major intraabdominal surgeries they were allocated, randomly using sealed envelopes techniques into two groups each comprising of 15 patients, to receive intravenous infusions of either dexmedetomidine or propofol and plan for elective mechanical ventilation.
Statistical analysis: All data’s was statistically analysed using Minitab® 16 (Minitab, Inc., State College, PA) software.
Results: In our study variables like demographic profile, baseline hemodynamics and ASA status were comparable in both the study groups. Our study results showed that total duration of mechanical ventilation was much earlier in the dexmedetomidine group compared to propofol (7.62 hours vs. 11.23 hours, P <0> 0.05). The incidence of delirium were more in patient receiving propofol group (6.6% vs. 20%, P = 0.346).
Conclusion: This study concluded that for any complex major intraabdominal surgeries dexmedetomidine has significant reduction in time on mechanical ventilation but no significant difference was seen in terms of incidence of delirium, duration of ICU or hospital stay and mortality.
Keywords: Major abdominal surgery, Sedation, Dexmedetomidine, Propofol.

Background: The well-known complication of spinal anaesthesia, postdural puncture headache (PDPH), is especially troublesome in young obstetric patients. The needle gauge and configuration of needle tip appear to be the important factors in reducing the incidence of PDPH. We compared the type and size of spinal needles namely whitacre 25G and Quincke 25G and 23G needles in obstetric patients undergoing caesarean section. Methods: Hundred women, age group 18-30 yrs., of ASA grade I and II undergoing spinal anaesthesia for elective caesarean sections were randomly allocated into three groups. In Group I and II, patients received spinal anaesthesia with 23G and 25G Quincke needles whereas in Group III, 25G Whitacre needles were used. The efficacy and usefulness of the needles were studied in preventing the complications like PDPH, backache, non-PDPH and the results obtained were compared statistically. Results: Of the 100 patients, PDPH occurred in 11 patients (11%). The overall incidence of PDPH is 20.5% in 23G Quincke group, 9.09% in 25G Quincke group and 3.03% in 25G Whitacre group. In the present study the incidence of back ache was 23.52% in 23G Quincke group, 15.15% in 25G Quincke group, 9.09% in 25G group. Conclusion: The pencil point 25G Whitacre needle was associated with a lower incidence of PDPH when compared with 25G and 23G Quincke needle and hence could be used routinely for spinal anaesthesia in caesarean section.

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.
Keywords: Premedication, Midazolam, Ketamine, Pediatric patients, Sedation

Introduction: Management of children’s fear and anxiety during treatment is a primary concern of
paediatric dental practitioners. There are a number of children who are difficult to be managed by basic
behaviour guidance techniques.
Objective: To evaluate the safety and efficacy of intranasal Dexmedetomidine with and without Nalbuphine
procedural sedation in paediatric dental patients.
Materials and Methods: This study was conducted in Department of Pedodontics and Preventive
Dentistry, Babu Banarasi Das College of Dental Sciences Lucknow in collaboration with Department of
Pharmacology, King George Medical University Lucknow. Ninety six systemically healthy children (ASA
type I) between 4-8 years of age for whom basic behaviour modification techniques were not successful in
providing dental treatment were included in the study. Each parent/guardian was requested to fill a written
informed consent form at the initial appointment. Data analysis was carried out using SPSS 16.0 version.
Result: Considering the efficacy parameter (duration, time of recovery) the intranasal dexmedetomidine
(group 1, 2.5 mg/ kg) was found to be the better for procedural sedation. Intranasal administration with
atomizer and nasal drop had no significant difference.
Conclusion: Intranasal dexmedetomidine alone and in combination with nalbuphine showed comparable
sedative efficacy with no additional advantage of combination over dexmedetomidine alone. Use of a
commercially available atomizer showed improved patient’s acceptance of intranasal administered drugs
but did not influence efficacy as compared to nasal drops.

Introduction and Objectives: Hypotension after spinal anaesthesia (SA) for a cesarean section may
sometimes lead to significant consequences in mother and may also lead to a compromise in neonatal
outcome. The objective of this study was to compare the effects of prophylactic Ephedrine and
Phenylephrine to prevent hypotension, nausea, and vomiting, along with the possible changes in fetal
outcome.
Materials and Methods: After approval from the institute and with informed consent, 100 parturients
undergoing cesarean section under SA, and who satisfied the inclusion criteria were divided into two
groups. All patients received 10 mg of 0.5% Bupivacaine heavy for SA, and the drug was injected at the
L3-4 level. All parturients were co-loaded with Ringer’s lactate (RL), and either 100mcg Phenylephrine
or 6mg Ephedrine was added in the RL solution. Occurrences of maternal hypotension, nausea, vomiting,
and APGAR score for neonate were noted and compared.
Results: Phenylephrine group had a significant reduction in the incidence of hypotension. However, it
did not translate into any significant reduction in the incidence of nausea or vomiting. There were also
significant differences in the APGAR scores of the neonate in 1 and 10 minutes; Phenylephrine group had
a better outcome as compared to Ephedrine group.
Conclusion: Prophylactic Phenylephrine 100 mcg added to co-loading crystalloid prevents maternal
hypotension significantly more than prophylactic Ephedrine 6 mg. The fetal outcome in terms of APGAR
score was also better in the Phenylephrine group. However, there was no difference in the maternal heart
rate, nausea, and vomiting among the groups.

Background and Aim: Racemic bupivacaine is known to be the most cardio toxic among the amide local anaesthetic. In search of an alternative it was found that the levo enantiomer has a better safety profile. This purpose of this study is to compare the clinical efficacy of 0.5% levobupivacaine with 0.5% racemic bupivacaine in epidural anaesthesia. Materials and Methods: After the institutional ethical committee approval this double blind randomized prospective study was conducted on 50 male patients between January and August 2011. 25 patients were allocated to each group; group L received levobupivacaine and group R received racemic bupivacaine. Onset time, duration of block, level of sensory block and motor block were assessed and compared. Observation and Results: The mean onset time was 7.739±3.3033 and 8.04±3.048 minutes in group L and in group R respectively. Level of sensory block level noted was between T10 to T5, but most patients had the level at T6. The mean duration of residual analgesia was 412.56 ± 39.11 minutes in L group and 409.56 ± 44.46 minutes in R group. The onset time, duration of block, level of sensory block were comparable and were not statistically significant. But the motor block was found to be intense and was statistically significant in the patients in R group (p 0.0498) than in L group. Conclusion: In comparison to racemic bupivacaine, levobupivacaine produces a differential blockade but onset, duration, level of sensory blocks was similar. However racemic bupivacaine produces intense motor blockade when compared with levobupivacaine.

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

Introduction: Ultrasound guided (US) rectus sheath block, blocks ventral rami of 7th to 12th thoracic
nerves by injection of local anaesthetics (LA) into the space between the rectus muscle and posterior
sheath. The aim of the study was to evaluate the analgesic efficacy of Bupivacaine, Levobupivacaine and
Ropivacaine in ultrasound guided bilateral rectus sheath block in patients undergoing umbilical surgeries.
Materials and Methods: Patients received bilateral US-guided injection of total 30 mL of levobupivacaine
(GpL) 0.25 % (or 0.375% of Ropivacaine (GpR) or 0.25%of Bupivacaine (GpB) respectively, behind the
rectus muscle to detach it from its sheath. Analgesic efficacy of LA was evaluated using duration of
analgesia, pain score at extubation and 1-16 hrs postoperatively and mean VAS (visual analogue scale)
score to assess the quality of analgesia.
Results: There were statistically significant differences in VAS scores between the groups L, R and B at all
postoperative time points - 1hr, 2 hr, and 3hr till 16hrs. (P < 0.00001). The mean duration of analgesia in
three groups was 9.300.92 hrs in Gp L, 13.021.17 hrs in Gp R and 6.2 0.83hrs in Gp B respectively.
This difference was statistically significant (p =< 0.0001).
Conclusions: Single shot of different local Anaesthetics in Ultrasound guided bilateral rectus sheath block
provides postoperative analgesia up till 16hrs in patients with BMI 25-40kg/m2 undergoing umbilical
surgeries with excellent VAS scores with Ropivacaine.

Introduction: Spinal anaesthesia is a popular anaesthesia technique for lower limb surgeries. The haemodynamic changes that occur, may be sudden and deleterious, particularly in geriatric patients. Moreover the duration of spinal anaesthesia is limited. Thus, a safer approach of sequential combined spinal epidural (SCSE) anaesthesia is emerging currently. The technique combines benefits of both.
Aim: To evaluate the changes in hemodynamic parameters while using SCSE block and spinal anaesthesia for lower limb surgeries.
Study Design: A prospective, randomised, double blind study.
Materials and Methods: Sixty ASA grade I and II physical status, who underwent lower limb procedures were included in the study. They were divided equally into Group I (spinal) and Group II (SCSE). The haemodynamic parameters in the two groups was observed.
Results: From 2 minutes to 20 minutes, there was statistically significant rise in pulse rate in group I, associated with decrease in blood pressure in group I (p value<0>
Conclusion: Sequential combined spinal epiduralblock maintains hemodynamic stability with minimal complications as compared to spinal anaesthesia.
Key messages: Sequential spinal epidural anaesthesia maintains cardiovascular stability.
Keywords: Sequential spinal epidural, Spinal, Haemodynamics, Side effects.

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.
Keywords: ProSeal LMA, Suction Catheter insertion.

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.

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: 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.
Keywords: Postoperative sore throat, Nebulisation, Hoarseness, Cough, Dexamethasone, Magnesium sulphate.

Functional endoscopic sinus surgery (FESS) requires good intraoperative surgical field visualization for better identification of structures. Among the many modalities for improving visibility, antifibrinolytic agent like Tranexamic acid has shown good results in many other surgeries. In this study, we have evaluated the effect of a single bolus dose of 15mg/kg intravenous Tranexamic acid when used as an adjunct.
Materials and Methods: We have studied group T (n=30), who received Inj. Tranexamic acid against group C (n=30) i.e. control group. They were compared for surgical field using Boezaart scale, surgical duration and blood loss. Statistical analysis was done by unpaired t test and chi square test as was appropriate.
Results: T group showed significantly lower values of Boezaart scale score i.e. better visualisation for surgical field (p<0>
Conclusion: We found that Tranexamic acid has a beneficial role in functional endoscopic sinus surgeries by improving the quality of surgical field when used as an adjunct.
Keywords: Tranexamic acid, surgical field, functional endoscopic sinus surgery.

Introduction: Succinylcholine, is one of the most commonly used muscle relaxant for rapid sequence airway management. It increases the Intraocular pressure (IOP) which is deleterious in open globe injuries. We studied the effects of Inj. dexmedetomidine, a highly selective α2-adrenoceptor agonist, on IOP and hemodynamic responses to succinylcholine and tracheal intubation.
Materials and Methods: Sixty ASA I–II patients, scheduled for elective non-ophthalmic surgeries requiring general anesthesia were randomly premedicated by intravenous Inj. dexmedetomidine 0.4 µg/kg (Group-D) or saline (Group-S) (30 patients each group). Heart rate (HR), mean arterial pressure (MAP), and IOP (using Schiotz tonometer) were measured 10 minutes before and after the premedication, 30 seconds after succinylcholine and at 1, 5 and 10 minutes after intubation.
Results: Ten minutes after Inj. dexmedetomidine administration, there was marked decrease in IOP. After intubation there was a rise in IOP, however it remained below baseline IOP (p=0.315) and remained low at 10th minute after intubation (p<0.001) which was statistically significant. In the control group, there was a significant rise in IOP following Inj. succinylcholine and intubation which remained above baseline IOP even at 10th minute after intubation. HR, Systolic and diastolic blood pressure, and MAP markedly increased at 1 minute following intubation in the control group whereas in dexmedetomidine group, they remained below baseline (p<0.001).
Conclusions: Intravenous dexmedetomidine at a dose of 0.4 μg/kg can be used for attenuation of rise in IOP associated with succinylcholine and tracheal intubation in patients with open globe injuries.
Keywords:  Dexmedetomidine, Eye, Intraocular pressure, Rapid sequence intubation, Succinylcholine.

Introduction: Post-operative nausea and vomiting (PONV) is associated with wound dehiscence, pulmonary aspiration, electrolyte disturbances, delayed recovery and patient dis-satisfaction. The present study was aimed to compare antiemetic efficacy of intravenous palonosetron with dexamethasone versus ondansetron with dexamethasone to prevent PONV in patient undergoing laparoscopic sleeve gastrectomy (LSG).
Materials and Method: Prospective, double blind randomized study of 24 morbidly obese patients planned for LSG. Preoperative gastric emptying scintigraphy (GES) done to know about gastric emptying. All patients premedicated with tablet ranitidine 150 mg a night before and 2 hours before surgery. Patients randomized into two groups PD (n=12) and OD (n=12) according to antiemetic agents used 30 min prior induction. Perioperative hemodynamic parameter were measured every 10 min interval during intraoperative and incidence of PONV along with hemodynamic parameters were assessed at arrival 0, 6, 12, 24, 48 and 72 hours postoperative period.
Observation and Results: Demographic data, perioperative hemodynamic parameters were well matched. The overall incidence of nausea/vomiting was 54.6%/18.2% and 63.6%/18.2% in group PD and group OD; respectively during 72 hours follow-up. The total dose of rescue antiemetic was 10 mg in group PD and 11.67 in group OD (p=3.14). GES done in 8 patients (PD; 3 and OD; 5) indicated normal gastric emptying and only one patient had PONV in this subset.
Conclusions: In this preliminary study, palonosetron and ondansetron in combination with dexamethasone had comparable antiemetic efficacy after LSG. Further studies can be conducted to find-out the role of preoperative GES as a tool to predict PONV.

Aim: The aim of this study is to assess the efficacy and safety of spinal anaesthesia by comparing the severity of hypotension and intraoperative requirement of Phenylephrine to treat it in severe pre-eclamptic and normotensive parturients undergoing elective caesarean section.
Materials and Methods: A total of 50 parturients, 25 each of normotensive and pre-eclamptic were given spinal anaesthesia with 12.5mg of hyperbaric bupivacaine after preloading with 10ml/kg of Ringer lactate solution. The vitals namely heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and the mean arterial blood pressure (MAP) were monitored during caesarean section. Severity of hypotension and the mean requirement of Phenylephrine to manage this hypotension were compared in the two groups. Foetal outcome was compared in two groups by studying the Apgar score.
Results: There was statistically less hypotension following spinal anaesthesia and less requirement of vasopressor in pre-eclamptic as compared to normotensive parturients. The mean requirement of Phenylephrine was 156.3±62µg in normotensive (group I) and comparatively more than the requirements of pre-eclamptic (group II) parturients and was statistically significant (p<0.05). The Apgar score at 1 and 5 minutes were equal in both the groups.
Conclusion: Spinal anaesthesia is ideal and safe option for severe pre eclampsia undergoing elective caesarean section without any additional risk to baby.

Pharyngeal mass often presents to the anaesthesiologist for airway management and anaesthesia, needed to aid in diagnosis or treatment. These patients present a challenge to the anaesthesiologist as they block the pathway for ventilation as well as intubation. Spindle cell carcinomas are rare tumors with very few cases of oropharyngeal spindle cell carcinomas reported. These tumors of the pharynx usually present as pedunculated masses of less than 2 cm in size. The anesthetic management for excision is usually simple. We report a unique case of a large size 5 cm pedunculated oro pharyngeal mass, which was mobile causing dynamic airway obstruction. A thorough pre operative examination and planning for the airway management lead to anticipation of difficulties and easy navigation through them.

Introduction: Currently, the safety of spinal anaesthetic techniques is well established for caesarean
section in pregnancy induced hypertension (PIH) patient. Addition of fentanyl to local anaesthetic allows
achievement of adequate anaesthesia with lower dose of local anaesthetic in spinal anaesthesia, thereby
reducing the occurence of hypotension and need for vasopressor.
Materials and Methods: A prospective, randomized, double blind, case control study was carried out
in 80 parturients having PIH undergoing caesarean section in spinal anaesthesia were randomized into
2 groups depending on intrathecal drug received by them as Group C (Conventional dose group- received
hyperbaric bupivacaine 10 mg)and Group Lflow dose group, hyperbaric bupivacaine (7.5 mg) with fentanyl
(25 mcg)g and compared regarding sensory- motor block characteristics, incidence of hypotension (fall in
MAP > 25% from baseline) vasopressor requirement Phenylephrine and Ephedrine.
Result: Patient in Group L had significantly less number of hypotension episodes as compared to Group
C(20 vs 31, p= 0.011). Hence vasopressor requirement was also significantly less in Group L than in Group
C [Phenylephrine (1600 mcg vs 2500 mcg, p=0.044), Ephedrine (66 mg vs 18 mg, p= 0.030)].
Conclustion: Low dose spinal anaesthesia using 7.5 mg hyperbaric bupivacaine with 25 mcg fentanyl
seems to be superior alternative to conventional dose of 10 mg hyperbaric bupivacaine for caesarean section
in parturients having pregnancy induced hypertension, because it was associated with better hemodynamic
stability, reduced vasopressor requirement.

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 2-4 mg/kg, while labetalol has been tried in all doses ranging from 0.25, 0.5, 0.75, and 1 mg/kg.17
Keywords: Esmolol, Labetalol, Stress response, Laryngoscopy and Intubation.

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.
Keywords: Ketamine, Midazolam, Premedication, Pediatric

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.

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: 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.
Keywords: Nausea, Vomiting, Intrathecal midazolam, Spinal anesthesia, Cesarean section.

Introduction: One of the most important disadvantages of propofol injection is intense burning pain. The present study was conducted with the aim to assess the effect of low dose Ketamine (100 µg/kg) in the alleviation of pain on propofol injection.
Materials and Methods: Patients who underwent surgical procedures under general anaesthesia were allocated into two groups viz. Group K (n=35) - pre-treatment with ketamine 100µg/kg (1ml) and Group S (n=35)- pre-treatment with 0.9% normal saline (1ml) in this double-blinded, randomized study. After venous occlusion, ketamine was injected over 10 seconds, after which the occlusion was removed and over 20 seconds, the first 25% of the calculated dose of propofol was injected. The evaluation of the severity of pain was done by the verbal rating scale (VRS) during the injection of the induction agent for every 5 seconds and graded as 0 to 3.The data were recorded and analysedusing unpaired‘t’ test and chi-square test as and where appropriate.
Results: The demographic profiles were comparable between the two groups. It was observed that 42.9% of patients in normal saline and 80% in ketamine groups experienced no pain (p<0>0.05).
Conclusion: It may be concluded that pre-treatment with low dose ketamine with a tourniquet just before propofol injection, significantly reduced the incidence and degree of propofol induced pain without significant adverse hemodynamic effects.
Keywords: Induction, Propofol, Pain, Low dose ketamine, Alleviation.

Introduction: Spinal anaesthesia is a commonly employed anaesthetic technique for caesarean section. Levobupivacaineis a new long acting amide, local anaesthetic. Only few studies have investigated spinal anaesthesia using plain levobupivacaine in obstetrics.Levobupivacaine has all the desirable qualities of local anesthetics like with rapid onset, wide margin of safety, adequate surgical anaesthesiawith minimal side effects on the mother as well fetus.
Aim and Objectives: To study the effects of spinal anaesthesia induced in lateral and sitting position during caesarean section using plain levobupivacaine.
Materials and Methods: The study was carried out in tertiary care centre between Jan. 2014-June 2015 on total 100 patients posted for caesarean section. The parameters observed included- Sensory blockades onset and its duration, motor blockades onset, duration and degreeand quality of anaesthesia.
Results: In group L (that received plain levobupivacainein left lateral position) 90% of patients had onset to T10 in 3-4 minutes. Onset of sensory block in group L was in 3.62±0.09 minutes and 3.77±0.11 minutes in group S (those received plain levobupivacainein sitting position). Two dermatome regression in group L were 80.96 ± 1.75 min and in group S were 81.44 ± 1.70 minutes. Motor onset in group L and S was 5.747 ± 0.375 minutes and 5.876 ± 0.396 min respectively. Total duration of motor block in group L was 157.90 ± 3.23 minutes.
Conclusion: We concluded that 12.5mg dose of isobaric levobupivacaine 0.5% provides effective spinal anaesthesia, ensures haemodynamic stability, excellent quality of sensory and motor block with no influence of gravity on the spread in sitting as well as lateral position.
Keywords: Caeserrian, Lateral, Levobupivacaine, Spinal.

ntroduction: The aim of preoxygenation is to replace nitrogen in the Functional Residual Capacity (FRC) with oxygen. This increases body oxygen store and increases tolerance to apnoea significantly.
Materials and Methods: This study was conducted in PESIMSR, Kuppam between July 2012 and November 2013 in a selected population of 60 adults of either sex scheduled posted for elective surgery. The patients were distributed into 2 groups, Group Tidal Volume Breathing, T and Group Deep Breathing, D. Each group had 30 patients. Group T patients were preoxygenated with Tidal Volume Breathing and group D patients were preoxygenated with 8 deep breaths in 1 minute. The measured variables were SpO2, Heart rate, inspired oxygen concentration, Endtidal Oxygen concentration, End tidal Carbon Dioxide and Duration of Apnoea without desaturation (DAWD).
Results: There were no statistically significant differences between both the groups in age, gender, height, weight and BMI. All the patients in both the groups attained ETO2 values of above 90 at the end of preoxygenation. The mean ETCO2 value in T group was 32.16 ± 1.51 and 27.36 ± 1.73 in Group D. This value was statistically significant with a p value of < 0>
Conclusion: Preoxygenation with 8 deep breaths in 1 minute is a more effective method of preoxygenation because there is a significant increase in the time taken for desaturation. This method will be more effective in patients with full stomach posted for emergency surgery.
Keywords: Tidal volume breathing, Deep breathing technique, Preoxygenation, Safe duration of apnoea.

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.
Keywords: Enteral nutrition, Nutrition protocol, Malnutrition, Mechanical ventilation, ICU.

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.

Introduction and Aims: Supraglottic airway devices are safe and efficient in airway management. I-gel TM and Proseal TM laryngeal mask airway are supraglottic airway devices which are used to secure and maintain airway during anaesthesia with additional gastric channel. Aim of our study is to compare the efficacy of both the supraglottic airway devices, I-gel and Proseal LMA(PLMA) in patients under general anaesthesia with controlled ventilation. Materials and Method: A total of 126 patients of ASA Grade I and II who underwent short surgical procedures were included and were randomly allocated to I-gel or PLMA group. Patients were induced with standard doses of propofol airway was secured with either of the supraglottic airway devices. We compared ease, duration of insertion, insertion attempts, mean pulse rate, mean arterial pressure (MAP), ease of gastric tube insertion and adverse events. Data was compiled and analyzed statistically by Mann –Whitney U test and Student t-test, the means and Chi-square test was compared for categorical variables. Results: There was no significant change in demographic data and hemodynamics before premedication, after premedication, at induction and insertion in mean pulse rate and MAP. Mean time for insertion was significantly less in I-gel compared to PLMA. There was significant change in mean pulse rates and MAP in both groups at 1, 3, 5, 10 and 15mins with mean pulse rate and MAP being higher in PLMA than I-gel. Gastric tube insertion was easier in I-gel group and sore throat was significant in PLMA. Conclusion: I-gel is a better supraglottic airway device with higher first attempt success rate, was easy to insert, had better hemodynamic stability, with less incidence of sore throat compared to PLMA for controlled ventilation.

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.

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: 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.

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.

Transurethral resection of prostate (TURP) is a very common surgical procedure in urological practice worldwide. Bladder rupture due to explosion is a very rare complication of this surgery. We report a case of 64 year old diabetic patient who underwent TURP for benign prostatic hyperplasia (BPH). Procedure was uneventful for 40 min. After that a loud thump was heard and sudden fall in blood pressure (BP) was noticed, despite aggressive management BP was not maintained. Then intraabdominal exploration revealed bladder rupture, which was repaired by surgeon. Blood pressure was gradually maintained towards normal. Then patient was shifted to intensive care unit (ICU) and then discharged uneventfully.

Use of prompt and efficient anesthetic management of an actively convulsing gravid to term female in the OPD. In this case report, we present a successful anesthetic induction and management in a case of gravid to term female with active convulsions and complaints of vomiting and headache, later diagnosed as Posterior Reversible Encephalopathy Syndrome under General anesthesia.