Indian Journal of Clinical Anaesthesia

Introduction: This study was conducted to evaluate the effect of Intraperitoneal Bupivacaine alone or with dexmedetomidine or tramadol for relief of pain after laparoscopic cholecystectomy. Material and Methods: The patients were divided into 3 Groups of 50 each, Group A was given 50 ml 0.25% bupivacaine and 5 ml normal saline, Group B 50ml 0.25% bupivacaine plus tramadol 1mg/kg wt and Group C, 50ml 0.25% bupivacaine plus dexmedetomidine 1ug/kg. The duration of analgesic effect was noted based on the time difference between the disappearance of pain after the analgesic injection and reappearance of pain was recorded and assessed by using VAS scale. Results: The number of females were slightly more than the male. The age group of the patients predominantly ranged between 31-40 years. Pain was significantly lower in Group C i.e. patients given bupivacaine plus dexmedetomidine compared to the patients in Group A and Group B. Patients in Group A i.e. with bupivacaine alone had the highest VAS score. Post-surgery, minor complications were seen in a few patients, with nausea being most common, followed by vomiting and pruritis. Conclusion: Bupivacaine plus dexmedetomidine given to patients who underwent laparoscopic cholecystectomies was more effective as an analgesic compared to Bupivacaine alone or in combination with Tramadol

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.

Various adjuvants like opioids, alpha-2 agonists, steroids and many more drugs have been mixed with local anaesthetic (LA) solutions for Intravenous Regional Anaesthesia (IVRA). These drugs are added with the aim of hastening the onset of action and prolonging the duration of analgesia. They may also allow for a reduction in the total dose of LA used and related side effects. In this article, we have reviewed clinical trials using nitroglycerine (NTG) as an adjuvant to LA in IVRA and have summarized the advantages, disadvantages and current role of this drug. To the best of our knowledge, no meta-analysis, or review article has analysed the role of NTG as an adjuvant to Bier’s block.

Theanteriorapproach to the cervical spine is commonly utilized for a variety of degenerative, neoplastic, traumatic, and infectious indications. The distinctive anatomy of the anterior neck presents a unique set of hazards. We encountered a case of delayed esophageal perforation after cervical spine surgery, who presented to us forty-two days post-surgery. Although, timely detection and management of esophageal perforation has a good prognosis, associated vascular complications added on to airway management challenges. We outline the issues with diagnosis and key aspects of airway management in this patient.

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.

A randomized comparative study on brachial plexus block using nerve stimulator: infraclavicular-coracoid approach vs supraclavicular approach Abstract Introduction: Pain relief with peripheral nerve block (PNB) is devoid of side effects such as somnolence, nausea, vomiting, hemodynamic instability and voiding difficulties inherent to general and central neuraxial anesthesia. Aim: To compare the clinical efficacy of infraclavicular and supraclavicular approach of brachial plexus block by using peripheral nerve stimulator. Materials & Methods: Sixty patients of ASA grade I and II undergoing upper limb surgeries were randomly assigned into two groups, Group I and Group S group I: received infraclavicular block by coracoid approach, group S: received Supraclavicular block. Surgeries below the level of elbow were selected for this study. Parameters observed were – block performance time, sensory and motor blockade, and its quality, duration of post op analgesia, and block related complications. Results: Time to perform block, onset of both motor and sensory blockade, duration of post op analgesia were not different in group I and Group S. Success rate of blocking four nerves to the elbow (musculocutaneous, ulnar, radial, median,) was comparable between the groups. The incidence of complications in the form of vascular puncture was not significant in both group I and Group S. Conclusion: From our study it is inferred that nerve locator guided Infraclavicular block of brachial plexus by coracoid approach is at least as rapidly executed as nerve locator guided Supraclavicular approach and produces a similar degree of surgical anaesthesia with similar complication rates.

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.

Background: The pain experienced after upper abdominal surgery leads to a reduction in 70-75% of vital capacity which leads to postoperative pulmonary complications. The ideal adjuvant for epidural analgesia in patients undergoing upper abdominal surgery seems to be every effective for better outcome and early immobilization in the immediate postoperative period. With this background we planned to conduct a study on epidural analgesia by comparing two alpha 2 agonists. Methods: 50 patients who have planned for elective upper abdominal surgery under general anaesthesia were enrolled in our study. Before induction of general anaesthesia, epidural catheterization was done. The surgical procedure was carried out under routine general anaesthesia with endotracheal controlled ventilation. The patients were given either Dexmedetomidine or Clonidine in the dosage of 2mcg/Kg with 0.125% Bupivacaine via epidural catheter after extubation. Patients were shifted to Post Anaesthesia Care Unit for observation. Sedation and pain were assessed with monitoring of vital parameters. The side effects were also noted. Results: Statistical analysis showed that the duration of analgesia was prolonged in the patients who received Dexmedetomidine as an adjuvant with local anaesthetic agent (417.32±67.36 minutes, p value < 0.05). The time to first rescue analgesia was comparatively delayed in Dexmedetomidine group while comparing with Clonidine group (425.6±64.27 minutes, p value < 0.05). The incidence of hypotension and bradycardia was greater in Clonidine group. There was no significant statistical difference with respect to side effects in both groups. Conclusion: From our study we concluded that Dexmedetomidine provides both analgesia and sedation with better hemodynamic status while compared to Clonidine used as adjuvants in epidural analgesia. But needs further study to optimize the dosage of these two adjuvants while giving via epidural route along with local anaesthetic agent.

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.

Pain during positioning in patients with fracture femur results in improper position and makes subarachnoid block difficult. The aim of our study was to evaluate femoral nerve block and intravenous fentanyl for positioning the patient for subarachnoid block. Material and Methods: This open labelled prospective, clinical study was carried out in 60 patients aged 18-70 years of either sex, of ASAPS/ EASAPS-I, II and III, posted for fracture femur surgery under subarachnoid block and likely to have pain while positioning and who understand VAS score. Patients with contraindications to subarachnoid block, allergy to study drugs, history of drug or alcohol abuse, patient with multiple fractures and unable to understand VAS score were excluded from the study. Patients were assigned into two groups alternately in Group FNB (femoral nerve block was given) and Group FENT (intravenous Fentanyl 1µg/kg was given) for positioning before subarachnoid block. Assessment of pain was done using VAS score before and after positioning, time taken to achieve position, quality of position, patient acceptance and additional doses of fentanyl requirement during positioning. Patients were also observed for sedation score, pulse rate, NIBP and oxygen saturation. Results: VAS score 10 minutes after giving analgesia and during positioning was less in group FNB (1.97±0.56) as compared to group FENT (2.87±0.35), which was statistically very highly significant (P < 0.0001). None of the patient required additional dose in either group. Conclusion: FNB provides adequate analgesia, hence satisfactory positioning for sub arachnoid block with stable hemodynamics as compared to intravenous fentanyl.

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.

Robot-assisted pelvic surgeries in steep Trendelenburg position present unique challenges to the anaesthesia team. Pneumoperitoneum, also, puts additional strain on the cardiovascular and respiratory requirements of the patient. In-depth knowledge of the effect of this position on patient&#39;s physiology is essential for intraoperative safety and better management. Robotic arms can also cause steric hindrance and limited access to the patient thus better intraoperative communication may help in averting any untoward event. With this review, we discuss the effect of steep Trendelenburg position and pneumoperitoneum on the intraoperative physiology of the patient.

Background: Appropriate management of endotracheal tube (ETT) cuff pressure is essential during mechanical ventilation of an intubated patient. The ETT cuff should be inflated in order to seal the airway without volume loss or pharyngeal content aspiration. It is desirable that the cuff seal the airway without exerting high pressure on the trachea to compromise mucosal circulation. The aim of this study is to assess importance of monitoring of ETT cuff pressure in intubated patients and effect of intervention in preventing complications related to over and under inflation of ETT cuff .
Method: An observational prospective study performed between January and April 2015. All patients having cardiac surgery with cuffed ETT insertion were included. In Group1 cuff pressure manometer was used to monitor the cuff pressure and adjusted in the range of 20-30 cm H2O within 15 min before going on cardiopulmonary bypass. In Group2 only minimal leak test (MLT) done to guide inflation and cuff pressure measured by cuff pressure manometer but no intervention was made. Patients were followed in postsurgical care till extubation and observed till discharge for complication like sore throat, voice changes and tracheomalacia.
Results: In group 1 9(25.7%) patient had cuff pressure within normal limit whereas 25 (71.4%) patient had cuff pressure higher than normal and 1 (2.9%) patient had cuff pressure measurement less than 20 cm H2O. Volume of air added or removed from cuff was -0.89 ± 1.14 to optimize cuff pressure. Cuff pressure ranged from 15 to 120(47 ± 23) cm H2O.In group 2 11(32.4%) patient had cuff pressure within normal limit whereas 22 (64.7%) patients had cuff pressure higher than normal and 1 (2.9%) patient had cuff pressure measurement less than 20 cm H2O. Cuff pressure ranged from 18 to 100(47.4±20.3) cm H2O. In group 1, 11 patients developed hoarse voice compared to 32 patients in group 2. P=0.000 In group 1, 15 patient developed sore throat versus 21 patients in group 2, P = 0.187.
Conclusion: Measurements of endotracheal tube intra cuff pressure are essential to avoid over or under inflation of ETT cuff. Adjusting the cuff pressure to 20-30cmH2O will prevent volume loss during ventilation and complications like sore throat, hoarseness of voice and tracheomalacia. Measurement of cuff pressure with timely intervention should be made standard of care in operation theatre and ICU.

Background: Propofol does not possesses the analgesic properties but is a safe anaesthetic agent for day care surgeries while ketamine is an excellent analgesic but has concerns regarding recovery. Fentanyl is a short acting potent opioid with pharmacokinetics suitable for day care anaesthesia. There are many short procedures in which you need procedural sedation with good analgesia and calm patient without need of intubation and relaxation. This study was conducted to compare and find suitable sedoanalgesia regime of TIVA using Propofol-Ketamine (Ketofol) or Propofol-Fentanyl (Fentofol) mixture infusion to facilitate comfortable and stable sedation experience with rapid recovery in short orthopaedic surgeries. Settings and Design: Randomized, Double blind. Patients and Methods: This prospective, randomized, double-blind study was conducted on 100 adult patients of age 20–55 years of either sex having ASA physical status I-II, posted for short orthopaedic procedures. Patients were assigned to receive slow bolus of fresh premixed injection of either ketofol or fentofol followed by TIVA infusion to a predetermined sedation level using Ramsay sedation scale. Haemodynamics, vital signs, side effects and recovery profiles were recorded. Results: There was significant decrease (P<0.001) in the pulse rate, systolic and diastolic blood pressure in intraoperative and postoperative period in group II (FP, fentanyl group) whereas there was significant rise in pulse rate and systolic and diastolic blood pressure in group I (KP, ketamine group). Respiratory depression was more pronounced in fentofol group. Total dose of propofol consumed was less in ketofol group with less involuntary movements. Mean total sedation time as well as recovery time was significantly prolonged in fentofol group compared to ketofol group. No major adverse effects were observed with ketofol group. Conclusion: As compared to fentofol, continuous TIVA infusion with ketofol (1:1) provided better sedoanalgesia, stable haemodynamics with favourable recovery profile.

Background: The Transversus Abdominis Plane block is a new regional anaesthesia technique described for postoperative pain management with a potential utility as a sole anaesthetic for increasing number of surgical procedures. TAP block improves postoperative pain management, decreases postoperative visual analog scale score, opioid demand and time to first administration of rescue analgesic in patients undergoing lower abdominal surgeries. Aims and objectives: In our study, we have used TAP block as a sole anaesthetic technique in elective patients undergoing unilateral inguinal hernia repair and compared two different local anaesthetics, 0.5% Bupivacaine and 0.75% Ropivacaine for their duration of anaesthesia/ analgesia and cardiovascular stability. Materials and Methods: A prospective randomized clinical study was conducted on 60 ASA I and II patients aged between 30 and 80 years coming for inguinal hernia repair fulfilling inclusion and exclusion criteria. They were divided into two groups of 30 each. Group B received injection 0.5% bupivacaine, group R received injection 0.75% ropivacaine, not exceeding 2.5 mg/kg body weight. Results and Conclusion: We have found that both the drugs give excellent anaesthesia for inguinal hernia repair with hemodynamic stability. 0.75% Ropivacaine with significant delay in onset of anaesthesia (13.46+/-3.2 min.) compared to 0.5% bupivacaine (7.86 +/-2.47 min.) (P value <0.001), gives prolonged postoperative analgesia, (675.54 +/-30.31 vs 573+/-45.72 minutes with P value <0.001). Transversus abdominis plane block can be used as a sole anaesthetic for inguinal hernia repair.

Enhanced recovery after surgery (ERAS) protocol consists of entire spectrum of pre, intra and postoperative designed to enhance patient outcomes. Since its first introduction for major abdominal surgery in the 1990's, ERAS protocols have been successfully used extensively in many countries in several major surgical procedures. When effectively implemented, ERAS resulted in reduction in hospitalization, improvement in satisfaction of the patients, and reduction in complication rate without an increase in readmissions. Implementation of ERAS in India has also positively affected the patient experience and led to efficient utilization of valuable hospital resources. Many of the ERAS components are linked to the anaesthesia team. Anaesthesiologists help in preparing anaesthesia, they also ascertain the fasting regime in preoperative period, assess premedication, and introduce prophylaxis for post-operative nausea and vomiting (PONV). Intraoperatively, they introduce low sodium fluid therapy, help in preventing hypothermia, and utilize short acting drugs. They also help in important decision making during postoperative analgesia. An anaesthesiologist role is foremost important in the implementation of ERAS protocol. The article aims to discuss the various components of ERAS and the role of anaesthesiologist in implementing them.

Introduction: Pain is a unique emotional experience, which is associated with actual or potential tissue damage. Postoperative pain management is necessary. The most effective preemptive analgesic regimens are those that are capable of limiting sensitization of the nervous system throughout the entire perioperative period.
Material & Methods: Radomly patients were assigned in two groups of 60 patients who underwent lower limb orthopedic surgery. The clinical effects of intrathecally administered Inj Bupivacaine 0.5% hyperbaric 2.5 ml (group B) with Inj Buprenorphine preservative free 150 mcg additional to the hyperbaric bupivacaine 0.5% 2.5 ml (group B) for lower limb orthopedic surgeries were studied .
Results: Surgery had mean duration of 87.3(16.7) min for group B and 96.3(17.1) min for group BN. There was statistically no significant (P>0.05) difference of time of onset, maximum level and time required reaching maximum level of sensory block in between the groups. All patients in both groups had complete motor blockade. There was statistically no significant (P>0.05) difference in preoperative, during surgery and postoperative hemodynamic parameters in between two groups. Sensory recovery was significantly (P<0.01) delayed in BN group compared to B group. Mean duration of effective analgesic was markedly raised (P<0.001) to 909 (216.9) min in group BN from 158(17.3) min in group B. Complication of nausea, vomiting and shivering was noted in both the groups with no significant difference(P>0.05).
Conclusion: Buprenorphine added to Bupivacaine hyperbaric have effective and considerably prolonged postoperative analgesia.

Background and Aim: Supraglottic airway devices are increasingly being used as an excellent alternative to mask ventilation and tracheal intubation with least complications. The present randomized, prospective study was conducted to compare the I-Gel with LMA-Supreme with respect to time taken for insertion, insertion success rate, ease of insertion of gastric tube, hemodynamic changes before and after insertion and post-operative airway morbidity.
Materials and Methods: Sixty American Society of Anaesthesiologist (ASA) grade-I and II patients between 18-60 years age, of either sex, were randomly assigned to two groups of 30 patients each. Group A: I-gel was inserted and Group B: LMA- supreme was inserted by grasping firmly along the integral bite block (Digital Technique). Hemodynamic responses were recorded before induction and at the intervals after insertion of LMA Supreme/I-Gel. Time taken for insertion, insertion success rate and ease of insertion of gastric tube was noted. Patients were inspected for any trauma to mouth, lip and tongue in the immediate postoperative period and asked about sore throat, hoarseness and dysphonia 24 hours after the surgery. Statistical analysis was carried out with student’s t-test and chi-square test and value of P0.05 was considered statistically significant.
Results: Insertion time of I-Gel (11.07±1.93 seconds) was faster than the LMA-Supreme (12.50±2.35 seconds) and the results were statistically significant (P=0.01). Ease of insertion of gastric tube was more in LMA Supreme (28/30) as compared to I Gel (26/30) but statistically this difference came out to be non-significant (P=0.157).The two groups were comparable as far as the insertion success rate , hemodynamics and post-operative airway morbidity were concerned.
Conclusion: I-Gel is better than LMA-Supreme in terms of faster insertion time. Insertion success rate, ease of insertion of gastric tube, hemodynamics and post-operative airway morbidity is comparable in both the groups.

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 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

A prospective double blinded study on effect of intrathecal dexmedetomidine as adjuvant to hyperbaric bupivacaine on onset and duration of subarachnoid blockade Abstract Objective: To study the effect of low dose intrathecal dexmedetomidine as adjuvant to hyperbaric Bupivacaine in relation to onset & duration of sensory & motor block Material and Methods: In the present double blinded prospective, randomized controlled trial study, we have aimed to compare the two groups of ASA –grade I patients divided in two groups i.e., group B-Bupivacaine 2.5ml (12.5 mg) alone (control group) and group BD-Bupivacaine 2.5 ml (12.5 mg) combined with Dexmedetomidine 5 μg undergoing lower abdominal and lower limb surgeries to evaluate whether there is any clinching evidence of augmentation of motor and sensory block by addition of low dose dexmedetomidine (5μg). Results: Among both the groups, mean time to achieve onset of sensory & motor blockade was found to be not statistically significant (P>0.05). The duration of sensory block observed in group BD was 143.6±12.74 in contrast to group B 107±9.74. The difference in mean duration of analgesia between group B vs. BD, is statistically significant (P<0.001).The duration of motor blockade in group B found was 174.2±11.26 in relation of group BD 276.4±13.96which is statistically significant (P<0.001). Conclusions: It was concluded from the present study that addition of low dose dexmedetomidineto hyperbaric bupivacaine for subarachnoid block definitely prolongs the duration of sensory and motor blockade.

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.

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.

Background: Hypotension after spinal anaesthesia is preventable by adequate pre-loading with colloids or crystalloids. Women posted for emergency caesarean section are more vulnerable for hypotension as they are not preloaded adequately due to time constraints. The idea of the study is to maintain haemodynamics by administering preload solution without any delay. Here 6% Hydoxyethyl starch (HES) is compared with Ringer lactate (RL) as a preloading solution. Materials and Methods: 50 pregnant women posted for emergency caesarean section were randomly allocated into 2 groups – Group H of 25 women received 500 ml of 6% HES and Group R of 25 women received 500 ml of RL intravenously as preload prior to spinal anaesthesia. The requirement of ephedrine to counter hypotension and the changes in the haemodynamic parameters were noted. Statistical analysis was done using Student's 't' test, Fisher's test and Chi square test, and p <0.05 was considered statistically significant. Results: The requirement of ephedrine was less in 6% HES group (p <0.001). The haemodynamical parameters were more stable in 6% HES group where there was minimal fall in blood pressure (p < 0.001) and minimal rise in heart rate (p <0.01) compared to RL group. Conclusion: The administration of 6% HES as a preloading solution before spinal anaesthesia in pregnant women undergoing Emergency Caesarean section is superior to Ringer lactate as it causes less incidence of hypotension and requires less ephedrine and intra-operative intravenous fluids.

Aims and Objectives: The aim of this study is to evaluate the effects of Dexmedetomidine and Fentanyl as intrathecal adjuvant to Bupivacaine on the onset and duration of sensory and motor block in spinal anaesthesiain orthopaedic lower limb and lower abdominal surgeries. Materials and Method: Ninety patients of ASA status I and II posted for lower limb and lower abdominal surgery were randomly divided into three groups. Group D was administered Hyperbaric Bupivacaine 15mg + Dexmedetomidine 5µg in 0.5 ml normal saline,group F was administered Hyperbaric Bupivacaine 15mg + Fentanyl 25 µg in 0.5 ml normal saline and group C were administered Hyperbaric Bupivacaine 15mg plus in 0.5 ml normal saline.Duration and quality of sensory and motor block were assessed. Results: Sensory and motor block in group D patients were longer than group F and C patients. Conclusion: Intrathecaldexmedetomidine when added tobupivacaine heavy (0.5%)provide better and prolonged analgesia in comparison to fentanyl.

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.

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.

A prospective randomized study for comparison of epidural 0.5% levobupivacaine with 0.5% racemic bupivacaine using fentanyl as common adjuvant in lower limb orthopedic surgeries Abstract Background: Levobupivacaine, an S(-) isomer of bupivacaine, has been shown a lower risk of cardiovascular and central nervous system toxicity than bupivacaine. This study was aimed to compare racemic bupivacaine and levobupivacaine in epidural anesthesia for lower limb orthopedic surgeries using fentanyl as a common adjuvant. Methods and Material: A randomized prospective study was planned on sixty patients of ASA grade I and II who were admitted for elective lower limb orthopedic surgeries under epidural anesthesia. Patients were randomly divided into two Groups, Group B (n=30) received bupivacaine 0.5% (13ml) and fentanyl 100 µg, Group L (n=30) received levobupivacaine 0.5% (13ml) and fentanyl 100 µg. In both the Group's onset of sensory and motor block, highest level of sensory block, duration of sensory and motor block, degree of motor block and hemodynamic parameters and complications were assessed perioperatively. Results: Mean duration of onset of sensory block was 9.54±1.03 and 9.85±0.97 min for Group B and Group L respectively and onset of motor block for Group B was 19.48±1.58 min and for Group L was 19.01±1.30 min, which were comparable for both Groups (P >0.05). Mean duration of sensory block was 371.33±13.23 min and 366.17±5.83 min in Group B and L respectively and mean duration of motor block was 273.0±11.0 min and 274.9±18.45 min in Group B and L respectively which were comparable in both Groups, (P > 0.05). The degree of motor block assessed by modified bromage scale was higher in Group B than Group L. Hemodynamic changes and complications having no significant differences between two Groups, (P > 0.05). Conclusion: The combination of levobupivacine and fentanyl is equipotent to bupivacaine and fentanyl in epidural anesthesia. Rather it seems to be a better alternative local anesthetic agent in epidural anesthesia for lower limb orthopedic surgeries.

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.