CONTROL OF INTRAOPERATIVE SHIVERING UNDER SPINAL ANAESTHESIA- A PROSPECTIVE RANDOMIZED COMPARATIVE STUDY OF NALBUPHINE WITH TRAMADOL

spinal anesthesia is a widely used technique for both elective and emergency surgeries. Shivering is one of the most commonly recognized complications of the central neuraxial blockade because of impairment of thermoregulatory control, reported in 40%-70% of the patients undergoing surgery under spinal anaesthesia. Post-anesthetic shivering is defined as an involuntary,spontaneous,rhythmic oscillating muscle hyperactivity that increases metabolic heat production up to 600% after anesthesia. Shivering during neuraxial anesthesia is a common issue that could have possibly adverse impacts, for example, increased oxygen consumption, carbon dioxide production, lung ventilation and cardiac work, as well as causing diminished mixed venous oxygen saturation. Spinal anesthesia impedes the thermoregulatory system by restraining tonic vasoconstriction which assumes significant role in the regulation of temperature

Above knee amputation in a geriatric patient with severe ICMP and DM2: A case report

Geriatric patients with cardiac dysfunction are always a nightmare for anaesthetist in terms of successful intraoperative and postoperative management. We are presenting a case of 68-year-old male patient admitted in surgical emergency with rapidly progressive wet gangrene of right leg. He was a diagnosed case of severe Ischemic cardiomyopathy (ICMP) and Diabetes mellitus type 2 (DM-2) since last 10 years on medications. However, he was non-compliant with medications and had developed severe limitation in the functional status with metabolic equivalents <4 (METs<4) and complaints of chest pain even on minimal exertion. In view of the rapidly progressive wet gangrene and risk of sepsis leading to high possibility of morbidity and mortality, an urgent above knee amputation was planned. However due to the risks associated with general anaesthesia and central neuraxial blockade, an safe anesthesia plan was formulated and implemented utilising only the lower limb blocks to achieve a safe conduct of anaesthesia.

Comparing the efficacy of tramadol, ketamine and dexmedetomidine in the prevention of intraoperative shivering in patients undergoing surgery under subarachnoid blockade

The most common nagging and inconveniencing complication of spinal anesthesia is intra operative shivering. Central neuraxial blockade blunts the thermoregulatory mechanism by restricting vasoconstriction, resulting in shifting of central heat to the periphery from the trunk. Various pharmacological and non pharmacological methods are used for the control of intraoperative shivering.The aim of our study was to compare the efficacy of Tramadol, Ketamine and Dexmedetomidine in the prevention of intra operative shivering in patients undergoing surgeries under subarachnoid blockade.90 patients of age group between 20 to 65 years belonging to ASA 1 and 2 posted for elective surgery under spinal anaesthesia will participate in this study. The patients were randomly allocated into 3 groups of 30 each and were named as by computer generated random table number. Group T received Tramadol 0.5 mg/kg in 100 ml NS over 10 – 15 minsGroup K Ketamine 0.25 mg/kg in 100 ml NS over 10 – 15 mins and Group D Dexmedetomidine 0.5 μg/kg in 100 ml NS over 10 – 15 mins. Data were statistically analysed with the SPSS version 22.0 software using two-sided unpaired t-test and Chi-square test. A repeated measure of ANOVA was applied for the three groups to know the with-in subject variability in prevention of shivering following subarachnoid blockade and p value < 0.05 was considered to be significant.The conclusion of our study is that Dexmedetomidine at the dose of 0.5 μg/kg decreases effectively in the prevention of intra operative shivering in patients undergoing surgery under subarachnoid blockade when compared with Tramadol and Ketamine.

Comparison of the Effects of Different Regional Blockade Techniques on Occurrence of Acute Kidney Injury (AKI) After Major Thoracic and Abdominal Surgeries Under General Anesthesia: A Propensity Matching Analysis

Background: Recently, it has been under consideration that the anesthetic techniques used during general anesthesia may have influence over the development of acute kidney injury and other postoperative outcomes. For this reason, we aimed to compare the effects of different regional blockade techniques (peripheral nerve blockade versus neuraxial epidural) on occurrence of acute kidney injury (AKI) after thoracic and abdominal surgeries under general anesthesia.Methods: In a single-center retrospective cohort study, 2846 patients undergoing elective thoracic or abdominal surgery during a period of seven years were included into the study. The primary endpoint was the occurrence of AKI postoperatively within a seven-day period in-hospital. Perioperative data were obtained and analyzed to provide data for secondary endpoints that include all other outcome related parameters. To reduce the influence of potential confounding factors, propensity score (PS) analysis was performed. Multivariate logistic regression models examined the selection of an epidural or PNB in general anesthesia before and after propensity score weighting analysis.Results: Of the 2846 patients, 7.3% (207 cases) suffered AKI. The odds ratio of AKI for PNB (epidural as reference) was 0.61 (0.40~0.83), P = 0.006. After propensity score matching, the odds ratio for PNB was [0.49 (0.28~0.70), P = 0.001]. All other outcome related parameters were considered and evaluated.Conclusions: After PS matching analysis, there is no difference in secondary outcome analysis of groups that received PNB or epidural neuraxial blockade who were both under general anesthesia. However, patients who received PNB under general anesthesia showed lower incidence of AKI within seven days postoperatively.

Reinvestigation on Newer Facts to Anticipate, Avoid And Mitigate The Development of Post-Dural Puncture Headache-A Prospective Cohort Study

Purpose: Various researchers have described the size and the type of spinal needle used for neuraxial anesthesia as the most common risk factor for developing postdural puncture headache (PDPH). Even though the occurrence of the PDPH is rare in modern anesthesia practice, we come across many such patients despite following all guidelines or precautions. Patient-related factors for developing PDPH are relatively understudied. For that, clinical features commonly present in such patients may require a thorough investigation. Methods: This prospective cohort study included fifty patients admitted for lower extremities orthopedic surgeries and developed PDPH following the neuraxial blockade. We screened all patients in this study for the presence or absence of common manifestations suggestive of connective tissue disorders (CTD). The other outcomes, like the effect of spinal needle size/type to develop PDPH and time to develop PDPH, were also measured. Results: Almost all PDPH patients included in this study had common features suggestive of CTD: the ligamentous laxity (96%), high-arched palate (96%), the blue sclera (45%), joint hyperextensibility (82%), and ejection clicks (64%). PDPH occurred more frequently with the 25G spinal needle of Quincke type than 27G of Whitacre type (82% vs. 18%). The mean (SD) headache freedom time was 73.14 (24.74) hours. Conclusions: The CTD might also be a causative factor responsible for the development of PDPH in some individuals. It can be considered a risk factor to anticipate, avoid, and mitigate the development of PDPH.

Ultrasound Assisted Neuraxial Blockade in Obstetric Anesthesia

Central Neuraxial Blocks (CNBs) relevant to the practice of obstetric anesthesia and analgesia are spinal, epidural and combined spinal-epidural injections. These techniques are routinely used for cesarean deliveries and labor pain relief. Traditionally, CNBs are performed using surface anatomical landmarks. In the first instance the highest point of each iliac crest is identifies. The imaginary line connecting these points allegedly passes through the L4 vertebral body in non-pregnant women, and L3 vertebral body in pregnant women [1]. Based on this, the operator palpates and counts the spinous processes and decides on the needle entry point. Although this technique is widely accepted as relatively reliable, the correlation is inconsistent even in non-complicated cases. Obesity, tissue edema, pelvic rotation, limited ability to bend forward, hyperlordosis, labor pain, underlying spinal deformity or previous back surgery and instrumentation pose additional difficulty for anesthesiologists to correctly locate the intervertebral levels.

Ultrasound-guided lumbar ESP block for post-operative analgesia as an alternative mode of analgesia in hip arthroplasty with multiple systemic issues: a case report

Background Patients with multiple systemic diseases present an anaesthetic challenge in terms of perioperative pain management. We propose that ultrasound-guided erector spinae plane block be used as an alternative mode of analgesia in patients undergoing hip arthroplasty. Case presentation We report a case of a 54-year-old female, a known case of autosomal dominant polycystic kidney disease on continuous ambulatory peritoneal dialysis, hypertension, and deranged coagulation profile with fractured neck of femur planned for hemiarthroplasty. She was administered ultrasound-guided single-shot erector spinae plane block at L3 level with 20 mL of 0.25% ropivacaine and 4 mg dexamethasone. This block provided excellent post-operative analgesia for up to 24 h with early mobilisation. Conclusion Single-shot ultrasound-guided erector spinae plane bock can be used as an alternative mode of analgesia in patients undergoing hip arthroplasty, with multiple systemic diseases in whom neuraxial blockade cannot be performed. This technique needs to be further explored in the form of randomised controlled trials.

Difficult subarachnoid anaesthesia Prediction and Performance

Spinal anaesthesia (SA) has enjoyed a long history of success, celebrating soon its 125th anniversary. Puncturing the dura mater is considered a simple procedure, followed by a subarachnoid injection of a local anaesthetic (LA) agent into the cerebrospinal fluid (CSF). Even when the technique is performed perfectly, there is no guarantee that the block sits perfectly. Failure is not uncommon and encompasses a range from total absence of any neuraxial blockade, a partial block (insufficient height, quality or duration) or a patchy block. Table 1 lists a large number of potential causative factors that may result in a failed spinal anaesthetic, providing suggestions of solutions. Analysing each distinct phase of the procedure, i.e., spinal puncture, injection of local anaesthetic solution, spread of the local anaesthetic solution through the cerebrospinal fluid, action of the drug on subarachnoid neural tissue and patient management, are the keys to success at each stage. Mechanisms of failure of spinal anaesthesia include insufficient preparation and check of equipment and drugs, suboptimal positioning of the patient, unsuccessful puncture due to inadequate training or experience and inadequate use of needles and local anaesthetic solution.1-5 Besides operator, preparation, technique-dependent and patient-related factors (anatomical variations), there are also organisational factors (lack of block room, lack of adequate monitoring and trained personnel, insufficient time between block and onset of surgery, subsequent management following block). The use of the correct local anaesthetic (dose, volume, concentration) injected at the correct lumbar interspace is of paramount importance to produce an adequate spinal block for the right surgical intervention. Nevertheless, failures may still occur. Therefore, the anaesthetist should always have a contingency plan for a failed spinal block. Indeed, patients expect reliable surgical anaesthesia when undergoing an operation