COMPARISON OF HAEMODYNAMIC STABILITY WITH 0.5% AND 0.75% HYPERBARIC BUPIVACAINE DURING SPINAL ANAESTHESIA IN WOMEN UNDERGOING CAESAREAN SECTION

Objective: To compare the effect of 0.5% and 0.75% hyperbaric Bupivacaine on haemodynamic stability in terms of mean systolic blood pressure and heart rate recorded at 4 min in patients undergoing caesarian section in spinal anesthesia. Study Design: Quasi experimental study. Place and Duration of Study: Department of Anaesthesiology, Combined Military Hospital, Malir, from Jul to Dec 2018. Methodology: The patients were assigned in two groups (A and B) using lottery method. Group A received 0.5% hyperbaric Bupivacaine solution. Group B received 0.5% hyperbaric Bupivacaine solution. Spinal anaesthesia was given, blood pressure and heart rate were recorded. Data were analyzed in SPSS version 23. Both groups were compared for mean systolic blood pressure and heart rate by using independent sample t-test. Results: The mean age of patients was 29.62 ± 6.21 years in 0.75% Bupivacaine group while 29.31 ± 6.20 years in 0.5% Bupivacaine group. The mean systolic blood pressure of patients was 111.63 ± 5.96 mmHg in 0.75% Bupivacaine group while 117.16 ± 7.12 mmHg in 0.5% Bupivacaine group. The difference was significant in both groups (p-value <0.05). The mean heart rate of patients was 92.27 ± 4.71 beats per min (bpm) in 0.75% Bupivacaine group while 97.68 ± 4.58 bpm in 0.5% Bupivacaine group. The difference was significant in both groups (p-value <0.05). Conclusion: 0.5% hyperbaric Bupivacaine was better than 0.75% hyperbaric Bupivacaine solution in spinal anaesthesia during caesarean section.

Effects of Intraoperative Dexmedetomidine Infusion on Postoperative Pain after Craniotomy: A Narrative Review

Craniotomy involves procedures with high incidences of postoperative pain. Dexmedetomidine, a highly selective a2-adrenoreceptor agonist, has been shown to be beneficial in neuroanaesthesia. The purpose of this narrative review was to assess the effect and safety of dexmedetomidine given intraoperatively during anaesthesia compared to placebo and demonstrate the effect on acute postoperative pain in adult patients undergoing craniotomy. Literature published from 1996 until 2021 were analysed through a search of PubMed, Medline and Embase. Randomised controlled trials investigating intraoperative administration of Dexmedetomidine with evaluation of postoperative pain were included. Medical Subject Headings terms and free-text words were used to identify articles related to the intraoperative use of Dexmedetomidine and postcraniotomy pain. Thirteen distinct randomized controlled trials with 882 recruited patients undergoing craniotomy were identified as eligible for final inclusion. Intraoperative administration of dexmedetomidine is associated with decreased postoperative pain and opioid consumption, and it assures haemodynamic stability. Dexmedetomidine is an efficacious adjunct in craniotomy in adults, showing benefits in reduction of postoperative pain and analgesic consumption. Dexmedetomidine also offers haemodynamic stability. However, widespread methodological heterogeneity of the papers prohibits a valid meta-analysis.

Outcome of ultrasound guided reduction of intussusception in children by saline enema

Background: Intussuception is a common cause of acute intestinal obstruction in children and contributor of morbidity and mortality in children. The purpose of this study was to evaluate efficacy of hydrostatic reduction of intussusception over operative reduction using normal saline enema in children and to identify procedure related complications.Methods: All patients presenting to us with features of intussusception clinically and confirmed by ultrasonography between June 2015 to November 2017 were included in study. Depending on haemodynamic stability of patient and surgeon’s preference, patients were subjected to trial of hydrostatic reduction by normal saline enema or operative procedure. Patients with failure or partial reduction were taken for surgery.Results: The mean age was 21.07 months with a male preponderance. Of 53 patients attending the institute, 32 were given a trial of hydrostatic reduction which was successful in 28. Thus success rate was 87.5%. 1 patient succumbed resulting in 1.4% mortality rate after the procedure. It was observed that longer duration of symptoms reduced chances of reduction. 88%patients with successful hydrostatic reduction were discharged within 4 days of admission.Conclusions: We conclude that ultrasound guided saline enema is simple ,safe and effective method of treating intussusception in children with low rate of complications and can be strongly recommended as first line of treatment of intussusception in select group of paediatric patient, especially those reporting early to the hospital.

Comparison of the Effect of Ketamine, Ketamine-Midazolam and Ketamine-Propofol on Post-Tonsillectomy Agitation in Children

Background: Emergence agitation (EA) in children is one of the most common complications following anaesthesia. We aimed to compare the effect of ketamine, ketaminemidazolam and ketamine-propofol on EA after tonsillectomy. Methods: This study was a randomised, double-blind clinical trial conducted on 162 children undergoing adenotonsillectomy surgery. The participants were randomly divided into three groups of receiving ketamine (0.5 mg/kg) (N = 54), ketamine (0.5 mg/kg) + propofol (1 mg/kg) (N = 54) and ketamine (0.5 mg/kg) + midazolam (0.01 mg/kg) (N = 54) 10 min before the end of the operation. At the time of the patients’ entry into the post-anaesthesia care unit (PACU) and at intervals of 5 min, 10 min and 20 min after that, consciousness, mobility, breathing, circulation and SpO2 were recorded. Modified Aldrete recovery score (MARS), the objective pain score (OPS) and Richmond agitation-sedation scale (RASS) were also evaluated. Results: At the time of entrance to the PACU and 5 min later, the ketamine-midazolam and ketamine-propofol groups had lower RASS scores than the ketamine group (P < 0.001); after 10 min and 20 min, the ketamine-propofol group showed the lowest RASS score (P < 0.001). Ketamine-propofol group had a significantly lower MARS score at all-time points (P < 0.001). Recovery time was the longest for the ketamine-propofol group (P = 0.008). Conclusion: The ketamine-midazolam group had lower RASS, greater haemodynamic stability and MARS values without delayed awakening.

A Comparative Study on Intrathecal Hyperbaric and Hypobaric Bupivacaine in Unilateral Lower Limb Surgeries under Lumbar Sub-Arachnoid Block Held at Central Region of Kerala

BACKGROUND This study compared the characteristics of hyperbaric and hypobaric bupivacaine in patients undergoing unilateral lower limb surgeries under lumbar subarachnoid block with regard to their onset and level of sensory and motor blockades, haemodynamic stability, and recovery profile in terms of analgesic duration and motor recovery. METHODS This is a comparative study. Two groups, each of 36 patients who satisfied American society of Anaesthesiologist (ASA) I & II aged 18 – 65 years, were observed intra operatively and during immediate post-operative period. Group 1 received 2.4 ml of 0.5 % bupivacaine (heavy) with operated limb in dependent position. Group 2 received 4 ml of reconstituted hypobaric bupivacaine 0.3 %, with the operated limb positioned in non-dependent position. Onset, level and duration of motor and sensory block, hemodynamic changes and duration of surgical analgesia were compared between groups. RESULTS The level of sensory block attained in the hypobaric group was at T12 with maximum at T9, in the hyperbaric group it is variable and at higher level. Duration of sensory blockade was less with hypobaric. Motor block of modified Bromage scale 3 after 10 minutes was none in group 2 and 91.7 % in group 1. Significant fall in systolic blood pressure at 15 to 30 minutes and diastolic BP at 15 and 20 minutes was noted in hyperbaric group after subarachnoid block. There was significant percentage of change in systolic blood pressure from 4 to 70 minutes and mean arterial pressure (MAP) from 4 to 90 minutes in hyperbaric group. Duration of surgical analgesia in hypobaric group was longer compared to hyper baric. CONCLUSIONS Intrathecal hypobaric bupivacaine showed better haemodynamic stability and longer duration of analgesia in comparison with hyperbaric bupivacaine in lower limb surgeries. KEYWORDS Anaesthesia, Bupivacaine, Hypobaric, Subarachnoid Block

Is Saddle block superior to spinal anaesthesia for patients undergoing transurethral resection of prostate- a comparative evaluation

Background: TURP is the most common surgical intervention for patients with benign prostatic hyperplasia. Aims and Objectives: This prospective randomized study was planned to evaluate spinal anaesthesia (SA) versus saddle block with regard to haemodynamic parameters, ephedrine consumption, patient and surgeon satisfaction, perioperative complications in patients undergoing TURP. Materials and Methods: Eighty patients between the ages of 50-80 years with BPH, belonging to ASA grade I- III, prostatic volume between 50 - 80 cc were included in our study. Patients were randomly divided into two groups of 40 patients each. Patients in group SA (n=40) received spinal anaesthesia and the patients in group SBBI (n=40) were given saddle block with bladder instillation of local anaesthetic jelly for undergoing TURP. Results: There was more statistically significant fall in MAP in Group SA as compared to Group SBBI (p<0.05). Complications like hypotension, bradycardia and vasopressor requirement was less but requirement (p=0.021) of supplemental analgesia was more in patients who were administered saddle block. There was significantly lower patient satisfaction in saddle block (p=0.044) but comparable surgical satisfaction in both groups. Conclusion: Both Spinal anaesthesia and saddle block are safe and effective techniques of anaesthesia for patients undergoing TURP. SA has advantages like less requirement of supplemental analgesia, longer duration of post-operative analgesia and more patient satisfaction. However, saddle block is superior to spinal anaesthesia with regard to haemodynamic stability; with less chances of hypotension, bradycardia and less vasopressor requirement. It is similar to SA in terms of providing adequate surgical conditions.

Effect of intrathecal buprenorphine on the haemodynamic response in patients undergoing laparoscopic appendicectomy under general anaesthesia

: Combined regional and general anaesthesia for laparoscopic appendicectomy offers better intraoperative haemodynamic stability. Buprenorphine is a long acting opioid which can be administered intrathecally and provides excellent analgesia intraoperatively and post operatively while allowing early ambulation without prolonged motor block. The study aimed to compare the haemodynamic response during laparoscopic appendicectomy using combined general anaesthesia with intrathecal buprenorphine and general anaesthesia alone. In this observational study 80 patients who underwent laparoscopic appendicectomy were divided into two groups of 40 each by random sampling. The patients in the GA group received general anaesthesia whereas patients in the GA+SAB group received intrathecal buprenorphine along with general anaesthesia. The heart rate, systolic and diastolic blood pressures and SpOwere noted after induction of general anaesthesia, immediately after endotracheal intubation, after creating pneumoperitonium and post extubation. Student’s t test was used for comparing the haemodynamic variables There were no statistically significant differences between GA and GA+SAB group in the heart rate, systolic and diastolic blood pressure after pneumoperitonium was created. When compared to general anaesthesia alone, addition of intrathecal burenorphine provides little advantage in preventing stress response during laparoscopic appendicectomy.

322 Clinical Factors Predictive of Both Successful and Unsuccessful Arterial Embolization in The Management of Lower Gastrointestinal Bleeding

Aim To develop a model of clinical factors that may predict: (1) technically and clinically successful embolization of a bleeding vessel at Digital Subtraction Angiography (DSA) for lower gastrointestinal bleed (LGIB); (2) a negative DSA in the presence of positive CT-mesenteric angiography (CTMA) for LGIB. Method A retrospective cohort study of all DSAs conducted with intent for embolization for acute LGIB over a 10-year period was undertaken. Pre-procedural and intra-procedural clinical variables were evaluated using uni- and multi-variate analysis. Results 123 DSAs were evaluated. Technical success was 81% (64/78) with clinical success 78%. Technical success was associated with super-selective approach, contrast extravasation on CT, haemoglobin drop, anatomical source and time from CT to DSA on univariate analysis. On multivariate analysis time from CT to DSA was significant with a higher success probability within 120 minutes with different factors being salient depending on degree of delay. Clinical success was only associated with APTT (&lt;27.5s). Technical failure from a negative DSA following a positive CTMA was associated with anatomical source, haemodynamic stability, platelet count and time from CT to DSA on univariate analysis. The latter three remained so on multivariate analysis. Conclusions A triaging approach to utilising emergency DSA may be helpful. If prolonged delay between a positive CT and DSA is anticipated, with haemodynamic stability and a near normal platelet count, the DSA may not be fruitful. Technical success may be more likely if DSA occurs within 120mins. Clinical success may be more likely if APTT is within normal range.

Bupivacaine Hydrochloride and Ketamine Hydrochloride with Dextrose Given Intrathecally for Inguinal Hernia Repair - A Randomized Controlled Study in a Tertiary Centre in South Kerala

BACKGROUND Spinal Anaesthesia is the most commonly used form of anaesthesia for surgeries below the level of umbilicus. Bupivacaine is the drug of choice for subarachnoid block. Spinal anaesthesia with bupivacaine is associated with many side effects and complications especially in patients with multiple co-morbid conditions. In our study we compared the anaesthetic effectiveness of 3.5 ml hyperbaric bupivacaine with a mixture of 100 mg ketamine and 0.1 mg adrenaline, the solution is made hyperbaric by adding 1.4 ml of 5 % dextrose given intrathecally. The objective of our study was to compare the anaesthetic properties and clinical effectiveness of intrathecally administered ketamine with bupivacaine for inguinal hernia repair. METHODS This randomised control study was conducted on fifty American society of Anaesthesiologists (ASA) 1 and 2 patients in the age group of 25 – 60 years posted for elective inguinal hernia repair from December 2004 to December 2005. They were randomized in to two groups. Group 1 (Bupivacine group) and Group 2 (Ketamine group). Bupivacaine group (group 1) received 3.5 ml of bupivacaine heavy and ketamine group (group 2) received preservative free ketamine 100 mg with 0.1 mg adrenalin 1/1000 solution in 1.4 ml of 5 % dextrose to make it heavy. Anaesthetic properties, side effects and complications of both groups were compared intraoperatively. RESULTS The onset of action of ketamine (1.58 minutes) was faster than bupivacaine (3.31 minutes) which is statistically significant. Duration of blockade was longer in bupivacaine group (sensory 227.92 and motor 203.08) compared to ketamine group (sensory 143.40 and motor 109.46). Ketamine group showed a greater level of haemodynamic stability than bupivacaine group. CONCLUSIONS Intrathecal ketamine produces optimal anaesthetic conditions for surgeries like inguinal hernia repair. Haemodynamic stability provided by intrathecal ketamine is beneficial in patients with multiple comorbidities. KEYWORDS Hyperbaric Bupivacaine, Ketamine in Hyperbaric Solution, Intrathecal Block, Inguinal Hernia Repair

A COMPARATIVE STUDY ON THE TOTAL DOSE REQUIREMENTS AND HEMODYNAMIC ALTERATIONS WITH AND WITHOUT THE APPLICATION OF PRIMING PRINCIPLE AMONG PATIENTS INDUCED WITH PROPOFOL

Background:- Propofol given at standard induction dose, is known to produce haemodynamic instability, especially hypotension. Application of “priming principle” helps to reduce the total dose of propofol. Objectives:- To study the total dose requirements of propofol and peri-intubation haemodynamic stability in patients undergoing surgery under GACV when priming principle is applied. Methodology:- This was an observational study among 54 ASA I and II patients undergoing surgery under GACV, who were randomly divided into three groups of 18 patients each. All patients received fentanyl 1 mcg/kg over 30 seconds followed by propofol. Group 1 patients received the total (100%) calculated dose of propofol. Group 2 and 3 patients received 20% and 40% of the dose respectively as priming dose, and the remaining was given 30 seconds later, until there was loss of eyelash reex. The total dose of propofol given, the heart rate, systolic and diastolic blood pressures, mean arterial pressures at various time intervals before, during and after induction and intubation, and complications observed were compared and statistically analysed using SPSS 2.0. Results:- The mean induction dose of propofol was signicantly lower in the priming groups (71.7 ± 17.2mg in group 2 and 80.0 ± 17.1mg in group 3) compared to group1 (107.9 ± 8.0mg). The fall in mean arterial pressure was signicantly lower in groups 2 and 3 (p<0.05) compared to group1 at one minute post-induction. Conclusion:-Application of priming principle reduces the induction dose of propofol and is associated with better peri-intubation haemodynamic stability.