465 Split-thickness Skin Graft Harvest under Local Anaesthetic: A Single Pass Technique

Adequate local anaesthetic, in harvesting a split thickness skin graft (SSG), involves multiple passes of a needle across the length and width of the marked donor site. We describe a technique using hyaluronidase to uniformly anaesthetise an SSG donor site with one injection, in one pass of one needle. Mix 10mls 1% Lidocaine solution with Adrenaline 1:200,000 with 1 vial Hyaluronidase 1 Unit/ml solution. The mixture is buffered with 1 ml NaHCO3 to neutralise acidity and minimise pain. Mark out the SSG donor site Using a 27G long needle (sterican), enter perpendicular to the skin in the middle of the proximal aspect of the donor site. Inject some local anaesthetic subdermally, creating a mound. Change the angle of the needle to 180 degrees and continue to inject the remaining anaesthetic along one half of the width of the donor site. Using a rolled 4x4 swab, apply firm advancing pressure to distribute the mound across the remaining width and length of marked donor site. As the mound advances, the hyluronidase/anaesthetic mixture will distribute uniformly across the donor site within the same plane. The skin blanches secondary to the adrenaline during its distribution. The technique described is a fast, reproducible way to improve patient comfort through the elimination of repeated passes of a needle, distribute the anaesthetic uniformly across the donor site, and facilitate the acquisition of an SSG of uniform thickness The technique described is a fast, reproducible way to improve patient comfort through the elimination of repeated passes of a needle, distribute the anaesthetic uniformly across the donor site, and facilitate the acquisition of an SSG of uniform thickness

Non-invasive blood pressure monitoring in an anaesthetised calf - a case report

A six month old cross bred calf was presented with a swelling on lateral abdomen and diagnosed with lateral abdominal hernia, which underwent herniorrhaphy under general anaesthesia formed the subject of the study. The animal was administered with meloxicam @ 0.5 mg/kg body weight intravenously for pre-emptive analgesia. Thirty minutes later, xylazine @ 0.02 mg/kg and butorphanol @ 0.05 mg/kg, were administered intravenously. Upon sedation, the animal was administered with a loading dose of lignocaine @ 1 mg/kg body weight intravenously. Immediately following the loading dose of lignocaine, anaesthesia was induced using guaiphenesin @ 50 mg/kg and ketamine @ 2mg/kg intravenously. Following induction, anaesthesia was maintained using the prepared guaiphenesin-ketamine-lignocaine-butorphanol anaesthetic mixture as continuous rate infusion @ 3 ml/kg/hr. Indirect and direct blood pressure measurements were monitored and recorded. The non-invasive blood pressure values for systolic, diastolic and mean blood pressures did not differ significantly (p > 0.05) from those monitored invasively.

A Randomised Controlled Study of Two Different Doses of Bupivacaine in Ultrasound Guided Axillary Brachial Plexus Block

Introduction: The use of Ultrasound (USG) for needle precision aids in reduction of local anaesthetic volume needed for peripheral nerve blockade. Conventional dosages of 30 to 40 mL of local anaesthetic mixture have been used in peripheral nerve blockades but using a lesser volume will reduce the incidence of local anaesthesia associated systemic toxicity. Aim: To assess the efficacy of two different doses 20 mL and 25 mL of Bupivacaine in USG guided axillary plexus block. Materials and Methods: Sixty patients requiring forearm and hand surgeries were randomised into two groups. Group A received low volume (20 mL of 0.375% bupivacaine) and group B received intermediate volume (25 mL of 0.375% bupivacaine). The quality of anaesthesia in regards to sensory and motor blockade, duration of analgesia, haemodynamic variability and complications were evaluated. Successful block was defined by Vester Anderson’s criteria. Duration of analgesia was measured using Visual Analogue Scale (VAS). Statistical comparison of all continuous variables were assessed utilising Student’s t-test and Mann-Whitney U-test as applicable. Results: No significant difference in onset times were observed as far as sensory and motor blockade was concerned between the two groups A and B with p-values of 0.69 and 0.40, respectively. Group B had significantly longer duration of block in comparison with Group A (p<0.001). Two patients in group A and one patient in Group B required supplemental analgesia with fentanyl boluses. Haemodynamics were stable and no complications were seen in both the groups. Conclusion: Lower volume of Bupivacaine is convincingly prudent for regional blockade under USG guidance than suggested in literature.

Pain and outcomes of carpal tunnel release under local anaesthetic with or without a tourniquet: a randomized controlled trial

We conducted a prospective randomized controlled trial to investigate carpal tunnel decompression under local anaesthesia. Carpal tunnel decompression was performed in 37 wrists using local anaesthesia and an arm tourniquet and 36 without tourniquet but with a local anaesthetic mixture containing adrenaline. Patients who underwent carpal tunnel decompression using a tourniquet experienced a significantly greater degree of pain when compared with those who did not have a tourniquet. Pain and hand function improved to a similar degree in both groups. We conclude that carpal tunnel decompression performed with a tourniquet causes patients unnecessary pain with no additional benefit as compared with the wide-awake carpal tunnel decompression without use of a tourniquet. Level of evidence: I

High Thoracic Epidural anaesthesia for Off-pump CABG in a spontaneously breathing (conscious) patient (ACAB)

A 68 yr old man with ischemic heart disease (IHD) affecting triple vessels was admitted in National Institute of Cardiovascular Diseases & Hospital (NICVD), Dhaka for Coronary artery bypass grafting (CABG). He had been suffering from angina with minimal exercise with mild left ventricular systolic dysfunction. He was also suffering from hypertension and mild obstructive airway disease for the last ten years. He underwent off-pump CABG on beating heart using high thoracic epidural anaesthesia (TEA) without intubation. The patient was awake and breathing spontaneously, tolerated each phase of the operation without having any harmful effect. The effect of movement of the chest wall and the heart during spontaneous respiration did not influence the conduction of the operation. Epidurall catheter was placed at TI-2 interspace, in lateral decubitous position. After a test dose of 2% lignocaine 5ml, 0.5% Bupivacaine 14 ml + Fentanyl 2 ?gm/ml was injected epidurally. Central venous catheter was placed under local anaesthesia and inj Morphine 7.5 mg was given intramuscularly. After mid sternotomy left internal mammary artery (LIMA) and venous grafts were anastomozed to coronary arteries on beating heart. Haemodynamically patient was stable throughout the procedure and oxygenation was maintained by assisted facemask ventilation. At the end of operation laryngeal mask airway (LMA) was used for better oxygenation, which was withdrawn one hour later in the postoperative period. After transferring to the ICU, the patient was fully conscious, oriented, responds to commands, capable of coughing and clearing of secretions and pain free. He didn't require any ionotropic support or any systemic analgesic. Postoperative analgesia was maintained by continuous epidural infusionn of local anaesthetic mixture (0.5% Bupivacaine 20 ml + 2% Lignocaine 20 ml + Fentanyl (50?gm) I ml + NS 9 ml= 50 ml) via syringe pump at 1ml /hour. Liquid diet was allowed to the patient from the first POD and epidural analgesia was provided upto the third POD. Patient was shifted to HDU from ICU on the third POD. The patient was highly satisfied about the anaesthetic and operative procedure. DOI: http://dx.doi.org/10.3329/jbsa.v17i1.4052 Journal of BSA, Vol. 17, No. 1 & 2, 2004 p.48-51

Effect of Addition of Clonidine to Local Anaesthetic Mixture for Peribulbar Block

Clonidine added to local anaesthetics prolongs the duration of anaesthesia and analgesia of peripheral, neuraxial and retrobulbar blocks. The present randomized blinded controlled study was conducted to evaluate the effect of the addition of clonidine to local anaesthetic mixture on the quality, onset time, duration of peribulbar block, perioperative analgesia and patients’ comfort. The study comprised two groups of 12 patients each. Group A (control) patients received 7 ml of a mixture of 2% lignocaine and hyaluronidase with 1 ml normal saline, while group B (clonidine group) patients had clonidine 1 μg/kg added to the above mixture. Onset and duration of lid akinesia, globe anaesthesia and akinesia, time to first analgesic medication and total analgesic requirement were assessed. Patients were monitored for heart rate, blood pressure, sedation and respiratory depression. Addition of clonidine to local anaesthetic mixture resulted in a significant increase in duration of lid akinesia (85.4±25.6 vs 173.3±35.3 min, P<0.001), globe anaesthesia (63.2±6.9 vs 78.8±17.5 min, P=0.012) and globe akinesia (161.3±24.3 vs 201.2±45.7 min, P=0.016). The onset time and quality of block were similar in both the groups. No significant haemodynamic, respiratory or sedative effects were recorded. The perioperative pain scores and the analgesic requirements were significantly (P<0.01) lower in group B patients. We found that addition of clonidine 1 μg/kg to local anaesthetic mixture significantly increases the duration of anaesthesia and analgesia after peribulbar block.