Postoperative nausea and vomiting (PONV) is one of the complex and significant problems in anesthesia practice, with growing trend toward ambulatory and day care surgeries. This review focuses on pathophysiology, pharmacological prophylaxis, and rescue therapy for PONV. We searched the Medline and PubMed database for articles published in English from 1991 to 2014 while writing this review using “postoperative nausea and vomiting, PONV, nausea-vomiting, PONV prophylaxis, and rescue” as keywords. PONV is influenced by multiple factors which are related to the patient, surgery, and pre-, intra-, and post-operative anesthesia factors. The risk of PONV can be assessed using a scoring system such as Apfel simplified scoring system which is based on four independent risk predictors. PONV prophylaxis is administered to patients with medium and high risks based on this scoring system. Newer drugs such as neurokinin-1 receptor antagonist (aprepitant) are used along with serotonin (5-hydroxytryptamine subtype 3) receptor antagonist, corticosteroids, anticholinergics, antihistaminics, and butyrophenones for PONV prophylaxis. Combination of drugs from different classes with different mechanism of action are administered for optimized efficacy in adults with moderate risk for PONV. Multimodal approach with combination of pharmacological and nonpharmacological prophylaxis along with interventions that reduce baseline risk is employed in patients with high PONV risk.

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Background: Intravenous (IV) fluids are an integral part of perioperative management. Intraoperative hyperglycemia is associated with poor clinical outcomes in patients undergoing major surgeries even in nondiabetics. Aim: This study was conducted to observe the effect of different maintenance fluid regimens on intraoperative blood glucose levels in nondiabetic patients undergoing major surgeries under general anesthesia. Settings and Design: Randomized double-blind study. Materials and Methods: One hundred nondiabetic patients of either sex were divided randomly into two Groups I and II of 50 each undergoing elective major surgeries of more than 90 min duration under general anesthesia. Both groups were given calculated dosage of IV fluids accordingly 4-2-1 formula while Group I was given Ringer lactate (RL) and Group II was given 0.45% dextrose normal saline and potassium chloride 20 mmol/L. Changes in vital parameters, % oxygen saturation, and urine output were monitored at regular intervals. Capillary blood glucose (CBG) was measured half-hourly until end of surgery. If CBG level was more than 150 mg%, then calculated dose of human insulin (CBG/100) was given as IV bolus dose. Statistical Analysis: Statistical analysis was done using SPSS 22.0 software (IBM Corporation, Armonk, New York, USA), paired t-test and Chi-square test. Results: A significant increase of CBG level and was observed during intraoperative and immediate postoperative period (P < 0.001) in Group II. Conclusion: RL solution is probably the alternative choice of IV fluid for perioperative maintenance and can be used as replacement fluid in nondiabetic patients undergoing major surgeries.

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Intestinal obstruction is associated with significant morbidity and mortality. Scientific assessment of the cause, site of obstruction, appropriate correction of the fluid deficit and electrolyte imbalance with preoperative stabilization of blood gases is ideal as a preoperative workup. Placement of a preoperative epidural catheter especially in the thoracic interspace takes care of perioperative pain and stress reduction. Intraoperative management by controlled general anesthesia administering a relative high inspired fraction of oxygen with invasive monitoring in selected sick cases is mandatory. Preoperative monitoring and stabilizing raised intra-abdominal pressure reduces morbidity. Caution should be exercised during opening and closure of abdomen to avoid cardiorespiratory ill effects. There should be an emphasis on avoiding hypothermia. The use of nonsteroidal anti-inflammatory drugs may worsen sick, fragile patients. The use of sugammadex rather than neostigmine will obscure certain controversies in the healing of intestinal anastomotic site. Replacement of blood loss continued correction of fluids and electrolytes with possible postoperative mechanical ventilation in sick cases may improve outcomes in these patients.

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Dental pain management is one of the most critical aspects of modern dentistry which might affect patient's quality of life. Several methods are suggested to provide a painless situation for patients. Desensitization of the oral site using topical anesthetics is one of those methods. The improvements of topical anesthetic agents are probably one of the most important advances in dental science in the past 100 years. Most of them are safe and can be applied on oral mucosa with minimal irritation and allergic reactions. At present, these agents are various with different potent and indications. Eutectic mixture of local anesthetics (EMLA) (lidocaine + prilocaine) is a commercial anesthetic agent which has got acceptance among dental clinicians. This article provides a brief review about the efficacy of EMLA as a topical anesthetic agent when used during dental procedures.

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Introduction: To compare the efficacy of combination of epidural local anesthetic with tramadol and butorphanol in major abdominal surgeries. Aims: To evaluate duration of analgesia, analgesic efficacy, and safety profile of two groups of drugs-epidural butorphanol with bupivacaine and epidural tramadol with bupivacaine. Materials and Methods: A prospective, randomized controlled, double-blinded study was undertaken in 50 patients scheduled for major abdominal surgeries. Group B received epidural butorphanol 2 mg + bupivacaine 0.125% first dose and subsequent doses, butorphanol 1 mg + bupivacaine 0.125% (total volume 10 ml). Group T received epidural tramadol 2 mg/kg + bupivacaine 0.125% first dose and subsequent doses, tramadol 1 mg/kg + bupivacaine 0.125% (total volume 10 ml). Observed parameters were the quality of analgesia, sedation, and hemodynamic parameters in the intra and post-operative period. Time for request of rescue analgesia was noted in all the patients. Continuous data are analyzed by Student's t-test using IBM SPSS software version 20. P ≤0.05 was considered to be statistically significant. P≤ 0.001 was considered to be statistically highly significant. Results: Visual analog scale better with butorphanol group than tramadol (0.12 ± 0.332 and 0.84 ± 0.746 for Group B and Group T) at 30 min after first dose. Onset of action (8.44 ± 1.158 min in Group B and 12.80 ± 1.354 min in Group T) faster with butorphanol but duration of analgesia longer with tramadol (5.92 ± 0.76 h in Group B vs. 7.68 ± 0.76 h in Group T). Sedation was seen in patients with butorphanol group. Nausea and vomiting more frequent with tramadol group. Conclusions: Epidural tramadol with antiemetic is better than butorphanol for its longer duration in ambulatory surgery, elderly patients, obese patients, and suitable high-risk patients.

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Introduction: Peripheral nerve blocks are gaining popularity for many infraumblical surgeries with the development of new techniques such as ultrasound and peripheral nerve stimulator. It provides stable hemodynamic, better, and prolonged postoperative analgesia. This study was carried out to see the effectiveness of combined femoral and sciatic nerve block with ropivacaine alone and by adding fentanyl. Materials and Methods: The study was carried out on 100 patients scheduled for lower limb surgeries and were randomly divided into two groups of 50 each. In Group A, patients received 20 ml of 0.5% ropivacaine for femoral nerve block and same dose for sciatic nerve block and in Group B, 25 μg fentanyl was added each for femoral nerve and sciatic nerve block along with ropivacaine. All hemodynamic parameters, onset and duration of sensory and motor blocks were noted. The patient characteristics were analyzed using the “Chi-square tests” and the intergroup comparison of the parametric data was carried out using the unpaired t-test using software IBM SPSS 17.0. Results: Combined femoral and sciatic nerve block provide longer duration of postoperative analgesia of about 12–13 h. All the above-mentioned parameters were statistically non-significant. Conclusion: Hence in this study, onset and duration of sensory and motor block was comparable in both groups. However postoperative analgesia was prolonged as compared to neuraxial blockade without any hemodynamic instability.

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Aims and Objectives: Supplementation of dexmedetomidine produces a dose-dependent sedation, anxiolysis and analgesia without respiratory depression. This study was conducted to evaluate the possible effect of dexmedetomidine as an adjuvant to levobupivacaine for supraclavicular brachial plexus block in upper limb surgery. Settings and Design: Tertiary care institute, Department of Anaesthesiology and Intensive Care, a placebo-controlled study. Materials and Methods: After obtaining Ethical Committee approval, a randomized, double-blind, placebo-controlled study was conducted on sixty American Society of Anesthesiologists physical status I and II patients in the age group of 18–60 years, divided randomly into two groups, Group I received 30 ml of 0.5% levobupivacaine with 1 ml of isotonic sodium chloride solution and Group II received 30 ml of 0.5% levobupivacaine and 1 ml (100 mcg) of dexmedetomidine for supraclavicular brachial plexus block. The onset and duration of sensory and motor blockade, duration of analgesia (DOA) and any adverse effects were noted. At the end of the study, data were compiled and analyzed using appropriate statistical tests. The value of P< 0.05 was considered significant. Results: Demographic profile was comparable in both the groups. The time to onset of sensory and motor block was 10.54 ± 2.333 min and 12.21 ± 2.529 min in Group I while it was 3.24 ± 0.951 min and 2.83 ± 1.197 min in Group II, respectively. The duration of sensory and motor block was 7.79 ± 2.007 h and 9.18 ± 1.701 h in Group I, and it was 16.31 ± 2.606 h and 17.52 ± 2.098 h in Group II, respectively. The DOA was 678.68 ± 20.492 min in Group I and 1273.79 ± 83.139 min in Group II. On statistical comparison, these values were highly significant (P < 0.001). Side effects such as nausea, vomiting, hypoxemia, pruritis, or urinary retention were not observed in either of the groups. Conclusion: Dexmedetomidine shortens the onset time for sensory and motor block significantly and prolongs DOA as well when used with levobupivacaine for supraclavicular brachial plexus block, without increasing the incidence of any adverse effects.

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Background: The advent of laparoscopic surgeries has proved to be beneficial for both patient and surgeon although increased morbidity may result from hemodynamic changes associated with laryngoscopy, intubation, and pneumoperitoneum (PNP). Aim: The present study was prospective, randomized, double-blind conducted to evaluate the efficacy of dexmdetomidine and fentanyl in attenuation of pressor responses to laryngoscopy, intubation, and PNP in laparoscopic cholecystectomy (LC). Materials and Methods: A total of 60 patients of 18–65 years, American Society of Anaesthesiologists Class I/II of either sex for elective LC, were included. The patients were divided into two groups of 30 patients each. Group I received dexmedetomidine and Group II Fentanyl loading 1 μg/kg over 15 min followed by maintenance 0.2 μg/kg/h throughout the PNP. Measurements: Heart rate (HR), systolic blood pressure, diastolic blood pressure, and mean arterial blood pressure (MAP) were recorded preoperatively, 15 min after infusion of study drug, 1 min after induction, 1 min after intubation, throughout the PNP, end of surgery, and until 60 min in postoperative period. Sedation score, visual analog scale score along with modified Alderete score applied in postanesthesia care unit. Results: Control of HR and MAP in Group I was better than in Group II during laryngoscopy, intubation and PNP. There was also smooth extubation, less sedation and better control of pain in Group I than in Group II. Conclusion: The present study demonstrates the benefits of dexmedetomidine over fentanyl in hemodynamic stability and analgesic quality in LC. Thus, it is establishing its utility over for attenuation of pressor response.

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Context: Various adjuvants are being used with local anesthetics for prolongation of intraoperative and postoperative analgesia. The α2-adrenergic agonist clonidine and potent opioid buprenorphine have the ability to potentiate the effects of local anesthetics. Aims: The purpose of this prospective, double-blind study was to compare onset, duration of sensory and motor block, effect on hemodynamics, level of sedation, duration of postoperative analgesia, and any adverse effects of clonidine and buprenorphine. Settings and Design: Seventy-five American Society of Anesthesiologists Class I and II patients undergoing lower limb surgery under spinal anesthesia were randomly allocated into three Groups A, B, and C. Subjects and Methods: Control Group A received injection bupivacaine 0.5% (heavy) 2.5 ml + saline 0.5 ml whereas Group B received injection bupivacaine 0.5% (heavy) 2.5 ml + injection buprenorphine 50 μg and Group C received injection bupivacaine 0.5% (heavy) 2.5 ml + preservative free injection clonidine 50 μg intrathecally. Statistical Analysis Used: Unpaired Student's t-test and Z-test were used for comparing data. Results: Statistically highly significant differences in mean time of sensory regression to L1, mean time to attain the Bromage Score of 1, and mean time of first rescue analgesic request were observed between the three groups. The patients did not suffer any serious side effects. Conclusion: Administration of buprenorphine and clonidine intrathecally does potentiate the duration of analgesia, sensory and motor block, with buprenorphine having a long-lasting effect.

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Background: Fentanyl and dexmedetomidine have been tried to attenuate airway and circulatory reflexes during emergence and extubation individually but have not been compared with respect to the level of sedation to evolve a reliable technique for rapid and smooth extubation. Aim: To compare the effects of fentanyl and dexmedetomidine in attenuating airway and circulatory reflexes during emergence and extubation of the endotracheal tube. Setting and Design: This double-blind, randomized, controlled study was done in patients undergoing surgery under general anesthesia belonging to the American Society of Anesthesiologists physical status 1 or 2. Methodology: All patients received a standardized anesthetic protocol. Patients were randomized to receive either fentanyl 1 μg/kg or dexmedetomidine 0.75 μg/kg. Fifteen minutes before expected last surgical suture, isoflurane was cutoff and equal amount of test solution was given when train-of-four ratio was 0.3. The degree of sedation, airway, and circulatory responses at the time of suction and extubation were analyzed. Statistical Analysis Used: Chi-square test for nonparametric data and t-test for parametric data. Results: Heart rate (HR) was comparable in both the groups until endotracheal extubation. Later, there was rise in HR in fentanyl group. There was stastisticaly significant drop in blood pressure at 5 min after test drug administration in both the groups. Airway response for suctioning and extubation was better in dexmedetomidine group and it was associated with better sedation score than fentanyl group. Conclusion: Single dose of 0.75 μg/kg dexmedetomidine given 15 min before extubation provides smooth extubation when compared to fentanyl.

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Background: Subarachnoid block is the preferred technique for providing anesthesia for patients undergoing cesarean section. Various pharmacological agents in added to local anesthetics (LA) modify their original effects in terms of block characteristics and quality of analgesia. However, there is ongoing debate about this practice of using adjuncts with LA. We tested whether addition of lipophilic versus lipophobic opioids to LA gives any clinical benefits to maternal and fetal outcome when used in these patients requiring spinal anesthesia. Subjects and Methods: Sixty American Society of Anesthesiologists I and II parturients, undergoing elective cesarean section requiring subarachnoid block, were included in our study. The parturients were allocated randomly to three groups of 20 each to receive bupivacaine 12.5 mg (Group I), bupivacaine 12.5 mg + morphine 0.2 mg (Group II), bupivacaine 12.5 mg + fentanyl 25 μg (Group III), preservative free physiological saline 0.9% was added to all the solutions to achieve a total volume of 4 ml. The parameters studied were the time of onset, sensory level of the block achieved, total duration of analgesia, any need of rescue analgesics, maternal side effects, and fetal outcome. Results: Onset of block was early 4.30 ± 0.12 min in Group III as compared to Group I 4.64 ± 0.28 min and Group II 4.505 ± 0.22 min. Mean duration of analgesia (hours) was higher in Group II 15.91 ± 0.96 h as compared to Group I 1.95 ± 0.55 h and Group III 4.39 ± 0.2 h. Incidence of nausea, vomiting, and shivering was more in the control group as compared to study groups, whereas sedation and pruritus were seen more in the study groups. No adverse effects on fetus were seen with use of opioids and comparable Apgar scores were noted. Conclusion: Addition of intrthecal fentanyl causes rapid onset of block whereas intrathecal morphine provides prolonged analgesia with comparable neonatal wellbeing.

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Background: Carbon dioxide pneumoperitoneum for laparoscopic surgery increases arterial pressures, heart rate (HR), and systemic vascular resistance. In this randomized, single-blind, placebo-controlled clinical study, we investigated and compared the efficacy of esmolol and dexmedetomidine to provide perioperative hemodynamic stability in patients undergoing laparoscopic cholecystectomy. Methods: Sixty patients, of either sex undergoing elective laparoscopic cholecystectomy, were randomly allocated into three groups containing twenty patients each. Group E received bolus dose of 500 μg/kg intravenous (IV) esmolol before pneumoperitoneum followed by an infusion of 100 μg/kg/min. Group D received bolus dose of 1 μg/kg IV dexmedetomidine before pneumoperitoneum followed by infusion of 0.2 μg/kg/h. Group S (control) received saline 0.9%. Results: Mean arterial pressure and HR in Group E and D were significantly less throughout the period of pneumoperitoneum in comparison to Group S. IV nitroglycerine was required in 45% (9 out of 20) patients in Group S to control intraoperative hypertension, and it was clinically significant in comparison to Group E and D. Conclusion: Both esmolol and dexmedetomidine attenuate the adverse hemodynamic response to pneumoperitoneum and provide hemodynamic stability during laparoscopic surgery.

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Background: Transversus abdominis plane (TAP) block has been used to provide intra- and post-operative analgesia with single incision laparoscopic (SIL) bariatric and gynecological surgery with mixed results. Its efficacy in providing analgesia for SIL cholecystectomy (SILC) via the same approach remains unexplored. Aims: The primary objective of our study was to compare the efficacy of bilateral TAP block with local anesthetic infiltration for perioperative analgesia in patients undergoing SILC. Settings and Design: This was a prospective, randomized, controlled, double-blinded trial performed in a tertiary care hospital. Materials and Methods: Forty-two patients undergoing SILC were randomized to receive either ultrasound-guided (USG) bilateral mid-axillary TAP blocks with 0.375% ropivacaine or local anesthetic infiltration of the port site. The primary outcome measure was the requirement of morphine in the first 24 h postoperatively. Statistical Analysis: The data were analyzed using t-test, Mann–Whitney test or Chi-square test. Results: The 24 h morphine requirement (mean ± standard deviation) was 34.57 ± 14.64 mg in TAP group and 32.76 ± 14.34 mg in local infiltration group (P = 0.688). The number of patients requiring intraoperative supplemental fentanyl in TAP group was 8 and in local infiltration group was 16 (P = 0.028). The visual analog scale scores at rest and on coughing were significantly higher in the local infiltration group in the immediate postoperative period (P = 0.034 and P= 0.007, respectively). Conclusion: USG bilateral TAP blocks were not effective in decreasing 24 h morphine requirement as compared to local anesthetic infiltration in patients undergoing SILC although it provided some analgesic benefit intraoperatively and in the initial 4 h postoperatively. Hence, the benefits of TAP blocks are not worth the effort and time spent for administering them for this surgery.

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Background and Aims: Early extubation is a desirable goal after general anesthesia. Very few studies have compared the effect of bispectral index (BIS) monitoring versus standard end-tidal anesthetic gas (ETAG) concentration monitoring on tracheal extubation time for halothane-based anesthesia. The aim of this study was to compare the effect of BIS versus ETAG-guided anesthesia on time to tracheal extubation for halothane-based anesthesia in general surgical setting. Methods: This was a randomized, controlled double-blind study. Sixty patients with the American Society of Anesthesiologists physical status Class 1 or 2, receiving halothane-based general anesthesia were randomized to BIS-guided (n = 30) and ETAG-guided anesthesia (n = 30). Time to tracheal extubation was measured. In BIS group, BIS value was kept between 40 and 60 while in ETAG group; ETAG value was kept between 0.7 and 1.3 minimum alveolar concentration. The two groups were compared using Student's t-test, and P< 0.05 was considered statistically significant. Data were processed and analyzed using SPSS version 17 software. Results: Mean time to tracheal extubation was significantly longer in BIS group (9.63 ± 3.02 min) as compared to ETAG group (5.29 ± 1.51 min), mean difference 4.34 min with 95% confidence interval (3.106, 5.982) (P < 0.05). Conclusion: In our study, the extubation time was significantly longer in BIS-guided anesthesia as compared to ETAG-guided anesthesia. ETAG monitoring promotes earlier extubation of patients as compared to BIS monitoring during halothane anesthesia.

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Background: A major change in anesthesia practice as regards to intraoperative infusion therapy is the present requirement. Switching over to balanced fluids can substantially decrease the incidence of lactic acidosis and hyperchloremic acidosis. The deleterious effects of unbalanced fluids are more recognizable during major surgeries. We prospectively studied the influence of Sterofundin (SF) and Ringer lactate (RL) on acid–base changes, hemodynamics, and readiness for extubation during scoliosis surgery. Subjects and Methods: Thirty consecutive children posted for scoliosis surgery were randomized to receive either RL (n = 15) or SF (n = 15) as intraoperative fluid at 10 mg/kg/h. Fluid boluses were added according to the study fluid algorithm. Arterial blood was sampled and analyzed at hourly intervals during surgery. Red blood cell transfusion was guided by hematocrit below 27. Patients were followed for 24 h postoperatively in the Intensive Care Unit. Results: There was no statistically significant difference in the volume of infused fluid (2400 ± 512 ml in Group RL and 2200 ± 640 ml in Group SF. There were no significant changes in pH of patients infused with SF. Statistically, significant higher lactate levels were seen in RL-infused group. The strong ion difference was decreased in both groups, but it normalized earlier with SF. Conclusions: SF-infused patients had nonremarkable changes in acid–base physiology in scoliosis surgery.

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Background: Fiberoptic intubation is a technique commonly used for difficult airways. Conscious sedation is desirable to make this procedure tolerable, and it is essential that patients are cooperative, relaxed, and comfortable especially when difficult airway anatomy or pathology is encountered. Objective: To compare the safety and efficacy of propofol versus midazolam in oral fiberoptic endotracheal intubation in terms of hemodynamic changes, level of sedation, ease of intubation, and patient comfort and complications. Materials and Methods: In a prospective randomized study, 60 patients of age group 18–60 years and American Society of Anesthesiologists health classification of I and II with anticipated difficult intubation were randomly allocated into two groups. Both the groups were premedicated with injection glycopyrrolate 0.005 mg/kg and injection butorphanol 1 mg and nebulized with 4 ml of 4% lignocaine starting 20 min before the surgery. After that patients in Group I received intravenous propofol 1–2 mg/kg to a maximum of 2 mg/kg followed by 20 mg increments if needed and Group II received 0.05 mg/kg midazolam followed by 2 mg increments till the adequate level of sedation was reached. Patients were monitored for hemodynamic parameters, sedation according to observer's assessment of alertness score, intubation score, intubation time, patient comfort, satisfaction score, and complications, if any. Results were statistically analyzed. Results: The mean sedation score, patient comfort score, and patient satisfaction were greater in propofol group (P < 0.05) but there were no significant differences in hemodynamics, intubating conditions, and complications. Conclusion: We conclude that compared with midazolam, propofol provides better sedation for fiberoptic endotracheal intubation and better patient comfort and satisfaction.

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Context and Aim: The assessment of severity of low back pain includes subjective questionnaires to quantify the impact on routine life. The objective of current study was to correlate various quality of life (QOL) scores to the clinical outcome measured as improvement in Visual Analog Score (VAS) after interventional treatment. Subjects and Methods: Fifty-one consecutive chronic low backache patients were assessed for pain intensity using VAS, revised Oswestry Disability Index (ODI), Quebec's, Roland–Morris disability questionnaire (RMDQ), and depression score at presentation. All subjects received interventional therapy complemented with physiotherapy; changes in scores were evaluated at 2 weekly intervals till 12 weeks. Type of Study: Prospective, observational, cohort study. Results: All scores depicted highly significant statistical improvement over baseline scores (P < 0.001). The Pearson correlation of VAS with rest of the scores showed that all variables correlate well with VAS at various time periods till 3 months. However, the best outcome predictor for VAS in QOL scores was Oswestry score as well as depression score which had an additive predictive effect. Among the QOL scores best intercorrelation was found with ODI and RMDQ scores at baseline as well as at all treatment follow-ups. Interpretation and Conclusion: ODI and depression score closely parallel trends of reduction in VAS indicating that these scores may be the best outcome predictor after interventional treatment of pain. Among QOL scores ODI and RMDQ evaluated in the current study record comparable degree of physical incapacity; the exception is Quebec's score.

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Background: The present study was undertaken to compare and evaluate the efficacy of intravenous (IV) fentanyl and lignocaine airway nebulization and a combination of both in attenuating the hemodynamic response to laryngoscopy and tracheal intubation. Materials and Methods: Ninety-six patients of either sex aged between 18 and 65 years of age, belonging to the American Society of Anesthesiologists (ASA) health status Classes I and II, undergoing elective surgery requiring general anesthesia with endotracheal intubation were included in the study. Patients were randomly divided into three groups. Group F received IV fentanyl 2 μg/kg, Group L received nebulization with 3 mg/kg of 4% lignocaine, and Group FL received both nebulization with 3 mg/kg of 4% lignocaine and IV fentanyl 2 μg/kg before intubation. Hemodynamic parameters were noted before and immediately after induction, 1 min after intubation, and every minute after intubation for 10 min. Results: Hemodynamic response to laryngoscopy and intubation was not completely abolished in any of the groups. Nebulized lignocaine was least effective in attenuating hemodynamic response to intubation, and hemodynamic parameters were significantly high after intubation as compared to other groups. Fentanyl alone or in combination with nebulized lignocaine was most effective, and Group F and Group FL were comparable. The maximum increase in mean blood pressure after intubation from baseline in Groups F, L, and FL was 7.4%, 14.6%, and 5.4%, respectively. Conclusion: In our study, IV fentanyl 2 μg/kg administered 5 min before induction was found to be the most effective in attenuating the hemodynamic response. There was no advantage to the use of nebulized lignocaine in attenuating the hemodynamic response to laryngoscopy and intubation.

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Background and Aims: Perioperative stress is an often ignored commonly occurring phenomenon. Little or no prior knowledge of anesthesia techniques can increase this significantly. Patients awaiting surgery may experience high level of anxiety. Preoperative visit is an ideal time to educate patients about anesthesia and address these fears. The present study evaluates two different approaches, i.e., standard interview versus informative audiovisual presentation with standard interview on information gain (IG) and its impact on patient anxiety during preoperative visit. Settings and Design: This prospective, double-blind, randomized study was conducted in a Tertiary Care Teaching Hospital in rural India over 2 months. Materials and Methods: This prospective, double-blind, randomized study was carried out among 200 American Society of Anesthesiologist Grade I and II patients in the age group 18–65 years scheduled to undergo elective surgery under general anesthesia. Patients were allocated to either one of the two equal-sized groups, Group A and Group B. Baseline anxiety and information desire component was assessed using Amsterdam Preoperative Anxiety and Information Scale for both the groups. Group A patients received preanesthetic interview with the anesthesiologist and were reassessed. Group B patients were shown a short audiovisual presentation about operation theater and anesthesia procedure followed by preanesthetic interview and were also reassessed. In addition, patient satisfaction score (PSS) and IG was assessed at the end of preanesthetic visit using standard questionnaire. Statistical Analysis Used: Data were expressed as mean and standard deviation. Nonparametric tests such as Kruskal–Wallis, Mann–Whitney, and Wilcoxon signed rank tests, and Student's t-test and Chi-square test were used for statistical analysis. Results: Patient's IG was significantly more in Group B (5.43 ± 0.55) as compared to Group A (4.41 ± 0.922) (P < 0.001). There was significant reduction in total anxiety from the baseline values in both the groups. This reduction was significantly more in Group B (8.47 ± 1.861) as compared to Group A (9.29 ± 1.616) (P < 0.001). PSS was also more in Group B (29.27 ± 2.378) as compared to Group A (25.62 ± 1.745) (P < 0.001). Conclusion: Audiovisual presentation provides unhurried, detailed, and reliable information about the perioperative environment and anesthesia procedure. This helps in significant IG and reduction of patient anxiety.

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Introduction: Opioids are widely used in conjunction with local anesthetics as they permit the use of lower dose of local anesthetics while providing adequate anesthesia and analgesia. It both provides adequate anesthesia as well as lower drug toxicity neuraxial administration of opioids in conjunction with local anesthetics improves the quality of intraoperative analgesia and prolongs the duration of postoperative analgesia. Bupivacaine is the most commonly used drug for subarachnoid block due to its lesser side effects. The present study was conducted to decrease the overall dose of local anesthetics with opioid combination for urological procedure with respect to quality of anesthesia and recovery with patient's satisfaction. Materials and Methods: The study population was randomly allocated by computer generated table into two groups; Group A: 5 mg 0.5% bupivacaine + 25 mcg and Group B: 5 mg 0.5% bupivacaine + 25 mg butorphanol. Results: Highest level of sensory block was T9 and T8 with the fentanyl group and butorphanol group, respectively. The onset of sensory block was early in fentanyl group than butorphanol group. Duration of both sensory and motor block was significantly higher in butorphanol group. There was no incidence of itching in both groups. There were two patients in fentanyl group and one in butorphanol with hypotension for which injection mephentermine was given. Two patients in fentanyl group complained of nausea and vomiting, for which injection ondansetron was given. One patient complained of pain in fentanyl group for which injection propofol with injection fentanyl was supplemented. Conclusion: Low-dose bupivacaine with butorphanol group was devoid of any side effects in the present study but low dose bupivacaine in addition with fentanyl is superior in terms of early postoperative recovery resulting in early discharge and better outcome in comparison to bupivacaine and butorphanol group, which is beneficial in elderly patients with comorbidity.

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Background and Objectives: Laryngoscopy and intubation elicits huge spectrum of stress response which is hazardous in high-risk patients. Many drugs and techniques have been used to attenuate the stress response. Lornoxicam 16 mg is a potent nonsteroidal anti-inflammatory drug agent with analgesic potency equivalent to morphine 10 mg, fentanyl 100 μg and tramadol 100 mg. Lornoxicam has been found to attenuate stress response in some studies. We compared the lornoxicam with fentanyl in attenuating stress response. Materials and Methods: A double blind randomized controlled study was conducted on 60 adult patients of American Society of Anesthesiologist physical status 1 and 2. Group L (n = 30) receives injection lornoxicam 16 mg intravenous 30 min before induction, Group F (n = 30) receives injection fentanyl 2 μg/kg during induction. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR) were recorded baseline (BL), before induction, every minute up to 5 min and at 10 min after intubation. Results: After intubation, there is a gradual decrease in SBP and DBP in both groups. The MAP was also comparable between the two groups except at 5 min and 10 min during which MAP recovered toward BL in Group L where as it remained low in Group F which was statistically significant (P < 0.05). Both the drugs have successfully attenuated the HR response. Conclusion: Lornoxicam successfully attenuated the hemodynamic response to laryngoscopy and endotracheal intubation and is equally efficacious as fentanyl.

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Background: Cooling of local anesthetic potentiates its action and increases its duration. Magnesium sulfate (MgSo₄) added to local anesthetic prolongs the duration of anesthesia and postoperative analgesia with minimal side effects. Aim: The aim of this prospective, randomized, double-blind study was to compare the effect of cold to 4°C bupivacaine 0.5% and Mg added to normal temperature (20–25°C) bupivacaine 0.5% during sonar-guided combined femoral and sciatic nerve blocks on the onset of sensory and motor block, intraoperative anesthesia, duration of sensory and motor block, and postoperative analgesia in arthroscopic anterior cruciate ligament (ACL) reconstruction surgery. Patients and Methods: A total of 90 American Society of Anesthesiologists classes I and II patients who were scheduled to undergo elective ACL reconstruction were enrolled in the study. The patients were randomly allocated to 3 equal groups to receive sonar-guided femoral and sciatic nerve blocks. In Group I, 17 ml of room temperature (20–25°C) 0.5% bupivacaine and 3 ml of room temperature saline were injected for each nerve block whereas in Group II, 17 ml of cold (4°C) 0.5% bupivacaine and 3 ml of cold saline were injected for each nerve block. In Group III, 17 ml of room temperature 0.5% bupivacaine and 3 ml of MgSo₄ 5% were injected for each nerve block. The onset of sensory and motor block was evaluated every 3 min for 30 min. Surgery was started after complete sensory and motor block were achieved. Intraoperatively, the patients were evaluated for heart rate and mean arterial pressure, rescue analgesic and sedative requirements plus patient and surgeon satisfaction. Postoperatively, hemodynamics, duration of analgesia, resolution of motor block, time to first analgesic, total analgesic consumption, and the incidence of side effects were recorded. Results: There was no statistically significant difference in demographic data, mean arterial pressure, heart rate, and duration of surgery. Onset of both sensory and motor block was significantly shorter in both Groups II and III compared to Group I. Intraoperative anesthetic quality was comparable between groups with good patient and surgeon satisfaction. The time to first analgesia was significantly longer in Groups II and III compared to Group I with nonsignificant difference between each other. Moreover, the total opioid consumption was significantly lower in Groups II and III and duration of analgesia and motor block were significantly longer in Groups II and III compared to Group I. There was no difference in the incidence of side effects. Conclusions: The use of cold 0.5% bupivacaine or the addition of Mg to normal temperature 0.5% bupivacaine prolongs the sensory and motor block duration without increasing side effects and enhances the quality of intra- and post-operative analgesia with better patient satisfaction in sonar-guided femoral and sciatic nerve block for arthroscopic ACL reconstruction surgery.

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Background: Combined spinal-epidural analgesia has become the preferred technique for labor analgesia as it combines the benefits of both spinal analgesia and flexibility of epidural catheter. Study was carried out with the primary aim to compare levobupivacaine and ropivacaine with fentanyl in terms of onset and duration of sensory block and to know maternal and fetal outcome. Materials and Methods: In a prospective randomized double-blind study, 60 primipara of the American Society of Anesthesiologists health status Class I and II with singleton pregnancy in active stage of labor were randomly allocated into two groups of 30 each. Group A received 3 mg intrathecal levobupivacaine with 25 μg fentanyl followed by epidural top-ups of 14 ml of levobupivacaine 0.125% with fentanyl 30 μg whereas Group B received 4 mg intrathecal ropivacaine with 25 μg fentanyl followed by epidural top-ups of 14 ml of ropivacaine 0.2% with fentanyl 30 μg. Patients were monitored for sensory and motor block characteristics, hemodynamics, maternal and fetal outcome, side effects, and complications. These characteristics were analyzed using the “Chi-square tests” and “unpaired t-test.” Results: Onset of analgesia was rapid in Group A (4.72 ± 0.54 min) as compared to Group B (5.58 ± 0.49 min). Duration of analgesia was also prolonged in Group A (117.00 ± 11.86 min) as compared to Group B (90.17 ± 8.85 min). Patients remained hemodynamically stable and side effects, and complications were comparable in both groups. Conclusion: Levobupivacaine with fentanyl leads to early onset and prolonged duration of analgesia as compared to ropivacaine with fentanyl during labor analgesia.

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Context: The purpose of adding an adjuvant to local anesthetic in a central neuraxial blockade is to augment the desirable pharmacological actions of the agent and/or to minimize its undesirable pharmacological effects. Clonidine is an alfa-2 receptor agonist which has gained popularity in recent times as an adjuvant in spinal anesthesia. Aims: To evaluate the influence of clonidine on the hemodynamic stability and the duration of anesthesia when added to intrathecal hyperbaric bupivacaine. Settings and Design: Prospective randomized double blind study. Subjects and Methods: Fifty patients scheduled for spinal anesthesia were randomized into two Groups A and B with 25 in each. Group A patients received 3 ml 0.5% heavy bupivacaine + 30 μg (0.2 ml) clonidine and Group B patients received 3 ml 0.5% heavy bupivacaine + 0.2 ml normal saline in the subarachnoid space. The blood pressure and heart rate were closely monitored. The time for attaining peak sensory block, time for two segment regression, decrease in the heart rate, total requirement of mephentermine to counter the hypotension, and the number of patients requiring mephentermine in each group was tabulated and analyzed. Statistical Analysis Used: Descriptive and inferential statistical methods were used to analyse the data. The power of the study was calculated using online power calculator for two independent sample study. Results: The time for attaining peak sensory block was similar in both the groups. The time for two segment regression in Group A was 62.6 min and in Group B was 38.08 min. Twelve percent of patients in Group A and 52% of patients in Group B required mephentermine with the mean consumption being 0.72 mg in Group A and 5.65 mg in Group B. Conclusions: Addition of low-dose clonidine to intrathecal bupivacaine not only prolonged the duration of spinal anesthesia but also provided a stable intraoperative hemodynamic profile.

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Background: Multimodal analgesia (MMA) by synergy with volatile anesthetics minimizes their use thus decreasing operation theater pollution and greenhouse gas emission. Aims: To estimate minimum alveolar concentration (MAC) requirement of isoflurane (ISO) for skin incision with use of MMA in the study group versus conventional regime in the control group for a constant bispectral index (BIS). To observe the side effects of analgesic drugs administered in the study. Settings and Design: Forty-two patients of American Society of Anesthesiologist Class I and II scheduled for lumbar spine surgery were included in this prospective, randomized, double-blind, clinical study. They were randomly allocated into two groups of 21 each. Materials and Methods: Group A (MMA group/study group) received injections diclofenac sodium, paracetamol, clonidine, and fentanyl and local infiltration (bupivacaine with adrenaline). Group B (conventional regime group/control group) received injections paracetamol and fentanyl and local infiltration (saline with adrenaline). Preemptive analgesia was practiced in the study. The MAC of ISO for skin incision was documented. Statistical Analysis Used: Independent sample t-test: To compare MAC_ISOfor skin incision between the two groups. One sample t-test: To compare the standard mean concentration with the means of the two groups. Chi-square test: To compare adverse effects between the groups. P < 5% was considered statistically significant. Results: The MAC_ISOrequirement was significantly lower in the study group at the time of skin incision for BIS of 50–55 compared to the control group (P < 0.001). Post extubation, 43% had nausea and 9% had vomiting in the control group. None of the patients in either group had intraoperative awareness. Conclusion: We conclude that preemptive MMA has synergistic effect with ISO. It effectively reduces MAC_ISOto skin incision to a greater degree.

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Background: Sufentanil is widely used for patient-controlled intravenous analgesia (PCIA). Oxycodone has a powerful analgesic effect and mild side effects. We conducted this study to compare the efficacy of oxycodone and sufentanil for PCIA on postoperative pain after laparoscopic radical gastrectomy. Methodology: A total of fifty patients scheduled for laparoscopic radical gastrectomy were equally randomized to receive postoperative pain treatment with either oxycodone (Group O) or sufentanil (Group S) for 48 h postoperatively. PCIA was set on demand mode without loading dose or background infusion. Postoperative cumulative sufentanil or oxycodone consumption, pain intensity, sedation status, and side effects were assessed. Results: No significant differences were detected in visual analog scale score at rest and during coughing in the two groups at various time points after operation. Group S was associated with more doses delivered by PCIA than Group O. The overall satisfaction degree was higher in Group O. The incidences of side effects were comparable between the two groups. Conclusion: Oxycodone is a valuable alternative for PCIA in patients undergoing laparoscopic radical gastrectomy.

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Background: Current guidelines adopted by the American Academy of Pediatrics calls for prolonged fasting times before performing pediatric procedural sedation and analgesia (PSA). PSA is increasingly provided to children outside of the operating theater by sedation trained pediatric providers and does not require airway manipulation. We investigated the safety of a shorter fasting time compared to a longer and guideline compliant fasting time. We tried to identify the association between fasting time and sedation-related complications. Methods: This is a prospective observational study that included children 2 months to 18 years of age and had an American Society of Anesthesiologists physical status classification of I or II, who underwent deep sedation for elective procedures, performed by pediatric critical care providers. Procedures included radiologic imaging studies, electroencephalograms, auditory brainstem response, echocardiograms, Botox injections, and other minor surgical procedures. Subjects were divided into two groups depending on the length of their fasting time (4–6 h and >6 h). Complication rates were calculated and compared between the three groups. Results: In the studied group of 2487 subjects, 1007 (40.5%) had fasting time of 4–6 h and the remaining 1480 (59.5%) subjects had fasted for >6 h. There were no statistically significant differences in any of the studied complications between the two groups. Conclusions: This study found no difference in complication rate in regard to the fasting time among our subjects cohort, which included only healthy children receiving elective procedures performed by sedation trained pediatric critical care providers. This suggests that using shorter fasting time may be safe for procedures performed outside of the operating theater that does not involve high-risk patients or airway manipulation.

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Context: Laryngeal mask airway (LMA) Classic™ has an inflatable cuff while i-gel™ has a noninflatable cuff made of thermoplastic elastomer. Aims: To compare ease of insertion, number, and duration of insertion attempts among the two device. Secondary objectives were to evaluate the hemodynamic response and SpO₂during device insertion and during maintenance of general anesthesia. Settings and Design: This study was conducted as randomized observational study in a teaching hospital. Subjects and Methods: One hundred American Society of Anesthesiologists I and II, patients posted for surgery under general anesthesia were divided in two groups of fifty each. LMA Classic™ and i-gel™. Ease of insertion, duration of insertion, hemodynamic data, and episodes of hypoxia during insertion, 1, 3 and 5 min for 30 min, during removal and 1 min after removal. Statistical Analysis Used: Descriptive analyses were expressed as a mean ± standard deviation. Independent t-test used for parametric data, Chi-square test for nonparametric data and hemodynamic data were analyzed using repeated measures ANOVA to find statistical difference within the groups. Results: Devices were easy to insert, the mean duration of insertion attempts was 15.92 ± 1.62 s in the i-gel™ group, while it was 26.06 ± 5.12 s in the LMA Classic™ group, was statistically significant (P = 0.0001). Conclusions: Successful and shorter duration of insertion, with less hemodynamic response makes i-gel™ a suitable alternative to LMA Classic™ during general anesthesia.

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Background: The fast-track concept refers to all phases of perioperative care: Preoperative, intraoperative, and postoperative strategies. Although most research has focused on adherence to medication, adherence also encompasses numerous health-related behaviors. The aim of this prospective study was to determine the attitudes and awareness among health professionals involved in the treatment of elderly patients with fractures of the femur and the results of 400 patients. Methods: The postoperative protocol acceleration was presented to various hospital departments through four seminars. Questionnaire with four ex-residents in the Department of Anesthesiology was conducted. Every 6 months, the results of project implementation to all departments were presented. It was considered adherence to the project when the professionals agreed with all the steps and routines of the project. Patients underwent spinal anesthesia with postoperative analgesia by lumbar plexus block. Results: All departments involved in the treatment of elderly patients' adhered completely to the project and reported the importance of preanesthetic visit, the explanations of design, and reduction of fasting period. Just one anesthetist completely adhered to the project. No former resident of anesthesia joined the program. All parameters studied in 400 patients compared with the data before the project showed a reduction from 21.38% to 100%. Conclusion: Improving adherence requires a continuous and dynamic process. We can be inferred that the implementation of fast-track project Brazilian Public Health System (Sistema Único Saúde, SUS) costs decreased with elderly patients with hip fractures. The anesthesiologist was the major obstacle to deployment to all patients.

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Osteogenesis imperfecta (OI) is a rare genetically inherited syndrome involving connective tissues, resulting in anatomic and physiologic abnormalities, which results in any form of anesthesia, a challenging task. We hereby report a case of OI type I presented with distinctively blue sclera, hearing loss, kyphoscoliosis, and mild pulmonary restrictive disease who underwent rush nail removal in the femur.

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Background: Clonidine is an effective adjuvant to local anesthetics in peripheral nerve blocks. We studied the effect of clonidine as an adjuvant in wound infiltration for postoperative analgesia. Aim: To evaluate the role of clonidine as an adjuvant to bupivacaine in wound infiltration in terms of quality and duration of postoperative analgesia in patients undergoing total abdominal hysterectomy. Settings and Study Design: Prospective, randomized, double-blinded study. Materials and Methods: One hundred patients of American Society of Anesthesiologists I–II posted for abdominal hysterectomy were randomly allotted to two groups. Group A received wound infiltration with 45 ml of 0.25% bupivacaine with 3 μg/kg clonidine while Group B received wound infiltration with 45 ml of 0.25% bupivacaine. A standard general anesthesia technique was used in all the patients. Postoperative analgesia was provided with injection ketorolac 0.5 mg/kg intravenous infusion and tramadol being the rescue analgesic. Postoperative pain score, duration of effective analgesia before the first rescue analgesic, percentage of patients requiring rescue analgesic at different time intervals, and total number of rescue analgesic doses in 24 h were compared between the groups. Statistical Analysis: Difference between the bivariate samples in independent groups with Mann–Whitney U-test. For categorical data, Chi-square test was used. Results: Clonidine group has better pain score, longer duration of effective analgesia, lower percentage of patients requiring rescue analgesic, and less number of doses of rescue analgesia in the first 24 h. Conclusion: We conclude that Clonidine 3 μg/kg is an effective adjuvant to bupivacaine for wound infiltration in terms of quality and duration of postoperative analgesia following total abdominal hysterectomy.

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Background: Caudal block is a reliable regional analgesic technique for pediatric urogenital surgeries. Various adjuvants have been tried to enhance the duration of action of bupivicaine. Though clonidine is extensively used as an adjuvant in caudal anaesthesia, it can have troublesome adverse effects like bradycardia, hypotension and sedation. Lately dexamethasone has become popular as an adjuvant in paediatric caudals due to its safety profile. Aim: The aim of this study was to compare dexamethasone and clonidine coadministered with bupivicaine caudally in paediatric patients undergoing urogenital surgeries in terms of analgesia and adverse effects. Settings and Design: Prospective, double blinded randomised study. Subjects and Method: Sixty American Society of Anesthesiologists physical status I and II children, aged 1-6 years undergoing urogenital surgeries were allocated in 2 groups: Group I: 0.5 mL.kg⁻¹ of 0.25% bupivicaine with dexamethasone 0.1 mg.kg⁻¹ in 1 ml normal saline (NS) Group II: 0.5 mL.kg⁻¹ of 0.25% bupivicaine with clonidine 1 μg.kg⁻¹ diluted in 1 ml normal saline. The parameters studied included duration of analgesia, intraoperative and postoperative hemodynamics, sedation scores and incidence of adverse effects like wound dehiscence, bleeding, vomiting and respiratory depression. Statistical Analysis Used: Statistical analysis was carried out using Stata Version 10. After checking for the normality assumption, t-test for comparing means of two independent samples was used for comparing baseline continuous variables. P values <0.05 were considered significant. Results: Patients in Group II had longer duration of analgesia postoperatively. Patients in this group also had lower heart rate and more sedation scores. Conclusion: Our study shows that caudal dexamethasone is a good alternative to clonidine with more stable hemodynamics and lesser sedation scores in the immediate postoperative period. Both the drugs offer good analgesia postoperatively with the duration of analgesia more in clonidine.

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Background: Anxiety is a concern in obstetrics, especially in preeclamptic mothers. Sedation is not commonly used in parturients for fear of adverse neonatal effect. We investigated maternal and neonatal outcome of midazolam as an adjuvant to spinal anesthesia for elective cesarean delivery. Methods: A prospective randomized controlled trial, in which eighty preeclamptic parturients received either an intravenous dose of 0.035 mg/kg of midazolam or an equal volume of normal saline, 30 min before spinal anesthesia. Maternal anxiety was assessed using Amsterdam Preoperative Anxiety and Information Scale (APAIS); postoperative maternal satisfaction was assessed using Maternal Satisfaction Scale for Cesarean Section (MSSCS). Newborns were assessed using Apgar score, Neonatal Neurologic and Adaptive Capacity Score (NACS), and umbilical artery blood gases. Results: Mothers premedicated with midazolam showed a lower level of preoperative anxiety and a higher degree of postoperative satisfaction than the control group. There were no between-group differences regarding the neonatal outcome. Conclusion: Preeclamptic parturients premedicated with midazolam (0.035 mg/kg) before spinal anesthesia have lower anxiety and higher postoperative satisfaction levels, with no adverse effects on the newborns.

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Background: Postoperative nausea and vomiting (PONV) is a common occurrence after laparoscopic surgeries. A number of pharmacological agents (antihistamines, butyrophenones, dopamine receptor antagonists) have been tried of which the 5-hydroxytryptamine type 3 receptor antagonists are devoid of most side effects and highly effective in prevention and treatment of PONV. Thus, we evaluated the effectiveness of granisetron and palonosetron in prevention of PONV after laparoscopic surgeries under general anesthesia. Aims: We conducted a study to evaluate the effectiveness of granisetron and palonosetron, to compare the duration of action and side effects if any, in patients undergoing elective laparoscopic surgery under general anesthesia. Settings and Design: This was a prospective, randomized, double-blinded, comparative study. Sixty patients (18–65 years of age) of the American Society of Anesthesiologists Grade I and II undergoing elective laparoscopic surgeries were considered. Materials and Methods: They were randomly allocated into one of the two groups (Group G and Group P) of thirty patients each. Group G received injection granisetron 0.05 mg/kg; Group P received injection palonosetron 1.5 mcg/kg intravenous bolus 30 min before the induction of anesthesia. Statistical Tests: All statistical analyses were performed using the SPSS^® statistical package version 18.0 (Chicago: SPSS Inc). Two independent sample t-test was used for quantitative data, and the χ² or Fisher's exact test was used for qualitative data. A difference was regarded as statistically significant at a P< 0.05. Results: The need for rescue antiemetic was significantly lower in Group P in the 24–72 h postoperative period (ρ - 0.007). The PONV score was significantly less in Group P in the same period (ρ - 0.008). The incidence of side effects was statistically insignificant in both the groups (ρ - 0.999). Conclusion: Prophylactic therapy with palonosetron is more effective than granisetron in the prevention of PONV after laparoscopic surgeries under general anesthesia.

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Objective: To study the efficacy and safety of intrathecal neostigmine at dose of 50 μg and 150 μg as an adjuvant to bupivacaine for postoperative analgesia under spinal anesthesia. Materials and Methods: 75 patients of either sex, belonging to American Society of Anesthesiologists (ASA) physical status I and II in the age group of 30-65 years scheduled to undergo lower abdominal and lower limb surgeries were allocated randomly into 3 groups of 25 each. Spinal anesthesia was administered in Group I (control group) with 12.5 mg (2.5 ml) of 0.5% hyperbaric bupivacaine, in Group II (50 μg group) with 12.5 mg (2.5 ml) of 0.5% hyperbaric bupivacaine and 50 μg (0.1 ml) of neostigmine methylsulphate and in Group III (150 μg group) with 12.5 mg (2.5 ml) of 0.5% hyperbaric bupivacaine and 150 μg (0.3 ml) of neostigmine methylsulphate. Hemodynamic parameters, onset and level of sensory block were recorded. Postoperative analgesic assessment was made in terms of total Visual Analogue Scale-Pain (VAS-P) scores in 24 hrs, duration of analgesia (time to requirement of first analgesic) and total number of rescue analgesic (diclofenac sodium 75 mg intramuscularly) consumption in 24 hours. Side effects were recorded. Results: The total VAS-P score in group I was 23.12 ± 3.21, which was higher than the VAS-P score in group II (18.4 ± 2.92) and group III (16.24 ± 1.85). The total duration of analgesia was significantly prolonged in neostigmine groups (224.40 ± 23.28 min in group I, 367.60 ± 42.15 min in group II and 625.60 ± 87.70 min in group III). In group I, the patients required 2.48 ± 0.51 number of analgesics in 24 hours, which was much higher than required in group II (1.92 ± 0.64) and group III (1.32 ± 0.47). The incidence of nausea and vomiting was more with 150 μg neostigmine group compared to 50 μg neostigmine. Conclusions: The administration of intrathecal neostigmine in dose of 50 μg as an adjuvant to bupivacaine produces hemodynamically stable analgesia with minimal side effects.

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Background: Regional anesthesia is the preferred technique for most of lower abdominal and lower limb surgeries. For decades, lignocaine had been the local anesthetic of choice for spinal anesthesia. Recent studies show that intravenous clonidine and dexmedetomidine can prolong the duration of the spinal anesthesia. Dexmedetomidine is a more suitable adjuvant compared to clonidine due to its more selective α2A receptor agonist activity. Aim: The study was undertaken to evaluate the effects of intravenous administration of dexmedetomidine on spinal anesthesia with 0.5% hyperbaric bupivacaine in lower abdominal surgeries. Study Design: Prospective randomized, double-blind control study. Materials and Methods: Sixty patients of American Society of Anaesthesiologists Grades I and II, 20–60 years age, undergoing lower abdominal surgeries under spinal anesthesia were randomized into two groups by computer-generated table. Group 1: Bupivacaine and dexmedetomidine group; and Group 2: Bupivacaine and saline group. Spinal anesthesia was given with 15 mg of 0.5% bupivacaine. Patients in Group 1 received dexmedetomidine 1 μg/kg over 20 min followed by 0.5 μg/kg/h, intravenously till the end of surgery. Patients in Group 2 received normal saline. Observations were analyzed using Student's unpaired t-test. Results: The mean duration of analgesia in group 1 was 219.7 ± 2.55 minutes and in group 2 was 150.2 ± 5.7 minutes. The prolongation in duration of analgesia in dexmedetomidine group was statistically significant. The mean durations of motor blockade in Group 1 and Group 2 were 189.6 ± 2.14 and 158.2 ± 5.31 min, respectively. Conclusion: Intravenous dexmedetomidine is useful to maintain hemodynamic stability and prolong spinal analgesia.

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Background: Regional anesthesia using paravertebral block has been suggested as an ideal adjunct to general anesthesia for modified radical mastectomy. Paravertebral block is an effective management of peri-operative pain for Modified radical mastectomy, however, there are no established guidelines regarding what is the most suitable strategy when varying drugs and dosages between different groups. Aim: To evaluate the effectiveness of paravertebral block comparing the most frequently employed drugs in this procedure (bupivacaine vs ropivacaine). Study Design: Prospective randomized double blind study. Methods: A total 70 ASA I and II adult female patients undergoing Modified radical mastectomy under paravertebral block followed by general anesthesia were randomly divided into two groups. The first group was administered 0.375% Ropivacaine in a dose 0.25 ml /kg in paravertebral block. The second group was administered bupivacaine 0.375% in dose 0.25 ml /kg in paravertebral block. Standard induction technique followed. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), were recorded pre block, post block 5 min, post block 10 min, at skin incision ,post skin incision initially at 5 interval for first 15 min till one hour, and every 30 min till end of surgery. Post-operative visual analogue score for pain was recorded at 1 hr, 6 hr and 24 hr. Statistical Analysis: Chi-square test (Fisher's exact test) for qualitative variables. Independent sample t-test for quantitative data. Results: Ropivacaine and Bupivacaine had no difference in intraoperative analgesia as shown by intraoperative hemodynamic parameters. Bupivacaine got better post-operative VAS scores (P < 0.05) in mean and after first , 6 h and 24 h.

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Introduction: Extubation in deep plane of anesthesia followed by Guedel's oropharyngeal airway (OPA^TM) insertion is a routine method to avoid hemodynamic changes associated with tracheal extubation. Exchange of endotracheal tube (ETT) with Classic laryngeal mask airway (LMA^TM) prior to emergence from anesthesia also serves similar purpose. We had compared the hemodynamic changes involved during this ETT/LMA^TM and ETT/OPA^TM exchange technique. Material and Methods: This was a randomized prospective study on ASA I and 2 patients undergoing elective surgery under general anesthesia. These patients were randomly divided into two groups i.e. OPA group and LMA group of 50 patients each. Hemodynamic parameters i.e. systolic blood pressure (SBP) and heart rate (HR) were recorded during exchange of ETT with OPA^TM or LMA^TM. Coughing / bucking during removal of OPA^TM and LMA^TM, and presence of post operative sore throat for both the groups were also graded and recorded. Data within the groups have been analyzed using paired “t” test while those between the groups were analyzed using unpaired “t” test. Chi square test was used to analyze grades of coughing and post operative sore throat. Results: In both groups, hemodynamic parameters rose significantly as OPA^TM/LMA^TM was placed (P < 0.05) and then started declining. Hemodynamic parameters continued to fall in LMA group after extubation. However in OPA group, hemodynamic parameters continued to rise even after extubation and declined only when OPA^TM was removed. There was no statistical significant difference between the LMA and OPA group in respect to coughing and post operative sore throat. Conclusion: LMA^TM is superior to OPA^TM for exchange of ETT as it provides greater hemodynamic stability.

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Background: Efficacy of caudal bupivacaine plus ketamine on postoperative pain in children. Aims: The aim of this study was to compare the analgesic efficacy and safety of caudal block with mixture of bupivacaine and ketamine to bupivacaine alone for postoperative analgesia in pediatric patients undergoing infraumbilical surgery. Settings and Design: A prospective randomized study was conducted in a tertiary care teaching hospital. Statistical Analysis: Data were collected; mean value and standard deviation were computed for age, weight, duration of surgery, and duration of analgesia. Then, the mean values of the two groups were compared using ANOVA. P< 0.05 was considered statistically significant. Materials and Methods: A total of 60 American Society of Anesthesiologists I and II pediatric patients of either sex, aged 1–10 years, undergoing herniotomy, orchidopexy, and urethroplasty were randomly allocated to receive one of the two analgesic regimens. Group A (30 patients) received caudal bupivacaine 0.25% in a dose of 1 ml/kg, and Group B received caudal block with 0.25% bupivacaine 1 ml/kg and preservative-free ketamine 0.5 mg/kg; duration of analgesia was recorded by objective pain scale to equate pain and discomfort in young children with changes in standardized behavioral and physiological parameters. Results: Mean duration of analgesia in Group A was 5.63 ± 0.98 h while the mean duration of analgesia in Group B was 10.18 ± 2.24 h with P< 0.001. There were no differences between groups in the incidence of motor block and side effects. Conclusion: On the basis of results derived from this study, it is concluded that addition of ketamine 0.5 mg/kg to caudal bupivacaine 0.25% in a dose of 1 ml/kg significantly prolonged the postoperative analgesia compared with administration of caudal bupivacaine 0.25% in a dose of 1 ml/kg alone.

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Background: Central neuraxial blockade (CNB) is an established technique of providing anesthesia for surgeries of the lower limb and abdomen. Hypotension is the most common side effect of CNB. It was hypothesized that by supplementing the initial burst of vasopressin following hypovolemia, hypotension following combined spinal epidural anesthesia (CSEA) could be avoided. Materials and Methods: A total of 122 patients undergoing lower limb and abdomen surgeries were included in the study, with 61 patients randomized into two groups - I and II. Patients in Group I received infusion of normal saline as soon as CSEA was applied. When systolic blood pressure (SBP) decreased to <90 mmHg, they received a 6 mg bolus of mephentermine to counteract hypotension. Patients in Group II received a continuous infusion of vasopressin as soon as CSEA was applied. If despite maximum dose of vasopressin, SBP dropped to < 90 mmHg, then intravenous mephentermine was administered to counteract hypotension. Hemodynamic parameters and side effects were noted. Results: Level of block attained in both groups was comparable in terms of dermatomal height. The mean SBP and mean arterial pressure values of Group I were significantly lower than in Group II in the initial 14 min. Diastolic BP was also significantly lower in Group I. Heart rate was found to be lower in Group II, especially after 30 min (P < 0.05). Conclusion: Maintaining plasma levels of the physiological burst of vasopressin helps to avoid hypotension following neuraxial blockade. Continuous infusion of vasopressin at 1–3 U/h can prevent hypotension following neuraxial blockade.

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Background: Radiofrequency (RF) is a minimally invasive target-selective technique that has been used with success for many years in the treatment of different pathologies, such as low back pain, trigeminal neuralgia, and others. Aim: The aim of this study is to compare different mode of RF - continuous RF (CRF) versus pulsed RF (PRF) along with steroid in the management of low back pain of discogenic origin. Setting and Design: Prospective, randomized, double-blind trial. Materials and Methods: Forty patients with chronic discogenic low back pain were randomized to receive CRF plus intradiscal triamcinolone 40 mg (Group 1) or to receive PRF plus intradiscal triamcinolone 40 mg (Group 2). Outcome measured includes immediate as well as long-term pain relief using visual analog scale, the Oswestry Disability Index and straight leg raising test. Statistical Analysis: The continuous variables were compared by one-way analysis of variance test. Discrete variables were compared by Fisher's exact test/Chi-square test/Student's t-test, whichever appropriate. The value of P< 0.05 was considered statistically significant. Results: There was a significant decrease in pain score after CRF without any added side effect. Pain relief after PRF was insignificant. Conclusion: CRF with steroid seems to be better for treatment of chronic discogenic low back pain than PRF with steroid.

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Background: Ropivacaine, a newer local anesthetic, is gaining increased acceptance due to its improved safety profile over bupivacaine and lignocaine. Analgesic adjuvants have proved to be valuable in improving the quality of anesthesia and duration of analgesia. Aim: To compare the efficacy of clonidine and fentanyl as adjuvants to ropivacaine in spinal anesthesia in lower abdominal surgeries. Materials and Methods: A randomized, double-blind control study was carried out in 100 patients who were randomly divided into two groups. Ropivacaine-clonidine group (RC) received 30 μg of clonidine with 18.75 mg of 0.75% isobaric ropivacaine, Ropivacaine-fentanyl group (RF) received 25 μg of fentanyl with 18.75 mg of 0.75% isobaric ropivacaine intrathecally. The onset and duration of sensory and motor block, hemodynamic parameters, quality of surgical analgesia, total analgesia time, sedation score, and side effects were statistically analyzed using SPSS statistical package, paired and unpaired t-tests and Chi-square test. Results: The duration of sensory block in RC (240.00 ± 20.99), RF (196.80 ± 18.34), and motor block in RC (192.20 ± 17.36), RF (139.20 ± 17.93) outlasted the duration of surgery. In clonidine group, there was significant prolongation of sensory block, motor block and the total analgesia time. Hypotension and bradycardia occurred more commonly in RC group, whereas pruritus was more in RF group. Conclusion: Ropivacaine when combined with either clonidine or fentanyl provided an adequate subarachnoid block for lower abdominal surgeries. As an adjuvant, clonidine has advantage over fentanyl as it increased the duration of the subarachnoid block and the postoperative analgesia.

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Background: The procedures in anesthesia such as laryngoscopy and endotracheal intubation are the most important skills to be mastered by an anesthesiologist. However, they produce marked cardiovascular responses such as hypertension and tachycardia. Various drugs have been used to suppress this response. One of those is a novel centrally acting α₂agonist - dexmedetomidine. It has numerous uses in anesthesia as it is having sedative, analgesic, hypnotic, and opioid sparing effects. It is also known to suppress the hemodynamic response to laryngoscopy and intubation. Aims: This study is aimed to know the effect of intravenous dexmedetomidine 0.6 μg/kg body weight on hemodynamic response to laryngoscopy and endotracheal intubation in patients undergoing thyroid surgeries. Setting and Design: Sixty patients of American Society of Anaesthesiologist health status class I and II scheduled for thyroid surgery under general anesthesia were considered in this prospective randomized controlled double-blind study. The study population was randomly divided into two groups with 30 patients in each group using sealed envelopes containing the name of the group and patient is asked to pick up the envelope. Materials and Methods: Sixty euthyroid patients, scheduled for thyroid surgeries was randomly divided into two groups with 30 patients in each group. Group A (n = 30) received injection dexmedetomidine 0.6 μg/kg body weight and Group B (n = 30) received 10 ml of normal saline. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded at regular intervals after intubation. Results: Statistically significant decrease in HR, SBP, DBP, and MAP were observed in Group A after intubation when compared to Group B. Conclusion: We conclude that dexmedetomidine 0.6 μg/kg body weight obtunds the hemodynamic responses to laryngoscopy and tracheal intubation in patients undergoing thyroid surgeries.

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Background: Spinal anesthesia is a preferred technique over general anesthesia for cesarean delivery. It avoids maternal airway related complications, aspiration and neonatal depression. However hypotension following spinal anesthesia can lead to decrease in uterine blood flow and neonatal hypoxia. Aims: We aimed to evaluate the efficacy of 15 mL.kg- 1of crystalloid preloading versus prophylactic intravenous bolus of 10 mg ephedrine as an antihypotensive measure for cesarean section. Methods: A prospective randomized double blind study was conducted in hundred ASA grade I/II parturient undergoing cesarean section, allocated to group P (n=50) who received preloading with ringer lactate 15 mL.kg- 1 over 20 minutes before spinal anesthesia and group E (n=50) received intravenous bolus of 10mg ephedrine within one minute of spinal anesthesia with 10mg of hyperbaric bupivacaine 0.5% at L2-3/L3-4 level. They were monitored for incidences of hypotension, need of rescue doses of ephedrine, Apgar score and adverse events. Appropriate statistical tests were applied and P < 0.05 was considered as significant. Results: Incidence of hypotension within 20 minutes of spinal anesthesia was significantly less in group E (28%) as compared to group P (58%) and need of rescue doses were more in group P. Adverse events like nausea vomiting and shivering were less in group E. Apgar score were better in group E than in group P delivered babies. Conclusion: Prophylactic intravenous bolus of 10mg ephedrine with spinal injection is more effective in maintaining maternal hemodynamic stability and better neonatal outcome as compared to crystalloid preloading during cesarean delivery.

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Background: Lumbar puncture is a difficult medical skill and is used for administering subarachnoid anesthetic medications. Estimation of skin to subarachnoid space depth (SSD) helps to reduce post spinal anesthetic complications. Aims: To measure the SDD in overall Egyptian population and to find a formula for predicting SSD in Egyptian patients. Settings and Design: Four hundred patients of American Society of Anesthesiologist class I and II adult Egyptian patients undergoing surgery using spinal anesthesia in general and obstetric surgery unit, Mansoura University main hospital, were included in this prospective, observational study. Subjects and Methods: Patients were divided into three groups: Males (Group M), nonpregnant females (Group F), and pregnant females (Group PF). SSD was measured after performing lumbar puncture. The relationship between SSD and patient characteristics was studied; correlated and statistical analysis was used to find a formula for predicting SSD. Statistical Analysis Used: Statistical analysis was done using Statistical Package for Social Sciences (SPSS 19.0, Chicago, IL, USA). One-way ANOVA with post hoc (Bonferroni correction factor) analysis was applied to compare the three groups. All the covariates in the study further were taken for multivariate analysis. Multivariate regression analysis was performed to evaluate important covariates influencing SSD for each group separately. Results: Mean SSD was 4.99 ± 0.48 cm in the overall population. SSD in adult males (4.93 ± 0.47 cm) was significantly longer than that observed in females (4.22 ± 0.49 cm) but was comparable with SSD in parturient (4.32 ± 0.47 cm). Formula for predicting SSD in the overall population was 2.1+ (0.009 × height) + (0.03 × weight) + (0.02 × body mass index [BMI]) + (0.15 × body surface area [BSA]). Craig's formula when applied correlated best with the observed SSD. Conclusions: SSD in adult males was significantly longer than that in both pregnant and nonpregnant females, but it was nearly the same in pregnant and nonpregnant females. SSD in Egyptian population can be calculated based on height, weight, BMI, and BSA. Craig's formula was the most suitable to be applied to Egyptian population.

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Context: Clinical need for a nondepolarizing agent with a rapid onset time and a brief duration of action has led to the development of rocuronium bromide. Aims: The aim of this study was to evaluate optimal dose of rocuronium bromide for intubation and to compare the onset time, duration of action, intubating conditions, and hemodynamic effects of two doses of rocuronium bromide. Settings and Design: A prospective, randomized, double-blind study. Materials and Methods: All the patients were divided in a randomized, double-blind fashion into two groups of twenty patients each. Group I patients received rocuronium bromide 0.6 mg/kg intravenously and intubated at 60 s, Group II patients received rocuronium bromide 0.9 mg/kg and intubated at 60 s. The neuromuscular block was assessed using single twitch stimulation of 0.1 Hz at adductor pollicis muscle of hand at every 10 s. Statistical Analysis Used: The results were compiled and analyzed statistically using Chi-square test for qualitative data and Student's t-test for quantitative data. Results: Time of onset was significantly shorter (P < 0.01) and duration of action was prolonged (P < 0.001) for Group II as compared to Group I. The intubating conditions were (excellent + good) in 100% patients of Group II and (excellent + good) in 80% of Group I. There was no significant change in pulse rate and mean arterial pressure from the baseline value after the administration of muscle relaxants in either of the two groups. Conclusions: Rocuronium bromide 0.9 mg/kg is a safer alternative to rocuronium bromide 0.6 mg/kg for endotracheal intubation with shorter time of onset and better intubating conditions.

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Background: Acute mesenteric ischemia is a life-threatening vascular emergency that requires early diagnosis, immediate anticoagulation, and intervention to restore mesenteric blood flow adequately. Aims: To investigate the effect of rectus sheath block (RSB) for postoperative analgesia in patients with mesenteric vascular occlusion. Settings and Design: Forty patients with mesenteric vascular occlusion, American Society of Anesthesiologists physical status I or II or III, scheduled for laparotomy were enrolled in this study. Subjects and Methods: Patients were randomized into two groups; control group (C Group) and rectus block group (RB Group). In both groups, general anesthesia was induced fentanyl 1 μg/kg with sleeping dose of propofol and 0.15 mg/kg cisatracurium. Then, anesthesia was maintained with sevoflurane in oxygen 100%. In RB Group, under aseptic condition, RSB guided by ultrasound was performed. Surgery is then continued and intravenous fentanyl patient-controlled analgesia pump started. Postoperative pain, sedation, and opioid side effects were assessed. Statistical Analysis Used: Statistical analysis was done using Statistical Package for Social Sciences (SPSS 19.0, Chicago, IL, USA). Results: Patients in the RB Group consumed statistically significant less opioid in comparison to control group either intraoperatively or postoperatively. Mean pain scores were statistically significant less in RB Group than in the control group at 2, 4, and 6 h postoperatively. Sedation score, incidence of nausea and vomiting were statistically significant less in the RB Group in comparison to control group. More patients' satisfaction was reported in the RB Group. Conclusions: Ultrasound-guided RSB resulted in postoperative reduction of pain scores and opioid consumption compared with general anesthesia alone. Moreover, RSB was associated with better patient satisfaction and less nausea and vomiting.

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Surgical removal of the kidney tumor outside the body, (ex vivo renal bench surgery) followed by auto transplantation is an emerging and often done procedure to reconstruct the urinary tract. It possesses immense challenges to both the anesthesiologists and the surgeons. The risks are multiplied if you are performing the surgery on a solitary functioning kidney. Here, we are describing the anesthetic management of 70-year-old male post nephrectomy patient undergoing renal auto transplantation by bench surgery. Our primary goals for perioperative management were to maintain a stable hemodynamics throughout the procedure, to reduce fluid overload during the period of extracorporeal surgery, to maintain perfusion for the transplanted solitary kidney, to control bleeding to a minimum, and to provide adequate analgesia for the patient. We made use of a balanced anesthetic technique and stringent monitoring standards to bring forth a successful outcome for the patient. At the end of his hospital stay, patient went home with a healthy, normally functioning kidney.

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Context: Catheter-related bladder discomfort (CRBD) is the most distressing symptom in patients due to intraoperative urinary catheterization. Amikacin significantly inhibits detrusor contraction evoked by prejunctional stimulation. Aims: The aim of this study is to evaluate the efficacy of amikacin in prevention of CRBD in patients undergoing percutaneous nephrolithotomy. Settings and Design: Study areas were operation theater and postanesthesia care unit of the Department of Anesthesiology, SGPGIMS, Lucknow. Subjects and Methods: One hundred adult patients of either sex were randomly assigned into two groups of fifty each. Patients in control group received normal saline whereas patients in amikacin group received amikacin 10 mg/kg just before induction. Grading of CRBD was done as none, mild, moderate, and severe by a blinded observer at 0, 1, 6, 12, and 24 h after surgery. Statistical Analysis Used: Data were analyzed using Student's t-test and Chi-square test among groups. Incidence of CRBD was compared with Chi-square test whereas severity was analyzed by the test of proportions (Z-test). Visual analog score was compared using Mann–Whitney U-test for surgical site pain. Results: Incidence of CRBD in control group was 66% as compared to 44% observed in amikacin group (P < 0.05). During intergroup comparison at different time points, incidence of CRBD was reduced at 1 and 6 h in the amikacin group (P < 0.05). Significant reduction in the severity of CRBD (moderate) was also observed at 1 h in the amikacin group (P < 0.05). At rest of the time points, there was no significant difference. Conclusions: Amikacin can significantly reduce the incidence and severity of CRBD in the first few hours after surgery.

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Background: Mask ventilation (MV) is an essential basic life support skill. We used chin lift maneuver for MV and named as modified chin lift technique (MCL). EC technique is most common technique used for MV. Aims: The aim of this study is to compare the efficacy of both techniques for MV in term of expired tidal volume (TV). Secondarily, we also assessed the effect of experience on the performance of these both techniques. Settings and Design: The study area was operation theater of our hospital. This was a prospective, randomized, crossover study. Methods: A total 108 adults undergoing elective surgery under general anesthesia were recruited. In all patients, operators (novice/anesthesiologist) randomly performed both techniques either to start with EC or MCL technique. Expired TV was measured for one minute for each technique. Statistical Analysis: Paired t-test was used to compare TV. Results and Conclusion: The mean TV was significantly higher in MCL group than EC group (528.08 [104.96] ml vs. 483.39 [103] ml; P< 0.001). The novice (521.89 [117.9] ml vs. 478.70 [130.29] ml; P< 0.001) as well as anesthesiologists (534.27 [110.85] ml vs. 488.08 [111.6] ml; P< 0.001) was able to generate significantly more TV with MCL technique than EC technique. The TV did not differ significantly between novice and anesthesiologist for EC technique (P = 0.474) or MCL technique (P = 0.187). Novices as well as anesthesiologist felt MCL technique more satisfactory (70%).

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Context: Epidural anesthesia is nowadays considered as the gold standard anesthetic technique for lower limb orthopedic surgeries, and the present study was conducted to evaluate the efficacy of levobupivacaine and ropivacaine in terms of onset, duration of sensory and motor block with duration of postoperative analgesia in patients undergoing lower limb orthopedic surgeries under epidural anesthesia. Aims: To compare the efficacy of 15 mL of levobupivacaine 0.5% with that of 15 mL of ropivacaine 0.75% in patients undergoing lower limb orthopedic surgeries under epidural anesthesia and to determine the better of the two agents with respect to onset, duration of sensory and motor blockade, postoperative analgesia, and adverse effects; if any. Settings and Design: A double-blind randomized study. Subjects and Methods: A total of seventy patients planned to undergo elective lower limb orthopedic surgeries fulfilling the criteria were enrolled in the study. Group I (n = 35): Received 15 mL 0.5% levobupivacaine epidurally. Group II (n = 35): Received 15 mL 0.75% ropivacaine epidurally. Statistical Analysis: Statistical Analysis was done by Statistical Package for Social Sciences (SPSS Version 15.0) statistical analysis software. The values were represented in number (%) and mean ± standard deviation. Results: Time to achieve sensory onset and motor onset were significantly lower in Group II (17.86 ± 2.51 and 23.14 ± 2.73) as compared to Group I (26.14 ± 2.45 and 31.43 ± 2.59) while the duration of sensory block was significantly higher in Group II (173.29 ± 6.29 min) as compared to Group I (156.71 ± 6.96 min). Although motor block duration of Group I (142.43 ± 8.43 min) was higher than that of Group II (141.43 ± 12.81 min), but this difference was not found to be statistically significant. Conclusions: The inference drawn from this discussion, in general, indicated that both the drugs are comparable for block onset, quality, and duration along with similar hemodynamic profile when given in same concentration. However, relatively better response of ropivacaine for block onset and duration as obtained in the present study coupled with higher but statistically.

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Congenital heart defects are associated with various physiological disturbances. They pose anesthetic challenges for both cardiac and noncardiac surgeries. Atrioventricular septal defects are due to a developmental failure in the separation of atria and the ventricles into separate chambers and failure in the separation of mitral and tricuspid valves. We present a case of a child (1½ years), weighing 10 kg, diagnosed as congenital hydrocephalus who was planned for ventriculoperitoneal shunt. Child was having an oxygen saturation of 76% on room air. Anesthesia was induced with morphine and propofol. After tracheal intubation, saturation improved to 93%. Anesthesia was maintained with a combination of oxygen and nitrous oxide along with isoflurane. Measures were taken to maintain normovolemia and avoid hypotension, hypoxia, tachycardia, cardiac dysrhythmias and acidosis. The patient remained hemodynamically stable, maintaining arterial blood gasses within normal limits. The overall intraoperative course remained uneventful. At the end of the procedure, patient was reversed with neostigmine 60 mcg/kg and glycopyrrolate 10 mcg/kg. Extubation was done after the child was alert and opening eyes and was shifted to intensive care on oxygen inhalation for further monitoring.

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Background and Objective: Various adjuvants have been introduced to decrease the dose of volatile agents and their side effects. Dexmedetomidine a potent alpha-2 adrenoreceptor agonist is one such agent. Our objective is to assess the effect of preanesthetic dexmedetomidine on isoflurane consumption and its effect on intraoperative hemodynamic stability and recovery profile. Setting and Design: This prospective, randomized controlled, double-blind study was done in a tertiary care hospital. Materials and Methods: One hundred patients were randomly allocated into two groups. Group 1 received saline infusion and Group 2 received dexmedetomidine infusion in a dose of 1 μg/kg over 10 min given 15 min before induction. Vital parameters and bispectral index (BIS) values were noted throughout the surgery. Patients were induced and intubated as per the standard protocol and maintained with N₂O: O₂ = 1:1 mixture at 2 L/min and isoflurane concentration adjusted to achieve BIS values of 45–60. Demographic profile, hemodynamic variables, total isoflurane consumption, and recovery profile data were collected. Statistics: Independent t-test and Mann–Whitney U-test were used to compare the average anesthetic consumption, hemodynamics, and recovery profile between two groups. Results: End-tidal concentration and total isoflurane consumption in Group 2 were 0.56 ± 0.11 and 10.69 ± 3.01 mL, respectively, with P< 0.001 which was statistically significant compared to Group 1 which were 0.76 ± 0.14 and 13.76 ± 3.84 mL. Postintubation and intraoperative mean arterial pressure values were significantly lower in dexmedetomidine group with P< 0.001. Conclusion: Preanesthetic bolus dose of dexmedetomidine is a useful adjuvant to reduce isoflurane consumption.

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Background: The synergism between local anesthetic agents such as bupivacaine with intrathecal adjuvants such as opioids and clonidine is well established. Aims: This study evaluates the clinical efficacy of clonidine75 μg versus fentanyl 25 μg as adjuvants to bupivacaine for spinal anesthesia. Settings and Design: A prospective, randomized, parallel arm study was conducted over a period of 12 months in a tertiary care hospital. Materials and Methods: Sixty patients were divided randomly into two groups, Group C and Group F. Patients in Group C received 2.5 ml of 0.5% bupivacaine heavy mixed with 0.5 ml (75 μg) clonidine intrathecally, and patients in Group F received 2.5 ml of 0.5% bupivacaine heavy mixed with 0.5 ml (25 μg) fentanyl intrathecally. Statistical Analysis: Data were analyzed using statistical tests for comparison of means. Results: The mean durations of sensory block was 253.3 and 249.6 minutes in group C and group F respectively, which was statistically not significant (P = 0.76). The mean durations of motor block were 302.3 and 293.6 min, respectively, in Group C and Group F, which were also statistically not significant (P = 0.53). The mean durations of postoperative analgesia were 653.4 and 611.2 min, respectively, in Group C and Group F, which were statistically not significant (P = 0.09). Mean heart rate after 10 min was 82.5 in Group C and 87.2 in Group F, which was statistically not significant (P = 0.29), and mean arterial pressure in mmHg after 10 min was 96.3 in Group C and 97.3 in Group F, which was also statistically not significant (P = 0.86). Conclusion: Both clonidine 75 μg and fentanyl 25 μg when used as adjuvants to bupivacaine in the subarachnoid block have comparable beneficial results in terms of duration of analgesia, duration of motor blocks, and hemodynamic stability and also have a comparable incidence of complications.

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