Background: Ephedrine was conventionally regarded as the first-choice drug to maintain maternal blood pressure during spinal anesthesia for cesarean delivery, due to its stimulant activity on α- and β-adrenergic receptors. Norepinephrine is a weak β-adrenergic and potent α-adrenergic receptor agonist. Therefore, it may be suitable for maintaining blood pressure with less chronotropic effects compared to ephedrine. Patients and Methods: One hundred and forty healthy patients having cesarean delivery under spinal anesthesia were randomized to Group N (n = 61) who received a prophylactic bolus of norepinephrine 5 μg intravenous (i.v.) at the time of intrathecal block or Group E (n = 61) who received a prophylactic bolus of i.v. ephedrine 10 mg. Rescue i.v. bolus interventions of norepinephrine 5 μg or ephedrine 10 mg were given as required to maintain systolic blood pressure. Maternal and fetal hemodynamic variables, Apgar score, and number of boluses of vasopressors used were recorded. Results: The numbers of maternal hypotension and hypertension episodes and the frequency of bradycardia and tachycardia were significantly lower in Group N compared with Group E (P = 0.02, 0.003, 0.0002, and 0.008, respectively). The number of boluses of vasopressors used was also lower in Group N (P = 0.005). Uterine artery pulsatility index was lower in Group N compared to Group E (P = 0.01) when measured 5 min after spinal anesthesia. Moreover, it was higher at 5 min in Group E when compared with the baseline readings in the same group (P = 0.001). Conclusions: Norepinephrine is a suitable and potent drug to counterbalance the hemodynamic effects of spinal anesthesia during cesarean delivery.

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Background: Postoperative pulmonary complications (PPC) following abdominal surgery are associated with increased morbidity and poorer outcomes. We prospectively examined risk factors associated with the development of PPC in patients undergoing abdominal surgery. Aims: The primary outcome was to determine the association of predefined risk factors in the prediction of PPC after abdominal surgery. Secondary outcomes were evaluation of outcomes of PPC. Setting and Design: This was a prospective study conducted in the gastrosurgical and urological units of a tertiary care referral hospital in patients undergoing abdominal surgery over a period of 6 months (November 2015–April 2016). Materials and Methods: Relevant preoperative and intraoperative variables were recorded by the anesthesiologist in a pro forma provided. Postoperatively, data from the Intensive Care Unit (ICU) were collected from data sheets. PPC were defined according to preset criteria and outcomes of the patients including ICU stay, hospital stay, and mortality were noted. Statistical Analysis: Chi-square test was used to find the association of risk factors of PPC. Mann–Whitney test was used for continuous variables and McNemar's test for postoperative respiratory variables. A final regression analysis was performed with factors with significant association (P < 0.1) Results: One hundred and fifty patients were included, and 24 patients (16%) developed PPC as defined by our criteria. Emergency surgery (44.4% of PPC) and cardiac comorbidity (23.9% of PPC) were significant associations for pulmonary complications. The length of ICU and hospital stay (LOICU, LOHS) and mortality were higher in the group with pulmonary complications (P < 0.001). Conclusions: Emergent surgery and cardiac comorbidities were independent predictors for the development of PPC. PPC are associated with increased LOHS, LOICU stay, and mortality.

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We present a 31-year-old primigravida with uncorrected pentalogy of Fallot, pregnant with monochorionic-diamniotic twins, undergoing elective lower segment cesarean section at 36 weeks gestation. Preoperative workup included a transthoracic echocardiogram which revealed a large ventricular septal defect of 1.8 cm with bidirectional shunting, a moderate size atrial septal defect of 1.8 cm with predominant left-to-right shunting, an overriding aorta, moderate right ventricular hypertrophy, and severe pulmonary valve stenosis. Notably, the patient was acyanotic with normal effort tolerance. Preoperative preparation involved the input of cardiologists and obstetric and cardiothoracic anesthetists. Issues such as the use of extracorporeal membrane oxygenation and cardiopulmonary support in the event of cardiac failure were discussed. Autotransfusion postdelivery was also addressed, and plans made for therapeutic venesection should need to arise. Intraoperatively, the planned anesthetic technique was slow and titrated combined spinal–epidural. However, a general anesthetic technique with rapid sequence induction was used in view of extreme patient anxiety. Intravenous induction was performed with ketamine and etomidate, followed by paralysis with succinylcholine. Anesthesia was maintained with desflurane on a mixture of air and oxygen. Phenylephrine infusion was titrated according to the patient's blood pressure and systemic vascular resistance. The uterotonic of choice was duratocin given as a slow bolus, followed by a 4-h infusion of oxytocin. The patient was put in a head-up position to prevent venous air embolism and to decrease autotransfusion to central circulation. Postoperatively, she was extubated and sent to the Intensive Care Unit for continuous monitoring with FloTrac^®.

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Background: Application of continuous positive airway pressure (CPAP) helps to recruit collapsed areas of the lung, which improves the oxygen reserve. Aim of the Study: To compare the time to desaturate to 90% during apnea following preoxygenation and apneic ventilation with tidal volume breathing for 3 min with and without the application of CPAP. Settings and Design: This prospective randomized study was conducted in a tertiary care institution. Subjects and Methods: Twenty adult surgical patients were allocated into two groups. Group C patients were preoxygenated with 100% oxygen with CPAP of 20 cm H₂O for 3 min. Group P patients were preoxygenated for 3 min without CPAP. In Group C, apneic oxygenation was initiated following induction and neuromuscular blockade with CPAP of 20 cm H₂O. In Group P, no CPAP was applied. The study was terminated when the patient desaturated to 90%. Statistical Analysis Used: Chi-square test and Mann–Whitney test. Results: Group C had a significantly longer apnea time as compared to Group P (816.00 ± 30.98 vs. 348.00 ± 122.64 s). Three patients in Group P desaturated to <90% by 3 min and the remaining soon after 6 min. No patient in Group C desaturated till 12 min of apnea. PaO₂was significantly higher in Group C at 3 and 6 min of apnea. At 3 and 6 min, Group P had significantly lower saturation as compared to Group C. Conclusion: Preoxygenation with CPAP significantly delayed desaturation during apnea with significantly higher arterial partial pressure of oxygen as compared to preoxygenation without CPAP.

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Introduction: Total knee replacement is a common surgical procedure in the elderly. The number of surgeries has increased owing to the increasing life expectancy of the population and better functional outcomes postsurgery. Postoperative cognitive dysfunction (POCD) is an identified entity postsurgery in elderly but most of the studies have been on patients undergoing cardiac and other nonorthopaedic surgeries. The studies have shown variable incidence due to selection bias. We studied the incidence and probable predictive factors of POCD in elderly Indian population undergoing total knee replacement under spinal anesthesia. Materials and Methods: We designed a prospective, observational study at a single center including patients above 60 years of age undergoing total knee replacement under spinal anesthesia. Preoperative mini-mental scale examination, electrolytes, urea and creatinine levels were recorded. Postoperatively, mini mental scale evaluation (MMSE) was done 2 days postsurgery, at 3 months, 6 months, and 1 year follow-up. Laboratory values postoperatively were recorded. Results: The average preoperative MMSE was 27 and declined to 25.4 on second postoperative day the value increased to 25.9, 26.6, and 27 at 3 months, 6 months, and 1-year follow-up, respectively. Sixty-three out of 600 patients developed POCD at second postoperative day. Forty-three patients showed recovery in subsequent visits and 20 patients had persistent dysfunction at the end of 1 year. Electrolyte imbalance, oxygen saturation, and age over 80 years were factors that showed statistically significant difference in multiple comparison analysis. Conclusion: In our study, we have found POCD to be a definitive entity which can cause short- and long-term cognitive defect in elderly Indian population undergoing total knee replacement and electrolyte imbalance, age, and oxygen saturation were the significant factors in the patients who developed POCD.

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Background: Video laryngoscope-aided intubations require less force to align oral, pharyngeal, and laryngeal planes to visualize the glottis opening during intubation. Aim: The primary objective of the study was to assess the incidence and severity of postoperative sore throat (POST) in patients who were intubated with C-MAC video laryngoscope using D-blade versus traditional Macintosh laryngoscope. Settings and Design: This prospective, randomized, open label study was conducted in a tertiary care institution. Subjects and Methods: A total of 130 patients undergoing short elective laparoscopic surgeries lasting <2 h were recruited. All patients received general anesthesia as per a standardized protocol. Laryngoscopy was performed using traditional Macintosh laryngoscope in Group M and with Storz^® C-MAC video laryngoscope using D-Blade in Group V. The endotracheal tube cuff pressure was maintained at 20–22 cm of H2O intraoperatively. Statistical Analysis Used: Pearson's Chi-square test, Fisher's exact test, and Independent sample t-test were used in this study. Results: As compared to Group M, number of patients who had POST, hoarseness of voice, and cough was significantly low in Group V at 2, 6, 12, and 24 h. Severity, as well as the incidence of all these symptoms, showed a downward trend in both groups with time. Significantly more number of patients in Group M required rescue therapy for POST (44.6% as compared to 7.7%, P < 0.001). Conclusion: C-MAC video laryngoscope-aided intubations using D-blade significantly reduced the incidence and severity of POST, hoarseness of voice, and cough following orotracheal intubation as compared to use of traditional Macintosh laryngoscope.

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Background: Pain associated with laparoscopic cholecystectomy is most severe during the first 24 h and the port sites are the most painful. Recent multimodal approaches target incisional pain instead of visceral pain which has led to the emergence of abdominal fascial plane blocks. This study embraces a novel combination of two independently effective fascial plane blocks, namely rectus sheath block and subcostal transversus abdominis plane (TAP) block to alleviate postoperative pain. Study Objective: The aim is to evaluate the effectiveness of the combination of rectus sheath block and subcostal TAP block, to compare its efficacy with that of subcostal TAP block alone and with conventional port site infiltration (PSI) in alleviating postoperative pain in patients undergoing laparoscopic cholecystectomy. Methodology: This prospective, randomized control, pilot study included 61 patients scheduled for elective laparoscopic cholecystectomy and distributed among three groups, namely Group 1: Combined subcostal TAP block with rectus sheath block (n = 20); Group 2: Oblique subcostal TAP block alone (n = 21); and Group 3: PSI group as an active control (n = 20). Results: Combined group had significantly lower pain scores, higher satisfaction scores, and reduced rescue analgesia both in early and late postoperative periods than the conventional PSI group. Conclusion: Ultrasound-guided combined fascial plane blocks is a novel intervention in pain management of patients undergoing laparoscopic cholecystectomy and should become the standard of care.

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Background: Preoxygenation and apneic ventilation prolong apnea time without desaturation. Aims: The primary objective of this study is to compare arterial oxygenation during the periods of apnea following preoxygenation and apneic ventilation with tidal volume breathing for 3 min with continuous positive airway pressure (CPAP) versus with transnasal humidified rapid-insufflation ventilatory exchange (THRIVE). Settings and Designs: This prospective randomized study was conducted in 20 adult patients at a tertiary care institution. Subjects and Methods: Group C patients (n = 10) were preoxygenated with 100% oxygen using a face mask at a rate of 6 L/min for 3 min with CPAP of 15 cm of H₂O. In Group H, oxygen was administered using THRIVE at 30 L/min for 3 min. Apneic ventilation was given in Group C with 10 L/min oxygen with CPAP of 15 cm H₂O and in Group H with THRIVE at 60 L/min. The endpoint was desaturation to 90% or maximum duration of 12 min. Statistical Analysis Used: Chi-square test and Mann–Whitney test. Results: Both groups tolerated apnea for 12 min without desaturation. PaO₂in Group C was significantly higher than Group H from 3 min of apnea to 12 min. The PaCO₂was significantly lower in Group C from 6 min. The pH was comparable in both groups except at 12 min with Group H having significantly lower pH. Conclusion: Tidal volume breathing with CPAP resulted in significantly higher arterial oxygen levels than THRIVE, though both modalities were equally effective in prolonging apnea time without desaturation up to 12 min. Group C showed an added advantage of lower PaCO₂with less acidemia.

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Background: Emergence agitation (EA) is common in pediatrics after sevoflurane anesthesia. Aims: We intended to study the effect of preoperative pregabalin on EA in pediatrics after sevoflurane anesthesia. Settings and Design: This study design was a prospective randomized controlled double-blinded study. Patients and Methods: Sixty children with American Society of Anesthesiologists physical status Classes I–II, aged 4–10 years, prepared for adenotonsillectomy under sevoflurane anesthesia were randomized to two equal groups (control Group C and pregabalin Group P). Children received either placebo syrup (Group C) or pregabalin syrup 1.5 mg/kg (Group P) ½ h preoperatively. We recorded postoperative EA scale (EAS) (10, 20, and 30 min postoperatively), time to open the eye, time to extubate, postanesthesia care unit (PACU) duration of stay, number of paracetamol doses (15 mg/kg) given (to control postoperative pain), and complications as vomiting and dizziness on discharge. Statistical Analysis Used: Independent sample t-test and Chi-square test were used as appropriate. Results: Pregabalin Group P showed less EAS, less analgesic (paracetamol) requirement, and less vomiting with insignificant effects on time to open the eye or extubation and PACU duration of stay compared to control group. Conclusion: Preoperative pregabalin decreased postoperative EAS, analgesic (paracetamol) requirement, and vomiting in pediatrics after adenotonsillectomy using sevoflurane anesthesia without affecting time to open the eye or extubation and PACU duration of stay.

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Hypertrophic cardiomyopathy (HCM) is a genetic myocardial disease usually characterized by asymmetric ventricular septal hypertrophy. HCM is an important cause of sudden cardiac death in adolescents and young adults. We are presenting a case report, ten years boy came in emergency with sudden loss of consciousness (witness cardiac arrest). Child was revived after cardiopulmonary resuscitation and send to coronary care unit. Echocardiography findings were suggestive of HCM. There was history of sudden death of her mother and maternal uncle. After stabilization ICD was implanted under total intravenous anesthesia. Post procedure his hospital stay was uneventful.

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Neurofibromatosis type 1 (NF1) is an autosomal-dominant neuroectodermal hereditary disorder, in which spinal skeletal deformities are one of the manifestations. Pectus carinatum, temporomandibular joint dysfunction, and kyphoscoliosis can be seen with this genetic disorder which can lead to cardiorespiratory system problems and can cause difficulty in airway management. We present the anesthetic management of a NF1 patient with a sharp thoracolumbar dystrophic kyphoscoliosis who have been posted for emergency cesarean section as a result of fetal distress. The operation was successfully performed with subarachnoid block. This case highlights the anesthetic challenges and the significance of early planning anesthetic technique.

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Leigh syndrome (LS) is a rare disease mainly affecting the central nervous system due to the abnormalities of mitochondrial energy generation and seen in early childhood with progressive loss of movement, mental abilities, seizures, nystagmus, ophthalmoparesis, optic atrophy, ataxia, dystonia, or respiratory failure. Anesthesia and surgery exacerbate the risks of aspiration, wheezing, and breathing difficulties. Tracheal irritability can be stimulated with the efforts of intubation. We report the anesthetic management of a rare case of an 11-year-old boy with a severe form of LS for percutaneous endoscopic gastrostomy insertion. The patient was closely monitored during the procedure and the postoperative period. Carefully chosen anesthetic agents, good pain control, and close monitoring are essential.

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Transient receptor potential (TRP) channels play key roles for the transition from acute to chronic postoperative pain after surgery. To evaluate TRP channels in the peripheral blood cells as blood biomarkers for chronic pain, we collected blood samples for genome-wide assays of the mRNA expression and assessed pain intensity and the number of pain symptoms in 13 patients with chronic pain. There was a significant association between increases in the number of pain symptoms and increases in the TRP vanilloid 1 (TRPV1) expression. Decreases in the TRP ankyrin 1 (TRPA1) expression, however, tended to increase the number of pain symptoms. There was likely an inverse relationship for TRPV1 and TRPA1 expressions with regard to the number of pain symptoms in chronic pain patients.

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Intubating a pediatric patient with temporomandibular joint ankylosis is a daunting task, and it becomes more challenging with limited mouth opening. Fiberoptic nasotracheal intubation technique is considered a gold standard. We describe an improvised technique of securing airway in the absence of appropriate-sized fiberoptic scope. The endotracheal tube inserted in the left nostril for maintaining depth of anesthesia was advanced under vision by the fiberoptic scope inserted into the right nostril, and with external laryngeal manipulation, the airway was secured with no complications.

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Pain treatment can comprise a combination of pharmacological, interventional, surgical, physical, psycological methods. Interventional procedures, particularly minimally invasive percutaneous therapies, have been widely used in recent years. Corticosteroid, hyperbaric saline or oxygen-ozone therapy is a safe procedure for patients in whom pain cannot be relieved by epidural adhesiolysis or other treatments. Complication related to oxygen-ozone therapy have been reported rarely in lumbar sciatalgia. Herein, we present a patient who developed cardiopulmonary arrest and pneumoencephaly as a rare but life-threatening complication of oxygen-ozone therapy, for epidural lysis, applied to the epidural space due to low back pain.

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Haemophilia is an inherited bleeding disorder with variable deficiency of Factor VIII in the plasma and is characterised by bleeding into joints, muscles and tissues either spontaneously or in response to trivial trauma. Perioperative care requires multidisciplinary involvement. Perioperative management involves the risk of excessive bleeding from surgical site as well as spontaneous bleeding into the brain in response to surgical stress in patients with previous history of intracerebral haemorrhage. Airway management of such patients during anaesthetic intervention is a challenge and entails the risk of life threatening haemorrhage into the airway. The I gel Supraglottic airway device may be best suited for the purpose considering its soft elastomeric non-inflatable cuff, ease of insertion, availability of gastric suction port and minimal leak fraction on controlled ventilation. The I Gel may be solution to avoiding airway instrumentation in patients with bleeding disorders. It may be an alternative to endotracheal intubation in patients with Haemophilia undergoing surgery.

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There are no reports for anosmia after caudal epidural steroid injections (CESIs). General anesthesia is among the reasons, but the reports up to date are extremely limited. There are no identifiable factors contributing to anosmia after epidural injection, so it is worth discussing. We present the case of a 50-year-old woman with no previous history of any sensory deficits. She experienced anosmia after CESI that had been performed due to her chronic low back pain and lasted for 4 months. Clinical and imaging studies did not reveal any pathology. After 4 months, the olfactory dysfunction demonstrated a significant improvement. Disorders of the olfactory system are unknown after regional anesthesia. The onset of the dysfunction in correlation with the imaging findings may indicate that anesthetics can affect the olfactory dysfunction. Further studies are needed.

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Background: Dexamethasone as an adjuvant to bupivacaine and ropivacaine for supraclavicular brachial plexus (SCBP) block prolongs motor and sensory blockade. However, comparison of effect of dexamethasone (8 mg) when added to these two local anesthetics has not been well studied. This study was conducted to compare analgesic efficacy of dexamethasone as adjuvant to bupivacaine and ropivacaine in SCBP block. Subjects and Methods: Nerve stimulator-guided SCBP block was given to 120 patients, randomly assigned to one of four groups: (n = 30 in each group) Group B, BD, R, and RD received 30 ml (0.5%) bupivacaine + 2 ml saline, 30 ml (0.5%) bupivacaine + dexamethasone 8 mg, 30 ml (0.5%) ropivacaine + 2 ml saline, and 30 ml (0.5%) ropivacaine + dexamethasone 8 mg, respectively. Time for request of the first rescue analgesic, 24-h analgesic consumption, and different block characteristics were assessed. Student's t-test, Chi-square test, ANOVA were used for statistical analysis. Results: Dexamethasone significantly prolonged time for request of the first rescue analgesic of both ropivacaine (1211.83 ± 32.86 vs. 283.17 ± 7.71 min){ p R, RD < 0.001} and bupivacaine (1205.17 ± 34.32 vs. 364.67 ± 16.50 min) {p B, BD < 0.001}. 24-h requirement for rescue analgesics was more in Groups B and R when compared to Groups BD and RD. The increase in duration of analgesia was more when Groups R and RD (928.66 min) were compared than Groups B and BD (840.5 min). Similar results were seen with onset times and duration of sensory and motor block. Conclusion: The addition of dexamethasone to bupivacaine and ropivacaine in SCBP block prolonged time for first rescue analgesia and reduced the requirement of rescue analgesics with faster onset and prolonged duration of sensory and motor block, with the effect being stronger with ropivacaine.

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Background: Minute ventilation (MV) and calorific requirement (CR) are both functions of metabolic demand. The Holliday-Segar formula is a weight-based tool for predicting CR. This study was performed to derive an equation, based on the Holliday-Segar formula, for calculating resting MV from body-weight (BW), which is applicable for all age groups. Methods: MV for BW (obtained from Radford normogram) was plotted against CR for BW (as per Holliday-Segar formula), for BWs ranging from neonates to adults. From the scatter plot thus obtained, best-fit line, with the origin as intercept, was drawn. Linear regression analysis was used to obtain R² coefficient and P value. Results: The plot of MV against CR yields a straight line passing through the origin with a slope = 46.87. R² value is 0.98886, P < 0.001. Conclusion: MV can be easily and reliably estimated for all age groups from the equation: MV (mL/min) = 47 × CR (kcal/h).

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Background: Caudal epidural analgesia is a proven technique for providing analgesia for spinal surgeries. Prolonged pain relief with no motor blockade is desired for early mobilization. Objective: The objective of this study is to compare the effect of adding 1 μg/kg of clonidine to injection ropivacaine 0.2% with respect to duration of analgesia, hemodynamic effects, and associated side effects. Methodology: In this prospective double-blind study, a total of 60 patients undergoing lumbosacral spine surgery were randomized to receive 25 cc caudal epidural injection of either injection ropivacaine 0.2% (Group R, n = 30) or a mixture of injection ropivacaine 0.2% and injection clonidine 1 μg/kg (Group RD, n = 30) under general anesthesia after the patient was positioned prone for surgery. Visual analog scale (VAS) scores, heart rate, blood pressures, and time to rescue analgesia and sedation score were recorded at regular intervals for the first 24 h. Results: Mean VAS scores were significantly lower in the RC Group for up to 12 h following the caudal block. The time to first rescue analgesic was prolonged in the RC group compared to the R Group, and it was statistically significant. No clinically significant hemodynamic changes were noted in either of the groups. No other side effects were seen in both the groups. Conclusion: These results suggest that injection clonidine is an effective additive to injection ropivacaine for caudal epidural analgesia in lumbosacral spine surgeries.

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Background: Pneumoperitoneum and altered positioning 1in laparoscopic cholecystectomy predispose to alterations in cardiorespiratory physiology. We compared the effects of volume controlled, pressure controlled, and the newly introduced pressure controlled-volume guaranteed ventilation (PCV-VG) modes of ventilation on respiratory mechanics and oxygenation during laparoscopic cholecystectomy. Materials and Methods: Seventy-five physical status American Society of Anesthesiologists Classes I and II patients with normal lungs undergoing laparoscopic cholecystectomy were randomly allocated to receive volume controlled ventilation (VCV), pressure-controlled ventilation (PCV), or PCV-VG modes of ventilation during general anesthesia. In all modes of ventilation, the tidal volume was set at 8 mL/kg, and respiratory rate was set at 12 breaths/min with inspired oxygen of 0.4. After pneumoperitoneum, respiratory rate was adjusted to maintain an end-tidal carbon dioxide between 32 and 37 mm Hg. The peak airway pressures, compliance, the mean airway pressures, oxygen saturation, end tidal carbon dioxide and hemodynamics were recorded at the time of intubation (T1), 15 min after pneumoperitoneum (T2) and after desufflation (T3) and were compared.. Arterial oxygen tension, arterial carbon dioxide tension at T2 and T3 were compared. Results: PCV-VG and PCV mode resulted in lower peak airway pressures than VCV (23.04 ± 3.43, 24.52 ± 2.79, and 27.24 ± 2.37 cm of water, respectively, P = 0.001). Compliance was better preserved in the pressure mediated modes than VCV (fall from baseline was 42%, 29%, and 30% in VCV, PCV, and PCV-VG). The arterial to end-tidal carbon dioxide gradient was lower in PCV-VG and PCV compared to VCV. No difference in oxygenation and hemodynamics were observed. Conclusion: PCV and PCV-VG modes are superior to VCV mode in providing adequate oxygenation at lower peak inspiratory pressures.

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Background: The application of the skull-pin head-holder, used to stabilize the head during neurosurgical procedures, produces an intense nociceptive stimulus and results in abrupt increases in blood pressure and cerebral blood flow under general anesthesia. Different anesthetic and pharmacologic techniques, including local anesthetics, narcotics, antihypertensives, and deepening of anesthesia with inhalation anesthetics, have been used to blunt this deleterious effect with variable success. Aim: To compare the analgesic and hemodynamic effects of ropivacaine scalp block, and intravenous (IV) clonidine in attenuating the hemodynamic response to the scalp pin insertion in neurosurgical patients. Settings and Design: A comparative two group's clinical study of 64 patients undergoing elective craniotomy in Department of Anaesthesiology, Bangalore Medical College and Research Institute. Methodology: Sixty-four patients were allocated into any one of two groups of 32 patients each, by means of computer-generated randomization: (1) Group S: Patients receiving scalp block with injected ropivacaine 0.25% 30 ml. (2) Group C: Patients receiving 2 μg/kg IV clonidine. Statistical Methods: Descriptive and inferential statistical analysis has been carried out in the present study. Results on continuous measurements are presented on mean ± standard deviation (minimum–maximum) and results on categorical measurements are presented in number (%). Significance is assessed at 5% level of significance. Results: Increase in heart rate and blood pressure during pin insertion was attenuated by clonidine hydrochloride (P < 0.001). The number of patients who required more fentanyl and propofol to stabilize the hypertensive response were more in control group than clonidine group. Conclusion: IV clonidine maximally attenuated the hemodynamic response to application of head pins in a dose of 2 μg/kg compared to ropivacaine scalp block, thus maintaining intracranial pressure for neurosurgical anesthesia.

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Background: For General anaesthesia perioperative administration of opioids are choice of drugs to attenuate intubation response and to provide good intraoperative and postoperative analgesia. Mixed agonist-antagonist opioids produces powerful analgesia without undesirable side effects. Aim: Aim of present study to compare efficacy of Nalbuphine and Pentazocine on hemodynamic response to tracheal intubation and postoperative analgesia. Settings: Present study carried out in operation theater. Design: This is prospective randomized double blind controlled trial. Material and Methods: Patients of ASA physical status I and II, age 20-60 years undergoing abdominal surgical procedure of 1-2 hour duration were randomly divided into two groups of 30 patients each (Group N) receiving nalbuphine 0.3 mg.kg^-1 and (Group P) receiving pentazocine 0.6 mg.kg^-1 intravenously before induction. Baseline vital parameters were noted and then noted till 15 minutes after intubation to see hemodynamic response. Time of rescue analgesia required was noted postoperatively. Stastical Analysis: Chi-square test, paired and unpaired t-test were used for statistical analysis. Results: There is rise in heart rate, blood pressure after intubation in both groups but rise was more with Pentazocine as compared to Nalbuphine (P < 0.05). Postoperatively within 30 minutes 60% of patient from Pentazocine group require rescue analgesia compare to only 16.60% of patient of Nalbuphine group (P = 0.05) which is highly significant. Conclusion: Nalbuphine is potent mixed opioid analgesic which can be used for attenuation of pressor response of tracheal intubation and for perioperative analgesia with minimal side effects.

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Background: Statin utilization had been associated with improved survival after cardiac surgery. We aim to study whether perioperative treatment with statin could be associated with increased postoperative complications. Design: This was a retrospective, descriptive, single-center study. Settings: We analyzed morbidity after cardiac surgery as well as the outcome related to statin therapy in a tertiary cardiac center. Patients: A total of 202 consecutive patients were enrolled over 1 year after cardiac surgery. Intervention: Patients were divided into two groups; Group I – statin users and Group II – nonusers. Measurements: Measurements were baseline and follow-up laboratory markers for muscular injury including cardiac muscle and hepatic injuries and renal injuries. Results: The incidence of rhabdomyolysis and elevation of liver enzymes did not differ between both groups. Postoperative atrial fibrillation was significantly lower in the statin group (P = 0.02). In addition, peak cardiac troponin and creatine kinase-MB did not differ significantly in the statin group. Statin-treated group had significant lower length of mechanical ventilation, and length of stay in the Intensive Care Unit and hospital (P = 0.036, 0.04, and 0.027, respectively). Conclusions: Therapy with statin before cardiac surgeries was not associated with high incidence of adverse events.

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Background: Laparoscopic procedures which are now established in pediatric population as well exposes the child to supplemental cardiorespiratory changes due to increase in intraabdominal pressure (IAP) and hypercarbia. Aims: This study aims to analyze the effects of pneumoperitoneum and postural modifications on cardiorespiratory system (primary outcome) during pediatric laparoscopic herniorrhaphy (LH) and its comparison with open herniorrhaphy (OH) and assessment of overall perioperative outcome (secondary outcome). Settings and Design: A prospective, observational study conducted in a tertiary care hospital. Materials and Methods: Fifty children undergoing either LH (n = 25) or OH (n = 25) were included in the study. Anesthetic procedure was standardized. Parameters monitored were heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressures (MAP), electrocardiogram lead-II, end-tidal CO₂(ETCO₂), airway pressures P_Peak, P_Plateau, P_Mean, pulse oximetry, IAP, minute ventilation/respiratory rate alterations. Statistical Analysis Used: Student's t-test and Chi-square test were applied to compare different variables between the two groups. Intragroup analysis was done using the analysis of variance test. Results: The HR was comparable in both groups. The rise in SBP, DBP, and MAP was 9% (102.88 ± 6.91–121.32 ± 6.63), 19% (60.88 ± 4.94–77.00 ± 9.75), and 14.8% (73.92 ± 4.65–90.40 ± 8.42), respectively, in group LH. The rise in peak, plateau, and mean airway pressures was 19.4% (14.20 ± 2.00–18.00 ± 2.54), 20.1% (13.32 ± 1.89–16.89 ± 2.60), and 16.1% (6.20 ± 1.00–7.47 ± 0.96), respectively, in group LH. ETCO₂showed a maximum rise of 19.4% (34.52 ± 3.61–41.21 ± 3.99) in group LH. In laparoscopic group, recurrence was seen in 3 patients. Conclusions: We found significant hemodynamic, airway pressure, and capnometric changes during pediatric LH with comparable perioperative outcome among the two groups.

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Background: The intranasal route is a reliable way to administer preanesthetics and sedatives to children. The aim of this study was to compare the anxiolytic and sedative effect of intranasal dexmedetomidine and midazolam as a premedication in pediatrics with simple congenital heart disease undergoing cardiac catheterization. Patients and Methods: Sixty children 3–6 years old of either sex with simple congenital heart disease undergoing cardiac catheterization were randomly allocated into two groups: Dexmedetomidine group who received intranasal dexmedetomidine (0.1 μg/kg) and midazolam group who received intranasal midazolam (0.2 mg/kg) 30 min before induction. Heart rate, mean arterial blood pressure, and oxygen saturation were monitored up to 30 min after drug administration. The sedation score, anxiety score, and child-parent separation score were recorded until the child taken to the operating room. The postoperative agitation score was also observed. Results and Conclusion: The premedication of children with intranasal dexmedetomidine attained satisfactory and significant sedation and lower anxiety level with better parental separation than those who received intranasal midazolam.

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Introduction: Effective postoperative analgesia is imperative for orthopedic surgeries to enhance recovery and facilitate early ambulation. Various additives have been used as adjuvants with local anesthetics in peripheral nerve blocks to provide postoperative analgesia. The aim of this study is to compare the duration of postoperative analgesia with buprenorphine and dexamethasone when administered as an adjuvant during ultrasound-guided brachial plexus blocks. Methodology: Sixty adult patients undergoing various upper arm surgeries were recruited for the study after acquiring ethics committee clearance. They were randomized into two groups of thirty; Group B was given ultrasound-guided supraclavicular block with 10 ml 2% lignocaine with adrenaline and 15 ml 0.5% bupivacaine and 4 mg dexamethasone as adjuvant. Group B was given the same amount of local anesthetics with 0.3 mg buprenorphine as the adjuvant. The duration of postoperative analgesia and incidence of adverse events if any were noted. Results: Both groups were comparable in demographics, time for onset of sensory, and motor block. The duration of postoperative analgesia was 17.4 ± 3.4 h in the buprenorphine group and 18 ± 3.49 h in the dexamethasone group. None of the patients had significant adverse effects. A single dose of buprenorphine and dexamethasone administered perineurally can provide significant postoperative analgesia for upper limb surgeries.

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Background and Aims: Cardiovascular stress response to extubation can result in elevated heart rate (HR) and mean arterial blood pressures which can be detrimental in high-risk patients. Settings and Design: The objective of this study is to compare the esmolol and labetalol efficacy in attenuating hemodynamic response to tracheal extubation. Materials and Methods: Sixty patients scheduled for elective surgical procedures were selected randomly and divided into two groups of thirty each. Group I - esmolol 1.5 mg/kg and Group II - labetalol 0.25 mg/kg were administered 2 min before extubation after following a standard perioperative anesthetic management. Hemodynamic parameters recorded include HR, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) at baseline, reversal, study drug, 1 min after study drug, extubation, and at 1, 2, 3, 4, 5, and 15 min postextubation. Statistical Analysis: Student's t-test and analysis of variance have been used to find the significance of study parameters between groups of patients. P <0.05 was considered statistically significant. Results: Both esmolol and labetalol obtunded extubation response throughout the extubation and postextubation period. At extubation and immediately postextubation at 1^st and 2^nd min, there was statistical significance (P < 0.05) in SBP, DBP, and MAP which showed esmolol was better than labetalol. Whereas labetalol was more efficient in controlling HR at 5^th and 15^th min postextubation having statistical significance. Conclusions: Both esmolol and labetalol attenuated hemodynamic response. Esmolol was more efficient than labetalol at extubation and immediately postextubation. If patient has tachycardia at extubation, labetalol is preferred. If patient has raised blood pressure, then esmolol is a good option in blunting the response.

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Background and Aims: Postspinal headache and low backache are common complaints following spinal anesthesia which regresses spontaneously but sometimes becomes very troublesome for the patient as well as for the anesthesiologists. The aim of this study was to evaluate the incidence of postspinal headache and low backache after spinal anesthesia in lower abdominal surgery. Materials and Methods: One hundred patients of 18–60 years of age group with patients physical status the American Society of Anesthesiologists Class I or II after due consent divided into equal numbers of two groups: median (M) approach and paramedian (P) approach scheduled for lower abdominal surgery. Group M (50 patients) received spinal by median approach while in Group P (50 patients) received spinal by paramedian approach. The incidence of postspinal headache and low backache was observed in each group. All the patients were observed up to 7 days postoperatively. Data collected was analyzed statistically by SPSS (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp) and Chi-square test, and P < 0.05 considered as statistically significant. Results: Postspinal headache was observed to be 4% in paramedian approach and 20% in median approach group. Backache incidence recorded in both the groups was 2% and 10%, respectively. P value calculated statistically was < 0.05 and hence statistically significant in paramedian approach in respect of incidence of both postspinal headache and backache. Conclusion: Incidence of postspinal headache and low backache is less in paramedian approach than in median approach.

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Aims: Dexmedetomidine is very dynamic drug, used for analgesia, sedation, blunting the laryngoscopic responses and as adjuvants in regional anesthesia. Studies have shown that intravenous (iv) dexmedetomidine given during spinal anesthesia increases the quality of subarachnoid block (SAB). In this study, we compare the two iv regimen of dexmedetomidine on analgesic effect of spinal anesthesia. One is bolus dose of dexmedetomidine and other is infusion during the surgery, both given after induction of spinal anesthesia. Subjects and Methods: Sixty American Society of Anesthesiologists I and II patients scheduled to undergo surgeries under SAB were randomly allocated into two groups namely B and I. After SAB with 3.0 ml of bupivacaine 0.5% heavy, Group B received 0.5 μg/kg of dexmedetomidine bolus over 15 min, Group I received 0.5 μg/kg/h of dexmedetomidine infusion until the end of surgery. Statistical Analysis Used: All parametric data were statistically analyzed using Student's t-test and nonparametric data analyzed using Chi-square test and Fischer exact test as appropriate. P < 0.05 was considered as statistically significant. Statistical analysis was performed using the SPSS. Results: Time to reach desired level T₁₀was quick in Group B compared to Group I. Regression of sensory and motor was prolonged in Group I compared to Group B. Total duration of analgesia was significantly prolonged in Group I 230.39 ± 16.20 compared to Group B 196.01 ± 14.32 and the difference is statistically significant (P = 0.0001). Both groups had Ramsay sedation score of 3 which lasted for 45 min in Group B while it was maintained in Group I. Side effects profile of both groups was comparable with few incidence of bradycardia and hypotension in both groups requiring treatment. Conclusions: We conclude that the continuous infusion of dexmedetomidine after SAB results in prolonged analgesia than just a bolus dose. Therefore, we suggest use of the maintenance dose of iv dexmedetomidine after SAB for prolonging the duration and achieving adequate sedation

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Background: Although videolaryngoscopes improve glottic visualization, their actual usefulness in intubation is not yet established. Aims: The primary objective was to compare the ease of oral intubation with the use of 60° angled styletted endotracheal tube versus that performed over bougie inserted under videolaryngoscopic guidance. The secondary objectives were assessment of incidence of airway loss, hemodynamic changes, and time and number of attempts at intubation. Settings and Design: This prospective randomized study was conducted in a tertiary care institution. Patients and Methods: Seventy surgical patients requiring oral intubation were randomly allotted to Group S or Group B. Laryngoscopy was performed with Storz^® C-MAC videolaryngoscope using D-Blade. In Group S, patients were intubated with a 60° angled stylletted endotracheal tube. In Group B, a bougie was introduced into the trachea and endotracheal tube was railroaded over the bougie. Statistical Analysis Used: Chi-square test and independent sample t-test were used as applicable. Results: The ease of intubation was significantly more in patients of Group S as compared to Group B (88.6% vs. 25.7%, respectively, P < 0.001) with significantly shorter intubation time (16.97 ± 7.91 vs. 77.43 ± 35.55 s, respectively, P < 0.001). The requirement of more than one attempt at intubation was significantly higher in Group B [57.1% vs. 5.7% P < 0.001, respectively]. Group B showed a significantly high mean arterial pressure at 1 and 3 min following intubation with no significant change in heart rate. Conclusion: Use of 60° angled styletted endotracheal tube resulted in easier and faster intubation as compared to intubation over a bougie when used with C-MAC videolaryngoscope.

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Background and Aims: The aim of the study was to evaluate the effectiveness of epidural volume extension (EVE) technique in terms of sensory and motor block characteristics along with hemodynamic parameters as a part of combined spinal–epidural anesthesia (CSEA). Materials and Methods: A total of 60 patients undergoing hip surgeries were assigned to one of the two groups containing 30 patients each. Group I (the CSE–EVE group) patients were anesthetized using CSE with EVE and Group II (the CSE group) patients were anesthetized using CSE without EVE, using the same technique and low dose of intrathecal hyperbaric bupivacaine. Sensory block characteristics were recorded using pinprick method, whereas motor blockade was assessed by modified Bromage scale. Results: There was a statistically significant difference between the two groups regarding the level of maximum sensory block (P < 0.001), as Group I showed sensory block level extending to up to T4, whereas in Group II, it was limited to below T6. Time required for maximum sensory blockade was faster in Group I, ranging from 7 to 12 min (mean ± standard deviation [SD]: 9.83 ± 1.72), whereas in Group II, it ranged from 9 to 15 min (mean ± SD: 12.33 ± 1.83; P < 0.001). Two-segment regression was faster in Group II, ranging from 50 to 70 min (mean ± SD: 60.0 ± 6.30), whereas in Group I, it ranged from 80 to 105 min (mean ± SD: 89.67 ± 8.19; P < 0.001). The time required to reach the maximum motor block was faster in Group I, ranging from 2 to 4 min (mean ± SD: 2.67 ± 0.84), whereas in Group II, the time ranged from 2 to 6 min (mean ± SD: 3.50 ± 1.31; P < 0.001). Conclusion: CSEA with EVE is associated with early onset of sensory and motor blockade, high level of sensory block, and longer time of two-segment regression while maintaining hemodynamic stability due to decreased dose of intrathecal local anesthetic.

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Background: Perforation peritonitis continues to be one of the most common surgical emergencies that need a surgical intervention most of the times. Anesthesiologists are invariably involved in managing such cases efficiently in perioperative period. Aims: The assessment and evaluation of Acute Physiology and Chronic Health Evaluation II (APACHE II) score at presentation and 24 h after goal-directed optimization, administration of empirical broad-spectrum antibiotics, and definitive source control postoperatively. Outcome assessment in terms of duration of hospital stay and mortality in with or without optimization was also measured. Settings/Design: It is a prospective, randomized, double-blind controlled study in hospital setting. Materials and Methods: One hundred and one patients aged ≥18 years, of the American Society of Anesthesiologists physical Status I and II (E) with clinical diagnosis of perforation peritonitis posted for surgery were enrolled. Enrolled patients were randomly divided into two groups. Group A is optimized by goal-directed optimization protocol in the preoperative holding room by anesthesiology residents whereas in Group S, managed by surgery residents in the surgical wards without any fixed algorithm. The assessment of APACHE II score was done as a first step on admission and 24 h postoperatively. Duration of hospital stay and mortality in both the groups were also measured and compared. Statistical Analysis: Categorical data are presented as frequency counts (percent) and compared using the Chi-square or Fisher's exact test. The statistical significance for categorical variables was determined by Chi-square analysis. For continuous variables, a two-sample t-test was applied. Results: The mean APACHE II score on admission in case and control groups was comparable. Significant lowering of serial scores in case group was observed as compared to control group (P = 0.02). There was a significant lowering of mean duration of hospital stay seen in case group (9.8 ± 1.7 days) as compared to control group (P = 0.007). Furthermore, a significant decline in death rate was noted in case group as compared to control group (P = 0.03). Conclusion: Goal-directed optimized patients with perforation peritonitis were discharged early as compared to control group with significantly lesser mortality as compared with randomly optimized patients in the perioperative period.

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Background: Robotic pelvic surgeries require steep Trendelenburg position which may result in rise in intraocular pressure (IOP). Aim: The aim of this study was to compare the changes that occur in IOP during robotic pelvic surgeries in steep Trendelenburg position with a restrictive intravenous fluid administration. Settings and Design: This prospective observational study was conducted in a tertiary care institution. Subjects and Methods: Twenty consenting patients scheduled for pelvic robotic gynecological surgeries were enrolled. All patients received general anesthesia following a standardized protocol. IOP was measured before induction of anesthesia, immediately after induction and intubation, at the end of surgery immediately after making the patient supine and immediately after extubation. Ringer's lactate was administered intravenously at a rate of 4 mL/kg/h targeting a mean arterial pressure of >65 mmHg and urine output of >0.5 mL/kg/h. Statistical Analysis Used: Paired t-test was used in this study. Results: There was a fall in IOP soon after induction from baseline which was not significant. Immediately, following intubation, there was a significant rise in IOP. At the end of surgery, though IOP remained high, it was not statistically significant. However, following extubation, IOP rose further and the difference from the baseline became statistically significant. Although there was a moderate increase in peak airway pressure and highest EtCO₂levels during Trendelenburg from baseline values, the differences were statistically insignificant. Conclusion: During robotic pelvic surgeries, adopting a restrictive intravenous fluid strategy with the maintenance of normal end-tidal carbon dioxide levels could abate effects of steep Trendelenburg position on IOP.

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Background: Endotracheal intubation is one of the most common measures in the Intensive Care Unit (ICU) which plays an important role in airway management of the critically ill patients. Aims: The study aimed to evaluate the effects of lignocaine spray on hemodynamic response of endotracheal intubation patients. Settings and Design: This study is a randomized clinical trial on a study population comprising patients admitted to the ICU. Subjects and Methods: The patients were divided into three groups using a permuted block randomization. In Group 1, inhaled nebulized lignocaine 4% (75.0 mg/kg) was sprayed around the patients' epiglottis and larynx. In Group 2, intravenous (IV) lignocaine 2% (75.0/mg/kg) was injected. No lignocaine was prescribed for or administered to the control group. One and four minutes after intubation, the patients' hemodynamic and vital signs were measured. Statistical Analysis Used: Data analysis was run using Stata 13 software through repeated measure ANOVA tests. Results: Although the mean arterial blood pressure (MAP) of Group 1 (inhaled nebulized lignocaine) was smaller than that of Group 2 (IV lignocaine), there was no significant difference between the two groups. Both groups' MAPs were significantly different from that of the control group. As for the average number of pulses, a significant difference was observed between the inhaled and IV lignocaine groups; hence, the average number of pulses in Group 1 (inhalation) was lower than that of Group 2 (IV injection). Conclusion: As blood pressure is considered to be normal under 140/90 and may not entail any hemodynamic complications, it can be concluded that inhaled nebulized lignocaine can control the hemodynamic changes of intubation more effectively than IV lignocaine.

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Introduction: In the past 25 years with the development of various supraglottic airway devices, the armamentarium for airway management has increased. In our study, the laryngeal mask airway (LMA)-ProSeal is compared with the LMA-Classic with respect to as follows: (a) Ease of insertion and number of insertion attempts, (b) Device positional stability and possible oropharyngeal leak, (c) Airway trauma, and (d) Hemodynamic changes; in children aged 3–15 years undergoing elective surgery under general anesthesia, hypothesizing that these would be different. Materials and Methods: Sixty consecutive American Society of Anesthesiologists Physical Status Classes I and II children aged 3–15 years and weighing 5–45 kg undergoing elective surgery in the supine position were randomized for airway management with the LMA-Classic or LMA-ProSeal. Results: Size of the LMA used in both LMA-Classic and LMA-ProSeal was 1.5, 2, and 2.5 and was statistically nonsignificant. There was no difference between LMA-Classic and LMA-ProSeal with regard to ease of insertion, number of attempts for insertion, device positional stability, airway trauma and hemodynamic changes. Conclusions: The complications of usage of the LMA are minimal and similar in both the devices. The LMA-ProSeal has advantages over LMA-classic such as the placement of gastric tube, adequate ventilation, and oxygenation without any gastric distension.

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Background and Aims: Unanticipated difficult intubation or the failed intubation in operating room and in emergency department is an imperative source of anesthesia-related patient's mortality. The aim of this study is to compare the predictive value of upper lip bite test (ULBT) and ratio of height to thyromental distance (RHTMD) with other commonly used preoperative airway assessment tests for predicting difficult intubation in Indian population. Materials and Methods: In this prospective, single-blinded observational study, 260 adult patients of either sex, belonging to American Society of Anesthesiologists physical Status I and II undergoing elective surgical procedure under general anesthesia were included in the study. ULBT, RHTMD, inter-incisor gap, modified Mallampati grade, horizontal length of the mandible, head and neck movements, sternomental distance, and TMD were assessed preoperatively and correlated with Cormack and Lehane's grading during laryngoscopy under anesthesia. Statistical analysis was done by Chi-square and Fisher's exact test. Results: ULBT and RHTMD had highest sensitivity (66.7% and 63.3%), specificity (99.1% and 89.6%), positive predictive value (90.9% and 44.2%), and negative predictive value (96.9% and 95.0%), respectively, when compared to other parameters in predicting difficult airway. Conclusion: ULBT and RHTMD may be used as a simple bedside airway assessment tools for prediction of difficult intubation.

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Background and Aims: Cesarean sections are performed mostly under spinal anesthesia. Shivering is one of the distressing complications. The aim of the study was to compare the efficacy of intravenous (i.v) magnesium sulfate and tramadol with placebo (normal saline) on postspinal shivering in elective cesarean section when used as prophylaxis. Methods: One hundred and thirty-five pregnant women between 18 and 35 years age, belonging to the American Society of Anesthesiologists' physical Status II, undergoing elective cesarean section under spinal anesthesia were enrolled into the study. Patients belonging to Group C (control group, n = 45) received isotonic saline 100 mL i.v, Group T (tramadol group, n = 45) received tramadol 0.5 mg/kg in 100 mL isotonic saline i.v, whereas those in Group M (magnesium sulfate group, n = 45) received magnesium sulfate 30 mg/kg in 100 mL isotonic saline i.v after administering spinal anesthesia. Incidence and grades of shivering were noted. Data were analyzed using one-way ANOVA test and Chi-square test. Results: The incidence of shivering in Group C, Group T, and Group M were 67.5%, 43.9%, and 39%, respectively. The incidence of shivering in Group M and Group T was significantly low when compared to Group C (P = 0.008; P = 0.026), whereas there was no statistically significant difference between Groups T and M (P = 0.654). Conclusion: Magnesium sulfate and tramadol significantly reduce the incidence of shivering compared to placebo when used as prophylaxis in pregnant women undergoing cesarean section under spinal anesthesia. Magnesium sulfate reduces the severity of the shivering.

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Background and Aims: The ideal dose of nalbuphine for brachial plexus block (BPB) is a matter of debate. This study was carried out to evaluate 5 mg or 10 mg of nalbuphine added to 0.375% levobupivacaine, with regard to the duration of analgesia. Our study also sought to assess the onset and duration of sensorimotor blockade, hemodynamic effects, sedation, and adverse effects. Materials and Methods: One hundred adult patients undergoing upper-limb surgeries under supraclavicular BPB were randomly allocated into two groups. Group LN5 received 29 ml of 0.375% levobupivacaine plus 5 mg of nalbuphine diluted in 1 ml of normal saline. Group LN10 received 29 ml of 0.375% levobupivacaine plus 10 mg of nalbuphine diluted in 1 ml of normal saline. Onset and duration of sensorimotor blockade, hemodynamic variables, duration of analgesia, and adverse effects were recorded. The data were analyzed with Students t-test and Chi-square test. Results: Onset of sensory block and motor block was 10.57 ± 3.5 and 17.16 ± 1.3 min, respectively, in Group LN5, while it was 8.64 ± 1.7 and 14.3 ± 1.2 min, respectively, in Group LN10. The duration of analgesia was significantly prolonged in Group LN10 compared to Group LN5 (833.55 ± 141.6 vs. 698.44 ± 138.6 min; P = 0.001). Postoperative visual analog scale value at 24 h was significantly lower in Group LN10 (P < 0.05). Conclusion: A higher dose of nalbuphine in BPB hastens the onset, and prolongs the duration of sensorimotor blockade and analgesia, without any significant side effects.

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Background and Aims: Anesthesia for total abdominal hysterectomies is not only concerned with relieving pain during intraoperative period but also during the postoperative period. We compared clonidine and dexmedetomidine as an adjuvant to levobupivacaine for epidural analgesia with respect to onset and duration of sensory block, duration of analgesia, and adverse effects. Materials and Methods: A total of 80 individuals between the age of 45 and 65 years of American Society of Anesthesiologists (ASA) physical status Classes I and II who underwent total abdominal hysterectomies were randomly allocated into two groups, comprising 40 patients in each group. Group LC received 10 ml of 0.125% levobupivacaine and 2 μg/kg of clonidine while Group LD received 10 ml of 0.125% levobupivacaine and 1 μg/kg of dexmedetomidine through the epidural catheter. Onset of analgesia, time of peak effect, duration of analgesia, cardiorespiratory parameters, side effects, and need of rescue intravenous (IV) analgesics were observed. The data analysis was carried out with Z-test and Chi-square test. Results: The demographic profile and ASA physical classes were comparable between the groups. Group LD had early onset, early peak effect, prolonged duration, and stable cardiorespiratory parameters when compared with Group LC. Less number of patients (42.5%) in Group LD required IV rescue analgesics when compared to Group LC (70%) and was statistically significant. The side effects' profile was also comparable. Conclusion: Dexmedetomidine is a better neuraxial adjuvant compared with clonidine for providing early onset and prolonged postoperative analgesia and stable cardiorespiratory parameters.

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Background: Magnesium sulfate and dexmedetomidine were used as adjuvants to local anesthesia to improve the quality of regional anesthesia. Aims: The aim of this study is to evaluate and compare the effects of magnesium sulfate and dexmedetomidine when added to ropivacaine on the quality of infraclavicular brachial plexus block (BPB). Settings and Design: This was a prospective randomized double-blinded controlled study. Patients and Methods: A total of 105 adult patients undergoing surgery in hands, wrist, and forearm using infraclavicular BPB were randomly assigned into three groups. Ultrasound-guided infraclavicular BPB was performed using 35 ml ropivacaine 0.5% diluted with 4 ml normal saline 0.9%. Magnesium sulfate 150 mg and dexmedetomidine 100 μg were added in the magnesium sulfate group and dexmedetomidine group, respectively. Duration of analgesia, onset times and durations of sensory block (SB) and motor block (MB), patient's satisfaction, and complications were recorded. Statistical Analysis: Statistical software SPSS 16 was used for statistical analysis. Results: Dexmedetomidine and magnesium sulfate provided longer duration of analgesia and lesser consumption of postoperative rescue analgesia than the control group (P = 0. 000); dexmedetomidine provided the longest duration of analgesia versus control and magnesium sulfate groups (P = 0.000). Dexmedetomidine provided the quickest onset times and the longest durations of both SB and MB than control and magnesium sulfate groups (P = 0.000). Dexmedetomidine group had higher incidences of bradycardia and hypotension. Conclusions: Magnesium sulfate or dexmedetomidine is a useful adjuvant to ropivacaine for infraclavicular BPB in lengthening the duration of analgesia. Dexmedetomidine provided quicker onset and longer duration of both SB and MB and longer duration of analgesia with lesser consumption of postoperative rescue analgesia; however, it showed a higher incidence of intraoperative hypotension and bradycardia than magnesium sulfate.

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Background: Awake fiberoptic intubation (AFOI) is the gold standard for the management of predicted difficult airway, and inappropriate sedation is a major cause leading to its failure. Aims: The primary objective was to compare the heart rate (HR) changes that accompany AFOI following sedation with dexmedetomidine and fentanyl. Secondary objectives included comparison of changes in blood pressure, patient comfort, ease of intubation, and degree of sedation. Settings and Designs: This prospective double-blinded randomized study was conducted in a tertiary care institution. Subjects and Methods: Forty patients with anticipated difficult airway requiring AFOI were included in the study. Group A received dexmedetomidine 1 μg/kg whereas Group B received fentanyl 2 μg/kg. After topical anesthesia of the airway, AFOI was performed. Statistical Analysis Used: Fisher's exact test, independent two-sample t-test, and Mann–Whitney U-test were used as applicable. Results: The hemodynamic parameters were comparable in both the groups except at 1 min postintubation when fentanyl group had significantly higher HR. There were lower alertness and muscle tone scores in dexmedetomidine group. Total comfort score was significantly higher in fentanyl group. Though more patients in dexmedetomidine group showed that no reaction to intubation and more patients in fentanyl had slight grimacing, the difference was insignificant. The ease of intubation was similar in both the groups. Conclusion: Though dexmedetomidine1 μg/kg and fentanyl 2 μg/kg premedication results in comparable hemodynamics and ease of intubation, in view of enhanced patient comfort, dexmedetomidine premedication is advantageous in patients with anticipated difficult airway undergoing AFOI.

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Introduction: Spinal anesthesia is a widely used technique providing faster onset with effective and uniformly distributed sensory and motor block. Due to decreased cardiovascular and central nervous system toxicity, levobupivacaine is a good alternative for spinal anesthesia. Dexmedetomidine when used intrathecally is associated with prolonged motor and sensory block, hemodynamic stability, and less requirement of rescue analgesia in 24 h. Materials and Methods: A prospective, randomized study was carried out which included 60 adult patients between the age group of 20 and 65 years of physical status American Society of Anesthesiologists Classes I and II who underwent infraumbilical surgeries. Group L patients received 3 ml (15 mg) of 0.5% isobaric levobupivacaine + 0.3 ml normal saline while Group LD patients received 3 ml (15 mg) of 0.5% isobaric levobupivacaine + 0.3 ml (3 μg) dexmedetomidine. The two groups were compared with respect to the onset and duration of sensory and motor block and hemodynamic stability. Results: The mean duration of sensory block in Group L was 199.50 ± 7.96 min while in Group LD was 340.20 ± 11.78 min. All the differences were statistically highly significant between the two groups (P < 0.001). Mean duration of motor block in Group L and LD was 150.83 ± 9.17 min and 190.20 ± 9.61 min, respectively. Both the differences were highly significant (P < 0.001). Conclusion: It is concluded that Group LD has early-onset and prolonged duration of sensory and motor block and longer duration of postoperative analgesia than Group L.

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Background: Magnesium (Mg) has been evaluated as an adjuvant to local anesthetics for prolongation of postoperative epidural and intrathecal analgesia but not with epidural levobupivacaine in lower abdominal surgeries. Aim of the Study: The aim of the study was to evaluate the preemptive analgesic effect of Mg added to epidural levobupivacaine anesthesia in infraumbilical abdominal surgeries. Settings and Design: This study design was a prospective randomized controlled trial. Patients and Methods: Two groups, each with fifty patients undergoing lower abdominal and pelvic surgeries with epidural anesthesia. Group M received 15 ml of a mixture of 14 ml levobupivacaine 0.5%, 0.5 ml magnesium sulfate 10% (50 mg), and 0.5 ml 0.9 NaCl at induction. Group L received 15 ml of 14 ml levobupivacaine 0.5% and 1 ml 0.9 NaCl at induction. Then, continuous infusion was used as 5 ml/h of the specific mixture of each group till the end of the surgery. Statistical Analysis: Chi-square test, unpaired t-test or Mann–Whitney, and Wilcoxon sign rank test were used. Results: No statistically significant difference between the two groups regarding intraoperative hemodynamics (P > 0.05). Sensory and motor block onset was significantly shorter in Group M (14.5 [±1.51] and 12.42 [±1.69]) compared to Group L (19.86 [±1.39] and 19.34 [±1.62]) (P = 0.001). Group M showed lower visual analog scale (VAS) pain score compared to Group L from the 2^nd to the 5^th h postoperatively. Time for first analgesic dose was longer in Group M (294.98 [±21.67]) compared to Group L (153.96 [±10.04]) (P = 0.001). Conclusions: Preoperative and intraoperative epidural Mg infusion with levobupivacaine resulted in prolonged postoperative analgesia and lower VAS.

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Background: Epidural analgesia has become the standard of care for knee replacement surgeries worldwide. Bupivacaine has been used successfully for many years. Epidural ropivacaine is now being used increasingly and seems to have benefits other than just pain relief, in terms of a better safety profile. Aim: To compare the efficacy of bupivacaine 0.125% (Group B) versus two concentrations of ropivacaine 0.1% (Group R1) and 0.2% (Group R2), in terms of pain scores, requirement of rescue analgesia, related adverse effects, and duration of postoperative (PO) hospital stay. Materials and Methods: A retrospective study was conducted from the acute pain service data of patients who underwent joint replacement surgeries in one or both limbs, over a span of 6 months. Patients were allocated to and analyzed under one of the three groups based on the drug concentration used postoperatively by epidural infusion. Data retrieved were demographic data, daily average visual analog scale (VAS) pain scores, rescue analgesia given, adverse effects, and PO hospital stay days for all three groups. Results: Demographic data were comparable between the three groups. Daily average VAS pain scores on days 1 and 2 were significantly higher in Group R1. Groups B and R2 were comparable. There was significantly more requirement of rescue analgesia in Group R1 on day 1. Day 2 showed no significant difference in rescue analgesic requirement in all three groups. Days of PO hospital stay were significantly higher in Group R1. Adverse effects such as hypotension and delayed motor block were higher in Group B. Conclusion: Ropivacaine 0.2% and bupivacaine 0.125% were equally efficacious in terms of VAS pain scores, rescue analgesic requirement, and duration of PO hospital stay, but ropivacaine had a better safety profile in terms of less hypotension and lesser motor block.

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Context: Laryngoscopy and endotracheal intubation lead to strong sympathetic response which may precipitate arrhythmias, myocardial ischemia and cerebrovascular accidents in patients with preexisting cardiovascular disease. Aims: This study was aimed to compare the effect of dexmedetomidine and esmolol on hemodynamic response to laryngoscopy and endotracheal intubation in patients undergoing elective surgery under general anesthesia. Settings and Design: This was a prospective, randomized controlled double-blinded study. Materials and Methods: A total of ninety patients were selected and randomized into three groups of thirty patients each: Group C received infusion of 20 mL 0.9% normal saline (NS) over 10 min, Group D received infusion of dexmedetomidine 1 μg/kg diluted in 20 mL NS over 10 min, and Group E received infusion of esmolol 1.5 mg/kg diluted in 20 mL NS over 10 min. Three minutes after the completion of infusion, patients were induced with general anesthesia. Baseline parameters such as heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MAP), and rate pressure product (RPP) were recorded before administration of study drugs and at 1, 3, 5, 7, and 10 min after intubation. Statistical Analysis Used: One-way ANOVA was used for comparison among the groups and unpaired t-test was used for comparison within the groups along with Tukey's test for post test analysis. Results: Mean HR, SBP, DBP, MAP, and RPP values remained significantly lower in Group D than that of Group C and Group E at all time intervals up to 10 min after intubation. Conclusions: Both dexmedetomidine and esmolol suppressed the hemodynamic response to intubation when compared to control group, but dexmedetomidine is more effective than esmolol in maintaining hemodynamic stability following laryngoscopy and intubation.

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Background and Aims: This study compared if perianal block using ropivacaine and dexmedetomidine was as good as spinal anesthesia (SA) using bupivacaine (heavy) for closed hemorrhoidectomies. Methods: A prospective randomized study was conducted in sixty patients who underwent closed hemorrhoidectomy. Thirty patients of Group A received SA. Thirty patients in Group B received local perianal block. Patients were evaluated for onset of the block, total pain-free period, and time to ambulation. Patient satisfaction in terms of pain during injection and satisfaction with the anesthesia technique was assessed after 2-week telephonically. Data were statistically analyzed using unpaired t-test for the continuous variables and Fischer's exact test for categorical variables. Results: Onset of anesthesia was significantly earlier in Group B, mean (standard deviation [SD]) value being 3.17 (1.28) min as compared to Group A, 6.24 (4.28) min (P = 0.0004). Total pain-free period (mean [SD]) in minute was longer in Group B, 287 (120) min as compared to Group A, 128 (38) min. Time to ambulation was significantly earlier in Group B, 22.83 (29.32) min as compared to Group A 302 (92.41) min. Pain during injection between the two groups was comparable. However, more patients in Group B (60%) were satisfied with the anesthesia technique as compared to Group A (27.5%). Conclusion: Perianal block for hemorrhoidectomy with ropivacaine 0.2% using dexmedetomidine as an adjuvant is an effective and reliable technique which is as effective as SA. It provides prolonged postoperative analgesia and early ambulation.

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Context: It is a well-known fact that severe pregnancy-induced hypertension (PIH) can be disastrous at times as it can cause a lot of complications to both pregnant women and her baby. Hence, it is always desirable to know the extent of severity by a real-time and easily accessible modality like ultrasound. Aims: The aim of the study was to evaluate the incidence of raised intracranial pressure (ICP) in severe preeclampsia and eclampsia patients using ocular ultrasonography with optic nerve sheath diameter (ONSD) measurement. Settings and Design: This study design was a prospective and clinically controlled blinded observational study. Materials and Methods: After taking necessary permissions from the Institution Ethical Committee, 75 patients were enrolled for the study. However, finally, 25 patients in severe preeclampsia and 24 in eclampsia group were compared with 25 normal term antenatal women. Demographic profiles, hemodynamic parameters, laboratory markers for severity of PIH, and ultrasonographic OSND were measured. Statistical Analysis Used: They were statistically analyzed and compared using one-way ANOVA and Tukey's test. Value of P < 0.05 was considered statistically significant. Results: All the three groups were comparable in terms of age, body weight, gestation age, gestity, and the number of primigravida in each group. There was a significant difference (P < 0.05) in mean levels of hepatic aminotransferase levels and platelet counts between groups. Aspartate transaminase and alanine transaminase levels were much higher in Group II and III as compared to Group I, while platelet levels were lower in study groups indicating increase in severity of PIH. There was also a significant difference for systolic blood pressure and diastolic blood pressure (P < 0.001) as both were significantly higher in study groups. Among severe PIH groups (Group II and III), the difference was comparable. Conclusions: OSND is a surrogate marker for raised ICP in severe PIH patients. It is a rapid, bedside, noninvasive, and readily accessible tool and could be a part of a holistic approach for managing such patients.

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Introduction: This study compares the efficacy in terms of pain relief and complications of intra-articular Botulinum toxin-A (BoNT-A) with intra-articular Triamcinolone versus Triamcinolone alone in the treatment of osteoarthritic knee pain of severe grade. If effective, BoNT-A may help in reducing the long term adverse effects due to prolonged analgesic consumption and reduce/delay requirement of knee replacement surgeries. Materials and Methods: In this prospective study, 30 patients of either sex, aged between 40 to 60 years with physical status ASA classes I or II suffering from knee joint osteoarthritis with knee pain and functional impairment were divided into 2 groups: The OA patients which received Botulinum toxin-A with Triamcinolone (Group A) & OA patients which received only Triamcinolone (Group B). Only patients with advanced OA of the knee; radiographically verified with a Joint space <2 mm were included. The efficacy of pain relief in the 2 groups were compared using Visual analog score (VAS) and Oxford knee Score and followed upto 6 months. Results and Conclusions: On comparing the VAS Score during the follow up period, there was a significant difference between groups A and B upto 3 months. During post treatment follow up, there was significant difference in pain relief as measured by the Oxford Knee score from 4 weeks to 6 months, where Group A patients fared much better in terms of pain relief than group B with a highly significant value of P=<0.001 during the time period of 6 weeks to 6 months. The study shows that the use intra-articular Botulinum toxin-A with steroid is far superior to intra-articular steroid alone in terms of pain relief as well as functional outcome.

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Background: The supraclavicular approach is considered to be the easiest and most effective approach to block the brachial plexus for upper limb surgeries. The classical approach using the anatomical landmark technique was associated with higher failure rates and complications. Ultrasonography (USG) guidance and peripheral nerve stimulator (PNS) have improved the success rates and safety margin. Aims: The aim of the present study is to compare USG with PNS in supraclavicular brachial plexus block for upper limb surgeries with respect to the onset of motor and sensory blockade, total duration of blockade, procedure time, and complications. Settings and Design: Prospective, randomized controlled study. Subject and Methods: Sixty patients aged above 18 years scheduled for elective upper limb surgery were randomly allocated into two groups. Group A patients received supraclavicular brachial plexus block under ultrasound guidance and in Group B patients, PNS was used. In both groups, local anesthetic mixture consisting of 15 ml of 0.5% bupivacaine and 10 ml of 2% lignocaine with 1:200,000 adrenaline were used. Statistical Analysis: Independent t-test used to compare mean between groups; Chi-square test for categorical variables. Results: The procedure time was shorter with USG (11.57 ± 2.75 min) compared to PNS (21.73 ± 4.84). The onset time of sensory block (12.83 ± 3.64 min vs. 16 ± 3.57 min) and onset of motor block (23 ± 4.27 min vs. 27 ± 3.85 min) were significantly shorter in Group A compared to Group B (P < 0.05). The duration of sensory block was significantly prolonged in Group A (8.00 ± 0.891 h) compared to Group B (7.25 ± 1.418 h). None of the patients in either groups developed any complications. Conclusion: The ultrasound-guided supraclavicular brachial plexus block can be done quicker, with a faster onset of sensory and motor block compared to nerve stimulator technique.

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Background: The onset time of neuromuscular blockade is a crucial time associated with the risk of hypoxia and pulmonary aspiration. Various strategies have been undertaken to shorten this onset time. Therefore, we investigated the effects of bolus of 20 ml saline followed by limb elevation after administration of rocuronium in a dose of 0.6 mg/kg to study the onset time. Methodology: Thirty patients were randomly allocated to the bolus saline group or control group. General anesthesia was induced and maintained with fentanyl and propofol. Rocuronium 0.6 mg/kg intravenous (IV) was administered followed by 20 ml saline bolus and limb elevation in the study group compared to administration of 0.6 mg/kg in a running drip only in the control. Onset of neuromuscular block was assessed by acceleromyography at the adductor pollicis muscle with train-of-four stimulation. Results: The lag time was shorter in bolus group (34 s median) than in control group (45 s median), P < 0.017. The onset time was shorter in bolus group (55 s median) than in control group (110 s median), P < 0.001. The T1 recovery to 25% was longer in bolus group (42 min median) than in control group (39 min median) which was statistically not significant. Conclusion: Rocuronium 0.6 mg/kg IV followed by bolus 20 ml saline and concomitant limb elevation resulted in shorter lag time, faster onset of neuromuscular blockade, good intubating conditions without prolonging clinical duration of action when compared to the control.

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Background: The aim is to compare the clinical effect of three different concentrations of levobupivacaine (0.25%, 0.125%, and 0.0625%) on the sensory and motor block characteristics and mode of delivery during epidural labor analgesia. We also studied the pharmacokinetic profile of the three concentrations during labor. Materials and Methods: Sixty pregnant females undergoing normal vaginal delivery under epidural analgesia were divided into three groups according to the concentration of levobupivacaine used. All parturients received an epidural bolus dose of 15 ml of the desired concentration followed by a continuous infusion of the same concentration at 10 mL/h, each combined with fentanyl 2 μg/mL. Sensory block was assessed by the visual analog score (VAS), whereas motor block was evaluated by the Bromage score. Assessments were performed every 5 min in the first 20 min after initiation of epidural analgesia and then at 30 min interval. The incidence of instrumental delivery and cesarean section was also recorded. The total plasma concentrations of levobupivacaine were determined before the start of epidural analgesia, 5 and 10 min after starting the infusion, at infusion stop time, and 3–8 h after infusion termination. Results: The VAS was significantly lower with levobupivacaine concentrations of 0.25% and 0.125% than 0.0625%. Motor block in the form of Bromage score 1 was observed in 39% of parturients receiving levobupivacaine 0.25% of which 43% were converted to cesarean delivery. No motor block was observed with the other two concentrations. Levobupivacaine peak plasma concentrations increased with increasing the concentration of the local anesthetic. There was no difference in other pharmacokinetic parameters between the three groups. Conclusion: levobupivacaine concentration of 0.125% is superior to other concentrations for epidural labor analgesia as it provides adequate analgesia without motor affection which reflects in a lower incidence of instrumental delivery or cesarean section.

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Background: Intraocular pressure (IOP) is increased during laparoscopic surgery with Trendelenburg position and may contribute to deleterious effects on optic nerve in susceptible patients. Aims: The primary objective of this study is to compare the effects of propofol-based total intravenous anesthesia (TIVA) with those of sevoflurane anesthesia on IOP in patients undergoing lower abdominal laparoscopic surgery in Trendelenburg position. Secondary objectives are to compare hemodynamic changes, mean arterial pressure (MAP), end-tidal CO₂, and peak inspiratory pressure changes. Materials and Methods: Sixty patients with physical status American Society of Anesthesiologists classes I and II were randomly allocated in two groups: Group A (propofol) and Group B (sevoflurane). IOP along with other parameters was measured at seven points including baseline (T0), 5 min after induction (T1), 5 min after CO₂pneumoperitoneum in supine position (T2), 30 min after CO₂pneumoperitoneum with Trendelenburg position (T3), 5 min after returning to supine position (T4), 5 min after CO₂desufflation (T5), and 5 min after extubation (T6). Results: The change in IOP was different between the two groups. Maximum rise in IOP was seen at T3, and mean ± standard deviation IOP was 15.5 ± 0.9 mmHg and 19.8 ± 1.2 mmHg in Group A and Group B, respectively (P < 0.01). In Group A (propofol), IOP remained almost equal to the baseline value at T3 and the IOP difference was 0.3 ± 0.9 mmHg less than baseline (statistically insignificant, P > 0.05), while in Group B (sevoflurane), IOP increased significantly at T3 and the difference was 4.0 ± 1.2 mmHg (P < 0.001). The IOP was significantly greater (P < 0.01) from T2 to T6 in sevoflurane group than propofol group. Conclusion: Propofol-based TIVA is more effective than inhalational anesthesia with sevoflurane in attenuating the increase in IOP during laparoscopic surgery requiring CO₂pneumoperitoneum with Trendelenburg position.

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Background: Establishing an intravenous access is indispensable for safe administration of anesthesia. Most of the times, it is executed without any analgesia although the pain associated with this procedure is quite agonizing to the patients. Aims: This study aims to evaluate the role of 3 different nonpharmacological measures such as Valsalva maneuver, flash of light, and distraction method in attenuation of pain during venous cannulation. Design: A clinical randomized controlled study. Materials and Methods: Two hundred patients of either sex, aged between 18 and 65 years, posted for elective surgery were enrolled in this study. Patients were randomly allocated into four groups, Group C-control, Group V (valsalva) - blew into sphygmomanometer raising the mercury column up to 30 mm of Hg, Group D (distraction) - pressed a rubber ball and Group L (light) - photographed with a flash of light before venous cannulation. During the process of cannulation, patients were observed and questioned, and pain was graded using a 4- point scale. After the cannulation, pain during the procedure was also assessed using visual analog scale (VAS) score. Data analysis was done using SPSS statistical package version 17. Results: A significant reduction in the incidence of pain was noted in distraction group 36% as compared to 44% in Group L, 46% in Group V, and 100% in the control group. The severity of pain as assessed by 4-point score was significantly lowest in Group D (0.26 ± 0.53) as compared to other three groups (Group V and L = 0.54 ± 0.16, Group C = 1.64 ± 0.6, P < 0.001). Mean VAS score was significantly low in Group D (0.6 ± 1.11) and Group L (0.54 ± 1.06) as compared to Group V (1.26 ± 1.76) and Group C (5.0 ± 1.21, P < 0.001). Conclusion: We conclude that distraction can be considered as a diligent, reasonable, and simple method to attenuate procedural pain during peripheral venous cannulation.

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Background: Since the development of laryngeal mask airway (LMA) by Dr. Brain, it is extensively used for airway management; satisfactory insertion of LMA requires administration of an induction agent and suppression of airway reflexes. Among intravenous agents, propofol has been the drug of choice in view of better safety profile, relaxation and depression of upper airway reflexes. Sevoflurane on the other hand, with pleasant odor, nonirritating to the airways and with bronchodilator property are best among the volatile induction agents. While it is true both propofol and sevoflurane have their merits, still both have certain limitations. We aimed to compare the quality and ease of LMA insertion, hemodynamic changes, and complications with inhalation of 8% sevoflurane vital capacity breath and propofol. Materials and Methods: A prospective randomized study of 100 American Society of Anaesthesiologists' Class I and II patients was conducted equal distribution among two groups with 50 each undergoing gynecological procedures under general anesthesia. Group P received injection propofol and Group S received sevoflurane. At the end point of induction, the LMA insertion was attempted. Scoring systems were used to grade the conditions for insertion of the LMA. Induction characteristics, hemodynamic changes, and complications were assessed. Results: Sevoflurane took a longer time for induction and jaw relaxation than propofol. There was no statistically significant difference between the two groups, with respect to LMA insertion time, and conditions. Apnea time was more in propofol group. Fall in heart rate and mean blood pressure was more in propofol. Conclusion: Propofol is associated with faster induction while sevoflurane is associated with good hemodynamic stability.

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Context: Optimization and providing excellent quality of postoperative analgesia after total abdominal hysterectomy is a determinant factor of better clinical outcome, increases patient satisfaction, and allows early mobilization of the patient. Aims: The aim of this study is to compare the postoperative analgesic efficacy of wound site infiltration (WSI) and ultrasound-guided transversus abdominis plane block (TAPB) with 0.5% ropivacaine in lower abdominal surgeries under spinal anesthesia. Settings and Design: This was a randomized controlled study. Subjects and Methods: One hundred and ten patients undergoing lower abdominal surgeries were randomly allocated to two groups (WSI and TAP) of 55 patients in each. At the end of the surgical procedure, 2.5 mg/kg of the drug ropivacaine 0.5% was administered by an anesthesiologist through either of the routes of study. Visual analog score (VAS) assessment was done at every 30 min, for 1½ h, every 2 for 24 h postoperatively. Injection diclofenac sodium 75 mg intramuscularly was given whenever VAS was >3 as rescue analgesic. Statistical Analysis Used: Epi Info 7.0 version software for Windows was used. All analyses were performed using Kolmogorov–Smirnov test. Mann–Whitney test was applied to detect the difference between the two groups. P < 0.05 was considered statistically significant. Results: Postoperative VAS scores in Group TAP were significantly reduced at 30 min, 1^st h, 1 h 30 min, 2, 4, 6, 8, 10, 12, 18, and 24 h (P < 0.001). The total doses of rescue analgesics administered were also low in the Group TAP (1.41 ± 0.538) with P < 0.0001 in comparison to Group WSI (2.24 ± 0.637) with P < 0.001. Conclusions: The quality of analgesia along with lesser rescue analgesic requirement and their side effects makes the TAPB, a good and safer option for lower abdominal gynecological surgeries. Both WSI and USG TAPB are effective in providing postoperative analgesia as a part of multimodal analgesia in lower abdominal surgeries. However, in our study the quality of analgesia along with lesser rescue analgesic requirement and their side effects makes the TAPB, a good and safer option for lower abdominal gynecological surgeries.

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Background: Several studies have been conducted in search of appropriate drugs to attenuate hemodynamic responses in laparoscopic cholecystectomy, but till date, no such study has been conducted on patients undergoing laparoscopic nephrectomy. Aim: The study was designed to assess the effect of esmolol and diltiazem infusions on hemodynamic changes during routine laparoscopic transperitoneal simple nephrectomy. Settings and Design: A prospective double-blinded randomized control trial. Subjects and Methods: A total of 120 nonhypertensive patients of the American Society of Anesthesiologists physical Status I and II aged 20–60 years about to undergo laparoscopic nephrectomy were enrolled for the study after obtaining Institute Ethical committee approval. The patients were randomly allocated to one of the three groups. Group I (control group) received 10 ml normal saline intravenously (i.v.) before induction of anesthesia, followed by continuous infusion 10–20 ml/h. Group II (esmolol group) received i.v. esmolol 1 mg/kg diluted in 10 ml similarly, followed by continuous infusion of 10–20 ml/h (5–10 μg/kg/min). Group III (diltiazem group) received i.v. diltiazem 0.2 mg/kg diluted in 10 ml before induction of anesthesia, followed by continuous infusion at 10–20 ml/h (0.08–1.25) μg/kg/min. After completion of surgery, all the infusions were stopped. Data recording were done for changes in hemodynamics throughout the surgery. Statistical Analysis: was done using Chi-square test for categorical data and one-way ANOVA for continuous data. Tukey (“honestly significant difference”) post hoc test was applied for intra- and inter-group comparison in cases where ANOVA was significant. P < 0.05 is considered statistically significant. Results: All hemodynamic data: Heart rate (HR), systolic, diastolic, and mean arterial pressure were observed to be significantly higher (P < 0.001) from baseline in control group at the time of creation of pneumoperitoneum, till 20 min thereafter. The values were comparable to baseline in both esmolol and diltiazem group. On intergroup comparison, the patients in esmolol group had significantly lower HR and blood pressures than in diltiazem group at the creation of pneumoperitoneum and at extubation (P < 0.05). Mean dose of esmolol and diltiazem used were 7.25 ± 1.33 μg/kg/min and 1.14 ± 0.77 μg/kg/min, respectively. Conclusion: Both esmolol and diltiazem infusion provide stable intraoperative hemodynamics and protection against stress response triggered by pneumoperitoneum in patients undergoing laparoscopic transperitoneal nephrectomy.

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Introduction: Colonoscopy is a mildly painful procedure requiring conscious sedation. Though propofol is a widely used anesthetic agent in day-care procedures due to its rapid onset and quick recovery has a drawback of requiring resuscitation maneuvers more often than the conventional methods. Dexmedetomidine, a newly introduced, highly selective α₂-adrenergic receptor agonist possessing hypnotic, sedative, anxiolytic, sympatholytic, and analgesic properties with impressive safety margin, needs to be explored for use in conscious sedation for colonoscopy procedure among South Indian population. Materials and Methods: A prospective randomized comparative study was conducted on patients aged between 25 and 60 years with the American Society of Anesthesiologist physical status classes I and II posted for colonoscopy under monitored anesthesia care. Study group was randomly divided into two groups and administered propofol and dexmedetomidine. The primary outcome variable was assessments of sedation scores between the two groups. Secondary outcome variables were pain score assessments, hemodynamic comparisons, and adverse events among the two groups. Appropriate statistical tests were applied to compare the findings. Results: After comparisons between the two groups, we found that patients on dexmedetomidine had similar sedation score as that of patients on propofol. However, there was a significantly higher incidence of systemic hypotension. Requirement of rescue analgesia and adverse events and other hemodynamic fluctuation were similar in both the groups. Conclusion: We conclude that dexmedetomidine has similar efficacy as propofol for conscious sedation required during colonoscopy. Occurrence of systolic hypotension was, however, significantly more among the group receiving dexmedetomidine.

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Carotid endarterectomy (CEA) has shown a significant benefit in preventing ipsilateral stroke when it is compared to conservative management. Surgical morbidity and mortality must be kept to a minimum to achieve this benefit. Neurological status of the CEA patients can be monitored easily during regional anesthesia depending on the awake testing (neurocognitive assessment) method of the CEA patients. In addition, specific parameters can help us to monitor and to predict the neurological status of the CEA patients during the procedures such as regional cerebral oxygen saturation (rSO₂) and middle cerebral artery velocity (MCAv) changes. We conducted a computerized literature search involving humans, published in English until December 2017, and indexed through Medical Databases; MEDLINE/PubMed, EMBASE, and Web of Science. We reviewed articles performed for prospective and other types of studies related to CEA procedures and techniques which can predict patient's status during the procedure. Searching relevant articles and discussing the results to allow meaningful rate comparison, and to conclude a result view which benefits the CEA patients and the medical staff during the CEA procedures. In total, studies observed cerebral rSO₂and MCAv have significant value during CEA procedures. Patients with neurological symptoms during the procedures showed changes of cerebral rSO₂and MCAv more than the patients without neurological symptoms. Mentioned parameters (cerebral rSO₂and MCAv) showed significant increasing right after the procedure. Mostly, CEA surgeries under local anesthesia were observed, for monitoring patients' consciousness status and comparing it to patients who undergo general anesthesia, to view the reliability of these techniques during CEA procedures, and to predict and avoid intraoperative neurological symptoms.

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