Comparison of Two Different Doses of Nalbuphine With Isobaric Ropivacaine in Patients Undergoing Lower Segment Cesarean Section Under Subarachnoid Block: A Randomized Controlled Trial.

INTRODUCTION: Obstetric analgesia and anesthesia is a challenge in itself. It requires an understanding of the physiological changes during pregnancy and labor and the effect of anesthetic agents on the fetus and newborn. Because neuraxial techniques provide superior analgesia and materno-fetal benefits, their use have increased significantly over the past three decades or so. A combination of local anesthetics like ropivacaine with opioids like nalbuphine has been shown to have additive beneficial effects in subarachnoid block (SAB) in lower segment cesarean section (LSCS). However, the optimal dose combination of ropivacaine and nalbuphine to maximize their benefits and minimize side effects remains to be established. Our study has compared the clinical efficacy and safety of 0.75% isobaric ropivacaine (15 mg) with two different doses of nalbuphine (0.4 mg and 0.6 mg) when given intrathecally for LSCS in terms of quality of sensory and motor blocks, hemodynamic parameters, duration of effective analgesia, Apgar score in newborn, and associated side effects. METHOD AND MATERIALS: In this prospective, randomized, double-blind study, a total of 69 parturients between the age of 20-45 years, belonging to American Society of Anesthesiologists (ASA) grade I and II, undergoing cesarean section under SAB were evaluated. Patients were randomly allocated into three groups of 23 each by using the draw-of-lots technique. The patient and the observer were kept blinded as to which dose of drug (intrathecal) was being given to the patient. Patients in Group A received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.3 ml normal saline; patients in Group B received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.4 mg of nalbuphine (0.2 ml) + 0.1 ml normal saline; patients in Group C received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.6 mg of nalbuphine (0.3 ml). The total volume of drug solution in all three groups was 2.3 ml. RESULT:  We found that the time to onset of sensory block was shortest in Group A (5.87±1.290 minutes) followed by Group C (6.00±1.087 minutes) and Group B (6.17±1.696 minutes); time to two-segment regression of sensory block was longest in Group C (101.74±8.996 minutes) followed by Group B (85.87±15.348 minutes) and Group A (65.00±7.071 minutes); duration of effective analgesia was longest in Group C (206.09±18.766 minutes) followed by Group B (183.91±15.880 minutes) and Group A (121.74±11.833 minutes); and time from SAB to complete regression of motor block was longest in Group C (216.52±15.553 minutes) followed by Group B (203.48±20.138 minutes) and Group A (174.78±14.731 minutes). Side effects were comparable among all three groups. CONCLUSION: The optimal dose combination in SAB for cesarean section was 15 mg of 0.75% isobaric ropivacaine + 0.6 mg nalbuphine, with minimal side effects.

Comparison of Normal Saline and Alkalinized 2% Lignocaine to Reduce Emergence Phenomenon and Post-Intubation Morbidities: A Prospective, Double-Blind, Randomized Study.

BACKGROUND:  Endotracheal intubation for airway management in general anesthesia is associated with post-intubation morbidities due to tracheal mucosa injury caused by endotracheal tube (ETT) cuff. Nitrous oxide (N2O) diffuses into tracheal tube cuffs filled with air. The rate of diffusion of N2O through the membrane is proportional to its concentration gradient. High-volume low-pressure cuffs expand with only a slight increase in pressure until fully inflated. At this point, owing to the inelasticity of the material, the cuff pressure rises rapidly. This increased pressure can damage the tracheal mucosa. This phenomenon can be avoided, if we inflate the cuff with either a liquid or a gas mixture identical to the inspired gas and monitor the cuff pressure and volume at regular intervals. When lignocaine is used to inflate the ETT cuff, it diffuses to the underlying tracheal mucosa. Thus reducing local irritation and inflammation of the airway through its local anesthetic action. Alkalinization of lignocaine increases its rate of diffusion across the ETT cuff. It also reduces the dose of local anesthetic required to achieve the desired result. AIMS AND OBJECTIVES:  We sought to determine the benefits of filling the ETT cuff with alkalinized lignocaine 2% over normal saline, to prevent ETT-induced emergence phenomenon and reduce the incidence of post-intubation morbidities like sore throat, hoarseness, and nausea. MATERIAL AND METHODS: This prospective, randomized, double-blind, and comparative study was done at a multispecialty hospital. A total of 120 individuals of American Society of Anesthesiologists (ASA) physical status 1 and 2, posted for surgery under general anesthesia, were randomly selected and divided into two groups: alkalinized 2% lignocaine group (group L) and normal saline group (group S). After induction of general anesthesia, the airway was secured with appropriate-sized ETT. The ETT cuff was inflated with either of the study media. Continuous cuff pressure monitoring was done to keep cuff pressure below 30 centimeters of water (cm of H2O), at all times. At extubation, the response was evaluated in terms of percentage change in heart rate (HR) and blood pressure from baseline, coughing, bucking, and restlessness. All the surgeries lasted more than two hours. Post-operatively, the patients were evaluated for sore throat and hoarseness, at regular intervals of up to 24 hours. OBSERVATIONS AND RESULTS: ETT cuff pressure was initially less in group S, which rose to a significantly higher level at extubation, compared to group L (p <0.001). At extubation, there was a significant increase in HR and systolic blood pressure (SBP) from baseline, in group S than in group L (p <0.001 and p=0.001, respectively). The incidence of cough and restlessness was less in group L, compared to group S (p<0.001 and p=0.002, respectively). Mean extubation time and emergence time was more in group S than in group L (p<0.001). Post-operatively, the incidence and severity of sore throat were significantly higher in group S than in group L (p<0.001). Meanwhile, the incidence of hoarseness and nausea was comparable in the two groups. CONCLUSION:  Continuous ETT cuff pressure monitoring helps to keep cuff pressure below tracheal mucosa capillary occlusion pressure. Filling the ETT cuff with alkalinized lignocaine further reduces extubation response and post-intubation morbidities.

Acute Transverse Myelitis in Pregnancy: The Use of ProSeal Laryngeal Mask Airway Without Curarization for Emergency Cesarean Section.

Transverse myelitis is a rare inflammatory neurological disorder of the spinal cord that damages the myelin covering the spinal cord and thus produces sensory, motor, and autonomic symptoms. A 26-year-old primigravida of 40 weeks gestation presented to the obstetric emergency of our hospital with complaints of weakness in both lower limbs and inability to walk for four days. A diagnosis of acute transverse myelitis was made, and due to fetal distress and arrest of labor in the second stage, an emergency cesarean section was planned. Considering the risks associated with the neuraxial technique and muscle relaxants, cesarean section was planned under general anesthesia and was successfully done with ProSeal laryngeal mask airway (LMA) using propofol and sevoflurane without muscle relaxant.

Raynaud's Phenomenon During Non-operating Room Anesthesia: A Case Report.

Non-operating room anesthesia challenges the anesthesiologist to deliver the same high-quality care as in the operating room. Amid the perplexity of the unfamiliar environment, scarcity of ancillary staff, and physical limitations, a distressing signal from pulse oximetry can cause a scare. We present a case of Raynaud's phenomenon in a patient posted for cystogastrostomy in the endoscopic retrograde cholangiopancreatography suite. The patient had pulmonary complications, a left-sided pleural effusion with underlying lung collapse related to pancreatitis; thus, a non-reassuring reading from pulse oximetry caused alarm. The patient had sinus tachycardia, with a heart rate of 104 beats per minute, and a blood pressure of 100/60 mmHg. We provided supplemental oxygen to the patient while planning for emergency tracheal intubation because of a low peripheral oxygen saturation of 87%. The patient was conscious during this time, prompting us to check the pulse oximeter probe. We then noticed that patient's digits had turned blue/pale. A sudden attack of Raynaud's in the perioperative period can mislead the caregivers, and an unwarranted state of panic can ensue.