The efficacy and safety of epidural dexmedetomidine and clonidine with bupivacaine in patients undergoing lower limb orthopedic surgeries.

BACKGROUND AND AIMS: Alpha (α-2) adrenergic agonists have both analgesic and sedative properties when used as an adjuvant in regional anesthesia. A prospective randomized double-blind study was carried out to evaluate the efficacy of epidural route and to compare the efficacy and clinical profile of dexmedetomidine and clonidine as an adjuvant to bupivacaine with special emphasis on their quality of analgesia, sedation and the ability to provide the smooth intra-operative and postoperative course. MATERIAL AND METHODS: The study was conducted in prospective, randomized and double-blind manner. It included 60 American Society of Anesthesiologists Class I and II patients undergoing lower limb surgery under epidural anesthesia. Patients were randomly divided into Group A receiving 0.5% isobaric bupivacaine 15 ml with dexmedetomidine 1 µg/kg and Group B receiving 0.5% isobaric bupivacaine 15 ml with clonidine 2 µg/kg epidurally. Onset and duration of sensory and motor blocks, duration of analgesia, sedation, and adverse effects were assessed. RESULTS: Demographic data, surgical characteristics cardio-respiratory parameters, side-effect profile were comparable and statistically not significant in both the groups. However, sedation scores with dexmedetomidine were better than clonidine and turned out to be statistically significant. The onset times for sensory and motor blocks were significantly shorter in Group A as compared to Group B. The duration of analgesia and motor block was significantly longer in A Group as compared to Group B. CONCLUSION: Dexmedetomidine is a superior neuraxial adjuvant to bupivacaine when compared to clonidine for early onset of analgesia, superior intra-operative analgesia, stable cardio-respiratory parameters, prolonged postoperative analgesia and providing patient comfort.

Comparison of dexmedetomidine-propofol versus fentanyl-propofol for insertion of laryngeal mask airway.

BACKGROUND AND AIMS: Laryngeal mask airway (LMA) insertion requires anesthesia and suppression of airway reflexes. In search of an optimal drug, we compared dexmedetomidine and fentanyl, in combination with propofol for insertion of LMA. MATERIAL AND METHODS: This study was a prospective double blind randomized study. Eighty patients of ASA class 1&2 were randomly divided into two groups of 40 each. Group D received dexmedetomidine 1 mcg/kg and group F received fentanyl 1 mcg/kg intravenously (IV) over 2 minutes. For induction, propofol 2mg/kg was given IV and 90 seconds later LMA was inserted. We observed apnea time, heart rate, respiratory rate, non invasive blood pressure and oxygen saturation before induction, 30 seconds after induction, 1, 3, 5, 10 and 15 minutes after insertion of LMA. Patient's response to LMA insertion like coughing, gagging or any movement were noted and scored. Statistical analysis of data was done using student t test for parametric data, Chi-square test for non parametric data and SPSS 15.0 for windows software. RESULTS: 37 (92.5%) patients of group D and 35 (87.5%) patients of group F had LMA insertion score of <2 and 5 (12.5%) patients of group F had score >2. Adverse events to insertion of LMA and hemodynamic variables were comparable in both the groups. Number of patients developing apnoea was larger and apnoea times were longer in group F compared to group D. When compared to group F, group D showed an increased respiratory rate. CONCLUSION: Dexmedetomidine can be a comparable alternative to fentanyl as an adjuvant to propofol for providing optimum insertion conditions for LMA and preservation of respiration.

Morphine Versus Loperamide with Intrasite Gel in the Treatment of Painful Dermal Ulcers: A Randomized, Crossover Study.

BACKGROUND: Topical morphine along with intrasite gel has been proven to be a simple and effective method to relieve pain. However, morphine is still not freely available in developing countries due to drug restrictions and stringent laws governing it. Loperamide has been reported to relieve pain caused by stomatitis effectively when given topically. Loperamide, being an mu receptor agonist with no systemic absorption, can serve a dual purpose here. Also loperamide being freely available as an over-the-counter drug can be a surrogate drug for topical application. OBJECTIVES: The primary aim was to compare the efficacy of loperamide and morphine in treating pain when applied topically along with intrasite gel. STUDY DESIGN: Adult patients with healthy wounds with pain on Numeric Rating Scale (NRS-11) greater than 5 with no systemic comorbid illness were divided randomly into 2 groups - group morphine or group loperamide - for 24 hours followed by a 1-day washout and crossover in the other group for 24 hours. Pain was assessed once every day. SETTING: Medical college and hospital. METHODS: The parameters assessed included: (1) characteristics of the ulcer; (2) pain was assessed by NRS-11 at 12-hour intervals for a period of 72 hours; and (3) patient satisfaction. Statistical analysis used repeated measures analysis of variance to measure change in mean NRS-11 within each group. Analysis of covariance was used to compare the mean change in NRS-11 in the 2 groups. RESULTS: Morphine and loperamide were equivocal in pain relief after 12 and 24 hours (P = 0.400 and P = 0.753); however, the patient satisfaction scores were better in the morphine group. LIMITATIONS: The earlier studies performed used injectable forms of morphine, for the sake of comparison, we used powdered morphine and powdered Loperamide diluted with saline. Confounding variables include ulcer size and aetiology, which can be a source of bias. The ulcer size was not standardized due to the paucity of sample to study. Equianalgesic doses of loperamide and morphine could not be found even after an extensive literature search. The loperamide dose used in our case was equal to the dose used orally since the same dose appears effective across a range of oral opioid analgesics. The morphine dose was standardized as 10 mg based on a mixture previously used to treat pain due to epidermolysis bullosa. CONCLUSIONS: Topical loperamide can be an efficacious and novel intervention to treat painful ulcers while avoiding systemic effects.

Comparative evaluation of anaesthetic efficacy and haemodynamic effects of a combination of isobaric bupivacaine with buprenorphine vs. isobaric levobupivacaine with buprenorphine for spinal anaesthesia - A double blinded randomised clinical trial.

BACKGROUND AND AIMS: Bupivacaine is the most frequently used local anaesthetic for spinal anaesthesia, however, use of levobupivacaine in clinical practice has advanced recently. This study aimed to compare the anaesthetic potency and haemodynamic effects of intrathecal bupivacaine with buprenorphine versus levobupivacaine with buprenorphine in infraumbilical surgeries. METHODS: This prospective randomised double blind study was conducted in seventy patients aged 18-65 years, American Society of Anesthesiologists grade I-II, scheduled for lower abdominal and lower limb surgery under spinal anaesthesia. The patients either received 0.5% isobaric racemic bupivacaine 3 ml with 2 µg/kg of buprenorphine (Group B) or 0.5% isobaric levobupivacaine 3 ml with 2 µg/kg of buprenorphine (Group L). The time for onset of sensory block between the two groups was the priomary end-point. Other measurements included haemodynamic variables, sensory and motor blockade characteristics, postoperative analgesia, and complications in the first 24 h. RESULTS: There was no significant difference in the onset of sensory block between the two groups. Sensory and motor blockade characteristics were similar between the two groups. However, there was significant fall in the heart rate at 5 min in Group B compared to Group L. There was statistically significant fall in systolic blood pressure in group B compared to Group L from 5 min up to 60 min and fall in diastolic blood pressure from 10 min to 45 min. CONCLUSION: Our study showed that onset of sensory block is similar between isobaric levobupivacaine with buprenorphine 37 38 and isobaric bupivacaine with buprenorphine.

Comparison between the Baska Mask® and I-Gel for Minor Surgical Procedures Under General Anaesthesia.

OBJECTIVE: Minor surgical procedures under general anaesthesia require a patent airway without the use of muscle relaxant. Supraglottic airway devices have been widely used for airway management. A study was undertaken to compare first-time insertion success rate, insertion time, sealing pressure and complications between the Baska® mask and I-gel. METHODS: After approval from the institutional ethical committee, a randomised single-blinded study was conducted on 50 American Society of Anesthesiologists' physical status I and II female patients aged 18-40 years who underwent minor surgical procedures under general anaesthesia. Patients were randomly categorized into two groups of 25 each; group Baska® mask and group I-gel, and the first-time success rate, mean insertion time and sealing pressure were measured. The results were analysed using unpaired t-test, Mann-Whitney U test, Chi-square test and ANOVA. A p value <0.05 was considered to be statistically significant. RESULTS: The first-time insertion success rate of the Baska® mask was 21/24 (88%) when compared with the I-gel, which was 23/25 (92%) (p=0.585). The insertion time of the Baska® mask was 14.9±6.2 s, whereas that of the I-gel was 14.7±4.4 s (p=0.877). The mean sealing pressure of the Baska® mask was significantly higher when compared with the I-gel (28.9±3.5 vs. 25.9±2.5 cmH2O) (p=0.001). CONCLUSION: The Baska® mask had a similar first-time insertion success rate and insertion time as the I-gel. The sealing pressure of the Baska® mask was significantly greater than that of the I-gel. Both devices had complications that were comparable.

Correlation between Weight of the Baby and the Level of Sensory Blockade in Spinal Anaesthesia for Caesarean Section: An Observational Study.

BACKGROUND: The spread of local anaesthetics during spinal anaesthesia is affected by various factors and can be unpredictable especially in parturients undergoing caesarean section. Factors like abdominal girth, symphysis fundal height etc have to studied to know their impact on level of sensory blockade. We hypothesized a study to find any correlation between weight of the baby and the level of sensory blockade. METHODS: 46 parturients posted for elective caesarean section belonging to American Society of Anaesthesiologists (ASA) physical status 1 and 2 were included in the study. Maternal height and weight were noted down before entering operation theatre. All patients were instituted subarachnoid block with 2 cc of 0.5% of hyperbaric bupivacaine in sitting position. Level of sensory blockade was assessed with pin prick along midline of the patient every min till 5th minute and 5 minutes till 15th minute. The birth weight of baby was recorded soon after delivery. RESULTS: The weight of the baby and height of the mother were correlated with the sensory blockade of T4. The number of babies weighing more than 3.5 kgs were 3 in our study out of which 2 babies were associated with maximum sensory blockade at 15th minute. It amounts to 66.7% when compared with 14.7% in babies weighing 2.5 to 3.5 kgs which is suggestive of significance ('P' value of 0.093). CONCLUSION: There is no statistically significant correlation between weight of the baby and the level of sensory blockade.

Comparison of Prophylactic Intravenous Magnesium Sulfate with Tramadol for Postspinal Shivering in Elective Cesarean Section: A Placebo Controlled Randomized Double-blind Pilot Study.

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.

Comparison of Epidural Clonidine and Dexmedetomidine for Perioperative Analgesia in Combined Spinal Epidural Anesthesia with Intrathecal Levobupivacaine: A Randomized Controlled Double-blind Study.

BACKGROUND: Epidural administrations of α2 agonists are being used as adjuvants as they lead to anxiolysis, sedation, analgesia, and hypnosis. AIM: This study aims to evaluate the analgesic effects of epidural α2 agonists-dexmedetomidine and clonidine in conjunction with intrathecal levobupivacaine in combined spinal epidural anesthesia (CSEA). METHODS: A prospective, randomized controlled study was done to assess and compare the efficacy and clinical profile of two α2 adrenergic agonists, clonidine, and dexmedetomidine administered epidurally in combination with intrathecal levobupivacaine in CSEA. The study was conducted for 1 year. Sixty adult patients physical status Class I and II undergoing below umbilical surgeries under CSEA were included in the study after a valid consent. Patients were randomly assigned into two groups, to receive either epidural dexmedetomidine (1.5 µg/kg) or clonidine (2 µg/kg) in 10 ml normal saline along with 0.5% isobaric levobupivacaine 15 mg (3 ml). Block characteristics, ability to provide sedation, duration, and quality of analgesia and side effects were studied and compared between the groups. RESULTS: The characteristics of intraoperative block were comparable among two groups. As compared to clonidine, dexmedetomidine provided a better sedation and prolonged analgesia, evidenced by the distribution of visual analog scale scores and requirement rescue analgesic among two groups. The side effect profile of the two drugs was comparable. CONCLUSION: Dexmedetomidine at 1.5 µg/kg epidurally with intrathecal levobupivacaine is a better adjuvant compared to clonidine at 2 µg/kg epidurally in CSEA because of better sedation, prolonged analgesia, and safe side-effect profile.

Comparison of the efficacy of lornoxicam and fentanyl in attenuating the hemodynamic response to laryngoscopy and intubation.

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

Epidural anesthesia for cesarean section in a primigravida woman with Ebstein's anomaly with recurrent supraventricular tachycardia.

Ebstein's anomaly is an uncommon congenital heart defect with an extremely variable natural history due to a wide spectrum of pathological features. We report on the anesthetic management of a 24-year-old primigravida woman with Ebstein's anomaly with recurrent supraventricular tachycardia for emergency cesarean section.

Pheochromocytoma an adrenaline addict - a case report.

Pheochromocytomas are rare catecholamine secreting neuroendocrine tumours arising from chromaffin cells of the sympathetic nervous system in the adrenal medulla or extra-adrenal paraganglia. A 20-years-old female presented with paroxysms of abdominal pain, palpitation, sweating and headache since last 2 years. Pheochromocytoma was confirmed by 24 hour urinary catecholamine level and CT of abdomen. After three weeks of preparation, tumour was excised. The following discussion outlines current approaches to preoperative, intraoperative and postoperative anaesthetic management of patients suffering from pheochromocytoma.

Parkinson's disease and anaesthesia.

Parkinson's disease (PD), one of the most common disabling neurological diseases, affects about 1% of the population over 60 years of age. It is a degenerative disease of the central nervous system caused by the loss of dopaminergic fibers in basal ganglia of the brain. PD is an important cause of perioperative morbidity and with an increasingly elderly population, it is being encountered with greater frequency in surgical patients. Particular anaesthetic problems in PD include old age, antiparkinsonian drug interaction with anaesthetic drugs and various alterations in the respiratory, cardiovascular, autonomic, and neurological systems. This brief review focuses on the preoperative, intraoperative, and postoperative anesthetic management of PD and gives a brief account of intraoperative exacerbation of PDs and anesthetic management of stereotactic pallidotomy.

Tracheal intubation without neuromuscular block in children.

Endotracheal intubation has been performed during the administration of Propofol anaesthesia without neuromuscular blockade. In the study, we have assessed tracheal intubating conditions and haemodynamic responses in children aged 4 to12 years by using combination of either Fentanyl and Propofol; or Propofol and a neuromuscular blocker, suxamethonium. Intubating conditions were assessed on a 1-4 scale based on ease of laryngoscopy, position of vocal cords, degree of coughing and jaw relaxation. Tracheal intubation was successful in 95% of patients receiving Fentanyl-Propofol and 100% of patients receiving Propofol-suxamethonium. Fentanyl-Propofol provided better haemodynamic stability than Propofol-suxamethonium. We conclude that Propofol-Fentanyl combination could be a useful alternative technique for tracheal intubation when neuromuscular blocking drugs are contraindicated or need to be avoided.