10-degree reverse Trendelenburg position on hemodynamic parameters and block characteristics in unilateral spinal anesthesia in below knee orthopedic surgeries - can head up position do the trick?

Unilateral spinal anesthesia (USpA) is a technique used to restrict the effect of the spinal block on the operative side. 10-15 degrees reverse Trendelenburg position has been used to control the height of the spinal block using hyperbaric drugs. We aimed to study the effect of the 10-degree reverse Trendelenburg position on the quality of block and hemodynamic stability in unilateral spinal anesthesia in this hospital-based, double-blind, randomized clinical trial. 60 patients of both sexes between 20-60 years of age, undergoing below-knee orthopedic surgeries, were randomized into 2 groups. In both groups, spinal anesthesia was given with 2 mL bupivacaine heavy (0.5%), and the lateral position was maintained for 10 mins. Group 2 patients were kept in a 10-degree reverse Trendelenburg position throughout the surgery. The hemodynamic parameters and block characteristics of the two groups were compared using Epi Info statistical software. The onset of sensory block was faster in Group 1 (recumbent) compared to Group 2 (reverse Trendelenburg). The two-segment regression time was longer in the second group. In group 2, 73.3% of patients reached a level at T8 or below T8, compared to 46.7% in Group 1. The duration of sensory block and anesthesia was longer in Group 2. We conclude that reverse Trendelenburg of 10 degrees immediately after spinal anesthesia significantly limits the level of sensory block and prolongs the duration of unilateral spinal anesthesia.

A dose-finding randomised controlled trial of magnesium sulphate as an adjuvant in ultrasound-guided supraclavicular brachial plexus block.

BACKGROUND AND AIM: Magnesium sulphate (MgSO4) has been used as an adjuvant in brachial plexus block with encouraging results; however, there is no consensus regarding its optimal dose. Thereby, we compared the efficacy of two doses of MgSO4 as an adjuvant in ultrasound (USG) guided supraclavicular brachial plexus block. METHODS: Ninety patients, aged 20-60 years, belonging to American Society of Anesthesiologists physical status 1 or 2, were given USG-guided supraclavicular block. Group B (n = 30) received 20 ml of 0.5%bupivacaine + 5 ml normal saline (NS), Group BM0.5(n = 30) received 20 ml of 0.5%bupivacaine + 3.75 ml NS and 125 mg MgSO4 (1.25 ml) and Group BM1(n = 30) received 20 ml of 0.5%bupivacaine + 2.5 ml NS and 250 mg MgSO4 (2.5 ml). The primary outcome of study was the duration of post-operative analgesia. The normally distributed data were analysed using analysis of variance and categorical data analysed using Chi-square test. RESULTS: Duration of post-operative analgesia was prolonged in Groups BM1 and BM0.5 (665.13 ± 97.874, 475.10 ± 53.294) min respectively as compared to Group B (272.03 ± 40.404 min: P = 0.00). The onset times of sensory and motor block were shorter in Group BM1 (5.17 ± 2.2 min) as compared to Groups BM0.5 and B (8.9 ± 2.3 and 17.7 ± 5.1 min: P = 0.00) respectively. Sensory and motor block durations were prolonged in Group BM1 as compared to BM0.5 and B (P = 0.00). CONCLUSIONS: MgSO4 as adjuvant in brachial plexus block increases the duration of post-operative analgesia. MgSO4 in the dose of 250mg has greater efficacy as compared to 125 mg.

Comparison of Analgesic Efficacy of Dexmedetomidine and Midazolam as Adjuncts to Lignocaine for Intravenous Regional Anesthesia.

BACKGROUND: Intravenous regional anesthesia (IVRA) is safe, technically simple, and cost-effective technique compared to general anesthesia with success rates of 94-98% for upper and lower limb surgeries. The main disadvantage of this procedure is its limited duration for surgery, lack of postoperative analgesia, and tourniquet pain. To overcome this disadvantage, various adjuvants to lignocaine have been studied from time to time. AIM: To compare the analgesic efficacy of dexmedetomidine and midazolam as adjuncts to lignocaine for IVRA for forearm and hand surgeries. SETTING AND DESIGN: The study was conducted by the Department of Anaesthesia of Medical College and patients posted for elective as well as the emergency forearm and hand surgeries were included in the study. It was a prospective comparative study. MATERIALS AND METHODS: Sixty patients of either sex belonging to the American Society of Anesthesiologists Class I and II, in the age range of 18-65 years, scheduled for upper limb orthopedic surgery, either elective or emergency, were included in the study. All patients were administered IVRA in this prospective, double-blind, randomized study. Patients enrolled in the study were randomly divided into two groups of thirty each. Group M-received 40 ml of 0.5% lignocaine with midazolam 50 µg/kg and Group D-received 40 ml of 0.5% lignocaine with dexmedetomidine 1 µg/kg. Time of onset of sensory block, duration of analgesia, total dose of fentanyl given, intraoperative blood pressure, oxygen saturation, heart rate, postoperative analgesia, and adverse effects were recorded and compared between the groups. STATISTICAL ANALYSIS USED: The statistical evaluation was performed using SPSS version 17.0 software. All values were calculated with a 95% confidence interval. The parameters were expressed as mean ± standard deviation and t-test was used for comparing demographic and clinical data. For comparisons, P < 0.05 was considered statistically significant. RESULTS: Mean duration of analgesia was 93 ± 28 min in dexmedetomidine group and 84 ± 28 min in midazolam group, and onset of sensory block was comparable in both groups. CONCLUSION: Dexmedetomidine and midazolam, when used as adjuvants to lignocaine for IVRA, significantly improve the intraoperative conditions by providing superior quality of block. The superiority of one over the other could not be established as midazolam produced the early onset of block and less requirement of fentanyl, whereas dexmedetomidine when added to IVRA provided longer duration of analgesia (93 ± 28 min) in comparison to midazolam (84 ± 28 min).

Ultrasound-guided femoro-sciatic nerve block for post-operative analgesia after below knee orthopaedic surgeries under subarachnoid block: Comparison between clonidine and dexmedetomidine as adjuvants to levobupivacaine.

BACKGROUND AND AIMS: The advent of ultrasonographic-guided techniques has led to increased interest in femoro-sciatic nerve block (FSNB) for lower limb surgeries. α2-agonists have been used recently as adjuvants to local anaesthetics in nerve blocks. We aimed to compare equal doses of clonidine or dexmedetomidine as an adjuvant to levobupivacaine in FSNB for post-operative analgesia. METHODS: Ninety patients scheduled to undergo below knee orthopaedic surgeries under subarachnoid block were divided into three groups: Group LL (n = 30) patients received 38 mL of 0.125% levobupivacaine with 2 mL normal saline, Group LD (n = 30) patients received 38 mL of 0.125% levobupivacaine with 0.5 µg/kg dexmedetomidine and Group LC (n = 30) received 38 mL of 0.125% levobupivacaine with 0.5 µg/kg clonidine in saline to make total drug volume of 40 mL. The primary and secondary outcome variables were duration of analgesia and rescue analgesic requirement, verbal rating score respectively. Continuous variables were analysed with analysis of variance or the Kruskal-Wallis test on the basis of data distribution. Categorical variables were analysed with the contingency table analysis and the Fisher's exact test. RESULTS: Duration of analgesia was prolonged with dexmedetomidine (10.17 ± 2.40 h) and clonidine (7.31 ± 1.76 h) as compared to control (4.16 ± 1.04 h, P = 0.00). Significantly lower pain scores were observed in dexmedetomidine group as compared to clonidine up to 8 h post-operatively. CONCLUSION: Equal doses of clonidine or dexmedetomidine added to levobupivacaine prolonged the duration of analgesia, decreased requirement of rescue analgesia. Dexmedetomidine delays the requirement of rescue analgesics with better pain scores as compared to clonidine.

Magnesium sulphate as an adjuvant to bupivacaine in ultrasound-guided transversus abdominis plane block in patients scheduled for total abdominal hysterectomy under subarachnoid block.

BACKGROUND AND AIMS: Transversus abdominis plane (TAP) block has proven to be an effective component of multimodal analgesic regimens for a variety of abdominal procedures. Magnesium sulphate (MgSO4) N-methyl-D-aspartate receptor antagonist has the potential to be an ideal adjuvant in TAP block. We studied the efficacy of MgSO4 as an adjuvant to bupivacaine in TAP block in patients scheduled for total abdominal hysterectomy (TAH) under subarachnoid block (SAB). METHODS: Sixty-five women belonging to American Society of Anesthesiologists physical status 1 or 2, aged between 35 and 70 years, scheduled for TAH under SAB were recruited. Patients in Group B (n = 32) received 18 mL 0.25% bupivacaine (45 mg) with 2 mL normal saline (NS), whereas those in Group BM (n = 33) received 18 mL 0.25% bupivacaine (45 mg) with 1.5 mL (150 mg) MgSO4 and 0.5 mL NS in the ultrasound (USG)-guided TAP block performed on each side after the completion of the surgery under SAB. They were evaluated for pain at 0, 2, 4, 6, 12 and 24 h, time to first rescue analgesic and duration of postoperative analgesia were noted. RESULTS: The post-operative visual analogue scale (VAS) scores were lower in Group BM at 4, 6 and 12 h (P < 0.05). Mean duration of analgesia was significantly prolonged in Group BM with lesser requirement of rescue analgesic (P < 0.05) up to 12 h. CONCLUSION: MgSO4 (150 mg) as an adjuvant to bupivacaine in USG-guided TAP block reduces post-operative pain scores, prolongs the duration of analgesia and decreases demands for rescue analgesics.