Introduction: In upper abdominal surgery, postoperative pain relief is the most challenging for anesthesiologist. Among multiple strategies, epidural analgesia using local anesthetics, opioids, or their combination, is popular technique for effective postoperative pain management. The aim of our study was comparison of effects of different doses of epidural tramadol for postoperative analgesia in adult patients scheduled for surgery of upper abdomen. Methods: This Prospective controlled interventional study included 60 adult patients posted for upper abdominal operations undergoing general anesthesia. The epidural analgesia was provided by administering 10 ml of epidural bupivacaine 0.25% via epidural catheter at the start of surgery and randomized into two different groups: Group A was administered 1 mg/kg tramadol diluted in 8 ml of normal saline and Group B was administered 2 mg/kg tramadol diluted in 8 ml of normal saline before extubation. Duration of analgesia, Pain score (numerical rating score-NRS), hemodynamic parameters and adverse event were monitored and time for need of first of rescue analgesic was recorded in both the groups. The student's t-test was used for analysis of continuous data. P value ≤0.05 was considered statistically significant. Result: Group B patients had significantly longer duration of postoperative analgesia (12.07 ± 1.48 hours) as compared to Group A (8.13 ± 0.82 hours) with P < 0.001. NRS pain score was significantly lower in Group B than in Group A. Hemodynamic parameter were comparable without any side effects in both the groups. Conclusion: Epidural tramadol 2 mg/kg resulted in superior and prolonged postoperative pain relief than epidural tramadol 1 mg/kg without compromising patient safety.
Introduction: Pentazocine has been used as only anesthetic for subarachnoid block in various infraumbilical surgeries but the role of pentazocine as an additive to local anesthetic in subarachnoid block has not been adequately evaluated. The study aims to compare the effect of pentazocine with fentanyl when added to 3.5 ml of 0.5% bupivacaine heavy for subarachnoid block in abdominal hysterectomy. Methods: A total of 150 patients undergoing abdominal hysterectomy were randomly distributed to group P, F and D with 50 patients in each group. Group P received 7.5 mg of pentazocine, Group F received 25 mcg of fentanyl and group C received 0.5 ml of normal saline as an additive to 3.5 ml of 0.5% bupivacaine heavy for spinal anesthesia. Duration of sensory and motor block along with duration spinal analgesia were compared among the groups. Parametric and nonparametric data were analyzed by one-way ANOVA and the Kruskal-Wallis test respectively. Results: Sensory block duration in group P (142.8±17.42 min) and F (155.58±10.78 min) were comparable (P 0.498). No significant difference was observed between group P (524.58±31.01 min) and F (552.42±31.11 min) regarding motor block (P 0.927). Duration of spinal analgesia was also similar in group P (485.00±30.93 min) and F (513.20±30.81 min) (P 0.931). Duration of block and spinal analgesia was significantly less in group D compared to other groups. Conclusion: For spinal analgesia and extension of block (sensory and motor), intrathecal pentazocine (7.5 mg) is just as effective as 25 mcg fentanyl with no side effects.
Introduction: More than 50% of children experience significant preoperative anxiety, which adversely affects anesthetic management and postoperative behavior. Premedication in pediatric patients should facilitate parental separation, venous cannulation, and smooth induction, while minimizing respiratory depression, particularly relevant in children undergoing tonsillectomy for airway obstruction. Intranasal administration offers rapid absorption, predictable effects, and non-invasive delivery. The main goal of this study is to compare the efficacy and safety of intranasal midazolam, S-ketamine, and dexmedetomidine as premedication in children undergoing tonsillectomy under general anesthesia. Methods: In this prospective, randomized study, 90 children aged 1-7 years (ASA I-II) were allocated to three groups (n=30 each) receiving intranasal midazolam (0.2 mg/kg), S-ketamine (0.1 mg/kg), or dexmedetomidine (1 µg/kg), 30 minutes preoperatively. Sedation (Ramsay scale), separation anxiety, and mask acceptance (MAS scale) were assessed. Intraoperative hemodynamics and opioid consumption were recorded. Postoperative sedation (Ramsay), pain (FLACC/FACES scales), and postoperative excitation (PAED scale) were evaluated. Children with sleep apnea or drug allergies were excluded. Results: No significant differences were observed between groups in separation anxiety or mask acceptance. Intraoperative fentanyl consumption differed significantly, with lower requirements in the S-ketamine group. Significant intergroup differences were also found in systolic blood pressure and heart rate after induction. Postoperative pain scores were significantly lower in children receiving S-ketamine compared with midazolam and dexmedetomidine. Conclusion: Intranasal premedication is effective and safe in pediatric tonsillectomy. S-ketamine provides superior analgesia and reduces intraoperative opioid requirements without compromising sedation or anxiolysis, suggesting it may be a preferable option in this population.
Objective: Apneic oxygenation increases safe apnea time and helps to secure the airway seamlessly, enhancing patient safety. Aim of this study was to determine safe apnea time achieved by perioxygenation including supplemental oxygen flow of five l/min through a nasal cannula compared to standard preoxygenation alone. Methods: This prospective double-blind randomized controlled trial included patients undergoing elective surgery under general anaesthesia with tracheal intubation. The sample size was 28 per group. Participants were randomly assigned to Groups 0 and 1. After induction of neuromuscular blockade, Group 1 received oxygen insufflation at five l/min through nasal cannula while Group 0 did not. Time to desaturate from 100 to 99% (T0), 99 to 95% (T1) and from 100 to 95% (T2) was noted. At SpO2 of 95%, ventilation was recommenced with 100% oxygen until SpO2 was restored to 100% and time to resaturation to 100% (T3) noted. Primary outcome was to determine whether perioxygenation including apneic oxygenation through nasal cannula prolongs safe apnea time. Secondary outcomes measured included resaturation time, lowest oxygen saturation levels during actual laryngoscopy and EtCO2 value immediately post intubation. Results: Demographics were similar in both the groups. Mean safe apnea time (T2) was 738 seconds in Group 1 and 325 seconds in Group 0 (p<0.001). T0 was longer in Group 1 (p<0.001). T3 was similar in both groups. Immediate EtCO2 values after intubation were higher in Group 1 (p<0.001). Conclusion: Perioxygenation including apneic nasal oxygen supplementation significantly prolongs safe apnea time.
Introduction: Postoperative pain following knee surgery is often severe and may delay rehabilitation. This study evaluated the safety and efficacy of adding fentanyl to levobupivacaine in ultrasound guided adductor canal block (ACB). Methods: One hundred patients scheduled for arthroscopic knee surgery were randomly assigned to two groups: Group L received 20 ml of 0.25% levobupivacane, while Group FL: who received Fentanyl (1µg/kg) with 0.25% levobupivacaine to a total volume of 20 ml. Postoperative analgesia, rescue analgesic requirement, patient satisfaction, hemodynamic stability, and complications were recorded. Results: Group FL demonstrated significantly lower VAS pain scores and reduced rescue analgesic use compared to Group L. Patients in Group FL reported higher satisfaction with pain management and showed greater hemodynamic stability. Mild adverse effects, including nausea, vomiting, hypotension, and tachycardia, reported in both the groups. Conclusion: The addition of fentanyl to levobupivacaine in ultrasound guided adductor canal block enhances postoperative analgesia, improves hemodynamic stability, increases patient satisfaction, and reduces analgesic requirements without increasing adverse effects in knee surgery patients.
Introduction: Epidural analgesia after abdominal surgery is most effective mode of postoperative pain relief. Relative effects of the volume and concentration of local anaesthetic used for epidural analgesia are still under debate. We compared postoperative analgesic efficacy and adverse effects with continuous epidural infusion of 0.5% levobupivacaine at 3 ml/h and 0.15% levobupivacaine at 10 ml/h after abdominal surgery. Methodology: Sixty patients in the age group of 18-60 yrs of either sex belonging to ASA I and II scheduled for abdominal surgery under general anaesthesia were randomly equally divided into two groups. Patients of group-A received continuous epidural infusion of 0.5% levobupivacaine at 3 ml/h and group-B received continuous epidural infusion of levobupivacaine 0.15% at 10 ml/h for 24hrs in postoperative period. Intra-operative hemodynamic, HR, SBP, DBP, MAP, quality of postoperative analgesia using VAS score, time for first rescue analgesia, consumption of rescue analgesic drug, motor blockade, sensory loss and side effects were observed during the study period. Results: No statistically significant difference was observed in VAS score in group-A and Group-B at rest and at cough at all times. Motor block was significantly higher in group-A after 16 hours. Heart rate, SBP, DBP and MAP were significantly lower in group-A as compared to group-B in postoperative period. Conclusion: Continuous epidural infusion of 0.5% levobupivacaine at 3 ml/h and 0.15% levobupivacaine at 10 ml/h provided equal postoperative analgesia after abdominal surgery. We observed that postoperative analgesia depends on total dose of local anaesthetic agent and not on the concentration or volume.
The specifics of children's age, the requirements during surgical intervention and the postoperative course affect the goals of perioperative fluid therapy. The dilemmas in these circumstances include when to administer intravenous fluid, which solution to choose, how much fluid to administer, and how to administer it to a sick child. In the preoperative period, we assess the child's hydration according to surgical disease, comorbidities, losses due to vomiting, diarrhea, fever and preoperative fasting. The intraoperative period is the most dynamic, when it is necessary to assess the need to administer crystalloids, colloids, blood, or vasopressors to support hemodynamics. Adequate fluid therapy is also essential during the postoperative period and affects the outcome of treatment. Fluid therapy requires hemodynamic monitoring as well as assessing acid-base balance.
Local anaesthetics are widely used for penile and genital surgery, with techniques tailored to the specific nerve supply and dermatomal distribution of the genitalia. For penile and genital surgery, local infiltration (ring block), dorsal penile nerve block, and pudendal nerve block are the most common techniques. The pudendal nerve block providing optimal analgesia for extensive penile or genital surgeries, while local infiltration and topical agents are appropriate for less invasive interventions. The recommended technique for providing local anesthesia for scrotal surgery is ultrasound-guided ilioinguinal and genitofemoral nerve blocks. This approach targets the nerves responsible for sensory innervation of the scrotum and adjacent regions, providing effective intraoperative anesthesia and postoperative analgesia.
Introduction: Pheochromocytoma is a rare neuroendocrine tumor of the adrenal medulla that secretes catecholamines. Surgical treatment of pheochromocytoma remains a challenge for all clinicians, particularly anesthesiologists. The complexity of managing adrenal medullary tumors lies in the necessity of meticulous preoperative preparation, the risk of hemodynamic instability, and a well-coordinated, team-based approach to patient care. Despite existing guidelines for preoperative preparation and surgical technique selection, pheochromocytoma can surprise us. Case Report: We present the case of a 46-year-old female patient in whom an adrenal medullary tumor was discovered incidentally. Due to tumor growth and secretory activity, diagnostic evaluation and surgical treatment were indicated. The patient underwent appropriate preoperative preparation and laparoscopic surgery with initially well-regulated hemodynamic parameters. Intraoperatively, however, she experienced pronounced and refractory hemodynamic instability, which required prompt and coordinated action by the anesthesiology team. Recurrent hypertensive crises during surgical manipulation of the tumor and the unavailability of nitroprusside made the intraoperative course particularly challenging. Conclusion: Adequate preoperative preparation, medication availability and a hemodynamically stable patient do not guarantee an uneventful intraoperative course. A review of the literature highlights the link between tumor characteristics, intraoperative behavior, and preoperative strategy, indicating the need for further advancement in this field.
Introduction: The clinical course of gas gangrene is often rapidly progressive, with a fatal outcome in up to 80% of treated cases. The disease is most commonly a consequence of trauma or surgical interventions. The causative agents are bacteria of the genus Clostridium. Tissue changes are induced by bacterial toxins. Case presentation: We analyzed the case of an 84-year-old, obese, female patient admitted for treatment due to weakness and dysuric symptoms. She fell at home the day before and sustained superficial skin changes. Previous medical documentation indicated poorly managed arterial hypertension. A few days after admission, the patient experienced worsening symptoms with the onset of edema and crepitus of the soft tissues, dyspnea, and renal insufficiency. Ultrasound examination revealed gas inclusions in muscular tissue, while radiography showed bilateral basal pulmonary changes. Laboratory findings initially showed lymphocytosis and elevated C-reactive protein. Anemia, increased muscle enzymes, and elevated nitrogenous compounds followed the progression of the disease. Urine culture isolated Escherichia coli. Clostridium spp. was identified in the soft tissue aspirate. Ceftriaxone and metronidazole were administered initially, followed by penicillin G. The disease progressed and resulted in a fatal outcome. Conclusion: The nature of gas gangrene is extremely severe due to the potential for multisystemic damage. It is necessary to suspect this condition more frequently, regardless of the circumstances of the injury. Clinical symptoms should be closely monitored, and antibiotic therapy should be initiated as early as possible to improve the chances of a favorable outcome.
A pneumatic cuff or tourniquet is a standard part of the operative procedure in orthopaedic surgery. Its role is to provide a bloodless surgical field, facilitate the surgeon's work, improve the visualisation and identification of anatomical structures, and reduce blood loss. Non-pneumatic and pneumatic cuffs are used in orthopaedics. The pressure in the pneumatic cuff should be 100mmHg above the patient's systolic blood pressure, and the highest allowed pressure is 300mmHg for a maximum of two hours. Local complications occur due to direct trauma, compression at the cuff placement site, or tissue ischemia distal to the cuff, while systemic ones arise as a result of reperfusion after inflation or deflation of the cuff. The most common local complications are skin damage, nerve damage, muscle damage with potential kidney failure, and blood vessel damage with the possibility of thrombosis. Systemic complications are observed in the form of changes in the respiratory, cardiovascular, urinary and central nervous systems and the occurrence of deep vein thrombosis of the lower extremities. Pain caused by tourniquets is one of the problems that anesthesiologists encounter in their daily work, which is difficult to regulate by administering analgesics and changing the depth of anaesthesia. Pain can persist for up to three weeks after surgery, making the patient's recovery difficult. The use of a tourniquet reduces intraoperative bleeding, and the thickness of the cement shell is greater, which achieves a better fixation of the implant to the bone.
Introduction: Caudal analgesia is considered a safe, simple and common procedure in children. As bupivacaine alone has short duration of action, addition of clonidine and dexmedetomidine has been shown to increase the duration of caudal analgesia. We aimed to evaluate caudal clonidine and caudal dexmedetomidine with bupivacaine in terms of the analgesic efficacy and sedation in children scheduled for infra-umbilical surgeries. Methods: We conducted a prospective, randomized, and interventional study. We randomized sixty patients into two groups aging 1 to 8 years belonging to ASA grade I and II posted for infra-umbilical surgeries. Group C was administered 0.25% bupivacaine (1 ml/kg) + clonidine 1 µg/kg, maximum total volume of 12 ml for caudal block, while Group D was administered 0.25% bupivacaine (1 ml/kg) + dexmedetomidine 1 µg/kg, maximum total volume of 12 ml for caudal block. Hemodynamic variables were monitored. Postoperative analgesia was assessed using FLACC score, sedation using the Ramsay Sedation Scale, and total analgesic requirements and side effects were recorded during the first 24 hour. Results: A significant difference in duration of postoperative analgesia was observed between the two groups. In Group D, the mean duration was 742 min ± 247.38 min, whereas in Group C, it was 608.87 min ± 251.16 min (p value < 0.043). The mean sedation score in the immediate postoperative period was lower in Group D compared to Group C. The rescue analgesic requirement in the first 24 hours in Group D was also lower than in Group C. Hemodynamic changes and adverse effects were comparable between the two groups. Conclusions: Dexmedetomidine was a safe and more effective adjuvant to bupivacaine as compared to clonidine for prolonging caudal in children undergoing infraumbilical surgeries, without an increase in adverse effects.
Consent form, an important legal document, is proof of communication between patient and doctor. The consent is an important process to be followed before procedure. We observed abbreviations in the anaesthesia consent forms which may result in improper understanding and communication when consenting patients for elective surgeries under anesthesia. For assessment of the quality of consent for patients, a pre-interventional audit was performed retrospectively by review of 50 anaesthesia forms for consent in our oncology center during August of 2023 for elective oncological procedures under anaesthesia. Information was collected exclusively through our institutional systems of medical record department. The data were analyzed and subsequently, a training session (in-person) was scheduled during September 2023 to highlight the value of written informed consent and to avoid abbreviations in the document. The post-interventional audit was done for during October 2023 that also included 50 anaesthesia forms for consent. The analysis of the results was performed and compared with pre-interventional results of audit. The usage of abbreviations was 44% in pre-intervention audit. It reduced to 16 % in the post-intervention audit (P value-0.0001). The abbreviations used were DM, LV, MI, PTCA, EF, STO and COPD. The most commonly used abbreviations were DM and LV in audit and DM in re-audit. A straightforward educational training intervention can improve consent quality and safety of patients and prevents likely medico-legal repercussions for institutions and persons as well involved in providing healthcare.
The effect of dexmedetomidine and fentanyl as an adjuvant with hyperbaric levobupivacaine in cesarean section has not been evaluated adequately by researchers until now. The present study is designed to compare the effect of 5 mcg of dexmedetomidine and 25 mcg fentanyl when added to intrathecal 0.5% hyperbaric levobupivacaine for cesarean section. This randomized controlled trial was done with 105 parturient undergoing cesarean section under spinal anesthesia. Parturient were randomly divided into three groups. Group DL received 5 mcg of dexmedetomidine along with 1.8 ml of hyperbaric levobupivacaine intrathecally. Group FL and group NL received 25 mcg of fentanyl and 0.5 ml of normal saline respectively along with 0.5% hyperbaric levobupivacaine. The primary objective was to compare the duration of sensory and motor block among the groups. Comparing the onset time of sensory and motor block and time to first analgesic medication was considered a secondary objective. Duration of sensory block was 138.14 ± 14.35 and 131.86 ± 7.85 min in group DL and FL (P < 0.05). Motor block duration was 250.2 ± 6.86 and 242.63 ± 4.71 min in group DL and FL respectively (P < 0.05). The time to first analgesic medication in group DL (273.43 ± 7.54 vs. 253.43 ± 6.52 min) was significantly prolonged compared to group FL (P < 0.001). A 5 mcg dose of dexmedetomidine when used as an adjuvant to intrathecal 0.5% hyperbaric levobupivacaine significantly prolongs the duration of sensory block, motor block, and the time to first analgesic medication compared to 25 mcg of fentanyl.
Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based approach designed to minimize surgical stress, accelerate recovery, and improve patient outcomes. Recent technological advancements have transformed ERAS protocols by integrating robotic-assisted surgery, artificial intelligence (AI)-driven monitoring, advanced thermoregulation, automated nutrition management, and real-time perioperative decision support. These innovations enhance surgical precision, metabolic stability, pain control, and personalized patient care, ultimately reducing complications and improving recovery efficiency. Robotic surgery improves minimally invasive techniques, while AI-powered glucose monitoring and pain management optimize metabolic control and analgesia. Advanced thermoregulation systems ensure perioperative normothermia, reducing risks associated with hypothermia, and automated nutritional support promotes postoperative recovery. However, challenges such as cost, accessibility, and seamless integration into clinical practice remain. Future directions in ERAS include AI-driven predictive analytics, remote patient monitoring, wearable biosensors, and closed-loop anaesthesia systems, which will further refine perioperative care, early risk detection, and personalized interventions. The continued integration of emerging technologies into ERAS pathways will drive safer, more efficient, and patient-centered surgical recovery, redefining perioperative medicine for the modern era.
Labour pain is one of the most severe pains with significant physiological and psychological consequences. Timely labour analgesia has considerable foeto-maternal benefits. There are many pharmacological and non-pharmacological techniques for ensuring labour analgesia. In the group of pharmacological methods for pain relief, neuraxial techniques have become more popular than non-neuraxial. Among the different regional techniques for labour analgesia, continuous labour epidural remains the "gold standard". Combination of ultra-low concentration local anaesthetic and low dose of lipophilic opioid has emerged as the "ideal" prescription for neuraxial labour analgesia. Continuous epidural infusion technique with a background programmed intermittent epidural bolus in addition to patient controlled epidural analgesia to manage breakthrough pain ensures effective labour analgesia with minimal side effects to mother and foetus. Even though refinements of the technique and newer advances have resulted in better outcomes, there are many persisting myths and controversies surrounding labour epidural technique.
Balloon pulmonary valvotomy is the treatment of choice in patients with isolated pulmonary stenosis and has shown good long-term results. It is generally considered a safe procedure with fewer complications. We report a case of 4-year-old male child with severe pulmonary stenosis with peak pressure gradient of 120 mmHg underwent balloon pulmonary valvotomy in non-operating room anesthesia.
Introduction: A transverse abdominis plane block is a recent and newer method to reduce post-operative pain due to abdominal incisions. The efficacy of anterior abdominal field block at the linea semilunaris technique compared with a placebo. Methods: A randomized controlled comparative interventional study was conducted at Government Dharmapuri Medical College and Hospital, Dharmapuri, Tamil Nadu, India between January 2023 to June 2023. Patients recruited for the study were randomized and allotted to receive either the drug or the placebo. One of the groups received an abdominal field block with 20 ml of 0.25% bupivacaine, and the placebo group received a Normal Saline injection at the same site. A standard institutional protocol of inj. diclofenac 100 mg rectal suppository; and Inj. Tramadol 100 mg intramuscularly was followed in all the cases. Visual Analog score was used to analyse post-operative pain. If indicated, rescue analgesia - injection of tramadol 100 mg (if VAS >4) was given intramuscularly. Results: Final analysis included 40 subjects. 20 participants in treatment and placebo group; This study shows that transversus abdominis plane (TAP) done at linea semilunaris provides adequate postoperative analgesia for a shorter duration. The difference in VAS score was between the procedure group and placebo at 4 hours was significant. After this, there was no significant difference in the VAS score between the two groups. There was a significant reduction in the need for rescue analgesia at 4 hours. The hemodynamic changes in the procedure group compared to the placebo group was not significant. Conclusion: There is a significant usage for anterior approach abdominal field block (Linea semilunaris block) in providing analgesia for post-Caesarean section.
