Introduction: Traditional spinal anesthesia produces significant levels of sensory block leading to spinal hypotension in the elderly population that affects the clinical outcomes postoperatively. Hence, the epidural volume extension (EVE) technique, a variation of combined spinal epidural anesthesia, is used on elderly patients to avoid the abrupt hypotension brought on by the higher level of sensory blockade in spinal anesthesia. Here, we compare the hemodynamic response following EVE technique and spinal anesthesia. Materials and Methods: In this study, 108 patients of age >60 years were divided into two groups: Group EVE receiving combined spinal epidural anesthesia, 10 ml saline was injected in epidural space after low dose spinal anesthesia and Group nonepidural volume extension (NVE) received spinal anesthesia only. The primary outcome was hemodynamic stability. Secondary outcomes were maximum levels of sensory block, motor block, two-segment regression time, duration of analgesia, total analgesic doses consumed in 24 h, and adverse effects if any. Results: In Group NVE, the mean arterial pressure (MAP) at 1 h was 88.28 and 86.73 in group EVE which was statistically significant (Friedman Test: χ2 = 37.4, P ≤ 0.001). There was no significant difference in the trend of MAP over time between the two groups (P = 0.123). Sensory and motor level block achieved in Group EVE was higher (P < 0.005). Two-segment regression time was earlier in Group NVE. The duration of analgesia in Group EVE was more. There was no statistically significant difference in 24 h analgesic consumption and adverse effects. Conclusion: EVE approach offers superior hemodynamic stability following induction than spinal anesthesia.
Introduction: Preoperative anxiety in the pediatric population leads to tachycardia, agitation, excessive crying, and postoperative emergence delirium. The intranasal route of premedication is effective, easy, has high bioavailability, and a rapid onset due to the highly vascularized nasal mucosa. This study compares the efficacy of intranasal ketamine with dexmedetomidine versus intranasal ketamine with midazolam as premedication for sedation in children. Materials and Methods: This randomized, double-blind study included 56 children aged between 3 and 8 years undergoing elective infraumbilical surgeries. Patients were randomized into Group “KD” – intranasal ketamine 1 mg/kg with dexmedetomidine 1 µg/kg and Group “KM” – intranasal ketamine 1 mg/kg with midazolam 0.2 mg/kg. The drugs were given 30 min before the induction of anesthesia. The level of sedation was assessed using the Modified Observer’s Assessment of Alertness/Sedation Score, Parental Separation Score, Parent Satisfaction Score, Mask Acceptance Score, and Postoperative Emergence Score. Results: TheMean Sedation Score, Postoperative Sedation Score, Parental Separation Score, Mask Acceptance Score, and Parent Satisfaction Score between the two groups were found to be statistically significant between both groups (P < 0.05). The mean Postoperative Emergence Score (Cravero score) between the two groups showed no statistically significant difference in score (P > 0.05). Two patients in Group KD had tachycardia, and one patient from each group developed hypotension in the postoperative area. Conclusion: A combination of intranasal ketamine (1 mg/kg) with midazolam (0.2 mg/kg) is better than intranasal ketamine (1 mg/kg) with dexmedetomidine (1 mcg/kg) in terms of premedication, mask acceptance, and separation anxiety.
Background and Aims: Laryngoscopic manipulation and endotracheal (ET) intubation are noxious stimuli capable of producing tachycardia, arrhythmias, and hypertension. This study compared the efficacy of 3 different doses of intranasal dexmedetomidine (0.75 µg/kg, 1 µg/kg, and 1.5 µg/kg) in attenuating the hemodynamic responses to laryngoscopy and ET intubation. Methods: After taking informed written consent, a total of 90 patients were divided into 3 groups. Group-1 was given dexmedetomidine 0.75 µg/kg, Group-2 given 1 µg/kg and Group-3 was given 1. 5 µg/kg. In all the patients, drugs were diluted to 1 ml with 0.9%normal saline. Intranasal drug was dripped into both nostrils in equal volume using 1 ml syringe in a supine head-down position about 40 min before induction (T0). The primary objective of this study is to compare pressor response of laryngoscopy and ET intubation in the preoperative period among 3 groups. Secondary objectives are the observation of sedation status via Ramsay sedation scale and to document side effects. Results: Groups were well matched for their demographic data. Hemodynamics were stable in both Group 2 and 3, but significant hypotension and bradycardia were noted in Group 3 in two cases, which were treated with a fluid bolus and a single dose of mephenteramine. Patients who were given dexmedetomidine at a dose of 1.5 µg/kg were significantly sedated during intubation (P = 0.013) as well as during extubation (P < 0.001) compared to patients in Groups 1 and 2. Conclusion: Dexmedetomidine in the dose of 1.0 µg/kg administered as intranasal drops produced a more satisfactory attenuation of hemodynamic response during laryngoscopy and ET intubation with hemodynamic stability.
Background and Aims: There is a need for research into opioid sparing analgesic options. The study aimed to compare postoperative pain scores at 24 h in patients receiving preoperative magnesium–lignocaine–ketorolac (MLK) or magnesium–lignocaine (ML) with control during laparoscopic cholecystectomy. Methods: The present randomized, controlled trial enrolled 120 patients, 18–60 years, American Society of Anesthesiologists I/II, scheduled for laparoscopic cholecystectomy. Patients were randomized preinduction to either Group MLK (n = 40), magnesium 50 mg/kg + lignocaine 1.5 mg/kg + ketorolac 0.5 mg/kg in normal saline (NS), Group ML (n = 40), magnesium 50 mg/kg + lignocaine1.5 mg/kg in NS, or group saline (S) (n = 40) NS. All patients received a standard general anesthetic (GA) technique. In the postoperative period, if the Visual Analog Scale (VAS) ≥30, the patient received morphine boluses of 1 mg by intravenous (IV) PCA pump with a lockout interval of 10 min. Results: VAS at rest in group MLK was lower in group S, (P = 0.001) at 12 h postoperatively. VAS on movement in group MLK and group ML was lower as compared to group S (P < 0.001) at 24 h postoperatively. IV Morphine consumption in the first 24 h after surgery was lower in groups MLK and ML versus group S (P < 0.001). The time to first rescue analgesia was early in Group S, delayed in Group MLK and Group ML (P < 0.001). Conclusion: A preoperative IV MLK or ML resulted in lower VAS on movement score in patients undergoing laparoscopic cholecystectomy under GA at 24 h postoperatively.
Background: Topicalization of the airway is crucial for managing difficult airways, particularly in uncooperative or emergency surgical patients. While peripheral nerve blocks are effective, they require patient cooperation and time, making them impractical in certain cases. Awake video-laryngoscopy (VL) is increasingly utilized due to its ease and minimal resource requirements. However, achieving adequate airway anesthesia for awake VL poses challenges, especially with hyperangulated blades. Methods: We propose an indigenous modification of the spray-as-you-go technique, tailored for CMAC D-Blade videolaryngoscopy. We introduce a method for the simultaneous instillation of local anesthetic (LA) by utilizing the side channel of the D-Blade, meant for paraoxygenation and suctioning. We inserted an infant feeding tube within the standard oxygen tubing attached to the oxygen source to facilitate LA spread in a 360° area around the tube, enhancing the effectiveness. Oxygen serves as a carrier for LA dispersion and simultaneously provides paraoxygenation, both beneficial in patients with difficult airways and compromised respiratory function. Conclusion: This modification overcomes the limitations of traditional methods of topicalization by ensuring effective LA distribution along the VL entry line and surrounding hypo- and laryngopharynx. Our approach offers a practical solution for awake VL-guided tracheal intubation, potentially improving patient comfort and procedural success.
Background and Aims: Postspinal hypotension is a common occurrence during cesarean section (CS) due to autonomic blockade and inferior vena cava compression by the gravid uterus. The aim of this study was to assess the role of the right common femoral vein (RCFV) diameter measurement in predicting the occurrence of hypotension following spinal anesthesia during CS. Materials and Methods: Fifty-three patients with term singleton pregnancy were included. Preoperative measurements of the transverse diameter of RCFV and baseline hemodynamic parameters were taken. Changes in parameters were measured immediately after spinal anesthesia and at every 3 min interval till delivery of the baby. The primary outcome was the association between the diameter of RCFV and postspinal hypotension. Association of RCFV diameter and hypotension was identified by binomial logistic regression analysis. Results: A longer transverse diameter of RCFV was associated with the occurrence of postspinal hypotension (odds ratio: 6.390, (95% confidence interval: 2.47–16.48), P < 0.001) with sensitivity of 96.20%, specificity of 96.30%, positive predictive value 96.15%, and negative predictive value 96.30%. A transverse diameter of >11.98 mm of RCFV could predict postspinal hypotension during CS. Conclusion: A longer transverse diameter of RCFV was associated with hypotension and could identify parturients at major risk of hypotension following spinal anesthesia in CS.
Introduction: Subarachnoid block (SAB) is the anesthetic technique of choice for elective cesarean delivery owing to its rapid onset, reliability, and favorable maternal and neonatal outcomes. Gestational diabetes mellitus (GDM) has been associated with autonomic nervous system dysfunction, which may influence cardiovascular regulation during anesthesia. This study aimed to assess the predictive value of preoperative frequency-domain heart rate variability (HRV) parameters for post-spinal hypotension in parturients with and without GDM. Materials and Methods: In this observational study, 40 parturients undergoing elective cesarean section were enrolled, including 18 women with GDM and 22 healthy controls. Baseline HRV was assessed 1 day before surgery using a standardized 5-min electrocardiographic recording analyzed with Kubios HRV Premium software. Frequency-domain parameters, including low-frequency (LF) power, high-frequency (HF) power, and LF/HF ratio were calculated. Following SAB administration, hemodynamic variables were monitored throughout surgery and the immediate postoperative period. Hypotension was defined as systolic blood pressure below 80% of baseline. Statistical analysis was performed using SPSS version 26.0, with P < 0.05 considered statistically significant. Results: Demographic characteristics were comparable between groups. No significant differences were observed in LF power, HF power, or LF/HF ratio between GDM and healthy parturients (P > 0.05). The incidence of hypotension was similar in both groups (55.6% vs. 50.0%; P = 0.726). Vasopressor requirements and the incidence of nausea and vomiting were also comparable. Conclusion: Preoperative frequency-domain HRV parameters showed limited predictive value for post-spinal hypotension. Parturients with GDM demonstrated autonomic and hemodynamic responses similar to healthy controls, suggesting that these findings suggest that HRV frequency-domain analysis alone may have limited clinical utility as a screening tool.
Background: Neurological and cardiotoxicity associated with bupivacaine led to research of alternatives for subarachnoid block (SAB) with comparable efficacy and better safety. This study aimed to compare the anesthetic efficacy and safety of 0.75% hyperbaric ropivacaine with 0.5% hyperbaric bupivacaine in SAB. Materials and Methods: A randomized, double-blinded study was conducted on 60 American Society of Anesthesiologists I-III patients undergoing lower limb surgeries. Patients were divided into two equal groups of 30 each. Group R received 2.5 ml of 0.75% hyperbaric ropivacaine with 25 mu g fentanyl, and Group B received 2.5 ml of 0.5% hyperbaric bupivacaine with 25 mu g fentanyl. Onset of sensory and motor block, maximum sensory level and time to achieve it, duration of complete motor block, two-segment sensory regression, duration of analgesia, and episodes of hypotension were observed. Results: Difference in onset of sensory and motor block, maximum sensory level and time to achieve it, and duration of motor block were statistically insignificant between the two groups (P > 0.05). Time to two-segment sensory regression was significantly longer in Group R (99.27 +/- 11.79 min) than Group B (85.17 +/- 19.19 min) (P = 0.001). The duration of analgesia was significantly lower in the Group R (264.33 +/- 46.72 min) than Group B (300.73 +/- 62.85 min) (P = 0.013). More episodes of hypotension were observed in Group B (P = 0.033). Conclusion: Intrathecal hyperbaric ropivacaine 0.75% offers a reasonable degree of sensory and motor block for lower limb surgeries and is thus a comparable alternative to bupivacaine with lower hypotensive incidence.
