Laryngoscopy as well as tracheal intubation cause significant changes in the hemodynamics of the patient.(1).A similar set of hemodynamic derangements have been noticed by various workers during tracheal extubation(2).These responses may produce myocardial ischemia or infarction in susceptible patients. Various agents like lidocaine and esmolol have shown to attenuate these responses(3).Dexmedetomidine, an α2 agonist has been successfully used for attenuating the stress response to laryngoscopy.(4)We conducted a double blind study to examine the role of Dexmedetomidine on hemodynamic changes during extubation of trachea.

A PAXpress™ (Vital Signs Inc., Barnham, UK) airway device was placed in 50 adult ASA grade I and II patients undergoing elective surgery under general anaesthesia. The alignment of the PAXpress to the larynx was scored fibreoptically. The patients were then intubated blindly through the PAXpress and the adjusting manoeuvres required for successful intubation and complications of intubation observed. Insertion of the PAXpress was successful in all patients, and intubation was successful in 42 (84%) patients. Eleven patients were intubated in the neutral position, seven with a flexion manoeuvre and 24 with an extension manoeuvre. Intubation was successful in 17/20, 18/20, 6/8 and 1/2 of patients with a fibreoptic alignment score of 1, 2, 3 and 4, respectively. When the fibreoptic alignment score was between 2 and 4 intubation was achieved predominantly with the extension manoeuvre (20/30, 66%) rather than the flexion manoeuvre (1/30, 3%) or the neutral position (5/30, 16%). Blood staining was observed in 20 patients. We conclude that blind tracheal intubation through PAXpress has a moderately good success rate and a high incidence of mucosal trauma. ‘Extension’ is the predominant adjusting manoeuvre required for blind tracheal intubation, especially when the alignment of the PAXpress to the larynx is poor.

The analgesic potency of sufentanil is approximately 5-7 times that of fentanyl because of its high lipid solubility and its potent opiate receptor binding. Epidural sufentanil produces spinal analgesia of rapid onset and moderate duration. We compared the effects of using 0.5% bupivacaine either alone or in combination with sufentanil in terms of the following: 1) Onset of analgesia; 2) Duration of analgesia; 3) Incidence of side effects. A prospective randomized double blind study was conducted in 60 patients (20-50 yrs, ASA I-II) scheduled for lower limb orthopedic surgery. Patients were randomly allocated to three group (n=20each). Group A bupivacaine0.5% (20 ml), Group B bupivacaine0.5% (20 ml) and 15 mcg sufentanil, Group C bupivacaine0.5% (20 ml) and 30 mcg sufentanil. Onset of analgesia was assessed as the time required to produce loss of prick sensation bilaterally at L4 dermatome. Duration of analgesia was recorded from injection of epiduaral till patient’s request for first dose of rescue analgesic. Results were analyzed with ANOVA test, using spss. ver-11. The onset of analgesia in Groups was A: 10.50 ± 1.10 mins, B: 10.70 ± 1.26 C: 4.60 ± 0.60. Duration of analgesia was Group A: 192.05 ± 9.02 mins, B: 191.50 ± 4.49 C: was 376.20 ± 12.28. Significant difference between group A & C, and Group B & C were observed. Hypotension and retention were common side effects in Group A and B, nausea and pruritus occurred more frequently in Group C. Our study concludes that 30 mcg of epidural sufentanil with 0.5% bupivacaine is superior to 15 mcg epidural sufentanil with 0.5% bupivacaine or 0.5% bupivacaine alone. The incidence of nausea and pruritus however was increased with 30 mcg of sufentanil. The analgesic potency of sufentanil is approximately 5-7 times that of fentanyl because of its high lipid solubility and its potent opiate receptor binding. Epidural sufentanil produces spinal analgesia of rapid onset and moderate duration. We compared the effects of using 0.5% bupivacaine either alone or in combination with sufentanil in terms of the following: 1) Onset of analgesia; 2) Duration of analgesia; 3) Incidence of side effects. A prospective randomized double blind study was conducted in 60 patients (20-50 yrs, ASA I-II) scheduled for lower limb orthopedic surgery. Patients were randomly allocated to three group (n=20each). Group A bupivacaine0.5% (20 ml), Group B bupivacaine0.5% (20 ml) and 15 mcg sufentanil, Group C bupivacaine0.5% (20 ml) and 30 mcg sufentanil. Onset of analgesia was assessed as the time required to produce loss of prick sensation bilaterally at L4 dermatome. Duration of analgesia was recorded from injection of epiduaral till patient’s request for first dose of rescue analgesic. Results were analyzed with ANOVA test, using spss. ver-11. The onset of analgesia in Groups was A: 10.50 ± 1.10 mins, B: 10.70 ± 1.26 C: 4.60 ± 0.60. Duration of analgesia was Group A: 192.05 ± 9.02 mins, B: 191.50 ± 4.49 C: was 376.20 ± 12.28. Significant difference between group A & C, and Group B & C were observed. Hypotension and retention were common side effects in Group A and B, nausea and pruritus occurred more frequently in Group C. Our study concludes that 30 mcg of epidural sufentanil with 0.5% bupivacaine is superior to 15 mcg epidural sufentanil with 0.5% bupivacaine or 0.5% bupivacaine alone. The incidence of nausea and pruritus however was increased with 30 mcg of sufentanil.

Chronic regional pain syndrome is a complex neurological disease that often follows trauma or surgery. There are various treatment modalities for this disorder. Continuous infra-clavicular brachial plexus block along with catheter placement is a technique that can produce dramatic relief in patients suffering from chronic regional pain syndrome (CRPS). A 30 years old male patient presented in the pain clinic of the Department of Anaesthesiology, with the complaints of pain in the left upper limb following a gunshot injury 2 months back. Pain was very severe, burning and continuous in nature with a score of 1 on a rupee scale (0 - no pain, 1– maximum pain) and used to get aggravated on movement, superficial touch and was not relieved by pain killers . Initially the pain was localized to the left arm but gradually it involved whole of the left upper limb. His left upper limb was cold, livid, swollen, range of motion was severely impaired and trophic changes of skin were clearly visible. As a treatment modality , initially a stelliate ganglion block was given, twice on alternate days using 10 ml of 0.25% bupivacaine. The patient reported reduction in the intensity and severity of pain and after 3 days the patient was given a continuous infra-clavicular brachial plexus block using 0.25% bupivacaine at the rate of 5 ml/ hr and was advised a combination of oral tramadol and paracetamol on SOS basis , with the advice that the dose should not exceed more than 4 tab / 24 hrs. The patient was reviewed after four weeks in the pain clinic, there was a marked reduction in the intensity of pain with a VAS score of 4/10 scale.

We present a case of postherpetic neuralgia (PHN) treated successfully with repetitive paravertebral blocks (PVB) with bupivacaine, ketamine and methylprednisolone. A 65-yr-old male patient, ASA II, weight 55 kg, previously healthy was referred with 24 month left sided parietal chest pain diagnosed as PHN with 8–9/10 on VAS scale. Previous pain treatment included non-steroidal anti-inflammatory drugs and tramadol, combined with oral oxcarbazepine 600 mg per day and amitryptyline 75 mg per day with no improvement. A few months later, gabapentin was added at a dose of 300 mg three times per day that was increased gradually to 1800 mg per day over a 6 month period. Upon presentation, the patient was still complaining of persistent pain with a VAS=8-9/10 in the left thoracic region mainly at T4 extending to T7 associated with mood changes and sleep disturbance. Physical examination revealed an allodynia and hyperaesthesia of the corresponding dermatomes. A unilateral left sided paravertebral block at T4–T5 levels was performed with 20 ml of bupivacaine 0.125% in ketamine 25 mg and methylprednisolone 80 mg. Sedation was achieved with midazolam 2-4 mg. Three more PVB injections were given on weekly interval with the same mixture in 40 mg of methylprednisolone. Blood pressure, ECG, and SpO2 were continuously monitored throughout the procedure and for two hours in the recovery room. There were no serious complications. The patient obtained satisfactory pain relief (VAS<3) over a 6 month follow-up period. Our report showed that weekly paravertebral injections of a mixture of bupivacaine, ketamine and methylprednisolone for 4 weeks resulted successfully in sustained pain relief for PHN.

Sir, Postdural puncture headache (PDPH) is usually related to persistence of the dural hole, with leakage of cerebrospinal fluid into the surrounding soft tissue. This leads to lowering of cerebrospinal fluid pressure. This in turn produces intracranial venous dilatation resulting in an increase in brain volume (Monro–Kellie doctrine) (1). This increase in brain volume results in brain sag, which exerts traction on the surrounding nerves, vessels and meninges resulting in headache. Methylergonovine maleate (methergine) is a semisynthetic derivative of the ergot alkaloid. Stimulation of vascular smooth muscles by ergot alkaloid through their agonist action at α-adrenergic receptors is the basis for their usefulness in the treatment of migraine headaches 2-4). We planned a pilot study to evaluate the usefulness of methergine in relieving PDPH in obstetric patients based on this observation. The study was conducted on 25 obstetric patients (ASA I and II, aged 18–30 years), undergoing cesarean section under spinal anesthesia, who developed PDPH that was not relieved by bedrest, analgesics and fluids for 24 h. Following approval by the Board of Studies, these patients were administered oral tablets of methergine, 0.25 mg three times a day for 24 h. If the intensity of headache reduced or disappeared within 24 h, the treatment was carried on for a further 48 h. Tablet metoclopramide 10 mg twice a day was also advised as a prophylactic antiemetic. At 8-h intervals, patients were asked to rate their intensity of headache on a Visual Analog Scale (VAS; 1 = no headache, 10 = maximum headache). All of the patients except one (4%) showed improvement in the intensity of headache within 24 h. Of these 24 (96%) patients who responded, headache disappeared completely in four (16%) patients, and reduced to less than half in the remaining 20 (80%) (VAS < 5) in the first 24 h. By the third day all of these 24 patients were completely relieved of their headache. Only one (4%) patient who showed no improvement in her condition had to undergo the application of an epidural blood patch for relief of PDPH. The probable mechanism of action of methergine in PDPH is the vasoconstriction of cranial and extracranial vessels leading to decrease in brain volume and corresponding traction on vessels, nerves and meninges. In conclusion, this preliminary trial suggests that tablet methergine can be successfully used to relieve PDPH in postcesarean section patients.

was given over ten minutes. Four percent lidocaine oral gargle and nebulization was used to anesthetize the oral cavity and supraglottic area. In addition, bilateral superior laryngeal nerve blocks were performed. A 7.0-mm internal diameter endotracheal tube (ETT) was pre-mounted over the fibrescope. Flexible fibrescopy was done via the left nostril with a continuous flow of 3 L·min –1 oxygen through the suction port. It required 40 sec for maneuvering the fibrescope to visualize the carina. While the ETT could not be railroaded on the first attempt, a slight rotation of the ETT and a deep breath facilitated its correct placement in the trachea. The whole procedure took about 100 sec, with the patient remaining awake and responsive to command throughout. During the awake intubation, the patient’s SpO 2 remained between 97% and 99%. The heart rate varied from 88 to 96 beats·min –1 and maximum systolic blood pressure was 124 mmHg, a rise of 16 mmHg from the immediate pre-fibrescopy value. The next day, the patient described his experience of fibrescopy procedure as only mildly uncomfortable. We believe that DEX 1 mg·kg –1 iv contributed to the stability of the hemodynamic course during this brief, but intense

Intraoperative stimulation of the P6 point controls postoperative nausea and

Summary Sixty adult patients undergoing minor peripheral surgery under general anaesthesia were randomly allocated to receive either the laryngeal mask airway (laryngeal mask airway; size 4 for females and size 5 for males) or the PA Xpress TM (adult size), inserted by a single operator with experience of > 50 insertions of each device. The laryngeal mask airway was correctly placed on the first attempt in 27 patients (90%) compared with 20 patients (67%) when using the PA Xpress (p < 0.01). No patient required more than two attempts at insertion and there were no failures with the laryngeal mask airway, compared with four (13%) who needed three attempts and two failures (7%) with the PA Xpress (p < 0.001 and p < 0.01, respectively). Mean (SD) total placement time was shorter with the laryngeal mask airway [24.6 (3.1) s] than with the PA Xpress [35.4 (2.5) s; p < 0.01]. The most common complication was sore throat, which occurred less frequently with the laryngeal mask airway (8 patients; 26%) than with the PA Xpress (15 patients; 53.5%; p < 0.001).

To the Editor: PAXpress™ (Vital Signs, UK), is a new, disposable alternative to laryngeal mask airway. We observed an unusual complication—the swelling of the parotid gland—during its use. To our knowledge, there has been no previous report of such a swelling. A 35-year-old, ASA-I, 52 kg, male patient was scheduled for interlocking of left humerus. A previous general anesthetic for appendectomy was uneventful. After premedication with tramadol 1.5 mg · kg−1, midazolam 0.025 mg · kg−1, and metoclopramide 0.15 mg · kg−1, anesthesia was induced with propofol 2 mg · kg−1 and relaxation achieved with vecuronium 0.1 mg · kg−1. PAXpress™ was introduced as per the manufacturer’s guidelines. The pharyngeal balloon was inflated with air until there was no leak (45 mL). Anesthesia was maintained with oxygen, nitrous, and halothane 0.5–2%. The surgery lasted for a little over 2 h and was uneventful. Toward the end of the surgery, we noticed the pharyngeal balloon had partially shifted from the oropharynx into the oral cavity. This did not seem to have hampered the ventilation, as suggested by adequate airway pressure (18 cm H2O) good chest expansion and oxygen saturation (98–100%) throughout the procedure. After removal of the PAXpress™, we noticed a swelling in the right parotid region (Fig. 1). This nontender sialadenopathy lasted 6 h. The insertion of the PAXpress™ was smooth, and no difficulties in manual ventilation were encountered. Occlusion of the duct from inside the oral cavity is unlikely because it has a thick wall and runs a superficial course in the cheek without being apposed on any firm surface. However, since the cuff had migrated into the oral cavity, it may have occluded the ductal opening. Furthermore, stretching of the oropharyngeal structure by the slightly misplaced cuff could have caused the stimulation of the vagus nerve, triggering the profuse secretion of watery saliva and vasodilatation of the gland (1). This, along with the possible mechanical obstruction of the ductal opening, could have resulted in a transient, painless parotid swelling. Therefore, in view of the large oropharyngeal cuff, greater intraoperative vigilance monitoring the correct position of the cuff is necessary.Fig. 1: Photograph showing enlarged parotid gland following the use of PAXpress™.R. M. Khan F. Jafri W. Huda S. M. Ahmed M. Maroof

BACKGROUND:Intraoperative hypovolemia is common and is a potential cause of organ dysfunction, increased postoperative morbidity, length of hospital stay, and death. The objective of this prospective, randomized study was to assess the effect of goal-directed intraoperative fluid administration on length of postoperative hospital stay.METHODS:One hundred patients who were to undergo major elective surgery with an anticipated blood loss greater than 500 ml were randomly assigned to a control group (n = 50) that received standard intraoperative care or to a protocol group (n = 50) that, in addition, received intraoperative plasma volume expansion guided by the esophageal Doppler monitor to maintain maximal stroke volume. Length of postoperative hospital stay and postoperative surgical morbidity were assessed.RESULTS:Groups were similar with respect to demographics, surgical procedures, and baseline hemodynamic variables. The protocol group had a significantly higher stroke volume and cardiac output at the end of surgery compared with the control group. Patients in the protocol group had a shorter duration of hospital stay compared with the control group: 5 +/- 3 versus 7 +/- 3 days (mean +/- SD), with a median of 6 versus 7 days, respectively ( = 0.03). These patients also tolerated oral intake of solid food earlier than the control group: 3 +/- 0.5 versus 4.7 +/- 0.5 days (mean +/- SD), with a median of 3 versus 5 days, respectively ( = 0.01).CONCLUSIONS:Goal-directed intraoperative fluid administration results in earlier return to bowel function, lower incidence of postoperative nausea and vomiting, and decrease in length of postoperative hospital stay.

S258 INTRODUCTION: Bupivacaine 0.1 % [1] has been used to provide effective sensory blockade for ano-rectal surgery. The present study was designed to evaluate the anesthetic properties of 0.1% bupivacaine, administered intrathecally in the sitting position for patients undergoing McDonald cerclage. METHODS: Following Institutional Research Board approval 10 ASA I and II adult female patients (29 +/- 5.3 yrs, 74 +/- 8.7 kg, 173 +/- 4 cm) undergoing elective McDonald cerclage were selected for this study. All patients had a forearm vein cannulated in the preanesthetic room and an infusion of lactated Ringer's 1.5 ml x kg-1 x hr-1 started without loading dose of crystalloid and this was not altered during the perioperative period. Dural puncture was performed in the lateral position under aseptic conditions using a 27-gauge Whitacre type spinal needle at the L3-4 space. Dural puncture was confirmed by aspiration of CSF. Spinal anesthesia was produced with 5 ml bupivacaine, 0.1%, given over 15-20 sec. The bupivacaine solution was prepared by taking 1 ml plain bupivacaine, 0.5% and mixing it with 4 ml distilled water. The solution had a specific gravity of 1.001 at 20[degree sign] C by refrectometer (Atago Co., Japan). Heart rate (HR), non-invasive arterial pressure, ECG and oxygen saturation were monitored during the perioperative period. Levels of sensory and motor block were monitored as per study protocol. RESULTS: The results of the variables recorded are expressed as mean +/- SD, or as median (range) for ordinal data (a) Time taken to perform the spinal block (7.2 +/- 2 min)(b) Onset time, progression and upper level of sensory blockade evaluated by pin prick (5.4 +/- 0.7 min) and the extent of motor block (1 = full motor movement at ankle and knee joint, 2 = restricted motor movements, 3 = full motor block, no movements) were measured at one-minute intervals for the first five minutes, then every five minutes for 30 min (the motor power was preserved in all patients). The number of dermatomes blocked was noted (median9, 7-12); (c) Heart rate and mean arterial pressure were recorded preoperatively (78.8 +/- 17, 90 +/- 8) and at 1 (77 +/- 16, 91 +/- 9), 5 (77 +/- 14, 89 +/- 8) 10 (78 +/- 13, 89 +/- 10) 20(80 +/- 15, 87 +/- 9) and 30 (75 +/- 16, 90 +/- 6) min after the post-spinal block; (d) Patients were discharged from the Post Anesthetic Recovery Room (PARR) on return of sensation and the ability to bend the knees and flex the hips (58 +/- 6.7 min); (e) Time of first post-surgical analgesic requirement requested by the patient (284 +/- 109 min). Repeated measure ANOVA was performed for statistical analysis of hemodynamic values. This was followed by Fisher PLSD, Scheffe F-test and Dunnett "t" test. Linear regression analysis was used to examine the correlation between dermatomes blocked at 30 min and age, height, weight and the postoperative analgesia requirements. There was no correlation between the level of sensory block and height, weight or age of patients. No post-spinal headache was observed in any patient. CONCLUSION: In conclusion, spinal anaesthetic with 5 ml, bupivacaine 0.1%, was found to be effective and safe for cerclage surgery with well preserved hemodynamic and motor power with prolonged post operative analgesia.

S66 INTRODUCTION: Open-heart bypass surgery and some other surgical procedures are frequently associated with considerable blood loss and require transfusion. To minimize complications and cost the practice of salvaging and retransfusing blood in patients with high normal haematocrits who may involve considerable perioperative blood loss is fairly common [1]. This reduces the risks associated with blood transfusion and provides patient with the clotting factors and platelet. There are several studies on risks and benefits of hemodilution [2,3] but no study addresses the issues related to heparinized blood removal at the commencement of cardiopulmonary bypass. In this study we compared post operative blood loss in patients who had blood removed either before or after the heparinization. This blood was reinfused to them at the end of cardiopulmonary bypass. METHODS: Following Institutional Research Board approval 60 patients 18 years of age undergoing elective coronary artery bypass graft surgery with a Hct of 35% were recruited for the study. Patients with renal, liver pulmonary and congenital heart disease and also those on heparin or warfarin treatment were excluded, informed consent was obtained. All patients were anesthetized using a standard cardiac anesthesia for their surgery including preoperative placement of arterial line, pulmonary artery catheter and peripheral intravenous line. Patients were randomly assigned to three groups. Patients in Group I had no blood withdrawn and were served as a control group. The patients in Group II had blood removed (7 ml/kg) after the induction of anesthesia via cordis into a Baxter Fenwall blood pack unit containing citrate phosphate solution and this was simultaneously replaced with an equal volume of 5% albumin. This process was completed before heparinization. Group III patients had their blood withdrawn after heparinization but before it reached the pump at the commencement of cardiopulmonary bypass. All patients had their haemodynamic parameters recorded during the entire length of their operation. All patients had their postoperative blood drainage measured and recorded for 24 hours postoperatively. The principal analysis will be whether the blood removal and reinfusion process reduces the average amount of bleeding in the post-operative period. The study will also examine whether there is any significant difference in the haemodynamic parameters among the three groups. Statistical comparisons within a study group were determined by repeated measures analysis of variance and Dunnett's multiple range test. Between-group comparisons were analyzed by one-factor analysis of variance at each time point. Albumin effect was examined by two-factor repeated measures analysis of covariance. P < 0.05 was considered significant for all statistical tests. All statistical analyses were carried out using STATVIEW 512+ software (Brainpower, Inc., Calabasas, Calif.) RESULTS: The results are expressed as mean ± SD. There was no statistical difference in age, wt, ht or hemodynamic variables. Use of albumin was statistically different amongst Gr 1 (425 +/- 270) and Gr II (575 +/- 152) p=0.031. Post operative blood loss Gr 1(588 +/- 175), Gr II (707 +/- 247), Gr III (661 +/- 245) was not statistically different in any group. CONCLUSION: In conclusion in our study the blood removal for hemodilution and reinfusion either before or after the heparinization did not make any difference in post operative blood loss,