End tidal concentration of sevoflurane and isoflurane for adequate depth of anaesthesia in caesarean section guided by BIS

Inadequate hypnosis in the absence of opioid analgesia may account for the increased incidence of awareness in caesarean section before delivery of the neonate. We investigated the concentration of sevoflurane and isoflurane required to maintain bispectral index [BIS] < 60 unitl delivery occurred. We enrolled 40 ASA physical status I, II parturients in an up-down sequential allocation study [group I [sevoflurane group] 20 patients and group II [isoflurane group] 20 patients]. The median effective end-tidal concentration [EC50] of sevoflurane and isoflurane was defined as that which maintain BIS<60 between skin incision and delivery in 50% of patients. The EC50 for sevoflurane and isoflurane was 1.2% [1.06-1.31] and 0.8% [0.64-0.92] respectively. There was no postoperative awareness in all patients in both groups. There were no differences regard haemodynamic parameters [HR-MAP] between both study groups. We conclude that sevoflurane concentration of at least 1.2-1.3% and isoflurane concentration of at least 0.8-0.9% should be administered during caesarean section to minimize the risk of awareness and recall

Premedication with low-dose oral midazolam reduces the incidence of emergence agitation in paediatric patients after sevoflurane anaesthesia

Sevoflurane is a volatile anaesthetic agent with low pungency, nonirritating odor, and low blood/gas partition coefficient that makes it an attractive alternative to halothane. However, a high incidence of emergence agitation [EA] has been reported in paediatric patients after sevoflurane anaesthesia. The underlying mechanism of sevoflurane-induced EA remains unclear. Rapid recovery of consciousness [emergence] from sevoflurane anaesthesia has been proposed as one possible mechanism. It was, therefore, hypothesized that sedatives such as midazolam may counteract sevoflurane's rapid emergence and thus reduce the incidence and the severity of sevoflurane-induced EA. This prospective, controlled, single-blinded study included 88 ASA class I or II paediatric patients scheduled for elective outpatient surgery. Patients were assigned to receive either oral midazolam [0.2 mg kg-_ as anaesthetic premedication] or saline [oral normal saline as premedication] before the conduct of anaesthesia. Induction and maintenance of anaesthesia were uniform in both groups. Induction of anaesthesia was made possible with 8% sevoflurane and N2O in 50% O2. Intubation was performed straight without the aid of muscle relaxant and the ventilator was set to maintain normocapnia. Anaesthesia was maintained with 3% sevoflurane and N2O in 50% O2 until the surgery was over. All matters of relevant time periods were recorded [induction, surgical procedure, extu bation and transportation]. In the post-anaesthesia care unit [PACU], adverse events, the incidence and the severity of EA, analgesic requirement, duration of PACU stay, and parental as well as PACU nurses' satisfaction were evaluated. A significant lower incidence and less severity of EA were noted in patients premedicated with midazolam. Less postoperative analgesia was required in patients who had received midazolam. Although midazolam premedicated patients remained sedated after sevoflurane anaesthesia, the duration of the PACU stay was not significantly different from that of saline-treated patients. Both parents and PACU nurses were more satisfied with midazolam as premedication. It was concluded that premedication with oral midazolam is safe, convenient and effective in decreasing the occurrence of sevoflurane-induced Emergence agitation [EA]. It does not delay discharge from PACU and is suitable for outpatient surgery

Sub-tenon's block in cataract surgery a comparison of 2% articaine and a mixture of 2% lignocaine and 0.5% bupivacaine

Articaine is a novel amide local anaesthetic with a shorter duration of action than prilocaine. Sub-Tenon's anaesthesia arguably provides a safer method of anesthetic delivery for cataract surgery. In our study we compared 2% articaine with mixture of 2% lignocaine and 0.5% bupivacaine through sub-Tenon's block for cataract surgery. 60 ASA [American Society of Anesthesiologists] I-III patients were selected for comparison and allocated in two equal groups in randomized double-blinded study. We found that sub-Tenon's block using articaine 2% resulted in a more rapid onset of motor block than lidocaine / bupivacaine mixture [mean time to readiness for surgery was 3.3 +/- 2.4 [SD] min. in articaine group vs. 5.1 +/- 3.2 [SD] min. in lidocaine/bupivacaine group [p=0.0077]. Ocular movement scores were significantly lower from 2 min. after injection until the end of surgery p = 0.021 [p

Sumatriptan and gabapentin for treatment of postdural puncture headache

Postdural puncture headache [PDPH] is one of frequent adverse complication of dural puncture. Although, it is a self limiting and non-fatal condition, its postural nature prevents the patient from performing routine activity and may make them anxious and depressed. In this study we evaluate a combination of sumatriptan and gabapentin for treatment of PDPH and compare it with sumatriptan or gabapentin as sole medication. ASA I and II 45 patients age between 20 and 40 years and non-parturient, who's developed PDPH after spinal or epidural neuraxial block was included in the study. Patients were randomized to receive either gabapentin 300 mg orally every 8 hours for one week group I, in group II patient was received sumatriptan 50 mg orally once daily for 3 successive days. In group III, patients received sumatriptan 50 mg orally every day for 3 days and gabapentin 300 mg every 8 hours for 7 days. PDPH was evaluated by using Visual Analog Scale [VAS], measured 20 min after patients assumed upright postures either sitting or standing. It was recorded before start the treatment as baseline and at 12, 24, 36, 48, 72 and 96 hours after. Satisfaction of patients with treatment was asked, after 4 days. Complications such as somnolence, dizziness, seizures, chest pain, nausea, vomiting and dry mouth were recorded. VAS was significantly low and patient satisfaction was high in group III when compared with the other two groups. Number of patients reported somnolence and dizziness were significantly high in group III compared to group I or II. Combination of sumatriptan and gabapentin could be beneficial for treatment of patients with PDPH, more than sumatriptan or gabapentin alone, as it relief the headache and decrease usage of epidural blood patch which is invasive and not safe procedure

Intraocular pressure during lumbar disc surgery - a comparative study between prone position and knee-elbow position

Post-operative visual loss occurs more commonly in spinal surgery. Increased intra-ocular pressure is often Implicated In the etiology of postoperative visual impairment. We Investigated intraocular pressure in 20 patients undergoing lumber disc surgery. We classified the patients into two groups: Group I: patients were in the knee-elbow position with the head resting on a cushion and turned to one side and group II: patients were in prone position and the head neutral. We classified patients in knee-elbow position into two sub-groups: subgroup A where we measured IOP in nondependant eye and subgroup B where we measured IOP in dependant eye. In both groups we measured lOP during 2 times, the first time in both group when the patients were awake and In supine position and the second time was In group I at the end of surgery when the patients were still anesthetized and in knee elbow position and in group II at the end of surgery when the patients were still anesthetized and in prone position. In group I after mean duration of surgery 120 +/- 18 min. [mean +/- SD], the mean intra-ocular pressure in the non-dependnnt eye was unchanged when compared to awake state 16.3 +/- 2.1 vs. 17.2 +/- 3.2 mmHg [p >/= 0.05]. whereas the intraocular pressure in the dependant eye had significantly increased 17.1 +/- 2.2 vs. 19.2 +/- 1.1 mmHg [p<0.05]. In group II after mean duration of surgery 119 +19 mmHg, mean Intra-ocular pressure had highly significant increase compared to awake state 16.7 +/- 2.2 vs. 21.3 +/- 2.1 mmHg [p<0.01]. We conclude that IOP increased when anesthetized - patients are placed in prone position more than when placed in knee-elbow position

Hemodynamic and catecholamine stress responses to insertion of the combitube as an alternative airway management in general anaesthesia for caesarean section

The introduction of Combitube to the field of airway management brought about a solution of the problem of difficult airway in trauma patients and during cardiopulmonary resuscitation. This trial was designed to assess the efficacy of Combitube in preventing the lethal complications of failed Intubation during caesarean section and compare the haemodynamic and stress response to the device with that resulting from endotracheal intubation. Forty-five healthy parturients scheduled for CS were randomized Into three equal groups. Combitube was inserted blindly in group I and facilitated by laryngoscopy in group II In group III, endotracheal intubation was performed under laryngoscopy. Patients were assessed for the degree of difficulty of insertion of the Combitube, manifestation of regurgitation or trauma to the oropharynx. haemodynamic changes and hormonal response to Combitube Insertion and endotracheal intubation. There was no significant difference in the degree of ease on Introduction of Cornbitube in group I as compared to group II. Combitube proved to be a safeguard against regurgitation as group I and II were compared to group III A high incidence of trauma was noticed in group I during blind insertion of Combitube as compared to laryngoscopy aided insertion in group II or endotracheal Intubation in group III Laryngoscopy aided Insertion of Combitube [group II] or endotracheal intubation [group III] produced a significant increase In heart rate as compared to blind insertion in group I. Comparison between groups II and III showed a significant increase In HR in group III. Systolic blood pressure Increased significantly in group III while the other two groups manifested an insignificant increase. Stress hormones manifested increases in all the groups. Nor- adrenaline level increased insignificantly in group I and II. while it was statistically significant In group III. Adrenaline levels increased insignificantly in all the study groups. Prolactine level increased insignificantly In group I and manifested a significant increase in groups II and III. This Increase was significantly higher in group III as compared to group II. It is concluded that Combitube provides a safe patent airway not only in emergency situations but also in patients scheduled for surgery if they were at risk of aspiration or difficult intubation as those scheduled for caesarean section

dose response study of three different concentrations of clonidine with local anesthetic mixture for peribulbar block

Clonidine, the alpha[2] agonist prolong anesthesia and analgesia when added to local anesthetics, in epidural anesthesia, subarachnoid anesthesia, plexus anesthesia and retrobulbar block. We evaluate the dose-response relationship of different concentrations of clonidine added to lidocaine in peribulbar block. Sixty patients undergoing cataract surgery were given peribulbar block with 7-10 ml of 2% lidocaine and hyaluronidase with either saline [control] or clonidine 0.5 ug/kg [0.5 clon] 1.0 ug/ kg [1.0 clon] or 1.5 ug/kg [1.5 clon] doses. The onset of globe anesthesia, akinesia and analgesia, the duration of anesthesia and analgesia, the postoperative analgesia requirement and the adverse effects [Hypotension, bradycardia, hypoxia, sedation and dizziness] were recorded. The onset of block was comparable in all groups. The duration of globe anesthesia, analgesia and akinesia was significantly [p<0.01] prolonged in patients receiving 1.0 and 1.5 ug/kg clonidine as compared with the control group. Perioperative pain scores and analgesic requirements were significantly less in these groups. 0.5 ug/kg clonidine did not significantly increase the duration of anesthesia and analgesia. The side effects were observed more with 1.5 ug/kg clonidine as compared with other groups. We conclude that 1.0 ug/kg clonidine significantly prolong the anesthesia and analgesia when mixed with local anesthetic with minimal side effects