Dexmedetomidine as an Adjuvant to Bupivacaine in Caudal Analgesia in Children Undergoing Infra-Umbilical Surgery.

When performing infra-umbilical procedures, caudal epidural analgesia with bupivacaine is frequently used to provide both intra- and post-operative analgesia. Dexmedetomidine, an alpha 2 agonistsare extensively used in neuraxial blocks and peripheral nerve blocks to prolong the action of bupivacaine. To find out the effects of dexmedetomidine as an adjuvant to bupivacaine for caudal analgesia in children undergoing infra-umbilical surgery. This was a randomized, controlled double-blinded prospective observational study and was performed from July 2019 to December 2019. A total of 60 (Sixty) patients with different infra-umbilical surgical problems underwent different procedure under caudal anaesthesia in different operation theatre in Bangabandhu Sheikh Mujib Medical University, Dhaka were enrolled in this study. Elaborate personal history, meticulous clinical examinations and relevant laboratory investigations was done. Post-operative adverse effects also were monitored. All information from history of illness, clinical, laboratory findings, duration of analgesia and post-operative adverse effects were recorded in a preformed data sheet (Appendix-I) and statistical analysis was done by SPSS 22.0. Mean age of the children in Group A (dexmedetomidine + bupivacaine) was 5.50±2.61 years and in Group B (bupivacaine) was 5.66±2.75. Mean weight of the children in Group A was 19.22±8.58 kg and in Group B was 19.70±8.94 kg in this study. Mean duration of anaesthesia was 27.5±6.5 minute in Group A and 28.5±5.5 minute in Group B. The mean duration of analgesia was 4.32±0.54 hours for Group A and 2.12±0.32 hours in Group B. In Group A, 46.7% patients required 1 and 3.3% required 2 rescue analgesic but in Group B, 43.3% patients required single rescue analgesic and 33.3% required two rescue analgesics (p<0.05). In Group A, 6.7% patients had nausea/ vomiting and in Group B, 16.7% patients had nausea/ vomiting (p>0.05). It can be concluded that dexmedetomidine with bupivacaine for caudal analgesia in infra-umbilical surgery significantly prolongs the duration of postoperative analgesia when compared to bupivacaine alone without any side-effects.

Assessment of Difficulties Associated with Endotracheal Intubation using Modified Mallampati and Upper Lip Bite Test.

This study was aimed at finding the parameters for prediction of difficulty in endotracheal intubation, that are easy to examine and that could better predict difficulty. The current observational prospective, cross sectional study was conducted in the department of Anaesthesia, Analgesia and Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from March 2015 to September 2015 comprising 180 patient of both sexes requiring endotracheal intubation were arranged into two groups, Group A: Modified Mallampati test Group and Group B: Modified Mallampati & upper lip bite test group (combined) Assessment of difficulty in intubation was done by Cormack & Lehane direct Laryngoscopic grading. Outcome was measured as no difficulty or difficulty in intubation. In Group A 33 cases were true positive, 15 false negative, 26 false positive, 16 true negative. In Group B 53 cases were true positive, 1 false positive, 8 false negative, 28 true negative. The validity tests for Group A for evaluation of difficult intubation were indicated by sensitivity 55.9%, Specificity 51.6%, Accuracy 54.41%, Positive predictive value 68.8% and Negative predictive value 38.1%. The values for Group-B were 86.9%, 96.6%, 90.0%, 98.1% and 77.8% respectively. Combined modified Mallampati & Upper Lip Bite Test has definite value in the diagnosis of difficulty in intubation and can be regarded as sensitive & specific test for operative discrimination of the patient.

Comparison of three fluid regimens for preloading in elective caesarean section under spinal anaesthesia.

The most common problem associated with subarachnoid block (SAB) for caesarean section remains the rapid onset of profound hypotension. This study was designed to compare the incidence of hypotension after preloading with Ringer's Lactate, Hydroxyethylstarch and combination prior to SAB in caesarean section. Ninety non-labouring ASA grade 1 and 2, aged 20-35 years, weight and height was 45-60kg and 153-165cm respectively divided randomly into three groups. Group-RL received Ringer's Lactate 20ml/kg as preloading fluid. Group-H received Hydroxyethylstarch-6% 8ml/kg and Group-RLH received preloading fluid with combination of Ringer's Lactate 10ml/kg and Hydroxyethylstarch-6% 4ml/kg. Blood pressure (Systolic, Diastolic & Mean arterial pressure) was measured every 5 minute for 20 minute and every 10 minutes thereafter. Hypotension was less in Group-RLH (6.7%) whereas in Group-H and Group-RL hypotension was 20% and 47.7% respectively. Systolic blood pressure decreased significantly in all three groups. But the decreasing was less in Group-RLH than other two groups. Less IV fluid was required in Group-RLH (403ml) and Group-H (577ml) in comparison to Group-RL (1032ml) to prevent and treat peroperative hypotension. No ephedrine was needed in Group-RLH. Variation in Pulse rate was not significant in Group-RLH (p=0.061). But in other two groups it was highly significant (Group RL p≤0.001 and Group H p=0.004). There was no significant difference in neonatal outcome between three groups. Preloading with low volume colloid (4ml/kg) plus crystalloid (10ml/kg) is superior to crystalloid or colloid alone.

Postoperatve pain relief in children after subumbilical surgeries-a comparison between caudal bupivacaine and bupivacaine-clonidine.

In a randomised case control study in children undergoing elective subumbilical surgery, we have assessed the clinical value of bupivacaine and bupivacaine-clonidine mixture for caudal analgesia. Sixty children aged 2-10 years, were allocated randomly to two equal groups (n=30) to receive 0.25% bupivacaine 1ml/kg (Group I) and 0.25% bupivacaine 1ml/kg with clonidine 2µg/kg (Group II). The baseline haemodynamic parameters, heart rate and blood pressure were recorded. Intraoperatively children in both groups maintained haemodynamic stability and required less amount of muscle relaxant. Duration of analgesia in minutes was assessed by the time interval between the caudal extradural injection and the first analgesic demand by the patient. It was significantly longer (p=0.000) in Group II (712 ± 15.30 minutes) as compared with Group I (246 ± 8.74 minutes). Group II required significantly less supplementary analgesia after operation. There was no significant difference in the incidence of side effects between the two groups. Group I received more doses of diclofenac suppository in first 24 postoperative hours. We conclude that, when added to bupivacaine, clonidine improves the duration of caudal analgesia in children undergoing subumbilical surgery.