Comparative Study of Spinal, Epidural, and Sequential Combined Spinal Epidural Anesthesia in Geriatric Patients for Transurethral Resection of the Prostate.

BACKGROUND:  Sequential combined spinal epidural anesthesia (CSEA) is probably the greatest advancement in the central neuraxial block in this decade for geriatric patients due to the potential advantages of both spinal and epidural anesthesia. This study was designed to compare the clinical effects of sequential CSEA versus spinal and epidural anesthesia in geriatric patients undergoing transurethral resection of the prostate (TURP). METHODS:  Ninety patients aged 65 to 80 years were randomly allocated into three groups of 30 each. Group A (n=30) patients were administered spinal anesthesia with 2.5 ml of 0.5% hyperbaric bupivacaine, group B (n=30) received epidural anesthesia with 15 ml of 0.5% isobaric bupivacaine, and group C (n=30) received sequential CSEA with 1 ml of 0.5% hyperbaric bupivacaine and 6 ml of 0.5% isobaric bupivacaine given through epidural route to extend the block up to T10. Patients were observed for hemodynamic parameters, sensory and motor block, total dose required to establish the desired level, and patient satisfaction score. RESULTS: None of the patients were excluded in the study. Group A patients reported rapid onset of sensory block (3.08±11.57 minutes) compared to group B (11.57±1.48 minutes), and group C (5.47±1.25 minutes). The onset of motor block was expeditious in group A (8.08±1.0 minutes) compared to group B (20.33±1.86 minutes) and group C (15.53±1.31 minutes). Patients in group B had maximum hemodynamic stability but with delayed onset and were technically more complex than group A. Patients in group C were hemodynamically more stable than group A. They had a faster onset of action with decreased doses of local anesthetic drug required compared to group B. CONCLUSION: Sequential CSEA is a safe, effective, and reliable technique that combines the advantages of both spinal and epidural while minimizing their disadvantages. It has the advantage of stable hemodynamic parameters along with the provision of prolongation analgesia for geriatric patients undergoing TURP surgery.

Comparing the Effect of Phenylephrine Bolus and Phenylephrine Infusion for Maintaining Arterial Blood Pressure During Cesarean Delivery Under Spinal Anesthesia: A Randomized Prospective Study.

INTRODUCTION:  Maternal hypotension is a common complication of spinal anesthesia in cesarean section and requires immediate intervention. Phenylephrine is most commonly used as a vasopressor agent for the treatment of hypotension due to subarachnoid block. Our aim was to compare the bolus dose of 50 µg of phenylephrine with a fixed infusion at 50 µg.min-1 of phenylephrine for maintaining arterial blood pressure during cesarean delivery. MATERIALS AND METHOD:  This was a prospective, randomized comparative study. One hundred normotensive pregnant females aged 18-35 years, body mass index 18-29kg.m2, American Society of Anesthesiologists (ASA) physical status classification II scheduled to undergo cesarean section (elective/emergency) under spinal anesthesia were randomly divided into two groups of 50 each. Group PB received a bolus dose of phenylephrine 50 µg after they developed hypotension i.e., a decrease in systolic blood pressure (SBP) ≥ 20% from the baseline. Similarly, patients in Group PI were administered prophylactic infusion using a syringe pump of phenylephrine 50 µg.min-1, started just after the administration of subarachnoid block. The phenylephrine infusion was continued either till the delivery of the baby or when SBP rises >20% above the baseline. Parameters like blood pressure, heart rate, and peripheral oxygen saturation were recorded. After the delivery of the baby, the neonatal APGAR score was assessed at one minute and five minutes. RESULTS: Demographic data were comparable in terms of demographic profile, duration of surgery, and ASA physical status classification between the groups. The heart rate was higher in Group PB compared to Group PI throughout the monitoring period (P<0.001). The fall in mean blood pressure was more in Group PB compared to Group PI till 18 minutes of surgery and was statistically significant (P<0.05). After 18 minutes of surgery, mean blood pressure stabilized and was comparable between the groups. Other variables like APGAR score at one minute and five minutes were comparable between the groups. Bradycardia and hypertension were more common in Group PI whereas hypotension, nausea, and vomiting were more common in group PB. CONCLUSION: We concluded that during cesarean section under spinal anesthesia, phenylephrine infusion provides better hemodynamic stability and APGAR score during the perioperative period.

Comparative Study Between Conventional Landmark Versus Ultrasound-Guided Paravertebral Block in Patients Undergoing Laparoscopic Cholecystectomy: A Randomized Controlled Study.

INTRODUCTION: Thoracic paravertebral block (TPVB) has emerged as an effective and safe regional technique for providing postoperative analgesia. We aimed to compare the ease and efficacy of conventional landmark and ultrasound-guided (USG) paravertebral blocks for postoperative analgesia in patients undergoing laparoscopic cholecystectomy. METHODS: This was a randomized controlled study. Seventy-six patients of either sex, age 18-40 years, body mass index (BMI) 18-29 kg/m2, American Society of Anesthesiologists physical status classifications I and II posted for elective laparoscopic cholecystectomy under general anesthesia were randomly allocated into two groups of 38 each. Patients in group A were administered a paravertebral block using the anatomical landmark technique (ALT), and group B using an ultrasound-guided paravertebral block in the sitting position. In both groups, 20 ml of 0.5% bupivacaine injection was administered at the T7 vertebral level on the right side. The primary outcome was the first-pass success rate. Secondary outcomes were the number of passes and attempts, duration of analgesia, visual analog scale (VAS) score for pain during 24 h postoperatively and complications if any, were recorded. RESULTS: No patients were excluded in the study. Demographic characteristics were comparable in both groups. The number of passes was less in group B (1.45±0.5) compared to group A (2.42±0.95) and was reported to be statistically significant (p = 0.001). The number of attempts was less in group B (1.00±0) as compared to group A (1.29±0.46) and was statistically significant (p = 0.001). The duration of analgesia was longer in group B (530.00±326.33 minutes) compared to group A (345.60±252.95 minutes) and was observed to be statistically significant (p<0.05). The VAS score was significantly lower in group B (1.87±0.78, 2.24 ±0.82) compared to group A (2.42±0.72, 3.13±1.07) at the second and fourth hours, respectively (p = 0.001).  Conclusion: We concluded that paravertebral block using an ultrasound-guided technique is more efficacious than the conventional landmark technique for postoperative analgesia in patients undergoing laparoscopic cholecystectomy.

Comparison of Intravenous Granisetron and Ondansetron on Hemodynamics and Sensory Motor Block After Spinal Anaesthesia With Hyperbaric Bupivacaine in Patients Undergoing Elective Surgery: A Randomized Double-Blind Study.

BACKGROUND: Bezold Jarisch reflex (BJR) is mediated by peripheral serotonin receptor 5-HT3 type. BJR and sympathetic blockade are important causes of hypotension and bradycardia after spinal anaesthesia. Premedication with serotonin receptor antagonists has a role in the attenuation of hemodynamic disturbances. AIM: To compare the effect of intravenous granisetron and ondansetron on the hemodynamic and sensory-motor block after spinal anaesthesia with hyperbaric bupivacaine in patients undergoing elective surgery. METHODOLOGY: Ninety patients posted for elective surgery under spinal anaesthesia were randomly divided into three groups of 30 each. Group A patients received ondansetron 4mg, group B received granisetron 1mg, and group C received normal saline intravenously. Hemodynamic variables such as heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and peripheral oxygen saturation, were recorded at baseline and then 2 minutes intervals for 20 minutes and thereafter every 5 minutes till the end of the surgery. The onset and duration of sensory and motor block were recorded at baseline and then every 2 minutes till the complete block was achieved. RESULT: No patient was excluded from our study. During the intergroup comparison, heart rate and mean arterial pressure remained stable in group A compared to groups B and C. Time to reach peak sensory block level T4 was faster in group A compared to group B and group C. The rate of sensory block regression to two segments (T4 to T6) and thereafter up to T10, T12, and S1 was faster in group B compared to groups A and C. The attainment of complete motor block, Modified Bromage Score (MBS)=4 was faster in group A compared to group B and group C. The rate of motor block regression to MBS=3 and MBS=0 was faster in group B compared to group A and group C. CONCLUSION: Premedication with ondansetron 4mg and granisetron 1mg intravenously significantly reduces ephedrine use. Ondansetron provides better hemodynamic stability, earlier onset of the sensory and motor blocks as well as prolonged duration of sensory and motor blocks, and duration of analgesia compared to granisetron.

Comparison of Ropivacaine Plus Dexmedetomidine and Ropivacaine Plus Magnesium Sulfate Infiltration for Postoperative Analgesia in Patients Undergoing Lumbar Spine Surgeries.

BACKGROUND:  Acute pain after lumbar spine surgery is due to soft tissue and muscle separation at the operation site. Local anesthetic wound infiltration is a safe and effective method for postoperative analgesia following lumbar spine surgery. In this study, we aimed to investigate and compare the efficacy of ropivacaine plus dexmedetomidine and ropivacaine plus magnesium sulfate for postoperative analgesia in lumbar spine surgeries. MATERIALS AND METHOD: This prospective randomized study was conducted on 60 patients, aged between 18 and 65 years, either sex, American Society of Anesthesiologists classification I and II patients scheduled for single-level lumbar laminectomy. Patients were randomly allocated into two groups 30 patients each. Twenty to 30 minutes before skin closure and after hemostasis was achieved, the surgeon infiltrated 10 mL of study drugs into paravertebral muscles on each side. Group A received 20 mL of 0.75% ropivacaine plus dexmedetomidine and group B received 20 mL of 0.75% ropivacaine plus magnesium sulfate. Postoperative pain was assessed by the visual analog scale at 0 minute (immediately after extubation), 30 minutes, 1st hour, 2nd hour, and thereafter at 4th hour, 6th hour, 12th hour, and 24th hour. Time to rescue analgesia, total analgesic consumption, hemodynamic variables, and complications if any were recorded. Statistical analysis was done using SPSS version 20.0 (Armonk, NY: IBM Corp.). RESULTS: The time to first requirement of analgesia in postoperative period was significantly longer in group A (10.05 ± 1.62 hours) than in group B (8.07 ± 1.83 hours) (p < 0.001). Total analgesic consumption was significantly higher in group B (197.50 ± 36.76 mL) compared to group A (142.50 ± 22.88 mL) (p < 0.001). Heart rate and mean arterial pressure were significantly lower in group A compared to group B (p < 0.05). CONCLUSION: Local infiltration of surgical site with ropivacaine plus dexmedetomidine provided better pain control than ropivacaine plus magnesium sulphate infiltration and is safe and effective analgesia for patients undergoing lumbar spine surgeries in postoperative period.

Comparative Study of Epidural Dexmedetomidine, Fentanyl, and Tramadol as Adjuvant to Levobupivacaine for Lower Limb Orthopedic Surgeries.

Background Dexmedetomidine, fentanyl, and tramadol as an adjuvant to local anesthetics improve postoperative analgesia when used in epidural anesthesia. We aimed to compare the efficacy of dexmedetomidine, fentanyl, and tramadol as an adjuvant to levobupivacaine in epidural anesthesia. Materials and methods This was a double-blinded randomized clinical trial (RCT). One-hundred twenty patients of either sex, aged 18-60 years, American Society of Anesthesiologists (ASA) physical status classification I and II, undergoing elective orthopedic procedures under epidural anesthesia were allocated into four groups of 30 each. The dexmedetomidine group received 15 ml of 0.5% levobupivacaine and 25 µg in 2 ml of dexmedetomidine, the fentanyl group received 15 ml of 0.5% levobupivacaine and 50 µg in 2 ml of fentanyl, the Tramadol group received 15 ml of 0.5% levobupivacaine and 100 mg of tramadol in 2 ml, and the control group received 15 ml of 0.5% levobupivacaine and 2 ml normal saline. Patients were monitored for the total duration of analgesia, time of first analgesic requirement, time to reach the T-10 level of sensory block, two-segment regression time of the sensory block, time to reach the motor block (Bromage 3), time to motor regression (Bromage 2), visual analog scale (VAS) scores at 0, 15 minutes, 30 minutes, and the first, second, sixth, twelfth, and twenty-fourth hours postoperatively, total analgesic consumption in 24 hours, and complications, if any, were recorded. Results During the inter-group comparison, VAS scores were lower, the duration of analgesia was longer, and the total analgesic consumption was less in the dexmedetomidine group compared to the fentanyl, tramadol, and control groups. The time to onset of sensory block to T-10 and the attainment of motor block up to Bromage 3 was lower in the dexmedetomidine group. Two segment regression and regression of motor block to Bromage score 2 was lowest for the dexmedetomidine group compared to the other groups. A lower incidence of hypotension and bradycardia was noted with dexmedetomidine. Conclusions Dexmedetomidine is the better alternative as an adjuvant to epidural anesthesia, with faster onset, good quality, and prolonged duration with no relevant adverse effects.

Anesthetic Stability of Propofol, Dexmedetomidine, and Isoflurane by Measuring Bispectral Index (BIS) and Hemodynamic Indices: A Comparative Study.

Background Hemodynamic changes and anesthetic awareness occurring during surgery under general anesthesia is a great concern for both surgeon and anesthesiologist. Maintenance of the adequate depth of anesthesia throughout the intraoperative period is important in maintaining hemodynamic stability, preventing intraoperative awareness, and avoiding postoperative recall. Aim This study aims to predict the anesthetic stability of propofol, dexmedetomidine, and isoflurane by measuring bispectral index (BIS) and hemodynamic indices. Materials and methods This is a prospective comparative study. Sixty patients of either sex, aged 18-60 years, with American Society of Anesthesiologist (ASA) physical status classification I and II, undergoing elective surgical procedures requiring general anesthesia were allocated into three groups of 20 each. Patients in each group were administered standard general anesthesia with routine hemodynamic monitoring along with BIS, and values were recorded at baseline and thereafter at every five-minute interval for the duration of surgery. Anesthesia was maintained in Group P using a bolus dose of propofol 1 milligram.kg-1 for 10 minutes followed by propofol infusion 50-75 microgram.kg-1.minute-1, Group D with a bolus dose of dexmedetomidine 1 microgram.kg-1 for 10 minutes followed by infusion 0.2-0.7 microgram.kg-1.hour-1, and Group I with isoflurane at 1 minimum alveolar concentration (MAC) for 10 minutes and then maintained between 0.5 MAC and 1.5 MAC until the duration of surgery. To maintain the surgical plane of anesthesia, the BIS score was monitored between 40 and 65. The quantitative variables were expressed as mean±SD and compared between groups using Student's unpaired t-test. Data analysis was done using SPSS Statistics for Windows version 20.0 (IBM Corp., Armonk, NY, USA). A p-value of <0.05 was considered statistically significant. Results During intergroup comparison among study drugs, the mean BIS values were statistically significant among the groups (p<0.05). Hemodynamic indices were significantly better maintained in the dexmedetomidine group as compared to the isoflurane and propofol groups throughout the intraoperative period (p<0.05). Conclusion Dexmedetomidine is better than propofol and isoflurane in maintaining the BIS score and hemodynamic parameters during the intraoperative period.

Wound Infiltration and Instillation Technique for Postoperative Analgesia Using Bupivacaine in Patients Undergoing Lumbar Spine Surgeries.

BACKGROUND: Pain relief after surgery continues to be a major medical challenge in clinical practice. Lumbar spine surgery is associated with significant postoperative pain. Providing optimal analgesia locally in the area of surgical wound, with little systemic side-effects, is a favourable option and has become an intrinsic part of multimodal analgesia. We aimed to assess and compare the effectiveness of local infiltration and instillation of bupivacaine for postoperative analgesia in patients undergoing lumbar spine surgery. MATERIALS AND METHODS: Forty-four adult patients of the American Society of Anesthesiologists (ASA) class I and II were randomly assigned into two groups, incorporating 22 patients per group. After the completion of lumbar spine surgery and after hemostasis was achieved, patients in group A received instillation of 20 ml of 0.25% bupivacaine at the surgical wound site and patients in group B received 20 ml of 0.25% bupivacaine infiltration into the paravertebral muscles on either side. Postoperative numerical rating scale (NRS) pain scores at 1, 2, 3, 4, 5, 6, 7, 8, 14, 20, and 24 hours; the time to first analgesic required, total rescue analgesic consumption, and adverse effects were recorded. Statistical analysis was done using IBM SPSS Statistics for Windows, Version 20.0 (Released 2011; IBM Corp, Armonk, New York, United States). RESULTS: Time to the first analgesic requirement was significantly longer in group A (12.39±1.56 hours) compared to the B group (2.48±0.58 hours) (P < 0.001). The amount of rescue analgesia (diclofenac sodium) required was significantly higher in group B (135.00±46.17 milligrams) compared to A (93.75±33.32 milligrams) (P = 0.001). The number of analgesic demands was higher in the infiltration group compared to the instillation group and was observed to be statistically significant. Hemodynamic parameters remained comparable between the groups. CONCLUSION: Local instillation of surgical wound site provided better pain control than infiltration technique and is effective and safe postoperative analgesia in patients undergoing laminectomy surgeries.

Comparison of Intravenous Nalbuphine and Paracetamol on Maternal Hemodynamic Status, Neonatal APGAR Score, and Postoperative Pain given before Induction of General Anesthesia for Elective Cesarean Section.

BACKGROUND: Stress response to endotracheal intubation and surgery is associated with exaggerated hemodynamic response and an increase in catecholamine levels which is deleterious to both the mother and fetus. We aimed to compare the effects of intravenous nalbuphine and paracetamol on maternal hemodynamic status, neonatal APGAR score, and postoperative pain using the visual analog scale for elective cesarean section under general anesthesia. STUDY DESIGN: This was a prospective, randomized, double-blinded clinical study. MATERIALS AND METHODS: Sixty full-term pregnant patients, belonging to the American Society of Anaesthesiologist physical status Classes I and II, scheduled for elective cesarean section under general anesthesia were enrolled for the study. The patients were randomly allocated into two groups of 30 patients each to receive paracetamol (15 mg.kg- 1) in Group Pand nalbuphine (0.2 mg.kg-1) in Group N before induction of general anesthesia. Maternal heart rate, blood pressure, and oxygen saturation were recorded before infusion of study drugs, after induction, after intubation, and during surgery across all periods. APGAR score of neonates was recorded by a pediatrician. Time to reach visual analogue score-1 was recorded. RESULTS: Significant attenuation of maternal hemodynamic response was observed with nalbuphine compared to the paracetamol group (P < 0.05). The time to achieve visual analogue score-1 in the postoperative period was higher in the nalbuphine group. APGAR score at 1 min was significant between the groups and at 5 min, nonsignificant difference was observed (P > 0.05). CONCLUSION: Nalbuphine and paracetamol are effective in perioperative hemodynamic stability of mother and APGAR score of neonates. However, nalbuphine had better hemodynamic stability as compared to paracetamol with a comparable APGAR score at 5 min.

A Randomized Controlled Study Comparing Dexmedetomidine-Midazolam with Fentanyl-Midazolam for Sedation during awake Fiberoptic Intubation in Anticipated Difficult Airway.

BACKGROUND: Awake fibreoptic nasotracheal intubation is an effective technique for the management of patients with difficult airways. Adequate sedation with effective topicalization of the airway is important to overcome discomfort and achieve intubation successfully. AIM AND OBJECTIVES: Our aim was to compare the effectiveness of dexmedetomidine-midazolam with fentanyl-midazolam infusion for providing conscious sedation during fibreoptic intubation in patients with anticipated difficult airway under topical anaesthesia. MATERIALS AND METHODS: Thirty adult patients of ASA physical status classification I and II with anticipated difficult airway and planned for elective awake nasal fibreoptic intubation under conscious sedation were randomly allocated into two groups. Dexmedetomidine 1 µg.kg-1 diluted in 50 ml saline was infused in Group DM over 10 min and Fentanyl 2 µg.kg-1 diluted in 50 ml saline was infused in Group FM over 10 min. Topicalization of the airway was done in all patients. All patients were assessed for sedation score, ease of endotracheal tube placement, patient comfort and cooperation, tolerance to endotracheal tube, any adverse events and recall of procedure. RESULTS: The score of the modified OAA/S was comparable between the groups (P > 0.05). Quality of AFOI was comparable in both groups (P > 0.05). The intubation time and first EtCO2 were significantly lower in dexmedetomidine group (P <0.05). Group DM also showed better hemodynamics and less episodes of desaturation than Group FM. CONCLUSION: Fentanyl-midazolam and dexmedetomidine-midazolam are both effective for awake fiberoptic intubation under topical anesthesia. Dexmedetomidine allows better endurance and more stable hemodynamics.

Dexmedetomidine and Magnesium Sulfate as Adjuvant to 0.5% Ropivacaine in Supraclavicular Brachial Plexus Block: A Comparative Evaluation.

BACKGROUND: Dexmedetomidine and magnesium sulfate (MgSO4) as an adjuvant to local anesthetics and ultrasound guidance improves the quality of peripheral nerve block. AIM: We aim to compare the efficacy of dexmedetomidine and MgSO4 as an adjuvant to ropivacaine in supraclavicular brachial plexus block. METHODOLOGY: Sixty patients undergoing upper extremity orthopedic surgery were randomly allocated into three groups of 20 each. Group A received 29 mL of 0.5% ropivacaine plus 1 mL of normal saline, Group B received 29 mL of 0.5% ropivacaine plus 1 mL dexmedetomidine (100 µg), and Group C received 29 mL of 0.5% ropivacaine plus 1 mL MgSO4 (250 mg). Onset and duration of sensory and motor block, duration of analgesia, quality of anesthesia, total 24 h analgesic consumption, sedation, and complications were recorded. STATISTICAL ANALYSIS: Software SPSS-16 was used for statistical analysis. RESULTS: The onset of sensory block and motor block was fastest for Group B, followed by Group C and slowest in Group A. The duration of sensory block and motor block was maximum for Group B, followed by Group C and minimum for Group A. The duration of analgesia was maximum for Group B, followed by Group C and minimum for Group A. Analgesic consumption was minimum for Group B. Quality of anesthesia was better in Group B than other groups. The visual analog scale was higher in Group A than other groups. Group B reported higher sedation score. CONCLUSION: Dexmedetomidine provides earlier onset of sensory and motor block as well as prolonged duration of sensory and motor blocks and duration of analgesia is longer and postoperative rescue analgesia is less as compared to patients receiving MgSO4. The incidence of hypotension and bradycardia and sedation score was higher with dexmedetomidine.

Comparison of End-Tidal Anesthetic Gas Concentration versus Bispectral Index-Guided Protocol as Directing Tool on Time to Tracheal Extubation for Sevoflurane-Based General Anesthesia.

BACKGROUND: Modalities for titrating anesthetic drug-like bispectral index (BIS) and end-tidal anesthetic gas (ETAG) concentration in predicting early extubation had been studied with old anesthetic agents such as isoflurane. AIM: The aim of this study is to compare the effect of ETAG concentration versus BIS-guided protocol as directing tool on time to tracheal extubation for sevoflurane-based general anesthesia. MATERIALS AND METHODS: This prospective, randomized, double-blind trial studied sixty patients with American Society of Anesthesiologists physical status classes I and II who received sevoflurane-based general anesthesia and were allocated to either BIS-guided anesthesia group (n = 30) or ETAG-guided anesthesia group (n = 30). Time to tracheal extubation was measured. BIS value was kept between 40 and 60 in BIS group, whereas minimum alveolar concentration value was kept between 0.7 and 1.3 in ETAG group. The two groups were compared using Student's t-test, and P < 0.05 was considered statistically significant. The statistical analysis was performed using the open source "R" programming language. RESULTS: Mean time to tracheal extubation was significantly shorter in BIS group (308.77 ± 20.48 s) as compared to ETAG group (377.90 ± 25.06 s) (P < 0.001). The sevoflurane concentration used was also significantly less in group BIS than group ETAG at multiple time intervals (P = 0.001). CONCLUSION: Prediction of extubation was significantly early with BIS monitoring as compared to ETAG monitoring in sevoflurane-based general anesthesia.