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Indian Journal of Anesthesia and Analgesia
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Govt. Medical College, Kozhikode 673008, Kerala
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SMH-Curie Cancer Center, Delhi Sanjay Gandhi Postgradaute Institute of Medical
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Saramma P Abraham
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INDIAN JOURNAL OF ANESTHESIA AND ANALGESIA
November – December 2020
Volume 7 Number 6
Contents
Original Research Articles
To Determine the Efficacy of Prophylactic use of Ephedrine and Mephentermine

in Caesarean Section to Manage Hypotension under Subarachnoid Block 1247
Asha G, Geethanjali S, Amith S, Yoganarasimha
Transdermal Diclofenac Patch versus Intra Muscular Diclofenac Injection for the
Management of Pain in the Post Operative Patients in a Teritiary Teaching Institute 1253
Chaitanaya, Karri Naga Venkata Harish
0.5% Lignocaine vs 0.5% Lignocaine with Dexmedetomidine for Bier’s Block:

A Comparative Study 1259
Vikas Joshi, Mohammed Yahya
Comparing Macintosh, Miller and Truview Laryngoscopes for Evaluation of

Intubation Difficulty in Patients with Immobilized Cervical Spine 1265
Abhishek Sharma, Anupama Gill Sharma, P R Chauhan, Vijay Kumar Nagpal,

Mohandeep Kaur, H K Mahajan
A Survey of Intubation of COVID-19 Patients in The Critical Care Units to

Assess Adherence to Guidelines and Critical Events Encountered 1273
Akhya kumar kar, Ayya Syama Sundar
Propofol vs Sevoflurane for Laryngeal Mask Airway Insertion Under General

Anaesthesia in Day Care Surgeries 1277
Gurpreet Singh, Haramritpal Kaur, Deepali Bansal, Divya Kavita,
Amandeep Singh, Shashank Gupta
A Comparative Study of Tramadol vs Butorphanol as an Adjuvant with Local

Anaesthetic in Supraclavicular Brachial Plexus Block in Upper Limb Surgeries 1283
Iramnaaz Shaikh, Pooja Fumakiya, Nidhi Asodariya
Effect of Intraoperative Esmolol Infusion on Haemodynamics and

Surgical Field in FESS Under General Anaesthesia 1291
Juhi Mattoo, Parth M Shah, Dinesh Thakur
Hemodynamic Stability of Dexmedetomidine in Laparoscopic Cholecystectomy Cases 1295

Naresh Kumar Tyagi, Pinu Ranawat, Arvind Kumar Gupta
Caudal Epidural Block for Transurethral Resection of Prostate in Patients

with Comorbidities: An Observational Study 1299
Nellimarala Appalaraju, Karri Bala Krishna
Dexmedetomidine versus MgSo4 in Hemodynamic Stability in

Laparoscopic Cholecystectomy Cases 1305
Pinu Ranawat, Naresh Kumar Tyagi, Arvind Kumar Gupta, Amit Jangir
A Comparative Study to Evaluate the Efficacy of Intravenous Dexmedetomidine

versus Clonidine for Post Spinal Anaesthesia Shivering in Caesarean Section 1309
Ramachandraiah R, Vigy Varghese

Absent Gastric Bubble: It’s Implications on Intra and Post-op Recovery in CABG Patients 1315
Rupinder Kaur Kaiche, Amol Shinde, Rahul Kaiche, Amogh Jagtap
A Study on Hemodynamic Changes in Dexamethasone 0.1 mg/kg When Combined

with 0.15% Ropivacaine for Caudal Analgesia in Children 1319
Samarth S P, Darshan M S
Comparitive Study of Epidural Fentanyl and Bupivacaine with Epidural Clonidine and
Bupivacaine for Postoperative Pain Relief in Lower Abdominal and
Lower Limb Surgeries: RCT 1323
S Selvamani, M Sathyasuba, Dipro Dey
A Randomized Double Blinded Comparative Study on Efficacy of Intraoperative

Dexmedetomedine versus Tramadol Intravenous Infusion in Prevention
of Postoperative Shivering Following Spinal Anaesthesia 1331
Shweta Kalkutiginahal, Preethi Goutham C
Comparative Study of Oral Clonidine, IV Fentanyl and IV Butorphanol in Attenuation

of Hemodynamic Stress Response to Laryngoscopy and Endotracheal Intubation 1343
Sorathiya Prashant C, Rashmi D Souza
A Randomized Prospective Study to Compare use of I-GELTM and LMA ProsealTM

in Patients undergoing Laparoscopic Cholecystectomy 1351
Spriha Mathur, Manjula Sudhakar Rao, Ravindra Kumar Arora
A Comparative Evaluation of Respiratory Parameters Spo2 and Etco2 with

Paediatric I-Gel, Proseal LMA Vs Endotracheal Tube 1359
Uma B R, Sridhara
A Comparitive Evaluation of Propofol, Sevoflurane and Desflurane for

Neuroanaesthesia in Patients Undergoing Elective Supratentorial Craniotomies 1365
B Sowbhagyalaxshmi, P Krishna Prasad, M Santhi Sree
Efficacy of Ultrasound Guided TAP Block with the Standard Post-Operative

Analgesic Regimen, In Providing Post-Operative Analgesia for Patients
Undergoing Total Abdominal Hysterectomies 1373
Samarth S P, Shreecharan P K, Sarala Mohan
Efficacy of Varying Doses of Dexamethasone with Lignocaine in Supraclavicular

Brachial Plexus Block in Upper Limb Surgeries 1381
M Santhi Sree, B Sowbhagyalakshmi, M Archana
A Study on Complications of Magnesium Sulphate as an Adjunct to Ropivacaine

Versus Plain Ropivacaine in Local Subcutaneous Infiltration for
Postoperative Analgesia 1391
Myakala Siddartha, P G Raghavendra
Comparison of Post Operative Sedation between Ultrasound Guided TAP Block

with the Standard Post-Operative Analgesic Regimen 1395
Samarth S P, Shreecharan P K, Sarala Mohan
Efficacy of Magnesium Sulphate as an Adjunct to Ropivacaine in Local Subcutaneous

Infiltration for Postoperative Analgesia Following Lower Segmental
Ceasfrean Section in Parturents under Spinal Anesthesia 1401
Myakala Siddartha, P G Raghavendra

Effects of Magnesium Sulphate on Hemodynamic Response to Carbondioxide
Pneumoperitoneum in Patients Undergoing Laparoscopic Appendicectomy 1405
G Karthikeyan, M Dhakshinamoorthy
Levobupivacaine vs Ropivacaine in Spinal Anesthesia for Lower Abdominal

and Lower Limb Surgeries: A Comparative Study 1411
Mohammed Yahya, Vikas Joshi, Abdul Azim Makandar
Efficacy of Dexamethasone 0.1mg/Kg when Combined with 0.15% Ropivacaine

for Caudal Analgesia in Children undergoing Infraumbilical Surgeries 1417
Samarth S P, Darshan M S
Comparison of Ondansetron 4mg, Dexamethasone 8mg and Ondansetron 4 mg

with Dexamethasone 8mg in Preventing Nausea and Vomiting
Post-Laparoscopic Cholecystectomy 1423
Priyadarshini M Bentur, Ashwini R
Comparative Assessment of Bupivacaine and Levobupivacaine in Elective

Cesarian Section Cases 1427
Vineeta Goda, Venus Sharma, Mamta Goda
A Comparative Study of the Anesthetic Potencies and Hemodynamic Changes of 0.5%

Isobaric Levobupivacaine and 0.5% Hyperbaric Racemic Bupivacaine for Spinal
Anesthesia in Lower Abdominal and Lower Limb Surgeries 1431
P Sridhar, V A Sabapathy, Pratheba, Poorna Uma, C R Lakshmi Narayanan
Review Articles
Anesthesia for Brachytherapy: A Review 1439

Kala, Tanya Elizabeth
Segmental Spinal: Is it Possible? 1445

Naresh W Paliwal, Sunil S Lawhale
Subject Index 1451
Author Index 1463
Guidelines for Authors 1473

1246
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Original Research Article November – December 2020;7(6)
DOI: http://dx.doi.org/10.21088/ijaa.2349.8471.7620.52
To Determine the Efficacy of Prophylactic use of Ephedrine and

Mephentermine in Caesarean Section to Manage Hypotension under
Subarachnoid Block
Asha G1, Geethanjali S2, Amith S3, Yoganarasimha4
Author’s Affiliation: 1-3Assistant Professor,4Professor, Department of Anesthesia, BGS Global Institute of Medical Sciences and
Hospital, Bengaluru, Karnataka 560060 India.
Corresponding Author: Geethanjali S, Assistant Professor, Department of Anesthesia, BGS Global Institute of Medical Sciences
and Hospital, Bengaluru, Karnataka 560060 India.
E-mail: ashabanuprakash1@yahoo.com
How to cite this article:

Asha G, Geethanjali S, Amith S, et al. To Determine the Efficacy of Prophylactic use of Ephedrine and Mephentermine in
Caesarean Section to Manage Hypotension under Subarachnoid Block. Indian J Anesth Analg. 2020;7(6):1247–1252.
Abstract
Introduction: Anaesthesia to a parturient is not only unique but also requires highest degree of care
because the anesthesiologist has to look after two individuals, the mother and foetus. Hypotension during
subarachnoid block for caesarean delivery can have detrimental effects on both mother and foetus.
Objectives: To determine the efficacy of Ephedrine and Mephentermine prophylactically in managing
the hypotension for caesarean section under sub arachanoid block and their undesirable side effects.
Materials and Methods: Patients were divided randomly into 2 groups (E group and M group) of 30 each.
Patients were premedicatated with inj. Pantaprazole 40mg and inj. Metoclopramide 10 mg and pre loaded
with ringer’s lactate at 10ml/kg infusion in the morning of the day of surgery. Baseline pulse rate, blood
pressure, and SpO2 were recorded. Subarachnoid block was performed in sitting position, under aseptic
conditions with a hyperbaric Bupivacaine 0.5%, 2cc (10mg) using 25 gauge Quincke’s needle. Group E
received Ephedrine 3mg and Group M received Mephentramine 3mg prophylacticaly immediately after
subarachnoid block.Blood pressure and pulse rate were measured every minute until the delivery, then
every 5 minutes till the end of surgery. APGAR score were noted to assess the fetal outcome. Patient
were monitored for 2 hours in the post operative recovery room soon after surgery for any untoward
complications.
Results: Mephentermine significantly increases the systolic blood pressure, mean arterial pressure and
reduces the heart rate compared to Ephedrine.
Conclusion: Maintenance of SBP between ‘hypotension value’ and baseline value by carefully titrating
the vasopressor results in a satisfactory fetal outcome. Both ephedrine and mephentermine are equally
efficacious for the management of maternal hypotension in terms of frequency of usage and result in a
similar neonatal outcome. Our results suggest that Mephentermine increases the systolic blood pressure
and decreases heart rate compared to Ephedrine and therefore more potent for management of hypotension
before delivery of the baby during spinal anaesthesia in patients undergoing elective Caesarean section.
Keywords: Ephedrine; Mephentermine; Subarachnoid block; APGAR score; Caesarean section.
© Red Flower Publication Pvt. Ltd.

Introduction 2. Incidence of undesirable side effects

3. Effects on neonatal outcome (APGAR score).
Anesthesia to pregnant women is very unique and
demands highest degree of care because it involves Materials and Methods
two lives, the mother and foetus. In elective
caesarean section under subarachnoid block nearly
85% mothers will have hypotension recorded.1 This double blind prospective randomized control
This recorded hypotension will have detrimental study was designed to evaluate the efficacy of
effect on both mother and foetus. This hypotension prophylactic use of Ephedrine and Mephentermine
will cause decreased uteroplacental blood flow, in managing hypotension during subarachnoid
impaired foetal oxygenation with asphyxia stress block for cesarean section done during the period
and acidosis. Mothers will develop symptoms of low of 2018 -2019 in our institute. After obtaining ethical
cardiac output such as nausea, vomiting, dizziness committee clearance and written informed consent
and decreased consciousness.2 In literature we 60 cases were taken.
have sufficient methods to prevent and manage Inclusion criteria:
hypotension during subarachnoid block. Initially
careful positioning with left uterine displacement 1. Full term elective singleton parturient,
and volume preloading with crystalloids or colloids 2. weighing less than 90 kg,
were used to prevent hypotension. Many times 3. height between 150 – 160cms (classified as
vassopressors are required to correct hypotension American Society of Anesthesiologists status
quickly during subarachnoid block.3 II).
These are the two commonly used definitions Exclusion criteria:
for hypotension. Firstly hypotension defined as a
decreased in arterial pressure greater than 20% from 1. Patients with severe pre-eclampsia, epilepsy,
baseline systolic pressure. Secondly combination of gestational diabetes, precious pregnancy
two criteria i.e a drop of systolic bloods pressure 2. Emergency LSCS with fetal distress
to 100mm Hg or lower and a drop to 80% from
Patients were divided randomly into 2 groups
baseline or lower.4
(E group and M group) of 30 each. Patients were
Vassopressors are group of drugs used to treat pre medicatated with inj. Pantaprazole 40mg and
hypotension by contracting blood vessels and inj. Metoclopramide 10 mg and pre loaded with
raise blood pressure.5 Ephedrine, Mephentermine, ringer’s lactate at 10ml/kg infusion before surgery.
Phenylepherine, Metaraminol and Methoxamine Baseline pulse rate, blood pressure, and SpO2 were
are commonly used vassopressors to treat recorded. Subarachnoid block was performed in
hypotension in subarachnoid block. sitting position under aseptic conditions with a
In following study we have compared the efficacy hyperbaric Bupivacaine 0.5%, 2cc (10mg) using 25
of Ephedrine and Mephentermine prophylactically gauge Quincke’s (BD, Becton Dickenson, Madrid,
in managing hypotension for caesarean section Spain) spinal needle in L3_4 intervertebral space.
under subarachnoid block and their undesirable Group E received Ephedrine 3mg and Group
side effects. This study is a double blinded M received Mephentramine 3mg prophylacticaly
prospective randomized control study to evaluate immediately after subarachnoid block.
the efficacy of prophylactic use of Ephedrine and
This study was done in a prospective double
Mephentermine in caesarean section to manage
blind randomized manner. The investigator was
hypotension under Subarachnoid block. The
blinded to the content of envelope and decoding
incidence of undesirable side effects and neonatal
was undertaken at the end of the surgery. After
outcome in terms of Apgar score were also studied.
intrathecal injection, upper level of sensory
block was assessed by loss of pinprick sensation.
Aim of the study Assessment of the block height was made and
recorded at the time of skin incision, 5min and
To compare the efficacy of Ephedrine and 10min. The target level of sensory anesthesia (block
Mephentermine in the management of hypotension height) was up to T-5 segment. The surgery was
during subarachnoid block for cesarean section asked to commence after obtaining the said level.
based on the following parameters Blood pressure and pulse rate were measured
1. Efficacy of vasopressors in managing every minute until the delivery, then every 5
hypotension minutes till the end of surgery. APGAR scores

Asha G, Geethanjali S, Amith S, et al. / To Determine the Efficacy of Prophylactic use of Ephedrine and 1249
Mephentermine in Caesarean Section to Manage Hypotension under Subarachnoid Block
were noted to assess the fetal outcome. Patients Statistical analysis of changes in heart rate at
were monitored for 2 hours in the post operative different time intervals in both the study groups is
recovery room soon after surgery for any untoward presented (Chart 1 and Table 2).
complications.
Statistical analysis:
Analysis of the present study was made using
the following parameters.
1. Percentages
2. The arithmetic mean (m or x)
3. The standard deviation (SD)
4. Student’s test
5. Proportion test.
The results of continuous variables are presented
as mean ± SD and proportion as percentage. The Chart 1: Analysis of heart rate (HR).
difference between the two groups was assessed by There was statistically significant increase in
Student’s test and Chisquare test. For all the tests, heart rate response after giving study drug in group
a P ≤ 0.05 was considered statistically significant. E when compared to group M at time intervals of
2nd, 5th, 10th, 20th, 40th and 60th minute and it was
Results statistically significant.
Statistical analysis of changes in systolic blood
60 pregnant patients were divided into two groups pressure at different time intervals in both the
of 30 each in this study. (Table 1). study groups is presented (Table 3).
Table 1: The two groups were comparable with respect to age No significant variations were noted in both the
and BMI and were statistically insignificant. groups in SBP at baseline, 1st and 2nd minute after
Variable Group E Group M P Value giving study drug.
Age 25.53±3.51 24.9±2.78 O.99 But there was increase in SBP in group M at
Bmi 28±1.7 29±1.17 0.46 different at 5, 10, 20, 40 and 60 time intervals and it
was statistically significant.
Table 2: Analysis of heart rate (HR).
HR Baseline 1 min 2 5 10 20 40 60 90 120
Group E 101.1±5.98 107.1±5.18 112.4±4.23 115.8±3.45 116±3.7 112.4±3.97 104.4±3.57 101.2±4.16 96.96±4.46 93.13±4.72
Mean ±SD
Group M 105.4±5.74 104.4±5.45 101±6.16 97.13±6.3 94.6±6.39 94.13±5.58 92±5.45 90±5.18 87.3±5.26 85.33±4.46
Mean ±SD
P Value 0.006 0.06 1.45E–11 1.45E–20 9.52E–23 4.62E–21 6.09E–15 5.6E–13 2.18E–10 1.54E–08
Table 3: Analysis of systolic blood pressure (SBP).

SBP Baseline 1 min 2 5 10 20 40 60 90 120
Group E 115.26±8.49 109±7.85 103.13±10.57 93.03±4.9 96.66±6.55 102±6.14 105.46±4.5 109.53±5.55 111±4.71 112.4±4.88
Mean±SD
Group M 116.53±9.86 110.2±10.75 104.86±10.91 95.16±12.4 105.53±9.16 108.7±6.77 110.66±6.68 112.06±5.9 113.1±6.39 113.33±7.26
Mean ±SD
P Value 0.596 0.64 0.53 0.38 6.43E–05 0.0001 0.0008 0.092 0.15 0.56
(<0.05)
Table 4: Analysis of diastolic blood pressure (DBP).

DBP Baseline 1 min 2 5 10 20 40 60 90 120
Group E 67.33±4.67 62.4±4.59 56.5±6.32 50.86±3.04 54.4±4.91 57.06±5.4 56.6±3.59 59.2±4.5 63.13±6.06 65.6±5.529
Mean±SD
Group M 67.06±6.208 62.33±6.26 57±7.38 52.46±5.47 55.33±5.44 56.53±4.48 57.76±4.04 61.4±6.14 63.2±5.93 64.66±5.78
Mean ±SD
P Value 0.851 0.96 0.79 0.167 0.488 0.67 0.24 0.108 0.96 0.496

Table 5: Analysis of mean arterial pressure (MAP).

Map Baseline 1 Min 2 5 10 20 40 60 90 120
Group E 80.6±8.8 77.5±5.39 71.6±7.57 64.6±3.21 68.3±4.89 71.7±5.53 72.6±3.56 75.6±4.35 78.76±5.19 81.53±4.43
Mean ±SD
Group M 82.4±8.14 78.13±7.8 72.6±8.47 66.16±7.7 73.03±8.24 73.5±4.76 75.3±5.602 77.9±5.33 79.43±5.41 80.93±5.47
Mean ±SD
P Value 0.43 0.73 0.63 0.329 0.009 0.166 0.0298 0.064 0.628 0.642
Statistical analysis of changes in diastolic blood whereas the drug information by Wyeth® India
pressure at different time intervals in both the gives a dose of 30 to 45 mg intramuscularly
study groups is presented (Table 4). for prevention and 30 to 45 mg IV infusion for
No significant variations in DBP between the two treatment of post-spinal hypotension.8 Other doses
groups were noted. used are 6 mg boluses9 and 5 mg bolus followed by
an infusion.10
Statistical analysis of changes in mean arterial
pressure at different time intervals in both the On other hand Ephedrine is a potent
study groups is presented (Table 5). sympathomimetic drug that has both α-and
β-adrenergic agonist actions and acts directly and
No significant variations were noted in MAP in indirectly at adrenergic nerve endings. Cardiac
both the groups at baseline, 1st to 5th minute. stimulation is a more prominent action, so that the
There was slight increase in MAP in group M blood pressure and cardiac output are increased.11
compared to group E from 10th to 40th minute and it Ephedrine is the most commonly used drug to
was statistically significant. treat hypotension associated with subarachnoid
Table 6: Analysis of APGAR score and efficacy of vasopressors block in obstetrics. According to a survey,
Variable Group E Group M P value Ephedrine is used as the sole vasopressor by 95% of
APGAR score at 1 8 8 consultant obstetric anesthetists in the UK.12
minute Recently, there have been reports of worsening
APGAR score at 5 9 9 fetal acidosis with the use of ephedrine,13
minute
and demonstrating better outcomes with
Frequency of usage 1.066±0.5208 1.033±0.49 0.799
of vasopressor other vasopressor drugs like angiotensin II,14
phenylephrine15 and metaraminol.16
According to the above findings, APGAR score
remains same in both the groups. (Table 6). The mechanism of action for ephedrine and
Mephentermine is similar. Both drugs have α and
Similarly, both the vasopressors are equally β-adrenergic agonist action, direct and indirect
efficacious in managing hypotension. effects at adrenergic nerve endings. But effect on
β-receptors is more prominent.
Discussion Despite similar actions, the studies comparing
efficacy and potency of these vasopressor drugs
In caesarean section under subarachnoid block have yielded variable results. During early studies
hypotension can be minimized by the use of IV Mephentermine was reported to be as potent as
fluid preload, avoidance of aortocaval compression Ephedrine with respect to its effect on total vascular
and use of vasopressor agents. It’s been well and venous resistance in the perfused foreleg of
documented that percentage decrease in placental the dog,17 whereas it was found to be more potent
perfusion is directly related to percentage reduction than other agents including Ephedrine for restoring
in maternal arterial pressure and not to the total the contractility of depressed and hypodynamic
reduction of pressure.6 isolated frog heart.18
Since many decades in India Mephentermine has Very few clinical studies have compared efficacy
been used to prevent hypotension during cesarean of Ephedrine and Mephentermine.
section under subarchanoid block. But there is lack Sahu et al9 compared 6mg bolus doses of
of literature regarding its dose and relative potency Ephedrine and Mephentermine following onset of
compared with other vasopressors. hypotension and observed similar requirements
In 1978, Lauckner et al used Mephentermine 30 for both drugs for maintenance of arterial
mg IV to treat hypotension in pregnant females,7 pressure. The apparently lower requirements of

Asha G, Geethanjali S, Amith S, et al. / To Determine the Efficacy of Prophylactic use of Ephedrine and 1251
Mephentermine in Caesarean Section to Manage Hypotension under Subarachnoid Block
Mephentermine due to longer half time period References

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Mephentermine is 17 to 18 hours.21 Prevention of hypotension after spinal anaesthesia
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titrating the vasopressor results in good fetal Indian Journal of Anaesthesia 2003; 47:125–128.
outcome. 10. Kansal A, Mohta M, Sethi AK, Tyagi A, Kumar
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Transdermal Diclofenac Patch versus Intra Muscular Diclofenac Injection

for the Management of Pain in the Post Operative Patients in a Teritiary
Teaching Institute
Chaitanaya1, Karri Naga Venkata Harish2
Author’s Affiliation: 1Assistant Professor, 2Post Graduate, Department of Anesthesia, Maharajah's Institute of Medical Sciences,
College of Allied Health Sciences, Vazhayoor, Karad, Malappuram 673633, Kerala, India.
Corresponding Author: Karri Naga Venkata Harish, Post Graduate, Department in Anesthesiology, Maharajah's Institute of
Medical Sciences, Vizianagaram, Andhra Pradesh 535217.
E-mail: drharish34@gmail.com

Chaitanaya, Karri Naga Venkata Harish. Transdermal Diclofenac Patch versus Intra Muscular Diclofenac Injection for the
Management of Pain in the Post Operative Patients in a Teritiary Teaching Institute. Indian J Anesth Analg. 2020;7(6):1253–1258.
Abstract
Background: Pain management in immediate postoperative period is an extremely important but

herculean task. As oral medication is not possible at this stage, it is injectable analgesia which is put to task.
In countries like India, where efficacy and cost both count, intramuscular diclofenac is the most commonly
employed analgesic.
Methodology: The study was cross sectional by using questionnaire in 80 healthy adult subjects of either
sex undergoing Hernia correction surgery under spinal anaesthesia. The subjects were assigned into two
groups (Group I and Group P) by computer generated randomization table to receive intramuscular
diclofenac 75mg or transdermal diclofenac patch 100mg immediately after spinal anaesthesia. The patients
were monitored for pain using Visual Analogue Scale. Duration of analgesia and request for rescue
analgesic (Tramadol 2mg/kg) were noted in both the groups. The study ended when patients had a VAS
> 8 or at first request for analgesic.
Result and Conclusion: It was concluded that if applied with proper planning, diclofenac patch was as
effective as diclofenac injection but at the same time administration of patch is devoid of pain, local side
effects, drug destruction by stomach and digestive enzymes and first pass metabolism in liver.
Keywords: Diclofenac; Transdermal Patch; Intra Muscular Injection; Postoperative analgesia; Hernia
surgeries.
Introduction reduces patient morbidity and improves patient

outcome, recent studies demonstrate that about
Pain is defined as an unpleasant sensory and 50–70% of patients experience moderate to severe
emotional experience associated with actual or pain after surgery indicating that post operative
potential tissue damage.1 Pain, an important pain remains poorly treated. The management
cause of post-operative complications, results in of post operative pain is an essential and integral
poor mobility, increased arterial pressure and part of care given to the patient that assumes an
myocardial work which may result in increased important role in transition from the recovery unit
morbidity or mortality following surgery.2 to the home environment.3,4
Post operative pain is a unique and common form Peripheral tissue injury as seen in post operative
of acute pain. Although ample evidence indicates patients provokes two kinds of modification in
than an efficacious post operative pain treatment the responsiveness of nervous system-peripheral
sensitization and central sensitization resulting 3. adhesive-adheres the components of the

in an overall hypersensitivity state in the post patch together and sticks the patch to the
operative period. Prevention and establishment of skin;
this hypersensitivity state could lead to reduced 4. membrane-controls the release of the drug
post operative pain, which forms the basis of from reservoir and multi-layer patches;
pre-emptiveanalgesia.5,6 Opioids have been
administered for hundreds of years to allay anxiety 5. backing laminates-protects the patch from the
and to reduce the pain associated with surgery. environment;
Though they are very useful in relieving post- 6. Permeation enhancers.
operative pain, they are associated with many side
effects.7 There is a need to reduce peri-operative
Methods
opioid consumption.8,9
Non-steroidal anti-inflammatory drugs exert
The present prospective randomised clinical study
anti-inflammatory and analgesic effects through the
was conducted in a teaching hospital attached to a
inhibition of prostagland in synthesis, by blocking
medical college to evaluate transdermal diclofenac
the activity of cyclo-oxygenase.10,11 They have
patch as pre-emptive analgesic compared to
been shown to have opioid sparing effects.12,13,14
intramuscular drug in providing post-operative
Diclofenac is a well established non-steroidal
pain relief. Institutional ethical committee approval
anti-inflammatory agent but the commonly used
was taken. Data was collected in pre-tested
intramuscular route is associated with patient
proforma meeting the objectives of the study.
resentment, pain on injection, peak to trough
variability. The transdermal route of diclofenac Inclusion Criteria: Normal adult patients of
delivery, which is recently introduced in India either sex between 20–60 years admitted for hernia
appears to be an attractive alternative in view of correction surgeries done under spinal anesthesia.
better patient acceptance, avoidance of first pass Exclusion Criteria:
hepatic metabolism, sustained absorption and bio-
1. Pregnant females.
availability and reduced incidence of systemic side
effects. However due to its prolonged onset time, 2. Patients posted for emergency surgeries.
it may not be useful for treatment of acute pain 3. Patients with co-morbid diseases like diabetes,
but can be used as pre-emptive analgesic to reduce hypertension,neurological, psychiatric or
post-operative pain. neuro-vascular disorders.
The advantages of transdermal diclofenac patch 4. Patients having absolute contra indication
over the orally administered drug are evaluated in for spinal anesthesia like raised intra cranial
acute blunt injuries, sports injuries,15 osteoarthritis16 pressure, severe hypovolemia, bleeding
etc, but pre-emptive use of transdermal diclofenac diathesis and local infection.
patchin reducing post-operative pain has not
been much studied. Hence the present study was Adult subjects in the age group between 20
undertaken in patients undergoing elective lower years and 60 years of either sex belonging to
abdominal surgery like hernia repair,under spinal ASA class I and class II posted for elective hernia
anaesthesia with an objective to evaluate the repair surgeries without any co-morbid diseases
efficiency of transdermal diclofenac patch against are grouped randomly by computer generated
the routinely used intramuscular diclofenac numbers into 2 groups with 40 patients in each
injection for post-operative pain relief. group.
Group I: Received intramuscular injection of
Transdermal patch diclofenac 75mg after giving spinal anesthesia at
the beginning of the surgery.
Composition Group P: Received a transdermal patch of
diclofenac 100mg after giving spinal anesthesia at
Components of a transdermal diclofenac delivery the beginning of the surgery.
system are:
Pre-operative assessment was done for each
1. release liner-protects the patch during storage patient and written informed consent was taken. All
and is removed before its use; the patients were pre-medicated on the night before
2. drug-drug solution in direct contact with the surgery with Tablet Ranitidine 150mg and Tablet
release liner; Alprazolam 0.5mg. Monitoring was done using
Chaitanaya, Karri Naga Venkata Harish / Transdermal Diclofenac Patch versus Intra Muscular Diclofenac 1255
Injection for the Management of Pain in the Post Operative Patients in a Teritiary Teaching Institute
multi parameter monitor having pulseoximetry, Statistical Analysis

ECG, NIBP and SPO2. Intra venous fluids were
administered through an 18G intra venous cannula. Data was entered in excel format and analysed
Under aseptic precautions,with the patient in the using SPSS version 17, descriptive statistics like
lateral position,lumbar puncture was performed frequency, proportions were calculated.
by the consultant anesthesiologist at the level of
L3 – L4 through a mid line approach using 25G Results
Quincke spinal needle and 3 ml of bupivacaine
0.5% heavy was injected after confirmation of
needle tip in the subarachnoid space by free and The age and sex difference was also not significant
clear flow of CSF. Subjects were made to lie down in the two groups. The mean age in group I was
in the supine posture immediately with the table 45.34±13.64 and Group P was 46.40±12.46 years.
kept flat horizontally and supplementary oxygen Table 1: Visual analogue score post operatively.
was given. Visual Analogue Score Group I Group P
After confirming the adequate level of sensory Before surgery 1.87±0.70 1.91±0.45
blockade for surgery, (level of 10th thoracic Immediately after 3.28 ± 0.72 3.26 ± 0.83
dermatome at the level of umbilicus) after spinal extubation (Mean ± S.D.)
anesthesia, transdermal diclofenac patch was At 4 hour (Mean ± S.D.) 3.36 ± 0.68 3.42 ± 0.56
applied on lateral aspect of contralateral thigh in At 8 Hour (Mean ± S.D.) 6.86± 0.98 6.82 ± 1.02
patient in Group P and intramuscular diclofenac At 12 Hour (Mean ± S.D.) 3.42 ± 0.78 3.64 ± 0.87
75mg (3ml) was injected in the contra lateral gluteal At 24 Hour (Mean ± S.D.) 3.34 ± 0.89 3.09 ± 0.73
region in the patients in Group I. Pain was assessed on VAS and was found that
The following parameters are noted, pain scores in both the groups were at their peak at
or around 8 hours. Mean time of first supplement
1. Time of administration of spinal anesthesia
dose requirement in group A was 7.12 hours and
2. Time of beginning of surgery in group B was 7.56 hours. The p value calculated
3. Time of administration of study drug and came out to be non-significant (Table 1 and 2).
route Table 2: Average time of first supplemental dose required post
operatively.
All subjects were monitored during the surgery
Group Time
and peri operative period till complete sensory
I 7.12 Hours
and motor recovery employing multi parameter
P 7.56 Hours
monitors which displays heart rate, systolic blood
pressure (SBP), diastolic blood pressure (DBP),
mean arterial pressure (MAP), ECG and SPO2. Discussion
In the post operated period,Patients were asked
to assess their post-operative pain on a visual analog With the increase in understanding of pain
scale using different facial expressions to grade the pathophysiology and treatment, new routes of drug
severity of pain from a scale of 0–10 where score 0 delivery are being discovered with the objective of
represents a very happy patient with no pain and blocking pain at peripheral sites, with maximum
score 10 representing hurting as much as we can active drug and minimal systemic effects. Topical
imagine. Quantitative measurement of pain was preparations are the result of such exploration. The
done on visual linear analogue scale at: goal of topical NSAIDs is to minimize systemic
1. Immediately after extubation adverse effects and encourage compliance. Most
topical preparations are available as transdermal
2. 4 hours after operation patches, ointments or creams.
3. 8 hours after operation Acute pain in the perioperative setting is defined
4. 12 hours after operation as pain that is present in a surgical patient because
of pre-existing disease, the surgical procedure or
5. 24 hours after operation.
a combination of disease related and procedure
At any time during the study, if visual analog scale related sources.17 Traditionally opioids have
is more than or equal to 8, then an intramuscular been the main-stay of acute postoperative pain
injection of tramadol 2mg /kg was administered as management. They provide excellent analgesia.
a rescue analgesia , and the study ended. The time However they are not suitable for treatment of
at which rescue analgesia is given is noted.
somatic pain due to peripheral tissue injury. offers several advantages as it avoids the need for
They are also associated with adverse outcomes intravenous or intramuscular drug administration,
like respiratory depressions, cardiovascular and is an option in patients who are unable to
depressions, post-operative nausea and vomiting, swallow oral medications.
impairment of bowel function, urinary retention,
Transdermal drug administration also by-passes
pruritus etc.
first pass metabolism in the liver29 and overcomes
Hence there is a need to reduce perioperative concerns regarding drugs that are poorly absorbed
opioid analgesic requirement, without in the gastro intestinal tract.
compromising analgesia component. Several
Application of diclofenac patch was shown to
modalities have been tried to provide pre emptive
reduce the incidence and severity of post-operative
perioperative pain relief which can reduce
sore throat30 and succinyl choline induced
dependence on opioids. Some of them are regional
myalgia in patients after ceaserian delivery under
anesthesia/analgesia, peripheral nerve block, field
block, NSAIDs, alpha 2 adrenergic agonists etc. endotracheal general anaesthesia.31
Non steroidal anti inflammatory drugs (NSAIDs) Transdermal diclofenac sodium patch, which
are among the most widely used medications in the delivers the drug into systemic circulation through
world because of their demonstrated efficacy in the skin, has been shown to produce higher pain
reducing pain and inflammation.18 Their efficacy has tolerance and no gastro intestinal complications
been documented in a number of clinical disorders, as compared to oral administration.32 Transdermal
including osteo-arthritis, rheumatoid arthritis, diclofenac sodium patch has been shown to achieve
ankylosing spondylitis, gout, dysmenorrhea, dental better bioavailability with no marked peak to
pain and headache.19–24 trough fluctuations.
The basic mode of action is inhibition of The diclofenac transdermal patch bioavailability
pro inflammatory enzyme cyclo-oxygenase is approximately 1% that of oral diclofenac, with
(COX). Although effective at relieving pain and an elimination half-life of 12 hours.33 The pharma
inflammation, NSAIDs are associated with a cokinetic profile and systemic and local absorption
significant risk of serious gastro intestinal adverse of diclofenac following dermal patch application
events and potential cardio vascular side effects.25,26 in Yokshire-Landrace pigs showed that it resulted
in high tissue penetration and low systemic
An evidence based update on NSAIDs in 2007,
absorption.34
has shown the NSAIDs to have pre-emptive effects
and reduce post-operative analgesic and opioid Topical diclofenac patch is shown to be effective
requirement. Also this update noted that the and safe for the treatment of acute blunt impact
parenteral route (intramuscular or intra venous) injuries.15 Galer et al conducted a multi-centre
had the same risks of gastro intestinal toxicity as the controlled clinical trial and showed that diclofenac
oral route and that the NSAIDs given by the topical patch is an effective and safe pain reliever for sports
route are an exception as they are not associated injury pain and the advantages of this novel therapy
with any gastro intestinal effects.27 includes its ease of use and lack of systemic side
Of the many NSAIDs available, diclofenac effect. In the post operative setting, due to the long
through intramuscular route, is commonly used onset duration, this may be useful when applied
in our institution for relief of post-operative pain. in anticipation of pain, and not after the patient
Systemic administration can lead to fluctuations experiences the pain.35
in pain control levels and gastro-intestinal Krishna et al. studied the analgesic effects of
complications. transdermal diclofenac patch in patients undergoing
Absorptions of the drug is faster leading elective lower limb orthopaedic surgery under
to rapid achievement of maximum plasma spinal anaesthesia.36
concentration followed by steep decline in plasma Allesandri et al compared pain management
concentration of the drug. This manifests as rapid of standard skin medication plus a diclofenac
onset of analgesia which however is not sustained. transdermal patch and standard skin medication
Intramuscular injections are painful and resented alone at all incisional areas in the patients who
by many patients.28 underwent laparoscopic gynaecologic surgery.
A newer route of diclofenac administration is They demonstrated that the diclofenac transdermal
now available with introduction of transdermal patch reduced post-operative analgesic
diclofenac patch. The transdermal drug delivery requirements and hospital stay.37
Chaitanaya, Karri Naga Venkata Harish / Transdermal Diclofenac Patch versus Intra Muscular Diclofenac 1257
Injection for the Management of Pain in the Post Operative Patients in a Teritiary Teaching Institute
Safinaz et al,38 showed that the diclofenac patch 4. Esther M pogatzki-Zahn, peter K Zahn, TimothyJ.
and intramuscular injection were equally effective Brennan post-operativepain-clinical implications
in the prevention of post-operative pain after of basic research :Best practise and research clinical
Anaesthesiology,2007 ; 21, 1:3–13.
laparoscopic surgery under general anaesthesia
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to intramuscular diclofenac injection for patient really mean? Anaesthesiology. 2000;93(5):1368.
tolerance. 6. Ong CKS, Lirk P, Saymour R. The efficacy of pre-
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7. Side effects of Opioids during short term
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post-operative analgesia.36 The pain was assessed 8. Wilson YG, Rhodes M, Ahmed R, Daugherty,
postoperatively at 2, 6 and 12 hrs postoperatively M Cawthorn, S J Armstrong, C P Intramuscular
on VAS. The study ended when patients asked for diclofenac sodium for postoperative analgesia
rescue analgesia or VAS >5. The mean duration of after laparoscopic cholecystectomy:a
analgesia in control group (injection group) was 7hr randomized,controlled trial. Surg Laparosc
28min and the study group was 8hr 6min (patch Endosc.1994;4:340–344.
group) which was comparable to our study. 9. Fredman B, Olsfanger D, Jedeikin RA.
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In the present study no local cutaneous or
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13. Johnson RC, Hedges AR,Morris R,et al.Ideal pain
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14. Louizos AA, Hadzilia SJ, Leandros E. Postoperative
non-invasive and can be self-administered. They
pain relief after laparoscopic cholecystectomy. A
also improve patient compliance and are generally placebo-controlled double-blind randomized trial
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0.5% Lignocaine vs 0.5% Lignocaine with Dexmedetomidine for

Bier’s Block: A Comparative Study
Vikas Joshi1, Mohammed Yahya2
Author’s Affiliation: 1Assistant Professor, 2Associate Professor, Department of Anesthesiology, Mahadevappa Rampure Medical
College, Kalaburagi, Karnataka 585105, India.
Corresponding Author: Mohammed Yahya, Associate Professor, Department of Anesthesiology, Mahadevappa Rampure
Medical College, Kalaburagi, Karnataka 585105, India.
E-mail: dr.yahya.imran@gmail.com

Vikas Joshi, Mohammed Yahya. 0.5% Lignocaine vs 0.5% Lignocaine with Dexmedetomidine for Bier’s Block: A Comparative
Study. Indian J Anesth Analg. 2020;7(6):1259–1264.
Abstract
Background: Intravenous regional anesthesia (IVRA) was introduced into clinical practice by August
Bier in 1908. This form of analgesia is ideally suited for emergencies, where patient is with full stomach
or suffering from other diseases that contraindicates general anaesthesia, moreover the feasibility and
simplicity of execution of this method, its effectiveness and its lack of any side effects have been gratifying.
IVRA is particularly suitable for day care surgeries as it requires minimal preparation and premedication.
Dexmedetomidine, a stereoisomer of medetomidine is a highly selective alpha 2 adrenergic agonist and has
been shown to decrease anesthetic requirements by upto 90% and to induce analgesia in rats, volunteers
and patients. The present study was designed to evaluate the quality, onset and recovery of IVRA with
0.5mcg/kg dexmedetomidine added to 3mg/kg of 0.5% lignocaine.
Methods: After institutional approval and informed consent, 60 ASA 1 and 2 volunteers, were taken into
the study. In Group A 30 patients were randomly allocated to receive IVRA for upper limb with 3mg/kg
for 0.5% lignocaine; in Group B 30 patients randomly received IVRA of upper limb with 3mg/kg of 0.5%
lignocaine with 0.5mcg/kg Dexmedetomidine. The onset and recovery of sensory block were tested in
six sites of the forearm and hand, determined by pin prick, touch and cold. The cuff was released after 45
minutes. The onset of complete motor block was also assessed and any symptoms after cuff deflation were
recorded. Usual haemodynamic monitoring was used.
Results: The speed of onset of sensory and motor block was higher in Group B than in Group A (p<0.05).
The recovery of sensory and motor block was prolonged in Group B than in Group A (p<0.05). The
tourniquet pain occurred significantly later in Group B as compared to Group A. There were few incidence
of bradycardia in Group B.
Conclusion: Addition of 0.5mcg/kg of Dexmedetomidine as an adjuvant to Bier’s Block effectively
enhances the anesthesia and post-operative analgesia obtained with lignocaine. The low dose of
Dexmedetomidine was effective and did not cause any major side-effects.
Keywords: Bier’s block; Intravenous Regional Anesthesia; Local Anesthetic: Lignocaine Hydrochloride;
α-2 agonist: Dexmedetomidine.
Introduction sparing effects, reduced delirium and agitation,

perioperative sympatholysis, cardiovascular
Dexmedetomidine is a new generation highly stabilizing effects, and preservation of respiratory
selective α2-adrenergic receptor (α2-AR) agonist function.1,2 It has been used successfully in
that is associated with sedative and analgesic combination with local anaesthetics for procedures
like spinal, epidural and brachial blocks.3 The Exsanguinating the extremity: The arm to be
present study was designed to evaluate the operated is elevated to 900 angle from the body
quality, onset and recovery of IVRA with 0.5mcg/ above the level of heart for 5 minutes to drain
kg Dexmedetomidine added to 3mg/kg of 0.5% the blood from the limb. Esmarch bandage was
lignocaine. wrapped tightly around the arm from the most
distal part to near the pneumatic tourniquet to
Materials and Methods further exsanguinate. The proximal cuff was
inflated to 100mmHg higher than the occlusion
pressure and esmarch bandage removed.
The present study was designed to compare and
evaluate the quality and onset of intravenous Injecting the anesthetic solution: The limb was
regional anaesthesia in the upper limb with placed horizontally and local anesthetic was
dexmedetomidine added to lignocaine. Based injected steadily.
on the findings of previous studies by M Bala Group A patients received solution containing
Muruganet al4, Esha et al5 and Nitin Purohit et al6, 0.5% lignocaine 3mg/kg.
sample size of 60 patients was taken belonging to Group B patients received solution containing
either sex and age between 18 and 65 years. All 0.5% lignocaine 3mg/kg and dexmedetomidine
the patients belonged to ASA (American Society 0.5mcg/kg.
of Anesthesiologist) grade 1 or 2 . Computer based
Randomisation was done and divided into two After injection IV cannula was removed and
groups of 30 patients each: pressure was applied to venepuncture site for some
time till bleeding stops. The following parameters
Group A: 0.5% lignocaine 3mg/kg
were observed and recorded continuously
Group B: 0.5% lignocaine 3mg/kg + throughout the surgical procedure: Pulse rate, Blood
dexmedetomidine 0.5mcg/kg. pressure, Respiratory rate, Level of consciousness.
Detailed history was taken and complete The following parameters were noted: Tourniquet
clinical examination was done to exclude patients time, Grade of analgesia, Complications arising
with history of epilepsy, hypersensitivity to local intraoperatively and postoperatively.
anesthetics, neurological, cardiac and hemolytic
Assessment of block: Six areas supplied by radial,
diseases. Routine investigations like blood
median and ulnar nerves were tested in sequence
grouping, haemoglobin, blood urea and blood
with the patient unable to observe testing. At 90
sugar were done. ECG whenever indicated was
second intervals after administration, the sensory
undertaken to rule out the presence of any cardiac
block was assessed by using a 24 G needle. The
disease. Pre-operative temperature, pulse rate,
patient reported verbally the sensation as pin prick,
respiratory rate, blood pressure and condition
touch or absent.
of heart and lungs noted. Patient’s weight was
recorded. Cold sensation was assessed using a cube of ice
placed in sterile test tubes. Motor function was
Written and informed consent was taken prior to
assessed by asking the patient to flex and extend
scheduled operation. Patients were explained about
his wrist and fingers.
the procedure of intravenous regional anesthesia.
Patients with Raynauds disease, sickle cell anemia Complete motor block was considered when no
were excluded from the study. voluntary movement was possible.
An 18 G intravenous cannula was inserted into Tourniquet pain: Proximal tourniquet deflated
a vein of the non- operated limb for the purpose of after inflating distal tourniquet once patient
administering fluids or drugs. Another 22 G cannula complains of discomfort. Then distal cuff was
was inserted into suitable vein on dorsum of hand inflated to 250 mmHg and proximal cuff was
that was to be operated as distally as possible and deflated.
firmly secured. Tourniquet release: At the end of case/after 45mins
Tourniquet: Cotton padding was placed on the the tourniquet was deflated using deflation and
proximal part of the limb to be operated. Double inflation technique before the cuff was let down
tourniquets were set up and connected to pneumatic permanently.
pressure gauge. Monitoring after tourniquet release: The patients
The occlusion pressure i.e the pressure at which were monitored for any change in pulse rate, blood
pulse disappears was noted for each tourniquet. pressure, loss of consciousness and for any signs of
Vikas Joshi, Mohammed Yahya / 0.5% Lignocaine vs 0.5% Lignocaine with Dexmedetomidine for 1261
systemic toxicity like twitching, convulsions and Onset of Motor Block

ECG abnormalities. 17
Sensory assessment was continued until full 16
recovery occurred at all six sites. 15
Onset of
14 Motor Block
Grading of Analgesia: Method adopted was one
13
given by R J Ware.
12
Grading of analgesia and muscle relaxation. Group A Group B
Graph 2: Onset of motor block.
Grade Description
1. (Excellent) Complete analgesia and motor loss as Recovery from Motor Block
evidenced by inability to move fingers. 7
2. (Good) Complete analgesia but no motor paralysis. 6
Recovery from
5
3. (Fair) Loss of pain sensation but discomfort to deep Motor Block
4
pressure still present.
4. (Partial) Only partial and patchy analgesia, requiring 3
supplementation. 2
5. (Poor) No analgesia at all, requiring general 1
anesthesia.
0
Descriptive and inferential statistical analysis has Group A Group B
been carried out in the present study. The results Graph 3: Recovery from motor block.
were analysed by using SPSS version 18 (IBM
There was statistically significant difference
Corporation, SPSS Inc., Chicago, IL, USA). Results
between the groups with Group A having higher
on continuous measurements were presented on
values (6.6±1.4 min vs 4.3±0.9 min) (Graph 4).
Mean±SD (Min-Max). Significance was assessed
at 5% level of significance. Normality of the data Lost of Cold Sensation
was assessed using Shapiro Wilk test. Independent 8
6 Lost of
t test and Chi- square test were used to find the Cold Sensation
4
significant difference of study parameters between 2
the groups. 0
Group A Group B
Results Graph 4: Loss of cold sensation.
There is statistically significant difference between

There was no significant difference in age and the groups with Group A having higher values
gender distribution between the groups i.e both the (8.5±1.5 min vs 5.4±1.2 min) (Graph 5).
groups were homogeneous. Loss of Pin Prick Sensation
There is statistically significant difference 10
Loss of
between the groups with Group A having higher
5 Pin Prick Sensation
values (14.1±2.9 min vs 8.8±1.2 min) (Graph 1).
Loss of Touch Sensation 0
Group A Group B
15
Loss of Graph 5: Loss of pin prick sensation.
10
Touch Sensation
5 There is statistically significant difference
0 between the groups with Group B having higher
Group A Group B values (8.3±1.4 min vs 11.4±1.4 min) (Graph 6).
Graph 1: Loss of touch sensation. Recovery of Cold Sensation
Recovery of
between the groups with Group A having higher 10
Cold Sensation
values (16.6±2.1 min vs 13.9±1.9 min) (Graph 2). 5
between the groups with Group B having higher Group A Group B
values (4.8±0.9 min vs 6.4±1.2 min) (Graph 3). Graph 6: Recovery of cold sensation.
There is statistically significant difference limitation of IVRA. Skin compression, tourniquet

between the groups with Group B having higher size, and inflation pressure have been implicated
values (7.9±1.2 min vs 9.3±1.4 min) (Graph 7). as factors involved in tourniquet pain. Another
Recovery of Pin Prick Sensation
drawback with this technique is the absence of
9.5 postoperative analgesia. In several studies it was
9 tried to find a local anesthesia mixture that allows
8.5 Recovery of Pin relief from tourniquet pain and prolonged duration
8 Prick Sensation
of analgesia after tourniquet release. Non-steroidal
7.5
7 anti-inflammatory drugs, opioids, and combination
Group A Group B of opioid and muscle relaxant have been used
Graph 7: Recovery of pin prick sensation.
without demonstrating clear advantage.7
Dexmedetomidine is approximately eight times
There was statistically significant difference
more selective toward the α2 -adrenoceptors than
between the groups with Group B having higher
clonidine.8 Centrally active α -adrenergic agonists
Values (5.9±1.4 min vs 8.2±0.9 min) (Graph 8).
exert powerful analgesic action that probably is
Recovery of Touch Sensation transduced at several levels. Dexmedetomidine has
9
been shown to enhance the local anesthetic action
8 of lignocaine via α 2A adrenoceptor.9 Perioperative
7 dexmedetomidine administration decreases the
6 requirements for opioid or non-opioid analgesics
Recovery of both intra and postoperatively.10
5
Touch Sensation
4 Addition of dexmedetomidine to prilocaine in
3 IVRA decreases pain scores, improves anesthesia
2 quality, decreases analgesic requirement,
1 shortens sensory block onset time, and prolongs
sensory block recovery time.2,11,12 Addition of
0
Group A Group B
dexmedetomidine to lignocaine in IVRA also
Graph 8: Recovery of touch sensation.
improves the quality of anesthesia and decreases
the analgesic requirements but has no effect on
There is statistically significant difference the sensory and motor block onset and regression
between the groups with Group B having higher time.2 Our study demonstrated that the addition of
values (11.3±3.5 min vs 16.9±2.8 min) (Graph 9). dexmedetomidine, in dose of 0.5mcg/kg of body
Onset of Tourniquet Pain weight, to lignocaine for IVRA not only improved
20
quality of anesthesia and postoperative analgesia
15 Onset of without causing significant side effects but also
10 Tourniquet Pain shortened the onset of sensory and motor block as
5 compared to placebo.
0
Group A Group B Memis et al12 in the year 2004 achieved IVRA
Graph 9: Onset of tourniquet pain. using 0.5% lignocaine 3mg/kg with saline in control
group and 0.5% lignocaine 3mg/kg with 0.5mcg/
kg dexmedetomidine in study group. Based on
Discussion
this we used 0.5mcg/kg dexmedetomidine with
lignocaine in the present study.
IVRA technique is widely used for surgery on arms.
Exsanguination: John Mabee et al13 showed that
IVRA is safe and problems are few. The advantages
while esmarch was most effective exsanguination
of IVRA are high indices of reliability, rapid
method, arm elevation or arterial compression also
onset of analgesia within 5–10 minutes and good
muscular relaxation. The disadvantage of IVRA is were effective. Hence in our study, first gravitational
the application of a tourniquet, which must remain drainage was done followed by esmarch bandage
inflated continuously throughout the procedure. application.
The duration of surgery is limited by the time Dose Selection: In our study, Group A received
during which the arterial tourniquet could be kept 0.5% lignocaine 3mg/kg and Group B received
safely inflated. Tourniquet pain, which is described 0.5%lignocaine 3mg/kg with dexmedetomidine
as a dull and aching pain sensation, is a well-known 0.5mcg/kg.
Vikas Joshi, Mohammed Yahya / 0.5% Lignocaine vs 0.5% Lignocaine with Dexmedetomidine for 1263
Similarly Dilek Memiset al4 used 0.5% lignocaine In our study there were no complications related
3mg/kg diluted to 40 ml in lignocaine group and to the use of tourniquet and also it was found that
0.5% lignocaine 3mg/kg with dexmedetomidine addition of dexmedetomidine reduced tourniquet
0.5mcg/kg diluted to 40 ml in dexmedetomidine pain during IVRA.
group. The present study showed significant
reduction of onset of sensory and motor block in Conclusion
Group B. Sensory and motor block recovery times
were also statistically prolonged in this group
(p<0.05), compared to Group A. Addition of 0.5mcg/kg of Dexmedetomidine as
an adjuvant to IVRA effectively enhances the
Dilek This anaesthesia and post-operative analgesia.
Memis et al4 study
Sensory block onset time (min ) 5± 2 5.4 Conflict of interests: Nil
Sensory block recovery time(min) 7±3 8.2
Motor block onset time(min) 10±4 13.9 References
Motor block recovery time(min) 8±3 6.4
Initial time of tourniquet pain 53±10 16.9
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damage of 1 in 80,000. The incidence was higher in selective α2-adrenergic agonist. Pharmacol Toxicol
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involving lower limb. The tourniquet time varied 9. Yoshitomi T, Kohjitani A. Dexmedetomidine
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together with 0.5% Lignocaine for IVRA. J Surg 14. Brown EM, Mcgriff JT, Maliinowski RW. Intravenous
Res.2010;164:242–7. regional anaesthesia (Bier block): review of 20 years’
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Comparing Macintosh, Miller and Truview Laryngoscopes for Evaluation

of Intubation Difficulty in Patients with Immobilized Cervical Spine
Abhishek Sharma1, Anupama Gill Sharma2, P R Chauhan3, Vijay Kumar Nagpal4,

Mohandeep Kaur5, H K Mahajan6
Author’s Affiliation: 1Associate Consultant, Department of Anesthesiology, Max Institute of Laparoscopy endoscopy and
Bariatric Surgery Max Super Speciality Hospital, Saket, New Delhi 110017, India, 2Associate Professor, 4Professor, 5Professor and
Head, Department of Anesthesiology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New
Delhi 110001, India, 3Senior Consultant, Department of Anesthesiology, 6Senior Consultant and Chief, Department of Anesthesia
Intensive Care Indian Spinal Injuries Centre, Sec C,Vasant Kunj, New Delhi 110070, India.
Corresponding Author: Anupama Gill Sharma, Associate Professor, Department of Anesthesiology, Atal Bihari Vajpayee
Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi 110001, India.
E-mail: dranupama.gill@gmail.com

Abhishek Sharma, Anupama Gill Sharma. Comparing Macintosh, Miller and Truview Laryngoscopes for Evaluation of
Intubation Difficulty in Patients with Immobilized Cervical Spine. Indian J Anesth Analg. 2020;7(6):1265–1271.
Abstract
Context: To evaluate intubation difficulty comparing Macintosh, Miller and Truview blades in patients
with immobilized cervical spine.
Aims:
1. To compare the difficulty during orotracheal intubation between Macintosh, Miller or Truview
laryngoscopes utilizing the Intubation Difficulty Scale (IDS).
2. To compare the time taken for intubation.
3. Success rate of intubation in the three groups.
Settings and Designs: Prospective randomized cross sectional study.
Methods and Materials: This study was conducted in healthy Patients to evaluate the difficulty during
intubation using the mentioned laryngoscopes, with the neck immobilized using Manual In-line Axial
Stabilization (MIAS). Evaluation was done using intubation difficulty score (having seven parameters),
success rate and duration of intubation. Intubation failure was defined as duration exceeding 120 seconds
for which MIAS was relaxed and intubation was done conventionally.
Statistics: One Way Analysis of Variance with Duncan’s mean test.
Results: All patients in the Macintosh group , 18 (90%) in Miller group and 16 (80%) in Truview group
were intubated successfully. The duration of intubation was significantly longer and IDS score, least in
Truviewgroup. Truview provided better glottic view and required less optimizing maneuvers.
Conclusions: The Intubation Difficulty Scale (IDS) score in parients with cervical spine immobilization
(MIAS) is significantly least with TruView laryngoscope compared to conventional laryngoscopy using
Macintosh or Miller laryngoscope.
The time taken for intubation was shortest with Macintosh laryngoscope. Success rate of intubation is
highest with Macintosh laryngoscope while it is least with TruView laryngoscope under the stipulated
time limit (120 seconds) for laryngoscopy.
Keywords: laryngoscopes Macintosh; Truview; Miller; Intubation difficulty scores laryngoscopes;
Cervical spine.

Introduction of intubation with manual inline stabilisation

(MILS) using Macintosh, Miller and TruView
Anaesthesiologists manipulate the cervical laryngoscopes utilising the Intubation Difficulty
spine (C-spine) every day of their lives (during Score (IDS).10
endotracheal intubation and patient positioning)
and they deal frequently with patients having Methods and Materials
C-spine disease.1 Patients with cervical spine injury
especially need to be handled with care. Nearly After approval from the hospital’s ethics committee,
4500 years ago an Egyptian physician described a 60 consenting patients scheduled for elective
patient with a cervical spine injury: “one having a surgery and requiring general anaesthesia with
dislocation of the vertebra of his neck while he is orotracheal intubation were entered into the study
unconscious of his two legs and his two arms and and were equally randomised into Patient Inclusion
his urine dribbles, an ailment not to be treated.”2 Criteria - Age 18 years and above; Either sex;
Although the current outlook is not so bleak, Patient scheduled for elective surgical procedure
cervical spine injury continues to be a catastrophic and requiring orotracheal intubation; A.S.A. grade
event.3 A considerable number of fractures are I – II; Mallampati Class I – II; Inter-incisor distance
missed on initial evaluation of patients in the > 3.5 c.m; thyro-mental distance > 6 c.m; sterno-
emergency. The major factor in the development mental distance > 12 c.m. Patients with risk factors
of a secondary injury is the failure to immobilise for gastric aspiration, cervical spine disorder, and
the neck.4 Under ideal situations, patients with those with history of difficult Intubation were
diagnosed or suspected cervical spine injury excluded from the study. After pre-anaesthetic
requiring intubation would simply be managed by evaluation and investigations, eligible patients
flexible fibre optic laryngoscopy and intubation; no were equally randomised into following three
neck motion would ever be required. Unfortunately, groups using draw of lots - Group I Macintosh;
this is not feasible in many situations.5 Usually, at Group II Miller; Group III TruView. All patients
many centres in India, fiberoptic laryngoscopy is received a standardised general anaesthetic and
not available especially in emergency departments. monitoring including electrocardiography, heart
Also, we are confronted by the combative or rate, pulse oximetry, non invasive blood pressure
intoxicated patient with the potential full stomach (NIBP), capnography and end-tidal carbon dioxide
in whom an awake fibre optic intubation is not and volatile anaesthetic levels. Patients were pre-
feasible, and in which an asleep intubation is not medicated with midazolam 40µg/kg to a maximum
deemed acceptable. We are hence constantly asking of 3 mg and fentanyl 2µg/kg before induction with
“in which patient is it acceptable to do a direct induction propofol 2mg/kg. Following induction
laryngoscopy (DL) and is there anything that can be of anesthesia, patients were manually ventilated
done to minimise the risk of C-spine injury during with oxygen and Isoflurane 1%. Neuromuscular
such a DL”.5 A key concern is the poor glottic view blockade was achieved with Rocuronium 0.9mg/
obtained during direct laryngoscopy with cervical kg following which the support below the head
spine immobilisation. Heath6 studied the effect (e.g. pillow, cushioned ring/halo) was removed so
on laryngoscopy of two different cervical spine that the head lied in the neutral position. Manual
immobilisation techniques in fifty patients. He In-line Axial Stabilization was then applied by an
recommended that manual inline immobilisation experienced assistant such that the mastoid process
should be the method of choice for cervical spine and the sides of the neck were held in position
stabilisation during tracheal intubation. In a in vivo preventing any movement (flexion, extension
cinefluroscopic study,7 compared with Macintosh, or rotation) of the neck. Laryngoscopy was then
the Miller blade was associated with a statistically performed, by an anaesthesiologist adequately
significant but quantitatively small decrease in experienced in the use all three laryngoscopes,
cervical extension. The TruView EVO2, an optical according to the group to which the patient had been
laryngoscope, (Truphatek International Ltd., assigned followed by orotracheal intubation with an
Netanya, Israel), provides a 42° angled deflection appropriate size regular cuffed endotracheal tube.
view through the 15 mm eyepiece.8 M. Barak et al In group III, to prevent fogging and to keep lens
have reported that TruView blade provided a better clear of secretions, TruView EVO2’s oxygen port
laryngoscopic view while requiring significantly was connected to oxygen supply line at a minimum
less force and resulted in less soft tissue trauma rate of 8 Litres/minute. It was held in left hand and
following intubation.9 We propose to study and with the right hand, patient’s mouth was opened
compare the ease of laryngoscopy and success slightly and blade was inserted in the mouth in
Abhishek Sharma, Anupama Gill Sharma, P R Chauhan, et al. / Comparing Macintosh, Miller and Truview 1267
Laryngoscopes for Evaluation of Intubation Difficulty in Patients with Immobilized Cervical Spine
the midline to the 0- depth line marked on the Table 2: Airway parameters of cases enrolled into study.
TruView EVO2 blade using two fingers as a guide. Group I Group II Group III
Glottis was viewed through the eyepiece from a (n =20) (n =20) (n =20)
comfortable distance while advancing TruView™ Mallampati 1 25% 35% 35%
EVO2 until the 1- line depth and it was possible Class 2 75% 65% 65%
to see the vocal cords. Once adequate glottic view IID (cm) Mean ± S.D. 4.5 ± 0.5 4.4 ± 0.4 4.4 ± 0.5
was achieved, endotracheal tube with the Opti TMD (cm) Mean ± S.D. 7.1 ± 0.6 6.7 ± 0.6 6.8 ± 0.6
Shape stylet -provided with the laryngoscope, (if SMD (cm) Mean ± S.D 16 ± 1.3 15.8 ± 0.7 16.1 ± 1
needed) was inserted from at right side of mouth
and advanced until the tip of the tube could be seen All patients in Group I (Macintosh) were
while looking through the optical view tube. Then successfully intubated while 18 patients in Group
the tube was passed through the vocal cords while II (Miller) and 16 patients in Group III (TruView)
observing through the optical view tube to verify were intubated successfully (Table 3). The success
tube placement. Duration of intubation of was rate of intubation was 100%, 90% and 80% in Group
noted by an independent observer not assisting or I, Group II and Group III respectively. The average
directly involved in the process of laryngoscopy duration of intubation (mean ± S.D.) was 16.2 ±
and intubation. The following observations were 6.7, 25.7 ± 15.4 and 53.4 ± 25.8 seconds in Group
made: The seven parameters of IDS score; total IDS I, Group II and Group III respectively, which was
score; total duration of intubation and success of statistically significant. Duration of intubation was
intubation. The duration of an intubation attempt significantly prolonged in Group III (TruView)
was defined as the time taken from insertion compared to Group I (Macintosh) and Group II
of the laryngoscope blade in the oral cavity till (Miller).
the placement of the endotracheal tube through Table 3: Comparison of success rate and duration of intubation
the vocal cords was visually confirmed by the among Group I, Group II and Group III. *Duration significantly
prolonged in Group III.
anaesthesiologist performing the intubation. In
Duration
situations where visual confirmation of the tube
of
passing through the cords was not done, the attempt Successful Unsuccessful Success intubation
was not considered complete till the tube was Intubations Intubations rate (Mean
connected to the breathing circuit and successful ± S.D.)
(seconds)
placement was confirmed by capnography/
end tidal CO2. A single attempt at laryngoscopy Group I 20 0 100% 16.2 ± 6.7
(n=20)
was given. Failure was defined as laryngoscopy
Group II 18 2 90% 25.7 ± 15.4
time exceeding 120 seconds. If the duration of (n=20)
laryngoscopy exceeded 120 seconds, manual in-line Group III 16 4 80% *53.4 ± 25.8
stabilisation was released and patient was intubated (n=20)
conventionally. Data was analysed using One Way
Analysis of Variance with Duncan’s mean test. Analysis of Parameters of Intubation Difficulty Scale
(IDS) (Table 4 to 9)
Results The average number of additional intubation

attempts (N1 points) were significantly increased
A total of 60 patients were enrolled in the study, 20 Table 4: Comparison of number of intubation attempts among
in each group. The demographic variables (Tables 1 Group I, Group II and Group III. n, number of successful
and 2) similar in all the groups. Although there was intubations;* Number of intubation attempts significantly
a male preponderance in the groups, the gender increased in Group III.
distribution between the three groups was similar. Average
N1
Table 1: Age, Gender and Body Mass Index of cases enrolled
Number of intubation attempts points
into study.
(Mean ±
Group I Group II Group III S.D.)
(n =20) (n =20) (n =20) 1 2 3 >3
BMI (kg/m2) Mean S.D ± 24.8 ± 1.9 24.5 ± 1.8 24.3 ± 2 Group I 6(30%) 7(35%) 4(20%) 3(15%) 1.2 ± 1.1
Age (years) Mean S.D.± (n=20)
42± 17.2 47.2± 15.1 44.8± 15
Group II 3(16.6%) 6(33.3%) 8(44.4%) 1(5.5%) 1.3 ± 0.8
Gender (n=18)
Male 15 13 14 Group III 0(0%) 2(12.5%) 6(37.5%) 8(50%) 2.5 ± 1.1*
Female 5 7 6 (n=16)

Table 5: Comparison of alternative technique used among Table 9: Comparison of IDS score among patients in Group I,
Group I, Group II and Group III. Group II and Group III.
Average N3 Intubation Difficulty Scale (IDS) Score
Used Not used points 0–5 >5 (Mean ± S.D.)
(Mean ± S.D.) Group I (n = 20) 9 (45%) 11 (55%) 5.8 ± 1.4
Group I 14 (70%) 6 (30%) 0.7 ± 0.5 Group II (n = 18) 10 (55.5%) 8 (44.4%) 5.3 ± 1.4
(n = 20)
Group III (n = 16) 14 (87.5%) 2 (12.5%) 3.8 ± 1.3*
Group II 11 (61.1%) 7 (38.8%) 0.6 ± 0.5 n, number of successful intubations.
(n = 18)
* IDS score significantly less in Group III compared to Group I
Group III 16 (100%) 0 (0%) 1 ± 0.0 and Group II.
(n = 16)
in Group III. All patients were intubated by a single
* Average N3 points significantly higher in Group III; n, number
anaesthesiologist without any additional operator
of successful intubations
directly attempting intubation. Therefore N2 points
Table 6: Comparison of glottic exposure among Group I, Group
II and Group III n, number of successful intubations. in all the cases were zero. Fourteen patients (70%)
in Group I and eleven (61.1%) in Group II required
Average
N4 points the use of a stylet for intubation. In Group III, all
Cormark Lehane Grade patients were intubated using the OptiShape stylet
(Mean ±
S.D.) provided with the Truview EVO2 laryngoscope.
1 2 3 4 Average N3 points were significantly higher in
Group I 0(0%) 2(10%) 18(90%) 0 (0%) 1.9 ± 0.3 Group III. Glottic view (N4 points) significantly
(n=20) improved in Group II compared to Group I while
Group II 0(0%) 8(44.4%) 10(55.5 %) 0(0%) 1.6 ± 0.5* it was significantly better in Group III compared to
(n=18) the other two groups. All patients in Group I and II
Group III 13(81.3 %) 3(18.7%) 0(0%) 0(0%) 0.2 ± 0.4** required an increased lifting force (N5 points) while
(n=16) all patients in Group III required a normal lifting
* Glottic view significantly better in Group II, compared to force during intubation which is significant. Most
Group I; cases in Group I (90%) required external laryngeal
** Glottic view significantly better in Group III compared to pressure (N6 points) while only two cases (12.5%)
Group I and Group II. in Group III needed external laryngeal pressure
Table 7: Comparison of lifting force during laryngoscopy among to optimise the glottic view during intubation. In
Group I, Group II and Group III, Increased lifting force needed all patients vocal cords were abducted and there
in Group I and II; n, number of successful intubations. was no impediment to intubation due the position
Average N5 of the vocal cords. Therefore the N7 points in all
Normal Increased points cases were zero. The IDS score and hence the
(Mean ± S.D) intubation difficulty was least in Group III which
Group I 0 (0%) 20(100%) 1.0 ± 0.0 was statistically significant.
(n = 20)
Group II 0 (0%) 18 (100%) 1.0 ± 0.0
(n = 18) Discussion
Group III 16 (100%) 0 (0%) 0 ± 0.0
(n = 16) Trauma patients with suspected cervical spine
Table 8: Comparison of applied external laryngeal pressure injuries pose several problems while securing
among patients in Group I, Group II and Group III. n, number of the airway and can be a challenge to the
successful intubations. anaesthesiologist.
Average N6 The acutely traumatised patient requires urgent
Applied Not Applied points
(Mean ± S.D.)
airway attention, owing to a high incidence of
profound hypoxia and acidosis, allowing little
Group I 18(90%) 2(10%) 0.9 ± 0.3
(n = 20) time for assessment. A cervical spine injury is not
confirmed in many such situations. Intubation
Group II 15(83.3%) 3(16.6%) 0.8 ± 0.3 must proceed promptly but with care.11
(n = 18)
Failure to adequately immobilise the neck
Group III 2(12.5%) 14(87.5%) 0.1 ± 0.3
(n = 16)
during tracheal intubation in patients with
cervical spine injuries can result in a devastating

neurological outcome. A widely used approach done. The TruView EVO2 laryngoscope (Truphatek
is neck immobilisation using manual in-line axial International Ltd., Netanya, Israel) is a recently
stabilisation (MIAS). The evidence base supporting introduced optical laryngoscope. It is quite similar
MIAS is surprisingly limited. In anatomical studies, to a conventional laryngoscope with a similar
after complete C4–C5 ligamentous injury, MIAS did handle and a modified blade incorporating a view
reduce segmental angular rotation and distraction, tube with a prism system.8
although it did increase subluxation, compared As compared to Macintosh and Miller blades,
with non immobilisation. In a case series of 150 it provides a anterior refraction of 42° to the
patients with traumatic cervical spine injuries
line of sight, improving the glottic view, hence
with well preserved neurological function, oral
reducing the lifting force required and possibly
tracheal intubation with MIAS, whether performed
less cervical spine movement. The glottic opening
after induction of general anaesthesia or with
procedure using the TruView is simpler to routine
patient awake, did not result in any neurological
laryngoscopy and does not require learning of any
complications.12
special skill. This principle formed the basis of
It is therefore an accepted practice in many analysis of this device. During the pilot phase of
institutions to remove rigid collars and use MIAS for this study, we noted that the duration of intubation
cervical immobilisation during tracheal intubation with the TruView was much prolonged with
in patients with suspected or proven cervical spine multiple attempts at laryngoscopy. Considering
injury. A key concern remains the fact that glottic the limited time available during an emergency
views obtained during direct laryngoscopy with situation and patient safety during the study,
cervical spine immobilisation are consistently duration of intubation was capped at 120 seconds,
poorer, compared with non-immobilised controls, beyond which the attempt would be considered
which is a major factor in determining the difficulty a failure, and allowing only a single attempt at
of intubation. Consequently, manoeuvres to laryngoscopy. Further, to reduce the incidence of
stabilise the neck patients at risk of cervical injury fogging, oxygen with a minimum flow of 8 L/min,
may result in failure to secure the airway, which may was connected to the side port of the laryngoscope.
result in substantial morbidity and even mortality in Our study demonstrated that intubation difficulty
this patient group. These issues highlight the need was significantly reduced with TruView in
to develop alternative approaches to securing the comparison to Macintosh or Miller blades. Most
airway in patients at risk of cervical spine injury.12 patients in TruView group (87.5%) had IDS score
In those centres that have developed skill with 0–5 (easy to slight difficulty).Eleven patients (55%)
the technique, the fiberoptc laryngoscopy and in Macintosh group, eight (44.4%) in Miller group
intubation has proved to be a very useful tool. while only two patients (12.5%) in TruView group
However its use is limited by various factors had IDS score >5 (moderate to major difficulty). In a
including availability, skill and feasibility in certain similar study by Smith et al using Wuscope87 there
situations. In such situations, a laryngoscope will were 79% patients in the fibreoptic group and 39%
be useful which improves the glottic view with patients in the Macintosh group with IDS = 0 (easy
MIAS, does not require learning of any special skill intubation).
for its use and takes minimum time to assemble Similar results were seen in a study by Maharaj
and intubate. et al using Airtraq laryngoscope 69, with 19 out of
There have been studies on various indirect 20 patients in the Airtraq group having an IDS of
optical view laryngoscopes in similar situations zero.
– Bullard laryngoscope,13 WuScope,14 Airtraq The main factor for a reduced IDS score was
laryngoscope,12 Gildescope.15 Although results have significantly improved glottic view in the TruView
been positive in most studies, there is no evidence group. 81.3% of patients in TruView group had
that one method is better than the others. Cormack-Lehane grade 1 view while no patient
Keeping these factors under consideration, in either Macintosh or Miller group had grade 1
we proposed that intubation difficulty would be view. 90% patients in Macintosh group and 55.55
reduced with TruView (a recently introduced in Miller group had grade 3 view. Glottic view in
optical laryngoscope) compared to conventional the miller group was significantly better than in the
laryngosocpy with Macintosh or Miller Macintosh group while glottic view was the best in
laryngoscope. To our knowledge at the time of the TruView group which is significant. In a vivo
beginning this study there was no such analysis cinefluroscopic study by LeGrand et al,5 it was

observed that direct laryngoscopy and orotracheal The success rate of intubation was least in the
intubation with Miller blade resulted in 15 – 20% TruView group (80%) compared to Macintosh
less cranio-cervical extension than with Macintosh (100%) and Miller (90%) group owing to the
blade, on average approximately 3º less at occiput prolonged intubation time in all the four failed
– C1 and approximately 5º less from occiput to C5. cases in the TruView group. Lesser success rate in
This could account for a better glottic view with the TruView group could be attributed the time
cervical spine immobilisation in the Miller group limit described (120 seconds) for patient safety
compared to Macintosh in our study. and to simulate emergency conditions in our
In a study of 200 patients by J.B. Li et al16 study. Thus success rates in our study might not
comparing TruView and Macintosh laryngoscope, reflect those during routine intubations. No cases
glottic view was significantly improved with in the TruView group encountered the problem of
TruView laryngoscope. Similar results were fogging. Keeping a minimum flow of 8L/min of
obtained in a study by Lieberman et al.17 Our study oxygen successfully avoided this problem.
confirms and extends these findings of improved
glottic view with TruView laryngoscope even The anaesthesiologist performing the
in patients with cervical spine immobilisation. laryngoscopy could not be blinded to the
Moreover, less number of patients in the TruView laryngoscope being used as this is obviously
group required manoeuvres like external laryngeal impossible. Hence observer bias cannot be
pressure to improve the glottic view, an observation completely ignored in our study especially
also made in the study by J.B. Li et al.16 regarding subjective parameters of the intubation
difficulty score.
However, the mean duration of intubation
was significantly prolonged, 53.4 seconds in the Despite the longer duration of intubation and
TruView group as compared to Macintosh or the less success rate, the TruView has a decreased IDS
Miller group (16.2 and 25.7 seconds respectively). score. This might be useful certain clinical situations
The average duration of intubation was the least as reported by M. Gotou et al.18
in the Macintosh group. Similar results were also
The manipulation procedure of the EV02 is similar
obtained in the study by J.B. Li et al wherein the
to the routine laryngoscopic and does not require
mean time to intubate with the TruView was
significantly prolonged (51 seconds) compared to learning of any special skill.18 The use of optical
Macintosh laryngoscope (34 seconds) 50. Similar laryngoscopes such as the EV02 may compensate for
results also obtained with the WuScope in the study the disadvantages of awake fibreoptic intubation,
by Smith et al. and their use allows safe tracheal intubation.18 In
our study however, lower difficulty score was
The increased duration of intubation was
associated with longer intubation times indicating
associated with an increased number of intubation
possibly a comparatively lesser experience with
attempts. 50% of patients in the TruView group
TruView than with conventional laryngoscopy.
required more than 3 attempts to intubate compared
to 15% in the Macintosh and 5.5% in the Miller Skilled hand eye coordination is perhaps required
group. Thus although the glottic view was better to manipulate the endotracheal tube under indirect
with the TruView, it required increased number of vision.
intubation attempts. As noted by Crosby et al,7 anaesthetists should
We observed that while advancing the intubate the patients in the manner with which
endotracheal tube towards the glottis in the they have the most expertise. The paramount issue
TruView group it tended to move posterior to the is to avoid spinal movement and not the mode of
glottis. Overcoming this problem required the use intubation.
of the preformed Optishape™ stylet provided with
the TruView laryngoscope. Further, it was noticed Conclusions
that withdrawing the TruView laryngoscope and
then advancing the endotracheal tube towards
the glottis resulted in successful placement of the Tru View Laryngoscope had the least difficulty
endotracheal tube rather than advancing and lifting but required more time to intubate in patients with
the laryngoscope blade further as this moved the cervical spine immobilization (MIAS), compared
larynx more anterior to the endotracheal tube to conventional laryngoscopy using macintosh or
which actually increased the difficulty. miller laryngoscopy.

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Todd MM. Craniocervical motion during direct 15. F. Agr, G. Barzoi, F. Montecchia. Tracheal intubation
laryngoscopy and orotracheal intubation with using a Macintosh laryngoscope or a GlideScope® in
the Macintosh and Miller Blade An an vivo 15 patients with cervical spine immobilization Br.
cinefluroscopic study. Anesthesiology 2007; 107:884 J. Anaesth. 2003 90: 705–706.
– 91. 16. J.B. Li, Y.C. Xiong, L. Wang, X.H. Fan, Y. Li, H. Xu,
8. Truphatek International Ltd. TruView EVO2 Y.Ma and M.Deng. An evaluation of the TruView
Optical View Larygoscope. Available from www. EVO2 Laryngoscope. Anesthesia, 2007; 62: 940–943.
truphatek.com. 17. Lieberman N., Abu Ras H. and Lemberg L. Truview
9. M. Barak, P. Phillipchuk, P. Abecassis and Y. blade improves laryngeal view when compared to
Katz. A comparison of the Truview blade with the blade. Anesthesiology, 2003; 99: A565.
Macintosh blade in adult patients. Anaesthesia, 18. Mayumi Gotou, Tetsuo Inoue. Application of the
2007; 62: 827– 831. TruView EVO2 optical laryngoscope to patients
10. Frédéric Adnet, Stephen W. Borron, Stéphane X. with cervical spine disease. Journal of Anesthesia,
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A Survey of Intubation of COVID-19 Patients in the Critical Care Units

to Assess Adherence to Guidelines and Critical Events Encountered
Akhya kumar kar1, Ayya Syama Sundar2
Author’s Affiliation: 1Assistant Professor, 2Associate Professor, Department of Anesthesiology and Intensive Care, Nizam’s
Institute of Medical Sciences, Hyderabad 500082, India.
Corresponding Author: Ayya Syama Sundar, Associate Professor, Department of Anesthesiology and Intensive Care, Nizam’s
Institute of Medical Sciences, Hyderabad 500082, India.
E-mail: sasyasyama@gmail.com

Akhya kumar kar, Ayya Syama Sundar. A Survey of Intubation of COVID-19 Patients in the Critical Care Units to Assess
Adherence to Guidelines and Critical Events Encountered. Indian J Anesth Analg. 2020;7(6):1273–1276.
Abstract
Background: The Coronavirus disease (COVID-19) pandemic affected the health care personnel with
the worse outcome as compared to the general population.Anaesthesiologists,being the first responders
in critical care units (ICU) for aerosol-generating procedures like endotracheal intubation are at higher
risk of getting infected with the virus.The updated SARS guideline (Severe Acute Respiratory Syndrome)
of the 2003 epidemic in Toronto, Canada, is quite instructive for endotracheal intubation. This study was
intended with the primary objective to find out the adherence of guidelines among the anaesthesiologists
while doing endotracheal intubation and the secondary objective is to assess the incidence of other critical
events.
Methods: This survey was conducted in a tertiary care centre among the anaesthesiologists about their
first COVID-19 patient intubation,based on a 40-point questionnaire about adherence of guidelines and
critical event encountered. All the responses collected in google form which was further evaluated with
the help of SPSS-17.
Results: Total of 112 patients intubated in the ICU, out of which 62% were emergency intubation, aerosol
boxes used while intubation in 20% cases. Hand hygiene before the procedure was not followed in 25%
and no gowns used while doing the procedure was recorded in 34% respondents. Clamping ET tube
and use of hydrophobic filter was missed in 15% and 22% cases. The surroundings contaminated in 51%
of respondents. Hypoxia, hypotension, arrhythmia, hypertension, cardiac arrest and aspiration during
intubation was observed in 58%, 62%, 29%, 21%, 22%, 11% cases respectively.
Conclusion: With the anaesthesiologists getting adapted to the new norms of intubation in COVID days,
the adherence to guidelines is suboptimal, and the complication rate was high during the first intubation
attempts.
Keywords: Intubation; Survey; SARS Coronavirus.
Introduction disease (COVID-19) is highly infectious and

affected the health care personnel with the worse
The control of the spread of the infective disease outcome as compared to the general population.
has always been a challenge to health care With many health care personnel succumbed
professionals. While the patient treatment remains to the disease the anaesthesiologists, being the
a priority but personal care also equally important first responders in critical care set-up (ICU) for
in such circumstances. The SARS Coronavirus aerosol-generating procedures like endotracheal
intubation are at higher risk of getting infected the responses collected in google form which was
with the virus. With the concerns about the direct further evaluated with the help of SPSS17.
relationship of viral load with the severity of the At the time the study responses taken India was
disease, utmost priority should be given for, nearing to 90,000 deaths due to COVID-19. Taking
personal protection of the anaesthesiologists.1 The in to account ICU bed strength and many cases of
personal protective equipment (PPE), use of face sudden cardiac death and failure to get a bed in
shield, aerosol boxes for intubation, frequent hand ICU we assumed that 20% COVID-19 patients in
washing, optimal care for sanitization of personal India were intubated in critical care where proper
belongings are proposed measures to curtail the institutional guidelines being set for procedures
spread of the virus.2 Many recommendations inside ICU, with a power of 80% and an alpha error
proposed to guide the treating physicians while of 0.05, the sample size was calculated to be 105
attempting intubation among which updated SARS to derive any meaningful conclusion. However,
guideline (Severe Acute Respiratory Syndrome) of considering the possibility of improper entries, we
the 2003 epidemic of in Toronto, Canada, is quite sought a minimum of 110 entries.
instructive.3 However, the procedures in ICU are of Table 1: Questionnaire
emergency in nature and the intensivist gets very
1. Designation
limited time to react on many occasions, making
2. Role
them miss the safety guidelines more often. With
the rotatory postings practised in critical care 3. Guidance of Experienced personnell
units, the first responder to crisis many times new 4. Intubation indication
to the unit or less experienced or working in the 5. Whether planned to use barrier protection with aerosol
unit with some time gap makes them prone to do box
error. The unsafe practices inside the ICU put both 6. Whether Practiced appropriate hand hygiene before
procedures
primary responder and the assistants at risk. With
7. Whether Practiced appropriate hand hygiene After
the availability of limited data about the critical procedures
incidences inside the ICU while intubation we tried 8. Whether used face shield/ eye protector before
to evaluate it through a questionnaire survey. This intubation?
study was intended with the primary objective 9. Whether used gown before procedure
to find out the adherence of guidelines among 10. Whether disposed the gowns and gloves appropriately
the anaesthesiologists while doing endotracheal after the procedure
intubation and the secondary objective is to assess 11. Used aerosol boxes for intubation
the incidence of other critical events. 12. Whether assessed airway before intubation
13. Number of intubations in COVID patients you have
done before attempting this patient
Methods
14. Whether the most experienced person did the
intubation.
This questionnaire survey was conducted among 15. No of Assistants available while intubation
anaesthesiologists who work in the critical care unit 16. Which laryngoscope used for intubation
of COVID-19 care centres. A 40-point questionnaire 17. Bougie use while intubation
put forward among the anaesthesiologists who 18. Muscle relaxation used for intubation
intubated a patient in a critical care unit. (Table 19. No of attempt for successful intubation
1). The questions were based on whether the 20. Was there any delay in intubation
recommendations for intubations followed and 21. Cause for delay in intubation
critical events encountered while doing the 22. Was there hypotension before intubation
procedure during their first attempted endotracheal 23. Arrythmia during intubation
intubation of a COVID-19 patient. First intubation 24. Cardiac Arrest during intubation
was chosen because most of the error occurs while 25. Hypotension >20% fall in MAP during intubation
the exposure to the situation is new and any 26. Hypertension during intubation >20% increase in MAP
intubation in which the safety protocols bypassed 27. Was there fall in spo2>10% during intubation
is a threat to the operator as well as assistants. Also 28. Before intubation patient was on Which mode of
with the rotatory postings among professionals oxygenation
to limit frequent exposures, the experience of 29. If on HFNO whether it was stopped before intubation
intubating a COVID-19 patient seems to be limited. 30. How did u confirm ET tube position
Endotracheal intubation is a high-risk procedure 31. Whether Airway trauma occurred while intubation
for generating aerosol was chosen to enquire. All 32. Which technique was used for intubation?

Akhya kumar kar, Ayya Syama Sundar / A Survey of Intubation of Covid-19 Patients in the Critical Care 1275
Units to Assess Adherence to Guidelines and Critical Events Encountered
33. Small tidal volumes or regular tidal volumes used for Discussion
bag and mask ventilation?
34. If RSI was planned, was 5 minutes of pre-oxygenation The SARS guidelines are useful recommendations
with 100% oxygen done?
for managing the airway of COVID-19 infected
35. Whether a filter was used while ventilation or
patients. But the emergency in ICU warrants
intubation
immediate attention to the deteriorating patients
36. Whether you followed all the institutional guidelines
for intubation in COVID patients?
which make it difficult for the primary caregivers
to follow the guidelines and safety protocols. Our
37. Which guideline u missed
study results were consistent with the finding
that emergency intubation was 62% were almost
38. Whether any aspiration occurred during the
procedure? equal incidence of non-use of aerosol boxes and
although in 33% cases it was planned to use but
39. Whether patient surroundings contaminated during
intubation finally used in only 20% cases because of various
40. Appropriate cleaning and disinfection of equipment
other reasons. Aerosol boxes are introduced at the
environment surfaces done after the procedure? start of the pandemic by a Taiwanese doctor with
a plan to reduce the aerosol exposure to the health
care person however it seems from our study that,
Results the acceptance of the same is sub-optimal.2 The
personal protection equipment (PPE) seems to be
Total of 112 responses collected and reviewed, acceptable but additional protection of disposable
out of which 62% were emergency and 25% were gowns during intubation was lacking in 34%
semi-emergency intubations. (Fig. 1) A total of 33% cases making the primary caregiver as well as the
responders planned to use aerosol boxes however assistants at risk. Use of a hydrophobic filter and
only 20% of cases aerosol boxes used while Clamping of ET tube before intubation and opening
intubation. All the respondents used either a face after attaching to the ventilator circuit was followed
shield or eye protector while doing the procedure. to reduce the threat of releasing aerosol. This was
Video laryngoscope was used for intubation in 55% missed in some cases which need to be addressed.
cases, bougie was used in 83% cases and 84% cases One of the major threat of COVID-19 transmission
paralytic agent used for intubation. Hand hygiene was through surface transmission, to prevent it
before the procedure was not followed in 25%, necessitates proper infection control measures to be
followed in ICU, however proper hand hygiene was
however, post-procedure the compliance was 100%.
not followed in 25% cases making the risk of cross-
No gowns used while doing the procedure was
contamination of patients as well as equipment
recorded in 34% of respondents. Clamping ET tube
inside the ICU. During intubation as high as 51%
and use of hydrophobic filter were missed in 15%
of respondents believed the surrounding got
and 22% respectively. In 56% of cases, airway was
contaminated during intubation.
not assessed before intubation. The surroundings
contaminated in 51% of respondents. Intubation Video laryngoscope is highly recommended
delay was faced in 44% of cases, the incidence of for intubation but not done so in half of the cases
hypoxia, hypotension, arrhythmia, hypertension, probably related to the availability of suitable
cardiac arrest and aspiration during intubation was gadgets. Also in 56% cases, airway assessment was
observed in 58%, 62%, 29%, 21%, 22%, 11% cases not done before intubation, and approximately
respectively. 30% cases pre-oxygenation for 5 minute was not
done, probably due to emergency situation, which
puts the anaesthesiologists at risk of encountering
more incidences un-anticipated difficult airway
and complication. Total of 44% of respondents
observed that there was a delay in intubation
while managing the airway and 50% of the time it
was attributed to positioning-related issues. The
ICU beds are always a concern while managing
difficult airway because of the height, closely
placed to the wall, and sometimes the negative
chambers in some beds consume additional time to
position the patient properly for intubation. Apart
Fig. 1: Type of intubations. from the critical events encountered related to
airway haemodynamic compromise occurred in a Conclusion

significant number of patients with sudden cardiac
arrest in more than 22% cases. In a study conducted
With the anaesthesiologists getting adapted to
in Wuhan of China, the incidence of cardiac arrest
the new norms of intubation in COVID days,
while intubation was found to be <10%. The high
incidence in our study was probably attributed to guideline adherence for intubating these patients is
the first intubation of the intensivist in COVID care suboptimal. The complication and unsafe practices
unit.4 So guidance of experienced anaesthesiologist incidence are high during the first intubation for
carries much importance for doing safe procedures which due precautions should be taken to prevent
in critical care units. With the worse outcome in adverse events in critical care units.
COVID-19 related patients requiring intubation
and ventilator support,5 Many patients managed References
in high flows or non-invasive ventilation (NIV)
support and mechanical ventilation delayed till very
late stage making patients prone for complication 1. Shufa Zheng, Jian Fan, Fei Yu, Baihuan Feng, Bin
during intubation. High flow nasal oxygen therapy Lou, Qianda Zou, et al:Viral load dynamics and
(HFNOT) is a threat to produce aerosol generation, disease severity in patients infected with SARS-
but only 3% of patients were on HFNOT during CoV-2 in Zhejiang province, China, January-March
airway intervention in our respondents, it was not 2020: retrospective cohort study: BMJ. 2020; 369:
further evaluated. A total of 83% of patients were m1443.
on NIV with continuous positive airway pressure 2. Everington K. Taiwanese doctor invents device
(CPAP). The incidence of hypoxia was 58–73% and to protect US doctors against coronavirus.
hypotension was 10–33% in the study conducted 2020. https://www.taiwannews. com.tw/en/
in China,4 whereas the hypoxia incidence was news/3902435 (accessed 28/04/2020).
almost similar (58%), hypotension incidence was 3. Beverley A. Orser, Recommendations for
much higher (62%) in our survey group. The Endotracheal Intubation of COVID-19 Patients:
high incidence of adverse events during probably Anesth Analag: 2020 : 130( 5):1109–10.
attributed to the removal of the mask depriving
4. Wenlong Yao, Tingting Wang, Bailin Jiang, Feng
the patients of oxygen, failure to provide pre-
Gao, Li Wang, Hongbo Zheng. Emergency tracheal
oxygenation, use of intravenous anaesthetic agents
intubation in 202 patients with COVID-19 in
and delay in intubation due to various issues.
Wuhan, China: lessons learnt and international
The limitation of our study includes, each expert recommendations: British Journal of
institution has different guidelines and set protocols Anaesthesia:2020: 125 (1): 28–37.
which was not considered while collecting data. 5. Yang X, Yu Y, Xu J, Shu H, Xia JA, Liu H, Wu Y,
Patients condition and associated comorbidity with Zhang L, Yu Z, Fang M, et al. Clinical course and
the patients not taken into account. With the survey outcomes of critically ill patients with SARS-CoV-2
conducted about the first experience of intubations, pneumonia in Wuhan, China: a single-centered,
more recent attempts and their outcome can be retrospective, observational study. Lancet Respir
enquired in future studies. Med. 2020;8(5):475–81.

Propofol vs Sevoflurane for Laryngeal Mask Airway Insertion Under

General Anaesthesia in Day Care Surgeries
Gurpreet Singh1, Haramritpal Kaur2, Deepali Bansal3, Divya Kavita4,

Amandeep Singh5, Shashank Gupta6
Author’s Affiliation: 1Professor, 2Associate Professor, 3Senior resident, 4Assistant Professor, 6Junior Resident Department of
Anaesthesia, 5Assoicate Professor, Department of Surgury, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab
151203, India
Corresponding Author: Haramritpal Kaur, Associate Professor, Department of Anaesthesia, Guru Gobind Singh Medical
College and Hospital, Faridkot, Punjab 151203, India.
E-mail: amritk_dr@yahoo.co.in

Gurpreet Singh, Haramritpal Kaur, Deepali Bansal, et al. Propofol vs Sevoflurane for Laryngeal Mask Airway Insertion Under
General Anaesthesia in Day Care Surgeries. Indian J Anesth Analg. 2020;7(6):1277–1281.
Abstract
Background: Laryngeal mask airway (LMA) is an excellent airway device used in day care surgeries.
We aimed to compare two induction anaesthetic agents, propofol and sevoflurane for LMA insertion
conditions in day care surgeries.
Patients and Methods: This prospective, randomized study was conducted on 80 adult, ASA grade I and
II patients, of either gender, undergoing elective day care surgical procedures. Patients were randomly
divided in two groups of 40 each. Group P received intravenous propofol infusion at the rate of 800ml/
hour for induction followed by LMA insertion. Group S received 8% sevoflurane for induction followed by
LMA insertion. Both groups were compared for LMA insertion conditions in terms of time taken from the
start of induction to loss of verbal contact, loss of eyelash reflex, jaw relaxation, successful LMA insertion
conditions, number of attempts of LMA insertion and effective airway establishment time. Unpaired
student – t test and Chi square test were used for statistical analysis.
Results: Patients in Group P achieved earlier LMA insertion conditions as compared to Group S i.e.
shorter time to loss of verbal contact (33.48 ± 6.55 seconds vs 41.30 ± 4.12 seconds), loss of eye lash reflex
(36.50 ± 6.67 seconds vs 44.40 ± 4.06 seconds), adequate jaw relaxation (40.35 ± 7.64 seconds vs 49.02 ± 4.45
seconds), and effective airway establishment time (44.88 ± 8.86 vs 54.65 ± 4.28 seconds) (P value <0.001).
Conclusion: We concluded that both the agents can be used for insertion of LMA however induction and
insertion of LMA is faster with propofol.
Keywords: Laryngeal mask airway; Propofol; Sevoflurane; Eye lash reflex; Airway establishment time.
Introduction including facemasks, supraglottic airway devices

and endotracheal tubes.1
Day care surgery help to reduce the burden on Facemask are usually used along with the triple
hospital and health care system and can improve jaw manoeuvre to keep the airway patent. But there
patient satisfaction and comfort. However, apart are several reports of pressure injuries to the eyes,
from proper patient selection, preparation, surgical lips and the nerves of the face with the use of face
techniques it requires a good balanced anaesthesia mask.2 Facemask also requires constant occupation
technique. Various techniques are employed for of the anaesthesiologist hand and undivided attention
maintaining airway during daycare surgeries to the patient’s head and neck during the procedure.
Tracheal intubation requires laryngoscopy that On day of the surgery after connecting standard
can cause injuries to the lips, teeth and soft tissues of ASA monitors, patient's baseline vital heart rate
the mouth. There is also significant pressor response (HR), systolic blood pressure (SBP), diastolic blood
during laryngoscopy which can have deleterious pressure (DBP), oxygen saturation (SpO2), end tidal
effect.3,4 There is also increased resistance while cardon-di-oxide (EtCO2) and temperature were
breathing spontaneously through a tracheal tube. recorded. Patients received injection pentazocine
A high incidence of postoperative sore throat has 0.5 mg/kg iv prior to induction.
made tracheal intubation an unattractive alternative Patients were randomly allocated into two
for short day care surgical procedures.5 groups of 40 each, Group P and Group S through
Laryngeal Mask Airway (LMA) is an excellent sealed envelope technique. In group P, induction
tool for maintaining airway in short duration was done with iv propofol infusion at the rate of 800
day care surgical procedures. This device sits ml/hour through infusion pump and in Group S
outside the trachea but provide a hands-free induction was done with inhalation of sevoflurane
means of achieving a gas tight airway.3 It is also 8%. All time intervals were recorded by using a
very useful in difficult intubation and emergency stop watch.
resuscitation.6,7 LMA can also be used for providing The point of start of injection of propofol or
both spontaneous and controlled ventilation. introduction of sevoflurane 8% was considered
Ideal induction agent for LMA insertion as the starting point of induction. Loss of eyelash
should be able to provide easy and early loss of reflex was considered as the desired end point
consciousness, adequate jaw relaxation, absence of for induction in both techniques. Loss of verbal
upper airway reflexes without anycardiorespiratory contact was assessed by the response to calling out
compromise.8 The choice of induction agent can the patient's name. Jaw relaxation was assessed by
affect the patient recovery and early ambulation.9 an anaesthesiologist responsible for maintaining
the airway. If jaw relaxation was not adequate,
Various anaesthetic agents have been used
it was reassessed after every 10 seconds. Once
for LMA insertion with each having its own
jaw relaxation was adequate, LMA insertion was
advantages and disadvantages. Present study was
attempted using method as described by Dr. Archie
planned to compare LMA insertion conditions in
Brain.10
adult patients following induction of anaesthesia
with sevoflurane or with propofol. Time taken from the start of induction to loss of
verbal contact, loss of eyelash reflex, jaw relaxation,
successful LMA insertion, number of attempts of
Methods
LMA insertion were recorded. The parameters of
insertion of LMA were graded by an observer on
The present study was conducted in a randomized a three-point scale using six variables as shown in
control manner in tertiary care rural hospital in 80 Table I. Total score was graded as 18 as excellent,
adult patients of either gender, aged 18–65 years 16–17 as satisfactory and < 16 as poor.
from October 2018 to October 2019. It included Table 1: Grades for LMA conditions Insertion.
American Society of Anaesthesiologists (ASA) grade
Variable 3 2 1
I and II patients with Mallampati Grade (MPG)
1. Jaw opening Full Partial Nil
grade I and II, who were scheduled for elective
2. Ease of insertion Easy Difficult Impossible
day care surgeries. Present study was approval
Patient response 3 2 1
by Institutional Ethical Committee (wide letter no
1. Coughing Nil Minor Severe
BFUHS/2K18p-TH/8599 dated 29/9/19) and was
2. Gagging Nil Minor Severe
registered under central trials registry-India with
3. Laryngospasm Nil Partial Total
registration number CTRI/2018/07/014944.
4. patients movements Nil Moderate Vigorous
Exclusion criteria were patients with difficult Airway establishment time was noted from the
airway, patients with history of oesophageal reflux time of start of induction till LMA is successfully
or hiatus hernia and pregnant women. inserted and confirmed by auscultation.
A routine preanesthetic check-up was conducted. Haemodynamic variables such as HR, SBP, DBP,
A written informed consent was obtained from all SpO2, EtCO2 and temperature were monitored
patients. All the patients were kept nil per orally for continuously. Side effects or complications if any,
6 hours prior to surgery. were also noted.

Gurpreet Singh, Haramritpal Kaur, Deepali Bansal, et al. / Propofol vs Sevoflurane for Laryngeal Mask 1279
Airway Insertion Under General Anaesthesia in Day Care Surgeries
The sample size was calculated using Statistical (P value <0.001). Hence, propofol group P showed
Package Software Statistical Analysis System early induction as compared to sevoflurane group
software based on previous studies with an alpha and also airway establishment time was less in
error of 0.05, confidence of 95% for an infinite group P.
population. The calculated power of the study Table III: Induction characteristics in both the groups ,P value
was 88%. Data was collected, tabulated, coded in <0.001, highly significant.
MS excel and then analysed using SPSS, computer Variables Propofol Sevoflurane P value
software version 16. Continuous variables were (n=40) (n=40)
presented as mean and standard deviation (SD) Mean SD Mean SD
while categorical variables were presented as Loss of verbal 33.48 6.55 41.30 4.12 <0.001
percent. As regard continuous variables, unpaired contact in seconds
student – t test was used. Chi square test was used Loss of eye lash 36.50 6.67 44.40 4.06 <0.001
reflex in seconds
to find out association between two categorical
Time to achieve 40.35 7.64 49.02 4.45 <0.001
variables. adequate jaw
relaxation in seconds
Results Effective airway 44.88 8.86 54.65 4.28 <0.001
establishment time
in seconds
The present study was conducted amongst 80
patients of either gender, aged 18–65 years, Comparison of groups on basis of LMA insertion
undergoing elective day care surgical procedures conditions is shown in Table IV. LMA insertion
under general anaesthesia. Age, weight, ASA status conditions were judged on the basis of jaw opening,
in both the groups were statistically comparable ease of insertion, coughing, gagging, laryngospasm
(p value >0.05) as mentioned in Table II. Mean and patients movements. Mean value of total score
duration of surgery in group P was 30.25 ± in group P was 17.70 ± 0.61 and in group S was 17.88
21.95 minutes and in group S was 19.50 ± 9.66 ± 0.40. P value was 0.133, which was insignificant
minutes. P value came out to be 0.006, which was statistically. Moreover, individual variables P value
significant. The difference in duration of surgery also came out to be less than 0.05 and insignificant
was attributable to the type of surgeries both statistically. Mean value of number of insertions
groups underwent. We studied only the induction attempts in group P was 1.05 ± 0.22 and group
characteristics of the drugs. S was 1.13 ± 0.33. P value was 0.241 which was
Table II: Demographic variables; P value >0.05, insignificant; P statistically insignificant. Hence both the agents,
value <0.05, significant. propofol and sevoflurane provide equally good
Propofol Sevoflurane insertion conditions in terms of jaw opening, ease
Variables P value of insertion, coughing, gagging, laryngospasm and
(n=40) (n=40)
Age in years 42.75±14.08 38.72± 12.48 0.180 patients movements with comparable insertion
(mean ± SD) attempts.
Weight in kg 57.57±7.86 53.37±4.16 0.233 Table IV: Comparison of groups on basis of LMA insertion
(mean ± SD) conditions, P value >0.05, insignificant.
Gender 7/33 5/35 0.531 Grade Propofol Sevoflurane P
(male/female) (n=40) (n=40) value
Asa grade (I/II) 30/10 31/9 0.793 Mean SD Mean SD
Duration of surgery 30.25 ± 21.95 19.50 ± 9.66 0.006 Jaw opening 2.98 .16 2.95 .22 0.562
in minutes
Ease of insertion 2.95 .22 2.92 .27 0.649
Induction characteristics in both the groups are Coughing 3.00 .00 3.00 .00 NA
shown in Table III. Loss of verbal contact in group P Gagging 2.98 .16 2.98 .16 1.00
was earlier, being 33.48 ± 6.55 seconds and in group Laryngospasm 3.00 .00 3.00 .00 NA
S, it was 41.30 ± 4.12 seconds (P value <0.001). Time Patients movements 3.00 .00 3.00 .00 NA
taken for loss of eye lash reflex in group P was Total score 17.70 .61 17.88 .40 0.133
36.50 ± 6.67 seconds and in group S was 44.40 ± 4.06 Number of insertion 1.05 .22 1.13 .33 0.241
seconds (P value <0.001). Time taken to achieve attempts
adequate jaw relaxation in group P was 40.35 ± 7.64
seconds and in group S was 49.02 ± 4.45 seconds(
Discussion
P value <0.001). Mean value of effective airway
establishment time in group P was 44.88 ± 0.22
seconds and in group S was 54.65 ± 4.28 seconds Safe and efficient airway management is the
foundation of anaesthetic practice.11 LMA has been litres/min for 30 second found out that mean time
shown to have numerous advantages over other to loss of eye lash reflex in propofol group was 41.7
invasive airway devices like increased speed and ± 10.1 seconds and in sevoflurane group was 51.1 ±
ease of placement, better hemodynamic stability, 10.4 seconds.15 Patel et al also reported that mean
avoiding pressor stress responses at induction time taken to loss of eye lash reflex in propofol
and during emergence. It has shown to have an group was earlier as compared to sevoflurane
easy learning curve. There is minimal increase in group.16
intracranial, intragastric and intraocular pressure
The results of this study also correlated well
following insertion. There is reduced anaesthetic
with Ravi et al study who reported that time to
requirements as compared to invasive devices for
achieve adequate jaw relaxation in propofol group
airway tolerance.
as 49.4 ± 5.69 seconds and in sevoflurane group
With acceptance of the LMA as a suitable airway as 107.3 ± 17.51 seconds. Hence induction with
management device in day care anaesthesia sevoflurane takes longer time for jaw relaxation as
practice, there is an ever-growing need for an inhaled anaesthetics may cause increased muscle
ideal anaesthetic agent which would be able to tone and spasticity whereas propofol is known to
provide good insertion condition without any have relaxant effect on jaw muscles.6 Therefore, for
cardiopulmonary compromise. The purpose of this similar depth of anaesthesia, there might be greater
study was to evaluate the LMA insertion conditions jaw relaxation with propofol than sevoflurane.
using propofol and sevoflurane as induction agents.
In present study, LMA insertion conditions
We found that patients in Group P achieved were judged on the basis of jaw opening, ease of
earlier LMA insertion conditions as compared to insertion, coughing, gagging, laryngospasm and
Group S i.e. shorter time to loss of verbal contact patients movements. Mean value of total score
(33.48 ± 6.55 seconds vs 41.30 ± 4.12 seconds), loss
insignificant statistically as sown in table III. Hence
of eye lash reflex (36.50 ± 6.67 seconds vs 44.40 ±
both the agents, propofol and sevoflurane provide
4.06 seconds), adequate jaw relaxation (40.35 ±
equally good insertion conditions. Other authors
7.64 seconds vs 49.02 ± 4.45 seconds), and effective
have also showed that LMA insertion conditions
airway establishment time (44.88 ± 8.86 vs 54.65 ±
were almost similar with both propofol and
4.28 seconds) (P value <0.001).
sevoflurane groups.12,15,16 Thus, this study indicated
Chavan et al used propofol 2.5 mg/kg at rate of that both the drugs provide almost equal ease of
40 mg every 10 seconds and sevoflurane 8% into LMA insertion.
fresh gas flow of 8 liters of oxygen in their study
and reported time taken for loss of verbal contact Patel et al reported 96.66% cases in propofol
in propofol group to be 40.13 ± 7.27 seconds and group and 83.33% cases in sevoflurane group
in sevoflurane group to be 64.80 ± 7.40 seconds.12 did not show laryngospasm while 3.33% cases in
Earlier loss of verbal contact in present study could propofol group and 16.66% cases in sevoflurane
be due to use of injection pentazocine 0.5 mg/kg group showed partial laryngospasm. This might be
iv as premedication. They used injection fentanyl again due to not use of any premedication before
1.2 mcg/kg iv as premedication. Injection fentanyl induction while we used pentazocine 0.5 mg/kg iv
is less sedative than injection pentazocine as before induction of anaesthesia.16
explained by Tammisto et al in their study where In this study, LMA insertion was successful at 1st
they compared injection pentazocine 3 mg/kg iv attempt in 95% cases in propofol group and 87.5%
and injection fentanyl 5 mcg/kg iv.13 cases in sevoflurane group. Mean value of number
Similarly study done by Soomro et al also of insertions attempts in group P was 1.05 ± 0.22
showed early induction with propofol.14 They and in group S was 1.13 ± 0.33. P value was 0.241,
used injection propofol 2 mg/kg and sevoflurane insignificant (Table III). So, we found that a smaller
6–8% on vaporizer setting with 50% nitrous oxide number of repeated attempts required for LMA
in oxygen with a total fresh gas flow of 10 litres/ insertion with propofol as compared to sevoflurane
min with circle carbondioxide absorber circuit and although it was statistically insignificant.
reported that time taken to loss of eye lash reflex in Haemodynamic parameters were comparable
propofol group as 27.9+6.71 seconds and 43.8+8.97 when compared statistically in both the groups.
seconds in sevoflurane group. However, this study had few limitations; we
Priya et al who used propofol 2.45 mg/kg body could not compare the depth of anaesthesia
weight with 100% oxygen via the face mask and achieved for LMA insertion in two groups and cost
sevoflurane 8% in N2O 50% and O2 at flow rate 8 effectiveness of agents was not compared. Use of
Gurpreet Singh, Haramritpal Kaur, Deepali Bansal, et al. / Propofol vs Sevoflurane for Laryngeal Mask 1281
Airway Insertion Under General Anaesthesia in Day Care Surgeries
bispectral index (BIS) monitor could have helped compared with endotracheal tube: a single-
in this regard. We studied only the induction blinded randomized controlled trial. BMC
characteristics of drugs, studying the recovery Anesthesiol2020,16:20.
characteristics in day care surgeries could have 6. Ravi S, Krishnamoorthy K, Ganesan I. Comparison
added to the significance of study. of sevoflurane and propofol for laryngeal mask
airway insertion in children. Indian J Clin Anaesth
2015;2:137–40.
Conclusion
7. Saeedi M, Hajiseyedjavadi H, Seyedhosseini J,
Eslami V, Sheikhmotaharvahedi H. Comparison
Both propofol and sevoflurane can be used as of endotracheal intubation, combitube, and
induction agent for LMA insertion in day care laryngeal mask airway between inexperienced and
surgeries. Both drugs provide with excellent LMA experienced emergency medical staff: A manikin
insertion conditions with negligible side effects. study. Int J Crit IlnInj Sci. 2014;4(4):303–308.
Propofol has an added advantage of early induction 8. Fulton B, Goa KL. Propofol a pharmacoeconomic
and early adequate airway establishment time. appraisal of its use in day case surgery.
Pharmacoeconomics 1996;9:168–78.
9. Scanlon P, Carey M, Power M. Patient response
References
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anaesthesia with propofol or thiopentone. Can J
1. Jadhav PA, Dalvi NP, Tendolkar BA. I-gel versus Anaesth 1993;40(9):816–8.
laryngeal mask airway-Proseal: Comparison of 10. Goyal M, Dutt A, Khan Joad AS. Laryngeal mask
two supraglottic airway devices in short surgical airway insertion by classic and thumb insertion
procedures. J Anaesthesiol Clin Pharmacol. technique: a comparison. F1000Res. 2013;2:123.
2015;31(2):221–225.
11. Cook TM. The classic laryngeal mask airway: A
2. Rathore FA, Ahmad F, Zahoor MU. Case Report of tried and tested airway. BJ Anaesth 2006;96:149–52.
a Pressure Ulcer Occurring Over the Nasal Bridge
12. Chavan SG, Mandhyan S, Gujar SH, Shinde GP.
Due to a Non-Invasive Ventilation Facial Mask.
Comparison of sevoflurane and propofol for
Cureus. 2016;8(10):e813.
laryngeal mask airway insertion and pressor reponse
3. Jarineshin H, Kashani S, Vatankhah M, in patients undergoing gynaecological procedures.
AbdulahzadeBaghaee A, Sattari S, Fekrat F. J Anaesthesiol Clin Pharmacol 2017;33(1):97–101.
Better Hemodynamic Profile of Laryngeal Mask
Airway Insertion Compared to Laryngoscopy and 13. Tammisto T, Takki S, Toikka P. A comparison of the
Tracheal Intubation. Iran Red Crescent Med J. circulatory effects in man of the analgesics fentanyl,
2015;17(8):e28615. pentazocine and pethidine. B J Anaesth 1970;42:317.
4. Singh G, Kaur H, Aggarwal S, Sharda G, Singh A, 14. Soomro A, Ali A, Aftab S. Comparison of propofol
Jha A, Aggarwal H. Intravenous dexmedetomidine and sevoflurane for laryngeal mask airway
vs. lignocaine in attenuating the hemodynamic insertion. JRMC 2013;17(2):268–70.
responses during laryngoscopy and endotracheal 15. Priya V, Divatia JV, Dasgupta D. A comparison of
intubation: a randomized double blind study. propofol versus sevoflurane for laryngeal mask
Anesth Pain and Intensive Care 2017;21(2):181–186. airway insertion. Ind J Anaesth 2002;46(1):31–4.
5. GongY, Xu X, Wang, J, Che Lu,Wang W, Yi j. 16. Patel AB, Soni E, Satasiya J. A comparison of
Laryngeal mask airway reduces incidence of propofol versus sevoflurane for laryngeal mask
post-operative sore throat after thyroid surgery airway insertion. IJISR 2016;5:582–4.


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A Comparative Study of Tramadol vs Butorphanol as an Adjuvant with

Local Anaesthetic in Supraclavicular Brachial Plexus Block in
Upper Limb Surgeries
Iramnaaz Shaikh1, Pooja Fumakiya2, Nidhi Asodariya3
Author’s Affiliation: 1,2Assistant Professor, 33rd Year Resident, Department of Anaesthesiology, Gujarat Adani Institute of
Medical Sciences, Bhuj 370001, Gujarat, India.
Corresponding Author: Pooja Fumakiya, Assistant Professor, Department of Anaesthesiology, Gujarat Adani Institute of
Medical Sciences, Bhuj 370001, Gujarat, India.
E-mail: pooja.fumakiya@gmail.com

Iramnaaz Sheikh, Pooja Fumakiya, Nidhi Asodariya. A Comparative Study of Tramadol vs Butorphanol as an Adjuvant with
Local Anaesthetic in Supraclavicular Brachial Plexus Block in Upper Limb Surgeries. Indian J Anesth Analg. 2020;7(6):1283–1289.
Abstract
Brachial plexus block is a versatile and reliable regional anaesthesia technique. It is a block of roots,
divisions and cords first performed by Halsted in 1884. It provides a useful alternative to general anaesthesia
for upper limb surgery by being safe, decreasing the cost of anaesthetic agents, decrease operation theatre
pollution and prolonged post-operative pain relief. Objectives: To study comparative effect of adding
tramadol and butorphanol as an adjuvant with local anaesthetic (bupivacaine + xyloadrenaline ) in
supraclavicular brachial plexus block in upper limb surgeries.
Methods and Material: 60 patients were divided into two groups:
Group A: inj. bupivacaine 0.5% (15ml)+inj xyloadrenaline (15ml) +inj tramadol(100mg) 2ml+inj ns 3 ml.
Group B: inj. bupivacaine 0.5% (15ml)+inj xyloadrenaline (15)ml +inj butorphanol (1mg)1ml + inj ns
4ml. Assessment of onset of sensory and motor blockade, surgical procedure and duration of surgery.
Perioperative complications were recorded and managed accordingly.
Results: The onset of sensory block was rapid with Tramadol (4.2 min) as compared to Butorphanol
(18.83min). The onset of motor blockade was faster with Tramadol (7.7min) as compared to Butorphanol
(24.13min). Tramadol has longer duration of sensory (634.66 min) and motor (458.33 min) blockade as
compared with butorphanol group (282.03min) and (350.16min) respectively (p<0.05). Duration of surgery
and VAS Score was also similar in both groups and statistically not significant.
Conclusion: Tramadol greatly reduce the onset time for sensory and motor block as well prolong the
sensory and motor block,while Butorphanol has minimal effect on onset and duration of block but it
provide post op analgesia.
Keywords: Supraclavicular brachial plexus block; Tramadol; Butorphanol; Upper limb surgeries.
Introduction of regional anaesthesia techniques as it provides

a safe, low cost method with advantage of early
The recent emergence of pain management and ambulation and prolonged post operative pain
increasing importance of outpatient (ambulatory) relief.1,2,3
surgery in anaesthetic practice have further Brachial plexus block is a versatile and reliable
increased interest in peripheral nerve blocks. regional anaesthesia technique. It is a block of roots,
Peripheral nerve block forms an important part divisions and cords first performed by Halsted in
1884. It provides a useful alternative to general Materials and Methods

anaesthesia for upper limb surgery by being safe,
decreasing the cost of anaesthetic agents, decrease After informed written valid consent, a study of
operation theatre pollution and with an advantage 60 patients of either sex, ASA-I/II in the age group
of prolonged post-operative pain relief. The of 16–70 years, scheduled for various elective
sympathetic block decreases post-operative pain, orthopaedic surgeries on upper limb under SCB.
vasospasm and oedema. There are different ways The study was done in a prospective, randomised
to block the brachial plexus. double blinded comparative manner. Patients
The supraclavicular approach to brachial refusal, ASA grade III and IV, Any bleeding disorder
plexus blockade was introduced in clinical or coagulopathy, Local infection at injection site,
practice in Germany by Kulenkampff in 1911. The h/o allergy to local anaesthetic, Severe respiratory
supraclavicular brachial plexus blockade (SCB) disease, Patients with h/o peptic ulcer disease,
provides anaesthesia of the entire upper extremity diabetes, hepatic or renal failure (contraindication
in the most consistent, time efficient manner of to steroids), Pregnant women were excluded from
many brachial plexus technique. It is performed the study.
at the trunk level where plexus is presented most For elimination of bias in the assigned study,
compactly. randomization was done by computer generated
The Brachial plexus block also performed random number table and care was taken that each
by other routes like axillary, infraclavicular, patient should get equal chance. All patients were
interscalene route. divided into two groups:
It is always be the interest of an anaesthetists Group A (Tramadol group): SCB will be given with
to increase the quality of local anesthetics. The 1.5% Xylocaine-adrenaline (1:200000)(15ml) + 0.5%
local anaesthesia prolongs the duration of surgical Bupivacaine (15ml) + Tramadol 100mg (2ml).
anaesthesia and analgesia With advent of opioid Group B (Butorphanol group): SCB will be given
receptors, variety of opioid agents is used for post with 1.5% xylocaine-adrenaline (1:200000)(15ml)+
operative analgesia in brachial plexus block.3 0.5% Bupivacaine (15ml)+Butorphanol 1mg (1ml).
Butorphanol is a synthetically derived opioid As Lignocaine with adrenaline is marketed in
antagonist acts as an analgesic of the phenanthrene 2% concentration, so 15 ml of drug was diluted to
series. It exhibits partial agonist and antagonist 20 ml with normal saline to get 1.5% concentration
activity at the μ(mu) opioid receptor and agonist of Lignocaine with adrenaline. Preoperative
activity at k(kappa) opioid receptors. Stimulation of assessment was done on previous day, detailed
these receptors on central nervous system neurons clinical history was taken, General and Systemic
cause an intracellular inhibition of adenylyl cyclase, examination was done and investigated. Routine
closing the influx membrane calcium channels and Investigations like complete hemogram, chest
opening of membrane potassium channels. This x-ray, ECG, Renal function test, liver function test,
leads to hyperpolarization of the cell membrane Blood sugar, serum electrolytes were documented.
potential and suppression of action potential Patient was kept NBM for 6 hours. On the day
transmission of ascending pain pathways. of surgery, Written informed valid consent was
Tramadol is an analgesic with mixed opioid and taken. In operation theatre, Routine and standard
non-opioid activity. It inhibits reuptake of Nor monitoring like ECG, pulse oxymetry, NIBP
epinephrine (NE) and Serotonin from the nerve applied and baseline values noted. Intravenous
endings and potentiate the effect of local anaesthetic access established using 18G or 20G cannula. After
when mixed together in peripheral regional nerve giving premedication (glycopyrrolate 0.004mg/kg
block. It has less respiratory depressant effect due i.v. and ondansetron 0.1mg/kg), after thorough
to weak receptor affinity. explanation of the procedure and emphasising the
This present study was conducted to evaluate need for patient co-operation, SCB was given by the
the effects of adding two opioids tramadol or classical technique.
butorphanol to local anaesthetic Bupivacaine and Technique: For performing brachial plexus
Lignoadrenaline in brachial plexus block through blockade through supraclavicular approach we
supraclavicular route in upper limb surgeries in used Classical technique (Kulenkampff’s). After
terms of onset and duration of sensory and motor placing the patient in dorsal recumbent position
blockade and duration of analgesia. with head turned away from site of injection

Iramnaaz Shaikh, Pooja Fumakiya, Nidhi Asodariya / A Comparative Study of Tramadol vs Butorphanol as 1285
an Adjuvant with Local Anaesthetic in Supraclavicular Brachial Plexus Block in Upper Limb Surgeries
with strict aseptic precautions midclavicular Grade 0: Complete movement of fingers and wrist.
point, external jugular vein and subclavian artery Grade 1: Reduced movement of fingers and wrist
pulsation were identified. About 2 cm above the
mid clavicular point just lateral to subclavian Grade 2: Only elbow movement
artery pulsation, a 22 gauge 1.5 inch hypodermic Grade 3: No movement.
needle attached with 2 ml saline filled syringe was Onset time was considered from injection of
introduced and directed caudal and medially until drug to patient felt heaviness on abduction of arm
paraesthesia or motor response was elicited or the at shoulder.
first rib was encountered.
Motor Peak effect time was from injection of
After brachial plexus was located the drug was drug to absence of any voluntary movement at the
injected and before every incremental dose negative level of arm and forearm.
aspiration for blood was performed to avoid any
Duration of motor blockade was defined as
intravascular placement
between the onset of peak motor effect and the
According to the drug administered the patients onset of weaning of motor effect in any of the nerve
were randomly allocated to 2 groups: distribution.
Group A: Inj. Tramadol (100mg) Onset of wearing off of motor blockade is the
Group B: Inj. Butorphanol (1mg) time when reduced movement of fingers and wrist
is present.
Heart rate, blood pressure, oxygen saturation
Complete wearing off of motor blockade is the
were recorded before the procedure and at 5, 10, 15,
time when complete movement of wrist and fingers
30, 45, 60, 90, 120 min and then every two hourly
return.
postoperatively till the complete wearing off of
effect. Patients were observed for any systemic side
effects like bradycardia, hypotension etc. Intra
Onset of Sensory block was assessed every 2 min
operative data were recorded at every 15–30 minute
by atraumatic pin prick test in the areas innervated
interval. Tourniquet inflation and deflation time
by radial, ulnar, and median nerves and compared and duration of surgery were noted.
with the same stimulation on contralateral hand.
Sensory blockade was graded as Intensity of post-operative pain was evaluated
using VAS with grade 0 (no pain) to 10 (worst
Grade 0: Sharp pain felt pain). Pain score were noted every 5 to 10 minutes
Grade 1: Dull sensation felt initially then hourly till the patient regain VAS
score of 4. Analgesia was considered satisfactory
Grade 2: No sensation felt
if the score was 3 or less. If score was more than
Onset time was defined as time from injection 4, analgesia was judged unsatisfactory and rescue
of drug to a dull sensation on any of the nerve analgesia was administrated and time for need of
distribution. first analgesia was noted. Evaluation was stopped
Sensory Peak effect time is defined as time from when complete wearing off of effect occurred. Both
injection of drug to complete loss of sensation along groups were compared for duration of analgesia,
all the nerve distribution. duration of sensory block, duration of motor block.
All the observations were recorded as mean and
Duration of sensory block was defined as time standard deviation. All the results were analysed
between the peak effect time and feeling of dull statistically using the student’s unpaired `t` test. p
sensation in any of the nerve distribution. value <0.05 was considered as significant.
Onset of wearing off of sensory block starts
from feeling of dull sensation in any of the nerve Results
distribution.
Complete wearing off of sensory block is defined All the patients were randomly and equally divided
as sharp pain felt in all the nerve distribution. into two groups with 30 patients in each group
Similarly, onset of motor block was evaluated (n= 30).
by asking the patient to move the forearm against Group A: Inj. Bupivacaine 0.5% (15ml)+Inj
resistance and to flex the forearm. Motor blockade Xyloadrenaline (15) ml +inj Tramadol(100mg)
was graded by four point scale 2ml+Inj NS 3 ml.

Group B: Inj. Bupivacaine 0.5% (15ml)+Inj The onset of sensory block was rapid with
Xyloadrenaline (15)ml + inj Butorphanol (1mg)1ml Tramadol (4.2 min) as compared to Butorphanol
+ Inj NS 4ml. (18.83 min) and onset of motor blockade was also
Demographic data between two groups were faster with Tramadol (7.7min) as compared to
comparable (Table 1). Butorphanol (24.13min) (Table 3, Graph 2).
Distribution of different type of surgery is almost Tramadol has longer duration of sensory (634.66
similar between both groups (Table 2, Graph 1). min with sd 25.78 min (10.14 to 11 hrs) and motor
(458.33 min with sd of 35.22 (7.01 to 8.22 hr) blockade
Table 1: Demographic data.
as compared with butorphanol group(282.03min
Variables Group A Group B
with sd of 17.04 min (4.41 to 4.98 hr) and (350.16min
1. Age in yrs
with sd of 20.14min (5.50 to 6.17 hr) respectively.
Mean 35.6 36.06 (p<0.05) (Table 4, Graph 3).
Standard deviation 12.6 11.15
Table 4: Duration of Anaesthesia and Analgesia.
2. Wt. in kg
Group A Group B p-value
Mean 65.94 65.22
Mean SD Mean SD
Standard deviation 4.40 4.68
Duration of 634.66 25.78 282.03 17.04 <0.0001 (S*)
3. Sex ratio sensory block
M:F 24:06 27:03 (min)
Duration of 458.33 35.22 350.16 20.10 <0.0001 (S**)
Table 2: Type of Surgery.
motor block
Arm Forearm Hand (min)
Group A 3 20 7 Duration of 842.66 82.88 663.3 20.54 <0.0001 (S*)
Group B 6 22 2 analgesia
(min)
25
900
20
800
15 Arm 700
Forearm 600
10 Hand 500
400
5
300
0 200
Group A Group B
100
Graph 1: Type of Surgery. 0
Duration of Duration of Duration
Table 3: Time for Onset of Sensory and Motor Block.
sensory motor of
Sensory block onset Motor block onset block(min) block(min) analgesia
time (min) time (min)
Graph 3: Duration of Anaesthesia and Analgesia.
Mean Sd Mean Sd
Duration of surgery (Table 5) and VAS Score
Group A 4.20 1.34 7.70 1.50
(Table 6, Graph 4) was also similar in both groups
Group B 18.83 1.29 24.13 2.14 and statistically not significant.
p-value <0.0001 <0.0001
9
25 8
7
20
Vas Score
6
5
15
4
Group A
10 Group A 3 Group B
Group B 2
5 1
0
0
90 in
45 in
min
15 in
30 i n
min
in
in
hr
14 r
hr
hr
r
r
r
r
2h
h
4h
6h
8h
Mean Sensory Mean Motor

m
m
m
m
0m
5m
10
12
16
block block onset

60
10
onset time (min) time (min) Time

Graph 2: Time for Onset of Sensory and Motor Block. Graph 4: Vas Score.

Table 5: Duration of Surgery (Min). anaesthesia. Another advantage is that it can be

Duration of surgery Group A Group B performed with the patient’s arm in any position
0-60 19 25 to provide excellent anaesthesia for elbow, forearm
61-120 11 5 and hand surgery.
Minimum duration (min) 35 30
Present randomized control study was done
Maximum duration (min) 120 120
to evaluate the effect of adding tramadol and
Mean + SD 61.3±17.46 56.5±19.7
butorphanol to most commonly used local
Table 6: Vas Score. anaesthetic bupivacaine and xyloadrenaline in
Post–operative Mean VAS Score brachial plexus block through supraclavicular
duration route posted for upper limb surgeries. The effects
Group A Group B were evaluated in terms onset of sensory and motor
0 Min 6.3 8.24 block, duration of sensory and motor block and
5 Min 2 6.18 duration of analgesia in 60 patients of ASA physical
10 Min 0 5.36 status I/II.
15 Min 0 4.62
Tramadol is a single entity centrally acting
30 Min 0 2.260
analgesic, used successfully for pain relief . Raffa
45 min 0 0
Br et al and Reimann W5 et al in their study
60 min 0 0
described antinociceptive property of tramadol
90 min 0 0
by opioid and non opioid mechanism . Reiman
2 hr 0 0
et al concluded from their study that tramadol
4 hr 0 0
inhibits noradrenaline uptake in the spinal cord
6 hr 1.44 1.82
contributing to its analgesic effect.
8 hr* 2.20 2.34
10 hr 3.08 3.06
12 hr 2.36 4.78 Demographic Data
14 hr 4.88 2.92
16 hr 3.28 3.06 All patients in our study were demographically
similar in both groups. There were no statistically
Complications: No significant intra-operative and significant intergroup variations regarding age,
post-operative complications like pneumothorax, body weight, and gender distribution.
intra-arterial or intravascular placement of drug,
nausea, vomiting, neurotoxicity or cardiotoxicity
Surgical Procedure and Duration of Surgery
were found in either group.
Majority of patients had surgical procedures like

Discussion
K-wire, platting, nailing implant removal, external
fixator, tendon or artery repair in upper limb and
Regional anaesthesia provides improved comparable in between the groups. Duration
satisfaction and cause less cognitive impairment of surgery was also similar in both groups and
and immuno suppression compared to general statistically not significant.
anesthesia (particularly in elderly patients).4
Peripheral nerve blocks offer an excellent
alternative for patients in whom postoperative Onset of Sensory and Motor Block
nausea and vomiting are a problem, who are at
risk for development of malignant hyperthermia, In present study, onset of sensory block was rapid
or who are hemodynamically compromised or with Tramadol as compared to Butorphanol. The
too ill to tolerate general anesthesia. SCB provides mean onset time was 4.2 min in group A while it
the most complete and reliable anaesthesia as it was 18.83 min with group B and the difference was
provides anaesthesia of the entire upper extremity statistically significant (p<0.05).
in the most consistent, time efficient manner of
many brachial plexus technique. It is performed The onset of motor blockade was significantly
at the trunk level where plexus is presented faster with Tramadol as compared to Butorphanol
most compactly. This anatomic compactness is (p<0.05). The mean duration of onset of motor block
responsible for rapid onset, complete and reliable was 7.7min in group A and 24.13min in group B.

In one study in which tramadol was added to There is a lot of evidence for presence of
20 ml of 7.5mg/ml ropivacaine, by Antonicci, it peripheral opioid receptors and their role in
was demonstrated that tramadol significantly alleviation of pain.
reduced the onset time of brachial plexus block Wajima Z et al9 have studied inj. Butorphanol
and prolonged the duration of anaesthesia and
in local anaesthetic via continuous brachial plexus
postoperative analgesia .
block and have demonstrated that Butorphanol
Chatopadhyay et al6 evaluated the use of produces pain relief in postoperative period.
tramadol 100mg as am adjuvant to bupivacaine Veil and colleaugues have shown that inj of
0.25%, total volume being 40 ml in supraclavicular Biprenorphine 3 Microgram /kg in supraclavicular
brachial plexus block given for various upper limb brachial plexus block produces significantly longer
surgeries and concluded that tramadol is useful pain relief than morpine after upper limb surgery.
adjuvant and reduces the onset time of motor and In our study tramadol and Butorphanol have
sensory block and enhances the duration of sensory similar duration of post operative analgesia.
block , motor block and postoperative analgesia
Robaux et al10 conducted a randomised double
blinded clinical trial to assess the effect of Tramadol
Duration of Sensory and Motor Block added to brachial plexus anaesthesia in which
100 patients planned for carpal tunnel release
In present study, Tramadol has longer duration surgery under brachial plexus anaesthesia were
of sensory and motor blockade as compared with randomised into different groups (tramadol 40 mg,
But orphanol group. The mean duration of sensory 100mg, 200mg). The number of patients requesting
block was 634.66 min with SD 25.78 min (10.14 to analgesia in post operative period was significantly
11 hrs) with group A and it was 282.03min with SD less in tramadol 200mg . This study demonstrate
of 17.04 min (4.41 to 4.98 hr) with group B and the that tramadol added to mepivacaine for brachial
difference was statistically significant (p<0.01). plexus block extends the duration and improve
the quality of postoperative analgesia in a dose
The duration of motor block was significantly
prolonged with tramadol as compared to dependent fashion.
butorphanol (p<0.05). The mean duration of motor
block was 458.33 min with SD of 35.22 (7.01 to 8.22 VAS (Visual Analogue Scale) SCORE
hr) with group A and it was 350.16min with SD of
20.14min (5.50 to 6.17 hr) with group B. Rescue analgesic was given when patient develop
In one study done by Ahmet Can Senel7 addition VAS score ≥ 4. In majority of patients, it was
of 50 mg of tramadol to 0.375% of ropivacaine achieved at around 12 to 14 hrs in both the groups.
significantly prolonged the duration of sensory and Results were clinically comparable and difference
motor blockade and post operative analgesia. between two group statistically significant (p<0.05).
In a study done by Ranjit Acharya8 addition Both the groups have similar trends of VAS score.
of 2 mg of butorphanol to 0.5% bupivacaine for
supraclavicular brachial plexus block results in
Complications
significant increase in duration of motor blockade
without affecting the time of onset of block . The
duration of motor block in butorphanol group was No significant intra-operative and post-operative
302+0.52min similar to our results. complications like pneumothorax, intra-arterial or
intravascular placement of drug, nausea, vomiting,
neurotoxicity or cardiotoxicity were found in either
Duration of Analgesia
group.
Peripheral nerve block given with local anaesthetic

Conclusion
drugs produce analgesia but to prolong the duration
of post operative analgesia , many agents including
variety of opioids have been used by various The supraclavicular approach provides the
investigators. These include Morphine, Pethidine, most complete and reliable anaesthesia of the
Tramadol, Butorphanol and Buprenorphine . entire upper extremity in the most consistent,
Primary afferent tissues have been found to contain time efficient manner of many brachial plexus
opioid receptors. technique. To conclude the study, we observed that

opioids when added to local anaesthetic agent in 4. Mahajan B K.: Methods in biostatistics; sixth
supraclavicular brachial plexus block prolong the edition,1997.
analgesia . Tramadol greatly reduce the onset time 5. Raffa BR, Friderichs, Reimann W, Shank R F,
for sensory and motor block as well prolong the Codd EE: Opioids and nonopioid components
sensory and motor block , while Butorphanol has independently contribute to the mechanism of
minimal effect on onset and duration of block but it action of tramadol , an “ Atypical” opioid analgesic.
provide post op analgesia . The Journal of Pharmacology and experimental
therapeutics. 1991; 260 [1] 275–285.
Abbreviations 6. Chattopadhyay S, Mitra LG, Biswas BN, Majumder

P. Tramadol as an adjuvant for Brachial Plexus
Block. J Anaesth Clin Pharmacol 2007; 23(2) : 187–9.
SCB: Supraclavicular brachial plexus block
7. Ahmet Can Senel, Ozlem Ukinc and Alper Timur
VAS: Visual Analogue Score Kayank et al: Does the addition of Tramadol and
ketamine to ropivacaine prolong the axilary brachial
PR: Pulse Rate
plexus block. Bio med research International
ECG: electrocardiogram Volume 2014 (2014), Article ID 686287, 5 pages.
BP: Blood Pressure 8. Ranjita Acharya, Monalisa Jena, Swati Mishra,
Shovan Kumar Rathi et al: Effect of Butorphanol
versus Placebo as adjuvant to Butorphanol
References
for Supraclavicular Brachial Plexus blockade .
International journal of applied Pharmaceutics
1. Moore D C, Bridenbaugh L D, Eather K F: Block of ISSN– 0975–7058. Vol 6 , Issue 1, 2014.
upper extremity supraclavicular approach versus 9. Wajima Z, Nakajima Y, Kim C, Kobayashi N,
axillary approach . Arch.Surg.1965; 90: 68–72. Kadotani H, Adachi H et al. IV Compared with
2. Young W S, Wamsley K, Zarbin M A, Kuhar M A: brachial plexus infusion of butorphanol for post
Opioid Receptors undergo axonal flow. Science operative analgesia. Br J Anaesth 1995;74:392–395.
1980; 210:76.
10. Robaux S, Blunt C, Viel E et al: tramadol added to
3. Fields HL, Emson PC, Leigh BK, et al. Multiple 1.5 % Mepivacaine for axillary brachial plexus block
opioid receptor sites on primary afferent fibres. improves postoperative analgesia. Anaesth Analg
Nature 1980; 284: 351–353. 2004 april ;98(4):1172–7.

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Effect of Intraoperative Esmolol Infusion on Haemodynamics and

Surgical Field in FESS Under General Anaesthesia
Juhi Mattoo1, Parth M Shah2, Dinesh Thakur3
Author’s Affiliation: 1Associate Professor, 2Assistant Professor, 3Professor and Head, Department of Anesthesia, Dr M K Shah
Hospital and Research Centre, Ahmedabad, Gujarat 382424, India.
Corresponding Author: Parth M Shah, Assistant Professor, Department of Anesthesia, Dr M K Shah Hospital and Research
Centre, Ahmedabad, Gujarat 382424, India.
E-mail: parthshah1291@gmail.com

Juhi Mattoo, Parth M Shah, Dinesh Thakur. Effect of Intraoperative Esmolol Infusion on Haemodynamics and Surgical Field in
FESS Under General Anaesthesia. Indian J Anesth Analg. 2020;7(6):1291–1294.
Abstract
Introduction: Functional endoscopic sinus surgery (FESS) is a commonly performed operation. Endoscopic
sinus surgery allows enhanced illumination and visualization and it has dramatically improved surgical
dissection. However major complications such as excess bleeding and poor visibility can arise do to work
in a confined space.Due to poor visibility longer time to perform the surgery may arise.
Material and Methods: This study was performed on randomly selected 60 patients, in a randomized
placebo controlled double blind prospective study. We evaluated the hypotensive efficacy of intravenous
Esmolol in FESS, reduction in blood pressure and Quality of surgical field and complications under general
anaesthesia.
Conclusions: Esmolol produces a lower surgical bleeding scores and better quality of operative field for
the surgeon as well as less adverse effects.
Keywords: FESS (Functional endoscopic sinus surgery); Controlled hypotension.
Introduction adrenergic antagonist and causes hypotension and

bradycardia on infusion due to its sympatholytic
FESS is minimal invasive surgical treatment which and vagomimetic properties.7-9
uses nasal endoscopes to enlarge nasal drainage It has rapid onset of action and on termination
pathways to improve sinus ventilation. Nasal of infusion gradual recovery of arterial blood
epithelium is highly vascular area and control pressure to the pre infusion level occurs without
of intra-operative bleeding assumes a lot more development of rebound hypertension.3,4
importance during the anaesthetic management of
FESS, where general anaesthesia is the technique of
choice. Bleeding impairs the visibility of the surgical Objective
field and increases operation risk and time.1,2
In controlled hypotension during anaesthesia, To evaluate the hypotensive efficacy of intravenous
the blood pressure of the patient is reduced such Esmolol in FESS under general anaesthesia. Effect
that the mean arterial pressure (MAP) is lowered by of Esmolol infusion with regard to reduction in
30% from baseline or at 60–70 mm Hg, whichever blood pressure and Quality of surgical field and
is greater.5,6 Esmolol is an ultra short acting Complications, if any.

Material and Methods compromised surgical dissection. All the collected

data parameters were analysed statistically using-
60 patients of either gender between age 18 to 55 2- Moderate bleeding – a nuisance but without
were randomly selected for this study and were interference with accurate dissection.
divided into two groups - Group N and Group
1- Bleeding, mild it is not a surgical nuisance.
E. Group E received Loading esmolol 1 mg/kg
Diluted upto 10 ml 5 min before induction and then 0- No bleeding and virtually bloodless field.
0.5 mg/kg/hr(in 50 ml NS) for duration of surgery. Results were analysed using One-Way ANOVA
Group N received 10 ml NS followed by 50 ml Calculator for Repeated Measures, Chi square
infusion for duration of surgery. test.‘P’ value less than 0.05 was considered
The patients with ASA score of III and more, significant.
patients on beta blockers, chronic hypertension,
A SFR (Surgical Field Rating) score of more than
coronary artery disease, arrhythmias, chronic
3 ,4 was considered significant.
obstructive pulmonary disease, chronic renal
or hepatic failure, history of cerebrovascular
disease, diabetes, severe anemia (less than 7g/dL), Results
coagulopathy, history of allergy to one of the study
drug, pregnant or lactating were excluded from the Table 1: Demographics.
study. Esmolol (n=30) NS (N=30) )
Pvalue
On arrival in the Operating Room, standard (Mean, SD) (Mean, SD)
monitors Including 5-Electrode Electrocardiogram Age 35+_12 40+_13 0.1
Monitoring, Noninvasive Blood Pressure, And Sex (M:F) 18:12 16:14 0.6
Pulse Oximetry were Connected and Vitals Weight (kg) 60+_10 58+_15 0.5
were recorded. Two IV access were secured and ASA (I/II) 25/5 26/4 0.1
infusion of Ringer’s lactate started. Thereafter, Table 2: Mean Blood Pressure.
each case received esmolol or normal saline as per
Esmolol(N=30) NS(N=30)
allocation. Following administration of study drug, (Mean+_SD) (Mean+_SD)
Pvalue
pre-oxygenation was done for 3 minutes during
Preoperative 89.1+_2.7 89.8+_2.3 NS
which pre-medications were given in the form of
After Loading 69.2+_1.4 83.7+_3.2 0.0001
IV ondansetron 0.1mg/kg, 2mc/kg fentanyl and
10 Min After 67.5+_2.9 81.1+_3.6 0.0001
glycopyrrolate 0.01 mg/kg. Patients were then Infusion
induced with IV propofol 2.5 mg/ kg. Atracurium Average 66.4+_2.4 80.2+_3.8 0.0001
0.5 mg/kg was then given to facilitate laryngoscopy Intraoperatively
and intubation. After successful intubation, the After 78.8+_5.3 80.3+_4.5 0.0001
patient were maintained using 33% oxygen in Extubation
66% nitrous oxide with isoflurane and intermittent
Table 3: Heart Rate.
boluses of IV atracurium 5 mg as and when needed.
Esmolol(N=30) NS(N=30)
Heart rate, Systolic and Diastolic blood pressures, Pvalue
(Mean+_SD) Mean+_SD)
Mean arterial pressure (MAP), Blood loss, Quality Preoperative 81.1+_4 82.4+_2.1 0.2(NS)
of surgical field were noted. Parameters were After Loading 72.4+_4.7 76.4+_4.3 0.0011
monitored every 10 minutes from the onset of 10 Min After 69.3+_3 73.5+_4.8 0.0001
the drug administration till the end of surgery. Infusion
Blood pressure monitored every 10 minutes using Average 66.3+_2.3 71+_3.5 < 0.0001
the automatic cuff method (NIBP). At the end of Intraoperatively
the surgery, blood loss was estimated using by After 70.4+_3.9 72.4+_2.5 0.02
measuring amount of blood collected in the suction Extubation
jar (Table 7). The quality of surgical field was Table 4: Quality of Surgical Field.
evaluated every 20 minutes using the Surgical Field Esmolol(N=30) NS(N=30) Pvalue
Rating scale proposed by Fromme et al5: Surgeon 2 10 < 0.00001
5- Massive uncontrollable bleeding. Score(3,4)
4-Heavy but controllable bleeding that Table 5: Adverse Event.

significantly interferes with dissection. Esmolol(N=30) NS(N=30) Pvalue
3-Moderate bleeding that moderately Bradicardia 3 1 0.5(NS)

Juhi Mattoo, Parth M Shah, Dinesh Thakur / Effect of Intraoperative Esmolol Infusion on Haemodynamics 1293
and Surgical Field in Fess Under General Anaesthesia
Table 6: Extubation Time. safety of perioperative esmolol has been studied

Esmolol(N=30) NS(N=30) by Yu SK et al16 and concluded that titration of
Pvalue
(Mean,SD) (Mean, SD) esmolol to haemodynamic end point can be a safe
Min 5.4+–2 4+–3 0.07 and effective method. There was no statistically
Table 7: Intraoperative Blood Loss. significant adverse effect with esmolol infusion
except bradicardia (heart rate less than 60) in 3
Esmolol(N=30) NS(N=30) Pvalue
patients.
ML 75+_10 142+–20 .0001
The effect of b blocker premedication on surgical
The demographic information and baseline field during endoscopic sinus surgery was studied
characteristics (age, sex, ASA status were not by Nair Salil17 et all and found optimum conditions
statistically different between the two drug groups in patients receiving b blockers (Table 5).
(Table 1). Intraoperative mean blood pressure
and heart rate measures were significantly lower
Conclusion
in patients of group Esmolol as compared to
patients of group (NS). After loading dose of
esmolol there was significant difference between Esmolol produced controlled hypotension with a
the haemodynamic parameters of the two groups better operative field for the surgeon and produced
(p value .00011). Details of hemodynamic findings lesser adverse effects.
are shown in (Table 2,3). There were no statistically
significant differences in the duration of extubation References
time between the drug groups (pvalue .07)
(Table 6). There were no episodes of excessive
hypotension (MAP <50 mm Hg), arrhythmias or 1. Stammberger H, editor Functional Endoscopic sinus
surgery. Philadelphia: BC Decker; 1991. p. 321–33.
reflex tachycardia and rebound hypertension in
esmolol group. The quality of the surgical field was 2. Atighechi S, Azimi MR et al. Evaluation of
significantly better in esmolol group as determined intraoperative bleeding during an endoscopic
by from me rating compared to the control group surgery of nasal polyposis after a pre-operative
single dose versus a 5-day course of corticosteroid.
(Table 4).
Eur Arch otorhinolaryngol 2013;270:2451–4.
3. Young WL, Ostapkovich N, Matteo RS, Diaz J.
Disscussion Deliberatehypotension in patients with intracranial
arteriovenus malformations: Esmolol compared
Bleeding during surgery can be reduced by ensuring with isoflurane and sodium nitroprusside. Anesth
Analg 1991;72:639–44.
a controlled hypotension.10-11 Improved surgical
field during FESS with beta blockers is probably 4. Blowey DL. Anihypertensive agents: Mechanism of
attributable to vasoconstriction of the mucous action, safety profiles, and current uses in children.
Curr Ther Res Clin Exp 2001;62:298–313.
membrane arterioles and the precapillary sphincters
that results from unopposed α-adrenergic effects 5. Fromme GA, MacKenzie RA, Gould AB, Lund BA,
of endogenous catecholamine and the increased Offord KP. Controlled hypotension for orthognathic
surgery. Anaesth Analg 1986; 65: 683–6.
sympathetic tone.12 Guney et al found that esmolol
provides hemodynamic stability and good surgical 6. Guney A, Kaya FN et al. Comparison of esmolol to
field visibility and should be considered as an nitroglycerine in controlling hypotension during
nasal surgery. Eurasian J Med 2012; 44:99–105.
alternative to nitroglycerin.13 Unopposed alpha
adrenergic activity causes vasoconstriction at the 7. Rodrigo C. Induced hypotension during
mucus membrane level resulting in better surgical Anaesthesia with special reference to orthognathic
field in esmolol groups. surgery. Anesth Prog 1995;42:41–58.
8. Testa LD, Tobias JD. Pharmacological drugs
Shen et al14 in a placebo controlled trial found that for controlled hypotension. Journal of Clinical
esmolol not only produces relative hypotension Anesthesia 1995; 7: 326–337.
and bradycardia but also improves the surgical
9. Boezaart AP, van der Merwe J, Coetzee A (1995)
field and reduces the average blood loss.14
Comparison of sodium nitroprusside- and esmolol
Pilli et al15 showed the efficacy and safety induced- controlled hypotension for functional
of esmolol for controlled hypotension. In our endoscopic sinus surgery. Can J Anesth 42:373–376.
study esmolol provided effective controlled 10. Degoute, C. Controlled Hypotension. Drugs 67,
hypotension and stable haemodynamics. The 1053–1076 (2007).

11. Jacobi KE, Bohm BE, Richauar AJ, Jacobi C, sevoflurane-anesthetized endoscopic sinus surgery:
Hemmerling TM (2000) Moderate controlled A double blind, randomized, placebo-controlled
hypotension with sodium nitroprusside does not trial. Am J Rhinol Allergy 2011;25:e208–11.
improve surgical condition or decrease blood loss in 15. Pilli, G and Güzeldemir, M and Bayhan, N. (1996).
endoscopic sinus surgery. J Clin Anesth 12:202–207. Esmolol for hypotensive anesthesia in middle ear
12. Jacob SM, Chandy TT, Cherian VT. Oral bisoprolol surgery. Acta anaesthesiologica Belgica. 47. 85–91.
improves surgical field during functional 16. Yu SK, Tait G, Karkouti K, Wijeysundera D,
endoscopic sinus surgery. J Anaesthesiol Clin McCluskey S, Beattie WS. The safety of perioperative
Pharmacol. 2014;30:59–64. esmolol: a systematic review and meta-analysis
13. Guney A, Kaya FN, Yavascaoglu B, Gurbet A, of randomized controlled trials. Anesthesia and
Selmi NH, Kaya S, et al. Comparison of esmolol to Analgesia 2011; 112(2): 267–281.
nitroglycerine in controlling hypotension during 17. Nair Salil,M Hung Patrick. The Effect of β-Blocker
nasal surgery. Eurasian J Med. 2012;44:99–105. Premedication on the Surgical Field During
14. Shen PH, Weitzel EK et al. Intravenous esmolol Endoscopic Sinus Surgery.The Laryngoscope
infusion improves surgical fields during 2009;(114).1042–1046.

Hemodynamic Stability of Dexmedetomidine in Laparoscopic

Cholecystectomy Cases
Naresh Kumar Tyagi1, Pinu Ranawat2, Arvind Kumar Gupta3
Author’s Affiliation: 1-3Assistant Professor, Department of Anesthesia, Pacific Institute of Medical Sciences, Udaipur, Rajasthan
313015, India.
Corresponding Author: Arvind Kumar Gupta, Assistant Professor, Department of Anesthesia, Pacific Institute of Medical
Sciences, Udaipur, Rajasthan 313015, India.
E-mail: dr.arvindgupta85@gmail.com

Naresh Kumar Tyagi, Pinu Ranawat, Arvind Kumar Gupta. Hemodynamic Stability of Dexmedetomidine in Laparoscopic
Cholecystectomy Cases. Indian J Anesth Analg. 2020;7(6):1295–1297.
Abstract
The advent of minimally invasive surgeries has heralded a new field in surgical practice. The procedure
of laparoscopy has been most beneficial to the clinician and patient alike however, it has also been
responsible for newer complications. The present study was conducted with a view to ascertain if the
hemodynamic instability brought about by pneumoperitoneum be effectively counteracted by using
dexmedetomidine in cases of elective laparoscopic cholecystectomy. The study employed 30 subjects and
who were evaluated in pre, intra and post operative stages for HR and BP. The results showed a significant
difference between parameters of subjects who were administered the study drug and a corresponding
control sample. The study concluded that the benefits of dexmedetomidine are accurate and the drug must
be considered as a necessary adjuvant in all minimally invasive surgeries.
Keywords: Cholecystectomy; Dexmedetomidine; Laparoscopy.
Introduction the most routinely used substance is CO2. This

may lead to an increased level of catecholamines
Presently, Laparoscopic cholecystectomy (LC) and vasopressin compounds in the patient, which
enjoys the status of being a safe, reliable and routine further elevates the heart rate and blood pressure.2
procedure, preferred by both surgeons and patients An increase in intra-abdominal pressure with
due to its minimal access technique which includes a raised diaphragm which occurs commonly
reduced postoperative pain, faster mobilization with pneumoperitoneum, causes adverse effects
of the patient, reduced hospital stay, and better on the cardiovascular system which include
cosmetic results as compared to the open technique, decreased cardiac output, raised arterial pressure,
which have further increased its applications.1 and increased systemic and pulmonary vascular
During laryngoscopic procedures done under resistance which further leads to hypertension
general anaesthesia, such as intubation and and tachycardia, proving detrimental to the safe
extubation, these procedures which instigate execution of procedure.3
a transient but marked sympathetic response Such elevations in blood pressure can be a
in the patient which causes hypertension and risk factor in patients with pre-existing cardiac
tachycardia, both of which are detrimental to intra disease, or increased intracranial pressure.
and postoperative recovery. Additionally, during To avoid such adverse circulatory responses
laparoscopic surgery, to create a pneumoperitoneum to pneumoperitoneum, drugs such as opioid

analogues, alpha-2-adrenergic agonists, beta- No pre existing cardiac or systemic illnesses were
blockers, or vasodilators are administered.1,3 reported by the subjects. Duration of surgery was
The present study was conducted to assess the between 60 to 120 minutes with an mean duration
effectiveness of dexmedetomidine in reducing the of 78 ± 18.14 minutes.
unfavourable inter operative cardiac manifestations The heart rate and blood pressure of both the
during laparoscopic cholecystectomy. groups did not display any significant differences
in the pre operative stage. The mean systolic blood
Material and Methods pressure for the entire population subset was 108 ±
14 mmHg while diastolic was 72 ± 9 mmHg. None
The study was an prospective double blind study of the subjects were on hypertensive medications.
conducted in the OT and recovery ward of Pacific The observations showed a reduction in mean
Institute of Medical Sciences, in Udaipur Rajasthan, heart rate after the loading dose was administered
the study employed a patient pool of 30 subjects who in group 1. The analysis revealed that a statistically
were divided in two groups. The first group involved significant difference in values of mean HR between
subjects who were administered study drug viz the two groups (p < 0.05). The mean blood pressure
dexmedetomidine, while the corresponding group values as recorded in the intra operative period at
was administered normal saline in similar doses. regular intervals from loading dose to extubation
Institutional ethical clearance and written informed also revealed a statistically significant difference
consent were obtained prior to start of the study. between the two groups. Fig. 1 and 2 represent the
The subjects included in the study were posted changes as recorded. The changes were recorded
for elective laparoscopic cholecystectomy and were after loading dose of dexmedetomidine/saline,
evaluated as Grade I or Grade II as per ASA. The after intubation, after 20 min of pneumoperitoneum,
patients were subjected to routine pre-anesthetic after 60 min of pneumoperitoneum, after infusion
evaluation and fasting as per department protocols. was stopped, after extubation.
Patients were blinded to the intervention used. All The observations revealed that the mean
patients were made to undergo general anesthesia values were significantly lower in group that was
with similar protocol. The study drugs were given administered dexmedetomidine as compared to
before the creation of pneumoperitoneum as a the saline group. No post operative complications
loading dose. Maintenance dose was given after were reported in any of the cases.
creation of pneumoperitoneum and stopped at a
predefined time interval before extubation. 85
80
Group 1 subjects received a loading dose of 1
75
ug/kg and maintenance infusion at the rate of 0.4
70
ug/kg/hr. Group B subjects received a similar dose
65
and maintenance infusion at the rate of normal
60
saline. Intra-operative haemodynamic parameters
55
such as heart rate, blood pressure were measured
50
at regular intervals in the OT. Parametric notations
continued in the recovery room for post operative 0 2 4 6 8
assessment. Demographic and clinical data was
collected as per a predefined proforma. Analysis Group 1 Group 2
was done using SPSS statistical analysis software in
Fig. 1: Mean HR Values.
consultation with institutional statistician.
90
Results
80
The study involved a sample size of 30 patients 70

who were equally divided in two groups. The
60
average of the subjects was 47 ± 3.77 years. There
were no statistically significant differences between Group 1 Group 2
the age and gender of the subjects. Prior history and
clinical evaluations showed no significant findings. Fig. 2: Mean BP Values.

Naresh Kumar Tyagi, Pinu Ranawat, Arvind Kumar Gupta / Hemodynamic Stability of Dexmedetomidine in 1297
Laparoscopic Cholecystectomy Cases
Discussion post operative adverse reactions in the selected

subjects. In minimally invasive surgery the use
The present study was conducted with the of dexmedetomidine can prove to be a beneficial
objective to assess the hemodynamic efficiency of additive for the surgeon, anaesthetist as well as the
dexmedetomidine in reducing the unfavourable patient.
outcomes such as tachycardia, elevated BP in Limitations: The study is limited by the lack of a
patients undergoing laparoscopic cholecystectomy. larger sample size/
The literature review revealed that the effects of
Conflict of Interest: Nil
dexmedetomidine are due its activity on the central
and peripheral nervous system, wherein its action Source of Funding: Self Funded.
leads to a reduction in circulation adrenaline levels
which further cascades its action via a reduction in References
arterial blood pressure and heart rate. The central
nervous system is acted upon through the activation
of medullary receptors which lead to an activity on 1. Wang Y, Wang YT, Jiang YY, Lin YH, Zou ZD. Effect
of different position and CO (2) pneumoperitoneum
peripheral vasoconstriction modules leading to a
on deep vein hemodynamics of lower limb.
stable and sustained reduction in blood pressure.
Zhonghuaweichangwaike za zhi= Chinese journal
This activity though still in the form of a accepted of gastrointestinal surgery. 2009 Jul;12(4):361-3.
hypothesis may be the reason for the reduced levels
2. S M Meftahuzzaman, M M Islam, K K Chowdhury
of HR and BP in the group of patients who were
et al., “Haemodynamic and end tidal CO2 changes
subjected to dexmedetomidine use.4-6 during laparoscopic cholecystectomy under
Study by Lawrence CJ and De Lange S7 had stated general anaesthesia,” Mymensingh Medical Journal,
that hemodynamic stability and dexmedetomidine vol. 22, no. 3, pp. 473–477, 2013.
use were corelated in their study sample and 3. D Jee, D Lee, S Yun, and C Lee, “Magnesium
concluded that this may infact be a drug of choice sulphate attenuates arterial pressure increase
when cases are suspected of having a cardiovascular during laparoscopic cholecystectomy,” British
element that can cause intra and post operative Journal of Anaesthesia, vol. 103, no. 4, pp. 484–489,
complication, which is further concurrent with the 2009.
findings observed in our trial. The findings were 4. Talke P, Richardson CA, Scheinin M, Fisher DM.
similarly reported in studies by Aho M et al8 wherein Postoperative pharmacokinetics and sympatholytic
the authors reported a sustained hemodynamic effects of dexmedetomidine. Anesthesia and
stability from the initial administration upto the Analgesia. 1997 Nov 1;85(5):1136-42.
stage of extubation in subjects given the drug. This 5. Talke P, Lobo E, Brown R. Systemically administered
further strengthen s ours findings. α2-agonist-induced peripheral vasoconstriction in
humans. The Journal of the American Society of
We surmised that the use of a drug such as Anesthesiologists. 2003 Jul 1;99(1):65-70.
dexmedetomidine was effective in supplementing
6. Scheinin B, Lindgren L, Randell T, Scheinin
the anaesthesia protocol by providing a stable
H, Scheinin M. Dexmedetomidine attenuates
hemodynamic environment from the induction to sympathoadrenal responses to tracheal intubation
post operative stage with no complications seen in and reduces the need for thiopentone and
recovery. peroperative fentanyl. British journal of anaesthesia.
1992 Feb 1;68(2):126-31.
Conclusion 7. Lawrence CJ, De Lange S. Effects of a single pre-
operative dexmedetomidine dose on isoflurane
requirements and peri-operative haemodynamic
The study concluded that the use of stability. Anaesthesia. 1997 Jul;52(8):736-45.
dexmedetomidine as an anaesthetic adjuvant was
8. Aho M, Lehtinen AM, Erkola O, Kallio A, Korttila
effective and beneficial in reducing the onset of
K. The effect of intravenously administered
any possible intra operative and peri operative dexmedetomidine on perioperative hemodynamics
complications. The drug showed a substantial and isoflurane requirements in patients undergoing
stabilization of blood pressure and heart rate abdominal hysterectomy. Anesthesiology: The
in the selected study sample and displayed no Journal of the American Society of Anesthesiologists.

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Caudal Epidural Block for Transurethral Resection of Prostate in Patients

with Comorbidities: An Observational Study
Nellimarala Appalaraju1, Karri Bala Krishna2
Author’s Affiliation: 1,2Assistant Professor, Department of Anesthesia, Great Eastern Medical School and Hospital, Srikakulam,
Ragolu, Andhra Pradesh 532484, India.
Corresponding Author: Karri Bala Krishna, Assistant Professor, Department of Anesthesia, Great Eastern Medical School and
Hospital, Srikakulam, Ragolu, Andhra Pradesh 532484, India.
E-mail: medcompass360@gmail.com

Nellimarala Appalaraju, Karri Bala Krishna. Hemodynamic Caudal Epidural Block for Transurethral Resection of Prostate in
Patients with Comorbidities: An Observational Study. Indian J Anesth Analg. 2020;7(6):1299–1304.
Abstract
Background: The most important goal of anaesthesia for geriatric patients with comorbid diseases is
to maintain normal homoeostasis of different systems during and after surgery. This prospective study
was conducted to evaluate the success rate and associated complications of the caudal epidural block for
transurethral resection of prostate in elderly patients with comorbid diseases.
Methods: This is a prospective study of a cohort of 110 elderly patients posted for transurethral resection
of prostate with comorbid diseases belonging to American Society of anaesthesiologist’s physical status
II, III and IV over a period of 1 year from November 2018 to November 2019. Standard recommended
technique for caudal epidural block was followed. Time of onset, spread, duration of analgesia, intensity
of block, complications, and unwanted effects were noted.
Results: The average age was 72. Eighty percent patients belonged to ASAIII and IV grade. The majority
had excellent to a good quality of anaesthesia with no motor block. 80% of patients had the onset of
analgesia between 5–15 minutes and 71% had a duration between 90–130 minutes. four patients had
patchy analgesia and they were considered as a failure. No death was encountered in the study.
Conclusion: Caudal epidural block is a safe, effective anaesthetic technique for transurethral resection of
the prostate in elderly with comorbid diseases of other systems.
Keywords: Caudal anesthesia; Comorbidities; Elderly; Transurethral Resection of Prostate.
Introduction gland. Transurethral resection of prostate (TURP)

is still considered as the gold standard for surgical
‘’Health and disease do not have any political or treatment of patients with moderate to severe
geographical boundaries’’said Paul Russell once symptomatic benign prostatic hyperplasia (BPH).
This is very much true in cases of diseases of Ideally, TURP should be reserved for prostate
the urinary tract like prostate pathology, which weighing below 60 grammes.1–3 As this is a disease
is a major health care problem throughout the of old age, so a large number of these patients also
world amongst all societies whether rich or poor. suffer from diseases of other systems, which add
Prostate pathology ranks 2nd out of all urinary tract to increased morbidity and mortality. Myocardial
diseases. Approx. 40,000 TURP’s are performed ischaemia may occur in up to 25% of these cases
annually in the UK.1 Despite the development of whereas 1–3% patients may develop myocardial
newer technologies for removal of the prostate infarction during surgery.4,5

The pelvic viscera receive double innervation 6ml/kg 20 minutes before the surgery. All baseline
from the sympathetic nervous system via the parameters like HR, ECG, SPO2, SBP, DBP and
inferior hypogastric plexus and parasympathetic MAP were noted. All the blocks were performed
via the pelvic parasympathetic outflow from S2– in prone position under strict aseptic measures
S4. So any neuraxial block up to T10 is sufficient for with a pillow under the anterior iliac crests, both
TURP and spinal anaesthesia became the standard the legs abducted 20°and toes turned in. Hiatus
anaesthetic management. But still, there exists was located by palpating the triangular shaped
some controversy over objective data to support gap at the posterior lowermost part of the sacrum
the dogma that low spinal anaesthesia is much bounded on both sides by the two sacral cornua.
safer for TURP than other techniques. Moreover, For reconfirmation both the posterior superior iliac
enough literature does not exist till date about the spines were located and by using a line between
role of using caudal epidural block (CEB) for TURP them as one side of an equilateral triangle, the apex
in patients with associated other systemic diseases.6 of the triangle coincided with the sacral hiatus.
So we planned to conduct a prospective study Under strict aseptic conditions, a wheal was then
during one year period from April 2015 to April raised over the hiatus, using no more than 2 drops
2016 at Nobel Medical College Teaching Hospital of local anaesthetic. A 20/21G 1.5’’ hypodermic
to see if caudal epidural block alone is sufficient blunt tipped needle (BD blunt needle) was then
to conduct TURP or not and is it safe in terms of inserted through the sacrococcygeal membrane so
morbidity and complications amongst geriatric that it made an angle of about 20° with a line drawn
patients with associated other comorbid diseases. at right angles to the skin surface. Once through the
membrane with a ‘pop‘; the needle was depressed
Methods further 45° towards the intergluteal cleft and finally
the needle was advanced into the sacral canal for
not more than 1–1.5 cm in the midline using the loss
After obtaining the clearance from the hospital of resistance technique.6,8,9 Proper care was taken to
ethical committee, a convenient sample of 110 ensure that tip of the needle did not ascend higher
patients with obstructing prostatic enlargement than the line joining PSIS. After negative aspiration
requiring TURP along with some comorbid for CSF and blood and absence of air crepitus in
diseases of other systems and willing to participate the subcutaneous tissue while injecting air, 25 ml
in the study were recruited from the department of of local anaesthetic solution of 1% preservative-
urosurgery and were included in the study. All the free lignocaine hydrochloride (loxicard®), mixed
patients had one or other comorbid diseases of other with freshly prepared 125mcg of adrenaline so
systems like hypertension (HTN), diabetes mellitus that the strength of adrenaline became 1:200000,
(DM), COPD, ischaemic heart disease, dilated was injected. To make this, 12.5ml of normal saline
cardiomyopathy. Informed consents were obtained was mixed with 12.5 ml of 2% preservative-free
from all the patients. A thorough pre-anaesthetic lignocaine hydrochloride (loxicard®). Separately
check-up and all necessary investigations were 1mg of adrenaline i.e, 1ml was diluted to 20ml
done and documented. For every patient, CBC, with 19 ml of NS. 1ml of this resultant solution
blood sugar, renal and cardiac profile, chest X-ray, contains 50mcg of adrenaline. So 2.5 ml of this
ECG, and transthoracic echocardiography were solution was added to 25 ml of 1% preservative-
done. PFT, TMT or stress TMT and coronary free lignocaine hydrochloride (loxicard®) to make
angiography were also advised in cases where these the final solution of 1% preservative-free lignocaine
were needed. All the patients were on several drugs hydrochloride (loxicard®) with adrenaline in the
for their associated diseases, which were continued strength 1:200000. Immediately the patients were
till the day of operation except metformin, and turned supine. All the patients received oxygen at a
enalapril, which were stopped 24 hours before flow of 4–6 litres /min via face mask. The intensity
surgery. Aspirin was withheld 7 days before of motor block was evaluated as per modified
surgery.6,7 Premedication was done with lorazepam Bromage scale.10 Complications and side effects if
2mg and ranitidine 150 mg orally the previous any were noted and treated promptly.11
night and 2 hours prior to the surgery. Patients with
obesity, coagulopathy, excessive fat deposition All vital parameters like HR, SPO2, ECG and SBP,
over the sacrum, the anatomical anomaly of the DBP and MAP were noted every 5 minutes for 15
lumbosacral and sacral region and local infection minutes then at 10 minutes interval throughout the
were excluded from the study. On arrival at the surgery. Patients were also asked to communicate
operation theatre, an intravenous infusion of RL/ if they feel any pain or discomfort during the whole
NS was started with an 18G cannula at the rate of procedure. For proper sedation and analgesia, all
Nellimarala Appalaraju, Karri Bala Krishna / Caudal Epidural Block for Transurethral Resection of Prostate 1301
in Patients with Comorbidities: An Observational Study
the patients received i.v midazolam 1–2.5 mg and regional anaesthesia (RA) for the treatment of pain
fentanyl 50–100 mcg as per body weight and physical particularly chronic pain as well as for various
status. The onset of analgesia was tested with blunt surgeries. Today a well-conducted RA technique is
pinprick at the penis, scrotum and perineum and a thing of beauty and gives satisfaction and comfort
spread was evaluated over the bony prominences. to the patients, anaesthesiologists and surgeons. As
Once analgesia spread to T10 the patients were a matter of fact, many patients today are requesting
put on lithotomy position. When the level of the the surgical team for RA for their surgeries. CEB
block did not extend above T12 it was considered is no exception to this, particularly for geriatric
as an inadequate block. When the block failed, patients with limited cardiopulmonary reserve
general anaesthesia was administered to patients. or other associated diseases undergoing surgery
Premedication was done with glycopyrrolate and below the umbilicus like TURP, which is still the
midazolam, then propofol, fentanyl and isoflurane gold standard surgical treatment for prostate
were administered as per body weight and patient pathology. The nerve supply to the prostate
was kept on spontaneous ventilation. The surgeon originates from inferior hypogastric plexus and
performed TURP with a 24G fibre-lit resectoscope carries both sympathetic fibres from T11 to T12 and
with continuous irrigation of the bladder with parasympathetic fibres from S2 to S4. Pain fibres from
1.5% glycine. Postoperatively normal saline was the prostate, prostatic urethra, bladder mucosa,
used for irrigation of the bladder. Throughout the lower anorectal area and perineum originate from
procedure, all the vital parameters and any signs the S2 to S4 sacral nerves. Pain signal from bladder
and symptoms of TURP syndrome were observed distension travels along T11 and T12 sympathetic
carefully. At the end of the surgery, patient was fibres whereas parasympathetic fibres of S2-S4 carry
transferred to post anaesthesia care unit for stretch sensation of the bladder.4,9,13,14 TURP can
observation. Patients, as well as surgeons, were also be performed under GA, SA, epidural, CSEB. But
asked about their comment of the whole procedure the choice of the majority is low spinal anaesthesia
in the operation theatre. with it's inherent perioperative and postoperative
morbidity and mortality particularly for geriatric
patients with limited cardiac reserve and other
Results associated diseases.1,4,6,14 All these drawbacks of low
SA are applicable to GA as well. Besides these GA
In the present study ages of 110 patients ranged for TURP in such geriatric patients with comorbid
from 62 to 86 years with an average of 72. In the diseases and limited cardiac reserve may be very
present study, some unanticipated technical problematic and life threatening because of many
difficulties were encountered during the needle factors like more incidence of moderate to severe
placement in 12 cases due to calcified ligaments. hypotension, arrhythmias, regurgitation and
Blood was transfused in 4 patients. aspiration, sudden cardiovascular catastrophe and
GA was administered to 4 patients where the respiratory insufficiency in the lithotomy position.11
block failed. Throughout the surgery SPO2 of all In light plane of anaesthesia penile erection is a
great problem.11 For all these CEB may be a better
the patients were maintained between 94% and
alternative than GA, SA, epidural and CSEB for
100% on oxygen. Throughout the surgery HR, SBP,
TURP in elderly with comorbid diseases. Definitely,
DBP, MAP were stable and did not show any major
CEB reduces perioperative and postoperative
fluctuation except in three patients who had mild
morbidities.15 Early discharges are possible so cost
hypotension and bradycardia where analgesia
is less. It also gives prolonged early postoperative
extended up to T6 and responded well to iv infusion.
analgesia if proper local anaesthetic mixtures are
There were no incidences of death, dural puncture,
used, less blood loss during surgery, and no need
headache, and hematoma or transient neurological
for tracheal intubation with its complications in
sequel.
geriatric age group and reduces the incidence of
DVT. For all these factors CEB is gradually gaining
Discussion popularity for TURP and reports are appearing in
the literature about its use. But exclusive literature
Since ancient times regional anaesthetic techniques on the use of CEB with preservative free lignocaine
have been used in Egypt, and have been mentioned hydrochloride mixed separately with adrenaline
in Erb’s papyrus. These were given up later till (1:200000) in geriatric patients with limited cardiac
the beginning of the 20th century.12 But since mid- reserve are scarce.15 So in the present study an
1970’s there was a dramatic boost in the use of attempt has been made about the usefulness of CEB

for TURP in geriatric patients with comorbidities. all techniques of anaesthesia so that he or she can
CEB was introduced by Sicard16 and Cathelin17 in tailor the anaesthetic technique as per need and risk
1901 in France and was used first for operation of the patient.21
by Schimpert of Freiburg in 1913.4 But, before CEB is also safe and cost-effective and is a
this Stoeck et al reported its use for painless very important factor for underdeveloped and
vaginal delivery.18 Hingson from Cleveland developing countries. In the present study,
Clinic after extensive work recommended its use adrenaline was mixed separately with 1% loxicard
for operations where a block of the sacral and so that the strength of adrenaline becomes 1:200000.
lumbar nerves are adequate like TURP.19 Zito SJ This was done because commercially available
in 1984 reviewed CEB extensively for the period xylocaine with adrenaline contains methylparaben
from 1901 to 1969 and finally concluded that CEB and sodium metabisulphite as preservatives, which
has distinct advantages over spinal and lumbar may give rise to allergic or any other unwanted
epidural for lower abdominal and urological side effects particularly in geriatric patients with
surgeries.8,11 CEB avoids most of the complications cardiac and other diseases. Literature did not reveal
of spinal and lumbar epidural anaesthesia such any such use of preservative free xylocaine and
as severe to moderate hypotension, transient adrenaline. Probably this may be one of the reasons
radicular irritation and epidural hematoma. why in the present study perioperative side effects
Another great advantage of CEB compared to any were minimum and duration of analgesia was little
other technique of neuraxial anaesthesia is that all less compared to many other studies. Further study
the vital parameters of all the patients were stable on this will be very much helpful and may open
and did not need any aggressive treatment. This a new horizon in the field of RA. In the present
is because CEB anaesthesia is apparent without study, 25 ml of LA was used. This is as per the
effect on the CNS, CVS, musculoskeletal and GI recommendation of many workers.6,15 Onset of
system.6 Very recently some researchers like Okeke analgesia, spread of analgesia, intensity of sensory
LI6, Yadav et al11, Bhattacharya et al14, Kose et and motor block in the present study were very
al15, followed up Zito’s study and also concluded good and similar to the previous studies like Kose et
that CEB should be recommended for TURP in al15, in 2012, Yadav et al, in 2015.11 Patchy analgesia
patients for prostate surgeries with associated in 4 patients may be due to sacral sparing and
comorbid diseases. Caudal epidural block involves inability to break all the septa leading to incomplete
the injection of a local anaesthetic drug into the sacral nerve root block which was considered as
epidural space through the sacral hiatus. Drugs failure.14 Majority of patients in the present study
injected act directly on spinal nerves and receptors had duration of analgesia from 85 to 120 minutes;
in the spinal cord due to diffusion across the dura almost similar was the observation by Yadav et al11,
and CSF. The level of anaesthesia is predictable the duration is comparatively less than observed by
and controllable so that sensory block below T8 others. This variation may be because we prepared
can be easily achieved.20 But anomaly of sacral the loxicard® and adrenaline ourselves so there
anatomy, thick presacral fat, excessive fatty gluteal may be some human error. Twenty Eight patients
region and calcified ligaments sometimes makes it who had poorly controlled HTN and DM with
difficult to perform the technique, leading to more LVEF <35% were taken up for surgery because they
failure rate. But these can be overcome by practice were developing features of obstructive uropathy
and experience. Though in paediatric age group it and had frequent UTI. They were not able to live
became quite popular since long, but could not find a healthy hygienic life because of obstruction. Also
its place as a popular technique in adults. Several this might be one of the reasons why HTN was
factors played a part for this like failure rate is higher not getting controlled and optimized. These ASA
than spinal or epidural as it is time-consuming, lack physical status III and IV patients were taken up
of training and experience, surgeon’s preference for anaesthesia and were considered as surgical
for other techniques. As a result, anaesthesiologists urgency. Limitations of the present study were that
are not well versed and trained in the technique. 1% preservative free xylocaine with adrenaline was
So in practice, they feel uncertain about the not available commercially. As previous reports to
block and instead use GA or other technique compare with were not available on this subject,
forgetting its usefulness in problematic geriatric especially in patients with comorbid diseases, it was
patients with comorbid diseases in whom these another limitation. Recommendations for remedies
other techniques may be life threatening or with are pharmaceutical firms should be convinced
increased morbidity and mortality. But a well- to prepare 1% preservative free lignocaine with
versed anaesthesiologist should be well trained in adrenaline and trainees and residents should be
Nellimarala Appalaraju, Karri Bala Krishna / Caudal Epidural Block for Transurethral Resection of Prostate 1303
in Patients with Comorbidities: An Observational Study
exposed more to the technique of caudal epidural therapy. American Society of Regional Anaesthesia
block. Lastly more research on the work to be and pain medicine Evidence Based Guidelines.Reg
reported. Anaesth pain med 2010;35:64–101. http://dx.doi.
org/10.1097/AAP.0b013e3181c15c70.
8. Crighton IM, Barry BP, Hobbs GJ. A study of
Conclusion the anatomy of the caudal space using magnetic
resonance imaging. Br J anaesth 1997;78:391–
‘’ In many instances, local anaesthesia means the 5. http://dx.doi.org/10.1093/bja/78.4.391
least strain to the patients’’– T. Gordh (1907 to 2010) [PMid:9135359].
9. Djokovic JL, Hedley-Whyte J. Prediction of Outcome
The present study justifies this statement of Gordh
of Surgery and Anesthesia in Patients over 80.
and concludes that CEB with an adequate volume of
JAMA 1979;21:2301–6. http:// dx.doi.org/10.1001/
LA drug is recommended and should be practised, jama.1979.03300210027016 [PMid:490827.
as it is safe and effective for TURP in elderly
10. Rostomashvili ET, Kostiuchenko AL, Stoiko I. Sacral
patients who have associated comorbid diseases.
epidural anesthesia in operations for varicose veins
It provides adequate satisfactory anaesthesia with of the lower extremities. Vestnik khirurgii imeni II
hemodynamic stability and sensory block up to Grekova 1994;152:104. [PMid:7740664].
T10. But it should be administered by a well-trained
11. Yadav SS, Gupta S, Choudhary B. A clinical study
experienced anaesthesiologist as.
of caudal epidural anaesthesia for transurethral
‘’Bright is the ring of words when the right man resection of prostate. JEMDS 2015;4:10309–20.
rings them up’’- Robert Louis Stevenson http://dx.doi.org/10.14260/jemds/2015/1485.
12. Adams RC, Lundy JS, Seldon TH. Continuous
caudal anaesthesia or analgesia: A consideration
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Laparoscopic Cholecystectomy Cases
Pinu Ranawat1, Naresh Kumar Tyagi2, Arvind Kumar Gupta3, Amit Jangir4
Author’s Affiliation: 1-4Assistant Professor, Department of Anesthesia, Pacific Institute of Medical Sciences, Udaipur, Rajasthan,
313015, India.
Corresponding Author: Naresh Kumar Tyagi, Assistant Professor, Department of Anesthesia, Pacific Institute of Medical
Sciences, Udaipur, Rajasthan, 313015, India.
E-mail: drnareshtyagi1982@gmail.com

Pinu Ranawat, Naresh Kumar Tyagi, Arvind Kumar Gupta, et al. Dexmedetomidine versus Mgso4 in Hemodynamic Stability in
Laparoscopic Cholecystectomy Cases. Indian J Anesth Analg. 2020;7(6):1305–1307.
Abstract
Laparoscopic surgery is associated with an elevation of cardiac parameters as well an elevation in blood
pressure due to effects of catecholamine activity and vaso constriction. Due to the widespread use of
laparoscopic techniques in modern day surgical practice it has become imperative for the anaesthetist to
maintain a stable hemodynamic environment in the patient in the operative and post operative period. The
use of dexmedetomidine and magnesium sulphate has been done with successfully in practice. The present
study aimed to ascertain whether the comparative efficacy of both these drugs is equal or different. The
study employed a subject pool of 60 subjects. The study found that there were no statistically significant
differences between the two drugs when used in the corresponding sample population.
Keywords: Dexmedetomidine versus Mgso4; Laparoscopic Cholecystectomy.
Introduction A drug commonly used is dexmedetomidine

which is an alpha 2 receptor agonist which provides
The applicability of laproscopic surgery has a reduction in sympathetic activity and aids in
increased due to the numerous advantages of sedation as well as providing with a analgesic cover.
the procedure over conventional surgery. The The drug has known to be effective in reducing
advantages include the reduced pain, cosmetic requirements of opiod analgesics after surgery as
advantage, early discharge and rapid recovery. well as providing a stable hemodynamic state in the
The conduct of laparoscopic surgery has been intra–operative period without any concomitant
instrumental in better patient prognosis. The respiratory depression.2
procedure of laparoscopic cholecystectomy has Another commonly used compound is
been a commonplace for quite some time and is magnesium sulphate. It is known to provide a
routinely conducted in multiple centres across the reduction in levels of circulating catecholamines
country. Despite its advantages, the procedure
as well as inhibit production of the same from the
does have the disadvantage of being prone to
adrenergic glands. It also has a role in providing a
hemodynamic disturbances especially an elevation
vasodilatory effect on all major blood vessels thus
of BP and Tachycardia. The modality has been
reducing the systolic blood pressure as well as
subjected to various drugs that are aimed at
regulating heart rate.3
alleviating the sympathetic response and providing
for a optimal intra–operative and post operative We conducted a study to ascertain if the
period.1 efficacy of these two drugs is comparable in case
of laparoscopic cholecystectomy and what may be Group A and Group B and C (p<0.05). This shows
the differences between them. The study aimed to that after intubation (T2), there was a slight elevation
ascertain the effects on hemodynamic changes in in HR values of normal saline group subjects as
a population sample undergoing cholecystectomy compared to Dexmedetomidine and magnesium
and being administered intravenous doses of sulphate groups. Analysis of dexmedetomidine
dexmedetomidine and magnesium sulphate in the and magnesium sulphate revealed a significant
operative period. difference in favour of dexmedetomidine. In terms
of mean blood pressure and mean arterial pressure
values, as depicted in Fig. 2, the values of mean BP
Material and Methods
were similarly elevated in Group A as compared
to Group B and C. Statistical analysis showed a
The present study was conducted in the operative significant difference (P<0.05) between Group
and recovery wards of Pacific Institute of Medical A and Groups B and C. There were no statistical
Sciences, Udaipur, which is a tertiary teaching differences between BP as recorded between
hospital. Institutional ethical clearance was Groups B and C. The mean arterial pressure also
obtained for the study prior to commencement. showed no significant difference between group
All subjects were counselled and explained the B and C, however the Group A had significantly
need for the study. Written informed consent was elevated values as compared to dexmedetomidine
obtained from all subjects with a reaffirmation that and magnesium sulphate groups.
they can opt out of the study at any point of time.
The patient pool comprised of 60 subjects who were 90
divided in three groups of 20 each. The first group 85
was administered normal saline. The second group 80
A
was administered dexmedetomidine, while the 75
third group received magnesium sulphate. 70 B
Pre anaesthetic investigations and preparations 65 C
were similar for all cases. The subjects falling in 60
ASA I and II were selected for the study. The Group T1 T2 T3 T4 T5
A, was given 20 ml normal saline as a IV infusion, Fig. 1: Mean HR
Group B was administered dexmedetomidine
1microgram/kg in 20 ml normal saline, while 100
Group C received magnesium sulphate 2g in 20 ml 90
normal saline. The hemodynamic parameters such A
as blood pressure, HR, Mean Arterial Pressure 80
were calculated at various intervals such as Prior B
70
to Intubation (T1), After Insufflation (T2), After C
deflation (T3), After Extubation (T4) and after 60
shifting in recovery ward (T5). The data collected T1 T2 T3 T4 T5
was entered in a MS excel sheet and subjected to
statistical analysis. Fig. 2: Mean BP
None of the subjects had any intraoperative
Results or post operative complications. Recovery was
uneventful and no complaints on follow up were
received.
The present study comprised of 60 subjects
comprising of 43 males and 17 females. The mean
age of the group was 45 ± 7.3 years. 18 of the subjects Discussion
had previous co morbidities such as hypertension,
but had stable BP in pre–operative period. 42 The present study had a sample of 60 subjects divided
subjects were ASA I while 18 subjects were ASA II. in three groups of 20 each who were administered
The study sample showed no significant differences normal saline, dexmedetomidine and magnesium
in terms of age, weight etc. The mean HR recorded sulphate respectively to record if any changes in
among the three groups is displayed in Fig. 1. hemodynamic stability is recorded and whether
The statistical analysis revealed that a significant these changes differ in the groups. Literature has
difference existed in mean HR values between provided us with evidence that CO2 insufflation is
Pinu Ranawat, Naresh Kumar Tyagi, Arvind Kumar Gupta, et al. / Dexmedetomidine versus MgSo4 in 1307
Hemodynamic Stability in Laparoscopic Cholecystectomy Cases
associated with hemodynamic disturbances that Conflict of Interest: Nil

can lead to adverse outcomes in the intra operative Source of Funding: Self Funded.
period in laparoscopic surgery cases. The advent of
newer medications had lead to a rapid fall in such
adverse outcomes. In the present study, the authors References
observed that the subjects with dexmedetomidine
and magnesium sulphate administration done 1. S M Meftahuzzaman, M M Islam, K K Chowdhury
in the pre operative period yielded a lower mean et al, “Haemodynamic and end tidal CO2 changes
heart rate than cases where normal saline was dur– ing laparoscopic cholecystectomy under
administered. This is in concurrence with studies general anaesthesia,” Mymensingh Medical Journal,
by J. Afonso and F. Reis ; R. Y. Klinger et al and M. vol. 22, no. 3, pp. 473–477, 2013.
C. Smania et al2,4,5 wherein the authors stated that 2. J Afonso and F Reis, “Dexmedetomidine: current
dexmedetomidine is an effective agent in stabilizing role in anesthesia and intensive care,” Revista
heart rate. The similar conclusion was obtained by Brasileira de Anestesiologia, vol. 62, no. 1, pp. 118–
an article by Zarif P et al wherein the authors stated 133, 2012.
that they observed a similar trend.6 Our study
3. S. Herroeder, M. E. Scho nherr, S G De Hert, and
showed a mildly significant difference between M W Holl– mann, “Magnesium—essentials for
dexmedetomidine and magnesium sulphate group. anesthesiologists,” Anesthe– siology, vol. 114, no. 4,
The group administered dexmedetomidine had pp. 971–993, 2011.
a marginally lower mean heart rate, this is also
4. R Y Klinger, W D White, B Hale, A S Habib, and
similar in findings by Zarif P et al.
E Bennett– Guerrero, “Hemodynamic impact
There were significantly similar differences seen of dexmedetomidine admin– istration in 15,656
in mean blood pressure and mean arterial pressure. noncardiac surgical cases,” Journal of Clinical
This is in concurrence with findings by Lang B et Anesthesia, vol. 24, no. 3, pp. 212–220, 2012.
al, Tan W et al, Zarif P et al and R. Bryskin and 5. M C Smania, J P Piva, and P C R Garcia,
B. C. Weldon6–9 wherein the authors supported “Dexmedetomidine in anesthesia of children
the notion that using magnesium sulphate or submitted to videolaparoscopic appen– dectomy: a
dexmedetomidine is an effective route in providing double–blind, randomized and placebo–controlled
a stable hypotensive status in laparoscopic cases. study,” Revista da Associacao Medica Brasileira,
There was no statistically significant difference vol. 54, no. 4, pp. 308–313, 2008.
in values of BP and MAP in dexmedetomidine 6. Zarif P, Abdelaal Ahmed Mahmoud A, Abdelhaq
and magnesium sulphate groups. This is similar MM, Mikhail H, Farag A. Dexmedetomidine versus
to findings by Zarif P et al and R Bryskin and B C magnesium sulfate as adjunct during anesthesia for
Weldon6,9 wherein they conducted an comparative laparoscopic colectomy. Anesthesiology Research
assessment ruling out any significant difference and Practice. 2016 Jan 1;2016.
between the two drugs in terms of efficacy of 7. Lang B, Zhang L, Lin Y, Zhang W, Li FS, Chen S.
hemodynamic stabilization. Comparison of effects and safety in providing
controlled hypotension during surgery between
Conclusion dexmedetomidine and magnesium sulphate: A
meta–analysis of randomized controlled trials. PloS
one. 2020 Jan 8;15(1):e0227410.
The authors conclude that using dexmedetomidine
8. Tan W, Qian DC, Zheng MM, Lu X, Han Y, Qi DY.
and magnesium sulphate proved equally effective
Effects of different doses of magnesium sulfate on
in maintaining a favourable range of blood pressure
pneumoperitoneum–related hemodynamic changes
and mean arterial pressure in the selected population
in patients undergoing gastrointestinal laparoscopy:
sample. The use of dexmedetomidine was slightly a randomized, double–blind, controlled trial. BMC
better in mean heart rate maintenance as compared anesthesiology. 2019 Dec 1;19(1):237.
to magnesium sulphate but the significance was
9. R Bryskin and B C Weldon, “Dexmedetomidine
marginal. The authors conclude that using either
and magnesium sulfate in the perioperative
magnesium sulphate or dexmedetomidine as an
management of a child under– going laparoscopic
adjuvant is a feasible and safe option.
resection of bilateral pheochromocytomas,” Journal
Limitations: The study is limited by the lack of a of Clinical Anesthesia, vol. 22, no. 2, pp. 126–129,
larger sample size. 2010.

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A Comparative Study to Evaluate the Efficacy of Intravenous

Dexmedetomidine versus Clonidine for Post Spinal Anaesthesia
Shivering in Caesarean Section
Ramachandraiah R1, Vigy Varghese2
Author’s Affiliation: 1Professor, 2Post Graduate Student, Department of Anesthesiology, Bangalore Medical College and
Research Institute, Bengaluru, Karnataka 560002, India.
Corresponding Author: Vigy Varghese, Post Graduate Student, Department of Anesthesiology, Bangalore Medical College and
Research Institute, Bengaluru, Karnataka 560002, India.
E-mail: vigyvarghese1990@gmail.com

Ramachandraiah R, Vigy Varghese. A Comparative Study to Evaluate the Efficacy of Intravenous Dexmedetomidine versus
Clonidine for Post Spinal Anaesthesia Shivering in Caesarean Section. Indian J Anesth Analg. 2020;7(6):1309–1314.
Abstract
Background: Lower segment caesarean section is widely performed under spinal anaesthesia and
shivering is a common complication encountered. Clonidine and Dexmedetomidine are α – 2 agonists
with anti-shivering property.
Aim: The aim was to compare the efficacy, hemodynamic and adverse effects of intravenous
Dexmedetomidine versus Clonidine for post spinal anaesthesia shivering in LSCS.
Materials and Methods: A randomized double blind study was carried out in 70 parturients of ASA
Physical Status II between 18 – 35 years who underwent LSCS under spinal anaesthesia and developed
grade 2 or above level of shivering (wrench grading) in the intraoperative period. Group C (n=35) received
intravenous Clonidine 1 mcg/kg and Group D (n=35) Dexmedetomidine 0.5 mcg/kg. Assessment included
hemodynamics, time taken for complete cessation of shiveringand sedation scores.
Results: Mean time taken in Group D for cessation of shivering was 2.26 ± 0.44 minutes and in Group C,
it was 5.48 ± 0.91min (p < 0.001). In Group C drug failed to control shivering in 17.4% and had recurrence
in 20.69% while there was no failure (p < 0.001) and recurrence (p = 0.01) in Group D. Ramsay sedation
scores were better with Group D when compared with Group C (p = 0.005). The incidence of hypotension
and bradycardia was 22.8% in Group C and in Group D 2.86% (p = 0.012).
Conclusion: We conclude that Dexmedetomidine (0.5 mcg/kg) has early onset of action with less failure
rate and recurrences with better hemodynamic stability and sedation when compared to Clonidine (1.0
mcg/kg) for post spinal shivering in LSCS.
Keywords: Shivering; Caesarean section; Spinal anaesthesia; Clonidine; Dexmedetomidine.
Keymessage: The study aimed to observe the efficacy of intravenous Dexmedetomidine versus
Clonidine for post spinal anaesthesia shivering in LSCS. The hemodynamic responses and sedation
achieved by Dexmedetomidine and Clonidine when used as antishivering agent were also compared.
Introduction spinal anaesthesia is a common problem and may

occur in 19%–33% of patients receiving spinal
Shivering is seen in patients who receives regional anaesthesia.1,2 Lower segment caesarean section is
anaesthesia as well as those recovering from general widely performed under spinal anaesthesia.
anaesthesia. Shivering that develops following Shivering is a very unpleasant and distressing
experience for the patients associated with many intravenous Clonidine for post spinal anaesthesia
adverse physiological effects. The undesirable shivering in caesarean sectionalong with their side
physiological consequences include increase in effects.
oxygen consumption, carbondioxide production
and minute ventilation. It may induce arterial Materials and Methods
hypoxemia, lactic acidosis, increased intra ocular
pressure and intra cranial pressure and interfere with
patient monitoring like ECG (electrocardiogram), After approval of the Institutional Ethics Committee,
NIBP (non-invasive blood pressure), pulse oximetry a prospective double blinded randomized study
etc. Shivering may damaged entalprosthesis and was conducted in 70 parturients belonging to ASA
negateorthopedic procedures like fractures and Physical Status II, aged between 18 to 35 years
dislocations which can be detrimental to patients posted for lower segment caesarean section under
with low cardiopulmonaryreserve.3 spinal anaesthesia who developed grade 2 and
above level of shivering in the intraoperative period
Spinal anaesthesia is known to decrease (as per Wrench grading). They were divided into
vasoconstriction and shivering thresholds. two groups of 35 each by using computer generated
Spinal anaesthesia induced vasodilation causes randomization table.
redistribution of heat from core to periphery and
so shivering is preceded by corehypothermia and All parturients underwent pre-anaesthetic
vasoconstriction above the level of block.2,4 The examination including history elicitation, detailed
interesting fact about corehypothermia following systemic examination and airway examination.
spinal anaesthesia is that it may not trigger They were kept fasting for 6 hours. Informed
sensation of cold as the cutaneous vasodilatation written consent was obtained after explanation
resulting from sympathetic blockade increases the of the anaesthesia technique. After establishing
skin temperature leading to asensation of warm wide bore venous access parturients received
thal though it is accompanied by thermoregulatory injection ranitidine 50 mg intravenously and
shivering.5 injection metoclopramide 10 mg intravenously 30
minutes before surgery. In the operating room,
Various methods are available for the control baseline parameters of heart rate, non-invasive
of shivering, which maybe non- pharmacological blood pressure, oxygen saturation, end tidal carbon
or pharmacological. Intraoperative hypothermia dioxide and axillary temperature were recorded.
can be minimized byanytechniquethat can limit The operating room temperature was maintained at
cutaneous heat loss to the environment such as 22–24 degree Celsius and fluids were administered
those due to cold operating room, evaporation at room temperature. No external warming devices
from surgical incisions and conductive cooling were used. Oxygen was administered via face mask
produced by administration of cold intravenous at 6 litres/minute.
fluids. Fluid warmers,6 ambient operation theatre
temperature, space blankets,7 surgical drapes The parturients received spinal anaesthesia under
and active circulating warm water mattress have aseptic precautions with 25 or 26 gauge Quincke
also been used. Pharmacological methods by spinal needle through L3– L4 intervertebral space
using variety of drugs like Pethidine, Morphine, with 2ml of 0.5% hyperbaric bupivacaine to achieve
Tramadol,8,9 Clonidine, Dexmedetomidine, Ketamine, a desirable level of T6.Hemodynamic parameters
Neostigmine, Magnesium sulfate10 have been tried. will be recorded every 3 minutes for 1st 15 minutes
These drugs are easily available and cost effective. and every 5 minutes for next 30 minutes and there
after every 10 minutes throughout the surgery.
There is always aquest for more safe ran The parturients were observed for shivering in the
defficacious drug. In our study, we compared entire intraoperative period by an anaesthesiologist
two α2 adrenergic agonists, Clonidine and who was blinded to the study group. The shivering
Dexmedetomidine administered intravenously for was graded on a scale of 1–4 as per Wrench grading
treating shivering in patients who received spinal of shivering.
anaesthesia for caesarean section.11
Parturients developing grade 2 and above levels
of shivering were included in the study. They
Aims of Study were randomly divided in two groups. Group C
received Clonidine 1 mcg/kg intravenously and
The major aim of the study was to compare the Group D received Dexmedetomidine 0.5 mcg/kg
efficacy of intravenous Dexmedetomidine versus intravenously diluted to 5ml with normal saline
Ramachandraiah R, Vigy Varghese / A Comparative Study to Evaluate the Efficacy of Intravenous 1311
Dexmedetomidine versus Clonidine for Post Spinal Anaesthesia Shivering in Caesarean Section
in coded syringe by an anaesthesiologist who is spinal anaesthesia in Group C was 18.17 ± 2.73
not involved in the study. Time taken to control minutes where as in Group D, it was 18.00 ± 2.80
shivering, response rate (shivering ceased after minutes which was also similar (p=0.796). The mean
treatment within 15 minutes), and recurrence if any Temperature during onset of shivering was 36.18 ±
before the end of the surgery were noted. Sedation 0.190C in Group C and in Group D, it was 36.21
was assessed using Ramsay sedation score (RSS) ± 0.220C which was of no statistical significance
and recorded after cessation of shivering. Any (p=0.57).
incidence of nausea, vomiting, hypotension, The mean duration of shivering or the time
and bradycardia was identified and treated. The taken for complete cessation of shivering after
parturients who do not respond to the drug within administration of study drug was 5.48 ± 0.911
15 minutes or in whom it recurs before the end of minutes in Group C and 2.26 ± 0.443 minutes in
surgery were treated with injection Pethidine 25mg Group D. There was strong statistical significant
intravenously as a rescue drug to control shivering. difference in mean duration of shivering between
Hypotension [SBP below 90 mmHg or a fall in two groups. (p<0.001).(Fig.1)
Mean arterial blood pressure >20% of baseline Duration of shivering
values] was treated with rapid infusion of 8
crystalloids [200ml] bolus followed by intravenous 7
injection Mephenteramine 6mg if hypotension 6 [Value] min
persisted. Bradycardia [<60beats/min] was treated Time (min) 5
with injection atropine 0.01mg/kg intravenously. 4
Nausea and vomiting were treated with intravenous 3 [Value] min
injection. Ondansetron 4 mg. 2
1
The qualitative parameters were represented 0
using frequencies and percentage and the Group C Group D
Group
quantitative parameters were depicted using Mean
(Standard Deviation) and Median (Inter Quartile Fig. 1: Bar diagram showing Duration of shivering comparison
between two groups.
Range). Student’s t test was used for normally
distributed quantitative data and Mann Whitney In Group C, drug failed in subsiding shivering
U test was used for skewed data. Chi – square of 17.14% parturients whereas no failure was noted
or Fisher’s exact probability test wasused for in Group D. This has strong statistical significance
qualitative variables. Data was analyzed by using ( p<0.001).(Fig.2)
SPSS 22 Version Software and p value less than 0.05 Failure Distribution Between Groups
was considered statistically significant.
18% 17.14%
Results 16%
Percentage of Failure
14%
12%
A total of 70 parturients aged between 18–35 10%
years who under went caesarean section under 8%
6%
spinal anaesthesia using 2 ml of 0.5 % hyperbaric 4%
Bupivacaine and developed grade 2 and above 2% 0.00%
levels of shivering were randomly assigned into 0%
two groups of 35 each. Group C Group
Group D
In Group C, mean age was 24.71 ± 3.94 years and
Fig. 2: Bar Diagram Showing Failure Distribution between two
in Group D, mean age of subjects was 25.86 ± 3.29 groups.
years (p=0.192). Mean Height and weight of both the
groups were comparable. Baseline hemodynamic In Group C, 20.69% had Recurrence of shivering
data were recorded in both groups. Demographic before the completion of surgery when compared
data were comparable in both the groups and none to 0% in Group D. There was moderate significant
of them were statistically significant. statistical difference in recurrence between two
groups (p=0.01). (Table 1)
In Group C, mean Temperature before the
starting of surgery was 37.04 ± 0.22 0C versus 37.06 In Group C, 0% had Nausea/ Vomiting
± 0.240C in Group D was similar in both groups compared to 2.86% in Group D which is not
(p=0.682).Mean Time of onset of shivering after statistically significant (p=0.314). In group C 22.86%

Table 1: Recurrence Distribution between two groups.

Group
Group C Group D Total
Count % Count % Count %
Recurrence Nil 23 79.31% 35 100.00% 64 91.43%
Yes 6 20.69% 0 0.00% 6 8.57%
Table 2: Nausea/Vomiting, Bradycardia and Hypotension Distribution between two groups.
Group Chi Square

Group C Group D
Count % Count %
Nil 35 100.00% 34 97.14% χ 2 =1.014, df =1, p = 0.314
Nausea/ Vomiting
Yes 0 0.00% 1 2.86%
Nil 27 77.14% 34 97.14% χ 2 =6.248, df =1, p = 0.012*
Bradycardia
Yes 8 22.86% 1 2.86%
Nil 27 77.14% 34 97.14% χ 2 =6.248, df =1, p = 0.012*
Hypotension
Yes 8 22.86% 1 2.86%
had Bradycardia and Hypotension and in group D is also associated with adverse physiological
it was only 2.86 %. There was moderate significant effects including increase in oxygen consumption,
difference in Bradycardia and hypotension between increased carbon dioxide production and increased
two groups (p=0.012).(Table 2) minute ventilation. This in turn induces arterial
Ramsay Sedation Score Distribution
hypoxemia, lactic acidosis, increased intra ocular
pressure and intra cranial pressure. Shivering will
100% also interfere with the monitoring parameters like
94.29%
90% Electrocardiogram, Noninvasive blood pressure
80% and Pulse oximetry etc. Spinal anaesthesia is
71.43%
70% known to decrease thresholds of vasoconstriction
and shivering. There will be redistribution of heat
Percentage
60%
50% from core to periphery following spinal anaesthesia
40% induced vasodilation. Various pharmacological
30% 25.71% and non- pharmacological methods are available
20% for the control of shivering. Pharmacological
10% 0.00%
5.71% methods was done using a variety of drugs like
2.86%
0% Pethidine, Morphine, Tramadol,8,9 Clonidine,
1 2 3
Group C Dexmedetomidine, Ketamine, Magnesium
Group D Ramsay Sadation Score
sulphate10 However, there is always a quest for more
Fig. 3: Bar Diagram Showing Ramsay Sedation Score Distribution safer and efficacious drug. There is comparatively
between two groups.
less studies on Dexmedetomidine and Clonidine as
In Group C, 25.71% had RSS score of 1, 71.43% antishivering agents in caesarean section.11
had RSS score of 2 and 2.86% had RSS score of 3. In The present study was done in 70 patients
Group D, 0% had RSS score of 1, 94.29% had RSS in two groups of 35 each who developed post
score of 2 and 5.71% had RSS score of 3. There was spinal shivering in Lower segment caesarean
strong significant difference in Ramsay sedation section. Group ‘C’ received intravenous clonidine
scale between two groups (p=0.005).(Fig. 3) 1microgram/kg whereas Group ‘D’ received
intravenous dexmedetomidine 0.5microgram/kg.12
Discussion Earlier studies were conducted by Manohar
Panneer et al with intravenous Dexmedetomidine
Shivering is seen as one of the most common (0.5 microgram/kg) and Clonidine (1 microgram/
complications after regional anaesthesia as well kg) for postspinal shivering in patients undergoing
as those recovering from general anaesthesia. lower limb orthopedic surgeries and a similar
Shivering incidence following spinal anaesthesia study was done by Rajagopalanvenkatraman
seems to be 19%–33%. It is a very unpleasant et al13 with intravenous Dexmedetomidine (0.5
and distressing experience for the patients which microgram/kg), Clonidine (1 microgram/kg) and

Ramachandraiah R, Vigy Varghese / A Comparative Study to Evaluate the Efficacy of Intravenous 1313
Dexmedetomidine versus Clonidine for Post Spinal Anaesthesia Shivering in Caesarean Section
Tramadol (1 milligram/kg)14 which showed that patients who received Clonidine, there was 22.86%
Dexmedetomidine is a good anti shivering agent incidence of hypotension with bradycardia which
compared to Clonidine with minimal side effects if is statistically significant (p = 0.012).
any which is easily treatable.15,16 Dexmedetomidine Only one patient in Dexmedetomidine group
is having the added advantage of giving good complained of nausea which is statistically
sedation. insignificant. This is in accordance with the study
In our study, the time taken to stop shivering done by Manohar Panneer et al where they noticed
after administration of study drug in clonidine that the incidence of hypotension and bradycardia
group was 5.48±0.91 minutes and who received is less with Dexmedetomidine when compared to
Dexmedetomidine was 2.26±0.44 minutes which clonidine which they attributed to less selective
is statistically significant (p value<0.001). We action of clonidine on alpha 2 receptors.19
observed that Dexmedetomidine has faster onset
We studied sedation properties of both the drugs
of action compared to Clonidine. Our results are in
and noticed that none of the patients in either of the
correlation with study done by Manohar Panneer et
group had profound deep sedation (sedation score >
al on post spinal shivering in patients undergoing
3) or respiratory depression.20 In Dexmedetomidine
lower limb orthopedic surgeries. They noticed
group, 94.3% had Ramsay sedation score of 2 and
that the mean time taken for clonidine was 5.54±
5.7% had sedation score of 3. In clonidine group,
0.58 minutes and Dexmedetomidinewas 2.23±0.43
25.7% had no sedation and 71.4% achieved Ramsay
minutes which also proved that Dexmedetomidine
sedation score of 2 and 2.9% had sedation score of
has faster action in terms of antishivering property.17
3. These findings were in agreement to the work
In our study, the response rate and the done by Rajagopalan Venkatraman et al where
percentage of patients whose shivering stopped they noted higher sedation scores with use of
by treatment within 15 minutes were compared Dexmedetomidine, 70% had a sedation score of 2
and found to be 100% in Dexmedetomidine group and 23% had a score of 3(17).21 They concluded that
and 82.86% in clonidine group with failure in 6 sedation achieved during treatment of shivering was
patients out of 35 (failure rate 17.14%). Hence, beneficial in these patients under spinal anaesthesia
we observed that Dexmedetomidine has better and contributed it to the alpha 2 agonist properties
efficacy in treatment of shivering when compared of drug. However, no respiratory depression was
to clonidine. Our results were similar to the study observed in both groups. The limitation of our
done by Manohar Panneer et al where response study was that we took relatively smaller size
rate with Dexmedetomidine was 100% and with sample. A larger study may be needed to evaluate
clonidine was 82.86% respectively and failure the side effects.
rate was 17.14% with Clonidine. This showed that
Dexmedetomidine is more efficient than clonidine
in treatment of post spinal shivering.18 Conclusion
Recurrence of shivering before the end of
surgery was also noted in our study and recurrence Dexmedetomidine 0.5 microgram/kg intravenously
rate was calculated. There was no recurrence in is more efficient than intravenous Clonidine 1
Dexmedetomidine group. However, in Clonidine microgram/kg in treatment of shivering with
group, 6 cases had recurrence out of 29 cases respect to faster onset of action, better response
who responded to Clonidine. The recurrence rate, lesser recurrence rate and decreased side
rate was 20.69% which is statistically significant. effects and an added advantage of better sedation.
Patients treated with Dexmedetomidine had
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Absent Gastric Bubble: It’s Implications on Intra and Post-op Recovery

in CABG Patients
Rupinder Kaur Kaiche1, Amol Shinde2, Rahul Kaiche3, Amogh Jagtap4
Author’s Affiliation: 1,Consultant, Department of Cardiac Anesthesiologist, 2Consultant, Department of Cardiothoracic and
Vascular Surgeon, 3Consultant, Department of Medicine, 4Consultant, Department of Radiodiagnosis, Ashoka Medicover Hospital,
Nashik, Maharashtra 422209, India.
Corresponding Author: Rupinder Kaur Kaiche, Consultant, Department of Cardiac Anesthesiologist, Ashoka Medicover
Hospital, Nashik, Maharashtra 422209, India.
E-mail: rrkaur8@gmail.com

Rupinder Kaur Kaiche, Amol Shinde, Rahul Kaiche, et al. Absent Gastric Bubble: It’s Implications on Intra and Post-op Recovery
in CABG Patients. Indian J Anesth Analg. 2020;7(6):1315–1318.
Abstract
Background: Absent gastric bubble was an X-ray chest finding preoperatively of a 68 year old gentleman
posted for CABG. Apart from symptoms of unstable angina consistent with his angiographic findings, he
complained of chest pain at night and lump in throat which we could attribute to gastroesophageal reflux
disease. The aim of this study was to find the causes of absent gastric air bubble, so as to understand its
implications and prevent the possible complications in patients undergoing CABG.
Methods: All patients undergoing cardiac surgery underwent prescribed blood investigation, ECG,
X-ray chest (PAview ) PFT, carotid doppler, 2D ECHO and coronary angiography. Over a period of 6
months we had 5 patients whose X-ray chest showed absent gastric air bubble. All of the 5 patients were
evaluated and managed preoperative,intra and postoperative keeping in mind the possible complications.
Results: Cause of absent gastric bubble in our patients:
1. Hiatus hernia -1
2. Achalesia cardia -1
3. Gastro-esophegael reflux disease -3
Conclusion: Absent gastric bubble is a sign which needs to be investigated pre-operatively for its cause.
Gastro-esophageal reflux disease is a common disease which mimics heart attack.1. and is common in
patients coming for CABG and can be a cause for concern for patient due to persistent chest pain post
surgery. Adequate precautions like duration of fasting preop-operatively, prevention of micro aspiration
post-operatively with head end elevation and low fat diet, abstinence from smoking, tea, coffee intake,
weightloss will help in relieving symptoms of GERD and improve patient satisfaction post CABG.
Confirmation and explanation of the observed relation between the presence of hiatal hernia and infarction
requires further research .
Keywords: Gastric air bubble; Ggastro-esophageal reflux disease; Hiatus hernia; Achalasia cardiac.
Introduction gastric bubble on chest radiograph. Abnormalities

in the position or shape of the gastric bubble may
Chestpain is a symptom not only signalling angina be the initialor sole manifestation of thoracic or
but also gastroesophageal reflex disease.1 The latter abdominal pathology. In 1939 Kirklin emphasized
can be easily correlated with a lesser appreciated the importance of evaluating the gastric bubble for

Table 1: Compilation of patients demographics, comorbidities, operative details, postoperative complications, ICU and hospital stay.
Gender Female Female Male Male Female

Diagnosis IHD,CAD,Critical IHD,CAD, TVD,USA, IHD, CAD, IHD, CAD, Critical IHD, CAD, Critical
DVD, USA, RT ICA- RWMA TVD, USA, TVD with LMCA, SVD, Large
100%, LT CCA-70% RWMA CCF, PWMI, MOD Lamyxoma,SEV
MR,LTCA-60% PH, SEV TR,SEV
RV Dysfunction
Co-morbidities HTN,Carotid artery HTN, Type 2 DM, COPD, COPD, GERD Hiatus hernia
stenosis, GERD GERD Achalasia cardia
Surgery CABG X2(LIMA CABG X 2 (VEIN) CABG X CABG X 3 (LIMA CABG X 1 +
VEIN Y) 3(LIMA VEIN) VEIN) LA MY X OMA
Exclision(Vein)
LVEF 40% 50% 45% 40% 50%
Post -OP Nil Nil Nil Nil Nil

Complications
ICU stay 2 days 2 days 2 days 2 days 3 days
Hospital stay 7 days 7 days 7 days 7 days 8 days
deformities produced by carcinoma in cardia or management helped us anticipate and prevent any
fundus.2 Though the likelihood of detecting occult complications.
gastric carcinoma on a chest radiograph is small,it
is an important indicator of pathologies causing
GERD.
X-ray chest is one of the routine investigations
done for all cardiac patients prior to surgery
for systematic evaluation of trachea, fats and
subcutaneous tissue, soft tissue like heart, lungs,
bony structures like clavicle, ribs, vertebrae and
the presence of metallic objects like defibrillator or
pacemaker. We also look for the gastric air bubble.
We present a case series of 5 patients who
underwent cardiac surgery with pre-operative
X-ray chest showing absent gastric bubble. They
were evaluated pre-op for the cause, and managed
pre-operatively, intra and post operatively to avoid
any complications.
Fig. 1: Absent gastric air bubble on his pre-operative
X-Ray
Methods
Results
A 68 years old gentleman posted for CABG showed (Table 1) shows a compilation of patients
absent gastric air bubble on his pre-operative X-Ray demographics, comorbidities, operative details,
(Fig.1 ) On analysing his symptoms given in history postoperative complications, ICU and hospital
during pre-anaesthetic evaluation some like chest stay. Patients can have complications which can
pain at night and lump in the throat were attributed affect morbidity. Our pre-operative precautions
to gastro-esophageal reflux. On further evaluation helped prevent them.
and discussion with gastro-enteroenterologist,
he was diagnosed as sufferring from GERD.
This prompted us to evaluate, over a period of 6 Discussion
months, 4 more patients whose X-ray showed
absent gastric air bubble. Proper history taking, Absent gastric bubble is a sign which can relate to
investigations with the involvement of radiologist many causes, the prominent and common being:
and gastroenterologist, helped us reach a diagnosis
A. GERD
in each case. Necessary pre-operative, intra and
post-operative precautions and appropriate B. Hiatus hernia

Rupinder Kaur Kaiche, Amol Shinde, Rahul Kaiche, et al. / Absent Gastric Bubble: It’s Implications on 1317
Intra and Post-op Recovery in CABG Patients
C. Opiate induced oesophageal dysmotility air is largely responsible for gastric air bubble on
D. Achalasia cardia. chest X-ray, an impairment of air transport may
alter this finding. Recent evidences indicate that
GERD: Gastro esophageal reflux disease is the this anautoimmune process triggered by some
transient relaxation of lower esophageal sphincter viruses like herpes virus in genetically predisposed
causing the gastric acid to regurgitate into the individuals resulting in degeneration of myenteric
esophagus. This gives rise to symptoms of heart neurons.5
burn, chest pain at night, difficulty swallowing,
sensation of lump in the throat. Night time acid Gastroscopy is recommended to rule out other
reflux may cause chronic cough, laryngitis, new or causes of dysphagia, especially pseudo achalasia
worsening asthma and disrupted sleep. due to gastro esophageal junction neoplasms.
Some of the symptoms overlap with symptoms Treatment modalities include:
of coronary artery disease as shown in our patients 1. Botulinum toxin injection
taking the form of “heart mask”. Korronek et al.
2. Pneumatic balloon dilation
attempted to find the relation between GERD
and CAD and found that 34% of CAD patients 3. Laproscopic Heller myotomy
showed symptoms of GERD.1.Smoking, intake 4. Per oral endoscopic myotomy (POEM )
of alcohol, coffee, fatty foods,obesity are some
of the aggravating factors which are modifiable. Other conditions which may present like
These patients are advised early dinner, lifestyle achalasia cardiac are:
modifications and raised head end of bed while 1. Esophageal cardia
sleeping. 2. Esophageal structure
GERD increases acid exposure on vulnerable 3. Gastro-esophageal reflux disease
epithelia usually esophagus, but may include
supraesophageal terrain including larynx, pharynx 4. Plummer Vinson syndrome
andairways.4 5. Rozyeki syndrome
Hiatus Hernia: Anytime an internal body part 6. Chagas disease
pushes into an area where it doesn’t belong is called
Complications of long standing achalasia which
hernia. Hiatus is an opening in the diaphragm.
need to be considered are:
Normally the esophagus goes through the hiatus
and attaches to the stomach. Commonly the stomach A. Aspiration pneumonia
bulges into chest. The paraesophagealhernia B. Oesophagael cancer
though less common is of concern. In this the
esophagus and stomach stay in their normal C. Candida esophagitis
location but part of stomach squeezes through the D. Acute airway obstruction
hiatus landing it next to esophagus. The danger is Opiate induced esophageal Dysmotility: Opioids are
that the stomach can become strangulated or have known to delay intestinal transit time. This occurs
its blood supply shut off. People with hiatus hernia by stimulation of non propulsive contractions
have no symptoms other than heart burn related to in intestine and colon via central and peripheral
GERD. There is a significant coincidence between actions.6. µ,d and ĸ receptors are present in central
hiatal hernia and esophageal reflux disease.3 Hiatal as well as enteric nervous system, more of µ and ĸ in
hernia can be viewed as a continium of progressive enteric system.7. Opioid receptors are also present
disruption of gastrointestinal esophageal junction,
in the esophagus.8 Use of opoids cause generation
highlights the difficulty of elucidating the relation
of high amplitude and simultaneous esophageal
between hiatalhernia, the diaphragmatic hiatus, the
waves causing impaired lower esophageal sphincter
lower esophageal sphincter and GERD, including
relaxation. Morphine is known to decrease lower
supraesophagael reflux.
esophageal sphincter relaxation.9
Achalasia Cardia: It is characterized by failure of
With increasing incidence of cancer, osteo-
lower esophageal sphincture to relax in response
arthritis, chronic back pain, the use of opioids has
to swallowing and by an absence of peristalsis
increased, which can be the cause of esophageal
in esophageal body. It is an esophageal motor
dysmotility.
disorder whose major symptom is dysphagia which
results from in effective transport of swallowed Since the various causes giving rise to absent
material from mouth to stomach. Since swallowed gastric air bubble are all inter-related, the

complications caused are similar. Knowledge, connection with GERD BlaszakA, WojtunS, Gil J et
prevention, anticipation and prompt management al. Pol Merkur Lekarski.2007May;22(131):357–61.
helped us avoid serious complications like acute 4. Supraesophageal complications of reflux disease
airway obtruction, aspiration pneunomia. All our and hiatal hernia. Kahrilas PJ. Am J Med.2001 Dec
patients were kept overnight fasting for 10–12 3;111Suppl 8A:51S–55S.
hours and taken up as first case in the morning. 5. GockelI, Becker J, Wouters MM, Niebischs et al.
Rocuronium was used as muscle relaxant to Common variants in the HLA-DQ region confer
facilitiate early intubation. Post-operatively susceptibility to idiopathic achasia.(2014)Nat Genet
46:901–904.
head end of the bed was kept elevated.10,11 It was
communicated to all doctors and nurses involved 6. Wood J D, Galligan J J. Function of opioids in the
enteric nervous system. Neurogastroenterol Motil
with patient care throughout the hospital stay to
2004;16(Suppl.2):17–28.
avoid supine position.12 RT was placed. Opioids
were replaced by paracetamol and tramadol for 7. Sternini C, Patierno S, Selmer I S, Kirchgessner
A. The opioid system in the gastrointestinal tract.
pain relief.13 H2–receptor blockers were started. Neurogastroenterol Motil2004;16(Suppl.2):3–16.
They were discharged with advise regarding life
8. 8.RattanS,GoyalRK.Identification and localisation of
style modifications.
opioid receptors in the opossum lower esophageal
sphincter.JPharma col Exp Ther1983;224:391–7.
Conclusion 9. Dowlatshahi K, Evander A, Walther B, Skinner
DB. Influence of morphine on the distal esophagus
and the lower esophageal sphincter-a manometric
Gastric bubble is an occasionally neglected
Study. Gut 1985;26:802–6.
sign which can give important information in
10. Klompas M, Branson R, Eichenwald EC, et
the preoperative period. Patients with cardiac
al. Strategies to prevent ventilator-associated
disease tend to overlook symptoms pertaining to pneumonia in acute care hospitals:2014 update.
GERD, however it’s persistence post-operatively Infect Control Hosp Epidemiol2014 Aug;35(8):915–
becomes their source of concern. Its pre-operative 36.PMID 25026607.
diagnosis,treatment with adequate precautions can 11. Van Nieuwenhoven CA, Vandenbroucke-Grauls
improve morbidity and patient satisfaction. C, van Tiel FH, et al. Feasibility and effects of the
Financial support: nil semirecumbent position to prevent ventilator-
associated pneunomia: A randomized study. Critical
Conflicts of Interests: nil Care Med 2006 feb;34(2):396–402 PMID:16424720.
12. Drakulovic MB,TorresA,Bauer TT et al. Supine
References body position as a risk factor for nosocomial
pneunomia in mechanically ventilated patients.A
randomized trial.Lancet 1999 Nov;354(9193):1851–
1. Gastroesophageal reflux disease among patients 8. PMID:10584721.
suffering from coronary artery disease. Korzonek 13. An Investigation of Safety and Efficacy of
M, et al Ann Acad med Stetin.2008;54(2):41–6. Intravenous Paracetamol in Pain Management
Following Cardiac Surgery. Ehsan Mahdavi,
2. Roentgenologic diagnosis of cancer of the cardia.
Ghasem Soltani, Shahram Amini. Journal of Cardio-
Kirklin BR.AJR 1939;41:873–880. Thoracic Medicine Aug2015;Vol 3:Issue 3,Pages
3. The analysis of hiatal hernia occurrence in 324–328.

A Study on Hemodynamic Changes in Dexamethasone 0.1 mg/kg When

Combined with 0.15% Ropivacaine for Caudal Analgesia in Children
Samarth S P1, Darshan M S2
Author’s Affiliation: 1Senior Resident, 2Associate Professor, Department of Anaesthesiology, Chamarajanagar Institute of
Medical Sciences, Chamarajanagara, Karnataka, India.
Corresponding Author: Darshan M S, Associate Professor, Department of Anaesthesiology, Chamarajanagar Institute of
Medical Sciences, Chamarajanagara, Karnataka, India.
E-mail: darshanms_jss@yahoo.com

Samarth S P, Darshan M S. A Study on Hemodynamic Changes in Dexamethasone 0.1 mg/kg When Combined with 0.15%
Ropivacaine for Caudal Analgesia in Children. Indian J Anesth Analg. 2020;7(6):1319–1322.
Abstract
Introduction: The efficacy of dexamethasone in prolonging the effect of local anesthetic has not been
extensively studied when compared to other adjuvants. So, in our study we evaluated the analgesic
efficacy of caudally administered dexamethasone along with dilute concentration of local anesthetics in
children undergoing infra umbilical surgeries.
Methodology: 60 children between the age group 1–5 years of ASA-PS I and II posted for elective
infraumbilical surgeries were randomly grouped into two equal groups using shuffled sealed opaque
envelope technique. Pre anesthetic evaluation was done and informed consent was obtained from the
parents after explaining about the procedure and the drugs being used.The two groups were Group R
(control group) and Group D (study group). Group R received 1 ml/kg of 0.15% ropivacaine with normal
saline (1ml) and Group D received 1 ml/kg of 0.15% ropivacaine with dexamethasone 0.1 mg/kg in saline
to make a total volume 1ml in the caudal epidural space.
Results: No significant variation was noticed in either of the groups with respect to heart rate. The p
values at all the various time intervals was >0.05.
Conclusion: There is no difference which is statistically significant between the diastolic blood pressures
of the two groups.
Keywords: Hemodynamic changes, Caudal analgesia, Children.
Introduction tachycardia, hypertension, increased peripheral

vascular resistance and neurobehavioral changes
Single shot caudal epidural block is one of the associated with inadequately treated pain.2
most commonly performed neuraxial blockade It also reduces the intraoperative requirements of
in children. The developmental anatomy of the anesthetic agents such as opioids and volatile agents
caudal space in children enables easy and precise thereby allowing a more rapid and smooth recovery
placement of the needle for providing analgesia for following anesthesia. Providing postoperative
infra umbilical surgeries.1 pain relief with minimal sedation is important in
The caudal blockade provides extended hours pediatric patient, as overtly sedated children may
of analgesia postoperatively, improving patient be unable to protect the airway.3
comfort and reducing the risk of possible harmful Understanding the pharmacology and
effects of untreated severe pain. It decreases pharmacodynamic properties of local anesthetic
the undesirable cardiovascular effects such as agents and adjuvant drugs have enabled us to
modify post operative pain management improving in saline to make a total volume 1ml in the caudal
patient comfort. The use of local anesthetics such epidural space.
as lignocaine, bupivacaine, ropivacaine etc., Study Design: It is a prospective, randomized,
in isolation provide only a limited duration of controlled, double blinded study.
analgesia. Addition of adjuvants such as pethidine,
clonidine, dexmedetomidine, magnesium, Sample Size: To calculate the sample size to get a
neostigmine, glucocorticoids, and ketamine to the statistically significant difference in postoperative
local anesthetic have been studied extensively in analgesia a power analysis of α=0.05 and power
80%, the following formula was used N= 2[(α+β)
children to maximize analgesia.4
]2/(µ1−µ2)2=2[(1.96+0.84)2×202]/152=2×13.93=
The efficacy of dexamethasone in prolonging the 28 assuming a difference of means to be detected
effect of local anesthetic has not been extensively in time of first rescue analgesic requirement in
studied when compared to other adjuvants. So, in ropivacaine plain group and ropivacaine with
our study we evaluated the analgesic efficacy of dexamethasone of 15min with expected standard
caudally administered dexamethasone along with deviation 20 min.
dilute concentration of local anesthetics in children
Based on a previous study done by Santhi sree et al
undergoing infra umbilical surgeries.5
and using the above formula the minimum number
As with other local anaesthetics, Ropivacaine of patients in each group was 25 considering the
has the potential to induce CNS and cardiovascular number of dropouts a sample size of 30 patients in
toxicity at high plasma concentrations such as each group was selected 60 children aged between
those occurring after large doses or inadvertent 1 year to 5 years of age undergoing elective
intravascular administration. Ropivacaine is less infraumbilical surgeries under general anesthesia
lipophilic than Bupivacaine and that, together were enrolled for the study after institutional ethics
with its stereo selective properties, contributes committee clearance.
to Ropivacaine having a significantly higher Inclusion Criteria:
threshold for cardiovascular and CNS toxicity than
Bupivacaine in animals and healthy volunteers. 1. Age 1 year to 5 years
The lower lipophilicity of Ropivacaine versus 2. ASA PS I and II
Bupivacaine correlated with the lesser cardio 3. Children scheduled for elective infraumbilical
depressant effects of both Ropivacaine isomers surgeries
than of the Bupivacaine isomer in animal studies.
The CNS effects occurred earlier than cardiotoxic Exclusion Criteria:
symptoms during an intravenous infusion of local 1. All contraindications for caudal analgesia like:
anaesthetic (10 mg of Ropivacaine and Bupivacaine) a. Infection at the site of caudal injection
in human volunteers and the infusion was stopped
at this point. Significant changes in cardiac function b. Any sacral bone abnormalities
involving the contractility, conduction time and c. Bleeding diathesis
QRS width was found to be significantly smaller 2. Parental refusal to give consent
with Ropivacaine than with Bupivacaine.6
3. Allergy to local anaesthetics/dexamethasone
Methodology
Results
60 children between the age group 1–5 years of

Table 1: Heart Rates at different time intervals in the two groups.
ASA-PS I and II posted for elective infraumbilical
surgeries were randomly grouped into two equal Group
groups using shuffled sealed opaque envelope D R
technique. Pre anesthetic evaluation was done and Mean SD Mean SD
informed consent was obtained from the parents HRBI 124.0 11.7 125.7 14.8
after explaining about the procedure and the drugs HRAI 137.0 11.9 137.9 13.3
being used. The two groups were Group R (control HR1MIN 133.0 13.8 133.9 14.2
group) and Group D (study group).Group R HR5MIN 130.2 12.9 132.7 14.4
received 1 ml/kg of 0.15% ropivacaine with normal HR10MIN 129.2 12.0 129.7 14.1
saline (1ml) and Group D received 1 ml/kg of HR15MIN 127.7 12.8 129.5 13.3
0.15% ropivacaine with dexamethasone 0.1 mg/kg HR20MIN 127.4 12.1 128.2 13.7

Samarth S P, Darshan M S / A Study on Hemodynamic Changes in Dexamethasone 0.1 mg/kg 1321
When Combined with 0.15% Ropivacaine for Caudal Analgesia in Children
HR30MIN 126.2 12.3 126.7 13.8 pipecoloxylidide) which was first registered for use
HR40MIN 124.9 12.0 125.7 12.7 in 1996.Ropivacaine was introduced in India only
HR50MIN 124.2 11.7 125.3 11.4 in 2009.
HR60MIN 121.8 15.7 122.4 15.5 Ropivacaine is produced as a pure ‘S’ enantiomer
No significant variation was noticed in either of with lower lipid solubility. Apart from reduced
the groups with respect to heart rate. The p values cardiovascular system toxicity, ropivacaine also
at all the various time intervals was>0.05.(Table 1) showed easier reversibility after inadvertent
Table 2: Systolic blood pressure variation at different time intravascular injection, significant reduction
intervals. incentral nervous system toxicity, lesser motor
block and greater differentiation of sensory to
Group
motor block.7,8
D R
Mean SD Mean SD It is used widely for caudal epidural analgesia in
SBPBI 106.1 9.2 105.1 7.1 children because of its long duration of action and
SBPAI 115.9 11.8 113.3 8.8 beneficial ratio of sensory to motor block. Based on
SBP1MIN 105.8 12.5 105.9 9.8 a study done by Hong JY et al Ropivacaine 0.15%
SBP5MIN 104.0 10.0 104.4 7.9 is the optimum concentration for this purpose,
SBP10MIN 105.4 10.1 104.3 7.8 providing equivalent postoperative analgesia to
SBP15MIN 104.9 10.7 104.8 8.7 ropivacaine 0.20% (4–6 hrs).9 Hence in our study
SBP20MIN 104.8 11.1 102.4 8.0 0.15% ropivacaine was used.
SBP30MIN 104.0 9.8 102.8 7.7 Since even long acting local anesthetics like
SBP40MIN 104.8 9.4 102.5 7.3 ropivacaine have a limited duration of analgesia of
SBP50MIN 104.1 9.5 102.8 7.4 about 4–6 hours, several adjuvants have been used
SBP60MIN 101.3 10.5 102.6 8.4 to prolong the duration of analgesia of caudal block.
There is no significant statistical difference Extended duration of analgesia can be achieved by
between the systolic blood pressure between the using caudal additives, however an ideal agent is
two groups.(Table 2) still not available, alpha–2 agonists, ketamine and
midazolam are some of the commonly used drugs
Table 3: Diastolic Pressure Variation at different time intervals.
as additives.10
Group
Recently dexamethasone has been used as an
D R
adjuvant for caudal analgesia and has been found
Mean SD Mean SD
to be effective in prolonging the post operative
DBPBI 67.1 10.2 64.9 9.5
analgesia.8 The advantage of dexamethasone
DBPAI 78.4 13.7 72.8 9.2
over other adjuvants is it doesn’t produce any
DBP1MIN 71.7 15.4 63.3 8.7
respiratory depression, PONV, pruritus, urinary
DBP5MIN 70.2 10.4 65.0 9.6
retention and increased sedation. Hence in our
DBP10MIN 67.2 11.9 63.6 8.4
study we considered dexamethasone to be the
DBP15MIN 65.7 14.0 61.3 9.3
adjuvant along with 0.15% ropivacaine.
DBP20MIN 63.7 16.5 60.2 7.3
DBP30MIN 65.0 9.9 62.4 7.5
Dexamethasone as an adjuvant to local anaesthetic
DBP40MIN 65.4 10.7 62.6 7.6
for peripheral nerve/ neuraxial block has various
DBP50MIN 64.4 11.8 62.8 5.4
mechanisms of actions like direct membrane action
in unmyelinated fibres, vaso constriction, action
DBP60MIN 65.0 10.6 60.4 9.5
on potassium channels and suppression of other
There is no difference which is statistically inflammatory mediators.
significant between the diastolic blood pressures of
the two groups.(Table 3) Many of the authors who have used
dexamethasone as caudal adjuvant have used
0.1mg/kg of the drug.9 Hence in our study we
Discussion selected dexamethasone dose to be 0.1mg/kg.
In a previous study regarding the analgesic
The search for alternatives to bupivacaine effect of epidural dexamethasone in adults which
(1butyl-2’,6’ pipecoloxylidide) which is extensively showed that effective analgesia was provided by
used for providing caudal anaesthesia, has 5 mg of epidural dexamethasone but not 5 mg
led to development of relatively new amide of i.v. dexamethasone in patients undergoing
local anaesthetic, ropivacaine (N-n propyl2’,6’- laparoscopic cholesystectomy, which implied that
epidural dexamethasone has greater analgesic ropivacaine or bupivacaine. British Journalof

efficacy than i.v. dexamethasone at the same dose. Anaesthesia, vol. 107, no. 3, pp. 446–453,2011
FLACC scale was used in the study to evaluate 2. De Bosscher K, Vanden Berghe W, Haegeman G.
pain postoperatively. The FLACC scale can be The interplay between the glucocorticoid receptor
applied to a wide range of ages including children and nuclear factor-kappa B or activator protein-1:
in the neonatal intensive care unit, preverbal Molecular mechanisms for gene repression. Endocr
children and children with cognitive impairment, Rev2003;24:488–522.
as well as for pediatric postoperative pain. It has 3. Jamali S, Monin S, Begon C, Dubousset AM,
been validated and is easy to use. Ecoffey C Clonidine in pediatric caudal anesthesia
AnesthAnalg. 1994Apr;78(4):663–6.
Motor function was assessed using the following
scale: 0, no motor block; 1, able to move legs; 2, 4. Cook B, Grubb DJ, Aldridge LA, and Doyle E.
unable to move legs. Comparison of the effects of epinephrine, clonidine
and ketamine on the duration of caudal analgesia
Demographic criteria and surgical parametres produced by bupivacaine in children. Br J Anesth
were comparable between the two groups. 1995; 75:698–701.
There was no significant decrease in heart rate 5. Kundra P, Deepalakshmi K, Ravishanker M,
and blood pressure from the base line with the Preemptive caudal bupivacaine and morphine for
use of dexamethasone with ropivacaine in caudal post-operative analgesia in children. Anesth. Analg
epidural analgesia, and all patients maintained 1998; 87:52–6.
hemodynamic stability with no episodes of 6. Luz G, Innerhofer P, Oswald E, Salner E, Hager
hypotension or bradycardia being reported in our J, Sparr H Comparison of clonidine 1 microgram
study. kg-1 with morphine 30 micrograms kg-1 for
There was no incidence of PONV and no cases of postoperative caudal analgesia in childrenEur J
motor block after surgery in the two groups. Anaesthesiol. 1999Jan;16(1):42–6.
Unlike other adjuvants to caudal block 7. Ivani, Giorgio M D; DeNegri, Pasquale M D;

investigated in previous studies, no adverse Conio, Alessandra M D; Grossetti, Roberto M D;
events were observed with dexamethasone during Vitale, Pasquale M D; Vercellino, Claudia M D;
Gagliardi, Ferdinando M D; Eksborg, Staffan Ph
postoperative recovery.
D.; Lonnqvist, Per-Arne Ph.D. Comparison of
Like, use of caudal opioids (has been associated Racemic Bupivacaine, Ropivacaine, And Levo-
with adverse effects like respiratory depression, Bupivacaine for Pediatric Caudal Anesthesia:
pruritus, nausea, vomiting and urine retention Effects on Postoperative Analgesia and Motor
and use of Alpha agonists as adjuvants have been BlockRegAnesth Pain Med 2002; 27:157–161.
associated with sedation, hypotension, bradycardia. 8. Bock M, Kunz P, Schreckenberger R, Graf BM,
Martin E, Motsch J. Comparison of caudal and
Conclusion intravenous clonidine in the prevention of
agitation after sevoflurane in children. Br J Anesth
2002;88:790–6.
The haemodynamic parameters like pulse rate,
blood pressure, respiratory rate were comparable 9. Hansen T G, Henneberg S W, Walther-Larsen
and statistically non significant. No adverse effects S, Lund J, Hansen M. Caudal bupivacaine
were observed in any of the groups supplemented with caudal or intravenous clonidine
in children undergoing hypospadias repair; a
double-blind study. Br J Anesth 2004; 92: 223–27.
References
10. S J Martindale, P Dixand P A Stoddart.Double-
blindrandomizedcontrolled trial of caudal versus
1. K C Cummings III, D E Napierkowski, I. Parra– intravenous S(+)-ketamine for supplementation of
Sanchez et al. Effect of dexamethasone on the caudal analgesia in children. Br J Anaesth 2004 92
duration of interscalene nerve blocks with (3):344±7.

Comparitive Study of Epidural Fentanyl and Bupivacaine with Epidural

Clonidine and Bupivacaine for Postoperative Pain Relief in Lower
Abdominal and Lower Limb Surgeries: RCT
S Selvamani1, M Sathyasuba2, Dipro Dey3
Author’s Affiliation: 1Professor, 2Assistant Professor, 3Junior Resident, Department of Anesthesiology and Critical Care, Sree
Balaji Medical College and Hospital, Chromepet, Chennai, Tamil Nadu 600044, India.
Corresponding Author: M Sathyasuba, Department of Anesthesiology and Critical Care, Sree Balaji Medical College and
Hospital, Chromepet, Chennai, Tamil Nadu 600044, India.
E-mail: drsathyasuba@gmail.com

S Selvamani, M Sathyasuba, Dipro Dey, et al. Comparitive Study of Epidural Fentanyl and Bupivacaine with Epidural Clonidine
and Bupivacaine for Postoperative Pain Relief in Lower Abdominal and Lower Limb Surgeries: RCT. Indian J Anesth Analg.
2020;7(6):1323–1330.
Abstract
Postoperative pain and discomfort are the major concerns in all patients undergoing any surgery. Delay
of discharge is mainly due postoperative pain. So, postoperative pain relief becomes very important.
Epidural anal gesiaisone of many recent evidence-base dregimens for postoperative pain relief after
surgeries particularly surgeries of abdomen. The objective of this study is to compare the efficacy, onset
and duration of epidural analgesia of Bupivacaine - Clonidinecombination Vs. Bupivacaine-Fentanyl
combination for post-operative analgesia in lower abdominal and lower limb surgeries.
Materials and Methods: 50 patients belonging to ASA 1 and 2 were assigned into two groups (25 each).
Group F received epidural Fentanyl with 0. 25% Bupivacaine and Group C received epidural Clonidine
with 0.25% Bupivacaine.
Results: With regard to anxiolysis, increased sedative property with easy arousal, longer and better
quality analgesia and patient comfort, epidural clonidine and Bupivacaine combination was found to be
superior to epidural Fentanyl and Bupivacaine. Various parameters like HR, Blood pressure (both systolic
and diastolic), SPo2, Visual Analogue Scale (VAS) and Ram say Sedation Score (RSS) were observed for
24 hours post operatively. It was follow edup at 15 minutes, 30 min, 120 min, 240 min, 360 min, 480 min,
600 min, 720 min, 840 min, 960 min, 1080 min, 1200 min, 1320 min and 1440 min. Incidencesof side effects
were also noted.
Conclusion: Clonidine has proved to be very efficient compared to Fentanyl in postoperative analgesia.
Keywords: Epidural; Postoperative; Pain; Clonidine; Fentanyl; Analgesia.
Introduction
patient outcome.1–4 Pain elevates the degree of
Proper pain management is crucial for ideal indisposition after surgeries due to a decrease in
care of surgical patients. Adequate postop pain the breathing effort and cough reflex suppression,
relief facilitates early ambulation, reduces postop there by interrupting bowel function 5 and mobility.
morbidity in terms of infection, neurological, Epidural analgesia is one of many recent evidence
cardiovascular and thrombo embolic sequelae based regimens for postop pain relief after surgeries
caused by immobility. Also it leads to shorter particularly abdominal surgeries . Advantages with
hospital stay, decreased hospital costs, better epidural analgesia in high risk patients were6

1. Significant decrease in surgical stress response. 5. Patients with local or systemic infection

2. Hemodynamic stability and reduction in 6. Coagulation disorders.
cardiac and pulmonary morbidity.
Study groups: The patients were randomized and
3. Early recovery of gastro intestinal function.7 allocated into two groups.

4. Early ambulation thereby reducing thrombo Group F 25 patients who received 0.25%
embolic events. Bupivacaine and Fentanyl (2 micrograms fentanyl/
Local anaesthetics are useful and effective in ml bupivacaine).
treatment of acute and chronic post-perative pain, Group C 25 patients who received 0.25%
but the limitations like short duration of action, Bupivacaine and Clonidine (2 micograms
adverse effects on Cardiovascular System (CVS) clonidine/ml bupivacaine).
and Central Nervous System (CNS) curb its use in
recent times.8
Pre anesthetic evaluation
Local anesthetics and adjuvants are the frequently
used combination for their synergistic and additive
analgesic effects. Also, the increased dose of local All patients were subjected to a thorough pre
anesthetics is being avoided whenever an adjuvant anesthetic evaluation, in which procedure was
is used.9 explained to the patients and all patients were
educated about the visual analogue scale (VAS)
The commonly used additives range from
pain score of 0–10. The patients were fasted for 8
opiods like Morphine, Fentanyl and Sufentanil
hrs before surgery. In all patients, age, body weight
to Hydromorphone, Buprenorphine, Tramadol,
and baseline vital parameters were recorded. A
Alpha 2 adrenergic agonists like Clonidine and
common conduct of anesthesia was followed in all
Dexmeditomidine. Steroids, anti inflammatory
patients which included alprazolam 0.25 mg orally
agents, Midazolam, Ketamine, Magnesium
sulphate and Neostigmine have also been used. at night before surgery and ranitidine 150 mg orally
at night and on the morning of surgery.
This study was undertaken with an aim to find out
whether Clonidine and Bupivacaine combination
has a better efficacy in epidural analgesia compared Procedure Details
to Fentanyl –Bupivacaine combination.
Standard monitoring included pulse oximetry, non
Materials and Methods invasive blood pressure, end tidal CO2 and three
lead electrocardiogram.
After obtaining instituitional ethical committee The i.v access was secured with 18G cannula in a
approval and informed written consent, 50 suitable vein on the dorsum of non dominant hand.
adult patients belonging to ASA 1 and 2 class, Ringers lactate was started. Baseline parameters i.e
scheduled for elective lower abdominal and lower heart rate, NIBP, Spo2, end tidal CO2 and ECG were
limb surgeries under combined spinal epidural monitored.
technique were enrolled for this study. Epidural block was performed in sitting position
Inclusion criteria: in T11-T12/T12-L1 interspace with 18G Tuohy needle.
1. ASA 1 and 2 patients. After ensuring epidural space by LOR technique,
catheter is placed at around 9 to 10 cm at skin and
2. Age 20 –70 years. epidural test dose was given .Spinal sub arachnoid
3. Patients undergoing elective lower abdominal block given with 0.5% Bupi vacaine heavy (volume
and lower limb surgeries. calculated according to patient characteristics
Exclusion criteria and type of surgery) without any adjuvant. After
injection, patient was put back in supine position
1. Patient refusal and 3L per min of O2 given by facemask .After
2. ASA 3 and 4 attainment of adequate level of sensory block , the
3. Morbidly obese surgery was proceeded.
4. Patients with spinal deformities, neurological After 90min of spinal anesthesia, study drug was
disease given via epidural catheter after negative aspiration
for CSF and blood.
S Selvamani, M Sathyasuba, Dipro Dey, et al. / Comparitive Study of Epidural Fentanyl and Bupivacaine 1325
with Epidural Clonidine and Bupivacaine for Postoperative Pain Relief in Lower Abdominal and
Lower Limb Surgeries: RCT
Volume was calculated according to the required 2. Comparison of time for First Rescue Analgesia
level analgesia. between two groups.
Group F–received Bupivacaine (0.25%) with 3. Comparison of Visual Analogue Scale
Fentanyl 2mcg/ml. between two groups.
Group C-received Bupivacaine (0.25%) with 4. Comparison of Ramsay Sedation Score
Clonidine 2mcg/ml. between two groups.
5. Comparison of Hemodynamic variables like
Parameters observed and analysed SBP, DBP, Heart rate and Pulse oximetry
between two groups.
Patients were observed in the OR for 15 minutes 6. Comparison of side effects between two
and then shifted to PACU (Post anesthesia care groups.
unit) for monitoring. 7. Comparison of patient acceptance between
Various parameters like HR, Blood pressure two groups.
(both systolic and diastolic), SpO2, VAS (visual There was no statistically significant difference
analogue scale) and RSS (Ramsay sedation score found between the two groups with respect to age,
were observed for 24 hours postoperatively. ASA PS and gender distribution.
It was followed up at 15 minutes, 30 min., 120 Table 1: Age, Sex and ASA PS distribution.
min., then every 2 hrs upto 1440 min. Incidences Age (in yrs) Grp C % Grp F % P value
of side effects were also noted. Injection Tramadol <50 yrs 5 20 3 12
50 mg i.v was used as rescue analgesia when pain 51–60 yrs 11 44 13 52 0.480
score was more than 4 (i.e VAS≥4). 61–70 yrs 9 36 9 36
Total 25 100 25 100
Statistical tools Male 14 56 13 52
Female 11 44 12 48 1.00
Total 25 100 25 100
The information collected regarding all the selected
ASA PS 1 12 48 14 56
cases were recorded in Master charts 1 and 2. Data
analysis was done with the help of computer using ASA PS 2 13 52 11 44 0.575
Epidemiological Information Package (EPI 2008). Total 25 100 25 100
Using this software, range, frequencies, *p value calculated by independent sample t test, p value<0.05
is significant
percentages, means, standard deviations, chi square
and ‘p’ values were calculated. Kruskal Wallis This study found that mean age of participants in
chi square test was used to test the significance Clonidine group (57.56±6.634 years) was comparable
of difference between quantitative variables and to that of Fentanyl group (58.84±8.067yrs) t
Yate’s test for qualitative variables. A ‘p’ value value=.712, p value: 0.48. No significant difference
less than 0.05 was taken to denote significant between two groups with respect to age.
relationship. Among 50 subjects, 8 belonged to <50 years of
age group, 24 belonged to 51–60 years of age group,
Observation and Results 18 belonged to 61–70 years of age group. 5(20%) of
<50 years were in clonidine group and 3(12,%,)
were in fentanyl group. 11(44%) were in clonidine
Results of this study are described under the
group in 51–60 yrs and 13(52%) in fentanyl group.
following headings:
Clonidine and Fentanyl group had equal number of
A. Comparison of baseline characteristics persons 9(36%) in 61–70 years of age group. (Table 1)
1. Age, Sex and ASA - PS distribution For gender,*p value was calculated by Chi square
2. Weight distribution test. p value<0.05 is significant.
3. Distribution of surgery done among study Among 50 subjects, 27(54%) of subjects were
subjects. males and 23(46%) were females.
B. Inferential statistics: Out of 27 males 14 were in Clonidine group and
13 in Fentanyl group. Among 23 females, 11 were
1. Comparison of duration of analgesia between in Clonidine group and 12 in Fentanyl group. Both
two groups. groups were comparable according to gender.
Table 2: Weight distribution between the groups. 240.4 ± 32.143 minutes in Group Fentanyl. There
No. of cases Mean ±S. D t value p value* was significant difference among two groups in
Group C 25 65.36± 6.975 the duration of time for rescue analgesia (p<0.05).
1.51 0.13
Group F 25 61.68 ± 9.949 (Table 5)
Table 6: Visual Analogue Score (VAS) Between Clonidine and
*p value calculated by independent sample t test, p value<0.05
Fentanyl Group at Different Times in Minutes.
is significant This study found that mean weight of participants
in Clonidine group (65.36± 6.975 Kg) was comparable to that of Time in Clonidine Fentanyl
Fentanyl group (61.68 ± 9.949 Kg) t value= 1.51, p value: 0.13. t value p value
Minutes Mean ± SD Mean ± SD
No significant difference between two groups with respect to
weight.(Table 2) 15 0 0 0 0
Table 3: Distribution of Surgery Done Among Study Subjects. 30 0 0 0 0
120 0.16±.55 0 1.4 .15
Surgeries done Frequency Percentage
240 2.44±1.19 4±0 6.53 0.001
B/B Leg fractures 7 14.0
360 2±0 2.08±0 1.45 .16
Bilateral inguinal hernia 5 10.0
480 2.04±.2 2.2±.41 1.76 .08
Femur shaft fracture 1 2.0
600 2.16±.45 2.28±.374 1.014 .316
Incisional hernia 8 16.0
720 2.64±.49 2.68±.47 .294 .771
Pelvis fracture 1 2.0
840 3±0 3±0 0 0
TAH BSO 9 18.0
960 3±0 3.04±.2 1 .327
THR 7 14.0
1080 3±0 3.36±.49 3.67 .001
TKR 4 8.0
1200 3±0 4±0 4.6 .001
Umbilical hernia 8 16.0
1320 3±0 4±0 3.8 .001
Total 50 100.0
1440 3.26±0.3 4±0 4.6 .001
About 9(18%) of 50 subjects had undergone Total At 240 minutes, the mean VAS score in Group C
Abdominal Hysterectomy and Bilateral Salphingo was 2.44±1.19 and in Group F was 4 ± 0; there was
Oophorectomy (TAH BSO), 8(16%) undergone statistically significant difference in both groups
surgery for Umbilical Herniation, 8(16%) for (p<0.05).
incisional hernias. 7(14%) for surgeries of B/B leg
fractures, 7(14%) undergone Total Hip Replacement At 1080, 1200, 1320 minutes the mean VAS score
(THR) Surgeries.(Table 3) between Clonidine group and Fentanyl group were
Table 4: Duration of Analgesia among Subjects.
statistically significant.(Table 6)
Table 7: Ramsay Sedation Score between Clonidine and Fentanyl
No. of Cases Mean±S.D t value p value Group at Different Times in Minutes.
Group C 25 415 ± 63.7
7.63 0.0001 Time in Clonidine Fentanyl
Group F 25 231 ± 30.754 t value p value
0 3±0 3±0 0 0
is significant.
60 2.88±.332 3±0 1.8 .08
The mean duration of analgesia was 415 ± 63.7 120 2.72±.458 3±0 3.05 .005
minutes in Group Clonidine and 231.00 ± 30.754 180 2.64±.490 3±0 3.67 .001
minutes in Group Fentanyl. There was statistically 240 2.52±.51 2.88±.34 2.88 .006
significant difference among two groups in the
300 2.04±.2 2.75±.44 7.19 <0.001
mean duration of analgesia (P<0.05). Higher
360 2±0 2.5±.51 4.79 <0.001
duration of analgesia for the group who received
Clonidine.(Table 4) There was no statistical significance in Ramsay
Table 5: Time For First Rescue Analgesia. Sedation score at 0 minutes and 60 minutes. The
No. of t p
mean Ramsay sedation scores of Clonidine group
Mean±S.D is gradually decreasing starting from 60 minutes.
Cases value value*
Grou P Clonidine 25 427.6 ± 62.168 The mean score of Clonidine group at 120 minutes
13.374 <0.001
Grou P Fentanyl 25 240.4 ± 32.143 was 2.72±.458 and that of Fentanyl group 3±0 which
was statistically significant. (Table 7)
is significant. The mean scores of Clonidine group at 180,
240, 300 and 360 minutes were 2.64±.490, 2.52±.51,
The mean time for 1st rescue analgesia (defined 2.04±.2, 2±0 respectively compared to Fentanyl
as the time at which patient demands some mode group where the scores were 3±0, 2.88±.34, 2.75±.44,
of pain relief i.e. when VAS score more than 4) was 2.5±.51 respectively and this was statistically
427.6 ± 62.168 minutes in Group Clonidine and significant.

Table 8: Systolic Blood Pressure (Sbp) between Clonidine and Fentanyl group and is statistically significant with
Fentanyl Group at Different Times in Minutes. p value 0.004.
Time in Clonidine Fentanyl At 1320 minutes, the mean SBP was 105.2
t value p value
±6.53in Clonidine group compared to 114.4±8.21 in
15 120±9.09 115.6±9.61 1.9 0.05
Fentanyl group and is statistically significant with
30 119.6±8.88 106.8±7.483 5.5 <0.001
p value <0.001.
120 114±11.55 120.8±8.62 2.36 .02
240 122±7.64 121.6±6.88 .195 .847 At 1440 minutes, the mean SBP was 103.6±6.37
360 122±8.165 124.8±6.532 1.33 .187 in Clonidine group compared to 108.8±7.26 in
480 101.6±3.47 105.2±5.09 2.85 .007 Fentanyl group and is statistically significant with
600 102.8±4.58 108.8±7.25 3.49 .001
p value.010.
720 104.4±7.12 112.8±7.37 4.09 <0.001 Table 9: Diastolic Blood Pressure (Dbp) Between Clonidine and
Fentanyl Group at Different Times in Minutes.
840 105.2±6.53 110.8±7.024 2.91 .005
960 106±7.07 112.4±7.789 3.04 .004 Time in Clonidine Fentanyl
t value p value
1080 104.4±6.51 111.2±8.327 3.22 .002
15 68±15.34 62.05±10.652 1.56 0.126
1200 104.78±6.53 111.2±8.327 3.024 0.004
30 62.80±14.89 63.23±8.04 .124 .902
1320 105.2 ±6.53 114.4±8.21 4.386 <0.001
120 54.60±4.77 55.23±3.93 .49 .62
1440 103.6±6.37 108.8±7.26 2.69 .010
240 57±5.59 56.14±4.86 .56 .57
is significant. 360 53.6±3.68 52.5±2.56 1.2 .24
480 53±2.5 53.41±2.38 .57 .57
Table 8 There was statistically significant
600 53.8±3.32 53.41±2.384 .47 .642
reduction in SBP in Clonidine group compared to
720 55.4±3.79 53.18±2.46 2.40 .02
Fentanyl group. The mean Systolic Blood Pressure
840 54.4±3.63 53.41±2.38 1.12 .27
reduction in Clonidine group wasmore compared
to Fentanyl group and the relation was significant 960 55.6±3.33 52.73±2.548 3.34 .002
from 480 minutes after surgery. 1080 55.2±4.44 52.95±2.52 2.16 .03
1200 55.6±4.64 53.41±2.84 1.97 .051
At 480 minutes, the mean SBP was 101.6±3.47 1320 55.4±4.77 53.64±3.513 1.45 .15
in Clonidine group compared to 105.2±5.09 in
1440 55.6±4.16 55.45±5.09 .11 .91
p value. 007. is significant.
At 600 minutes, the mean SBP was 102.8±4.58 Table 9 There was reduction in DBP in Clonidine
in Clonidine group compared to 108.8±7.25 in group and Fentanyl group., but nostatistical
Fentanyl group and is statistically significant with significant difference between two groups.
p value. 001.
At 720 minutes, the mean DBP was 55.4±3.79
At 720 minutes, the mean SBP was 104.4±7.12 in Clonidine group compared to 53.18±2.46 in
in Clonidine group compared to 112.8±7.37 in Fentanyl group and is statistically significant with
Fentanyl group and is statistically significant with p value .02.
p value <0.001.
At 840 minutes, the mean SBP was 105.2±6.53 in Clonidine group compared to 52.73±2.548 in
Fentanyl group and is statistically significant with p value 0.002.
p value 0.005.
At 960 minutes, the mean SBP was 106±7.07 in Clonidine group compared to52.95±2.52 in
Fentanyl group and is statistically significant with p value 0.03.
p value 0.004. Table 10: SPO2 between Clonidine and Fentanyl Group at
Different Times in Minutes.
At 1080 minutes, the mean SBP was 104.4±6.51
in Clonidine group compared to 111.2±8.327 in Time in Clonidine Fentanyl
t value p value
Fentanyl group and is statistically significant with Minutes Mean ± SD Mean ± SD
p value 0.002. 15 99.68±.476 99.52±.510 1.14 .257
30 95.88±17.901 98.72±.792 .792 .436
At 1200 minutes, the mean SBP was 104.78±6.53
120 99.28±.614 98.28±.542 6.108 <0.001
in Clonidine group compared 111.2±8.327 in
240 99.20±.764 98.76±.879 1.89 .065

360 99±.957 99±.71 .00 1.00 840 55.28±3.70 57.04±3.87 1.64 .107
480 99±.71 99±.866 .00 1.00 960 56.12±4.26 56.64±4.36 .426 .672
600 99±.71 98.84±1.18 .582 .564 1080 57.68±4.72 57.08±5.42 .417 .678
720 98.84±.943 98.76±.926 .303 .763 1200 55.92±4.06 56.28±5.32 .269 .789
840 98.64±.810 98.64±.995 .00 1.00 1320 55.64±4.42 56.28±4.198 .525 .602
960 98.76±.926 98.68±.945 .302 .764 1440 55.4±5.18 55.96±4.32 .415 .680
1080 99±.764 98.88±.726 .569 .572 *p value calculated by independent sample t test, p value<0.05
1200 99.12±.726 99.16±.800 .185 .854 is significant. There was no statistical significance in mean Heart
1320 98.76±.663 99.36±.569 3.434 .001 Rate in Clonidine group compared to Fentanyl group.
1440 98.76±.663 99.36±.569 3.434 .001 Table 12: Comparison of Side Effects and Drugs used.
*p value calculated by independent sample t test, p value<0.05 Side effects
is significant
Hypotension
Chi square
There was no statistical significance in mean SPO2
vomiting
p value*
nausea
Nil
in Clonidine group comparedto Fentanyl group.
At 120 minutes, the mean SPO2 was 99.28±.614
in Clonidine group compared to 98.28±.542 in Group C 20(80%) 4(16%) 1(4%) 0
Fentanyl group and is statistically significant with 4.31 0.456
Group F 22(88%) 1(4%) 0 2(8%)
p value .001. p value calculated by Chi-square test. P value<0.05 is significant.
At 1320 minutes, the mean SPO2 was 98.76±.663 Among 25 patients who received Clonidine, Side
in Clonidine group compared to 99.36±.569 in effects was not in 20(80%) of subjects, 4(16%) had
Fentanyl group and is statistically significant with hypotension. (Table 12)
p value .001.
In Fentanyl group, side effects were not found in
At 1440 minutes, the mean SPO2 was 98.76±.663 22(88%), 2(8%) had vomiting.
in Clonidine group compared to99.36±.569 in
This was not statistically significant with p
value=.456
p value .001. (Table 10)
Table 11: Comparison of Patient Acceptance and Drugs used.
Discussion
Patient acceptance
Excellent
Satisfied
Satisfied
p value*
square
In our study, the mean duration of analgesia was

Good
Not
Chi
415±63.7 minutes in group C (Clonidine) and

231.00±30.754 minutes in Group F (Fentanyl).There
Group C 4(16%) 9(36%) 9(36%) 3 (12%)
7.79 0.005 was statistically significant difference among two
Group F 0 4(16%) 16(64%) 5(20%)
groups in mean duration of analgesia (p<0.05).
*p value calculated by Chi-square test. P value<0.05 is significant.
Higher duration of analgesia was observed
Among 25 patients who received Clonidine, in Clonidine group. Clonidine as an adjuvant
patient acceptance was found to be 4(16%) were not promotes faster onset and longer duration of action
satisfied, 9(36%) were satisfied, 9(36%) were good, similar to the other studies done by El-Hennaway
3(12%) were excellent. (Table 11) AM et al10, Kambiyasashi et al.11 This might be due
In Fentanyl group, for patient acceptance, 4(16%) to the dermatomal effect of clonidine. Another
satisfied, 16(64%) were good, 5(20%) were excellent. study done by Dobrydnjov et al12 also had similar
This was statistically significant with p value=0.005. findings. Another study by Pooja Chopra et al13,
Table : Mean Heart Rate between Clonidine and Fentanyl Group
whereby adding 30 mcg of Clonidine to the mixture
at Different Times in Minutes. of 0.5% hyperbaric Bupivacaine and 15 µg Fentanyl
significantly enhances the duration of adequate
Time in Clonidine Fentanyl
t value p value analgesia. They also showed that intra operative
30 55.12±3.66 54.36±3.87 .713 .48
pain and requirement of postoperative analgesics
120 54.84±4.42 55.4±3.862 .477 .636
and duration of analgesia are significantly lesser
240 54.72±4.512 55.92±4.481 .943 .350
when Clonidine was added to Bupivacaine 0.5%
or in mixture of Bupivacaine and Fentanyl,in
360 55.16±4.298 56.96±4.605 1.43 .16
comparison with the group which did not receive
480 55.04±4.42 56.8±4.89 1.34 .188
Clonidine.
600 54.76±3.6 57.12±4.65 1.99 .052
720 55.28±3.95 57.8±7.42 1.49 .143 The faster action may be due to the spinal
cholinergic activation of Clonidine. Cholinergic the period of study which confirms the established
interaction in spinal α-2 adrenergic receptors which effects of α2 agonists in accomplishing a
are situated on downward route of nor adrenergic hemodynamically stable postoperative period.
pathways produces nor adrenaline release that Although a slight decrease in heart rate and blood
causes analgesia directly and also it releases Ach pressure (both systolic and diastolic) was observed
(acetyl choline) to produce analgesia. Clonidine in both the groups, in both the groups, It never fell
also blocks A delta and C fibres at lamina V, thereby down to more than 20% baseline values.
producing analgesia. This was similar to studies by SBP was significantly lower in Clondine group
Van Sujil et al14 and Strebel et al.15 during multiple follow up times (720, 960, 1080
The mean time for first rescue analgesia (time at minutes). Mean SpO2 was higher in Fentanyl
which patient demands some mode of pain relief group at 1320 minutes and 1440 minutes. All these
i.e when VAS score more than 4) was 427.6 ±62.168 findings were similar to Yoganarasimha et al and
minutes in Clonidine group and 240.4 ± 32.143 Bajwa et al.18,19
minutes in Fentanyl group and this difference Hypotension were observed more in 16% of
was significant. Other studies also showed similar Clonidine group patients corrected with bolus of
studies declaring the longer duration of action of IV fluids and ephedrine. None of patients in either
Clonidine. groups had excessive sedation, vomiting, pruritus,
There was no statistical significance in Ramsay post dural headache or transient neurological
sedation score at 0 minutes and 60 minutes. The symptoms at intra operative period or during
mean Ramsay sedation score of Clonidine group postoperative follow up.
is gradually decreasing starting from 60 minutes. The postop hemodynamic variables between
The mean score of Clonidine group at 120 minutes the groups were comparable and statistically
was 2.72±.458 and that of Fentanyl group 3±0 significant. The results of our observations show
which was statistically significant. The mean that in addition to prolonged analgesia and less
scores of Clonidine group at 180, 240, 300 and pain scores, Clonidine has a favourable safety
360 minutes were lower compared to Fentanyl profile and stable hemodynamics over Fentanyl,
group and this was statistically significant. The which correlates with the reports published by
results of our study clearly indicates the sedation other authors.
score between the two groups was similar in the
first two hours after study drug administration All the above results conclude that that the
and they had profound sedation but arousable by addition of Clonidine to Bupivacaine epidurally
gentle tactile stimulation-Ramsay sedation score-3. lengthens motor and sensory block and analgesia,
After 2 hours the mean Ramsay score in Clonidine without an amplified frequency of side effects
group decreased compared to Fentanyl group at which was estimated by study done by Gupta et
a faster rate. Overall decrease in Clonidine group al.20
is statistically significant showing a faster onset of
anesthesia in Clonidine group, which was similar Conclusion
to another study done by Yoga narasimha et al and
Celleno et al respectively.16,17
From this study, it is concluded that 2µg/ml of
There was no difference in pain score at 15 and Clonidine was found to be a better adjuvant to
30 minutes and was found to be statistically not epidural Bupivacaine (0, 25%) in postoperative
significant (p>0.05). At 240 minutes, the mean VAS analgesia. The postoperative analgesic effect as
core in Group C was 2.44 ± 1.19 and in Group F was well as the arousal sedation was excellent with
4±0; there was statistically significant difference in lowest side effects .The hemodynamic stability well
both groups (p<0.05). At 1080, 1200, 1320 minutes maintained with Fentanyl.
the mean VAS score between Clonidine and
Conflict of interest: None
Fentanyl groups were statistically significant. Pain
scores in Clonidine group is significantly lower
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8. Bagshaw KR, Hanenbaum CL, Carbone EJ, Lo KW, for epidural analgesia with 0.125% bupivacaine in
Laurencin CT, Walker J, et al. Pain management via the first stage of labor: A preliminary report. Int J
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to local anesthetics: Current understanding and Ropivacaine In Lower Abdominal and Lower Limb
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A Randomized Double Blinded Comparative Study on Efficacy of

Intraoperative Dexmedetomedine versus Tramadol Intravenous Infusion
in Prevention of Postoperative Shivering Following Spinal Anaesthesia
Shweta Kalkutiginahal1, Preethi Goutham C2
Author’s Affiliation: 1Resident, Department of Anaesthesia and Critical Care, G Kuppuswamy Naidu Memorial Hospital,
Coimbatore, Tamil Nadu 641037, India 2Senior Resident, Department of Anaesthesia and Critical Care, Bangalore Medical college,
Bengaluru, Karnataka 560002, India.
Corresponding Author: Shweta Kalkutiginahal, Resident, Department of Anaesthesia and Critical Care, G Kuppuswamy
Naidu Memorial Hospital, Coimbatore, Tamil Nadu 641037, India.
E-mail: Shwethareddy17@gmail.com

Shweta Kalkutiginahal, Preethi Goutham C.A Randomized Double Blinded Comparative Study on Efficacy of Intraoperative
Dexmedetomedine versus Tramadol Intravenous Infusion in Prevention of Postoperative Shivering Following Spinal Anaesthesia.
Indian J Anesth Analg. 2020;7(6):1331–1341.
Abstract
Introduction: Shivering is a frequent complication reported in 30 to 40% of patients undergoing surgery

under regional anaesthesia. It increases oxygen consumption, hypercarbia and minute ventilation. It
induces arterial hypoxemia, lactic acidosis, increased intra-ocular pressure, and interferes with patient
monitoring and comfort. Most of the studies done in the past have been in the treatment of shivering
rather than prevention. This study compared intravenous dexmedetomidine versus intravenous tramadol
for prevention of shivering in patients who received spinal anaesthesia for various surgical procedures.
Aims and objectives: The aim of this study was to study and compare the efficacy of intravenous infusion
of low dose dexmedetomidine (0.25mcg/kg) vs Tramadol (0.5mg/kg) in the prevention of postoperative
shivering. Primary objective was prevention of shivering and Secondary objectives were sedation,
hemodynamic changes and nausea and vomiting.
Materials and Methods: Prospective randomised double blinded comparative study was done on patients
scheduled for elective surgery during June 2018-March 2019 in GKNM Hospital, Coimbatore. Patients
were included as per criteria. Informed and written consent was obtained and randomized by computer.
Group D received IV Dexmedetomidine of 0.25mcg/Kg dose and Group T received IV Tramadol of
0.5mg/kg. Data was collected and analyzed. Patients were evaluated post operatively by the investigator
who was blinded to the group assigned.
Results: The mean age of the total population was 39.55 ± 11.73 years with male predominance in
tramadol group. Dexmedetomedine was more effective in preventing shivering, 16 patients (40%) of
group D had shivering compared to 24 patients (60%) of tramadol group. This difference though was not
statistically significant, numerically showed that dexmedetomedine was better in prevention of shivering.
The tramadol group had early onset of shivering in comparison to Dexmedetomedine group (p<0.05).
Dexmedetomedine group had higher grades of sedation and incidence of nausea and vomiting was higher
in tramadol group.
Conclusion: Dexmedetomedine even at a lower dose is comparatively a more effective drug for
prevention of shivering with fewer side effects than tramadol in patients undergoing surgery under spinal
anaesthesia.
Keywords: Dexmedetomedine; Tramadol; Prevention of postoperative shivering; Spinal anaesthesia.

Introduction and sweating in response to heat, shivering and

increase in metabolic rate.2,4,5,10
Spinal anaesthesia is widely used as a safe anaesthetic Several hypotheses explain the occurrence of post
technique for both elective and emergency lower anaesthetic shivering. These include perioperative
abdominal and lower limb surgeries. Shivering hypothermia, postoperative pain, perioperative
is a frequent complication reported in 30 to 40% heat loss, the direct effect of certain anaesthetics,
of patients undergoing surgery under regional hypercapnia or respiratory alkalosis, the existence
anaesthesia.1 of pyrogens, hypoxia, early recovery of spinal reflex
activity and sympathetic over activity.11 The first
Shivering can occur in patients receiving
clinical consequence of post anaesthetic shivering
regional anaesthesia as well as those patients
is discomfort and stressful sensation to the patient.
recovering from general anaesthesia. It causes
Other consequences of post anaesthetic shivering
patient discomfort and several undesirable
increased pain caused by muscular contractions on
physiologic consequences including increase in
the operated site and associated tension on suture
oxygen consumption, hypercarbia and increase in
lines. The main effect of post anaesthetic shivering
minute ventilation. It induces arterial hypoxemia,
is the increase in oxygen consumption (VO2) by
lactic acidosis, increased intra-ocular pressure, and
increase in metabolic demand. Rarely metabolic
interferes with patient monitoring.1
demand can exceed the capacity to deliver oxygen
Shivering can be very unpleasant and peripherally and result in anaerobic metabolism.2,9,11
physiologically stressful for the patients. Various
methods are available for the control of shivering Measures to combat shivering
under anaesthesia. Non-pharmocological methods
using equipments to maintain normothermia are
effective but may be expensive and are not practical Measures which reduce core hypothermia in
in all the settings. Pharmacological methods turn reduce anaesthesia induced shivering. They
include administering various drugs like pethidine, include: Passive insulators like Cotton blankets,
clonidine, doxapram, tramadol, nefopam, etc.2 cloth or paper surgical drapes, disposable plastic
drapes, and plastic bags. A single layer of an
In homeothermic species, a thermoregulatory insulator reduces the heat loss by approximately
system coordinates defences against environmental 30%; unfortunately adding additional layers does
temperature to maintain internal body temperature not proportionately increase the benefit. Active
within a narrow range, thus optimizing normal warming systems: Convection warming system
body function.2 (Bair Hugger Unit), radiant heat system infra-
red light, thermal ceiling lights can be used for
Thermoregulation warming body. Other measures like warming
inspired air, warming intravenous fluids, blood and
blood components before infusion can also be used.
The processing of thermoregulatory response has
Maintaining warm post-operative environment
three components: afferent thermal sensing, central
(24ºC), are useful in preserving body temperature
regulation, efferent pathway. Afferent thermal
and reducing shivering.2 Pharmacotherapy-
sensing which includes receptors, C nerve fibres,
biogenic monoamines, cholinomimetics, cations,
Anterior Spinothalamic tract.6,7 The nucleus raphe
endogenous peptides and possibly N-methyl-D-
magnus and the subcoeruleus are responsible for
aspartate (NMDA) receptor antagonists. All these
the modulation of thermal afferent information.9 appear to modulate central thermoregulatory
Central regulation is by anterior hypothalamus and control mechanisms. The normal functions of these
posterior hypothalamus. The anterior hypothalamus drugs are diverse and the predominant site of action
conducts the integration of afferent thermal of most of these drugs is difficult to establish.2
information, whereas the posterior hypothalamus
controls the descending pathways to the effectors.
The pre-optic area of hypothalamus contains heat Pharmacology of Dexmedetomidine
sensitive and cold sensitive neurons.2,9 The efferent
responses are characterized by- Altered behaviour, Dexmedetomidine is a new alpha 2-agonist that
quantitatively the most effective mechanism, received FDA approval in 1999 for use as a short-
vasomotor response, consisting of vasoconstriction term (less than 24 h) sedative-analgesic in the
and pilo-erection in response to cold, vasodilatation intensive care unit.6 Dexmedetomidine compared

Shweta Kalkutiginahal, Preethi Goutham C / A Randomized Double Blinded Comparative Study on 1333
Efficacy of Intraoperative Dexmedetomedine versus Tramadol Intravenous Infusion in Prevention of
Postoperative Shivering Following Spinal Anaesthesia
to Clonidine is a much more selective alpha III Use of Dexmedetomidine in the postoperative period:
2-adrenoceptor agonist, which might permit its Dexmedetomidine special properties favour its use
application in relatively high doses for sedation and in recovery room. In addition to its sympatholytic
analgesia without the unwanted vascular effects effects, analgesic effects and decreased rate of
from activation of alpha1-receptors. In addition, shivering, the preservation of respiratory function
Dexmedetomidine is shorter-acting drug than allows the continuation of the dexmedetomidine
clonidine and has a reversal drug for its sedative infusion in the extubated, spontaneously breathing
effect, Atipamezole.12 patient. The possibility of ongoing sedation and
Presynaptic activation of the alpha2-A sympathetic block could be beneficial in reducing
adrenoceptor in the Locus Ceruleus inhibits the high rates of early postoperative ischemic events in
release of norepinephrine (NE) and results in high-risk patients undergoing non-cardiac surgery.8
the sedative and hypnotic effects.14 In addition,
the Locus Ceruleus is the site of origin for Pharmacology of Tramadol
the descending medullospinal noradrenergic
pathway, known to be an important modulator of Tramodol is a centrally acting analgesic with a
nociceptive neurotransmission. Stimulation of the low affinity for opioid receptors. It is a synthetic
alpha 2-adrenoceptors in this area terminates the analogue of codeine. It has a unique dual mechanism
propagation of pain signals leading to analgesia. At tramadol is a recemic mixture of 2 enantiomers. It
the spinal cord, stimulation of alpha 2-receptors at has both opioid and non-opioid actions. It has a low
the substantia gelatinosa of the dorsal horn leads to affinity for opioid receptors. It acts as a selectiveµ-
inhibition of the firing of nociceptive neurons and receptor agonist, but also binds weakly to Kappa
inhibition of the release of substance P.9 The spinal and Delta receptors. Therapeutic efficacy: On
mechanism is the principal mechanism for the intravenous administration - tramadol is equivalent
analgesic action of Dexmedetomidine even though to pethidine, l/5th as potent as nalbuphine, 1/10th as
there is a clear evidence for both a supraspinal and potent as morphine.2,13 The Advantages of tramadol
and peripheral sites of action.2 Clonidine, the first are can be given through different routes - oral,
developed and the most known alpha 2- agonist is parenteral etc, less respiratory depression, less
considered as a partial alpha2-agonist since its alpha dependence, abuse, tolerance, less secretion in the
2/alpha1 selectivity = 200, while the alpha 2/alpha milk of lactating mother, freely available, no narcotic
1 selectivity of dexmedetomidine is 1620 and hence prescription restriction, comparatively cheap.
is 8 times more powerful alpha 2-adrenoceptor
than clonidine and is considered as a full alpha2 In the quest for safer and efficacious drug,
adrenoceptor agonist.16 Dexmedetomidine-induced we conducted a study comparing intravenous
sedation qualitatively resembles normal sleep. The dexmedetomidine versus intravenous tramadol for
participation of nonrapid eye movement sleep prevention of shivering in patients who received
pathways seems to explain why patients who spinal anaesthesia for various surgical procedures.
appear to be deeply asleep from Dexmedetomidine Most of the studies done in the past have been in
are relatively easily aroused in much the same the treatment of shivering rather than prevention.
way as occurs with natural sleep.14 Sedation A dose of dexmedetomidine of 0.5mcg/kg is
induced by Dexmedetomidine is dose-dependent; more effective in the treatment of shivering but
however, even low doses might be sufficient to associated with reciprocal increase in hemodynamic
produce sedation. Dexmedetomidine may lack instability. So to get the maximum benefit of the
amnestic properties: more patients who received drug with the least of adverse effects, we chose the
Dexmedetomidine for postoperative sedation were dexmedetomidine dose of 0.25mcg/kg.
able to recall their ICU stay when compared to
those receiving propofol for sedation.17 Aims and objectives
Peri-operative uses of Dexmedetomidine as
premedication: Dexmedetomidine possesses The aim of this study was to study and compare
anxiolytic, sedative, analgesic, antisialogogue and the efficacy of intravenous infusion of low dose
sympatholytic properties, which render it suitable dexmedetomidine (0.25mcg/kg) vs Tramadol
as a premedication agent. Dexmedetomidine used (0.5mg/kg) in the prevention of postoperative
intra-operative as adjunct to general anaesthesia, shivering. The outcomes analysed were:
as adjunct to regional anaesthesia, in monitored
1. Incidence of shivering after administration of
anaesthesia care (MAC), or as a sole agent for total
drug
intravenous anaesthesia (TIVA).
2. Time of onset of shivering after administration 3. Patients undergoing surgery under spinal
of drug anaesthesia.
Primary objective: Prevention of shivering Exclusion criteria:
Secondary objectives: 1. Patients not belonging to above mentioned
1. Sedation age, BMI<18.5 or ASA grade.
2. Hemodynamic changes 2. Patients suffering from fever, drug allergy,
thyroid disorders and neuromuscular
3. Nausea and vomiting diseases.
3. Surgeries expected to last more than 4 hours.
Materials and Methods
4. Patients who develop shivering even before
administering spinal anaesthesia.
Study area: Operation theatre and Postoperative
ward. GKNM Hospital, Coimbatore. 5. Patients requiring supplementation with
general anaesthesia
Study population: After an informed written
consent from the patients, those scheduled for 6. Pregnancy
elective surgery, meeting the following criteria 7. Patients requiring intraoperative bladder and
were studied. uterine irrigation.
Study design: Prospective randomised double
blinded comparative study. Methodology
Study duration: June 2018-March 2019.
Sample Size: Based on the article published by Lin Informed and written consent was obtained from
Fern Et al14, with an anticipated mean difference all patients and were assigned to any of two groups
of time elapsed from treatment to cessation of by computer generated random numbers. Numbers
shivering between two study groups as 3.1 and from 1 to 80 were randomised and allocated into 2
anticipated Standard deviation as 3.8 the minimum groups
sample size per group was 40 with 90% power and Group D: Dexmedetomidine 0.25mcg/kg intravenous
5% level of significance. infusion diluted to 20ml with normal saline was
Statistical Data: Statistical analysis given over 10 minutes using a syringe pump after
intiation of subarachnoid block.
Formula used N= (Zα + Zβ)2 x2 SD2
Group T: Tramadol 0.5mg/kg intravenous
MD2 infusion diluted to 20ml with normal saline was
Z= Statistic at a level of significance given over 10 minutes using a syringe pump after
intiation of subarachnoid block.
MD= Anticipated Mean Difference
Then these groups were written in a chart against
SD= Anticipated standard deviation
number 1 to 80 and kept in a sealed envelope. Small
Data was analysed using Mean+/-Standard cards with numbers 1 to 80 placed in a sealed box.
deviation, Chi square test for association, On the day of surgery a person not involved in
comparison of means using T test, Anova for the study prepared the drug according to the card
comparison between and within groups and selected. 20ml syringes were used to draw the drug
diagrammatic presentation. The required sample and normal saline was added to make a total volume
size was 34 subjects in each group as per the above of 20ml.The assigned drug was administered to
mentioned calculation. To account for a non- patient after subarachnoid block. Patients were
participation rate of 5% and loss to follow up of 5% evaluated post operatively by the investigator who
another 4 subjects were included. Hence the final was blinded to the group assigned. At the end of
required sample size was 39 subjects in each group the study all numbers were arranged in ascending
and was rounded off to 40. order and the corresponding drug was revealed
Inclusion criteria: and written down in the proforma.
1. Patients of either gender aged between 20 to
70 years. Anaesthesia technique
2. American Society of Anesthesiologists (ASA)
status I to II. Operation theatre room temperature was kept in
between 22–260 C. Standard monitoring devices Statistical methods

including ECG leads, sphygmomanometer cuff, and
pulse oximeter were connected and baseline values Intra-operative heart rate, diastolic blood pressure,
were recorded and monitored intra-operatively systolic blood pressure, SpO2 was considered as
and postoperatively. Baseline temperature was primary outcome variables. Grade of shivering,
recorded using a mercury thermometer in the nausea, vomiting and GOS (grade of sedation)
axilla placed in the vicinity of the axillary artery. were considered as secondary outcome variables.
All patients in our study group received spinal Study group (tramadol vs dexmedetomedine) was
anaesthesia in left lateral position using 25G considered as primary explanatory variable.
Whitacre needle via midline approach in the L3-L4
Descriptive analysis was carried out by mean
intervertebral space under strict aseptic precautions
and standard deviation for quantitative variables,
and local anaesthesia to skin. Following free flow of
frequency and proportion for categorical variables.
CSF, 2ml to 3ml of 0.5% Bupivacaine (hyperbaric) Non normally distributed quantitative variables
was injected depending on the requirement of were summarized by median and interquartile
surgery. Patients were administered 5 litres oxygen range (IQR). Data was also represented using
by Hudson transparent face mask and were appropriate diagrams like bar diagram and pie
adequately covered by surgical drapes. diagram.
Patients were closely monitored for a period All quantitative variables were checked for
of 4 hours in postoperative ward for shivering normal distribution within each category of
and side effects such as nausea and vomiting, explanatory variable by using visual inspection
bradycardia, hypotension, dizziness, respiratory of histograms and normality Q-Q plots. Shapiro-
depression and sedation score was recorded. The wilk test was also conducted to assess normal
vitals were recorded every 10 minutes in the intra- distribution. Shapiro wilk test p value of >0.05 was
operative period, every 10 minutes for 1 hour considered as normal distribution.
in the postoperative period and then every half
For normally distributed quantitative parameters
an hour for 4 hours in the postoperative period.
the mean values were compared between study
Bradycardia (<50 beats/min), hypotension (<20% groups using independent sample t-test (2
of baseline value) and vomiting was treated groups). For non-normally distributed quantitative
with atropine, ephedrine and metoclopramide parameters, medians and interquartile range (IQR)
respectively in titrated doses when required. Any were compared between study groups using Mann
shivering intra-operatively or postoperatively Whitney u test (2 groups).
inspite of administration of drug were treated with
external warming devices and reassurance. None Categorical outcomes were compared between
study groups using Chi square test /Fisher's
of the patients required blood transfusion during
Exact test (If the overall sample size was < 20 or
or after the surgery.
if the expected number in any one of the cells is
Crossly and Mahajan scale of shivering2 < 5, Fisher's exact test was used.) P value < 0.05
0 – No shivering was considered statistically significant. IBM SPSS
version 22 was used for statistical analysis.
1 – Piloerection or peripheral vasoconstriction,
but no visible shivering
Results
2 – Muscular activity in only one muscle group
3 – Muscular activity in more than one muscle A total of 80 subjects were included in the final
group, but not generalised analysis. In our study, both the groups had 40
4 – Shivering involving the whole body. patients in each group. The mean age of subjects in
tramadol group was 39.55 ± 11.73 years and it was
Sedation score will be assessed with a four point
39.48 ± 10.33 years in dexmedetomedine group (p-
scale as per Filos2
0.976). In tramadol group, 25 (62.5%) participants
1. Awake and alert were male and 15 (37.5%) participants were female.
2. Drowsy, response to verbal stimuli In dexmedetomedine group, 20 (50%) participants
were male and 20 (50%) participants were female
3. Drowsy, arousable to physical stimuli (p-0.26). The mean weight of subjects in tramadol
4. Unarousable group was 64.45 ± 11.91 kg and it was 60.60 ± 5.82

kg in dexmedetomedine group (p-Value 0.07). In administration of drug. The difference in the

tramadol group, 34 (85%) participants were ASA proportion of occurrence of shivering between
grade I and 6 (15%) participants were ASA grade II. study groups was statistically not significant p
In dexmedetomedine group, 32 (80%) participants value 0.074. (Table 1 and Fig. 1).
were ASA grade I and 8 (20%) participants were In tramadol group, 24 patients out of total
ASA grade II. The difference in the proportion of 40 had shivering, where 9 patients had grade
ASA grade between study groups was statistically 2 and 15 patients had grade 3 shivering. In
not significant p- value 0.556. The mean Surgery dexmedetomedine group 16 patients out of total
duration of subjects in tramadol group was 40 had shivering, where 9 patients had grade 1 and
65.75 ± 14.12 (min) and it was 61.91 ± 12.83 (min) 7 patients had grade 2 shivering. The degree of
in dexmedetomedine group (p- value –0.207). shivering was more in tramadol group compared
(Table 8). to dexmedetomidine. (Table 2 and Fig. 2).
In tramadol group the mean time interval from the
The mean Intra-operative heart rate at baseline of
time of administration of drug to onset of shivering
tramadol group was 84.1 ± 10.42 (bpm) and 83.95 ±
was 40.63 ± 6.38 (min), in dexmedetomedine group
10.32 (bpm) in dexmed group. The mean difference
44.69 ± 6.18 (min), the difference was statistically
between two groups was statistically not significant
significant with p value–0.053. (Table 8).
p value 0.949. (Table 3 and Fig. 3).
In tramadol group, 24 (60%) participants
The mean post-op heart rate at 90 mins of
had shivering. In dexmedetomedine group, 16
tramadol group was 86.83 ± 8.21 and it was 83.48
(40%) participants had shivering and started
± 6.2 min dexmed group. The mean difference
intraoperatively for all patients, so shivering was
between two groups was statistically significant p
prevented in 60% of patients in dexmed group
value 0.003. (Table 4 and Fig. 4).
and 40% of patients in tramadol group after the
Table 1: Comparison of occurrence of shivering between the 70%
study group (N=80). 60%
60% 60%
Occurrence Study group Chi P-value 50%
of shivering square 40%
Percentage
40% 37.5%
Tramadol Dexmed
30% 22.5% 22.5%
(N=40) (N=40)
20% 17.5%
Yes 24 (60%) 16 (40%)
3.200 0.074 10% 0.0% 0.0%
No 16 (40%) 24 (60%) 0%
Tramadol Dexmed
70% Study Group
60% 60%
60% 0 1 2 3
50% Fig. 2: Clustered bar chart of Comparison of grade of shivering
Percentage
40% 40% between the study group (N=80)

40%
Table 3: Comparison of mean of intra-op heart rate between the
30% study groups (N=80).
20% Intra-op Heart Study group P value
rate (bpm)
10%
Tramadol Dexmed
0% (N=40) (N=40)
Tramadol Dexmed (Mean± SD) (Mean± SD)
Study Group Baseline 84.1 ± 10.42 83.95 ± 10.32 0.949
Yes No
5 min 94.83 ± 12.58 83.9 ± 9.01 <0.001
Fig. 1: Clustered bar chart of Comparison of occurrence of
shivering between the study group (N=80). 10 min 94.3 ± 10.98 83.85 ± 8.94 <0.001
Table 2: Comparison of grade of shivering between the study 20 min 92.18 ± 13.4 82.9 ± 8.24 <0.001
group (N=80). 30 min 91.03 ± 11.93 82.35 ± 8.37 <0.001
Grade of shivering Study group 40 min 89.13 ± 11.18 82.68 ± 8.09 0.004
Tramadol (N=40) Dexmed (N=40)
50 min 90.85 ± 10.08 83.95 ± 7.81 <0.001
0 16 (40%) 24 (60%)
60 min 91.28 ± 10.28 82.72 ± 7.15 <0.001
1 0 (0%) 9 (22.5%)
2 9 (22.5%) 7 (17.5%) 70 min 92.08 ± 7.78 82.58 ± 5.52 <0.001
3 15 (37.5%) 0 (0%) 80 min 91.28 ± 8.21 82.88 ± 6.43 <0.001

96 94.83 94.3
Intra-op Heart rate (mean) 94 92.18
91.03 91.28
92.08
91.28
92 90.85
89.13
90
88
86 84.1 83.9 83.85 83.95
83.95 82.9 82.35 82.68 82.72 82.58 82.88
84
82
80
Baseline 5 min 10 min 20 min 30 min 40 min 50 min 60 min 70 min 80 min
Time periods
Tramadol Dexmed
Fig 3: Comparative line diagram of comparison of mean of intra-op heart rate between the study groups (N=80).
94 91.88
Post-op heart rate (mean)
92 90.85
89.68 90.13
89.23
90
87.45
88 86.83
86 84.83
83.48 84.03 83.53 83.2 83 83.18
84 81.93
81.13
82
80
90 min 100 min 110 min 120 min 150 min 180 min 210 min 240 min
Time periods
Tramadol Dexmed
Fig 4: Comparative trend line diagram of comparison of mean of post-op heart rate between the study group (N=80).
Table 4: Comparison of mean of post-op heart rate between the 90% 85.0%
study group (N=80). 80%
67.5%
Post-op Heart Study group P value 70%
rate (bpm) 60%
Percentage
Tramadol (N=40) Dexmed (N=40) 50%

(Mean± SD) (Mean± SD) 40% 32.5%
90 min 86.83 ± 8.21 83.48 ± 6.2 0.043 30%
100 min 89.23 ± 9 84.03 ± 5.54 0.003 20% 15.0%
110 min 87.45 ± 6.73 83.53 ± 5.13 0.004 10%
120 min 91.88 ± 12.77 81.93 ± 6.39 <0.001 0%
Tramadol Dexmed
150 min 89.68 ± 9.33 83.2 ± 7.05 <0.001
Study Group
180 min 90.13 ± 9.94 83 ± 7.06 <0.001
Yes No
210 min 90.85 ± 11.48 83.18 ± 6.59 <0.001
Fig. 5: Clustered bar chart of comparison of nausea between the
240 min 84.83 ± 11.09 81.13 ± 6.09 0.068
study group (N=80).
Table 5: Comparison of nausea between the study group (N=80). Table 6: Comparison of vomiting between the study group (N=80).
Nausea Study group Chi square P-value Vomiting Study group Chi square P-value
Tramadol Dexmed Tramadol Dexmed
(N=40) (N=40) (N=40) (N=40)
Yes 13 (32.5%) 6 (15%) Yes 8 (20%) 5 (12.5%)
3.382 0.066 0.827 0.363
No 27 (67.5%) 34 (85%) No 32 (80%) 35 (87.5%)

100% Table 8: Tables of various variables and respective p values.

90% 87.5%
80% Parameter Study group P
80%
value
70%
67.5% Tramadol (N=40) Dexmed (N=40)
Percentage
60%
(Mean± SD) (Mean± SD)
50%
Age (years) 39.55 ± 11.73 39.48 ± 10.33 0.976
40%
Male- 25 (62.5%) Male- 20 (50%) 0.260
30% Sex
20% Female–15 (37.5%) Female- 20 (50%)
20% 12.5%
10% Weight(kg) 64.45 ± 11.91 60.60 ± 5.82 0.070
0% Grade I -34 (85%) Grade I- 32 (80%) 0.556
Tramadol Dexmed ASA grade
Grade II- 6 (15%) Grade II- 8 (20%)
Study Group
Surgery 65.75 ± 14.12 61.91 ± 12.83 0.207
Yes No duration (min)
Fig. 6: Clustered bar chart of Comparison of vomiting between Temperature 37.18 ± 0.36 37.19 ± 0.49 0.917
the study group (N=80). (Celsius)
In tramadol group, 13 patients had nausea. In Time interval 40.63 ± 6.38 44.69 ± 6.18 0.053
to onset of
dexmedetomedine group, 6 patients had nausea; shivering after
the difference was not statistically significant with administration
p value 0.066. In tramadol group, 8 patients had of drug(min)
vomiting. In dexmedetomedine group, 5 patients There was no statistically significant difference
had vomiting. The difference was statistically not between two groups with regards to blood
significant with p value–0.363. (Fig. 5, 6 and Table pressure (SBP and DBP) in both intra-operative
5, 6). and post operative period (p value >0.05). There
In tramadol group, 24 patients had grade was no statistically significant difference between
1 and 16 patients had grade 2 shivering. In two groups in intra-operative SPO2 and also post-
dexmedetetomedine group, 35 patients had grade 2 operative SPO2.
shivering and 5 patients had grade 3 shivering. The
degree of sedation was higher in dexmedetomedine Discussion
group compared to tramadol group though we
could not apply any statistical test. (Table 7 and Postoperative period is associated with variable
Fig. 7). incidence of shivering. Around 30–40% of patients
Table 7: Comparison of GOS (Grade of Sedation) between the undergoing spinal anaesthesia will experience
study group (N=80).
shivering. Drugs like Dexmedetomedine, pethidine,
GOS Study group
tramadol, nefopam,clonidine are traditionally being
Tramadol (N=40) Dexmed (N=40)
used to prevent and treat postoperative shivering,
1 24 (60%) 0 (0%)
but these are associated with undesirable side
effects like respiratory depression, hemodynamic
2 16 (40%) 35 (87.5%)
instability, nausea and vomiting.
3 0 (0%) 5 (12.5%)
Most of the studies done in the past have been in
100%
87.5% the treatment of shivering rather than prevention. In
90%
a quest to address the issue of postspinal shivering,
80%
we conducted a study comparing the efficacy of
70%
60% dexmedetomedine and tramadol administered
Percentage
60%
immediately after subarachnoid block in the
50%
40% prevention of shivering.
40%
30% Dexmedetomedine decreases the
20% 12.5%
vasoconstriction and shivering threshold by acting
10% on central thermoregulation system. Tramadol is a
0% 0%
0% synthetic opioid, which acts by inhibiting reuptake
Tramadol Dexmed of norepinephrine and serotonin and activates
Study Group descending inhibitory spinal pathways. The
1 2 3 incidence of shivering may be associated with many
Fig. 7: Clustered bar chart of Comparison of GOS (Grade of factors including age, duration of surgery, type of
sedation) between the study group (N=80). surgery and also type of anaesthesia. These factors
can interefere with interpretation of the results conducted by Tanveer singh et al21 with 0.25mcg/
of the study. So we designed the study in such a kg of dexmedetomedine given for treatment, 41%
way that these factors were well balanced between of patients had shivering, which was comparable
both study groups. The anaesthetic technique was to our study.
standarised, patient related variables were also
In a study conducted by Samsettin Bozgeyik et
standardised. The demographic variables between
al19, the incidence of shivering of grade <2 was 96.6%
both groups are comparable to eliminate the
as against 100% in our study and the incidence of
confounding variables which could interfere with
the interpretation of the superiority of one drug in shivering of grade >2 was 3.4% as against 0% in our
a particular dosage over the other in the prevention study. Burhanettin usta et al18 conducted a study
of shivering. on comparing the efficacy of normal saline and
dexmed 0.5mcg/kg on prevention of post-operative
Tanveer singh kundra, Parminder kaur et al21 shivering .They concluded that 10% of patients had
conducted a prospective observational study on the shivering in their study which is less than incidence
minimum dose of dexmedetomedine required for
in our study, one of the contributing factor could be
cessation of postspinal anaesthesia shivering. They
use of 0.5mcg/kg of dexmed in their study.
studied the time taken for abolition of shivering in
90 patients having shivering who received different In our study, 24 patients (60%) of tramadol
doses from 1mcg/kg,0.5mcg/kg and 0.25mcg/kg, had shivering. In a study conducted by Samsettin
30 in each group and concluded that minimum dose Bozgeyik et al19, a fixed dose of 100 mg tramadol
required for control of shivering was 0.25mcg/kg to was administered to all patients in the group pre-
0.29mcg/kg. Lim Fern et al14 conducted a study on emptively. The incidence of shivering with grade of
the treatment of shivering and had concluded that shivering <2 was 90% as against 62.5% in our study
a dose of dexmed 0.5mcg/kg though more effective and grade of shivering >2 was 10% as against 37.5%
in the treatment of shivering was associated with in our study. But it is not possible to compare their
reciprocal increase in hemodynamic instability. So results as their study design is based on fixed dose of
to get the maximum benefit of the drug with the tramadol that is 100mg for all patients. The overall
least of adverse effects, we chose to the dexmed higher incidence of shivering in our study inspite
dose of 0.25mcg/kg. of pre-emptive administration can be attributed to,
In our study, group T patients were administered including the lower grades of shivering also unlike
tramadol of 0.5mg/kg. Lim Fern et al, Geeta Mittal other studies.
et al7,3 studied the effect of tramadol in treatment
of postoperative shivering, both the studies used Sedation
0.5mg/kg of tramadol, hence the dose of tramadol
0.5mg/kg used in the present study was based on
optimal dose used in previous studies. Our study In our study, in dexmedetomedine group all
group consisted of total 80 patients, 40 patients in patients were sedated with 87.5% of grade 2 and
each group and the outcomes were compared in 12.5% of grade 3 sedation. This is comparable to
terms of, efficacy in prevention of shivering and similar study done by Burhanettin usta et al19 in
adverse effects like sedation, nausea, vomiting and which also all the patients in the dexmedetomedine
hemodynamic instability. group were sedated, but the sedation score was 3 to
5 in their study which could be due to higher dose
Efficacy in the prevention of shivering (0.5mcg/kg) of dexmedetomedine used. The study
results are also similar to study done by Semsettin
et al, Tanveer et al and Rajagopal venkataraman et
In the present study, shivering was prevented al19,21,and 20 all of which report a higher incidence of
in 40% of patients in tramadol group and 60% of sedation with dexmed at different doses.
patients in dexmedetomedine group and these
patients did not have shivering in postoperative In our study 40% of patients were sedated in the
period as well. Shivering occurred in 16 patients tramadol group and all had grade 2 sedation. This is
(40%) of dexmedetomedine group compared close to the study results of Rajagopal venkataraman
to 24 patients (60%) of tramadol group. This et al20, though the tramadol dose was higher in their
difference though was not statistically significant, study. But the results are contradictory to that of
numerically showed that dexmedetomedine was study done by aditi dhimar et al15 which found 0%
better in prevention of shivering. In a similar study sedation with the same dose of tramadol.

Nausea and vomiting Infusion In Prevention of Postoperative Shivering

Following Spinal Anaesthesia our Primary
In our study, incidence of nausea and vomiting outcome measure was prevention of shivering
was 15% and 12.5% in dexmedetomedine group and secondary outcome measures were sedation,
respectively .The incidence of nausea and vomiting nausea, vomiting and hemodynamic stability. The
was 32.5% and 20% in tramadol group respectively. demographic parameters of all patients in two
This correlates with the study of Geeta mittal et groups were comparable. There was no statistically
al3, which gives closer incidence with same dose significant difference between Group D and group
of tramadol. Overall the incidence of nausea and T in terms of patient characteristics. The prevention
vomiting appears higher in both the groups in our of shivering was better in group D but not
study compared to other studies, which could be statistically significant. The incidence and grade
due to patient and surgical factors. of sedation was more in dexmedetomedine group.
The incidence of nausea and vomiting was higher
in group T when compared to group D which was
Hemodynamic parameters statistically insignificant. There was in fall in heart
rate in group D compared to group T but none of
In our study, both the groups had stable the patients in both.
hemodynamics and none of the patients in both the Dexmedetomedine even at a lower dose is
groups had significant bradycardia or hypotension comparatively a more effective drug for prevention
after the administration of the drug (tramadol or of shivering with a better side effect profile
dexmedetomedine) respectively. Tanveer Singh than tramadol in patients undergoing surgery
Kundra, Paraminder Kaur et al21 conducted a study under spinal anaesthesia. Time interval between
on minimum dose of dexmedetomedine required administration of drug and onset of shivering was
to treat postoperative shivering and concluded longer in dexmedetomedine group compared to
that minimum dose required was 0.25mcg/kg tramadol group and was statistically significant
and there was no significant bradycardia and with p value–0.053.
hypotension noted in their study. Same dose of
dexmedetomedine (0.25mcg/kg) was used in our
study as well. Many other studies have reported Limitations
some incidence of bradycardia and hypotension in
both the groups, more with dexmed groups which The limitations to our present study were;
could be due to the higher doses used.
1. Temperature was not checked in the
intraoperative and postoperative period
Time interval from administration of drug to onset of hence we could not make a correlation on the
shivering influence of hypothermia on shivering.
2. Axillary temperature was checked rather
In tramadol group of our study, the mean than core body temperature preoperatively.
time interval from administration of drug to
3. Small sample size was taken.
onset of shivering was 40.63 ± 6.38minutes. In
dexmedetomedine group 44.69 +/– 6.18minutes 4. The results cannot be extrapolated for long
from the time of administration of the drug, the duration surgeries.
difference was statistically significant with P
value–0.053.Burhanettin Usta et al (18) conducted a Recommendations
comparative study on prevention of postoperative
shivering with dexmedetomedine versus saline
and concluded that time to onset of shivering 1. A larger study population would have higher
from administration of drug was longer in statistical power so as to come to definite
dexmedetomedine group compared to saline group. conclusion.
2. Intraoperative temperature monitoring could
Conclusion have thrown a better light on those cases
where hypothermia was the causative agent
of shivering.
In our study A Randomized Double Blinded
Comparative Study On Efficacy of Intraoperative 3. The estimation of blood loss and volume
Dexmedetomedine Versus Tramadol Intravenous replacement should be considered since it
can be one of the contributing factors for hysterectomy. European journal of anaesthesiology.
shivering. 2008 May;25(5):357–64.
Conflicts of interest: none to declare. 11. Alfonsi P. Postanaesthetic shivering. Drugs. 2001
Dec 1;61(15):2193–205.
Source of funding: none to declare.
12. Gertler R, Brown HC, Mitchell DH, Silvius EN.
Dexmedetomidine: a novel sedative-analgesic
References agent. InBaylor university Medical center
proceedings 2001 Jan 1 (Vol. 14, No. 1, pp. 13–21).
Taylor and Francis.
1. Blaine Easley R, Brady KM, Tobias JD.
Dexmedetomidine for the treatment of 13. Gut- Stein HB, Akil H, Opiod analgesics. In:
postanesthesia shivering in children. Pediatric Hardman JG, Limbird LE, Gilman AG, editors.
Anesthesia. 2007 Apr;17(4):341–6. Goodman and Gilman’s the pharmacological basis
of therapeutics. 10th ed. New York: McGraw Hill;
2. David L. Brown; Miller 's Anaesthesia , 6th Edition, 2001 .p.337–619.
Vol: 2, Chapter 43, Spinal, Epidural and Caudal
Anaesthesia; Pages 1653–707. 14. Tsai YC, Chu KS. A comparison of tramadol,
amitriptyline, and meperidine for postepidural
3. Mittal G, Gupta K, Katyal S, Kaushal S.
anesthetic shivering in parturients. Anesthesia and
Randomised double-blind comparative study of
Analgesia. 2001 Nov 1;93(5):1288–92.
dexmedetomidine and tramadol for post-spinal
anaesthesia shivering. Indian journal of anaesthesia. 15. Dhimar AA, Patel MG, Swadia VN. Tramadol for
2014 May; 58(3):257. control of shivering (comparison with pethidine).
Indian Journal of Anaesthesia. 2007 Jan 1; 51(1):28
4. Buggy DJ, Crossley AW. Thermoregulation, mild
perioperative hypothermia and post-anaesthetic 16. Sessler DI. Temperature monitoring and
shivering. British Journal of Anaesthesia. 2000 May perioperative thermoregulation. Anesthesiology:
1; 84(5):615–28. The Journal of the American Society of
Anesthesiologists. 2008 Aug 1;109(2):318–38.
5. Mahesh T, Kaparti L. A randomised trial comparing
efficacy, onset and duration of action of pethidine 17. Hall JE, Uhrich TD, Barney JA, Arain SR, Ebert
and tramadol in abolition of shivering in the intra TJ. Sedative, amnestic, and analgesic properties of
operative period. Journal of clinical and diagnostic small-dose dexmedetomidine infusions. Anesthesia
research: JCDR. 2014 Nov; 8(11):GC07. and Analgesia. 2000 Mar 1;90(3):699–705.
6. Tamsen A, Gordh T. Epidural clonidine produces 18. Usta B, Gozdemir M, Demircioglu RI, Muslu B, Sert
analgesia. The Lancet. 1984 Jul 28; 324(8396):231–2. H, Yaldiz A. Dexmedetomidine for the prevention
7. Fern L, Misiran K. Comparison of dexmedetomidine, of shivering during spinal anesthesia. Clinics. 2011;
pethidine and tramadol in the treatment of post- 66(7):1187–91.
neuraxial anaesthesia shivering. Southern African 19. Bozgeyik S, Mizrak A, Kılıç E, Yendi F, Ugur
Journal of Anaesthesia and Analgesia. 2015 Jan BK. The effects of preemptive tramadol and
2;21(1):14–8. dexmedetomidine on shivering during arthroscopy.
8. Günaydin B, Özköse Z, Tarhan B. Intravenous Saudi journal of anaesthesia. 2014 Apr;8(2):238.
dexmedetomidine sedation for spinal anesthesia 20. Venkatraman R, Karthik K, Pushparani A,
in the prone knee-chest position for lumbar Mahalakshmi A. A prospective, randomized,
laminectomy surgery. Turkish Journal of Medical double-blinded control study on comparison of
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Comparative Study of Oral Clonidine, IV Fentanyl and IV Butorphanol

in Attenuation of Hemodynamic Stress Response to Laryngoscopy and
Endotracheal Intubation
Sorathiya Prashant C1, Rashmi D Souza2
Author’s Affiliation: 1Assistant Professor, Department of Anaesthesiology, Shri M P Shah Medical College, Jamnagar, Gujarat
361008, India, 2Assistant Professor, Department of Anaesthesiology, Bangalore Medical College and Research Institute, Bangalore,
Karnataka 560002, India.
Corresponding Author: Rashmi D Souza, Assistant Professor, Department of Anaesthesiology, Bangalore Medical College and
Research Institute, Bangalore, Karnataka 560002, India.
E-mail: rdsouza.cm@gmail.com

Sorathiya Prashant C, Rashmi D Souza. Comparative Study of Oral Clonidine, IV Fentanyl and IV Butorphanol in Attenuation of
Hemodynamic Stress Response to Laryngoscopy and Endotracheal Intubation. Indian J Anesth Analg. 2020;7(6):1343–1349.
Abstract
Introduction: Laryngoscopy and endotracheal intubation is invariably associated with haemodynamic

stress response which may have severe consequences in patients with comorbidities. Various drugs have
been tried to attenuate this response. Ease of use, cost effectiveness and minimal side effects are some
important considerations while choosing an agent. In this study we have compared the efficacy of oral
clonidine with IV fentanyl and IV butorphanol in attenuating the stress response to laryngoscopy and
intubation.
Materials and Methods: This is a prospective, randomised, comparative study carried out on 75 patients
aged 20–60 years, ASA I/II physical status, scheduled for elective surgery. These patients were randomly
allocated into three groups- GROUP A received IV Fentanyl 2mcg/kg and GROUP B received IV
Butorphanol 40 mcg/kg five mins prior to induction respectively. GROUP C received Oral Clonidine 4
mcg/kg 90 mins prior to induction. All thepatients were assessed for heart rate, systolic blood pressure
and diastolic blood pressure before induction, during laryngoscopy, after intubation at 1 min, 2 min, 3 min
and 5 minrespectively.
Statistical analysis: The data was compared and analysed using Kruskal-Wallis test.
Results: There was an increase in the hemodynamic parameters post laryngoscopy and intubation in all
the groups.Astatistically significant difference in the mean heart rate, systolic blood pressure and diastolic
blood pressure was observed; the increase being significantly lower and short-lived in the oral clonidine
group compared to the other two groups. Although all the three drugs were effective in attenuating
the pressor response, oral clonidine was moreeffective and consistent compared to IV fentanyl and IV
butorphanol.
Conclusion: Oral clonidine 4mcg/kg given 90 mins prior to induction is more effective than IV fentanyl
and IV butorphanol in blunting the hemodynamic response to direct laryngoscopy and intubation without
causing any significant side effects.
Keywords: Hemodynamic response; Oral clonidine; Fentanyl; Butorphanol.

Introduction Materials and Methods
Direct laryngoscopy and endotracheal intubation This prospective randomised study was carried out
is an integral part of general anesthesia. It is on 75 patients, after obtaining a written informed
invariably associated withcardiovascular response consent, in a tertiary referral hospital. The study
such as, hypertension, tachycardia and at times population consisted of patients aged 20–60 years,
arrhythmias, due to reflex sympathetic stimulation. of either sex, belonging to ASAI/ II physical status,
While these changes are transient and probably scheduled for elective surgeries under general
of little consequence in healthy individuals, they anaesthesia.
may be detrimental in patients with hypertension, Patients with ASA III/ IV physical status,
coronary artery disease and cerebrovascular age <20yrs and>60 years, with history of drug
diseases. dependence, undergoing emergency procedures,
To overcome these undesirable effects, many having anticipated difficult airway, requiring more
strategies have been tried. These include deepening than one attempt or more than 30 secs for intubation
the plane of anesthesia, pre treatment with were excluded from the study.
vasodilators, adrenoreceptor blockers, calcium The study population was randomly allocated to
channel blockers, lidocaine, opioids etc. However three groups of 25 each. Group A received injection
no single technique has been found to be entirely Fentanyl 2mcg/kg IV 5 minutes before induction,
successful. An ideal agent should attenuate the group B received injection Butorphanol 40mcg/kg
pressor response, be easy to administer, economical, IV 5 minutes before induction, group C received
cause minimal side effects and not affect recovery oral Clonidine 4mcg/kg (maximum of 200 mcg)
from anesthesia. 90 minutes before induction. Randomization was
done using sealed envelope method.
Opioidsbind to specific receptors located in the
cardiovascular regulatory centers, the sympathetic A detailed history, thorough clinical examination
nervous system, and the vagal nuclei. This and a written informed consent was taken a
enables them to attenuate the pressor response day prior to the surgery. Routine investigations
to laryngoscopy and intubation. They are also including CBC, random blood sugar, ECG was done.
commonly used in the perioperative period for On arrival in the operating room, under standard
analgesia, sedation and post-operative shivering. monitoring (ECG, Non Invasive blood pressure,
Fentanyl,a synthetic opioid, is a pure agonist SpO2 and Capnography), baseline parameters
which has a rapid onset and short duration of were noted and Inj. Glycopyrrolate 4mcg/kg IV,
action. It is a potent analgesic, cardio stable and Inj. Ondansetron 0.15mg/kg IV given as routine
isused widely to attenuate the pressor response to premedication. After pre-oxygenation with 100%
laryngoscopy and intubation. O2 for 3minutes, general anaesthesia was induced
with Inj. Thiopentone Sodium 2.5% 5mg/kg IV
Butorphanol, is an agonist-antagonist synthetic followed by Inj. Vecuronium 0.1mg/kg IV. Direct
opioid, provides analgesia, sedation and is also laryngoscopy and endotracheal intubation was
used to attenuate pressor responses. done 3 mins later by a resident with more than one
Clonidine is an imidazole derivative, α-2 year of experience in anaesthesiology.
adrenergic agonist with a central sympatholytic Anaesthesia was maintained using 0.8 to 1 MAC
effect. It decreases the heart rate and causes a of Isoflurane in O2 (50%) and N2O(50%) mixture,
dose dependent decrease in systolic and diastolic with Inj. Vecuronium as the relaxant. Patients were
blood pressure. It is well absorbed after oral mechanically ventilated with a tidal volume of
administration with nearly 80% bio availability. 8–10ml/kg and a respiratory rate of 12/min.
Oral route is easy to administer and cost effective.
The heart rate through continuous ECG
Thus, it can be used as an effective alternative to
monitoring, systolic blood pressure and diastolic
attenuate the pressor response to laryngoscopy and
blood pressure through NIBP were recorded by
intubation.
a single observeron arrival to the operating room
The present study was designed to compare the (baseline values): pre-induction (i.e. 90 min after oral
efficacy of Oral Clonidine with equipotent doses Clonidine in group C and 5 min after IV Fentanyl/
of IV Fentanyl and IV Butorphanol in attenuating Butorphanol in group A and B respectively):
the pressor response to direct laryngoscopy and during laryngoscopy: atintubation and at one, two,
endotracheal intubation. three and five minutes after intubation in all the
Sorathiya Prashant C, Rashmi D Souza / Comparative Study of Oral Clonidine, IV Fentanyl and IV 1345
Butorphanol in Attenuation of Hemodynamic Stress Response to Laryngoscopy and Endotracheal Intubation
groups. No surgical stimulus was allowed during 1. Heart Rate: The Heart rate at various time
this period. intervals in the three groups is as shown in
Hemodynamic response was defined as >25% Table 2. The baseline heart rate was comparable
increase in the value of hemodynamic parameters in all the groups. It was observed that heart
from thebaseline to 2 minutes after intubation. rate increased in all groups after intubation.
However, the increase was less than 25%
On completion of surgery, neuro-muscular of the baseline values in the oral clonidine
blockade was reversed with IV Neostigmine 0.05 group. The increase was significantly less in
mg/kg and IV Glycopyrrolate 8 mcg/kg. Patients oral clonidine group as compared to fentanyl
were extubated once the appropriate criteria were group and butorphanol group at all times of
met. Vitals- ECG, NIBP, SPO2were monitored for the assessment i.e. during laryngoscopy, after
an hour in the recovery room. Any postoperative intubation and at 1, 2, 3 and 5 minutes after
complications including nausea, vomiting, sedation intubation. At 5 minutes after intubation, the
etc. were noted. heart rate returned to the baseline value only in
the oral clonidine group and remained elevated
Statistical Analysis
in the fentanyl and butorphanol group.(Fig. 1)
The data at each of the measurement was presented 140
as Mean ± SD. Since normality assumption was 120
not followed, non-parametric tests were applied. 100
To test the efficiency of each drug, the intra-group
80
hemodynamic parameters were analysed using
60
the Wilcoxon Signed Ranks test. The demographic
profile and inter-group hemodynamic parameters 40
were compared using the Kruskal-Wallis test. P 20
value of < 0.05 was considered as significant. 0
Results
This study was carried out in 75 patients divided into

three groups of twenty-five each. The demographic
data is as shown in Table 1. The data in all the three
groups were comparable with respect to age, sex Group A Fentanyl Group B Butorphanol
distribution and weight (p >0.05). Group C Clonidine
Fig. 1: Heart rate in all groups at various time interval.
Table 1: Demographic data
Age (in years) Mean + SD Number of patients Weight (kgs) Mean + SD
Males Females
Group A Fentanyl 38.40±10.42 13 12 56.00±6.19
Group B Butorphanol 35.92±11.16 11 14 57.96±5.96
Group C Clonidine 35.28±10.51 12 13 56.04±6.16
P-value >0.05 >0.05 >0.05 >0.05
Table 2: Changes in heart rate.

Group A Fentanyl Group B Butorphanol Group C Clonidine
Time Intervals P-value
Mean ± SD Mean ± SD Mean ± SD
Baseline 82.08±10.33 79.73±10.10 78.08±9.39 0.112
Pre induction 92.92±8.33 94.04±13.41 70.24±7.40 <0.001
During laryngoscopy 103.08±10.40 104.12±14.32 76.32±8.10 <0.001
On intubation 114.92±10.91 118.00±13.71 79.8±8.72 <0.001
1 min after intubation 112.92±11.17 116.60±12.36 84.2±8.37 <0.001
2 mins after intubation 110.32±11.33 109.80±12.85 82.92±8.59 <0.001
# p<0.001 highly significant

2. Systolic Blood Pressure: The Systolic blood 3. Diastolic Blood Pressure: The diastolic blood
pressure at various time intervals in the three pressure at various time intervals in the three
groups is as shown in Table 3. The baseline groups is as shown in Table 4. The baseline
systolic blood pressure was comparable in diastolic blood pressure was not comparablein
all the groups. It increased in all groups after the three groups. The diastolic blood pressure
laryngoscopy and intubation. The extent of increased in all groups after laryngoscopy and
increase was less than 25% of the baseline intubation. The extent of increase was less than
values in all the groups. However, the increase 25% of the baseline values in all the groups.
was significantly less in oral clonidine group as However, the increase was significantly
less in oral clonidine group as compared to
compared to fentanyl group and butorphanol
fentanyl group and butorphanol group during
group at all times of the assessment i.e. during
laryngoscopy, after intubation and at 1, 3 and
laryngoscopy, after intubation and at 1, 2, 3 and
5 minutes after intubation. The diastolic blood
5 minutes after intubation. The systolic blood
pressure returned to the baseline value at 2
pressure returned to the baseline value at 2 minutes after laryngoscopy and intubation in
minutes after laryngoscopy and intubation in the oral clonidine group compared to 5 minutes
the oral clonidine group compared to 5 minutes after intubation in the butorphanol group. The
after intubation in the fentanyl and butorphanol diastolic blood pressure remained elevated above
group.(Fig. 2) the baseline values in the fentanyl group. (Fig. 3).
160 100
90
140 80
120 70
100 60
50
80 40
60 30
20
40
10
20 0
0
Group A Fentanyl Group B Butorphanol Group A Fentanyl Group B Butorphanol

Group C Clonidine Group C Clonidine
Fig. 2: Systolic blood pressure in all groups at various time Fig. 3: Diastolic blood pressure in all groups at various time
interval.
Table 3: Changes in systolic blood pressure.

Baseline 127.04±11.46 124.24±4.81 126.33±4.58 0.175
Pre induction 128.72±9.34 129.00±5.86 108.80±2.95 <0.001
On intubation 145.60±8.30 150.52±7.07 128.40±4.01 <0.001
1 min after intubation 146.72±7.97 142.16±6.66 129.73±4.89 <0.001
5 mins after intubation 117.60±4.92 114.16±7.20 116.60±3.60 0.022
# p<0.001 highly significant ## p<0.05 significant

Table 4: Changes in diastolic blood pressure.

Baseline 75.20±3.87 80.68±3.75 81.46±4.13 <0.001
Pre induction 86.12±4.41 85.92±3.26 67.00±4.22 <0.001
On intubation 83.32±3.80 85.96±4.22 84.13±3.96 0.048
1 min after intubation 82.12±3.00 83.72±3.28 84.00±3.96 0.044
# p<0.001 highly significant## p<0.05 significant
Table 5: Postoperative complications.

Bradycardia 1 0 2
Nausea / Vomiting 1 3 0
Sedation 0 2 6
interval. The incidence of nausea and vomiting was

All the groups showed attenuation of the systolic 4% in fentanyl group and 12% in butorphanol
group post operatively and was treated with
and diastolic blood pressure after laryngoscopy
inj.ondansetron 4 mg IV.
and intubation with the values returning to baseline
levels within 5 minutes after intubation. However, The incidence of sedation was 8% in the
butorphanol group and 24% in the oral
only oral clonidine group showed significant
clonidine group. However, all these patients
attenuation of the heart rate with values returning were easily arousable upon verbal command
to the baseline at 5 minutes after intubation. and required no other intervention.
4. Side Effects and Complications: The side effects There were no intra operative complications
observed post operatively are as shown in table seen.
5.
The incidence of bradycardia was 4% in the Discussion
fentanyl group and 8% in the clonidine group.
It was transient and resolved without any Induction of general anaesthesia, direct
treatment. laryngoscopy and endotracheal intubation are
7
known to produce marked cardiovascular changes
due to reflex autonomic activity.1 Studies have
6 shown an average increase in blood pressure of
40%–50% and heart rate of 20%.2 This response
5 may be particularly hazardous for patients with
N umber of Patient s
cardiovascular and cerebrovascular diseases.3

4 Numerous attempts have been made to obtund
these effects by various techniques like increasing
3 adequate depth of anesthesia, minimising the
duration of laryngoscopy, concomittant use of
2 drugs likeopioids, benzodiazepines, lignocaine,
adrenergic blockers, calcium channel blockers etc.4
1
Although these stratergies did obtund the response
to some extent, they failed to fulfil the desired
0
criteria for complete attenuation.5
G roup A G roup B G roup C
Fentanyl and Butorphanol are commonly used
Fentany l B utorphanol C lonidi ne
opioids for analgesic effects, sedation and also to
B radycardia N ausea vo miti ng Sedat ion attenuate the hemodynamic response to layngocopy
Fig. 4: Postoperative complications. and intubation.

Clonidine, an α2 agonist mainly used as an oral clonidine premedication on perioperative

antihypertensive agent, is now being increasingly hemodynamic response in patients undergoing
used as a premedicant as it provides attenuation laparoscopic cholecystectomy. They observed a
of hemodynamic responses to intubation in significant reduction in heart rate, systolic and
addition to sedation, anxiolysis and decrease in the diastolic blood pressure at 1minute and 5 minutes
anaesthetic requirement, while maintaining normal after intubation, with values remaining significantly
baroreceptor responses.6 lower than the control group throughout the
In our study, we have compared oral clonidine perioperative period. They also noted significant
with IV fentanyl and IV butorphanol for reduction in intra operative anaesthetic and post
attenuationof haemodynamic stress response to operative analgesic requirements. There was no
direct laryngoscopy and intubation. significant difference in the side effects observed in
both the groups.
Kautto UM et al7 studied the effect of IV fentanyl
in two different doses of 2 mcg/kg and 6 mcg/kg In 2019, Rukmini G et al12 compared oral clonidine
and IV fentanyl in attenuation of hemodynamic
for attenuation of stress response. He concluded
responses to laryngoscopy and intubation. The
that the hemodynamic responses were effectively
heart rate, systolic and diastolic blood pressure
controlled in the fentanyl 2 mcg/kg group as well
was significantly higher in the fentanyl group upto
with minimal side effects.Therefore, we selected
three minutes after intubation. The hemodynamic
the dose of IV Fentanyl 2 mcg/kg in our study.
parameters were comparable at five minutes
Pandit et al8 in their comparative study of after intubation. These findings are similar to the
Butorphanol 40 mcg/kg and Fentanyl 2 mcg/ findings in our study.
kg for outpatient anaesthesia observed that
In 2017, Anand S et al13 performed a study on
unlike butorphanol, the post-intubation arterial
comparison of two opioids, IV Fentanyl with
pressure and heart rate in the fentanyl group were
IV Butorphanol in propofol based anesthesia
significantly higher than the base line values.In
to attenuate the hemodynamic response. They
order to facilitate an effective comparison with IV
concluded that although both the drugs were
Fentanyl 2mcg/kg, we selected an equipotent dose
effective in attenuating the increase in heart rate,
of IV Butorphanol 40 mcg/kg in our study.
systolic and diastolic blood pressure, IV Fentanyl
Carabine UA et al9 studied the effect of oral was far more superior than IV Butorphanol to attain
clonidine in doses of 0.1 mg, 0.2 mg and 0.3 mg as hemodynamic stability. A similar finding was also
a premedicant. They concluded that 0.2 mg oral observed in our study.
clonidineproduces significant reduction in anxiety,
In our study we observed that although all
better quality of induction than 0.1mg and doses
the three drugs did aid in attenuation of pressor
of 0.3mg caused significant hypotension persisting response to laryngoscopy and intubation in
to the post operative period. Kulka Peter J et al10 varying extent, Oral Clonidine 4mcg/kg was
observed that the effects of clonidine on sedation stastically more significant, with the hemodynamic
and haemodynamic variables are dose related and parameters- heart rate, systolic and diastolic blood
increasing the dose to more than 4 mcg/kg does not pressure returning to baseline values within 3
further enhance efficacy. Therefore we selected the mins of endotracheal intubation. On comparing
dose of oral clonidine 4 mcg/kg in our study. IV Fentanyl 2mcg/kg and IV butorphanol 40mcg/
In 2002, Rawal DL et al5 studied oral clonidine as kg using descriptive stastistics (Co-efficient of
a premedicant for the attenuation of hemodynamic variation), IV Fentanyl was more consistent
response to laryngoscopy and intubation.Oral in attenuating hemodynamic response to
clonidine 4mcg/kg was compared with oral laryngoscopy and intubation than Butorphanol.
diazepam 0.2mg/kg, both given 90 minutes prior
to induction and hemodynamic parameters noted Conclusion
for every minute upto 5 mins after intubation.They
observed that oral clonidine caused significant
reduction in heart rate, systolic and diastolic In our study, we conclude that Oral Clonidine
blood pressure with values returning to baseline 4mcg/kg given as a pre-medicant is more effective
within 5 minutes of intubation. It also produced in attenuating the haemodynamic stress response
significant anxiolysis and lesser sedation compared to direct laryngoscopy and endotracheal intubation
to diazepam. No adverse effects were observed. as compared to IV Fentanyl 2mcg/kg and IV
Butorphanol 40mcg/kg. The ease of administration,
In 2011,Singh et al11 studied the effect of cost effectiveness, anxiolysis and peri-operative
hemodynamic stability it offers, projects it as a safe CliniAnaesth 1991;3(3);186–93.

and useful alternative. 7. Kautto UM. Attenuation of the circulatory response
Financial support and sponsorship: Nil to laryngoscopy and intubation by fentanyl. Anae
1982;26(3);217–21.
Conflict of interest: None declared
8. Pandit SK, Kothary SP. Comparison of fentanyl and
butorphanol for outpatient anaesthesia. Can J Anae
References 1987;34;130–4.
9. Carabine UA, Wright PMC, Moore J. Preanaesthetic
1. Russell W J, Morris R G. Changes in plasma medication with clonidine: a dose response study.
catecholamine concentrations during endotracheal Br J Anae 1991;67;79–83.
intubation. British Journal of Anaesthesia, 10. Kulka Peter J, Tryba Michael and Zenz Michael.
1981;53:837–839. Dose response effects of intravenous clonidine on
2. Brudder N, Granthil C, Ortega D. Consequencesand stress responses during induction of anaesthesia.
prevention methods of hemodynamicchanges Anaesthesia and Analgesia 1995;80:263–8.
during laryngoscopy and intubation. Br J 11. Singh S, Arora K. Effect of oral clonidine
Anesth1983;55:855–60. premedication on perioperative haemodynamic
3. T E Black, B Kay and T E J Healy. Reducing the response and post-operative analgesic
haemodynamic responses to laryngoscopy and requirement for patients undergoing laparoscopic
intubation; A comparison of Alfentanyl and cholecystectomy. Indian J Anaesth2011;55:26–30.
Fentanyl. Anaesthesia1984;vol 39:pages 883–887. 12. Rukmini G, Reddy MS. Oral clonidine versus
4. Wycoff Charles. Endotracheal intubation; intravenous fentanyl in attenuation of hemodynamic
Effects on blood pressure and pulse rate. responses to laryngoscopy and endotracheal
Anaesthesiology.1960(Mar-Apr);21(2):153–157. intubation: A comparative study. Int J Adv Med
5. Raval DL, Mehta MK. Oral clonidine pre 2019;6:xxx.
medication for attenuation of hemodynamic 13. Anand S. Nirgude, Varsha Suryavanshi. Study
response to laryngoscopy and intubation. Indian J on comparison of two opioids IV fentanyl with
Anaesth2002;46:124–9. IV butorphanol in propofol based anaesthesia
6. Laurito CE, Baughman VL, Becker GL, Desilva TW, to attenuate haemodynamic response in
Carranza CJ. The effectiveness of oral clonidine abdominal surgical cases. International Journal
as a sedative/anxiolytic and as a drug to blunt of Contemporary Medical Research 2017;4(10):
the haemodynamic responses to laryngoscopy. J 2139–2143.


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A Randomized Prospective Study to Compare Use of I-GELTM and LMA

ProsealTM in Patients undergoing Laparoscopic Cholecystectomy
Spriha Mathur1, Manjula Sudhakar Rao2, Ravindra Kumar Arora3
Author’s Affiliation: 1Senior Resident, Department of Anesthesiology, Rajiv Gandhi Super Specialty Hospital, Dilshad Garden,
New Delhi 110093, India, 2Senior Resident, Department of Anesthesiology, Father Muller Medical College, Kankanady, Mangalore
575002, Karnataka, India, 3Senior Consultant, Department of Anesthesiology, MAX Super Specialty Hospital, Vaishali, Ghaziabad,
Uttar Pradesh 201012, India.
Corresponding Author: Manjula Sudhakar Rao, Senior Resident, Department of Anesthesiology, Father Muller Medical
College, Kankanady, Mangalore 575002, Karnataka, India.
E-mail: manjul.kshema@gmail.com

Spriha Mathur, Manjula Sudhakar Rao, Ravindra Kumar Arora. A Randomized Prospective Study to Compare Use of I-GelTM
and LMA ProsealTM in Patients undergoing Laparoscopic Cholecystectomy. Indian J Anesth Analg. 2020;7(6):1351–1358.
Abstract
Introduction: With the availability of supraglottic devices in providing effective seal even in conditions
of raised airway pressures, use of these devices in laparoscopic surgeries has become popular. Of the
various supraglottic devices being used in laparoscopic surgery LMA ProSealTM and i-gelTM airway are
commonly used with efficacy. The aim of this study was to compare the use of i-gelTM and LMA ProSealTM
in patients undergoing Laparoscopic cholecystectomy.
Methodology: This was a prospective randomized, hospital based study conducted at a tertiary care
hospital. Adult inpatients of either gender posted for elective laparoscopic surgery were recruited in
the study. A total of 100 patients were included out of which 50 each were randomly allocated to either
i-gelTM group (Group I) or LMA ProSealTM group (Group P). After randomization, the chosen supraglottic
airway device (i-gel/Proseal LMA) was inserted. Airway insertion attempts, time to successful ventilation,
Gastric tube placement, Airway sealing quality, Numbers of attempts required for correct placement and
complications were recorded and the data was assessed.
Results: Demographic data were comparable in the two groups. The Ventilation time was found to be
significantly faster with PLMA as compared to i-gel. I-gel and Proseal showed no significant differences
in the airway and gastric tube insertion attempts, ventilation success rate, airway sealing pressures, SpO2,
EtCO2, airway sealing quality score and intra abdominal pressures.
Conclusion: Both i-gel and Proseal both provide adequate ventilation in laparoscopic cholecystectomy
surgeries. Complications such as airway injury and bleeding with Proseal LMA are significantly more as
compared to i-gel.
Keywords: Laryngeal Masks; Cholecystecomy; Laparoscopic.
Introduction increased intra abdominal pressure. General

anaesthesia is the preferred anaesthetic technique
The intraoperative requirements of laparoscopic of choice for laparoscopic surgeries. Endotracheal
surgeries produce significant physiological intubation was considered the gold standard for
changes. These changes are mainly the result airway management for laparoscopic procedures.1
of patient position, introduction of exogenous However with the availability of supraglottic
insufflating gas CO2, pneumoperitoneum and devices which provide effective seal even in

conditions of raised airway pressures, use of these Methodology

devices in laparoscopic surgeries has become
popular. This was a prospective randomized, hospital based
Of the various supraglottic devices being used study conducted at a tertiary care hospital. Adult
in laparoscopic surgery LMA ProsealTM (The inpatients of either gender posted for elective
Laryngeal Mask Company Limited, Le Rocher, laparoscopic surgery were recruited in the study.
Victoria, Mahe, Seychelles) is widely used. It has A total of 100 patients were included out of which
a unique double cuff and a two tube arrangement. 50 each were randomly allocated to either i-gelTM
This design allows an oropharyngeal seal of group (Group I) or LMA ProsealTM group (Group
>30cm H20 without increase in directly measured P). Approval was obtained from the Institutional
mucosal pressures. The drainage tube is effective Ethical Committee.
in preventing gastroesophageal insufflation and Randomization was done by using randomizing
allows regurgitation liquid to escape via the software from http://www.randomizer.org.
drainage tube and thereby preventing aspiration.2 Insertion time was taken as a primary outcome
i-gelTM airway (Intersurgical Ltd., Crane House, variable. The power of study was taken as 0.80,
Molly Millars Lane, Workingham, Berkshire, with 5% as level of significance. Based on a study by
RG412RZ, U.K) is a novel supraglottic device Chauhan et al the sample size to detect a difference
made of a thermoplastic elastomer (SEBS, styrene of 2 minutes in insertion time with SD =3 (assuming
ethylene butadiene styrene) with a soft gel like feel. to be true for both groups) worked out to be 42 for
The mask of the i-gelTM is designed anatomically to each group.9 Sample size for this study was then
fit the perilaryngeal and hypopharyngeal structures taken as 50 expecting 10% possible dropouts and
without the use of inflatable cuff. The shape of non compliance.
the outer cuff ensures adequate blood flow to the The study was conducted from January 2014
laryngeal and perilaryngeal framework and hence to January 2015.Adult patients of either gender
chances of neurovascular compression trauma are belonging to ASA I and II admitted for elective
minimized.3,4 laparoscopic cholecystectomy were included in
Various studies have assessed hemodynamic the study. Cases of difficult airway, Cervical spine
changes and ease of insertion of different disease, Body Weight <30kg, BMI >35 kg/m2,
supraglottic airway devices such as PLMA, History of gastroesophageal reflux disease (GERD),
SLIPATM (Steamlined Liner of the Pharynx Airway) previous gastric surgery were excluded from the
and i-gelTM along with their efficiency in providing study.
reasonable alternative to tracheal tube during Preoperative evaluation of the patients was done
pressure control ventilation with moderate airway by taking detailed history, physical examination,
pressures.5–7 airway assessment and investigations. The
Similarly Uppal et al compared i-gel and cuffed investigations carried out were blood haemoglobin,
tracheal tube using leak volume (Inspired tidal total leucocyte count, differential leucocyte count,
volume – Expired tidal volume) and leak fraction platelet count, coagulation profile, liver function
(Leak volume divided by Inspiratory tidal volume) tests, blood sugar (fasting and post prandial),
by in 25 patients and found i-gel to be an effective blood urea, serum creatinine, serum electrolytes,
alternative.8 chest radiograph and electrocardiogram. Informed
The aim of this study was to compare the use of consent was taken. The patients were asked to fast
i-gelTM and LMA ProsealTM in patients undergoing overnight for at least 8 hours.
Laparoscopic cholecystectomy. The primary On the morning of surgery, intravenous
objective was to assess the time taken for successful access was secured. Inj. Ranitidine 50mg and Inj.
placement of supraglottic airway device. The Metoclopramide 10mg was given to the patient 2
secondary objective was to compare the number hours before the surgery. Patients were shifted
of attempts for insertion of airway device and to the operation theater and randomization was
nasogastric tube, the airway sealing pressure and done by using randomizing software, Research
the intraoperative ventilation parameters (airway Randomizer from http://www.randomizer.org.
sealing quality score, SpO2, inspiratory, tidal Depending on the randomization and body weight,
volume, expiratory tidal volume, peak airway the appropriate sized airway device was prepared.
pressure and EtCO2) and Oropharyngeal and Monitoring included ECG, HR, pulse oximetry for
laryngeal morbidity among the two groups. SpO2 and PR and NIBP.

Spriha Mathur, Manjula Sudhakar Rao, Ravindra Kumar Arora / A Randomized Prospective Study to 1353
Compare Use of I-GelTM and Lma ProsealTM in Patients undergoing Laparoscopic Cholecystectomy
Patients were pre-oxygenated with 100% oxygen 35–45 mmHg. Carbon dioxide was insufflated by
for 3 min and given fentanyl 2μg/.kg, glycopyrrolate the surgeon into the peritoneal cavity at 2L/min
0.004mg/kg and midazolam 0.02mg/kg. Induction to create pneumoperitoneum. Intraabdominal
of anaesthesia was done with propofol 2.0–2.5 pressure was maintained between 12–14 mmHg
mg/kg. Facemask ventilation was done with 67% throughout laparoscopic procedure.At the end
nitrous oxide and 33% oxygen and is of lurane. of surgery, patient was manually ventilated
PLMA ( ProsealTM laryngeal mask airway) or i-gelTM with 100% oxygen till the return of spontaneous
was checked and lubricated with water soluble respiration. Inj. Neostigmine 0.05mg/kg and Inj.
jelly. After induction of anaesthesia was achieved, Glycopyrrolate 0.008mg/kg i.v was given for
vecuronium bromide 0.1mg/kg was given for the reversal of neuromuscular blockade. The
muscle relaxation and facemask ventilation was supraglottic device was removed when the patient
done for 3 minutes. After 3 minutes the placement awakened and attained regular spontaneous
of supraglotticdevice was attempted. Depending on respiration. The device was checked for any blood
the randomization, the chosen supraglottic airway stain and any injury to the lips, teeth and tongue
device (i-gelTM/ProsealTM LMA) was inserted. After was noted. Any other devicerelated complications
two attempts, if the device failed to be inserted or were recorded too.
did not provide proper ventilation, the airway was Only two attempts were made to insert the
secured with endotracheal tube and the patient chosen airway device. On failed insertion with 2
was excluded from the study. Correct placement of attempts, endotracheal intubation was done.Time
the airway device was ascertained by auscultation to successful ventilation was taken as the time from
of chest for bilateral air entry, appearance of insertion of device to establishment of square wave
square waveform on capnography and adequate capnography after insertion of supraglottic device.
expiratory tidal volume. Ryle's tube was inserted The gastric tube placement was confirmed by
through the gastric channel and correct placement aspiration of gastric fluid or epigastric auscultation
was confirmed by syringe test or aspiration. In case after injecting 10 ml of air. Numbers of attempts
of failure of gastric tube insertion in 2 attempts, required for correct placement were recorded.
alternative airway like endotracheal tube was Failure was defined as inability to advance gastric
inserted and the patient was excluded from the tube into the stomach within 2 attempts. In case of
study. The airway device was fixed with adhesive failure of gastric tube placement, alternative airway
tape and connected to anaesthesia machine Datex device was used and the patient excluded from the
Ohmeda 7100 (GE Healthcare, Datex-Ohmeda, Inc., study.
3030 Ohmeda Drive, Po Box 7550, Madison, WI,
53707, USA ) and ventilated with IPPV mode via the Airway sealing quality was measured using the
circle absorber breathing system with tidal volume Airway Sealing Quality Score:10
7–8ml/kg. Anaesthesia was maintained with 67% 1: No leak detected
nitrous oxide and 33% oxygen and isoflurane
2: Minor leak of tidal volume (Vt loss less than or
(0.2%–2.0%) with intermittent vecuronium bromide
equal to 20%)
for muscle relaxation. Airway sealing pressure
was measured by closing the expiratory valve of 3: Moderate leak of tidal volume (Vt loss between
the circle system. At a fixed gas flow rate of 3L/ 20%–40%)
min, the stethoscope was placed lateral to thyroid 4: Insufficient seal (VT loss >40%)
cartilage to detect the gas leakage. The airway
Airway sealing pressure was measured as
pressure at which leak was detected was noted
pressure at which leakage was heard with
from the analog pressure gauge on the anaesthesia
stethoscope as described in the methodology
machine.9 Hemodynamic and respiratory function
above. The following parameters were monitored-
monitoring was done using Datex Ohmeda monitor
Inspiratory tidal volume, Expiratory tidal volume,
7100 for inspiratory tidalvolume, expiratory tidal
End tidal CO2, SpO2, Peak airway pressure and
volume and peak airway pressure and Philips
Intra abdominal pressure. Monitoring of these
Gas Monitor G5-M1019A for SpO2 and EtCO2. The
parameters was done using Datex Ohmeda 7100
lungs were ventilated at a respiratory rate of 12–16
every 5min, forinitial 15 mins and then every
breaths/min to maintain tidal volume of 6–8 ml/
15mins till the end of surgery.
kg, inspiratory and expiratory ratio of 1:2 and fresh
gas flow of 3 L/min (nitrous oxide and oxygen) Complications such as oropharyngeal trauma
tomaintain cardiovascular parameters within were checked for by observing the blood staining of
20% of baseline values, SpO2>95% and EtCO2 device after removal or any injury to the lips, teeth

or tongue. After the removal of supraglottic device Airway Sealing Pressure (ASP)
post surgery, any trauma caused due to the device
and device related complications were noted. The Average ‘Airway sealing pressure’ for i-gel was
patient was monitored in the PACU during the 37.55 cm H2O with SD of 11.2 and for LMA Proseal
postoperative period for at least one hour. was 36.04 cm H2O with SD of 10.19. The p-Value is
Data was presented as mean±SD for Age, BMI, 0.997 with no statistical significance as seen in Table
MPS, ASA, ventilation time (time from insertion 3.
of airway device to attainment of ventilation),
ASP, SpO2, EtCO2, peak airway pressure and
Airway Insertion Attempts
intra abdominal pressure. Gender and ventilation
success rates were compared using fisher’s exact
value test. MPS, ASA, ventilation time, airway In Group I, i-gelTM insertion was successful at first
attempts, gastric tube attempts, ASP, SpO2, EtCO2, attempt in 38/50 patients, second attempt in 8/50
peak airway pressure and intra abdominal pressure patients and failed in 4/50 patients. In Group
were compared using one way ANOVA test. P,LMA Proseal insertion was successful at first
Qualitative data like ASQ score, airway sizes used attempt in 37/50 patients, second attempt in 10/50
and traumatic complications were compared using patients and failed in 3/50 patients. The F-value
Chi square test. is 0.221 and p-value is 0.640 with no statistical
significance at p > .05 as shown in Table 4.
Results
Gastric Tube Insertion
The mean age of the subjects in Group I in whom
i-gelTM was inserted was 42.78+13.32 years and that In Group I there was one failed gastric tube insertion.
in Group P in whom LMA ProsealTM was inserted 40 gastric tubes were inserted at 1st attempt and 5 at
was 47+12.72 years. Thus the mean age between 2nd attempt. In Group P there was no failed gastric
the two groups was comparable and there was no tube insertion. 45 gastric tubes were inserted at 1st
statistical significance. (p=0.091) attempt and 2 at 2nd attempt.. The F value is 0.551
There were 63 females and 37 males in the study. and p-value is 0.460. Hence the result is statistically
There was no statistical difference between the not significant at p > 0.05. (Fig. 1)
groups in terms of gender (p=0.5). The mean BMI Gastric Tube Insertion Attemps
In Group I In Group P
of the subjects in Group I was 25.3+2.60kg/m2 and
5 1 2
in Group P was 26.1+3.13kg/m2 with no statistical
significance (p=0.749). The most commonly used
airway I-Gel and Proseal LMA was size 3 for both 40 45
(29% and 27% respectively). Chi square test showed
a p-value 0.585 (p>0.05) indicating that airway size
distribution used in both groups was statistically Failed 1st attempts 2nd attempts
insignificant. 46(92%) patients were ventilated Fig. 1: Gastric tube insertion attempts among the two groups.
successfully with i-gel and 47(94%) patients with
Proseal.Unsuccessful ventilation with Proseal Airway sealing pressure (ASP) Group I had
and i-gel were 4 patients (8%) and 3 patients (6%) Airway sealing quality score of 2.02 with SD
patients respectively. Fisher’s exact value test of 14.506. Group P had Airway sealing quality
showed a p-value 0.500 (p>0.05) indicating that this score of 2 with SD of 10.193. Thep-valueis0.997 ,
difference is statistically insignificant as shown in hencetheresult is not statistically significant at p >
Table 1. 0.05 as shown in Table 5.
Mean Ventilation Time Average End Tidal CO2 (ETCO2)
The mean ventilation time for i-gel was 17.8 secand Average End Tidal CO2 in Group I was 34.87 and
for Proseal was 13.8 sec.The F-value is 28.759 and 34.55 Group P and was comparable throughout the
is p value is 0.000 hence the result isstatistically surgery with p values >0.05 indicating no statistical
significant at p < 0.05 as shown in Table 2. significance.
Table 1: Comparison of ventilation-success rate among Group I and Group P.

Variables Group I Group P Fisher’s exact-value p-value
Yes 46 (92%) 47 (94%)
0.154 0.500
No 4 (8%) 3 (6%)
Table 2: Relation between mean ventilation times among Group I and Group P(One-Way ANOVA test).
Variables N Mean S.D. F value p- Value Significance
Group I 50 17.8 4.354
Ventilation Time 28.759 0.000 Significant
Group P 50 13.8 2.642
Table 3: Airway Sealing Pressure (ASP)among the 2 groups.

Group I 50 37.5 14.506
ASP (cm) 0.000 0.997 Non Significant
Group P 50 36.04 10.193
Table 4: Relation between AirwayAttempt variables among Group I and Group P (One-Way ANOVA test).
Group I 50 1.17 0.383
Airway Attempts 0.221 0.640 Non Significant
Group P 50 1.21 0.413
Table 5: Relation between ASP variables among Group I and Group P (One-Way ANOVA test).
Group I 50 37.5 14.506
ASP (cm) 0.000 0.997 Non Significant
Group P 50 37.6 10.193
Table 6: Relation between Peak Airway Pressure in Group I and Group P (One-Way ANOVAtest).
Time Interval (mins) Group N Mean S.D. F value p- Value Significance
I 46 15.6 4.24
0 0.567 0.453 Non Significant
P 47 16.1 2.81
I 46 20.1 5.6
P 47 20.4 4.11
I 46 21.06 5.66
P 47 22.4 4.69
I 46 20.8 4.83
15 4.677 0.033 Significant
P 47 22.7 3.42
I 46 20.04 6.2
30 5.108 0.026 Significant
P 47 22.6 4.68
I 46 15.2 9.69
P 47 17.2 10.2
Table 7: Relation between Intra Abdominal Pressure and Group I and Group P (One-Way ANOVA test).
Time Interval (mins) Group N Mean S.D. F value p- Value Significance
I 46 0.17 1.17
P 47 0.00 0.00
I 46 8.02 5.84
P 47 7.44 5.25
I 46 10.8 3.3
P 47 11.02 2.38
I 46 10.5 3.24
P 47 11.3 1.79
I 46 10.2 3.61
P 47 10.6 4.39
I 46 7.1 5.64 0.078 0.781 Non Significant
45
P 47 7.44 6.01

Table 8: Comparision of Traumatic Complications in Group I and Group P.
Variables Group I Group P Chi square-val ue p-value

Blood staining 1(2%) 6 (11%)
Gum Bleeding 1(2%) 0(0%) 6.271 0.043
Airway Trauma 0(0%) 1(2%)
Peak Airway Pressure (PAP) Discussion
The result is statistically not significant with p > In our study, we compared i-gel with PLMA
0.05 at interval 0, 5, 10 and 45 minutes. At interval during laparoscopic cholecystectomy. The primary
of 15 mins. and 30 mins, both groups had PAP >20 outcome measured was the ventilation time (
cm H2O with p value <0.05 and were statistically The time taken from insertion of airway device
significant as depicted in Table 6. to attainment of ventilation) while the secondary
outcomes were the airway and gastric tube insertion
attempts, respiratory parameters- airway sealing
Intra Abdominal Pressure (IAP) pressure, peak airway pressure, SpO2, EtCO2 and
inspired and expired tidal volumes (for adequacy
The Group I surgeries recorded an average intra of ventilation) and oropharyngeal and laryngeal
abdominal pressure of 8.25 mmHg with SD of 2.17 morbidity. The demographic parameterswere
while Group P recorded an average intra abdominal comparable in both groupsshowed no significant
pressure of 8.31 mmHg with SD of 1.52. One way differences in Group I and Group P.
ANOVA test shows that the two groups had IAPs Ventilation success rates of both groups were
which were statistically not significant at p > 0.05 as not significantly different. Singh I et al compared
shown in Table 7. clinical performance of i-gel and LMA Proseal in
elective surgeries and found that in all patients both
devices were inserted successfully within three
Complications
attempts. There were no failures and the results
were statistically insignificant.11
Group I had 1 patient with blood staining and 1
Group P showed significantly shorter ventilation
with gum bleeding.Blood staining was seen in 2%
time as compared to Group I with p value <0.05.
cases. Gum bleeding was seen in 2% cases. There In Chauhan et al’s study mean insertion time
were no complications in 96% cases of Group I. for the i-gel (11.12 ± 1.814 sec) was found to be
Group P had 6 patients with blood staining and significantly lower than the mean insertion time
1 patient with airway trauma. Blood staining was for PLMA. A statistically significant difference
seen in 11% cases. Airway trauma was seen in 2% was found between the i-gel (grade 3 = 32/40) and
cases. There were no complications in 87% cases of PLMA (grade 3 = 25/40) groups with regard to
Group P. ease of insertion.9Similarly a study by Saran et al in
pediatric patients showed that the insertion times
The Chi square-value is 6.271 and p-value is were comparable in i-gel and Proseal.12
0.043. Thus the result is statistically not significant
at p>.05 as seen in Table 8 and Fig. 2. The number of attempts for airway device
insertion and gastric tube insertion showed no
significant difference between i-gel and LMA
Proseal which was similar to the findings of a study
by Jeon W.J et al.13 A similar comparative study
done by Chauhan et al showed success rate of first
time insertion of gastric tube was 100% with the
I-gel than with the PLMA.9 Singh et al however
concluded that success rate of device insertion
was better in i-gel (100%) than Proseal (93.3%) but
showed no statistical difference.11
In our study, Airway sealing pressures in both
groups were not significantly different. In a study
Fig. 2: Complications among the two groups. by Sharma B et al it was concluded that PLMA
had a better seal than i-gelTM.14 On the contrary, I-gelTM and Proseal have shown no significant
Jadhav et al compared i-gel and Proseal LMA in differences in the airway and gastric tube insertion
short surgical procedures and found that i-gel had attempts, ventilation success rate, airway sealing
acceptable airway sealing pressure.15 In Chauhan et pressures, SpO2, EtCO2, airway sealing quality
al’s study the mean airway sealing pressure in the score and intra abdominal pressures.
PLMA group was found to be significantly higher Both i-gelTM and Proseal both provide adequate
than that observed in the i-gelTM group which was ventilation in laparoscopic cholecystectomy
unlike the findings of our study. surgeries.
SpO2, end tidal CO2, airway sealing quality score Complications such as airway injury and
and intra abdominal pressure were comparable bleeding with Proseal LMA are significantly more
in both groups with no statistically significant as compared to i-gelTM.
differences. Peak airway pressures showed
significant differences only at 15 and 30 mins of Funding sources: None
laparoscopic cholecystectomy surgery in Group Conflicts of interest: None
I (mean 20.8 and 20.04 cm H2O respectively) and
Proseal (mean 22.7 and 22.24 cm H2O respectively).
References
Despite these statistically significant differences in
both groups, both i-gel and Proseal have maintained
satisfactory ventilation with an airway pressure 1. Sood J, Kumra VP. Anaesthesia for laparoscopic
above 20 cm of H2O. As such this difference in mean surgery. Ind J Surgery 2003;65(3):232–240.
airway pressure is unlikely to have any bearing in 2. Sharma B, Sood J, Sahai C, et al. Efficacy and safety
their clinical use. performance of ProsealTM Laryngeal Mask Airway
in Laparoscopic surgery: Experience of 1000 cases.
Jeon W.J et al showed that leak airway pressures Ind J Anaesth 2008;52(3):288–96.
10 min after insertion were similar between PLMA
3. Levitan RM, Kinkle WC. Initial anatomic
and the I-gelTM. Further, leak pressure did not vary investigations of the l-gelTM airway:a novel
significantly between or within groups 15 min supraglottic airway without inflatable cuff.
after CO2 insufflation. In addition, leak volumes Anaesthesia 2005;60(10):1022–1026.
and leak fractions of these devices before and after 4. Kannaujia A, Srivastava U, Saraswat N, et al. A
CO2 insufflation were not statistically significantly preliminary study of l-gel: A new supraglottic
different.The similarities in airway leak pressures, airway device. Ind J Anaesth 2009;53(1):52–56.
leak volumes and leak fractions demonstrated that 5. Keller C, Puehringer F, Brimacombe J. The influence
both devices sealed equivalently and protected of cuff volume on oropharyngeal leak pressure and
airway effectively. A study by Sharma Bimla et al fibreoptic position with the laryngeal mask airway.
however showed that the end tidal CO2 though Br J Anaesth 1998;81(2):186–187.
within normal limits in both the groups, was found 6. Richez B, Saltel L, Banchereau F, et al. A new single
to be higher at carboperitoneum in the PLMA use supraglottic airway device with a noninflatable
Group.15 cuff and an esophageal vent: An observational study
of the I-gelTM. Anesth Analg, 2008;106(4):1137–9.
Proseal showed significantly more post operative
7. Jindal P, Rizvi A, Sharma JP. Is I-gelTM a new
complications (blood staining and airway trauma) revolution among supraglottic airway devices? A
than i-gel. This was similar to independent studies comparative evaluation. MEJ Anaesth 2009;20(1):53–
by Jadhav et al and Singh et al where they compared 58.
i-gel and proseal in short surgical procedures and 8. Uppal V, Fletcher G, Kinsella J. Comparison of
found i-gelTM to be lesser traumatic than LMA I-gelTM with the cuffed tracheal tube during pressure
ProsealTM.11,15 controlled ventilation. Br J Anaesth 2009;102(2):
264–8.
Conclusion 9. Maltby JR, Beriault MT, Watson NC, et al. The
LMA ProsealTM is an effective alternative to tracheal
intubation for laparoscopic cholecystectomy. Can J
The following inferences were drawn from this Anaesth 2002;49:857–62.
study: 10. Proseal LMA instruction manual. The Laryngeal
The Ventilation time (The time taken from Mask Company Ltd, 2000.
insertion of airway device to attainment of 11. Singh I, Gupta M, Tandon M. Comparison of
ventilation) is significantly faster with PLMA as clinical performance of I-gelTM with LMA ProsealTM
in elective surgeries. Ind J Anaesth 2009;53(3):302–
compared to i-gelTM.
305.
12. Chauhan G, Nayar P, Seth A, Gupta K, Panwar M, 14. Saran Sai, Mishra SK, Badhe AS,Vasudevan A,
Agarwal N. Comparision of clinical performance Elakkumanan LB, MishraG. Comparision of
of IgelTM with LMA prosealTM. J Anaesthesiol Clin pediatric i-gelTM and Proseal under controlled
Pharmacol 2013;29(1):50–60. ventilation.J Anaesthesiol Clin Plaramacol
13. Saraswat N, Kumar A, Mishra A, Gupta A, Saurabh 2014;30:195–8.
G, Srivastava U. The comparision of Proseal 15. Jeon WJ, Cho SY, Baek SJ, Kim KH. Comparision of
laryngeal mask airway and endotracheal tube in the ProsealTM LMA and intersurgical i-gelTM during
patients undergoing laparoscopic surgeries under gynecological laparoscopy. Korean J Anesthesiol
general anaesthesia. Indian J Anaesth 2011;55:129–134. 2012 december;63(6):510–5.


Paediatric I-Gel, Proseal LMA Vs Endotracheal Tube
Uma B R1, Sridhara2
Author’s Affiliation: 1Professor, 2Post Graduate Student, Department of Anaesthesiology, Jagadguru Jayadeva Murugarajendra
Medical College, Davangere, Karnataka 577004, India.
Corresponding Author: Uma B R, Professor, Department of Anaesthesiology, Jagadguru Jayadeva Murugarajendra Medical
College, Davangere, Karnataka 577004, India.
E-mail: umarajshekar9@gmail.com

Uma B R, Sridhara. A Comparative Evaluation of Respiratory Parameters Spo2 and Etco2 with Paediatric I-Gel, Proseal LMA Vs
Endotracheal Tube. Indian J Anesth Analg. 2020;7(6):1359–1364.
Abstract
Introduction: Supra Glottic Airway devices have set a new trend in airway maintenance since their
invention. Availability of these devices in the paediatric sizes has revolutionized their use. Endo Tracheal
Tubes have always been considered “Gold Standard” owing to their ability of maintaining stable
respiratory parameters and in prevention of aspiration. We have compared the repiratory parameters
achieved with Paediatric I-Gel, Proseal -LMA and Endo Tracheal Tube.
Description: 120 children aged 2 to 12 years, both sex, ASA 1 and 2, posted for elective surgery were
included in the study. They were divided into 3 groups of 40 each - Endo Tracheal Tube (E), Proseal
LMA (P-LMA) and I-GEL respectively. The device was inserted after induction of anaesthesia and the
respiratory parameters namely SpO2 and EtCO2 were recorded at various time intervals.
Result: All values were analysed and expressed as mean +/– SD. Statistical comparison was done by
unpaired student “t”- test and chi square test. The values obtained for various time intervals were found
to be statistically insignificant for all the three devices.
Conclusion: PaediatricProseal LMA (P-LMA) and I-GEL are very much comparable with Endo Tracheal
Tube (E) with regard to respiratory parameters and hence can be safely used as an alternative airway in
the paediatric population.
Keywords: Airway; Endotracheal Tube; I-GEL; Paediatric; Proseal LMA.
Introduction port and integral bite-block.2 ex: Proseal LMA

(P-LMA) and I-Gel. P-LMA is considered a premier
Supraglottic airway devices (SAD) have formed supraglottic airway device in children. The I-Gel seal
a revolution in the art of airway maintenance. is made of thermoplastic elastomer and overcomes
These devices are designed in such a way that the cuff related problems of second generation
they maintain a clear airway while sitting above devices.3 The P-LMA allows a higher seal pressure
the larynx and creating a seal around it.1 The “ than LMA Classic due to its drainage tube for the
First – Generation “ SAD are simple airway tubes. same intra-cuff pressure and permits drainage
ex: Laryngeal Mask Airway – LMA Classic. The of gastric secretions and access to the alimentary
“ Second – Generation” SAD contain a suction tract.4 The Endo-Tracheal Tube (ETT) has always

been a gold standard in maintaining the airway due Once the device was inserted, correct placement
to its control over respiratory parameters namely was confirmed with bilateral chest rise, air entry
Saturation (SpO2) and End tidal CO2 (EtCO2). on auscultation and EtCO2 tracing (curve). The
Maintaining these parameters throughout the SpO2 and EtCO2 recording at this point was taken
intra-operative period in the paediatric population as baseline or “0” minute value. The airway
is all the more important as they have very minimal device was secured with adhesive tapes and an
reserves. This study was conducted to compare the
appropriate size gastric tube was placed through
respiratory parameters namely SpO2 and EtCO2 at
the drain tube of P-LMA and I-GEL. Anaesthesia
various time intervals after the insertion of Proseal
was maintained with O2(40%) + N2O(60%) +
LMA and I-Gel in paediatric population with
respect to the performance of ETT. Isoflurane + Non-Depolarising muscle relaxant +
IPPV with paediatric circle absorption system. The
SpO2 and EtCO2 readings were recorded every 10
Materials And Methods minutes upto 60 minutes or completion of surgery
which ever was earlier.
This clinical study was undertaken at a tertiary At the end of surgery, children were reversed
care hospital on 120 children aged 2 to 12 years,
with neostigmine + glycopyrrolate and extubated
both sex belonging to ASA physical status 1 and
after return of spontaneous ventilation, adequate
2 undergoing elective surgery under general
muscle power and when they were fully awake.
anaesthesia.
After obtaining Institutional Ethical Committee After the insertion of the airway device in case
clearance, an informed verbal and written consent of P-LMA and I-GEL, if satisfactory EtCO2 curve
was obtained from parent/ guardian. Children was not obtained or the chest lift was not adequate,
with airway anomaly, doubtful Nil Per Oral (NPO) then the device was removed and changed over
criteria, head and neck surgery were excluded from to an ETT of appropriate size. Such children were
the study. excluded from the study.
A thorough pre-anaesthetic evaluation was
performed and necessary investigations were done. Results
Fasting guidelines were advised. On the day of
surgery, children were premedicated according to Statistical Analysis: All values were analysed and
Institutional protocol and an appropriate IV canula expressed as mean +/– SD. Statistical comparison
was secured. Fluid administration was calculated
was done by unpaired student “t”- test and
according to Holiday and Segar formula.5
chi square test. A “p” value less than 0.05 was
On arrival into the operation theatre, children regarded as statistically significant whereas “p”
were connected to standard monitors like pulse value more than 0.05 was considered statistically
oximetry, ECG, NIBP and parameters were noted. insignificant.
The study population was divided into 3 groups of
40 each namely, Endo Tracheal Tube (E), Proseal The values of SpO2 and EtCO2 with the 3 airway
LMA (P-LMA) and I-GEL through computer devices were recorded every 10 minutes. The values
generated randomization table. After the children for all the children at particular time intervals are
were allocated into one of the 3 groups, General expressed as mean +/– SD. The values obtained
Anaesthesia (GA) was induced with Sevoflurane, in ETT group was kept as a standard. The values
Oxygen, Nitrous Oxide and Fentanyl 2 mcg/kg, obtained in P-LMA ang I-GEL group are compared
relaxed with Scholine 1.5mg/kg iv. After achieving with that of ETT group.
adequate muscle relaxation, airway was secured The comparison of SpO2 and EtCO2 values at
with the device to which the child was randomly different time intervals in ETT and P-LMA group is
allocated.
shown in Table 1 and Graph 1 and 2.
For children allocated to the ETT group,
The comparison of SpO2 and EtCO2 values at
laryngoscopy was performed and appropriate
different time intervals in ETT and I-GEL group is
size cuffed/ uncuffed ETT was used to secure the
shown in Table 2 and Graph 3 and 4.
airway.
For P-LMA and I-GEL group, appropriate size The p values obtained for the SpO2 and EtCO2
device was inserted. The cuff was inflated in the values at different time intervals was statistically
P-LMA group. not significant.

Uma B R, Sridhara / A Comparative Evaluation of Respiratory Parameters Spo2 and Etco2 with Paediatric 1361
I-Gel, Proseal LMA Vs Endotracheal Tube
Table 1: SpO2 and EtCO2 values: P-LMA vs ETT.

Time EtCO2 SpO2
PLMA ETT P – Value PLMA ETT P - Value
0 31.15 ± 4.142 30.775 ± 2.093 0.6108 99.375 ± 0.925 98.9 ± 1.335 0.068
10 31.275 ± 3.98 31.2 ± 1.963 0.9152 99.55 ± 0.749 99.275 ± 1.131 0.2036
20 31.2 ± 3.736 31.625 ± 1.674 0.5134 99.6 ± 0.708 99.4 ± 1.032 0.3153
30 31.525 ± 3.162 31.85 ± 1.888 0.578 99.775 ± 0.479 99.55 ± 0.714 0.1019
40 30.775 ± 2.759 31.325 ± 1.456 0.2683 99.875 ± 0.404 99.95 ± 0.316 0.3611
50 30.925 ± 3.253 30.975 ± 1.51 0.93 99.75 ± 0.543 99.65 ± 0.579 0.428
60 30.425 ± 3.265 30.3 ± 1.042 0.8182 99.75 ± 0.630 99.675 ± 0.764 0.633
P value not significant.
Table 2: SpO2 and EtCO2 values: I-GEL vs ETT.

Time EtCO2 SpO2
I-GEL ETT P - Value I-GEL ETT P - Value
0 30.9 ± 1.9 30.775 ± 2.093 0.7719 99.15 ± 1.122 98.9 ± 1.335 0.3674
10 31.15 ± 1.657 31.2 ± 1.963 0.9023 99.525 ± 0.933 99.275 ± 1.131 0.2842
20 31.2 ± 1.62 31.625 ± 1.674 0.2521 99.55 ± 0.875 99.4 ± 1.032 0.4853
30 31.35 ± 1.672 31.85 ± 1.888 0.2136 99.725 ± 0.598 99.55 ± 0.714 0.2383
40 31.1 ± 1.41 31.325 ± 1.456 0.4847 99.925 ± 0.349 99.95 ± 0.316 0.7379
50 30.75 ± 1.315 30.975 ± 1.51 0.4794 99.8 ± 0.464 99.65 ± 0.579 0.2048
60 30.5 ± 1.432 30.3 ± 1.042 0.4772 99.7 ± 0.648 99.675 ± 0.764 0.875
P value not significant.

SpO2
100.2
100
99.8
99.6
99.4
99.2
99
98.8
98.6
98.4
98.2
0 min 10 min 20 min 30 min 40 min 50 min 60 min
PLMA ETT
Graph 1: SpO2 values: P-LMA vs ETT.
ETCO2
32
31.5
31
30.5
30
29.5
PLMA ETT
Graph 2: EtCO2 values: P-LMA vs ETT.

100.2
SpO2
100
99.8
99.6
99.4
99.2
99
98.8
98.6
98.4
98.2
IGEL ETT
Graph 3: SpO2 values: I-GEL vs ETT.
EtCO2
32
31.5
31
30.5
30
29.5
I-GEL ETT
Graph 4: EtCO2 values: I-GEL vs ETT.
Discussion Most of the available literature on Supra Glottic

Airway Devices (SAD) have studied and compared
ETT have been a standard technique of securing the parameters like ease of insertion, oropharyngeal
airway in paediatric population since many years. leak pressures, ease of insertion of gastric drain tube
It no doubt provides a secure airway for ventilation etc,.The success of insertion of SAD were mainly
and protects against aspiration of gastric contents assessed based on the appearance of square wave
when an adequate size ETT is used. Maintenance capnography trace along with adequate chest-lift,
of respiratory mechanics and their monitoring auscultation of breath sounds.3, 7
has been very reliable with ETT. Use of ETT in We recorded the SpO2 and EtCO2 values of
paediatrics have their own disadvantage namely I-Gel, P-LMA and ETT at various time intervals.
(1) Expertise (2) Size selection – smaller tubes cause On comparison of SpO2 and EtCO2 values of ETT
resistance to ventilation, air leak, gastric distension and I-Gel at various time intervals, they were
leading to regurgitation and aspiration whereas a statistically insignificant with p-value more than
larger tube is difficult to pass beyond the sub-glottis 0.05.
and causes post-operative airway oedema, stridor Similarly, the comparison of SpO2 and EtCO2
and obstruction due to narrow sub-glottic anatomy. values of ETT and P-LMA were statistically
When cuffed ETTs are used, inadvertant high cuff insignificant.
pressures may further compromise perfusion of
pharyngeal mucosa. Various causes can be attributed to changes in
SpO2 and EtCO2 values. During placement of the
Many of the above mentioned disadvantages device, if longer time is taken for insertion, there
have been successfully over come by the availability may be desaturation and hence low SpO2 recordings.
and use of paediatric P-LMA since 20076 and I- Gel The I- Gel for instance is quicker to insert than the
since later part of 2009 and early 2010.2 LMA Classic or P-LMA as there is no cuff to inflate.2
Uma B R, Sridhara / A Comparative Evaluation of Respiratory Parameters Spo2 and Etco2 with Paediatric 1363
I-Gel, Proseal LMA Vs Endotracheal Tube
Upon insertion of the device, improper placement, mentioned techniques are accurate and reliable with
dislodgement and/ or disconnections can lead to regard to OPL pressure assessment.11 Maintenance
abnormal values of SpO2 and EtCO2. of appropriate OPL pressure avoids post -operative
Lighter planes of anaesthesia combined with complications of SAD. We however did not notice
any complications in our study group.
Pre-existing infections may be disastrous with
laryngospasm, bronchospasm, desaturation and With the extensive availability and use of
increasing EtCO2 values. 2nd generation SAD in paediatric population,
anaesthesiologist may have to select between
Proper fixation of any airway device is of prime
I-GEL and P-LMA. I- Gel has added advantages
importance after its insertion. Some have even
over P-LMA. I-Gel can be used in difficult airway
recommended technique of fixation of SAD with
scenario likes burns contracture,12 syndromic
adhesive tapes from maxilla to maxilla. If the SAD
children with airway abnormality.13 Since the I-Gel
is not fixed properly, chances of dislodgement is
is devoid of an inflatable cuff, it is quicker to insert.2
high as they are bulkier compared to ETT.
I-Gel promotes easy passage of fiberoptic scope and
Selection of appropriate size of SAD reduces also an ETT as it has a wide bore stem and lacks
the time of insertion or in other words minimizes epiglottic bars.2
the time of securing the airway. Availability of P-LMA insertion is easier due to the absence of
different sizes of paediatric SAD minimizes the time a rear cuff. The side by side presence of the airway
required to change the device in case of inadequate tube and drainage tube prevents its rotation during
ventilation. Adhering to the flow chart of size insertion. This is in contrast to the cuff in LMA
selection based on body weight recommended by classic which folds on itself when deflated and
the manufacturer in most of the cases overcomes makes its insertion theoretically difficult.7
this problem. In conditions where the body weight
cannot be measured as in emergency scenario,
bed ridden children etc, many authors have Conclusion
recommended pinna or auricle size based selection
criteria.8,9 Paediatric supraglottic airway devices like I-Gel and
Knowledge and prior experience of the P-LMA are novel approach of securing the airway
with adequate control of respiratory parameters like
anaesthesiologist regarding SAD plays an important
SpO2 and EtCO2. They are very much comparable
role in many situations dealing the airway.
to the stable respiratory parameters provided by
However White MC and colleagues concluded that
ETT and hence are a suitable alternative airway
an effective airway can be provided even without
devices.
prior experience using P-LMA.1 There is more than
90% success rate of first time insertion of I-Gel as Acknowledgement: We are grateful to all the
observed by P. Smith and C. R. Bailey.2 In our study, surgeons, OT staff, patients’, their parents/
the insertion of SAD was successful in all children guardian without whom this study would not have
and we have used the standard insertion technique been possible.
recommended by the manufacturer. Various
other techniques like introducer and gum elastic References
bougie have been compared by many authors.10
The anaesthesiologist inserting the device was
1. White MC, Cook TM, Stoddart PA. A critique of
experienced and had thorough knowledge of SADs elective pediatric supraglottic airway devices.
and airway maintenance. None of the children in Pediatric Anesthesia 2009; 19(Suppl. 1): 55–65.
our study had any airway complications requiring
2. P. Smith, C R Bailey, A performance comparison of
change of SAD to ETT. the paediatric i-gel™ with other supraglottic airway
The end-point of cuff inflation or assessing devices,Anaesthesia,Volume 70, Issue 1, January
oropharyngeal leak pressure (OPL) of P-LMA 2015:84–92.
was left to the individual anaesthesiologist. They 3. Yogita Dwivedi, Amrita Gupta, Uma Srivastava,
used one of the 4 techniques of determining the Keshav Dev Jagar, Atiharsh Mohan, Sandeep
OPL pressure namely (1) Detection of audible Mangla, Comparison of i-gel™, LMA Proseal™
and LMA Classic™ in spontaneously breathing
noise (2) Determination of EtCO2 in oral cavity
pediatric patients, Anaesthesia, Pain and Intensive
(3) Airway pressure monitoring (4) Audible noise Care, ISSN 1607–8322, ISSN (Online) 2220–5799.
by neck stethoscopy. M Lopez-Gil and colleagues
4. Brain AI, Verghese C, Strube PJ, The LMA ‘ProSeal’-
have concluded in their study that all the above
a laryngeal mask with an oesophageal vent. Br J children: a prospective observational study, Braz J
Anaesth 2000;84:650–4. Anesthesiol,Jan-Feb 2017;67(1):15–20.
5. Rachel S. Meyers, Paediatric Fluid and Electolyte 10. Chuan Yeong Teoh , Felicia S K Lim, The Proseal
Therapy, J Pediatr PharmacolTher. 2009 Oct- laryngeal mask airway in children: a comparison
Dec;14(4):204–211. between two insertion techniques, PaediatrAnaesth.
6. Fiona Kelly, A cohort evaluation of the 2008 Feb;18(2):119–24.
pediatricProSeal laryngeal mask airway in 100 11. M Lopez-Gil MD, J Brimacombe MB, CHB, FRCA
children, Paediatric Anaesthesia, 2008.
MD, C Keller MD, A comparison of four methods
7. H Shimbori, Comparison of the LMA-ProSeal™ for assessing oropharyngeal leak pressure with
and LMA-Classic™ in children, BJA: British Journal the laryngeal mask airway (LMA™) in paediatric
of Anaesthesia, Volume 93, Issue 4, 1 October 2004, patients, PediatricAnesthesia;Volume 11 (3) , 2001.
Pages 528–531, https://doi.org/10.1093/bja/aeh
238. 12. Gupta R, Gupta R, Wadhawan S, Bhadoria P.
Tracheal intubation through I-gel conduit in
8. Ramya Ravi, VK Mohan, Ashok Shankar Badhe,
a child with post-burn contracture. Journal of
Sandeep Kumar Mishra, Prasanna Udupi Bidkar,
Comparison of weight-based and pinna size–based Anaesthesiology and Clinical Pharmacology 2012;
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OzgeKoner, Simple method for determining with Goldenhar syndrome – a case report. Korean
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A Comparitive Evaluation of Propofol, Sevoflurane and Desflurane for

Neuroanaesthesia in Patients Undergoing Elective
Supratentorial Craniotomies
B Sowbhagyalaxshmi1, P Krishna Prasad2, M Santhi Sree3
Author’s Affiliation: 1Professor and HOD, 2,3Associate Professor, Department of Anaesthesiology, Rangaraya Medical College,
Kakinada, Andhra Pradesh 533001, India.
Corresponding Author: P Krishna Prasad, Associate Professor, Department of Anaesthesiology, Rangaraya Medical College,
E-mail: santhisreemulam@gmail.com

B Sowbhagyalaxshmi, P Krishna Prasad, M Santhi Sree. A Comparitive Evaluation of Propofol, Sevoflurane and Desflurane for
Neuroanaesthesia in Patients Undergoing Elective Supratentorial Craniotomies. Indian J Anesth Analg. 2020;7(6):1365–1372.
Abstract
Aim: To compare the effects of propofol, sevoflurane and desflurane in patients undergoing supratentorial
craniotomies under general anaesthesia with regard to, perioperative haemodynamic stability, emergence
and recovery characteristics.
Materials and Methods: A prospective randomized study of 150 adult patients belonging to both sexes
undergoing elective supratentorial craniotomies under general anaesthesia were takenup for study and
divided into three groups of 50 each. Group P : Anaesthesia was induced with Inj. Thiopentone sodium
and maintained with 66% nitrous oxide (N20), in 33% oxygen (02) and Propofol (3-6mg/kg/hr) Group S:
Anaesthesia was induced with Inj.Thiopentone sodium and maintained with 66% nitrous oxide (N2O) in
33% oxygen (O2) and Sevoflurane. (1-2%) Group D: Anaesthesia was induced with Inj. Thiopentone sodium
and maintained with 66% N2O and 33% O2 and Desflurane. (4-6%). The effects of Propofol, Desflurane and
Sevoflurane on haemodynamics and recovery characteristics were observed.
Results: In Desflurane Group the mean time taken for response to verbal commands was 4.61±0.47 min,
spontaneous eye opening was 5.3±0.49 min,to squeezing fingers and lift limb was 6.17 ± 0.31 min. While
the mean time taken for extubation was 7.72±0.53 min and time taken to orientation to place, name was
9.38±0.52min. These desflurane values are very much lower than the other two groups.
Conclusion: We conclude that Desflurane as the inhalational agent ensures faster recovery in the early
postoperative period as evident from significant decrease in the time required for extubation and the time
required to achieve a modified Aldrete score of ≥ 9 when compared to patients receiving Sevoflurane and
Propofol.
Keywords: Desflurane; Sevoflurane; Propofol; Emergence; Recovery.
Introduction autoregulation, Minimal effect on ICP, Early

emergence and recovery. Both intravenous
Anaesthesia for neurosurgery is a challenge. The and inhalational anaesthetics are used. In the
ideal anaesthesia for neurosurgical procedures present scenario three agents, which are very
must have the following characteristics.1 Reduction popular for use in the neurosurgical patients are
of cerebral metabolism, Neuroprotection, propofol, sevoflurane and desflurane.2 The present
Haemodynamic stability, Preservation of cerebral preliminary study was carried out to assess and

compare the effects of propofol, sevoflurane and Pts with severe obesity (BMI>30).
desflurane on intraoperative haemodynamics, and Surgery related complications like - vascular
emergence characteristics in patients undergoing injury, massive intraoperative bleeding or injury to
elective supratentorial craniotomies. vital structures necessitating elective postoperative
mechanical ventilation.
Aims and Objectives
Preanaesthetic Evaluation and Consent
Aim: To compare the effects of propofol,
sevoflurane and desflurane in patients undergoing All the patients posted for surgery underwent
supratentorial craniotomies under general a preanaesthetic evaluation which consisted of
anaesthesia with regard to: detailed history regarding present complaints,
Primary Objectives past medical history, history of previous surgeries
1. To assess perioperative haemodynamic or anaesthesia, physical examination and routine
stability. investigations. Other relevant investigations such
as 2D echo were done if indicated in that particular
2. To assess the emergence and recovery case. Selected patients were explained about the
characteristics study in their own language and a written informed
Secondary Objectives: To compare side effects like consent was taken to participate in the study.
drowsiness , nausea and vomiting . Patients undergoing surgery were kept nil by
mouth for a minimum of 6 hours for solid food and
Material and Methods 2 hours for clear liquids before starting of surgery.
They were premedicated with Tab. Rantidine
150mg , Tab. Alprazolam 0.5mg orally on the night
Study Design: A prospective randomized study of 150
before surgery.
adult patients belonging to both sexes undergoing
elective supratentorial craniotomies under general Anaesthesia technique: On the morning of the
anaesthesia were carried out at RangarayaMedical surgery, anaesthesia machine and monitors were
College Kakinada from December 2016-August checked. Emergency drugs tray was kept ready.
2018. After shifting the patient into the operation theatre,
patients were monitored for baseline heart rate,
Selection of Subjects: Age group ranging from
systolic blood pressure, diastolic blood pressure,
20–60 yrs.
mean arterial pressure, ECG (lead II) and oxygen
ASA Grade 1–3 saturation using multi parameter monitor. An two
Either sex 18 G I.V. cannulas was secured and an infusion
of dextrose normal saline was started at a rate of
Glasgow Coma Scale (GCS) ranging from 12–15.
10ml/kg body weight .
The subjects are divided into 3 groups - Group
Inj. Ondansetron 0.1mg/kg IV, Inj. Fentanyl
P, Group S, Group D by computer generated
1mcg/kg IV, Inj.Midazolam 0.01mg/kg IV are
randomization table.
given as premedication.
Group P: Patients anaesthesia maintained by
Group P: Anaesthesia was induced with Inj.
Propofol.
Thiopentone sodium and maintained with 66%
Group S: Patients anaesthesia maintained by nitrous oxide (N20), 33% oxygen (02) and Propofol
Sevoflurane. (3–6mg/kg/hr).
Group D: Patients anaesthesia maintained by Group S: Anaesthesia was induced with Inj.
Desflurane. Thiopentone sodium and maintained with
Exclusion Criteria: Pts with ischemic and/or 66% nitrous oxide (N2O) , 33% oxygen (O2) and
congestive heart disease Sevoflurane.(1–2%)
Pts with Chronic obstructive pulmonary disease Group D: Anaesthesia was induced with Inj.
Thiopentone sodium and maintained with 66%
Pts with Hepatic and Renal dysfunction N2O , 33% O2 and Desflurane.(4–6%).
Pts with known Drug allergy or abuse Preoxygenation was done with 100% O2 for
Pts using CNS depresents drugs and anti 3–5 min using closed circuit. Patient was induced
psychotics with Inj. Thiopentione sodium 5–7 mg/kg IV till
B Sowbhagyalaxshmi, P Krishna Prasad, M Santhi Sree / A Comparitive Evaluation of Propofol, Sevoflurane 1367
and Desflurane for Neuroanaesthesia in Patients Undergoing Elective Supratentorial Craniotomies
loss of eyelash reflex .After confirming adequate iii. Time taken to squeeze fingers and lift limb
mask ventilation, Inj. Vecuronium bromide– 0.1 (time taken from discontinuation of the
mg/kg IV was given and ventilated with 50% inhalational agent or intravenous agent to
N2O and 50% O2 Laryngoscopy and Intubation squeeze fingers and lift limb).
was done with appropriate size, cuffed portex
iv. Extubation time (from the time of
endotracheal tube. Closed circuit was connected administering reversal agent to removal of
to endotracheal tube and bilateral equal air entry endotracheal tube).
was confirmed and endotracheal tube was secured.
Anaesthesia was maintained with O2 : N2O (50:50)
3. After extubation, orientation was assessed
at 2 L/min + Sevoflurane 1–2% or Desflurane4– Time taken to state name, place of stay and date
6% or Propofol 3–6mg/kg/hr infusion as per the of birth ( i.e, from the time of extubation to the
group the patient was assigned to using mind time patient states name, place of stay and date
ray A6 machine compatible with Sevoflurane, of birth)
Desflurane vapourizers and propofol infusion. 4. Duration of surgery (defined in this study as
The Dial concentration or infusion pump was the time period from incision to the application
adjusted to control mean arterial pressure (MAP) of last skin suture)
and heart rate (HR) within 20% range of the

5. Duration of anaesthesia (from the time of
preoperative values. Ventilation was controlled
induction to discontinuation of the inhalational
using closed circle absorber system and end tidal
agent or intravenous agent)
carbon dioxide (etco2) was maintained between
30–45 mm Hg using volume control mode (VCV) of
6. In the post - anaesthesia care unit (PACU)
ventilation. Incremental doses of muscle relaxant, intermediate recovery was assessed by the
Inj.Vecuronium Bromide were given in doses of modified Aldrete score every 5 min. till the
– 0.025 mg/kg IV and .Intraoperative fluids were score became greater than 9 [time taken to
given as per the requirement of the patient. achieve modified Aldrete score of >9 is defined
in this study as the time when patient was
At the end of surgery, after the last skin
shifted to PACU till he/she reaches modified
suture was placed, N2O and volatile agent or
Aldrete score of > 9].
propofol infusion were discontinued, patient was
ventilated with 100% oxygen with fresh gas flow Recovery Scores: In 1995, Aldrete published the
of eight to ten liters/min till patient establishes modified Aldrete score.29 In this score, the variable
spontaneous respiration. Then reversal was done colour is replaced by saturation/spo2.
with Inj. Neostigmine 0.05mg/kg IV and Inj. Modified Aldrete Score: Modified Aldrete Score of
Glycopyrrolate 0.01 mcg/kg IV.Patients were ≥9 indicates good intermediate recovery.
extubated once they fulfilled the extubation criteria
Oxygenation SPO2>92% on room air 2
and were hemodynamically stable. Early recovery
characteristics were assessed. Patients were then Spo2>90% on oxygen 1
shifted to post-anaesthesia care unit (PACU). Spo2<90% on oxygen 0
Respiration Breathes deeply and coughsfreely 2
1. Heart rate, Systolic blood pressure, Diastolic
blood pressure,Mean Arterial Pressure and Dyspnoeic, shallow or limited breathing 1
SpO2 were recorded before induction, after Apnoea 0
induction, every 5 min for initial 15 min and Circulation BP±20mmhg of normal 2
every 15 min till the end of surgery and then BP±20–50mmhg of normal 1
postoperatively every 5 min till the modified BP morethan±50mmhg of normal 0
Aldrete score was >9 Consiousness Fully awake 2
2. Following emergence times were noted: Arousable on calling 1
i. Time taken for response to verbal command Not responsive 0
(Time taken from discontinuation of the Activity Moves all extremities 2
inhalational agent or intravenous agent to the Moves two extremities 1
patient's response to verbal commands. No movement 0
ii. Time taken for spontaneous eye opening 7. Patients were observed for adverse effects like
( time taken from discontinuation of the drowsiness, nausea, vomiting, respiratory tract
inhalational agent or intravenous agent to irritation in the form of cough and were treated
spontaneous eye opening). accordingly depending on severity.

Observation and Results Chi-square test. A p-value <0.05 is considered

statistically significant. The data was tabulated in
In this prospective, randomized study, 150 adult MS Excel and analysis performed using Statistical
patients admitted to Rangaraya Medical College Package for Social Sciences (SPSS) version 16.0
And Government General Hospital Kakinada, software.
undergoing elective supratentorial craniotomies Demographic Data: All the three groups have
under general anaesthesia were randomly patients aged between 20–60 yrs .The difference
given Desflurane or Sevoflurane or Propofol
in age groups between the three groups was
as maintenance agents .The effects of Propofol,
statistically insignificant. There is no statistically
Desflurane and Sevoflurane on haemodynamics
and recovery characteristics were observed. significant difference between patients age, gender,
weight and duration of surgery.
Statistical Analysis: The descriptive summary
of variables will be presented through frequency Haemodynamic Characteristics: The difference
distributions as well as mean±sd. Quantitative in the mean heart rate between the three groups
variables are expressed as mean±sd and compared in the intraoperative period was statistically
between groups using Unpaired t-test and insignificant(p value>0.05). The changes in the
within groups across follow-ups using paired mean heart rate were within ±20% baseline values.
t-test. Qualitative variables are compared using (Table 1).
Table 1: Changes In Intraoperative Mean Heart Rate (BPM).

Propofol Sevoflurane Desflurane p-values
Heart Rate
mean ±sd mean ±sd mean ±sd P vs S P vs D S vs D
Baseline 88.58 ±4.93 89.66 ±4.74 88.52 ±4.63 0.134 0.475 0.114
5min 87.84 ±6.3 89.66 ±7.58 88.22 ±6.02 0.097 0.379 0.148
10min 87.92 ±6.39 89.52 ±6.08 87.82 ±6.89 0.101 0.470 0.097
15min 87.74 ±5.5 89.34 ±6.54 88.56 ±6.51 0.094 0.249 0.276
30min 86.70 ±5.68 88.62 ±6.1 88.54 ±6.76 0.053 0.072 0.475
60min 86.06 ±5.57 86.36 ±5.64 87.26 ±6.37 0.395 0.159 0.228
90min 84.38 ±4.93 84.28 ±4.06 84.74 ±5.93 0.456 0.371 0.326
120min 83.08 ±3.92 82.18 ±4.2 83.56 ±4.9 0.135 0.295 0.067
180min 82.17 ±3.48 82.74 ±3.64 82.33 ±4.93 0.258 0.439 0.333
240min 84.18 ±2.99 83.60 ±5.51 82.48 ±4.9 0.372 0.145 0.217
300min 84.60 ±4.51 81.29 ±5.28 84.64 ±4.13 0.141 0.494 0.076
Postop 5min 91.12 ±8.27 90.26 ±8.31 88.80 ±6.03 0.303 0.056 0.159
Postop 10min 88.72 ±6.89 88.88 ±7.21 86.98 ±7 0.455 0.107 0.092
Postop 15min 91.12 ±8.13 89.40 ±6.87 89.60 ±5.69 0.128 0.141 0.437
Table 2: Changes In Intraoperative Mean SBP (mmHg).

Blood Pressure Propofol Sevoflurane Desflurane p-values
(Systolic) mean ±sd mean ±sd mean ±sd P vs S P vs D S vs D
Baseline 120.16 ±10.62 121.58 ±9.96 122.68 ±10.1 0.246 0.113 0.292
5min 117.80 ±8.15 117.62 ±17.61 118.90 ±10.03 0.474 0.274 0.328
10min 125.68 ±10 126.72 ±7.37 125.04 ±8.42 0.278 0.365 0.145
15min 127.52 ±11.68 128.40 ±7.95 126.60 ±7.89 0.330 0.323 0.129
30min 125.86 ±14.03 129.08 ±8.46 126.92 ±6.96 0.084 0.317 0.083
60min 130.00 ±11.12 129.66 ±7.84 128.08 ±7.09 0.430 0.153 0.147
90min 127.42 ±11.83 127.38 ±9.06 124.88 ±7.96 0.492 0.105 0.073
120min 123.14 ±13.31 122.64 ±7.18 125.14 ±8.47 0.408 0.186 0.057
180min 123.08 ±9.47 123.34 ±10.11 126.07 ±9.39 0.467 0.175 0.131
240min 120.00 ±11.95 118.24 ±6.81 120.67 ±7.76 0.310 0.436 0.163
300min 120.00 ±8.16 115.63 ±4.78 120.38 ±7.44 0.131 0.469 0.076
Postop 5min 118.60 ±9.69 118.40 ±9.55 120.12 ±9.12 0.459 0.211 0.180
Postop 10min 123.20 ±5.87 123.20 ±6.21 124.70 ±7.6 0.500 0.136 0.141
Postop 15min 118.00 ±9.04 117.60 ±8.94 119.74 ±8.96 0.412 0.168 0.117

Table 3: Changes in The Intraoperative Mean DBP (mmHg).
Blood Pressure Propofol Sevoflurane Desflurane p-values

(Diastolic) mean ±sd Mean ±sd mean ±sd P vs S P vs D S vs D
Baseline 78.60 ±9.48 80.76 ±8.76 78.16 ±3.64 0.120 0.380 0.028
5min 76.20 ±8.3 77.00 ±9.6 75.42 ±5.22 0.328 0.288 0.155
10min 75.20 ±8.39 77.08 ±10.07 75.72 ±10.07 0.157 0.390 0.251
15min 75.20 ±7.89 77.28 ±10.24 76.96 ±7.97 0.129 0.135 0.431
30min 75.80 ±7.31 76.48 ±11.73 75.54 ±8.31 0.364 0.434 0.322
60min 76.40 ±8.51 77.60 ±13.6 75.32 ±8.7 0.299 0.266 0.160
90min 77.60 ±8.22 78.02 ±9.33 75.30 ±12.19 0.406 0.136 0.107
120min 77.40 ±8.53 78.52 ±8.31 76.43 ±9.67 0.254 0.298 0.125
180min 78.46 ±6.89 78.68 ±7.58 75.46 ±11.78 0.463 0.201 0.086
240min 77.50 ±8.86 77.81 ±6.01 79.59 ±9.65 0.457 0.305 0.246
300min 80.00 ±8.16 76.25 ±5.28 74.44 ±8.82 0.177 0.154 0.311
Postop 5min 80.20 ±6.85 79.80 ±6.85 79.34 ±6.71 0.385 0.264 0.368
Postop 10min 76.40 ±8.02 77.20 ±8.34 75.02 ±7.13 0.313 0.183 0.082
Postop 15min 82.40 ±5.91 82.20 ±5.82 80.70 ±9.44 0.432 0.141 0.170
Table 4: Changes in Intraoperative Oxygen Saturation (SPO2).

SpO2
Baseline 98.71 ±0.85 98.58 ±0.7 98.78 ±1.09 0.208 0.359 0.140
5min 98.94 ±0.81 98.66 ±0.63 98.88 ±1.08 0.030 0.384 0.108
10min 98.69 ±0.77 98.80 ±0.86 99.02 ±1.06 0.259 0.042 0.128
15min 98.96 ±0.73 98.88 ±0.92 99.10 ±0.97 0.315 0.209 0.124
30min 97.00 ±12.72 99.24 ±0.77 98.98 ±0.84 0.108 0.137 0.056
60min 98.80 ±0.76 98.92 ±0.8 99.04 ±0.92 0.222 0.079 0.245
90min 98.60 ±0.64 98.72 ±0.78 98.94 ±1.22 0.202 0.042 0.143
120min 98.78 ±0.76 98.72 ±0.61 99.00 ±1.23 0.332 0.142 0.076
180min 98.18 ±0.94 98.03 ±0.72 99.0 ±1.06 0.259 0.042 0.128
240min 98.40 ±0.52 98.64 ±0.64 99.08 ±1.09 0.315 0.209 0.124
300min 98.50 ±0.58 98.71 ±0.49 99.09 ±0.98 0.108 0.137 0.056
Table 5: Early Recovery Profiles (Min).

Time Taken for
mean ±sd mean ±sd Mean ±sd P vs S P vs D S vs D
Response to verbal commands 7.34 ±0.58 9.53 ±0.53 4.61 ±0.47 <0.001 <0.001 <0.001
Spontaneous eye opening 7.75 ±0.45 10.3 ±0.57 5.3 ±0.49 <0.001 <0.001 <0.001
Squeesing fingers and lifting limb 8.05 ±0.57 11.16 ±0.58 6.17 ±0.31 <0.001 <0.001 <0.001
Extubation time 8.52 ±0.96 11.81 ±0.63 7.72 ±0.53 <0.001 <0.001 <0.001
Orientation to time place 9.21 ±0.38 12.62 ±0.64 9.38 ±0.52 <0.001 0.038 <0.001
The difference in the mean systolic blood pressure 100.00

between the three groups in the intraoperative
Mean Arterial Pressure
95.00
period was statistically insignificant. (Table 2).
90.00
The difference in the mean diastolic Blood
pressure between the three groups in intraoperative 85.00 Propofol
period was statistically insignificant. (Table 3). 80.00
Sevo? urane
The difference in the Mean Arterial Pressure Des? urane

75.00
between the three groups in intraoperative period
was statistically insignificant (p >0.05) (Fig 1). 70.00
n
15 n
30m n
60 n
90 n
12 i n
180 i n
24 i n
300 i n
n
e
From the above data intra operative oxygen

lin
i
i
mi
i
mi
mi
5m
10m
m
0m
m
0m
se
saturation between three groups was statistically

Ba
insignificant (Table 4). Fig. 1: Showing mean arterial pressure between groups.

Table 6: Modified Aldrete Scores at 5Min and 10Mins.

MAS 5 6.78 ±1.2 5.49 ±0.54 8.74 ±0.69 <0.001 <0.001 <0.001
MAS 10 7.82 ±1.24 6.47 ±0.5 9.62 ±0.52 <0.001 <0.001 <0.001
Table 7: Time Taken For Modified Aldert Score>9.

MAS >9 10.97 ±1.42 14.61 ±1.13 9.64 ±0.66 <0.001 <0.001 <0.001
(Table 5) shows the early recovery profiles In this range of Mean Arterial Pressure cerebral
between three groups. In Desflurane Group the blood flow is kept constant in the presence
mean time taken for response to verbal commands of changing cerebral perfusion pressure. The
was 4.61±0.47min, spontaneous eye opening was importance of cerebral blood flow autoregulation
5.3±0.49min,to squeezing fingers and lift limb lies in its relationship to Intra Cranial Pressure. If
was 6.17 ±0.31min .While the mean time taken for the cerebral blood flow increases the cerebral blood
extubation was 7.72±0.53min and time taken to volume increases and that leads to increase in intra
orientation to place ,name was 9.38±0.52min.These cranial pressure. Conversely a reduction in cerebral
desflurane values are very much lower than the blood flow may produce a reduction in cerebral
other two groups blood volume and intracranial pressure.
The early recovery proflie as indicated by the Recovery from general anaesthesia is a period of
above observed parameters were significently faster intense stress and strain for the patient. The stressful
in Group D compared to other two groups with p events increases the cerebral oxygen consumption
value being <0.005 indicating significant difference. and cerebral blood flow.This leads to increase in intra
The intermediate recovery profile indicated by cranial pressure thus promoting cerebral insults.
modified Aldrete score at 5min and 10min interval The main aim for a rapid awakening strategy
and time taken to achieve modified Aldrete score after craniotomy with general anaesthesia is that
of >9 was significantly faster in Group D compared an early recognition of postoperative neurologic
to Group P and Group S with P VALUE <0.001 complications and it is essential to limit potentially
which is highly significan (Table 6). The mean dangerous consequences and improve patient
time taken to achieve modified Aldrete score of >9 outcome.3
in Group D was when compared to Group S and Anaesthetic agents in this study appear
Group P indicating faster intermediate recovery to subserve the objectives of maintaining
in Desflurane group compared to Sevoflurane and haemodynamic stability, providing adequate
Propofol group.Side effects are very less in number brain condition and providing early emergence.
and there was no statistically significant difference considering the observations of our study, it is
between the three groups (p value >0.05) (Table 7). reasonable to interpret that propofol, sevoflurane
and desflurane are acceptable for use in practice of
Discussion neuroanaesthesia.
Regarding the haemodynamic parameters,
The goals of anaesthesia in neurosurgical patients changes in HR, SBP, DBP and MAP, SPO2 when
are providing haemodynamic stability throughout compared to the baseline values, there was
the procedure ,providing slack brain to surgeon statistically insignificant difference between
and facilitating early emergence and recovery. the three groups at various intervals during
The preservation of stable haemodynamics maintenance of general anaesthesia till the patients
in supratentorial craniotomies is crucial were extubated. The changes in the mean heart
for postoperative morbidity and mortality. rate, systolic blood pressure and diastolic pressure
Autoregulation of Cerebral Blood Flow (CBF) refers were within ±20% of the baseline values in the
to the intrinsic control over vascular smooth muscle three groups. Similar findings were observed in
tone in the cerebral vessels as the body maintains a the studies conducted by Priska Bastola,Hemanth
relatively constant blood flow to the brain despite Bhagat And Jyostsna WIG4 in 2015.
variation in the systamic Mean Arterial Pressure The stable haemodynamics during the
across a range of 50 to 150mmhg. maintenance period and the lack of any difference

between the three groups in our study was K Gupta8 they concluded that both desflurane and
predictable, since the study was designed to propofol are comparable as anesthetic agents for
maintain mean arterial pressure (MAP) within patients undergoing CP angle tumor resection in
20% of the baseline values by varying the inspired terms of hemodynamics, brain relaxation scores
concentration of the volatile anaesthetic agents and and response to surgical stimulus and the use of
intravenous agent. desflurane in these patients associated with faster
Cerebral vasodilatation and increased ICP are emergence when compared with propofol. which
concerns with the use of inhalational anesthetics in is comparable with our study.
patients with intracranial pathologies. Desflurane Modified Aldrete score: In our study, the patients
is supposed to have more cerebral vasodilation who received Desflurane had significantly higher
and intracranial pressure raising potential than
mean modified Aldrete score at 5min.and 10min.
isoflurane and sevoflurane. However, these
After extubation, the patients were monitored and
drawbacks with the use of desflurane have been
observed until they achieved a modified Aldrete
found to have little clinical significance. Propofol
score of ≥ 9. Analysis of the recovery profiles
decreases CBF and CMRO2, as well as ICP.
revealed that the patients who were enrolled in the
We measured the ICP intraoperatively and group that received Desflurane achieved a modified
compared the hemodynamic parameters during Aldrete score of ≥ 9 faster when compared to the
the perioperative period between the two groups. patients in the Sevoflurane and Propofol groups.
Our study results have shown that the ICP and These results were similar toSonia Kapil Nidhi
hemodynamic parameters in the three groups were
Panda Sujay Samanta Asish Kumar Sahoo9 study.
comparable.and our study correlates with the study
In the study conducted by Jeffrey L Apfelbaum MD
conduced by Fragaet et al5.
et al10 they compared postanaesthetic and residual
Recovery profiles: We studied different criteria recovery of desflurane verses propofol anaesthesia
for early and intermediate recovery profiles:We and founded that awakening and early recovery
observed in our study that there was a statistically for as long as one hour after anaesthesia is faster
highly significant difference between Desflurane with Desflurane than Propofol but there were no
and Sevoflurane groups regarding all the difference in time to home readiness or in residual
parameters in the recovery profile with patients in
effects .
group D having shorter recovery time compared to
patients in group P andGroup S.
Conclusion
Extubation time: In our study, we switched off
the volatile agents and intravenous agent at the
application of last skin suture.Our data analysis From our study entitled A comparitive evaluation
revealed that the time to extubation (from the time of Propofol, sevoflurane and desflurane in
of administering reversal agent to the removal of neuroanaesthesia- in patients undergoing supra
endotracheal tube) was consistently less in the tentorial craniotomies under general anaesthesia-A
Desflurane group as compared to the Sevoflurane prospective randomized study". The patients
group and Propofol group which was statistically receiving Desflurane opened their eyes and
highly significant. verbalised sooner. It was also not associated
Desflurane gives the fastest recovery from with any significant adverse effects.Desflurane
anaesthesia and would become the choice for or Sevoflurane or Propofol administration has no
neurosurgery which coincides withmetaanalysis negative effects on the intraoperative as well as the
done by Dexter F etal6. early postoperative haemodynamic parameters and
In our study, we observed that the patients in provided cardiovascular stability when titrated to
Group D, consistently opened their eyes to verbal maintain within 20% of the baseline values.
command faster than the patients in Group S and We conclude that Desflurane as inhalational agent
Group P. Also, as compared to the patients in ensures faster recovery in the early postoperative
Group S, Group P the patients in Group D were period as evident from significant decrease in the
able to verbalise faster and thiscoincides with a time required for extubation and the time required
study conducted by La Colla et al7. to achieve a modified Aldrete score of ≥ 9 when
In the study conducted by Hemant Bhagat, compared to patients receiving Sevoflurane and
Ishwar Bhukal, Neeru Sahni, Puneet Khanna, Sunil Propofol.

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Efficacy of Ultrasound Guided TAP Block with the Standard Post-

Operative Analgesic Regimen, In Providing Post-Operative Analgesia for
Patients Undergoing Total Abdominal Hysterectomies
Samarth S P1, Shreecharan P K2, Sarala Mohan3
Author’s Affiliation: 1Senior Resident, Department of Anesthesiology, Chamarajanagar Institute of Medical Sciences,
Chamarajanagara, Karnataka 571313, India, 2Registrar, Department of Anesthesiology, Manipal Hospital, Bangalore, Karnataka
560017, India, 3Senior Consultant, Department of Anesthesiology, St. Martha’s Hospital, Bangalore, Karnataka 560001, India.
Corresponding Author: Shreecharan P K, Registrar, Department of Anesthesiology, Manipal Hospital, Bangalore, Karnataka
560017, India.
E-mail: shreecharanpk@gmail.com

Samarth S P, Shreecharan P K, Sarala Mohan. Efficacy of Ultrasound Guided TAP Block with the Standard Post-Operative
Analgesic Regimen, In Providing Post-Operative Analgesia for Patients Undergoing Total Abdominal Hysterectomies. Indian J
Anesth Analg. 2020;7(6):1373–1379.
Abstract
Introduction: A recent development in the treatment of post-operative pain is the use of peripheral
nerve blocks. The technique involves blocking the conduction of nerve impulses by deposition of local
anaesthetic around the nerve or nerves supplying the area of interest. Consequently, the sensory and/
or motor supply to the area supplied by the nerves, are effectively abolished, thus helping to achieve
anaesthesia and analgesia.
Methodology: The patients were selected by convenience sampling and those who matched the selection
criterion, were briefed about the nature of the study and the procedures involved, in a language understood
by them and written informed consent was taken. Descriptive data of the patient such as name, age, sex
and detailed medical history, was collected. They were randomized into two groups with the help of
computerized randomization software.
Results: In our study it was noted that the mean total rescue analgesic consumption in patients belonging
to Group S (over a period of 24 hours) was 73.3 mg. Whereas the mean total rescue analgesic consumption
in Group T was only 35 mg. This difference in the mean total rescue analgesic consumption between the
two groups was found to be statistically significant (p value < 0.001).
Conclusion: Patients in both Group T and Group S experienced some degree of nausea at the 2, 4 and 6
hour intervals, but the PONV scores of both the groups were comparable. Thereafter, patients in both the
groups were asymptomatic.
Keywords: Ultrasound guided TAP block; Post-Operative analgesia; Total abdominal hysterectomies.
Introduction pain and discomfort, which is maximal in the first

24–48 hours post-operatively.
The International Association for the Study of Any unaddressed pain stimulus triggers a
Pain defines pain as “an unpleasant sensory and neuro-hormonal stress response involving the
emotional experience associated with actual and
hypothalamus-pituitary-adrenocortical axis and
potential tissue damage, or described in terms of
such damage”. Patients undergoing abdominal the sympathetic autonomic nervous system. The
surgeries experience significant post-operative activation of this stress response shifts the body

into a hyper-catabolic state, which leads to negative Neuraxial modalities, such as epidural analgesia,
nitrogen balance and delayed convalescence. are associated with problems like hypotension,
Activation of the stress response to pain causes delayed ambulation secondary to slow recovery
post-operative hyper-coagulability due to reduced of muscle tone and sedation, when narcotics are
levels of natural anticoagulants and increased used as adjuvants in neuraxialanaesthesia. This
levels of pro-coagulants, thereby predisposing the warrants close monitoring of the patients in a High
patients to develop episodes of venous thrombo- Dependency Unit or the Post Anaesthesia Care Unit.
embolism. It also increases the risk for myocardial The nerve involvement in neuraxial modalities
ischaemia and infarction, secondary to imbalances of anaesthesia and analgesia is not selective. Due
in myocardial oxygen demand and supply. to the involvement of a large number of nerves,
Inadequate pain control may hinder the respiratory there is unwanted sensory and/or motor blockade,
efforts of the patients and may be associated with which can cause undue anxiety in the patient.
an inadequate cough, thereby predisposing the Consequently, there arises a need for other effective
patients to the development of post-operative post-operative analgesic modalities to overcome the
pulmonary complications . shortcomings of neuraxial modalities of analgesia,
Therefore, it is highly necessary to contain the as well as those of parenteral analgesics.
stress response following surgery by providing Peripheral nerve blocks can be used in multiple
adequate post-operative analgesia. This ensures settings to provide adequate anaesthesia and/or
reduced post‑operative morbidity, and facilitates analgesia in patients undergoing surgeries. They
improved surgical outcome.1 can be used to anaesthetize single nerves, such as the
In the current scenario, most surgeries are ilio-inguinal and ilio-hypogastric nerves in patients
performed as laparoscopic surgeries. Despite this undergoing inguinal hernia repairs. In addition,
trend, some surgeries, such as the total abdominal these nerve blocks can be employed to block an
hysterectomy, are performed as open surgeries, entire plexus of nerves, if a larger area needs to
requiring an incision on the abdominal wall. The be anaesthetized viz. brachial plexus blocks for
skin incision and muscle retraction contribute upper extremity surgeries, lumbar plexus blocks
significantly to the development of post-operative for patients undergoing hip and knee surgeries.
pain. Therefore, most of the pain that the patient Field blocks, such as the transversusabdominis
experiences, originates in the abdominal wall. This plane block, the quadratuslumborum block and
pain is called parietal pain, because of the somatic the erector spinae plane block, help to anaesthetize
innervation of the structures involved.2 the nerves providing cutaneous innervation to the
operative site i.e. the abdomen and thorax respectively.4
In order to tackle the problem of post-operative
pain, multiple analgesic modalities have been Due to the targeted nature of nerve blockade
developed and practiced. The most commonly used and lack of systemic effects such as hypotension
modality is the administration of oral/ per rectal/ and bradycardia, peripheral nerve blocks are safer
parenteral analgesics (opioids or non-steroidal as compared to neuraxial modalities of analgesia.
anti-inflammatory drugs) at regular intervals. In These blocks provide effective analgesia over a
many institutes, this is supplemented by patient long duration of time and hence, decrease the need
controlled analgesia (PCA) with intravenous for postoperative analgesics and their antecedent
analgesics and neuraxial blocks (epidural analgesia adverse effects such as post-operative nausea,
in the form of continuous epidural infusions). vomiting and sedation. Consequently, the patient
can be mobilized earlier and the duration of stay
Parenteral opioids, commonly used for in the post-anaesthesia care unit is shortened.
postoperative analgesia, are associated with a This leads to increased patient satisfaction. Hence,
significant incidence of adverse effects, such as peripheral nerve blocks find application as a
postoperative nausea and vomiting, sedation modality for administering anaesthesia, providing
and pruritus. Besides, the analgesia provided by post-operative analgesia and also to treat chronic
parenteral analgesics is not uniformly adequate. pain disorders.5
Pain scores tend to increase towards the end of
a dose, secondary to the falling concentrations In patients undergoing lower abdominal
of the drug in the plasma. Consequently, there surgeries, most of the post-operative pain
arises a need to use a poly-pharmacy approach or originates from the abdominal wall, which receives
a continuous infusion based approach, to tackle its innervation from the anterior rami of the spinal
breakthrough pain. This, in turn, increases the nerves T7-L1. In such a setting, by administering
incidence of adverse effects in patients.3 field blocks such as the transversusabdominis

Samarth S P, Shreecharan P K, Sarala Mohan / Efficacy of Ultrasound Guided TAP Block with the Standard 1375
Post-Operative Analgesic Regimen, In Providing Post-Operative Analgesia for Patients Undergoing
Total Abdominal Hysterectomies
plane block (TAP block), one can achieve the goal Pre-anaesthetic evaluation: All patients selected for
of providing adequate and effective post-operative the study underwent a thorough pre-anaesthetic
analgesia, while avoiding any compromise in the evaluation via history and clinical examination.
patient's physiology.6 In all the patients- height, weight, basal heart rate,
The goal of our study is to evaluate the efficacy respiratory rate and blood pressure was measured
of the TAP block in providing post-operative and recorded. In addition to standard investigations
analgesia in patients undergoing total abdominal bleeding time, clotting time, prothrombin time and
hysterectomies, in comparison to the standard International Normalized Ratio was done for all
post-operative analgesic regimen being followed at patients in the study.
our hospital.
Results
Methodology
60
54
55
The patients were selected by convenience sampling
Mean VAS score at rest (mm)

50
and those who matched the selection criterion, 45 46.67 45
were briefed about the nature of the study and the 40 36.67
procedures involved, in a language understood 35 36.33
by them and written informed consent was taken. 30 29 Group S
Descriptive data of the patient such as name, age, 25 20.33 Group T

19
sex and detailed medical history, was collected. 20 17.33
15 18.33
They were randomized into two groups with the
10
help of computerized randomization software. The 5
groups were: 0
2hrs 4hrs 6hrs 12hrs 24hrs
I. Group S- Standard regimen group: The patients in Time interval (in hours)
this group received the standard post-operative
Graph 1: Comparison of mean VAS scores at restbetween the
analgesic regimen of intravenous paracetamol two study groups.
1 gm every 8th hour following the surgery.
Inference: In our study, it was observed that there
II. Group T- TAP block group: Patients in this group was no statistically significant difference in the
received post-operative ultrasound guided TAP mean VAS scores at rest of Group S and Group T,
block with 0.25% bupivacaine as the analgesic at the 2 hour interval (p value: 0.098). However,
modality. at the subsequent intervals of 4 hours, 6 hours, 12
Patients in both the groups received rescue hours and 24 hours, the mean VAS scores at rest
analgesic in the form of intramuscular tramadol of both the groups showed an increasing trend.
(50mg), when VAS scores at rest were greater than Notwithstanding the increase in scores, the mean
50 mm. The patients were then assessed for the VAS scores at rest of patients in Group T were
efficacy of analgesia over a 24 hour post-operative significantly lesser than those of Group S (p value
period, with the help of the following parameters: in the range of 0.012 to < 0.001). (Graph 1).
• Visual Analog Scale scores at rest at 2 hours,
70
4 hours, 6 hours, 12 hours and 24 hours, post- 65 64
Mean VAS score on coughing (mm)
operatively. 60 56.67
55
• Visual Analog Scale scores with cough at 50 55.33
2 hours, 4 hours, 6 hours, 12 hours and 24 46.67
45
46.67
hours, post-operatively. 40
35 30.33 39
• Time to the first dose of rescue analgesic. 29 Group S
30
Group T
• Total amount of rescue analgesic used over a 25 27.33 28.33
post-operative period of 24 hours. 20
15
• Post-operative nausea and vomiting at 2 10
hours, 4 hours, 6 hours, 12 hours and 24 5
0
hours assessed via a graded score. 2hrs 4hrs 6hrs 12hrs 24hrs
• Post-operative sedation at 2 hours, 4 hours, 6 Time interval (in hours)
hours, 12 hours and 24 hours assessed via the Graph 2: Comparison of mean VAS Score on coughing between
Ramsay Sedation Scale. the two study groups.

Inference: In our study, it was noted that the two

groups did not show any statistically significant 80
73.33
difference in the mean VAS scores on coughing at 70
Rescue analgesic consumed

the 2 hour interval (p value: 0.098). Thereafter, the 60
in 24 hours (mg)
mean VAS scores on coughing in both the groups 50
Group S
increased, when the patients were evaluated at 40 35 Group T
the 4 hour, 6 hour, 12 hour and 24 hour intervals. 30
Despite this increase, it was observed that the mean 20
VAS score on coughing of patients in Group T were 10
significantly lesser than those in Group S at all the 0
time intervals studied (p value in the range of 0.012 Graph 4: Comparison of mean rescue analgesic consumption
to < 0.001). (Graph 2). (over 24 hours) between the two study groups.
25 Inference: In our study it was noted that the mean

21.37
total rescue analgesic consumption in patients
Time (in hours)
20
14.7 belonging to Group S (over a period of 24 hours)
15 Group S was 73.3 mg. Whereas the mean total rescue
10 Group T analgesic consumption in Group T was only 35 mg.
5
This difference in the mean total rescue analgesic
consumption between the two groups was found to
0
be statistically significant (p value < 0.001).(Graph
Graph 3: Comparison of time to first request for rescue analgesic 4).
between the two study groups. Inference: In our study it was observed that the
Inference: In our study, it was observed that the total number of patients in Group T experiencing
mean time for first request for rescue analgesic nausea (PONV score 1) were lesser than those in
in patients belonging to Group S was 14.7 hours. Group S, when assessed for the same at 2 hours,
It was noted that the mean time for first request 4 hours, 6 hours. But this difference was not
for rescue analgesic was 21.37 hours in patients statistically significant (p value > 0.05). At the
belonging to Group T. This difference in the time subsequent intervals of 12 and 24 hours there was
to request between the two groups was found to be no difference in the incidence of PONV between the
statistically significant (p value < 0.001). (Graph 3). two groups. (Graph 5).
120
100 100 100 100 100

Percentage of study population
100 96.7
90 93.3
80
66.7
60
53.3
46.3
40 33.3
20
10 6.7
3.30
0
2 hrs 2 hrs 4 hrs 4 hrs 6 hrs 6 hrs 12 hrs 24 hrs
Score 0 Score 1 Score 0 Score 1 Score 0 Score 1 Score 0 Score 0
Time interval (in hours)
Graph 5: Comparison of PONV scores between the two study groups.

Discussion group receiving sub arachnoid morphine (8 hours)

as compared to the group receiving TAP block (4
In our study, it was observed that the mean time hours) (p value: 0.005). This is in stark contrast to the
for first request of rescue analgesia in patients findings of our study, where there wasa significant
belonging to Group S was 14.7 hours, whereas it prolongation in the time to first request for rescue
was 21.37 hours in patients belonging to Group T. analgesia in Group T. This can be explained by the
This difference in the time to first request for rescue fact that intrathecal morphine produces an effective
analgesic between the two groups was found to be and prolonged analgesia, thereby delaying the need
statistically significant (p value < 0.001). for any rescue analgesic.
In a randomized controlled trial conducted In a meta-analysis conducted by Mishriky B M

by Sivapurapu V et al.,7 to compare the analgesic et al.,10 to evaluate the efficacy of the TAP block
efficacy of the TAP block with direct infiltration of in providing analgesia in women undergoing
local anaesthetic the time to first request for rescue Caesarean sections, the time to first analgesia was
analgesic was noted. It was found that the mean assessed. In the sub analysis comparing TAP blocks
time to request for patients in the TAP block group with controls in patients who did not receive intra-
was around 148 minutes while for the infiltration thecal morphine, it was noted that TAP blocks
group it was 85.38 minutes. This difference between produced a significant prolongation in the time
the two groups was statistically significant (p value: to first analgesia when compared to the controls.
0.001). Similar results were obtained in our study, These results concur with the findings of our
where the mean time to request for rescue analgesia study. In patients who had received intra thecal
was 21.37 hours in Group T and 14.7 hours in Group morphine, it was noted that the mean time to first
S (p value < 0.001). analgesia was longer in patients who had received
intrathecal morphine when compared to those who
Bharti et al.,8 carried out a study to evaluate had received the TAP block.
the analgesic efficacy of a novelapproach to TAP
block, in patients undergoing colorectal surgeries. In our study it was noted that the mean rescue
The time to first request for rescue analgesic was analgesic consumption over 24 hours post-
noted in both the TAP block group and the control operatively, in patients belonging to Group S (73.3
group. It was observed that although the time to mg) was greater than those in Group T (35 mg).
first request for rescue analgesic was prolonged This difference in the amount of rescue analgesic
in the TAP block group, the difference was not consumed between the two groups was statistically
statistically significant. It was also noted that the significant (p value < 0.001).
time to subsequent doses of rescue analgesic were In a study evaluating the analgesic efficacy
significantly prolonged in patients belonging to the of ultrasound guided TAP block in patients
TAP block group (p value < 0.01). The comparable undergoing open appendicectomy conducted by
values for the time to first request for rescue Niraj G et al.,11 both the groups were assessed for
analgesia could be due to the administration of 24 hour morphine consumption. It was found that
intravenous morphine (0.15 mg/kg) as a part of there was a significant reduction in the 24 hour
the standard general anaesthetic plan. This could morphine consumption in the group receiving
have provided a sufficient duration of analgesia TAP block (28 mg) when compared to the group
peri-operatively in patients of both the groups. receiving standard post-operative analgesia (50
However, the longer intervals between subsequent mg) (p value < 0.002). This is in concordance to the
instances of rescue analgesic administration could results of our study, which showed that the total
be due to the efficacious analgesia provided by the dose of rescue analgesic consumed was significantly
TAP block. In our study there was a significant lesser in Group T when compared to Group S.
prolongation in the time to first request for rescue In a randomized controlled trial conducted
analgesia in patients receiving TAP block due to by Sivapurapu V et al.,7 to compare the analgesic
effective analgesia obtained by the block. efficacy of the TAP block with direct infiltration of
Kanazi et al.,9 carried out a study to compare local anaesthetic the 24 hour morphine consumption
the analgesic efficacy of sub arachnoidmorphine was observed. It was found that the patients who
with that of TAP block in women undergoing had received a TAP block had a significantly lesser
Caesarean sections. Time to first request for rescue 24 hour morphine consumption (22.15 mg) when
analgesic was noted in patients belonging to both compared to the group that received surgical site
the groups. It was observed that the median time to infiltration (29.15 mg) (p value: 0.001). In our study
first request for rescue analgesic was longer in the too the total dose of rescue analgesic consumed
over 24 hours was significantly lesser in Group T administration of antiemeticsperi-operatively and

when compared to Group S (p value < 0.001). the predisposition of the patient towards GERD.
Ebru Salman et al.,12 conducted a prospective These variables could lead to variations in the
double blinded randomized studycomparing incidence of PONV in patients undergoing surgery.
the TAP block with the placebo block in patients
undergoing inguinal hernia repair. In the study the Conclusion
24 hour morphine requirement in both the TAP
block group and the control groups was assessed. It The mean time for first request for rescue
was found that the 24 hour morphine requirement analgesic in patients belonging to Group T (21.37
was significantly reduced in the group receiving hours) was significantly longer than that of patients
TAP block (p value <0.001). Similar results were in Group S (14.7 hours) (p value < 0.001).
found in our study.
The mean total rescue analgesic consumption in
Bharti et al.,8 in their study to evaluate the patients belonging to Group S (over a period of 24
analgesic efficacy of a novel approach toTAP block, hours) was 73.3 mg, whereas in Group T it was only
found that the 24 hour morphine requirement (as 35mg
a rescue analgesic) was significantly lower in the
group receiving the TAP block (6.45 mg) when This difference in the mean total rescue analgesic
compared to the control group (17.55 mg) (p value < consumption between the two groups was found to
0.0001). Similar results were obtained in our study. be statistically significant (p value < 0.001).
In our study, patients in both Group S and Group

T were assessed for severity of post-operative References
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multiple factors such as the use of opioids in 8. Bharti N, Kumar P, Bala I, Gupta V. The efficacy of
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block for postoperative analgesia after colorectal 11. Niraj G, Searle A, Mathews M, Misra V, Baban M,
surgery. AnesthAnalg. 2011;112(6):1504–8. Kiani S, et al. Analgesic efficacy of ultrasound-
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Efficacy of Varying Doses of Dexamethasone with Lignocaine in

Supraclavicular Brachial Plexus Block in Upper Limb Surgeries
M Santhi Sree1, B Sowbhagyalakshmi2, M Archana3
Author’s Affiliation: 1Associate Professor, 2Professor and HOD, 3Senior Resident, Department of Anesthesiology, Rangaraya
Medical College, Kakinada, Andhra Pradesh 533001, India.
Corresponding Author: B Sowbhagyalakshmi, Professor and HOD, Department of Anesthesiology, Rangaraya Medical College,
E-mail: santhisreemulam@gmail.com

M Santhi Sree, B Sowbhagyalakshmi, M Archana. Efficacy of Varying Doses of Dexamethasone with Lignocaine in Supraclavicular
Brachial Plexus Block in Upper Limb Surgeries. Indian J Anesth Analg. 2020;7(6):1381–1389.
Abstract
Objectives: To compare the effectiveness of inj. Dexamethasone 4mg added to 1.5% lignocaine with
adrenaline with inj Dexamethasone 8mg added to 1.5% lignocaine with adrenaline in Supraclavicular
Brachial Plexus Block in terms of onset of sensory and motor blockade andduration of sensory and motor
blockade.
Materials and Methods: The study was carried out as a Prospective, randomized clinical trial among 150
patients who underwent different surgical procedures under supraclavicular brachial plexus block. They
were randomized into three groups.
GROUP A: Patients belonging to this group are given supraclavicular brachial plexus block with 4 mg
dexamethasone as adjuvant to 1.5 %lignocaine with adrenaline (7mg/kg).
GROUP B: Patients belonging to this group received supraclavicular brachial plexus block with 8 mg
dexamethasone as adjuvant to 1.5 % lignocaine with adrenaline (7mg/kg).
GROUP C: Patients belonging to this group received supraclavicular brachial plexus block with 2ml of
normal saline added to 1.5 % lignocaine with adrenaline (7mg/kg). The three groups were compared with
regard to onset of sensory and motor blockade andduration of sensory and motor blockade.
Results: No statistically significant difference was reported between the three groups in demographic
variables. The mean time required for onset of sensory block in Group A and Group B is 11.2 minutes and
in Group–C is 14.26, onset of motor block Group A and Group B is 13.0 minutes and in Group–C is 17.0
min. The average duration of sensory block in Group B>A>C. The average duration of Motor block in
Group B is 242min, and in Group A with 192 min and with Group C is 153min.
Conclusion: In conclusion, addition of dexamethasone to local anaesthetics in supraclavicular brachial
plexus block results in a faster onset and prolonged duration of sensory and motor blockade. Higher dose
(8mg) of dexamethasone is more efficacious than lower dose (4mg) of dexamethasone as an adjuvant with
local anaesthetics in terms of duration of sensory block, motor block and analgesia but equally efficacious
in onset of sensory and motor blockade.
Keywords: Brachial plexus block; Clonidine; Dexamethasone; Analgesia.
Introduction and central neuraxial anesthesia. Peripheral nerve

block of upper limb includes the various techniques
Peripheral nerve blocks are now gaining widespread
of brachial plexus block. Multiple approaches to
popularity for perioperative pain management
brachial plexus block have been described like
because of their distinct advantages over general
interscalene, supraclavicular, infraclavicular and supraclavicular brachial plexus block in our study
axillary. Of all, supraclavicular approach is the because it has been reported to prolong duration
easiest and most consistent method for anaesthesia of action of local anaesthetics and respiratory
and perioperative pain management in surgery depression is less common.
below the shoulder joint.
Supraclavicular brachial plexus block is popular Aims and Objectives
mode of anaesthesia due to its effectiveness in
terms of cost, performance, margin of safety and
To evaluate the efficacy of inj. dexamethasone 4mg
good post operative analgesia1. It is done at the
added to 1.5% lignocaine with adrenaline (7mg/
distal trunk – proximal division level. At this
kg ) compared to inj. Dexamethasone 8mg added
point the brachial plexus is compact and a small
to 1.5% lignocaine with adrenaline (7mg/kg ) in
volume of local anaesthetic provides rapid onset of
supraclavicular brachial plexus block in patients
reliable blockade of brachial plexus. Pneumothorax
undergoing upper limb surgeries with respect to
(1–6%).2,3,4,5,6 Hemothorax, Horner’s syndrome and
phrenic nerve block are the potential complications. 1. Onset of sensory blockade and motor blockade
In 1885, brachial plexus is introduced by William 2. Duration of motor blockade
Halstead who performed block by exposing the 3. Duration of analgesia (time to first rescue
roots, many modifications has been done in the analgesic)
technique. Classical method to locate nerves for
peripheral nerve blocks. 4. Complications /side effects if any
With the introduction of peripheral nerve

stimulator which uses electric current to elicit Materials and Methods
motor stimulation of nerves and confirm the
proximity of the needle to the nerve, there has been After institutional approval, this randomized
good success rate in brachial plexus block along controlled clinical control comparative study was
with reduction of drug requirement. Peripheral conducted from December 2016 to October 2018
nerve stimulator technology utilizes objective end over a period of two years in the Department of
points for nerve localization and does not depend Anaesthesiology, Government General Hospital/
on patient’s subjective feeling for effective nerve Rangaraya Medical College, Kakinada.
localization. An effective use of PNS technology
Inclusion Criteria: The following criteria were
mandates knowledge of anatomy with respect to
taken for including the patients in this study,
optimal needle insertion site to achieve desired
evoked motor response (EMR). 1. ASA status I and II of both genders
Wide variety of drugs have been used as adjuvant 2. Age between 18– 65 years
with local anaesthetics in brachial plexus block to 3. Patients posted for elective hand and forearm
achieve quick, dense and prolonged block.7 Drugs surgeries under supraclavicular block
like Morphine, Clonidine, Dexmedetomidine,
pethidine, Butorphanol, Buprenorphine are Exclusion Criteria:
commonly used along with local anaesthetics for this 1. Patient refusal
purpose. As Morphine, Buprenorphine, Pethidine
2. Known allergy to local anaesthetics
are associated with side effects like heavy sedation,
respiratory depression and psychomimetic effects, 3. Local infection
drugs with as minimal side effects as possible are 4. Inability to insert needle due to splint, cast
always looked for.
5. Chronic obstructive pulmonary disease
Dexamethasone is the most widely studied
6. Phrenic nerve palsy on contralateral side
drug used as an adjuvant to local anaesthetic in
peripheral nerve block.5,6 Steroids have nerve block Study Design: This prospective, randomized,
prolonging effects. Analgesic action is by blocking controlled study conducted on 150 ASA I and II
transmission of nociceptive myelinated c-fibers and patients undergoing upper limb surgeries under
suppressing ectopic neuronal discharge. This effect supraclavicular brachial plexus block who fulfilled
is brought by altering the function of potassium inclusion criteria. The study was started after
channels in the excitable cells. Thus, dexamethasone receiving institutional ethical committee approval
was selected as an adjuvant to local anaesthetics in and informed written consent from all the patients

M Santhi Sree, B Sowbhagyalakshmi, M Archana / Efficacy of Varying Doses of Dexamethasone with 1383
Lignocaine in Supraclavicular Brachial Plexus Block in Upper Limb Surgeries
and they were randomly divided into three groups. Land Marks
Group A: Patients belonging to this group are
given supraclavicular brachial plexus block with 4 - A point midway and 1 cm above the superior
mg dexamethasone as adjuvant to 1.5% lignocaine border of the clavicle.
with adrenaline (7mg/kg). - The midpoint of the clavicle is the point midway
Group B: Patients belonging to this group between the acromioclavicular and the sterno
received supraclavicular brachial plexus block with clavicular joints.
8 mg dexamethasone as adjuvant to 1.5% lignocaine - The lateral border of the sternocleidomastoid
with adrenaline (7mg/kg). muscle, lateral to subclavian artery above the
Group C: Patients belonging to this group midpoint of the clavicle.
received supraclavicular brachial plexus block with
2ml of normal saline added to 1.5 % lignocaine with
Technique
adrenaline (7mg/kg).
An intradermal wheal was raised 1cm above the

Methodology
midpoint of corresponding clavicle with 0.5cc of
1.0% lignocaine solution. Neural localisation was
Pre anaesthetic evaluation achieved by using a nerve locator connected to a
22G, 50 mm long short bevel, insulated stimulating
All the patients were thoroughly evaluated needle which was passed 1 cm above the midpoint
preoperatively by taking detailed history, and of the clavicle after palpating subclavian artery
general and systemic examination of patient. The pre pulsations, downwards, backwards, and medially
anaesthetic evaluation included the demographic towards upper surface of 1st rib.
data of the patient like age, sex, height and weight The location end point was distal motor response
of the patients. with a current of 0.5mA following negative
Informed consent was obtained from all study aspiration of blood to confirm that the needle was
patients after explaining the procedure which is not in a subclavian vessel or in pleura, 25 to 30ml
performed and the patients are educated regarding of solution containing local anaesthetic with added
the pain scale. adjutants was injected in 3ml increments. A 3 min
massage was performed to facilitate an even drug
distribution.
Procedure
Group A–25 to 30 ml of 1.5% lignocaine
with 1:200000 adrenaline (7mg/kg) plus 2ml of
The basal parameters pulse rate, respiratory rate, dexamethasone (4mg).
blood pressure and spo2 were recorded before
starting the case. Peripheral venous cannulation Group B–25 to 30 ml of 1.5% lignocaine with
was done with 18G IV cannula in opposite arm 1:200000 adrenaline (7mg/kg) plus 2ml of
and all the patients were preloaded with 10ml/ dexamethasone (8mg).
kg. Ringer lactate solution. Each patient would be Group C–25 to 30ml of 1.5% lignocaine with
given 0.03mg/kg of midazolam intravenously (IV) 1:200000 adrenaline (7mg/kg plus 2ml of normal
as a premedication 15 mins before beginning the saline.
block technique. Under strict aseptic precautions all
In supraclavicular route of brachial plexus
the patients received brachial plexus block through
block the plexus is blocked where it is compactly
the supraclavicular approach.
arranged at the level of the 3 trunks. The medial
aspect of upper arm, up to the elbow supplied
Position of the Patient by the intercostobrachial nerve which is lateral
cutaneous branch of the anterior primary ramus
Patient is kept in supine position, with a pillow of the second thoracic nerve is not anaesthetized
under the shoulder and head turned to non by the block. This nerve is blocked at the medial
operative side with arm by side drawn to depress aspect of the upper arm by infiltrating 5cc of 1.5%
the shoulder. In this position, the superior surface lignocaine solution, starting at the medial aspect of
of the first rib is raised anteriorly and ensures more upper arm up to the insertion of pectoralis major.
space and better approach. From the time of performing supraclavicular
blockade, parameters observed in the three groups are:
1. onset time of sensory blockade 500mg at visual analogue scale of ≥5 which was
2. onset time of motor blockade assessed every hour after shifting the patient to the
post operative ward. The time of administration of
3. duration of motor blockade first rescue analgesia was noted.
4. duration of sensory blockade The patients were observed for any side effects
5. time to first rescue analgesic like nausea, vomiting and complications like
pneumothorax, haematoma, local anaesthetic
6. complications
toxicity, and post –block neuropathy in the intra
7. hemodynamic variables like Heart rate, Systolic and post operative periods.
Blood Pressures, Diastolic Blood Pressures,
Statistical Data: At the end of study, all the
Mean Arterial Pressures, and Saturation
data were entered in Micro Soft excel sheet and
SpO2, were monitored continuously every
statistically analysed using SPSS Software version
15 min intra operatively and every one hour
16.0.
postoperatively.
• Diagrammatic representation
Sensory block was assessed by pinprick method.
Assesment of sensory block was done at each • Descriptive data presented as mean, SD.
minute after completion of drug injection in the • ANOVA test was applied for demographic
dermatomal areas corresponding to median nerve, data, haemodynamic parameters, onset and
ulnar nerve,radial nerve and musculocutaneous duration of sensory and motor blockade and
nerve till complete sensory nerve blockade. duration of analgesia.
Onset of sensory block: it was measured as the • Chi Square test was applied for sex , ASA.
period from the time of injection of local anaesthetic
solution to the absence of pinprick sensation as • P- value was considered significant if <0.05 and
experienced by the patient. highly significant if<0.001.
Sensory block was graded as:

Observations and Results
Grade 0: sharp pin felt.
Grade 1: analgesia, dull sensation felt (sensory The present clinical study consists of 90 patients
onset). of ASA grade 1 and II undergoing upper limb
Grade 2: anaesthesia, no sensation felt (complete surgeries under supraclavicular block were selected
sensory block). and divided into 3 groups.
Assessment of motor blockade was carried out Data was collected in all three groups for
by the same observer at each minute till complete following parameters and observations of the
motor blockade after drug injection. analysed data were tabulated as follows.
Motor blockade was determined using a All demographic data like Age, weight, sex, ASA
modified bromage scale for upper extremities on a grading and duration of surgery are comparable in
3 point scale. all three groups indicating no ststistical significance.
Grade 0: It is normal motor function with full
flexion and extension of elbow, wrist, and fingers. Comparison of onset of Sensory Block
Grade 1: It is decreased motor strength with
ability to move the fingers only (onset). Table 1: Comparison of onset of sensory block between three
groups.
Grade 2: It is complete motor block with inability
Standard
to move the fingers. Variable Group N MEAN
Deviation
P value
Duration of sensory block: It was taken as the Onset of GROUP A 50 11.200 1.5119
period from the time of loss of pinprick sensation sensory GROUP B 50 11.260 1.8605 0.001
to the reappearance of pinprick sensation. block GROUP C 50 14.260 1.7120
Duration of analgesia: It was the time between P=0.001 which is statistically significant.
the injection and the onset of pain and request In group A and group B the mean onset time of
for rescue analgesic. Rescue analgesia (RA) was sensory blockade was around 11.20 minutes and in
given in form of inj Diclofenac sodium (1.5mg/ group C, onset time is 14.26. P value is 0.001 which
kg) intramuscularly along with oral paracetamol is statistically significant, indicating that onset of

sensory blockade was faster when dexamethasone minutes in group A and significantly greater than
is added to lignocaine than plain lignocaine. average duration of block 153 minutes in group C
with a p value of 0.001 indicating that the duration
Comparison of onset of Motor Blockade of analgesia was significantly increased in group B
when compared to group A patients and group C
Table 2: Comparison of onset of motor block between three
patients.
groups.
Standard Comparison of Duration of Analgesia (time of

Time Group N MEAN P value
Deviation administration of first rescue analgesia )
Onset of Group A 50 13.600 1.6162
motor Group B 50 13.900 1.6812 0.001 Table 5: Comparison of duration of analgesia ( time to first
block Group C 50 17.020 1.6720 rescue analgesic).
P=0.001 value which is clinically significant. In Time Group N MEAN

Standard
P value
both the groups A and B the onset of motor block Deviation
was around 13 minutes, when compared to 17 Time Group A 50 311.600 22.9783
for first Group B 50 358.400 26.2919
minutes in group C, showing that onset of motor Rescue
0.001
blockade was earlier when dexamethasone is added Group C 50 249.200 24.647
analgesia
to lignocaine than plain lignocaine. P = 0.001 (p<0.05)
The average duration of analgesia in group B was
Comparison of Duration of Sensory Blockade 358 minutes which was significantly greater than
the average duration of analgesia of 311 minutes in
It was taken as time interval between the end of group A which is significantly greater than average
local anaesthetic administration and return of duration of analgesia of 249 minutes in group C
sensations by pin prick. with a p value of 0.001 indicating that the duration
Table 3: Comparison of duration of sensory block between three of analgesia is significantly prolonged in group B
groups. when compared to group A followed by group C
Standard
patients.
Variable Group N Mean P value
Deviation
Duration Group A 50 240.000 26.8784 Visual Analogue Scale
of sensory Group B 50 300.800 28.2727 0.001
block Group C 50 195.000 25.2538
After shifting the patient to post operative ward the
P = 0.001 (< 0.05) represent statistical significance, pain scores of the patient were assessed every hourly
and the duration of sensory blockade is more in by visual analogue for pain assessment 0–10.The
Group B > Group A > Group C., showing that time of shifting the patient to postoperative ward
addition of 8mg Dexamethasone to lignocaine has was taken as 0 hour and assessed .The observations
prolonged sensory blockade than addition of 4mg of the scores were tabulated as follows
Dexamethasone to lignocaine which is superior to
Table 6: Comparison of VAS.
plain lignocaine.
Visual
Standard
Time Group analogue P value
Deviation
Duration of Motor Block scale
1HR Group A .000 .0000
Table 4: Comparison of duration of motor block between three Group B .000 .0000
groups. Group C .000 .0000
Standard 2 HR Group A .000 .0000
Variable Group N Mean P value
Deviation Group B .000 .0000
Duration Group A 50 192.200 29.9176 Group C .000 .0000
of motor Group B 50 242.800 30.9074 0.001 3 HR Group A .000 .0000
block Group C 50 153.800 20.6911 Group B .000 .0000 0.00
P less than 0.001(<0.05) Group C .980 .9998
The mean duration of motor block in group B 4 HR Group A 1.420 1.3566
was 242 minutes which was significantly greater Group B .000 .0000 0.00
than the average duration of motor block 192 Group C 4.240 .9381

5 HR Group A 4.120 1.0230 drugs in the fascial spaces surrounding the nerve
Group B .720 .9697 0.00 plexus, thereby blocking the autonomic, sensory
Group C 3.840 .7656 and motor fibres supplying the upper extremity.
6 HR Group A 3.700 .7071 It is simple, safe and effective technique of
Group B 4.060 .8901 0.00 anaesthesia having distinct advantages over general
Group C 3.420 .7584 and intravenous regional anaesthesia. Whenever
7HR Group A 3.300 .5440 general condition of the patient is very poor, or the
Group B 3.420 .4986 0.55 patient is not adequately prepared or in the presence
Group C 3.340 .6263 of associated conditions like, cardiovascular or
The results were, up to 3 hours, none of the respiratory diseases, uncontrolled diabetes a
patients in all the groups complained of pain. By regional technique should always be considered. It
4th hour mild pain was complained in group A is also useful when it is important for the patient to
which did not required any analgesia and severe remain ambulatory and when the patient prefers to
pain was complained in group C patients with preserve his consciousness during surgery.
VAS nearly 5 which required rescue analgesia. By In our study, we selected supraclavicular
5th hour, patients in group A complained of severe approach to brachial plexus block because in upper
pain which required rescue analgesia. extremity surgeries, Supraclavicular brachial
By the end of 6th hour there was significant pain plexus block is widely employed regional nerve
complained by group B that required administration block to provide anaesthesia and analgesia and it
of rescue analgesia where was as in group A and provides a rapid, dense and predictable anaesthesia
group C only mild pain was complained as rescue of the entire upper extremity in the most consistent
analgesia was given to them. manner of any brachial plexus technique.
By the end of 7th hour mean pain scores were The development of nerve stimulators allowed
comparable between the three groups where all an anatomical approach to regional anaesthesia
groups had decreased pain scores because of rescue leading to more reliable injection and a possibly
analgesia administration. decreased risk of nerve trauma.8 The nerve
stimulator technique allows for exact needle
location without eliciting paraesthesia9,10,11 hence
Comparison of Haemodynamic Parameters there is increase in the specificity and reliability
of peripheral nerve block technique. The method
The basal haemodynamic parameters like heart rate, of postoperative pain relief must be effective, safe,
systolic blood pressure, diastolic blood pressure and feasible.
and mean arterial pressures were recorded initially Of various local anaesthetics, lignocaine is the
and after drug administration every 5 min till 15 most frequently used as it has faster onset of action.
minutes and every 15 min till 1 hour and every On the other hand, there are limitations like shorter
30 minutes until 120 minutes were recorded and duration of action with lignocaine and increased
compared which showed no statistical significance. incidence of toxicity.
To decrease the toxicity and to increase the
Side Effects and Complications volume of local anaesthetic to be injected, 2%
lignocaine is diluted to 1.5% lignocaine and 1:
We did not observe any complications like 200000 Adrenaline is added to it (5 µg/ml).
haemothorax, pneumothorax, convulsions local To prolong regional blockade, different additives
anaesthetic toxicity in any patients of our study like opioids, neostigmine, midazolam, clonidine,
groups. dexamethasone etc., have been used but they are
associated with side effects.
Discussion Dexamethasone improves the duration and
quality of peripheral nerve blockade. This action
Regional anaesthesia techniques can be utilized for is considered to be mediated by attenuating the
analgesia not only during the operative period, but release of inflammatory mediators reducing ectopic
during the postoperative period as well and avoids neuronal discharge and inhibiting potassium
complications of general anaesthesia. The brachial channel-mediated discharge of nociceptive
plexus block consists of injecting local analgesic C-fibres.

Various steroids has been used for prolonging mean duration of 1.39±1.68 minutes in group B and
the regional nerve blockade, but dexamethasoneis mean duration of 17.02± 1.67 minutes in group C,
preferred because of its high potent anti and a p value of 0.01 (p<0.05) (Table 2).
inflammatory property, about 25–30 times as
The time to onset of motor blockade is earlier in
effective as hydrocortisone and without any
both the group A and group B when compared to
mineralocorticoid activity. Hence it was found to
group C, which is significant as p value is less than
be safer and devoid of potential side effects.
0.05.
Dexamethasone is also known to reduce
Duration of sensory blockade: In present study we
postoperative nausea and vomiting (PONV). The
observed that the duration of sensory blockade
possible mechanism of analgesic and antiemetic
in group A had a mean duration of 240.0 ± 26.87
actions are due to anti inflammatory properties of
minutes and the mean duration of sensory blockade
dexamethasone.
in group B was 300.8 ± 28.27minutes in group B and
To summarise, the prolongation of duration that value in group C was 195.0 ± 25.25 minutes
of both sensory and motor blockade after a p value of <0.001(p<0.05) which is considered
administration of dexamethasone perineurally may statistically significant (Table 3).
be secondary to its local action on C fibers mediated
There was a significant increase in duration of
via membrane associated glucocorticoid receptors.
sensory blockade in dexamethasone 8mg followed
To date, several studies evaluated the effect of by 4mg group than control group and the difference
dexamethasone in peripheral nerve blocks and was shown statistically significant.
found that dexamethasone had an improving effect
in postoperative analgesia. Our study correlates well with one such
randomised prospective trial was done by Shrestha
A study by Pradeep Dhumane and Nilofar BR, Maharjan SK, Tabedar S.14
Shakir,12 found that when dexamethasone is
added to local anaesthetic in brachial plexus block, Duration of motor blockade: In present study we
provided good intraoperative and postoperative observed that the duration of motor blockade
analgesia and decreased postoperative opioid in group A had a mean duration of 192.2 ± 29.9
consumption without any adverse effects. minutes , 242.8 ± 30.9 minutes in group B, and 153.8
± 20.69 minutes in group C and a P value of <0.001
In our study, we aimed to evaluate the efficacy (p<0.05) which is considered to be statistically
of dexamethasone along with local anaesthetic in significant. (Table 4).
supraclavicular brachial plexus block..
There was a significant increase in duration of
We ensured that the demographic variables age, motor blockade in dexamethasone group A and
weight, height have been shown to be comparable group B than control group and the difference was
in both groups. shown statistically significant.
Onset of sensory block: In the present we observed Our study correlates well with one such
that the onset of sensory block had mean duration study conducted by Dr. Dheeraj R Patel Chirag
of 11.20 ±1.51minutes in group A and 11.26 ± 1.86
Babu et al15 studied in 90 patients, effect of 2
minutes in group B and mean duration 14.2 ±1.71
doses of Dexamethasone added as adjuvant for
minutes in group C with a p value of 0.01 (p<0.05).
ultrasound guided supraclavicular block. The
(Table 1).
onset of both sensory and motor blockade in
The time for onset of sensory block is reduced group 3 [169.83±30.157sec ; 237.67±31.287 sec] were
in group A and group B than group C, the p significantly faster when compared to group 2
value is 0.01 (<0.05) which was shown statistically [228.33±32.386 sec; 313.33±33.767 sec] and group1
significant. [328.50±40.538 sec; 405.50±41.259 sec] [p<0.001
The present study correlates to the study (HS)]. The duration of motor blockade in group 3
conducted by P Nageswara rao, S Seetharamaiah [653.33±57.630 min] was significantly prolonged
and B Venu Gopalan13 who studied the effect of when compared to group 2 [479.83±37.312 min]
Supraclavicular brachial plexus block with and and group 1 [325.33±36.434 min] [p<0.001(HS)].
without Dexamethasone In addition the duration of analgesia in group
3 [766.50±46.278 min] was significantly more
Onset of motor blockade: In present study we
compared to group 2 [601.67±58.492 min] and
observed that the onset of motor block had a mean
group1 [390.50±38.019 min] [p<0.001(HS)].
duration of 13.6±1.61 minutes in group A and had a

Duration of analgesia (Time to first Rescue Analgesic ) References
In our study, we observed that the time to first 1. Winnie AP, Collins VJ: The Subclavian Perivascular
rescue analgesic in group A had a mean duration of Technique of Brachial Plexus Anesthesia.
311.6 ± 22.97 minutes and 358.4 ± 26.29 minutes in Anesthesiology 1964; 25: 353–63.
group B and 249.2 ± 24.67 minutes in group C with 2. Moore D: Supraclavicular approach for block of the
a P value of 0.001 which is statistically significant. brachial plexus, in Moore D(ed): Regional block. A
(Table 5). handbook for use in the clinical practice of medicine
and surgery, 4th ed. Springfield, Charles C Thomas
The pain scores of the patient were assessed every Publisher, 1981; pp 221–42.
hourly by visual analogue for pain assessment 0–10
3. Lanz E, Theiss D, Jankovic D: The extent of blockade
(Table 6). There was a significant increase in time to following various techniques of brachial plexus
first recue analgesic in group B followed by group block. AnesthAnalg 62:55–8, 1983.
A when compared to group C.
4. Urmey W: Upper extremity blocks, in Brown D (ed):
Haemodynamic parameters: In our study the basal Regional anesthesia and analgesia. Philadelphia,
heart rate, systolic, diastolic and mean arterial W.B. Saunders Company, 1996; pp 254–78.
pressures were comparable. No patient in either 5. Moore DC. regional block 4th ed.
groups developed significant bradycardia or Springfield:IL:Charles C , Thomas: 1965.
hypotension that required treatment and both 6. Urmey WF. Upper extremity blocks. in: brown
the groups were comparable in Haemodynamic DL editor. Regional anaesthesia and analgesia.
parameters throughout the surgery and in the Philadelphia: W.B.saunders,1996:254–278.
postoperative period. 7. Yaksh TL, llfeld BM, wieseAJ.perineural local
Side effects: In the present study side effects like aneasthatic and adjuvant action: the meaning of an
nausea, vomiting and dry mouth were negligible ex vivo data set for efficacy and safety. Reg anesth
pain med 2012;37:366–8.
and were comparable in both the groups.
8. Fanelli, Casati A, Garancini P, Torri G Nerve
The side effects profile of the present study stimulator and multiple injection technique for
correlates with study conducted by Kalpana K, upper and lower limb blockade:failure rate ,patient
Natesh S. Rao, Sadanand Gopal, showed that no acceptance, and neurological complications-
significant side effects were reported in first 24 Anaesthesia Analg 88:847–52.
hours post operatively and incidence of side effects 9. ReeglerFX.Brachial plexus block with nerve
were minimal and comparable in both the groups. stimulator :motor response characterstics at three
sites.RegAnasth 1992:295–9.
We did not observe any complications like
haemothorax, pneumothorax, convulsions, local 10. Lavoie J, Martin R, Tetrault JP, et al Axillary plexus
anaesthetic toxicity or post block neuropathy in any block using peripheral nerve stimulator ,Can J
Anaesth 1992;39:583–6.
of our groups
11. Koscielniak– Nielsen ZJ, Stenss–Pedersen
The major limitation of our present study was HL,LippertFK.Readiness for surgery after axillary
that we did not use ultrasound guided blocks block Eur J Anaesthesiology 1997;14:164–71.
because of unavailability at the time of our study;
12. Pradeep Dhumane and Nilofar Shakir–
this could have helped us to lower the dosages and supraclavicular brachial plexus block with
volumes of local anaesthetic and without dexamethasone as adjuvant to
local anaesthetics – a prospective randomised
Conclusion comparative study IJBAR, International journal
of biomedical and advance research 2016 ; 7(9) :
456–459.
In conclusion, addition of dexamethasone to local 13. P Nageswara rao, S Seetharamaiah B Venu
anaesthetics in supraclavicular brachial plexus block Gopalansupraclavicular brachial plexus block
results in a faster onset and prolonged duration of with and without dexamethasone – a prospective
sensory and motor blockade. Higher dose (8mg) of randomised controlled study, IOSR–JDMS
dexamethasone is more efficacious than lower dose International organisation of scientific research –
(4mg) of dexamethasone as an adjuvant with local journal of dental and medical sciences 2018, volume
anaesthetics in terms of duration of sensory block, 17, issue 1 , pp 47–52.
motor block and analgesia but equally efficacious 14. Shreshta BR, Maharjan SK, Shreshta S et al-
in onset of sensory and motor blockade. comparative study between tramadol and

dexamethasone as an admixture to bupivacaine in Arun kumarAjjappa- comparison of two doses of

supraclavicular brachial plexus block, a prospective, dexamethasone added as adjuvant for ultra sound
guided supraclavicular brachial plexus block; a
randomized, double blind study.-J Nepal Assoc
prospective randomised double blinded study;
2007,46(168). IJSR- International journal of scientific research :
15. Dheeraj R Patel; Chirag babu P S ; Kiran B R; dec 2013, volume 2 , issue 12 ;432–433.

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A Study on Complications of Magnesium Sulphate as an Adjunct to

Ropivacaine Versus Plain Ropivacaine in Local Subcutaneous Infiltration
for Postoperative Analgesia
Myakala Siddartha1, P G Raghavendra2
Author’s Affiliation: 1,2Assistant Professor, Department of Anesthesiology, Raichur Institute of Medical Sciences, Raichur,
Corresponding Author: P G Raghavendra, Assistant Professor, Department of Anesthesiology, Raichur Institute of Medical
Sciences, Raichur, Karnataka 584102, India.
E-mail: drpgraghavendra@gmail.com

Myakala Siddartha, P G Raghavendra. A Study on Complications of Magnesium Sulphate as an Adjunct to Ropivacaine Versus
Plain Ropivacaine in Local Subcutaneous Infiltration for Postoperative Analgesia. Indian J Anesth Analg. 2020;7(6):1391–1394.
Abstract
Introduction: Local anaesthesia have been employed during the operation as an adjuvant to anaesthesia
or to alleviate postoperative pain. Local anaesthetic is injected to block the nerves before cutting the
skin at the beginning of the operation, or after closing the skin at the end. Subcutaneous infiltration of
bupivacaine microcapsules prolongs analgesia in humans for up to 96 h, and pre surgical infiltration of
levobupivacaine significantly decreases the intensity of postsurgical pain, especially for the first 12 h,
thereby reducing analgesic consumption.
Methodology: The minimum samplesize required for the study per group is 23. We have considered 30
patients per group for better statistical representation. A total of 60 patients were included in the study.
Results: None of the patients suffered from bradycardia, hypoxaemia, respiratory depression, skin rash
or incision site excessive redness nor was there any evidence of infection. The incidence of sedation and
pruritis was similar in both groups with no statistically significant difference.
Conclusion: The incidence of nausea and vomiting was infact lower in group B as compared to group A.
This could be explained by the lesser use of rescue analgesic agent in group B since Inj tramadol itself is
associated with increased incidence of nausea and vomiting.
Keywords: Local Subcutaneous Infiltration; Postoperative Analgesia; Ropivacaine.
Introduction component of caesarean delivery that can make

the period immediately after the operation less
Childbirth is an emotional experience for a woman uncomfortable and more emotionally gratifying.2
and her family. The mother needs to bond with Postoperative pain after Caeserean delivery is
the new baby as early as possible and initiate early usually managed with opioids in combination
breastfeeding, which helps to contract the uterus with other forms of analgesics. Caesarean section
and accelerates the process of uterine involution in is performed under spinal anaesthesia, combined
the postpartum period.1 spinal epidural, epidural block or general
Any form of intervention that leads to anaesthesia.
improvement in pain relief can positively impact Local anaesthesia have been employed during
on early breastfeeding. Prompt and adequate the operation as an adjuvant to anaesthesia or to
postoperative pain relief is therefore an important alleviate postoperative pain. Local anaesthetic is

injected to block the nerves before cutting the skin We have considered 30 patients per group for
at the beginning of the operation, or after closing better statistical representation. A total of 60
the skin at the end. Subcutaneous infiltration of patients were included in the study.
bupivacaine microcapsules prolongs analgesia in e) Study Duration: study was conducted for 1 year.
humans for up to 96 h, and pre surgical infiltration
of levobupivacaine significantly decreases the f) Inclusion Criteria:
intensity of postsurgical pain, especially for the first • Parturients belonging to American Society of
12 h, thereby reducing analgesic consumption.3 Anaesthesiologists (ASA) grade I or II.
Incisional infiltration achieved analgesia and • Parturients posted for elective ceaserean section.
patient satisfaction comparable with epidural
g) Exclusion Criteria:
analgesia. Wound infiltration with local anaesthetics
is a simple, effective and inexpensive means of • patients refusal to participate.
providing good analgesia for a variety of surgical • Patients with a history of drug abuse, patients
procedures without any major side effects.4 with psychiatric disease.
In particular, local anaesthetic toxicity, wound • morbidly obese patients.
infection and healing do not appear to be major
• patients with history of allergic reactions
considerations.Postoperative analgesia is a major
to local anaesthetics, opioids and/or
component of peri-operative care and local
magnesium.
anaesthetic (LA) techniques are more effective than
systemic analgesia regardless of the operation and Patients were also observed for any adverse
mode of delivery. effect like postoperative nausea or vomiting, Skin
rash (redness or itching), hypotension (defined as
By allowing patients to mobilize more quickly,
blood pressure less that 20% of baseline values),
wound infiltration may be as effective as central
sedation (as per Ramsay sedation scale), respiratory
and proximal peripheral blocks in ensuring a
depression (defined as respiratory rate less than 10/
safe postoperative recovery. Although untreated
minute), need for supplemental oxygen (saturation
postsurgical pain may cause chronic pain.5
less than 93%), bradycardia (heart rate less than 60
Ropivacaine infused intravenously at a beats/min), any redness or signs of inflammation
rate of 10mg/min (to maximum cumulative at the skin incision site.
dose of 150gm) had a higher threshold than
similarly administered Bupivacaine. The mean
Results
cumulative doses of Ropivacaine and Bupivacaine
tolerated before mild symptoms of CNS toxicity
Table 1: Baseline Characteristics.
(lightheadedness, tinnitus, numbness of tongue)
developed were 124mg and 99mg respectively. Group A Group B p-value
Both drugs significantlyincreased blood pressure Mean Age (Years) 27.93±1.99 28.10±2.55 0.779
and heart rate; stroke volume and ejection fraction Mean Weight (Kg) 63.87±5.28 64.73±4.32 0.490
were reduced but cardiac output was not affected. Mean Height (cm) 161.70 ± 3.03 162 ±2.49 0.677
Although both drugs significantly altered various Gestational Age (weeks) 38.17±0.69 38.17±0.69 1
aspects of ECG, no overt dysrhythmias were Previous surgery (%age) 52 % 47 % 0.791
observed.6
The mean Age in the group A and group B are
almost similar and there is no statistical significant
Methodology between the mean ages between the two groups.
The mean weight in group A and group B is
a) Study Area: Study was conducted in department almost similar and there is no statistical significant
of Anaesthesia. difference between the means of the two groups.
b) Study Population: Adult parturients classified The mean height in the group A and group B is
under ASA class I and class II, scheduled to almost similar and there is no statistical significant
undergo elective caesarean section. difference between the mean Heights.
c) Study Design: A Prospective Randomized Group A and group B has similar gestational age
controlled Study. at presentation.
d) Sample Size: The minimum sample size required Both groups have similar history of previous
for the study per group is 23. surgery.

Myakala Siddartha, P G Raghavendra / A Study on Complications of Magnesium Sulphate as an Adjunct to 1393
Ropivacaine Versus Plain Ropivacaine in Local Subcutaneous Infiltration for Postoperative Analgesia
Level of sensory block was similar in both the vascular resistance are minimal at therapeutic
groups with no statistically significant difference. concentrations. At toxic levels depression of
Table 2: Total Tramadol consumption. cardiac conduction and excitability leads to AV
Std.
block, ventricular dysrythmias and fatal cardiac
Group N Mean p-value arrest. Depression of myocardial contractility and
Deviation
Total Tramadol Group A 30 383 23.97 peripheral vasodilatation occur leading to decrease
0.001 in cardiac output and arterial blood pressure.
Consumption Group B 30 208 18.95
Cardiac toxicity is less than that with Bupivacaine
The cumulative analgesic requirement in
but more than that with Lidocaine.8
group A was also greater in group A (383 mg) as
compared to group B (208 mg) and the difference It can produce both stimulation and depression of
was statistically significant (p =0.001) (Table 10). central nervous system. Stimulation is manifested
Table 3: Incidence of Postoperative Adverse Effects. as restlessness, tremors, and shivering progressing
Incidence of Postoperative
to convulsions, followed by depression and coma
Group A Group B progressing to respiratory arrest. It has a primary
Adverse Effects
Nausea (N) 53.3%(16 pts) 26%(8 pts) depressant effect on the medulla andhigher centers.
Vomiting (V) 30%(9 pts) 10%(3 pts) The total analgesic consumption in our study in
Sedation (S) 16.66%(5 pts) 10%(3 pts) the initial 24 hours was also significantly reduced
Hypotension (H) 16.66%(5 pts) 20%(6 pts) in group B as compared to group A. Lee et al., also
Pruritus (P) 38.66%(11 pts) 30.66%(9 pts) reported reduced opioid consumption in patients
whoreceived wound infiltration with magnesium.9
Discussion None of the patients suffered from bradycardia,
hypoxaemia, respiratory depression, skin rash or
Ropivacaine in common with other local incision site excessive redness nor was there any
anaesthetics, reversibly blocks the conduction of evidence of infection. The incidence of sedation
nerve impulses by decreasing the permeability of and pruritis was similar in both groups with no
nerve cell membranes to sodium ions. statistically significant difference. The incidence of
Results from a recent study, show Ropivacaine nausea and vomiting was infact lower in group B as
induced blockade dissipates more rapidly than compared to group A. This could be explained by
bupivacaine induced blockade at equimolar the lesser use of rescue analgesic agent in group B
concentrations (5micromol/L). Blockade of since Inj tramadol itself is associated with increased
potassium channels may contribute to cardiotoxic incidence of nausea and vomiting.10
effects of local anaesthetic drugs by promoting
a lengthening of the cardiac action potential. Conclusion
Ropivacaine has been shown to block open
human delayed rectifier potassium channels
in a concentration dependent manner in vitro. Thus, while the potential adverse effects of IV
Ropivacaine has a lower affinity for these channels magnesium mentioned above are avoided, still
than bupivacaine. The cardio-depressive effects the benefits accrued by its adjunct analgesic effect
of Ropivacaine have been shown to be dependent can be availed. Thus, subcutaneous infiltration in
on the extra cellular potassium concentration. conjunction with local anaesthetic agents holds
Compared with lower concentrations (2.7mmol/L, great promise.
a sub physiological level), high extra cellular
potassium concentration (8.7mmol/L, a References
supraphysiological level which in isolation,would
be expected to reduce the strength of concentration)
reduced the EC 50 of Ropivacaine with respect to 1. Sandeep Kundra, Rupinder M Singh, Gaganpreet
negative ionotropic effect and maximum upstroke Singh, Tania Singh, Vikrant Jarewal, SunilKatyal.
Efficacy of maganesium sulphate as an adjunct to
velocity. Ropivacaine had less effect on cardiac
ropivacaine in local infiltration for postoperative
rhythm than Bupivacaine. Ropivacaine 5.33mg and
pain following lower segment caesarean section.
Bupivacaine 4mg, respectively, increased the QRS Journal of clinical and diagnostic research.2016 Apr,
interval by about 75 and 155% (p<0.01) and QT vol-10(4):UC18-UC22.
interval by 18% and 20%.7
2. Karen Miotto, MD et al. Trends in Tramadol:
Changes in cardiac conduction, excitability, Pharmacology, Metabolism, and Misuse. Anaesthesia
refractoriness, contractility and peripheral and Analgesia journal.2017;124(1):44–51.
3. Ko SH, Lim HR, Kim DC, Han YJ, Choe H, Song HS. Effect of high-volume systematic local infiltration
Magnesium sulfate does not reduce postoperative analgesia in Caesarean section: a randomised,
analgesic requirements. Anaesthesiology. placebo-controlled trial. ActaAnaesthesiol Scand.
2001;95(3):640–46. 2015;59(5):632–39.
4. Kussman B, Shorten G, Uppington J, Comunale 8. Donadi PK, Srilata M, Ramachandran G. Comparison
ME. Administration of magnesium sulphate before of bupivacaine and bupivacaine plus magnesium
rocuronium: effects on speed of onset and duration sulphate infiltration for postoperative analgesia
of neuromuscular block. Br J Anaesth. 1997;79:122– in patients undergoing lumbar laminectomy: A
24. prospective randomised doubleblinded controlled
study. Journal of Neuroanaesthesiologyand Critical
5. Kiran S, Gupta R, Verma D. Evaluation of a single- care. 2014;1(3):183–87.
dose of intravenous magnesium sulphate for
9. Lee M, Silverman SM, Hansen H, Patel VB,
prevention of postoperative pain after inguinal
Manchikanti L. A comprehensive review of
surgery. Indian J Anaesth. 2011;55:31–35.
opioid-induced hyperalgesia. Pain Physician.
6. Vissers RJ, Purssell R. Iatrogenic magnesium 2011;14(2):145–61.
overdose: two case reports. J of Emerg Med.
10. Shahid M, Manjula BP, Sunil BV. A comparative
1996;14:187–91. study of intravenous paracetamoland intravenous
7. Larsen KR, Kristensen BB, Rasmussen MA, tramadol for postoperative analgesia in
Rasmussen YH, Weber T, Kristensen B, et al. laparotomies. Anaesth Essays Res. 2015;9(3):314–19.

Comparison of Post Operative Sedation between Ultrasound Guided

TAP Block with the Standard Post-Operative Analgesic Regimen
Samarth S P1, Shreecharan P K2, Sarala Mohan3
Author’s Affiliation: 1Senior Resident, Department of Anaesthesiology, Chamarajanagar Institute of Medical Sciences, Yadapura,
Karnataka 571313, India, 2Registrar, Department of Anaesthesiology, Manipal Hospital, Bangalore, Karnataka 560017, India, 3Senior
Consultant, Department of Anaesthesiology, St. Martha’s Hospital, Bengaluru, Karnataka 560001, India.
Corresponding Author: Shreecharan P K, Registrar, Department of Anaesthesiology, Manipal hospital, Bangalore, Karnataka
560017, India.
E-mail: shreecharanpk@gmail.com

Samarth S P, Shreecharan P K, Sarala Mohan. Comparison of Post Operative Sedation between Ultrasound Guided TAP Block
with the Standard Post-Operative Analgesic Regimen. Indian J Anesth Analg. 2020;7(6):1395–1399.
Abstract
Introduction: From its humble beginnings, ultrasound guided regional anaesthesia has evolved over
the years, with the development of newer blocks and alternative approaches to existing peripheral nerve
blocks. Therefore it finds application in not only the anaesthesia set-up but also in critical care and trauma
triages, as a modality to provide anaesthesia and analgesia to patients. It is currently the standard of care
for administering regional anaesthesia.
Methodology: The patients were selected by convenience sampling and those who matched the selection
criterion, were briefed about the nature of the study and the procedures involved, in a language understood
by them and written informed consent was taken. Descriptive data of the patient such as name, age, sex
and detailed medical history, was collected.
Results: In our study it was observed that some patients in both Groups S and T experienced mild
sedation (Ramsay Sedation Score 3) when assessed for the same at the 2 hour and 4 hour interval. The
number of patients experiencing mild sedation at these intervals, were more in Group T as compared to
Group S.
Conclusion: But this difference in Sedation scores between the two groups was not found to be statistically
significant (p value> 0.05). At the subsequent intervals of 6, 12 and 24 hours, there was no difference in the
incidence of sedation between the two groups.
Keywords: Post Operative Sedation; TAP Block; Post-Operative Analgesic Regimen.
Introduction nerve blocks were administered by surface

anatomy "landmark" techniques. This technique
Peripheral nerve block is a technique of was fraught with complications such as inadequate
administering anesthesia and analgesia to patients, blockade of nerves, trauma to the surrounding
where the nerves supplying the area of interest are soft tissue, vascular and neural damage. The
blocked by deposition of local anaesthetic agent shortcomings of the blind approach were overcome
around them. While administering a peripheral with the development of nerve stimulators, which
nerve block, the goal is to ensure optimal helped the practitioner to identify the target nerve
distribution of local anaesthetic around the targeted by stimulating it and observing the response
nerve or plexus.1 elicited. But this technique too was fraught with
shortcomings such as inadequate nerve blockade
Prior to the advent of ultrasound, peripheral and damage to the nerves as a result of direct
puncture.2 TAP group and standard deviations of 19 and 18

With the advent of ultrasound, it was possible respectively, with 5% error and 99% power, the
to overcome the shortcomings associated with the minimum required sample size was 26 per group.
landmark and the nerve stimulator techniques. For the sake of consistency in the results the number
Ultrasound imaging of the anatomical structures of patients included in each group was 30.
enabled practitioners to ensure optimal needle Assumptions:
positioning and thereby safely administer regional a) The outcome variable is continuous.
anaesthesia. Since the blocks are administered
under vision, the volume of drug used could also b) The sampling distribution of the sample mean
be significantly reduced, thereby reducing the risk is approximately normal.
of local anaesthetic toxicity.3 c) The observations are independent.
In 1880, Pierre and Jacques Curie discovered the Duration of study: Two years (December
piezoelectric effect in crystals. A student of Pierre 2016-November 2018).
Curie, Paul Langevin, subsequently developed
Inclusion criteria:
piezoelectric materials which had the capability to
generate as well as absorb mechanical vibrations a) ASA-I and ASA-II patients.
with high frequency. Thereafter, ultrasound b) Patients undergoing total abdominal
found application in the navy to detect enemy hysterectomies.
submarines. In 1942, the clinical utility of the
c) Patients in the age group of 18-70 years.
ultrasound as a diagnostic tool was discovered
by Karl and Friedrich Dussik. It was also utilised Exclusion criteria:
to treat patients suffering from Meniere's disease, a) Patients allergic to bupivacaine.
Parkinson's disease and rheumatoid arthritis.4
b) Patient with bleeding or coagulation disorders.
It was only in 1978, that ultrasound was utilised
for the administration of peripheral nerve blocks. c) Patients undergoing emergency surgeries.
P. La Grange et al., used a Doppler transducer The patients were selected by convenience
to perform a supraclavicular brachial plexus sampling and those who matched the selection
block. In 1989, P. Ting and V. Sivagnanaratnam criterion, were briefed about the nature of the
extensively studied the utility of the B mode study and the procedures involved, in a language
ultrasonography to visualise the axillary anatomy understood by them and written informed consent
and to observe thespread of local anaesthetics in was taken. Descriptive data of the patient such as
the axillary brachial plexus block. Stephen Karpal name, age, sex and detailed medical history, was
and colleagues conducted extensive studies on the collected. They were randomized into two groups
brachial plexus block using the B mode ultrasound.5 with the help of computerized randomization
From its humble beginnings, ultrasound software. The groups were:
guided regional anaesthesia has evolved over I. Group S: Standard regimen group: The patients
the years, with the development of newer blocks in this group received the standard post-
and alternative approaches to existing peripheral operative analgesic regimen of intravenous
nerve blocks. Therefore it finds application in paracetamol 1 gm every 8th hour following the
not only the anaesthesia set-up but also in critical surgery.
care and trauma triages, as a modality to provide II. Group T: TAP block group: Patients in this

anaesthesia and analgesia to patients. It is currently group received post-operative ultrasound
the standard of care for administering regional guided TAP block with 0.25% bupivacaine as
anaesthesia.6 the analgesic modality.
Methodology Results
Study population: Patients undergoing total Table 1: Mean Age of patients in the two study groups.
abdominal hysterectomies. Group P Value
Study design: This was a prospective, single Group S (n=30) Group T (n=30)
blinded, randomized comparative study. Mean (SD) Mean (SD)
Mean Age 45.87 (7.22) 43.93 (6.07) 0.267
Sample Size: Considering a mean difference of (in years)
the rescue analgesic used in the standard and
Samarth S P, Shreecharan P K, Sarala Mohan / Comparison of Post Operative Sedation between 1397
Ultrasound Guided TAP Block with the Standard Post-Operative Analgesic Regimen
120
100 100 100 100 100 100 100
93.3
Percentage of study population
100 90
80 73.3
60
40
26.7
20
10 0 6.7
0
0
2 hrs 2 hrs 4 hrs 4 hrs 6 hrs 12 hrs 24 hrs
Score 2 Score 3 Score 2 Score 3 Score 2 Score 2 Score 2
Time interval (in hours)
Graph 1: Comparison of Sedation scores between the two study groups.
Unpaired t Test, P Value Not Significant. between the two groups.(Graph 1)

In our study, there was no statistical difference
in the mean age of the patients in Group S (Mean: Discussion
45.87 years) and Group T (Mean: 43.93 years) (p
value: 0.267). (Table 1)
Using the Ramsay Sedation Scale the sensorium
Table 2: Comparison of ASA grade distribution between the two
study groups. of patients in Group S and Group T was assessed
and evaluated. In our study it was observed that
ASA Grade Percentage of study P Value
population some patients in both the groups experienced mild
sedation (Ramsay Sedation Score 3) at the 2 hour
Group S Group T
and 4 hour interval. Thereafter none of the patients
(n=30) n (%) (n=30) n (%) in either group experienced any sedation or
drowsiness (Ramsay Sedation Score 2). There was
1 16 (53.3) 17 (56.7) no statistically significant difference in the sedation
0.795 scores of patients in the two groups (p value> 0.05).
2 14 (46.7) 13 (43.3)
Sivapurapu V et al.,7 conducted a randomized
controlled trial to compare theanalgesic efficacy
Chi-Square Test, P Value Not Significant. of the TAP block with direct infiltration of local
In our study, there was no statistically significant anaesthetic into surgical incision in patients
difference in the ASA grading distribution of undergoing lower abdominal gynaecological
patients between Group S (ASA 1: 53.3%; ASA 2: surgeries. The incidence of sedation was assessed
46.7%) and Group T (ASA 1: 56.7%; ASA 2: 43.3%) in both the groups at regular intervals, post-
as the p value is 0.795. (Table 2) operatively. It was found that there was a
significant reduction in sedation scores in the group
In our study it was observed that some patients
receiving TAP block at 2 (p value: 0.001) and 4
in both Groups S and T experienced mild sedation
hour intervals (p value: 0.003). Thereafter sedation
(Ramsay Sedation Score 3) when assessed for the
scores were comparable between the two groups.
same at the 2 hour and 4 hour interval. The number
These findings could be due to the higher demand
of patients experiencing mild sedation at these
for rescue analgesia (morphine 0.1 mg/kg bolus,
intervals, were more in Group T as compared to
followed by morphine PCA) in the group receiving
Group S. But this difference in Sedation scores
infiltration, in the early post-operative intervals.
between the two groups was not found to be
In our study, patients in both in both Group S
statistically significant (p value> 0.05). At the
and Group T experienced mild sedation at the 2
subsequent intervals of 6, 12 and 24 hours, there
and 4 hour interval, but there was no statistically
was no difference in the incidence of sedation

significant difference in the sedation scores et al,10 to evaluate the efficacy of the TAP block
between the two groups. This could be attributed in providing analgesia in women undergoing
to the sedative effects of intrathecal buprenorphine Caesarean sections, incidence of sedation was
used in the present study. Thereafter patients in evaluated. In the sub analysis comparing TAP
both the groups had no complaints of sedation. blocks with controls in patients who did not receive
This could be due to the lack of usage of opioids intra-thecal morphine, it was noted that there was
as rescue analgesics or as a part of the standard no significant difference in sedation scores between
analgesic regimen and the wearing off of the effects the two groups. Even in patients who had received
of buprenorphine. intra thecal morphine, it was noted that there was
Bharti et al.,8 compared the analgesic efficacy no significant difference in the sedation scores when
of a novel approach to TAPblock with controls, in compared to the TAP block group. The findings of
patients undergoing colorectal surgeries. Patients our study with respect to sedation scores are in
in both thegroups were assessed for sedation scores concurrence with the findings of the above meta-
at regular intervals, post-operatively. It was found analysis.
that the sedation scores were significantly lower in In the meta-analysis conducted by Abdallah F
the TAP block group at 2, 4, and 6 hours (p value W et al,11 to assess the relative analgesic efficacies
< 0.05). Thereafter the results were comparable of the posterior and lateral approaches of the TAP
between the two groups. The reason for the higher block, the sedation scores of the patients were
sedation scores in the patients of the control group, assessed. It was found that when compared to
in the early post-operative intervals could be due the controls, there was a significant reduction in
to the higher demand of the rescue analgesic, sedation scores at the 24 hour interval in patients
morphine. In our study, the sedation scores were who had received the TAP block by the posterior
comparable at the early post-operative time approach. No such difference was observed at the
intervals whereas, the patients in both Group S and 24 hour interval, in the patients who had received
Group T were asymptomatic in the later intervals. TAP block by the lateral approach, when compared
This was due to the use of buprenorphine, which to controls. In our study the sedation scores of
produced comparable sedation in patients of both patients in Group S and Group T were comparable
Group S and Group T at 2 and 4 hour intervals. in the early post-operative intervals due to the use
The absence of any sedation in patients of both the of intrathecal buprenorphine. At the subsequent
groups at subsequent time intervals was due to the intervals patients in both the groups did not have
wearing off of the effects of buprenorphine and any sedation. This is similar to the results of the
the absence of opioids in the standard analgesic aforementioned meta-analysis.12
regimen as well as the rescue analgesic plan.
Since sedation scores are a function of the
Kanazi et al,9 compared the analgesic efficacy of timing of the rescue analgesia, dose of analgesic
sub arachnoid morphine with thatof TAP block in administered and the nature of the analgesic used
women undergoing Caesarean sections. Sedation (opioid or non-opioid), there can be heterogeneity
scores of patients in both the groups were noted in the sedation scores observed in the patients.
at regular intervals, post-operatively. It was found
that the sedation scores were comparable at all
Conclusion
post-operative time intervals assessed (less than or
equal to 2), between the two groups. The reason for
comparable sedation scores in both the groups could Mild sedation was present in patients of both
be due to the low dose of morphine used in the sub Group S and Group T at the 2 and 4 hour interval,
arachnoid block. In our study, the sedation scores but the sedation scores were comparable between
were comparable at the 2 and 4 hour intervals. At the two groups. At the subsequent time intervals,
the subsequent intervals patients in both Group S patients in both the groups did not experience
and Group T did not experience any sedation. This any sedation.
was because patients in both the groups received
intrathecal buprenorphine, resulting in comparable References
sedation scores in the early post-operative intervals.
Thereafter, due to the wearing off of the effects of
intrathecal buprenorphine, patients in either group 1. Siddiqui MRS, Sajid MS, Uncles DR, Cheek L, Baig
MK. A meta-analysis on the clinical effectiveness of
did not experience any sedation.
transversus abdominis plane block. J Clin Anesth
In a meta-analysis conducted by Mishriky B M. [Internet]. 2011;23(1):7–14. Available from: http://
Samarth S P, Shreecharan P K, Sarala Mohan / Comparison of Post Operative Sedation between 1399
Ultrasound Guided TAP Block with the Standard Post-Operative Analgesic Regimen
dx.doi.org/10.1016/j.jclinane.2010.05.008. 8. Bharti N, Kumar P, Bala I, Gupta V. The efficacy of

2. Borley NR. Anterior Abdominal Wall. In: Standring a novel approach to transversus abdominis plane
S, editor. Gray's Anatomy: TheAnatomical Basis of block for postoperative analgesia after colorectal
Clinical Practice. 40th ed. International: Churchill surgery. AnesthAnalg. 2011;112(6):1504–8.
Livingstone: Elsevier; 2008. p. 1055–67.
9. Kanazi GE, Aouad MT, Abdallah FW, Khatib MI,
3. Karmakar MK, Soh E, Chee V, Sheah K. Sonoanatomy
Adham AM, Harfoush DW, et al. The analgesic
Relevant for Ultrasound-Guided Abdominal
Wall Nerve Blocks. In: Atlas of Sonoanatomy for efficacy of subarachnoid morphine in comparison
Regional Anesthesia and Pain Medicine. McGraw- with ultrasound-guided transversus abdominis
Hill Education; 2018. p. 214–31. plane block after cesarean delivery: A randomized
4. Tsai HC, Yoshida T, Chuang TY, Yang SF, Chang controlled trial. Anesth Analg. 2010;111(2):475–81.
CC, Yao HY, et al. Transversus Abdominis Plane 10. Mishriky BM, George RB, Habib AS. Transversus
Block: An Updated Review of Anatomy and
abdominis plane block for analgesia after Cesarean
Techniques. Biomed Res Int. 2017;2017:3–9.
delivery: A systematic review and meta-analysis.
5. Marhofer P, Greher M, Kapral S. Ultrasound Can J Anesth. 2012;59(8):766–78.
guidance in regional anaesthesia. Br J Anaesth.
2005;94(1):7–17. 11. Abdallah FW, Laffey JG, Halpern SH, Brull R.
6. Xu D. Ultrasound Physics. In: Hadzic A, editor. Duration of analgesic effectiveness after the
Hadzic's Peripheral Nerve Blocks and Anatomyfor posterior and lateral transversus abdominis
Ultrasound-Guided Regional Anesthesia. Second. plane block techniques for transverse lower
McGraw Hill Companies; 2012. abdominal incisions: A meta-analysis. Br J Anaesth.
7. Sivapurapu V, Vasudevan A, Gupta S, Badhe A. 2013;111(5):721–35.
Comparison of analgesic efficacy of transversus
12. Belavy D, Cowlishaw PJ, Howes M, Phillips F.
abdominis plane block with direct infiltration of
local anesthetic into surgical incision in lower Ultrasound-guided transversus abdominis plane
abdominal gynecological surgeries. J Anaesthesiol block for analgesia after Caesarean delivery. Br J
Clin Pharmacol [Internet]. 2013;29(1):71. Anaesth. 2009;103(5):726–30.

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Efficacy of Magnesium Sulphate as an Adjunct to Ropivacaine in Local

Subcutaneous Infiltration for Postoperative Analgesia Following Lower
Segmental Ceasfrean Section in Parturents under Spinal Anesthesia
Myakala Siddartha1, P G Raghavendra2
Author’s Affiliation: 1,2Assistant Professor, Department of Anesthesiology, Raichur Institute of Medical Sciences, Raichur,
Corresponding Author: P G Raghavendra, Assistant Professor, Department of Anesthesiology, Raichur Institute of Medical
Sciences, Raichur, Karnataka 584102, India.
E-mail: drpgraghavendra@gmail.com

Myakala Siddartha, P G Raghavendra. Efficacy of Magnesium Sulphate as an Adjunct to Ropivacaine in Local Subcutaneous
Infiltration for Postoperative Analgesia Following Lower Segmental Ceasfrean Section in Parturents under Initial Anesthesia.
Indian J Anesth Analg. 2020;7(6):1401–1404.
Abstract
Introduction: Magnesium is an antagonist of NMDA receptors and associated ion channels. It is found in
very small concentrations in the plasma and is chiefly an intracellular ion. It is suggested that magnesium
has many important roles to play in nociception. An inverse relationship has been documented between
the severity of pain with different painful medical and surgical conditions and the serum magnesium
levels.
Methodology: Patients were monitored for postoperative pain and any analgesic requirement for a
period of 24 hours. Any patient complaining of pain or reporting VAS ≥4 at any time was administered Inj
tramadol 100 mg IV slowly over 2-3 minutes. If pain was not relieved after 30 minutes and patients still
complained of pain, additional doses of Inj tramadol 50mg IV was given and this dose could be repeated
every 30 minutes upto a total dose of 250 mg in 6 hourly and maximum of 400mg of Inj tramadol over 24
hours.
Results: The number of patients who were administered 2nd, 3rd and 4th doses of rescue analgesics was
significantly greater in group A as compared to group B. None of the patients in group B needed more
than 4 doses of rescue analgesia while in group A, 5 patients were administered a rescue analgesic for
5th time. The study suggests that local infiltration of local anaesthetic agent alone or in conjunction with
magnesium is safe.
Conclusion: The addition of magnesium to local anaesthetics potentiates the effect of local anaesthetics
and reduces the postoperative opioid requirement.
Keywords: Magnesium Sulphate; Ropivacaine; Spinal Anaesthesia.
Introduction since a parturient who is experiencing pain finds it

difficult to feed her new born.1
Plan for postoperative pain is the hallmark of Opioids, which otherwise are the mainstay
a good anaesthetic practice. Pain relief after analgesics in the postoperative period are avoided
caesarean delivery is especially important as the in the parturient since almost all opioids find their
consequences of inadequate pain relief are borne way in the milk predisposing the neonate to their
not only by the mother but by the new born as well, adverse effects.

So other modalities for pain relief are often randomisation was administered by local
selected. Now-a-days, multimodal approach to subcutaneous wound infiltration at the incision
pain relief is recommended so that adverse effects site, by the obstetrician who was blinded to the
of individual drugs can be reduced. Neuraxial study drug administered.This time was labeled as
blocks, peripheral Nerve blocks, NSAIDS and local ‘0’ and recording of parameters was started from.
anaesthetic infiltration of wound have all been used
Group A patients, administered a Local
as part of multimodal approach.2
subcutaneous wound infiltration of Injection
Local wound infiltration is an attractive strategy (Inj) ropivacaine (0.5%) 100 milligrams (mg)
since it is efficacious and side effects are minimal. or 20 millilitres (ml) whereas, group B patients
However, this modality is limited by the fact that administered a Local subcutaneous wound
duration of analgesia is provided only till the effects infiltration of Inj magnesium sulphate 500mg
of local anaesthetic action lasts. Efforts are being (1 ml of 50% Inj Magnesium sulphate) added to
made to prolong the duration of action of local Injropivacaine 0.5%(19 ml) making the total volume
anaesthetic skin infiltration and magnesium is one of injectate to 20 ml. After this, skin closure was
such agent which has been used for this purpose.3 done and patients were shifted to Post anaesthesia
Magnesium is an antagonist of NMDA receptors care unit (PACU).
and associated ion channels. It is found in very On arrival to PACU, patients were asked to rate
small concentrations in the plasma and is chiefly the pain using VAS rulers having slide indicator
an intracellular ion. It is suggested that magnesium
and were asked to bring the slider on the scale on to
has many important roles to play in nociception. An
the point that they feel represents their current state
inverse relationship has been documented between
of pain with ‘0’ mark corresponding to no pain and
the severity of pain with different painful medical
‘10’ mark representing worst imaginable pain.
and surgical conditions and the serum magnesium
levels. Recently, intra-articular infiltration of Patients were monitored for postoperative
magnesium has been used in knee and shoulder pain and any analgesic requirement for a period
arthroscopies with good results.4 of 24 hours.Any patient complaining of pain or
reporting VAS ≥4 at any time was administered
We hypothesized that subcutaneous infiltration
of magnesium has the potential to prolong the Inj tramadol 100 mg IV slowly over 2–3 minutes. If
duration of action of subcutaneous infiltration of pain was not relieved after 30 minutes and patients
local anaesthestic agent at the incision site. Only still complained of pain, additional doses of Inj
a handful of studies have evaluated this route of tramadol 50mg IV was given and this dose could
administration of magnesium. be repeated every 30 minutes upto a total dose of
250 mg in 6 hourly and maximum of 400mg of Inj
tramadol over 24 hours.
Methodology
Results
Patients were enrolled in the study after a thorough
pre anaesthetic check up and routine investigations Mean VAS
which included a Complete Haemogram, B. urea, S. 6
creatinine, BT, CT and Random Blood sugar, ECG.
5
After shifting the patients to the operation theatre,
4
pre induction pulse rate (PR), Non Invasive Blood
Pressure (NIBP), Respiratory Rate (RR), Oxygen 3
Group A
Saturation (SpO2) and Electrocardiography (ECG) 2 Group B
was recorded. These parameters were monitored
1
throughout the procedure and recorded every 10
minutes. 0
0 min 1 hr 2 hr 3 hr 4 hr 8 hr 12 hr 16 hr 20 hr 24 hr
Intra-operative complications like hypotension, TIME

bradycardia, nausea/vomiting, etc were managed Graph 1: Mean VAS.
as per departmental policy in both the groups. VAS was similar in both the groups with no
After the closure of uterus and muscle layer statistically significant difference till 8th hour There
but before closure of skin, the allocated drug was statistically significant difference in VAS from
as per random grouping based on computer 12 to 24 hours in both the groups (Graph 1).

Myakala Siddartha, P G Raghavendra / Efficacy of Magnesium Sulphate as an Adjunct to Ropivacaine in 1403
Local Subcutaneous Infiltration for Postoperative Analgesia Following Lower Segmental Ceasfrean
Section in Parturents under Initial Anesthesia
The need for IV rescue analgesic for the first administration of magnesium as an adjunct to the
time was at 4.65±0.418 hours in group A and at local anaesthetic agents.6
6.01+0 425hours in group B. Thus, the need for The dose of ropivacaine used in our study is as
first dose of rescue analgesia was earlier in group per the recommended dosage guidelines and is
A as compared to group B the difference was well within the safety limits.
statistically significantly (p=0.001). However, the
need for 2nd and 3rd doses of rescue analgesics was The dose of magnesium co-relates with the
significantly later in group B and the difference was dose used by Tauzin et al., who used 750 mg of
statistically significant with p-value of 0.001 and magnesium in 0.25% bupivacaine to a total volume
0.001 respectively. The time for 4th rescue analgesic, of 20 ml. Larger doses than the dose administered
also showed statistically significant difference by us, have been safely used in parturients in earlier
(p=0.001). (Table 1). studies.7
Table 1: Time to Rescue Analgesia. The mean heart rate and mean blood pressure
Mean S.D Mean S.D p-value
did not change significantly from baseline
1st time 4.65 0.41833 6.016667 0.425144 0.001
suggesting there are no adverse cardiovascular
2nd time 9.833333 0.379049 14.1875 0.247268 0.001
adverse effects of a small dose of magnesium when
used for subcutaneous infiltration. Our results are
3rd time 14.92308 0.744208 18.5 0.408248 0.001
similar to those of Donadi et al., who also observed
4th time 18.97619 0.511766 22.95455 0.522233 0.001
no significant change in blood pressure on using
5th time 21.175 0.24468 – – –
magnesium.8
The number of patients who were administered
VAS in both the groups was similar in both the
2nd, 3rd and 4th doses of rescue analgesics was
groups at various time intervals and also showed
significantly greater in group A as compared to
significant difference from 12 to 24 hours.whereas,
group B. None of the patients in group B needed
the total supplemental analgesic consumption
more than 4 doses of rescue analgesia while in group
washigher in group B. This was expected, as patients
A, 5 patients were administered a rescueanalgesic
were administered supplemental IV analgesics
for 5th time. (Table 2).
whenever, patients reported VAS more than 3. For
Table 2: Number of patients requiring rescue analgesia.
this reason, supplemental analgesic consumption
Group A Group B P-Value may give a better idea regarding the effectiveness of
1st 30 30 adjuvant added to the local anaesthetic infiltration.
2nd 30 24 0.008
The need for first dose of supplemental analgesic
3rd 26 16 0.001
was later in the group B as compared to group A, the
4th 21 11 0.001
difference was statistically significant. Afterwards,
5th 10 0 0.017
the second, third and fourth supplemental doses
of analgesics were consumed much later in group
Discussion B as compared to group A, and the difference was
statistically significant.Group A received five doses
Concerns regarding opioid induced hyperalgesia of supplemental analgesics as compared tofour
and sensitization are growing and efforts are on to doses in the group B.
mitigate this opioid related adverse effect. Our results are similar to Eldaba et al., who
Recently, there is an interest in the use of NMDA used continuous wound infiltration of bupivacaine
antagonists like magnesium in postoperative pain along with magnesium sulphate in patients
relief. These agents have the potential to prevent undergoing caesarean section and reported an
central sensitization to peripheral nociceptive effective analgesiaand reduced postoperative
stimulation and also abolish hypersensitivity, if it Patient controlled analgesia (PCA) requirements
is established.5 as compared to continuous wound infiltration with
local anaesthetic only or placebo.9
The administration of intravenous magnesium
in the perioperative period, however, is fraught
with risk, as it may potentiate neuromuscular Conclusion
blockade after administration of neuromuscular
blocking drugs, increase sedation and contribute The result of our study brings out some interesting
to serious cardiac morbidity . These adverse effects findings. Our study indicates that subcutaneous
have brought attention towards subcutaneous infiltration of magnesium reduces postoperative

analgesic requirements after Cesarean delivery 6. De Oliveira GS Jr, Castro-Alves LJ, Khan JH,
and is not associated with any significant adverse McCarthy RJ. Perioperative systemic magnesium
effects. to minimize postoperative pain: a meta-analysis
of randomized controlled trials. Anaesthesiology.
2013;119(1):178–90.
References
7. Tauzin FP, Sesay M, Svartz L, Krol-Houdek MC,
Maurette P. Wound infiltration with magnesium
1. Kuczkowski KM. Postoperative pain control in the sulphate and ropivacaine mixture reduces
parturient: new challenges in the new millennium. J
postoperative tramadol requirements after
MaternFetal Neonatal Med. 2011;24(2):301–04.
radical prostatectomy. ActaAnaesthesiol Scand.
2. Verstraete S, Van de Velde M. Post-cesarean section 2009;53(4):464–69.
analgesia.ActaAnaesthesiol Belg. 2012;63(4):147–67.
8. Donadi PK, Srilata M, Ramachandran G. Comparison
3. McDonnell NJ, Keating ML, Muchatuta NA, Pavy
of bupivacaine and bupivacaine plus magnesium
TJ, Paech MJ. Analgesia after caesarean delivery.
sulphate infiltration for postoperative analgesia
Anaesth Intensive Care. 2009;37(4):539–51.
in patients undergoing lumbar laminectomy: A
4. Carvalho B, Clark DJ, Yeomans DC, Angst prospective randomised doubleblinded controlled
MS. Continuous subcutaneous instillation
study. Journal of Neuroanaesthesiology and Critical
of bupivacaine compared to saline reduces
care. 2014;1(3):183–87.
interleukin 10 and increases substance P in surgical
wounds after cesarean delivery. AnaesthAnalg. 9. Eldaba AA, Amr YM, Sobhy RA. Effect of wound
2010;111(6):1452–59. infiltration with bupivacaine or lower dose
5. Bailard NS, Ortiz J, Flores RA. Additives to local bupivacaine/magnesium versus placebo for
anaesthetics for peripheral nerve blocks: Evidence, postoperative analgesia after cesarean section.
limitations, and recommendations. Am J Health Anaesthesia, Essays and Researches. 2013;7(3):
Syst Pharm.2014;71(5):373–85. 336–40.

Effects of Magnesium Sulphate on Hemodynamic Response to

Carbondioxide Pneumoperitoneum in Patients undergoing
Laparoscopic Appendicectomy
G Karthikeyan1, M Dhakshinamoorthy2
Author’s Affiliation: 1Post Graduate, 2Professor, Department of Anaesthesiology, Rajah Muthiah Medical College, Annamalai
nagar, Tamil Nadu 608002, India.
Corresponding Author: M Dhakshinamoorthy, Professor, Department of Anaesthesiology, Rajah Muthiah Medical College,
Annamalai nagar, Tamil Nadu 608002, India.
E-mail: karthikeyangopalakrishnan83@gmail.com

G Karthikeyan, M Dhakshinamoorthy. Effects of Magnesium Sulphate on Hemodynamic Response to Carbondioxide
Pneumoperitoneum in Patients undergoing Laparoscopic Appendicectomy. Indian J Anesth Analg. 2020;7(6):1405–1409.
Abstract
Carbondioxide pneumoperitoneum in laparoscopic appendicectomy is associated with adverse

hemodynamic effects like increases in blood pressure, heart rate and systemic vascular resistance. These
adverse effects are due to release of catecholamine and vasopressin. We conducted this randomized double
blinded study to assess the effect of magnesium sulphate on attenuating these adverse hemodynamic
responses.
Materials and Methods: Sixty ASA I and II patients of either sex aged 20–60 years posted for elective
laparoscopic appendicectomy were randomized into two groups of thirty patients each. Group M received
magnesium sulphate 20 mg / kg intravenously before creating pneumoperitoneum. Group C received
same volume of 0.9 % saline.
Results: Systolic blood pressure, diastolic blood pressure and heart rate were significantly less in patients
of Group M when compared to the placebo group.
Conclusion: Magnesium sulphate given at a dose of 20 mg / kg before pneumoperitoneum attenuates
adverse hemodynamic responses and ensures better hemodynamic stability during pneumoperitoneum
created for laparoscopic surgery.
Keywords: Hemodynamic; Laparoscopic surgery; Magnesium sulphate; Pneumoperitoeum.
Introduction and decrease in cardiac output.3 In response to

carbondioxide pneumoperitoneum there is release
of catecholamines and vasopressin.4,5 which causes
Laparoscopic surgery is well known as minimally
these adverse hemodynamic responses.The rise
invasive surgery or key hole surgery. In 1983,
in blood pressure and heart rate occurring during
Kurt semm performed the first laparoscopic
carbondioxide pneumoperitoneum will have
appendicectomy. Laparoscopic surgery is the
serious consequences in patients especially those
latest surgical technique for operating in abdomen.
with compromised cardiac function.6
The abdomen is insufflated with an exogenous
gas usually carbondioxide during laparoscopic In our study, we used magnesium sulphate to
appendicectomy to create pneumoperitoneum.1,2 attenuate these adverse hemodynamic effects of
Carbondioxide pneumoperitoneum have carbondioxide pneumoperitoneum. Magnesium
adverse hemodynamic effects like rise in blood blocks the release of catecholamines from
pressure, rise in systemic vascular resistance the adrenal gland and the sympathetic nerve
terminals.7 Magnesium acts on blood vessels to test drug and the placebo drug were given
cause vasodilation.8 Magnesium also attenuates 10 mins before creating pneumoperitoneum.
vasopressin induced vasoconstriction.8 Intraoperative monitoring of heart rate,systolic
James et al studied the efficacy of magnesium BP, diastolic BP were done when the test drug
sulphate administered intravenously in given and at 5, 10, 20, 30, 45, 60 mins after
attenuating catecholamine release associated pneumoperitoneum. Pneumoperitoneum inflation
with tracheal intubation. We intend to study the pressure were maintained between 13 and 15
effects of magnesium sulphate in attenuating the mmHg. Duringsurgery, anaesthesia is maintained
adverse hemodynamic responses associated with with nitrous oxide 66 % and oxygen 33 % and
atracurium 0.5 mg / kg loading dose and 0.1 mg/
carbondioxide pneumoperitoneum in patients
kg as maintainence dose. Fentanyl 0.5 mcg / kg
undergoing laparoscopic appendicectomy.
was given every 30 mins during surgery. End-tidal
carbondioxide was maintained at 35–40 mmHg.
Materials and Methods At the end of the surgery, ondansetron 4 mg was
given for prophylaxis against post operative
Our study was conducted as a randomized nausea and vomiting. Residual neuromuscular
experimental double blinded study in patients blockade was reversed with neostigmine 0.05 mg
undergoing laparoscopic appendicectomy / kg and glycopyrolate 0.01mg/kg, Extubation
at the department of anaesthesiology, Rajah was done under thorough suction. Patients were
Muthiah Medical College, Annamalai university, observed in the postoperative period for sedation
Chidambaram, Tamilnadu. using Ramsay’s sedation score. Patients were also
monitored for signs of hypermagnesemia in the
The study protocol was approved by the ethics postoperative period.
committee for human experiments and informed
consent was taken from each of the patients. Sixty The results obtained from the study were
ASA I and II patients aged 20–60 years undergoing presented in the following section. The data was
laparoscopic appendicectomy under General entered into Microsoft excei 2013. The data was then
Anaesthesia were assigned to one of the two groups imported into SPSS (Statistical package for social
each containing thirty patients. sciences) version 23 by IBM corporation for analysis.
Descriptive stastistics and inferential statistics
Group M (Magnesiumsulphate group): patients included mean, proportion and percentages.
receive magnesium sulphate 20mg/kg diluted in Inferential statistics included unpaired ‘t’ test, chi
10ml normal saline intravenously. square test and repeated measures ANOVA.
Group C (Control group): patients receive 10ml
normal saline intravenously. Results
Patients with hypermagnesemia, known allergy
to magnesium sulphate, patients with heart block, Both the groups were comparable with respect to
hypertension, diabetes mellitus, other systemic demographic profile (age, sex) and did not vary
disease like cardiovascular disease, kidney significantly between the two groups (Tables 1, 2).
disease, endocrine disease, metabolic disease were
excluded from the study. All the patients were There was a significantly greater decrease in
given T. diazepam 5mg, T. ranitidine 150 mg orally heart rate in the group M as compared to the
on the night before surgery. Glycopyrolate 0.2 mg group P (Fig. 1) (p < 0.05). There was a significantly
was given intramuscularly 45min before surgery. greater decrease in the systolic BP in the group
On the arrival to operation theatre, monitors like M as compared to the group P (Fig. 2) (p < 0.05).
pulse oximeter, NIBP, ECG were attached. Baseline There was a clinically significant greater decrease
parameters namely BP, heart rate, SPO2 were in diastolic BP in group M as compared to group
recorded. An intravenous line was secured. A ryle’s P (Fig. 3). Postoperative sedation is evaluated with
tube was inserted nasogastrically. Ramsay sedation score and it is comparable in both
the groups.
All patients were preoxygenated with 100 % Table 1: Age Distribution.
oxygen for three minutes and were administered
T P
1mcg / kg of fentanyl intravenously. Thiopentone Group N Age
value
dof
value
sodium 5mg/kg was used for induction and Mean SD
endotracheal intubation was facilitated with Magnesium group 30 32.37 11.02 0.012 58 0.991
succinylcholine 1–2 mg/kg intravenously. The Control group 30 32.33 11.01 0.012 58 0.991

G Karthikeyan, M Dhakshinamoorthy / Effects of Magnesium Sulphate on Hemodynamic Response to 1407
Carbondioxide Pneumoperitoneum in Patients undergoing Laparoscopic Appendicectomy
Table 1 shows no significant difference in age Fig 2 shows systolic BP is significantly lower
distribution between 2 groups. in the magnesium group when compared to the
Table 2: Sex Distribution. control group.
Sex Magnesium group Control group Total 90
n % n % n % 88
Male 14 46.7 17 56.7 31 51.7
Diastolic BP (mmHg)
86
Female 16 53.3 13 43.3 29 48.3
84
Total 30 100 30 100 60 100
82
X2 : 0.601; p value : 0.438 ( > 0.05 )
80
Table 2 shows there is no significant difference in 78
the sex distribution between both groups. 76
Table 3: Sedation Score Table.
74
Sedation Magnesium Control Total
72
score group group Base 0min 5min 10min 20min 30min 45min 60min
n % n % n % Time
Score 1 13 43.3 13 43.3 26 43.3 Magnesium Group Control Group
Score 2 17 56.7 17 56.7 34 56.7
Fig. 3: Changes In Diastolic BP.
Total 30 100 30 100 60 100
Fig 3 shows diastolic BP is significantly lower
X2 : .000 df : 1 p value : 1.000 ( > 0.05).
in the magnesium group when compared to the
Table 3 shows there is no significant difference in control group.
the sedation score between both groups.
100
Discussion
98
96
94 In our study, we investigated the effects of
Heart rate (/min)
92 magnesium sulphate on hemodynamic response

90
to pneumoperitoneum during laparoscopic
88
appendicectomy. In laparoscopic procedures,
pneumoperitoneum is usually created with
86
carbondioxide.10,11 Magnesium sulphate is one of
84
the therapeutic regimens used to optimize adverse
82
hemodynamic responses to pneumoperitoneum.
80
Base 0min 5min 10min 20min 30min 45min 60min Magnesium sulphate has direct vasodilator action12
Magnesium Group Control Group and also attenuates the release of catecholamines.13
Raised IAP associated with pneumoperitoneum
Fig 1: Changes In Heart Rate.
and carbondioxide absorbed systemically cause
Fig 1 shows heart rate is significantly lower in the adverse hemodynamic responses.14 With the
magnesium group when compared to the control creation of pneumoperitoneum, there is immediate
group. increase in catecholamine and vasopressin levels in
140 the blood. This sympathetic stimulation activates
the renin-angiotensin aldosterone system (RAAS),
135 which induces hemodynamic changes14,15 like
reduced cardiac output, raised arterial pressure,
Systolic BP (mmHg)
130
elevated systemic and pulmonary vascular
resistance.16 Various drugs have been studied
125
and utilized to blunt these adverse hemodynamic
120
alterations associated with pneumoperitoneum. As
mentioned earlier, magnesium sulphate is effective
115 in attenuating the release of catecholamines from the
adrenergic nerve terminals and the adrenal gland.17
110 In addition, magnesium sulphate acts directly on the
Base 0min 5min 10min 20min 30min 45min 60min blood vessels18 to cause vasodilation. Vasopressin
Magnesium Group Control Group also contributes to the hemodynamic changes
Fig. 2: Mean Systolic BP. associated with pneumoperitoneum. Magnesium
suiphate modulates the vasoconstriction caused by References

vasopressin.19 The study conducted by James et al20
revealed that magnesium sulphate can optimize 1. Hodgson G, Mc Clelland RM, Newton JR. Some
the adverse hemodynamic effects associated effects of the peritoneal insufflation of carbon
with endotracheal intubation. We also studied dioxide at laproscopy. Anaesthesia. 1970;25:382–90.
the effect of magnesium sulphate administered 2. Blobner M, Felber AR, Gögler S, Weigl EM,
intravenously at a dose of 20 mg/kg to attenuate Jelen ES. Carbon dioxide uptake from the
the hemodynamic response to pneumoperitoneum. pneumoperitoneum during laparoscopic
Telci et al21 studied the efficacy of magnesium cholecystectomy. Anesthesiology. 1992;77:A37–40.
sulphate to reduce anaesthetic requirements. They 3. Richardson JD, Trinkl JK. Haemodynamic and
gave magnesium sulphate 30 mg/kg as bolus respiratory alterations with increased intra
before induction then 10 mg/kg/hr as continuous abdominal pressure. J Surg Res. 1976;20:401–4.
infusion. In our study, we do not intend to study 4. Lenz RJ, Thomas TA, Wilkins DG. Cardiovascular
the efficiency of magnesium sulphateto decrease changes during laparoscopy. Studies of stroke
the anaesthetic requirements. So we did not give volume and cardiac output using impedance
any magnesium sulphate infusion intra operatively. cardiography. Anaesthesia. 1976;31:4–12.
Still it is observed in our study that magnesium 5. Myre K, Rostrup M, Buanes T, Stokland O. Plasma
sulphate 20 mg/kg diluted in 10 ml normal saline catecholamines and haemodynamic changes during
administered 10 min before pneumoperitoneum pneumoperitoneum. ActaAnaesthesiol Scand. 1998;
42:343–7.
was able to attenuate the hemodynamic alterations.
Diament et al22 observed in their study conducted 6. Walder AD, Aitkenhead AR. Role of vasopressin
in dog that 35% decrease in cardiac output with in the haemodynamic response to laparoscopic
cholecystectomy. Br J Anaesth. 1997;78:264–6.
an IAP of 40 mmHg. Ishizaki et al23 observed in
their study, a significant fall in cardiac output at 7. McLaughlin JG, Scheeres D, Dean R, Bonnell BW.
16 mmHg. They also observed that hemodynamic The adverse haemodynamic effects of laparoscopic
cholecystectomy. SurgEndosc. 1995;9:121–4.
alteration were not that much with IAP of 12
mmHg. We also tried to keep IAP of 12–13 mm 8. Lishajko F. Releasing effect of calcium and
phosphate on catecholamines, ATP, and protein
Hg in our study. Inspite of maintaining 12–13
from chromaffin cell granules. ActaPhysiol Scand.
mmHg and normocapnia, there was significant rise 1970;79:575–84.
in arterial pressure and heart rate in the control
9. Altura BM, Altura BT. Magnesium and vascular
group. However in the magnesium sulphate group
tone and reactivity. Blood Vessels. 1978;15:5–16.
hemodynamic changes to pneumoperitoneum were
10. Vecchio R, Macfayden BV, Palazzo F. History
effectively attenuated and both arterial pressure
of laparoscopic surgery. Panminerva Med
and heart rate remained at significantly lower 2000;42:8790.
level compared to control group. We observed in
11. Hodgson G, Mc Clelland RM, Newton JR. Some
our study that magnesium sulphate administered
effects of the peritoneal insufflation of carbon
intravenously before creating pneumoperitoneum dioxide at laproscopy. Anaesthesia 1970;25:38290.
at a dose of 20 mg/ kg effectively attenuated the
12. Myre K, Rostrup M, Buanes T, Stokland O. Plasma
adverse hemodynamic responses. In our study, catecholamines and haemodynamic changes during
no patient of either group suffer from tachycardia pneumoperitoneum. ActaAnaesthesiolScand 1998;
or hypotension. Hypertension occurred in few 42:3437.
patients in the control group which was managed 13. Walder AD, Aitkenhead AR. Role of vasopressin
with inj. Nitroglycerine. in the haemodynamic response to laparoscopic
cholecystectomy. Br J Anaesth 1997;78:2646.
Conclusion 14. Blobner M, Felber AR, Gögler S, Weigl EM,
Jelen ES. Carbon dioxide uptake from the
pneumoperitoneum during laparoscopic
We conclude that, magnesium sulphate used in our cholecystectomy. Anesthesiology 1992; 77:A3740.
study provided better hemodynamic stability in
15. Richardson JD, Trinkl JK. Haemodynamic and
patients undergoing laparoscopic appendicectomy. respiratory alterations with increased intra
Hence magnesium sulphate is effective in abdominal pressure. J Surg Res intraoperative
attenuating adverse hemodynamic responses anesthetic requirements. Br J Anaesth 2002;89:5948.
during laparoscopic appendicectomy. 16. Lenz RJ, Thomas TA, Wilkins DG. Cardiovascular
Acknowledgements: No source of funding. changes during laparoscopy. Studies of stroke

G Karthikeyan, M Dhakshinamoorthy / Effects of Magnesium Sulphate on Hemodynamic Response to 1409
Carbondioxide Pneumoperitoneum in Patients undergoing Laparoscopic Appendicectomy
volume and cardiac output using impedance magnesium sulfate inhibits catecholamine release
cardiography. Anaesthesia 1976; 31:412. associated with tracheal intubation. Anesth Analg
1989;68:7726.
17. Lishajko F. Releasing effect of calcium and
phosphate on catecholamines, ATP, and protein 21. Telci L, Esen F, Ackora D, Erden T, Canbolat T,
from chromaffin cell granules. ActaPhysiolScand Akpir K. Evaluation of effects of magnesium sulfate
1970;79:57584. in reducing intraoperative anesthetic requirements.
Br J Anaesth 2002;89:5948.
18. Altura BM, Altura BT. Magnesium and vascular
22. Diamant M, Benumof JL, Saidman LJ.
tone and reactivity. Blood Vessels 1978;15:516.
Haemodynamics of increased intraabdominal
19. Laurant P, Touyz RM, Schiffrin EL. Effect of pressure: Interaction with hypovolemia and
magnesium on vascular tone and reactivity in halothane anesthesia. Anaesthesiology 1978;48:237.
pressurized mesenteric resistance arteries from 23. Ishizaki Y, Bandai Y, Shimomura K, Abe H, Ohtomo
spontaneously hypertensive rats. Can J Physiol Y, Idezuki Y. Safe intraabdominal pressure of carbon
Pharmacol 1997;75:293300. dioxide pneumoperitoneum during laparoscopic
20. James MF, Beer RE, Esser JD. Intravenous surgery. Surgery 1993; 114:54954.


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Levobupivacaine vs Ropivacaine in Spinal Anesthesia for Lower

Abdominal and Lower Limb Surgeries: A Comparative Study
Mohammed Yahya1, Vikas Joshi2, Abdul Azim Makandar3
Author’s Affiliation: 1Associate Professor, 2Assistant Professor, 3Junior Resident, Department of Anesthesiology, Mahadevappa
Rampure Medical College, Kalaburagi, Karnataka 585105, India.
Corresponding Author: Vikas Joshi, Assistant Professor, Department of Anesthesiology, Mahadevappa Rampure Medical
College, Kalaburagi, Karnataka 585105, India.
E-mail: vikassbjoshi@gmail.com

Mohammed Yahya, Vikas Joshi, Abdul Azim Makandar. Levobupivacaine vs Ropivacaine in Spinal Anesthesia for Lower
Abdominal and Lower Limb Surgeries: A Comparative Study. Indian J Anesth Analg. 2020;7(6):1411–1415.
Abstract
Background: Till recently Bupivacaine 0.5% Heavy was the only drug used for spinal anesthesia after the
discontinuation of Lidocaine’s intrathecal use. The last few years, its pure S (-) enantiomers, ropivacaine
and levobupivacaine, have been introduced into clinical practice because of their lower cardiac and central
nervous system toxic effects. This study was performed to compare the anesthetic efficacy and safety of
the ropivacaine and levobupivacaine, in patients undergoing lower abdominal and lower limb surgery.
Methods: 60 patients of ASA physical status I–II between the ages of 20–60 years, scheduled for spinal
anesthesia were prospectively enrolled in our randomized controlled trial. They were divided into 2
groups, R and L, of 30 pts each. 3.0ml (15mg) of 0.5% isobaric ropivacaine in study group R and 3.0ml
(15mg) of 0.5% isobaric levobupivacaine in study group L was given.
Results: The mean Time of onset sensory blockade and Time of onset of Motor Blockade was significantly
high in Group R as compare to Group L, whereas mean Duration of sensory blockade, mean Duration of
motor blockade and mean Duration of analgesia were significantly less in Group R as compare to Group
L (P<0.001).
Conclusion: Intrathecal administration of either 15 mg ropivacaine or 15 mg levobupivacaine was
well-tolerated and provided similar, effective anesthesia for lower limb and lower abdominal surgery.
Intrathecal ropivacaine may prove useful when surgical anesthesia of a similar quality but of a shorter
duration is desired.
Keywords: Levobupivacaine; Ropivacaine; Spinal Anesthesia.
Introduction practice because of their lower toxic effects for heart

and central nervous system.3–5 Ropivacaine is an
Spinal anesthesia is a safe, reliable and inexpensive amide local anesthetic agent, less lipophilic than
technique with the advantage of providing bupivacaine and is less likely to penetrate large
surgical anesthesia and prolonged post operative myelinated motor fibres, resulting in a relatively
pain relief by using various adjuvant drugs along reduced motor blockade. The reduced lipophilicity
with local anesthetic agents.1 Bupivacaine is is also associated with decreased potential for
available as a racemic mixture of its enantiomers, central nervous system toxicity and cardiotoxicity,6
dextrobupivacaine and levobupivacaine.2 The last and when compared to bupivacaine, the lower
few years, its pure S-enantiomers, ropivacaine and lipid solubility of ropivacaine would predict that
levobupivacaine, have been introduced into clinical it is likely to produce a greater differential block

of sensory and motor function than bupivacaine.7 intervertebral space with 23G Quincke spinal
This feature is particularly useful when early needle. After ensuring free flow of CSF, 3.0ml
mobilization is important to enhance recovery. (15mg) of 0.5% ropivacaine in study group R and
Levobupivacaine is an S (-) enantiomer of the long 3.0ml (15mg) of 0.5% levobupivacaine in study
acting local anesthetic bupivacaine having less group L was given. After the intrathcal injection
cardiotoxic and central nervous system effects patients were immediately turned to supine
in comparison with both R (+) bupivacaine and position. Heamodynamic parameters such as heart
bupivacaine. Clinical studies have shown that rate (HR), systolic blood pressure (SBP), diastolic
ropivacaine and levobupivacaine are effective in blood pressure (DBP), mean arterial pressure
providing analgesia and anesthesia when used for (MAP) and respiratory rate (RR) , oxygen saturation
upper or lower limb surgery, but little information (spo2) of the patients were recorded.
is available regarding their comparable clinical
● Onset of analgesia was assessed by loss of
profile, with regards to onset time and duration of
sensations to pin prick every 30 seconds till the
sensory and motor blockade, and any side effects.
levels of T10 dermatome was achieved.
In the present study we have compared the spinal
effects of isobaric levobupivacaine 15mg, with ● Intensity of motor blockade was assessed by
isobaric ropivacaine 15mg in patients undergoing modified bromage scale every 2 minutes for
lower abdominal and lower limb surgeries. first 10 minutes
Intra operative, non invasive blood pressure
Material and Methods (NIBP), electrocardiogram (ECG), Pulse oximeter
were used. HR, SBP, DSP, MAP, RR were recorded
at 0min, 2min, 5min, 10min, 20min, 30min, 60min,
After approval of the Institutional Ethical
90min, 120min, 150min and 180min. The patients
Committee and written informed consent, 60
were carefully monitored for any untoward effects
patients of ASA physical status I-II between the
like inadequate block, hypotension, bradycardia,
ages of 20–60 years, scheduled for elective lower
respiratory distress, nausea, vomiting, restlessness,
abdominal and lower limb surgery under spinal
shivering, anaphylactic reaction.
anesthesia were prospectively enrolled in our
randomized controlled trial. Definitions used:
Patients with ASA physical status III or more, 1. Onset of sensory block: It is defined as the
patients on any opioid or any sedative medication time taken from time of injection of drug
in the week prior to the surgery, patients who have into subarachnoid space to loss of pin-prick
known allergies to any of test drugs, patients with sensation.
coagulation disorders or on anti coagulant drugs, 2. Quality of motor block assessed by Modified Bromage
patients with spinal deformities, and patient with scale:
refusal were excluded from the study.
Grade 0: Free movements of legs,feet,with
Sixty patients undergoing elective lower limb ability to raise extended legs.
and lower abdominal surgeries under spinal
anesthesia were selected randomly after applying Grade 1: Inability to raise extended leg and
the already mentioned stringent inclusion and knee flexion is decreased but full flexion to feet
exclusion criteria. All the patients were divided and knee present.
into two groups, group L and R. Group L received Grade 2: Inability to raise leg or flex knees,
isobaric levobupivacaine 15mg, and group R flexion of ankle and feet present.
recieved isobaric ropivacaine 15mg. An informed
Grade 3: Inability to raise legs,flex knees,ankle
written consent was taken for every case selected
or move toes.
for the study. Using computer generated random
allocation chart, patients randomly allocated to one 3. Duration of sensory blockade: This is defined as
of the two groups according to the drug to be used. the time interval from completion of intrathecal
Each patient was assessed in detail preoperatively drug injection to time of return of pin prick
and baseline readings of pulse rate, blood pressure sensation to L2 dermatomal area.
and oxygen saturation were recorded. 4. Duration of motor blockade: This is taken as
The patient was placed in left lateral position on a the time interval from complete motor block
horizontal table. Under strict aseptic precautions, Bromage grade 3 to complete motor recovery
a lumbar puncture was performed at L3-L4 Bromage grade 0.

Mohammed Yahya, Vikas Joshi, Abdul Azim Makandar / Levobupivacaine vs Ropivacaine in Spinal 1413
Anesthesia for Lower Abdominal and Lower Limb Surgeries: A Comparative Study
Hypotension is defined as decrease in systolic Table 1: Age wise distribution of patients.

blood pressure by 20% of baseline or any value Age in years Group L Group R Total
<90mmHg. Hypotension was treated by rapid No. % No. % No. %
infusion of IV fluids, inj mephentramine 6mg 21–30 12 40.0 10 33.3 22 36.7
increments. 31–40 9 30.0 8 26.7 17 28.3
Bradycardia (HR <60/minute) was treated by inj 41–50 4 13.3 8 26.7 12 20.0
atropine 0.6mg IV. 51–60 5 16.7 4 13.3 9 15.0
Total 30 100.0 30 100.0 60 100.0
Nause and vomiting were treated with inj
Mean ± SD 37.07 ± 10.44 37.67 ± 10.60 37.34 ± 10.52
ondensetron 4mg IV.
t-test and t = 0.432 P = 0.921 NS
Shivering was treated with warm drapes and P-value
warm IV fluids. NS = not significant, S=significant, HS=highly significant,
VHS=very highly significant.
The mean comparison between the two groups
The mean sensory block onset time in
was done using unpaired t test. Two group
levobupivacaine group was 4.00±1.91 min, while
proportions were compared using Chi square test
it was 6.67±0.78 min in ropivacaine group. The
for two sample proportion. A P-value of <0.05 was
mean duration of sensory block in levobupivacaine
taken as statistically significant, P-value of <0.005
group was 218.8±15.7 min, while it was 168.3±11.1
was taken as highly significant and P-value of
min in ropivacaine group. The mean motor block
<0.0005 was taken as very highly significant.
onset time in levobupivacaine group was 6.00±1.86
min, while it was 9.67±0.97 min in ropivacaine
Results group. The mean duration of motor block in
levobupivacaine group was 206.0±16.5 min, while
Study observes that, maximum number of patients it was 142.2±9.5 min in ropivacaine group.(Table 2)
in the two groups, 22 (36.7%) cases were belongs The mean Time of onset sensory blockade and
to the age group of 21–30, followed by 17 (28.3%) Time of onset of Motor Blockade was significantly
and 12 (20.0%) cases were belongs to the age high in Group R as compare to Group L, whereas
groups of 31–40 and 41–50 respectively. But there mean Duration of sensory blockade, mean Duration
was no statistical significant difference of mean age of motor blockade and mean Duration of analgesia
between the groups Group L (Levobupivacaine) were significantly less in Group R as compare to
and Group R (Ropivacaine) (P>0.05). (Table 1) Group L. Duration of analgesia was 227.9±15.9 min
In the present study, Male patients were in levobupivacaine group and it was 175.9±11.3
dominant 42 (70.0%) in two groups L and R, min in ropivacaine group.
female patients were 18 (30.0%). But there was no Study reveals that, there was no statistical
statistical significant difference of gender between significant difference of distribution of side effects
the groups L and R (P>0.05). The mean height of of patients between the groups L and R (P>0.05).
patients in group L was 159.00 ± 5.21 and the mean Two patients in each group developed nausea and
height of patients in group R was 161.67 ± 5.46. vomiting, which were treated with inj ondensetron
There was no statistical significant difference of 4mg IV. Two patients in levobupivacaine group and
mean height between the groups L and R (P>0.05). five patients in ropivacaine group had hypotension,
The mean weight of patients in group L was 59.51 which were treated wth inj mephenteramine 6mg
± 5.35 and the mean weight of patients in group R IV bolus. One patient in levobupivacaine group and
was 61.80 ± 5.20. There was no statistical significant two patients in ropivacaine group had bradicardia,
difference of mean weight between the groups L which were treated with inj atropine 0.6 mg IV.
and R (P>0.05). One patient in each group had shivering, which
Table 2: Comparison of sensory and motor variables between the groups.
Group L Group R P- Value and
Variables t-test value
Mean ± SD Mean ± SD Significance
Time of onset sensory blockade 4.00 ± 1.91 6.67 ± 0.78 t = 47.97 P= 0.000, VHS
Time of onset of Motor Blockade 6.00 ± 1.86 9.67 ± 0.97 t = 15.37 P= 0.000, VHS
Duration of sensory blockade 218.8 ± 15.7 168.3 ± 11.1 t = 17.21 P= 0.000, VHS
Duration of motor blockade 206.0 ± 16.5 142.2 ± 9.5 t = 21.87 P= 0.000, VHS
Duration of analgesia 227.9 ± 15.9 175.9 ± 11.3 t = 23.92 P= 0.000, VHS
NS= not significant, S=significant, HS=highly significant, VHS=very highly significant.

was treated with inj tramadol 25 mg slow IV after findings are similar to the findings in our study.
dilution. In their study, the mean duration of sensory and
motor block in both the groups, (levobupivacaine
Discussion and ropivacaine group) was more than in our study
group. This could be attributed to the higher dose
(17.5mg) used in Sunita Jain et al. study.
Spinal anesthesia is safe reliable technique with an
effective treatment for operative pain and blunts Prem Swarup et al.15 done a study on patients
autonomic, somatic and endocrine responses.8 undergoing various lower abdominal and lower
Till recently Bupivacaine 0.5% Heavy was the limb surgeries, and found that there was no
only drug used for spinal anaesthesia after the statistically and clinically significant difference
discontinuation of Lidocaine’s intrathecal use. The in mean time for onset of peak sensory block
last few years, its pure S (-) enantiomers, ropivacaine between ropivacaine group (8.28±2.2 mins) and
and levobupivacaine, have been introduced into levobupivacaine group (7.98±2.2 mins), with p=0.49.
clinical practice because of their lower cardiac and In their study, the mean time for onset of motor
central nervous system toxic effects. They have block (Bromage 3), in ropivacaine group (13.9±2.9
been developed as safer alternative to racemic mins) and levobupivacaine group (12.9±3.9 mins)
bupivacaine having desirable blocking property was similar, with p=0.16, which was clinically and
with greater margin of safety.9 Many clinical studies statistically not significant. This is in contrast to our
have showed that bupivacaine is the most potent study. This may be due to the additive they have
local anesthetic equivalent to levobupivacaine used in their study, that is fentanyl 25µg added
followed by ropivacaine.10–12 to 3ml of ropivacaine and levobupivacaine each.
In their study Ropivacaine group was associated
The present study demonstrates that with the shorter duration of sensory and motor
levobupivacain and ropivacaine are effective local block compared to levobupivacaine group. This
anesthetics for spinal applications. Levobupivacaine correlates with the findings in our study.
presented a faster onset of sensory and motor
blockade compared to the ropivacaine group, and In a study done by Ashton et al.1 for elective
levobupivacaine produced a prolonged duration of lower abdominal surgery there was no
sensory and motor block and prolong duration of significant difference between ropivacaine and
analgesia than ropivacaine. levobupivacaine group with respect to median
onset of sensory block at T10 (P Value < .05/3 i.e. ≈
The study done by S.Vani et al.13 on 100 pts .02). Time for onset of Bromage 3 Motor block was
for infra umbilical surgeries showed faster onset significantly different between Levobupivacine
of sensory and motor block in levobupivacaine group, with a median time of 5 min, and ropivacaine
group compared to ropivacaine group, which group, with a median time of 18 minutes. This
approximates our findings. It also showed a more difference in the onset of a dense motor block
rapid postoperative recovery of sensory and motor is due to the differential sensory blockade by
function in the ropivacaine group compared with the ropivacaine. In Median Duration of Sensory and
levobupivacaine group, which is also in accordance Bromage 3 motor Block, there was no difference
with our findings. In their study the mean duration between ropivacaine and levobupivacaine group.
of sensory block (186.4±26.86 min) and motor block This is in contrast with our study. The reason for
(154.6±36.04 min) in levobupivacaine group was the observed differences between our results and
less than in our study group (sensory 218.8±15.7 those seen in their study, is not apparent, but can
min, motor 206.0±16.5 min). The reason for the be attributed to methodological differences, such as
observed differences is not apparent, but it could a difference in the percent use, in the population
be attributed to methodological differences, such studied, or in the potency.
as difference in the population studied, or in the
potency. M. Mantouvalou et al.16 showed, in a study,
statistically significant differences in sensory
Sunita Jain et al.14 conducted a study on patients block onset between the ropivacaine and the
posted for elective gynecological surgeries. In their levobupivacaine groups(P < 0.05). The duration of
study also, there was faster onset of sensory and sensory block was significantly shorter in patients
motor blockade in levobupivacaine group compared receiving ropivacaine than in those receiving
to ropivacaine group. The mean duration of sensory bupivacaine or levobupivacaine (220 ± 30 min, 237 ±
and motor blockade was shorter in ropivacaine 88 min and 230 ± 74 min, respectively). Ropivacaine
group compared to levobupivacaine group. These presented a shorter duration of motor block than

Mohammed Yahya, Vikas Joshi, Abdul Azim Makandar / Levobupivacaine vs Ropivacaine in Spinal 1415
Anesthesia for Lower Abdominal and Lower Limb Surgeries: A Comparative Study
bupivacaine and levobupivacaine (269 ±20 min, 278 8. David L Brown. Spinal, Epidural and Caudal
± 70 min and 273 ± 80 min, respectively) (P < 0.05). Anaesthesia, Churchill Livingstone, Elsevier,
Miller’s Anaesthesia 7th Edition, 2010.
Conclusion 9. Leone S, DiCiani S, Fanelli ACG. Pharmacology,

toxicology and clinical use of new long acting local
anesthesia ropivacaine and levobupivacaine. Acta
Intrathecal administration of either 15 mg Biomed. 2008;79:92–105.
ropivacaine or 15 mg levobupivacaine was well-
10. Lee YY, Ngan Kee WD, Fong SY, Liu JT, Gin
tolerated and provided similar, effective anesthesia
T. The median effective dose of bupivacaine,
for lower limb and lower abdominal surgery.
levobupivacaine, and ropivacaine after intrathecal
The onset of sensory and motor block is faster in
injection in lower limb surgery. Anesth Analg.
levobupivacaine group compared to ropivacaine
2009;109(4):1331–4.
group. In an equal milligram dose, ropivacaine
produced a shorter duration of motor and sensory 11. Alley EA, Kopacz DJ, McDonald SB, Liu SS.
block than levobupivacaine. So intrathecal Hyperbaric spinal levobupivacaine: a comparison
ropivacaine may prove useful when surgical to racemic bupivacaine in volunteers. Anesth
anesthesia of a similar quality but of a shorter Analg. 2002;94(1):188–93.
duration is desired like in ambulatory surgeries. 12. Gautier PE, De Kock M, Van Steenberge A, Poth
N, Lahaye-Goffart B, Fanard L et al. Intrathecal
ropivacaine for ambulatory surgery. Anesthesiol.
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1. Ashton Dionel D’Souza1, Nichelle Mrinali Saldanha, Srinivas. Comparative Study Of Intrathecal Isobaric
Ashma Dorothy Monteiro, Harshavardhan H. Levobupivacaine 0.5% With Isobaric Ropivacaine
Comparison of Intrathecal Hyperbaric 0.5%
0.5% For Infra Umbilical Surgeries. Int. J. Modn.
Bupivacaine, Isobaric 0.5% Levobupivacaine and
Res. Revs. Volume 3, Issue 10, pp 834–836, October,
Isobaric 0.75% Ropivacaine for Lower Abdominal
Surgeries. Int J Health Sci Res. 2014;4(1):22–29. 2015.
2. Vanna O, Chumsang L, Thongmee S. 14. Sunita Jain, Hari Prasad Bendwal, Pooja Deodhar,
Levobupivacaine and bupivacaine in spinal Pawan Bhambani, Rakesh Romday, Preeti
anesthesia for transurethral endoscopic surgery. J. Jain. Comparative study of ropivacaine (0.5%)
Med. Assoc. Thai, 89 (8), 1133–9,2006. plain versus levobupivacaine (0.5%) plain in
3. Foster R H, Markham A. Levobupivacaine : a review gynecological surgeries. Int J Reprod Contracept
of its pharmacology and use as a local anaesthetic. Obstet Gynecol. 2017 Apr;6(4):1573–1577.
Drugs,59 (3), 551–79, 2000. 15. Prem Swarup Vampugalla, Venkata Ramana
4. Markham A, Faulds D. Ropivacaine A review of Vundi, Kamala Subhashini Perumallapalli,
its pharmacology and therapeutic use in regional Ch. Vinod Kumar, Chandrakala Kambar, P.
anaesthesia, Drugs, 52 (3), 429–49, 1996. Mallika Mahalakshmi et al. A comparative study
5. Milligan K R Recent advances in local anaesthetics of intrathecal ropivacaine with fentanyl and
for spinal anaesthesia, Eur. J. Anaesthesiol., 21, 837– L-bupivacaine with fentanyl in lower abdominal
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its use in regional anaesthesia. Drugs. 2000 Nov; 60, 16. M Mantouvalou, S Ralli, H Arnaoutoglou, G
(5): 1065–1093. Tziris And G. Papadopoulos. Spinal anesthesia :
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Efficacy of Dexamethasone 0.1mg/Kg when Combined with

0.15% Ropivacaine for Caudal Analgesia in Children undergoing
Infraumbilical Surgeries
Samarth S P1, Darshan M S2
Author’s Affiliation: 1Senior Resident, 2Associate Professor, Department of Anaesthesiology, Chamarajanagar Institute of
Medical Sciences, Yadapura, Karnataka 571313, India.
Corresponding Author: Darshan M S, Associate Professor, Department of Anaesthesiology, Chamarajanagar Institute of
Medical Sciences, Yadapura, Karnataka 571313, India.
E-mail: darshanms_jss@yahoo.com

Samarth S P, Darshan M S. Efficacy of Dexamethasone 0.1mg/Kg when Combined with 0.15% Ropivacaine for Caudal
Analgesia in Children undergoing Infraumbilical Surgeries. Indian J Anesth Analg. 2020;7(6):1417–1421.
Abstract
Introduction: Recent research has focused on the addition of the glucocorticoid dexamethasone as an
adjuvant to local anesthetics in regional anesthesia.8 Although the exact mechanism of action is unknown,
preliminary studies suggest its addition can impressively prolong the duration of analgesia with minimal
adverse effects.
Methodology: 60 children between the age group 1-5 years of ASA-PS I and II posted for elective
infraumbilical surgeries were randomly grouped into two equal groups using shuffled sealed opaque
envelope technique. Pre anesthetic evaluation was done and informed consent was obtained from the
parents after explaining about the procedure and the drugs being used.
Results: The number of rescue analgesics required by patients receiving only ropivacaine in their caudal
block was compared to in patients receiving Dexamethasone as adjuvant with ropivacaine and was found
to be statistically highly significant with a p value of 0.001.
Conclusion: The mean pain scores at different time intervals in between 2 groups were compared using
Independent t test and was found to be statistically highly significant with a p value of <0.0001.
Keywords: Dexamethasone; Ropivacaine; Caudal analgesia.
Introduction systematically inadequate. Children are special in

this regard as this complex phenomenon and the
The alleviation of pain has been the focus of importance of pain relief is often underestimated in
continuing human effort over centuries. Pain is a them.
protective mechanism designed to alert the body Considering the facts that biology of pain,
to potentially injurious stimuli. The International development of pain perception in infancy,
Association for Study of Pain (IASP) defines pain as assessment of pain, behavioral and psychological
an “unpleasant sensory and emotional experience aspects of pain and pharmacology of analgesics
associated with actual or potential tissue damage, are unique to this age group, the approach to a
or described in terms of such damage”.1 paediatric patient and the modalities to reduce
However it has been recognized for some time pain should also be specialized. Under treatment
that the management of acute pain, especially of post–operative pain may trigger biochemical and
post operative pain, has been consistently and physiologic stress response and cause impairments

in pulmonary, cardiovascular, neuroendocrinal, Hence the present study is to find out the lower
gastrointestinal, immunological, and metabolic volume (1ml/kg) and lower concentration (0.15%)
function seven in the children and newborns.2 of ropivacaine along with dexamethasone in
Assessment of pain is the most important and prolonging the post operative analgesia in children
critical component of pain management. Assessing undergoing infraumbilical surgeries.
pain in children is a difficult task, mainly because
so far no single reliable method of assessing and Methodology
measuring child’s pain is available.3
Regional anaesthetic techniques decrease the 60 children between the age group 1–5 years of
requirement of inhaled anaesthetics, opioids, ASA-PS I and II posted for elective infraumbilical
attenuate the stress response to surgery, facilitate surgeries were randomly grouped into two equal
smooth recovery and provide good immediate groups using shuffled sealed opaque envelope
postoperative analgesia with less systemic analgesic technique. Pre anesthetic evaluation was done and
requirements.4 informed consent was obtained from the parents
Caudal analgesia is a safe and reliable after explaining about the procedure and the drugs
technique, easy to perform and has been found to being used.The two groups were Group R (control
be very effective in children, especially in infra- group) and Group D (study group).Group R
umbilical surgeries when combined with general received 1 ml/kg of 0.15% ropivacaine with normal
anaesthesia.5 It is one of the most popular, reliable saline (1ml) and Group D received 1 ml/kg of
and safe techniques in pediatric anaesthesia that 0.15% ropivacaine with dexamethasone 0.1 mg/kg
can be used for intra and postoperative analgesia. It in saline to make a total volume 1ml in the caudal
is a relatively simple technique with a good success epidural space.
rate.4 All the children were premedicated with syrup
The main disadvantage of caudal analgesia is midazolam 0.5 mg/kg 1 hr before surgery, the
the duration of action after a single injection which patients were then shifted to the operation room.
is limited by the duration of action of the local Routine preinduction monitors were instituted
anesthetics used. Placement of a catheter has an which included pulse oximetry, electrocardiogram
inherent risk of infection. Prolongation of caudal and noninvasive blood pressure monitoring . The
analgesia using a single-shot technique has been baseline values were recorded and documented.
achieved by the addition of various adjuvants such Venous access (I.V) would have been secured by the
as opioids, ketamine, neostigmine, midazolam paediatric surgeon in the ward which is routinely
and α2 agonists. Many of these adjuvants have done in our hospital. Anaesthesia was induced with
side effects like respiratory depression, vomiting, injection thiopentone 5 mg/kg and intubation aided
pruritus etc.5 by administering injection atracuriumbesylate 0.5
mg/kg after ensuring adequate chest rise with
Recent research has focused on the addition of
mask ventilation. Endotracheal (ET) intubation
the glucocorticoid dexamethasone as an adjuvant
was done as per standard protocol of our hospital
to local anesthetics in regional anesthesia.
with appropriate size ET tube, position confirmed,
Although the exact mechanism of action is
and ET tube secured in place, Anaesthesia was
unknown, preliminary studies suggest its addition
maintained with 33% O2: 67% N2O mixture and
can impressively prolong the duration of analgesia
sevoflurane 1–2%.
with minimal adverse effects.6
Various studies using dexamethasone along with
Preparation of The Drug and Blinding
ropivacaine for caudal analgesia in children for
infra umblical surgeries have been done. Majority
of the studies used 0.2% of Ropivacaine along with The drug as per the allocated group was prepared
0.1mg/kg of dexamethasone.The volume used of by an anesthesiologist who was not involved in
ropivacaine was 1ml/kg when 0.2% ropivacaine administering caudal block and data collection
was used and 1.5ml/kgwhen 0.15% ropivacaine for the study. The caudal block was performed by
was used 11. Only one study has found out that another anesthesiologist who was blinded to the
reducing both the concentration (0.15%ropivacaine) drug that was injected and also was the observer.
and volume (1ml/kg) along with dexamethasone 3ml of 0.2% ropivacaine (Ropin 0.2% (2mg/ml)
(0.1mg/kg) has found to be effective in prolonging Neon laboratories ltd, preservatives free) was
postoperative analgesia.5 added with 1ml of normal saline to make 0.15%

Samarth S P, Darshan M S / Efficacy of Dexamethasone 0.1mg/Kg when Combined with 0.15% Ropivacaine 1419
for Caudal Analgesia in Children undergoing Infraumbilical Surgeries
ropivacaine. If a child of 13kg total volume of Table 2: Sex distribution in both the groups.
16ml (12ml of 0.2%ropivacaine+4ml NS) of 0.15% Sex Group Total
ropivacaine was prepared and 13 ml of that will R D
be taken for the study and 1 ml of either saline Male 23 27 50
or 0.1mg/kg of dexamethasone (Dexona 4mg/ml Female 7 3 10
Zydus Cadilla, contains methyl paraben 0.85mg Total 30 30 60
and propyl paraben 0.15mg as preservatives) saline
was added. Syringe containing either equal volume The sex distribution between 2 groups were
of 0.15%ropivacaine with normal saline or 0.15% compared using Pearson Chisquare test. There was
ropivacaine with dexamethasone were prepared no significant difference between the 2 groups with
and given to the investigator who was blinded to a p value of 0.16.(Table 2)
the identity of drugs . Table 3: Mean weight in kilograms in the two groups.
After intubation, patients were placed in lateral Mean weight Standard

Group N P value
(kgs) deviation
decubitus position and a single dose caudal block
R 30 11.2 2.8
was performed under sterile conditions using 22G, 0.2
D 30 12.2 3.1
2.5cm blunt tipped and short beveled needle and
a standard "give away”(piercing sacrococcygeal) The mean weight in Group R was 11.2 kgs, and
technique after identification of the caudal space. in Group D was 12.2 kgs. The mean weight of the
The drug was given as per allocated group. Group patients were compared using Anova test and found
R received 1 ml/kg of 0.15% ropivacaine with that there was no statistical significance difference
normal saline (1ml) and Group D received 1 ml/kg between 2 groups with a p value of 0.20. (Table 3)
of 0.15% ropivacaine with dexamethasone 0.1 mg/ Table 4: Number of rescue analgesics in each group.
kg in saline to make a total volume 1ml. Children Number of
were turned to supine posture immediately after Group R Group D P value
rescue analgesics
the administration of caudal analgesia. 0 0 (0%) 3 (10%)
The surgical incision was made after 10 min of 1 8 (26.7%) 18 (60%)
0.001
caudal placement. The caudal block was considered 2 15 (50%) 9 (30%)
to have failed if the patient had an increase in heart 3 7 (23.3%) 0(0%)
rate, had an increase in mean arterial pressure, or The number of rescue analgesics required
both of more than 15% compared with baseline by patients receiving only ropivacaine in their
during the surgery. In such instances, the patient caudal block was compared to inpatients receiving
was to be withdrawn from the study and treated Dexamethasoneas adjuvant with ropivacaine and
with 1–2 µg /kg of fentanyl. was found to be statistically highly significant with
The recorded parameters were documented a p value of 0.001. (Table 4)
every 5 minutes intraoperatively till awakening. Table 5: Mean pain scores at different time intervals in the two
The duration of surgery was noted down. groups.
Group
Neuromuscular blocking drugs blockade was
reversed with neostigmine (0.05 mg/kg) and D R
glycopyrollate (0.01 mg/kg). Standard Standard
Mean Mean
Deviation Deviation
After extubation, pain score was assessed using FLACC PAINSCORE .0 .0 .0 .0
FLACC scale. At emergence
FLACC PAINSCORE .0 .0 .0 .2
30min
Results
FLACC PAINSCORE .0 .0 1.0 .7
1hr
Table 1: Mean age (in years) in each of the groups. FLACC PAINSCORE .5 .5 1.7 .7
2hr
Group N Mean (years) Standard deviation P value
FLACC PAINSCORE 1.1 .7 2.7 1.0
R 30 3.2 1.4
0.2 3hr
D 30 2.8 1.3
FLACC PAINSCORE 1.7 .7 1.7 1.6
The mean age of the two groups were compared 4hr
using Anova tests and found to be insignificant FLACC PAINSCORE 2.1 .9 1.1 1.6
with a p value of 0.20. Group R and D had a mean 6hr
age of 3.2 and 2.8 years respectively.(Table 1) FLACC PAINSCORE 1.8 1.4 .8 1.0
7hr
FLACC PAINSCORE 1.4 1.7 1.7 1.1 statistically significant).8

9hr Yousef et al observed that addition of magnesium
FLACC PAINSCORE .8 1.3 1.6 1.2 or dexamethasone to caudal ropivacaine
12hr significantly prolonged analgesia duration to 8
FLACC PAINSCORE .6 1.0 1.4 1.0 hours (5–11 hours) and 12 hours (8–16 hours),
15hr respectively compared with 4 hours (3–5 hours)
FLACC PAINSCORE .8 .9 1.4 .9 with the use of ropivacaine alone. The time to first
20hr
analgesic dose was significantly longer in groups
FLACC PAINSCORE .8 .8 1.6 .9
with Magnesium and Dexamethasone (500 ± 190
24hr
and 730 ± 260 min) respectively compared with
The mean pain scores at different time intervals Ropivacaine alone (260 ± 65 min).9
in between 2 groups were compare dusing
In a study by Naghipour et al, the duration of
Independent t test and was found to be statistically
analgesia was significantly longer in the group
highly significant with a p value of<0.0001. (Table 5)
receiving dexamethasone in the epidural space (372
± 58.1) than with plain bupivacaine (234.6 ±24.3
Discussion min).10
Pain score was assessed using the FLACC
The total duration of analgesia was defined as the scoring system. A pain score of more than three
time from administration of caudal anaesthesia till was considered significant at which point a rescue
the time the pain score was more than 3. analgesic was given.
In our study, patients in Group R who received Pain scores were assessed every thirty minutes
caudal block with 0.15% ropivacaine alone had for the first two hours, then every hour till the 6th
a mean duration of analgesia was 234.17±61.37 hour, following which the pain score was assessed
mins. The minimum duration of analgesia was 120 every two hours uptil 24 hours. This assessment
minutes and the maximum duration of analgesia was done by a person who was blinded to which
observed was 960 minutes. drug was given in the caudal block. In our study,
Patients in Group D received 0.15% ropivacaine none of the patients in either of the two groups had
with 0.1 mg/kg dexamethasone had a mean any pain for the first 1.5 hours. The earliest onset
duration of analgesia of 447.13±96.26 mins. The of pain score of more than 3 was at 120 minutes in
minimum duration of analgesia was 300 minutes a patient who received plain ropivacaine, and 300
and maximum was 24 hours, beyond which minutes in a patient who received ropivacaine with
monitoring was not done. dexamethasone.
The difference between the duration of analgesia Overall, the mean pain scores were found to be
was statistically highly significant between the two lower in subjects who received dexamethasone
groups, with a p value of< 0.0001. as a caudal additive as compared to patients who
Similar observations were made by many of the received local anesthetic alone. Rectal paracetamol
authors using dexamethasone as an adjuvant for suppository 30 mg/kg was the rescue analgesic
caudal analgesia like: given to patients when their pain score was >3 as
measured by FLACC scale. The number of rescue
In a study by Kim Lee et al, the number of subjects analgesics required by patients receiving only
who remained pain free up to 48 h after operation
ropivacaine in their caudal block was compared to
was significantly greater in the group who received
in patients receiving Dexamethasone as adjuvant
Dexamethasone (0.1 mg/kg) in caudal block [19
with ropivacaine and was found to be statistically
of 38 (50%)] as compared to patients in the control
highly significant with a p value of 0.001.
group who received 0.15% ropivacaine alone[four
of 37 (10.8%); P<0.001. Time to first oral analgesic There were patients who required no dose
administration after surgery was also significantly of rescue analgesia at all in the group with
longer in Group D than in Group C (P=0.014).7 Dexamethasone as compared to ropivacaine alone
(3/30 patients 10% in group D as compared to none
Girgis et al demonstrated the analgesic efficacy of
in group R).
dexamethasone (0.2 mg/kg) added to bupivacaine
(1ml/kg 0.25%) in caudal blocks. The duration of Similar observations were made by many of the
analgesia was± 3.5hrs with dexamethasone vs. authors using dexamethasone as an adjuvant for
7.1 ± 3.2 hrs with plain bupivacaine. (P<0.001, caudal analgesia like:

Samarth S P, Darshan M S / Efficacy of Dexamethasone 0.1mg/Kg when Combined with 0.15% Ropivacaine 1421
for Caudal Analgesia in Children undergoing Infraumbilical Surgeries
Naghipour et al showed in their study that Classification of chronic pain.In:Mersky NB(ed).

pain score and rescue analgesia use were less in Task Force on Taxonomy; 1994.2nd ed. p.209–14.
the Dexamethasone group than the control group 2. Rawal N, Sjostrand U, Christofferson E et al.
(37.1+/– 19.7 mg v.s. 73.1+/– 17.6 mg, respectively; Comparison of intramuscular and epidural
p=0.001).7 morphine for postoperative analgesia in the grossly
In a study by Kim Lee et al, the number of subjects obese: influence on postoperative ambulation
who received oral analgesic was significantly and pulmonary function. AnaesthAnalg 1984; 63:
lower in Group D (28.9%) than in Group C (54.1%) 583–592.
P=0.027.11 3. Rice LJ. Pain management in children. Can J
Dexamethasone with local anaesthetic has Anaesth 1996; 43: R155–R158.
been shown to prolong peripheral nerve block in 4. Markakis DA. Regional anesthesia in pediatrics
animalsand humans. AnesthesiolClin North America. 2000 Jun;18(2):
355 81.
It has been found to be superior than other
adjuvants in terms of duration of analgesia, 5. Gehdoo RP. Postoperative pain management in
requirement of rescue analgesia, and lesser motor pediatric patients. Indian J Anaesth 2004;8(5):
block. 406–14.
6. McNeely JK, Trentadue NC, Rusy LM, Farber
NE. Culture of bacteria from lumbar and caudal
Conclusion
epidural catheters used for postoperative analgesia
in children RegAnesth. 1997 Sep-Oct;22(5):428–31.
The mean duration of analgesia between 2 groups
7. E M Kim, J R Lee, B N Koo, Y J Im, H J Oh, and J H
were compared using Independent t test. The mean
Lee Analgesic efficacy of caudal dexamethasone
duration of analgesia was 234.17±61.37 mins in
combined with ropivacaine in children
Group R and 447.13 ±96.26 mins in Group D with undergoing orchiopexy Br. J. Anaesth. (2014) 112
a p value <0.0001 which was statistically highly (5):885–891.
significant. The number of rescue analgesics
required by patients receiving only ropivacaine 8. Karim Girgis. The effect of adding dexamethasone
in their caudal block was compared to inpatients to bupivacaine on the duration of postoperative
analgesia after caudal anesthesia in children. Ain-
receiving Dexamethasone as adjuvant with
Shams Journal of Anesthesiology 2014,07:381–387.
ropivacaine and was found to be statistically highly
significant with a p value of 0.001. The mean pain 9. Gamal T. Yousef, Tamer H. Ibrahim, Ahmed Khder,
scores at different time intervals in between 2 MohamedIbrahim. Enhancement of ropivacaine
groups were compared using Independent t test caudal analgesia using dexamethasone or
and was found to be statistically highly significant magnesium in children undergoing inguinal hernia
with a p value of <0.0001. repair. Anesthesia: Essays and Researches; 8(1); Jan-
Apr 2014.
References 10. B Naghipour, R Azarfarin, M Mirinazhad, A.

Dorosti and Samad EJ Golzari. Dexamethasone
added to bupivacaine prolongs duration of epidural
1. International Association for Study of Pain IASP. analgesia M.E.J. Anesth 2013; 22 (1):53–57.

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Comparison of Ondansetron 4mg, Dexamethasone 8mg and Ondansetron

4 mg with Dexamethasone 8mg in Preventing Nausea and Vomiting Post-
Laparoscopic Cholecystectomy
Priyadarshini M Bentur1, Ashwini R2
Author’s Affiliation: 1Professor, 2Senior Resident, Department of Anaesthesia, Jagadguru Jayadeva Murugarajendra Medical
College, Davangere, Karnataka 577002, India.
Corresponding Author: Priyadarshini M Bentur, Professor, Department of Anaesthesia, Jagadguru Jayadeva Murugarajendra
Medical College, Davangere, Karnataka 577002, India.
E-mail: priyadarshiniveereshangadi@gmail.com

Priyadarshini M Bentur, Ashwini R. Comparison of Ondansetron 4mg, Dexamethasone 8mg and Ondansetron 4 mg
with Dexamethasone 8mg in Preventing Nausea and Vomiting Post-Laparoscopic Cholecystectomy. Indian J Anesth Analg.
2020;7(6):1423–1426.
Abstract
Introduction: The most common distressing symptom following surgery and anaesthesia are nausea and
vomiting with an incidence of up to 20 to 30% despite newer medications like Ondansetron and steroids
in our armamentarium.
Aims: To determine the efficacy of combination therapy with Ondansetron and Dexamethasone
and each drug alone in prevention of Postoperative nausea and vomiting (PONV) post laparoscopic
cholecystectomy.Also to assess adverse effects if any.
Methods: 105 patients aged between 18 and 55 years belonging to ASA status 1 and 2, electively posted
for lap cholecystectomy were randomly divided into three groups of 35 each. Gp A received 4mg Inj
Ondansetron, Gp B received Inj Dexamethasone 8mg and Gp C received both drugs together. Similar
anaesthesia and surgery techniques were used. Upto 24 h period was assessed for incidence of nausea and
vomiting and need for rescue antiemetic.
Statistical analysis: Chi square test and Student t test were used.
Results and Discussion: Overall cumulative incidence of PONV was 54.2% in A Gp, 25.7% in B Gp and
14.2% in Gp C. Complete response, that is no nausea and vomiting was seen in 85.7%in Gp C, 74.2%
in Gp B and 45.82%in Gp A which was statistically significant. Ondansetron, a selective 5HT3 receptor
antagonist is a good drug for PONV in gynaecological laparoscopy. Dexamethasone is effective against
onco and chemotherapy related nausea and vomiting. Combination therapy of the 2 showed good results
and reduction in incidence of PONV in lapchole cystectomy.
Keywords: Ondansetron; Dexamethasone; Post-operative nausea and vomiting; Laparoscopic
cholecystectomy.
Introduction had ‘eaten recently ‘or following movement shortly

after surgery. Treatment included use of wine,
smelling salts, etc. Due to use of ether, opioids and
150 years ago, John Snow described the other drugs, PONV was a common distressing
phenomenon of nausea7 and vomiting in 1848, 18 problem in the early years of Anaesthesia inception.
months after introduction of anaesthesia into Great Subsequent research unfolded a spectrum of non-
Britain. He observed it to be high in patients who anaesthetic factors in the pathogenesis of PONV.
There has been a general trend towards decrease in 2 categories posted for elective laparoscopic
the incidence and intensity of the problem because cholecystectomy under general anaesthesia were
of a change in Anaesthesia practice from opioid and selected. Institutional ethical committee approval
deep ether use to non-opioid or supplemental opioid was taken and patients divided into Gp A
to lighter and non-ether Anaesthesia, use of less (receiving Inj Ondansetron 4mg), Gp B (receiving
emetic Anaesthesia agents, improved preoperative Inj Dexamethasone 8mg) and Gp C (receiving both).
and postoperative medication, refinement of Excluded were those belonging to ASA Gp 3 or 4,
operative techniques and identification of patient those who received opioids, NSAIDS, steroids, anti-
predictive factors. emetics in the previous 24 h, pregnant and lactating
Yet the 'big little problem'8 of PONV still persists mothers, those with history of motion sickness
and can cause potentially serious consequences to Diabetes, peptic ulcer disease, P/H/O PONV,
the patient as well as financial implications in the significant cardiac, hepatic orrenal insufficiency.
form of delayed discharge from hospital. Now Pre-operative visit was conducted on the previous
with an array of surgical procedures being done day and general, systemic and airway examination
in the ambulatory setting, the need to find more were done. Necessary investigations were
effective alternatives to the options available has reviewed. Patients were told to remain 6 hours
become more urgent. The potential cost saving by NPO and given T. Alprazolam 0.25 mg HS. On the
performing ambulatory procedures may be offset day of surgery, they were hydrated with 15 ml/
by an unanticipated post-operative admission for kg of Inj RL and premedicated with Inj. Glyco 10
intractable nausea and vomiting. microgram/ kg and Inj Fentanyl 2 microgram/
Drugs like antihistamines1, anticholinergics, kg and the study drugs intravenously before
dopamine antagonists, physical manoeuvres induction. Inj Propofol 2mg/ kg was given for
like imposing ‘nothing per Os’8 regimens, pre induction followed by Inj Atracurium 0.6 mg/kg to
anaesthetic suctioning of gastric contents, use of facilitate endotracheal intubation. Anaesthesia was
cricoid pressure, avoiding gastric inflation during maintained with Isoflurane with 60% nitrous oxide
bag mask ventilation, none of these alone or in and oxygen mixture and IPPV to maintain eTCO2
combination have been entirely successful. between 35–45 mm of Hg and top up doses of
Dexamethasone has shown promising results muscle relaxant. Ryle’s tube was passed to empty
in chemotherapy9 related nausea and vomiting. the stomach which was suctioned and removed
Ondansetron introduced in 199110, 5HT3 receptor before extubation.
antagonist, is a good antiemetic without the side During laparoscopy, intra-abdominal pressure
effects of cholinergic, adrenergic, dopaminergic or was maintained between 8 to 12 mm of Hg by CO2
histaminergic receptor activation.4 insufflation and patient positioned 15 to 20-degree
Incidence of PONV is high in laparoscopies due to head up and left lateral tilt. At the end of the
pneumoperitoneum, (extent and duration), general procedure, residual neuromuscular blockage was
anaesthesia, manipulation of viscera, etc. Many reversed with Inj. Neostigmine 50 microgram/
drugs have been used to prevent it either alone or kg and Inj. Glyco 10 microgram/kg. Duration of
in combination.5 Anaesthesia and surgery were noted. Postoperative
analgesia was provided with Inj. Paracetamol 15
mg/kg iv. Until post-operative 3 hours, oxygen
Aims was given through face mask at 4 lpm. Throughout
the procedure ECG, HR, NIBP, EtCO2 and SpO2
To compare the efficacy of combination of were continuously monitored.
Ondansetron and Dexamethasone with either Patient was assessed hourly for first 4 hours and
drug alone in prevention of post laparoscopic then till the end of 24 hours and the number of
cholecystectomy nausea and vomiting. episodes of nausea and vomiting were recorded.
To study any adverse effects due to the use of the Need for use of rescue antiemetic was recorded.
drug.
Results
Methods
All 105 patients were comparable with respect to
105 patients aged between 18 and 55 years,weighing age, gender, weight, ASA grading, duration of
between 50 and 75 kg belonging to ASA1 and Anaesthesia and surgery as shown in Tables 1 to 7.

Priyadarshini M Bentur, Ashwini R / Comparison of Ondansetron 4mg, Dexamethasone 8mg and 1425
Ondansetron 4 mg with Dexamethasone 8mg in Preventing Nausea and
Vomiting Post-Laparoscopic Cholecystectomy
Overall cumulative incidence (0–24 h) PONV was Table 5: ASA distribution.

54.2% in Gp A, 25.7% in Gp B and 14.2% in Gp C Group ASA 1 ASA 2 Total
which was statistically significant. (Table 8). A 20 (57.1%) 15 (42.9%) 35
No nausea and vomiting was seen in 85.7% patients B 20 (57.1%) 15 (42.9%) 35
in Gp C, 74.2% in Gp B and 45.8% in Gp A. Thus,Gp
C 17 (48.6%) 18 (51.4%) 35
C received maximum benefit of prevention of
PONV (Table 9). Table 6: Duration of Anaesthesia.
Early nausea (Table 10) defined as nausea Group Mean (min) S. D
occurring within first 4 hours was statistically A 85.8571 1.39627
insignificant among all the groups. Early vomiting
B 87.0857 2.04898
that is vomiting occurring in the first 4 hours was
significantly less in Gp C when compared to other C 87.1714 2.26853
groups (Table 10). P value = 0.19 insignificant
Late nausea, defined as nausea occurring between 4 Table 7: Duration of Surgery.

and 24 hrs did not differ significantly among all the Group Mean (min) S. D
groups (Table 11). Late vomiting that is between 4
A 78.2000 2.12548
and 24 hours postoperative was again significantly
less in Gp C (Table 11). Need for rescue antiemetic B 77.7714 2.55626
and adverse effects (Table 12) were not statistically C 78.2857 2.25664
significant.
P value = 0.65 insignificant
Table 1: Age distribution among the groups.
Table 8: Cumulative incidence of PONV in 0– 24 hours.
Gp Age (years) Freq
Group Patients with PONV Percentage
21–40 16
A A 19 54.2%
>41 19
B 9 25.7%
21–40 10
B C 5 14.2%
>41 25
P value =< 0.001 highly significant
21–40 12
C Table 9: Complete response in 0– 24 hours.
>41 23
Group Patients with no PONV no RE Percentage
Mean age in Gp A was 42.56 y, Gp B was 43.26 y and Gp C was
43.77 which was statistically insignificant. A 16 45.8%
B 26 74.2%
Table 2: Age distribution in years.
C 30 85.7%
Age group Frequency Percentage
P value =< 0.001 highly significant
21–40 38 36.2%
Table 10: Early PONV (0– 4 h).
40 67 63.8%
Group Nausea Vomiting Rescue Anti emetic
Total 105 100%
A 3 (8.6%) 10 (28.5 %) 3 (8.6%)
Table 3: Gender wise distribution among groups B 2 (5.7%) 5 (14.2%) 1 (2.9%)
Gender Frequency Percentage C 1 (2.9%) 1 (2.9%) 0
M 37 35.2% P value 0.58 0.001 0.36
F 68 64.8% Incidence of vomiting was significantly less.
Total 105 100%
Table 11: Late PONV (4– 24 h).
Table 4: Weight distribution. Group Nausea Vomiting Rescue Anti emetic
Group Mean in kg S.D A 1 (2.9%) 5 (14.2%) 1 (2.9%)
A 60.49 6.026 B 0 2 (5.7%) 2 (5.7%)
B 60.49 5.590
C 1 (2.9%) 0 0
C 57.89 6.914
P value 0.61 0.05 0.35
P= 0.13 not significant Incidence of vomiting was significantly less.

Table 12: Adverse effects. care system. Dexamethasone can be used as an

Group None Dizziness Dry mouth Headache Total
inexpensive alternative to other antiemetic alone or
in combination.
A 33 1 0 1 35
B 32 2 0 0 35
References
C 31 2 1 1 35
Total 97 5 1 2
1. Elkahim M, Nafie M, Mahmoud K, Atef A.
Chi square 9.9, p value = 0.33. Dexamethasone 8 mg in combination with
Ondansetron 4 mg appears to be the optimaldose
Discussion for the prevention of nausea and vomiting after
laparoscopic cholecystectomy. Can J Anesth .2002
Nov 1; 49(9): 9922–6.
Our study revealed better results with combination 2. Chattopadhyay S, Biswas A, Ferdous SK, Bhowmik
group which was comparable to a similar study DK, Dey S, Biswas B. Comparison of Ondansetron,
conducted by Suman Chattopadhyay et al2 (62% Dexamethasone and Ondansetron plus
Ondansetron vs 64.2% Dexamethasone vs 84.6% Dexamethasone for The Prevention of Postoperative
in combination group) and Gautam et al study3 Nausea and Vomiting after Laparoscopic
(66.7% Ondansetron vs 66% Dexamethasone vs Cholecystectomy. Indian J Clin Anaesth. 2016;
89.4% combination). 3(3):459–63.
3. Gautam B, Shreshta BR, Lama P, Rai S. Antiemetic
In our study, incidence of early vomiting in A Gp
prophylaxis against postoperative nausea and
was 28.5% and delayed vomiting was 14.2%. This
vomiting with Ondansetron- Dexamethasone
is comparable to V Rajeeva et al6 who observed combination compared to Ondansetron or
15% early emesis and 35% delayed emesis after Dexamethasone alone for patients undergoing
Ondansetron. In our study, in the combination Laparoscopic cholecystectomy. Kathmandu
group it was less, 2.9% (early vomiting) and 0% University Medical Journal. 2008; 6(3): 319–28.
(late emesis) which was comparable to the same 4. Thacker M, Patel N. Utilization of Ondansetron
study (V Rajeeva et al6). and Dexamethasone for postoperative Nausea
In our study post-operative pain scores were and Vomiting (PONV) after laparoscopic
cholecystectomy at Bhuj, Kutch, Gujarat. A
comparable in all groups. Rescue analgesic
Randomized Controlled Trial. Ind J Anaesth and
requirement was not significantly different Analg. 2017;4(2): 215–9.
in all groups. Use of Fentanyl as premedicate
5. Kortilla K. The study of postoperative nausea and
may have masked the effect of Dexamethasone
vomiting. Br J of Anaesth 1992 Jan 1; 69: 205– 35.
on postoperative pain. All patients were
hemodynamically stable. 6. Rajeeva V, Bharadwaj N, Batra YK, Dhaliwal LK.
Comparison of Ondansetron with Ondansetron
3 patients in go A and 1 patient in Gp B needed and Dexamethasone in prevention of PONV in
rescue antiemetic in first 4 h, 1 patient in Gp A and diagnostic laparoscopy. Can J Anesth. 1999 Jan
2 patients in Gp B in the period of 4 to 24 sought 1;46(1) :40 L.
rescue antiemetic. 7. Andrews PL, Davis CJ, Bingham S, Davidson HI,
Adverse effects due to drugs were not significant Hawthorn J, Maskell L. The abdominal visceral
innervation and the emetic reflex, pathways,
enough to warrant treatment. Less than 24 hour of
pharmacology and plasticity Canadian Journal of
Dexamethasone therapy is considered safe. Physiology and Pharmacology. 1990 Feb 1; 68(2):
325–45.
Conclusion 8. Kapur PA. The big ‘little problem‘. Anaesthesia and
Analgesia.1991 Sep 1; 73(3):243– 5.
We conclude that Ondansetron and Dexamethasone 9. Lopez Oleando L, Carrascosa F, Pueyo FJ, Monedero
given intravenously just before Anaesthesia P, Busto N, Saez A. Combination of Ondansetron
and Dexamethasone in the prophylaxis of
induction is safe and more effective than either
postoperative nausea and vomiting. Br J Anaesth
drug given alonein long term prophylaxis of 1996 Jun 1; 76(6): 835–40.
PONV inpatients under going elective laparoscopic
10. Russell D and Kenny GNC, 5HT3 antagonist in
cholecystectomy under general anaesthesia.
postoperative nausea and vomiting. Br J Anaesth
Cost is an ever-increasing concern in today’s health 1992;69(s1): 63–8.

Comparative Assessment of Bupivacaine and Levobupivacaine in

Elective Cesarian Section Cases
Vineeta Goda1, Venus Sharma2, Mamta Goda3
Author’s Affiliation: 1,2Assistant Professor, Department of Anesthesia, Pacific Institute of Medical Sciences, Udaipur 313015,
India 3Senior Resident, Department of Anesthesia, Government Medical College, Dungarpur, Rajasthan 314001, India.
Corresponding Author: Mamta Goda, Senior Resident, Department of Anesthesia, Government Medical College, Dungarpur,
Rajasthan 314001, India.
E-mail: meethi.20goda@gmail.com 314001

Vineeta Goda, Venus Sharma, Mamta Goda. Comparative Assessment of Bupivacaine and Levobupivacaine in Elective
Cesarian Section Cases. Indian J Anesth Analg. 2020;7(6):1427–1430.
Abstract
The anesthetist is held responsible for ensuring a stable and safe operative and post-operative
environment so as to aid in the faster and uneventful recovery of the patient. Spinal anesthesia in obstetric
surgeries has been gaining rapid acceptance as a choice method but the agent of choice for anesthesia
must be such that it can provide a stable state for both the mother and child. The present study was
done to ascertain the comparative efficacy of two agents levobupivacaine and bupivacaine in elective
cesarian surgery cases. The results showed that levobupivacaine had a shorter duration of sensory and
motor block as well as statistically significant lower levels of side effects as compared to bupivacaine. The
authors concluded that levobupivacaine may be a more feasible alternative in such surgeries as compared
to bupivacaine.
Keywords: Bupivacaine; Cesarian section; Levobupivacaine.
Introduction capable of providing a regular and low level block

sustaining a analgesic atmosphere conducive to the
Spinal Anesthesia has been now made a part surgery.2
of almost all routine elective surgeries and has Despite its widely advocated use in spinal
been awarded the distinction of being a safer and anaesthesia, the compound bupivacaine does suffer
superiorly effective modality in surgical analgesia from its share of adversities, namely, the incidence
and anesthesia. During elective cesarian sections, of sudden cardiac arrest, which can be found to
using a subarachnoid block has been documented occur along with bradycardia and hypotension
and evidentiarily proved to be the most effective in the operative period if the block is extended.3
technique owing to its quick initiation and effect This conundrum has driven studies that have
of sensory-motor blocks.1 In these procedures the eluded the so called best spinal agent and yielded
commonly used agent is bupivacaine. This drug a promising drug from bupivacaine itself, namely
is a mixture of a combination of two isomeric levobupivacaine. This enantiomeric drug has
forms, namely dextro and levobupivacaine. This provided better results in many studies owing to
innate combination renders the anesthetic agent its stable and isomeric, isobaric nature that displays
a hypobaric property in contrast to cerebrospinal lower toxicities in the central nervous systems as
fluid which is isobaric. The bupivacaine is thus well as the cardiac functions. It has been reported
rendered in a hyperbaric state by mixing with 8 per that a more rapid rate of protein binding has
cent dextrose that provides a more stable compound effectively lowered the adverse manifestations in

case of levobupivacaine as were encountered with till end of caesarean section. Sensory block was
its parent drug bupivacaine.4,5 assessed using pin prick method over the anterior
In the region of southern Rajasthan, literature axillary line, while motor block was recorded using
review did not yield any study that assessed modified bromage scale.
the comparative effects of these two drugs on
expecting mothers who were posted for elective Results
cesarian sections. The present study was conducted
to compare and report the features of spinal block,
The study pool comprised of 40 adult females
adverse reactions and general features of these
having no pre morbidities and no pregnancy
subjects when administered bupivacaine and
related complications. All the subjects were having
levobupivacaine.
a single non complicated intrauterine pregnancy.
The demographics of the subjects showed no
Materials and Methods variations and no significant differences were seen
in their data (Table 1).
The study was a prospective, randomized double Table 1: Patient Demographics.
blind study conducted in Pacific Institute of Medical Group A Group B
Sciences, Udaipur over a period of 8 months. The Age (Yrs) 22.9 22.4
authors submitted a proposal for the study to the Height (cms) 147 151
Institutional Ethical Clearance Committee and Weight(Kgs) 59.2 58.6
obtained a permission prior to commencement of Duration of Surgery (mins) 41.3 42.1
the study. The study included willing volunteers
who were expectant mothers and were scheduled Sensory block duration was recorded for both the
to be posted for elective cesarian section. All the groups and revealed that there was no significant
subjects were explained the details of the study difference in the time taken for onset of sensory
and written informed consent was obtained before block and in achieving complete sensory block
their inclusion. The subjects were free to recuse in the selected subjects. However a statistically
themselves from the study at any stage. The significant difference was observed in the time
inclusion criteria included expectant mothers with taken for regression of the sensory block as well as
no premorbidities and who were preoperatively the total duration of the sensory block among the
assessed to fall under ASA-I or II category. The two groups. (Table 2).
subjects were assessed preoperatively to ascertain
The data showed that the subjects who received
if the mother and fetus were normal and had no
levobupivacaine were having a lower duration of
complications. The subjects were divided in two
sensory block duration as well as a shorter duration
categories by a randomized method and only one
of sensory block as compared to the bupivacaine
author was aware of the distinction. The subjects
group.
were attended to along routine preoperative
Table 2: Sensory Block Comparison (Minutes).
management guidelines. The subjects were
counselled and made aware of the methods for Group A Group B P Value
sensory and motor testing as well as the procedure Onset of Sensory Block 2.9 ± 0.65 3.1 ±0.76 NS
of the surgery. The subjects in group A were Complete Sensory Block 7.54 ± 1.23 7.66 ± 1.87 NS
administered 2 ml of 0.5% isobaric levobupivacaine Removal of Block 49 ± 3.66 57 ± 4.87 P< 0.05
(10 mg) and those in Group B received 2 ml of 0.5% Duration of Sensory Block 78 ± 5.77 84 ± 2.99 P< 0.05
hyperbaric bupivacaine (10 mg) intrathecally. The
anaesthesiologist administering the study drugs In terms of motor block durations, both the
as well as the patients were blinded to the group groups showed statistically significant differences
allocation. The patients were placed supine with between the time taken for onset as well as complete
a left lateral tilt following the subarachnoid block. motor blockage in the selected sample. The time
Surgery was allowed to start once T6 or above was considerably shorter in the bupivacaine group
level of sensory block was achieved. Non invasive as compared to levobupivacaine, however in the
monitoring of vital parameters was continued measurement of total duration of motor block, we
from the pre op period till discharge from recovery observed that the regression of motor block took
room. Parameters were recorded every 2 mins till significantly longer in the bupivacaine group as
first 20 minutes thereafter recorded every 5 mins compared to the levobupivacaine group. (Table 3).

Vineeta Goda, Venus Sharma, Mamta Goda / Comparative Assessment of Bupivacaine and Levobupivacaine 1429
in Elective Cesarian Section Cases
Table 3: Motor Block Comparison (Minutes). opioid analgesic was not warranted nor needed in
Group A Group B P Value their sample pool in the intra-operative period, but
Onset of motor Block 3.1 ± 1.12 2.97 ± 0.78 P < 0.05 recommended that this be done on a case to case
Complete Motor block 7.88 ± 1.19 5.88 ± 1.76 P < 0.05 basis rather than using it as a standard protocol.
Duration of Motor block 68 ± 9.87 96 ± 8.14 P < 0.05 The subjects in our study were regularly assessed
for their pain scores in the post-operative period.
Subjects reported a statistically significant
lower incidence of unfavourable effects in the post We observed that in terms of achieving sensory
operative period in the levobupivacaine group as block, the group A or levobupivacaine group
compared to the bupivacaine group. (Table 4). showed a faster incidence and faster regression as
Table 4: Adverse Effects in Post Operative Period. compared with group B or bupivacaine group. This
is inclement on the idea that levobupivacaine can
Group A Group B P Value
be a better alternative for faster or rapid induction
Hypotension 1 (5 %) 4 (20 %) P < 0.05
and easier regression as compared to traditional
Bradycardia 1 (5 %) 4 (20 %) P < 0.05
bupivacaine. This is similar to findings done in
Nausea 2 (10%) 5 (25%) P < 0.05 studies by a number of authors9–11 who stated that
Vomiting 0 3 (15%) P < 0.05 in spinal anesthesia cases, using a levobupivacaine
agent proved to have a better outcome. The
Discussion study by Glaser C et al10 also stated that the exit
from anaesthesia was only marginally better in
The present study provided us with observations levobupivacaine group of patients but was still
that stated that it was the use of isobaric significant statistically.
levobupivacaine that rendered a more stable In observations related to motor block, it was
operative anesthetic and analgesic state as seen that bupivacaine or group B subjects had
compared to the older bupivacaine component. a faster onset of motor block as well as a longer
Both the agents were effective in providing a stable motor block duration as compared to Group A
environment in the operating room but the relative or levobupivacaine group subjects. This is in
and comparative efficacy of levobupivacaine was concurrence with studies by Duggal R et al and
higher in terms of sensory and motor block as well Gori et al8,12, wherein the authors reported similar
in reduced incidence of post-operative adverse findings. The rationale behind this is stated to be the
effects. The patient compliance was absolute and fact that levobupivacaine being an isobaric agent
none of the subjects had any major effects. All the has the stability to provide a block lower than the
deliveries were uneventful. segment along which it is introduced thus making
Our study finds concurrence with studies by it slightly longer in onset and rapid in regression.
various authors6–7 wherein they have mentioned In contrast, it has been stated that bupivacaine is a
the relative efficiency of levobupivacaine in hyperbaric agent and has been known to provide
spinal anesthesia and abdominal surgeries. In a higher level of block. This works actually as a
terms of elective cesarian sections, a study on disadvantage to the anesthetist as it can mitigate
Indian population by Goyal et al7 and a western circumstances in the operating room which can
study by Gautier et al15 concluded that using cause unfavorable outcomes.12,13 The findings of
levobupivacaine singularly may not provide an this observation are not in agreement with the
effective analgesia and that fentanyl may be used findings by Gautier et al,15 wherein the authors
as an additive, however, our study found that the found the use of traditional bupivacaine as a better
use of any opioid analgesic may not be required option, however the authors also stated in their
as the operative analgesia was well managed by conclusion that addition of sufentanil was a factor
using levobupivacaine singularly. In the study by in declaring superiority of traditional bupivacaine
Gautier et al,15 the dosages of levobupivacaine used in their study.
were approximately 2 mg lower than those in the The side effects observed in the study sample
present study and could be the responsible to lower were higher in the bupivacaine group. The prone
analgesic effects. nature of bupivacaine to cause hypotension leads
This is in concurrence with a study done by to a fall in placental perfusion which can cause
Duggal R et al8 wherein the authors conducted a decreased blood flow to the foetus. This is grossly
similarly planned study and reported that use of a lower when levobupivacaine is used. The other

aspect of nausea and vomiting stems from the Cardiovascular and central nervous system effects
fact that hypotension can also cause a reduced of intravenous levobupivacaine and bupivacaine
blood flow to the cerebral circulation. This is also in sheep. Anesthesia and Analgesia. 1998 Apr
1;86(4):797–804.
significantly lower in levobupivacaine cases in
our study as well as many reported studies.8,13–14 5. Povey HM, Jacobsen J, Westergaard-Nielsen J.
Sundarathiti P et al stated that they found a more Subarachnoid analgesia with hyperbaric 0.5%
bupivacaine: effect of a 60-min period of sitting.
superior block in cases of hyperbaric bupivacaine,
Acta anaesthesiologica scandinavica. 1989
the results showed that levobupivacaine was a May;33(4):295–7.
effective alternative. The side effects observed were
6. Guler G, Cakir G, Ulgey A, Ugur F, Bicer C, Gunes
non significant in their study.15
I, Boyaci A. A comparison of spinal anesthesia with
levobupivacaine and hyperbaric bupivacaine for
Conclusion cesarean sections: A randomized trial.
7. Goyal A, Shankaranarayan P, Ganapathi P. A
randomized clinical study comparing spinal
The present study and its observations led us to
anesthesia with isobaric levobupivacaine with
the conclusion that in surgical practice, both the fentanyl and hyperbaric bupivacaine with fentanyl
agents bupivacaine and levobupivacaine provide in elective cesarean sections. Anesthesia, Essays
us with an effective anesthetic and analgesic cover. and Researches. 2015 Jan;9(1):57.
The duration of block observed was lower in 8. Duggal R, Kapoor R, Moyal G. A comparison
levobupivacaine cases as well as the incidence of of intrathecal levobupivacaine with hyperbaric
hypotension and side effects. This can be helpful for bupivacaine for elective cesarean section: A
the anesthetist in deciding to use levobupivacaine prospective randomized double-blind study. J
as a viable and safer alternative in short duration Obstet Anaesth Crit Care 2015;5:78–83.
surgeries like the cesarian section. The study is 9. Fattorini F, Ricci Z, Rocco A, Romano R, Pascarella
limited by its small sample size and lack of in MA, Pinto G. Levobupivacaine versus racemic
depth diagnostic monitoring during the surgery, bupivacaine for spinal anaesthesia in orthopaedic
but the authors are confident that larger scale major surgery. Minerva Anestesiol 2006;72:637–44.
studies will yield positive results in favor of using 10. Glaser C, Marhofer P, Zimpfer G, Heinz MT,
levobupivacaine in routine short term surgeries. Sitzwohl C, Kapral S, et al. Levobupivacaine versus
racemic bupivacaine for spinal anesthesia. Anesth
Source of Funding: Self Funded. Analg 2002;94:194–8.
Conflict of Interest: Nil. 11. Lee YY, Muchhal K, Chan CK. Levobupivacaine
versus racemic bupivacaine in spinal anaesthesia
for urological surgery. Anaesth Intensive Care
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Hyperbaric spinal ropivacaine a comparison to spinal anesthesia in cesarean section. Anesthesiol
bupivacaine in volunteers. Anesthesiology: The Res Pract 2010;2010. pii: 212696.
Journal of the American Society of Anesthesiologists.
13. Carpenter RL, Caplan RA, Brown DL, Stephenson
1999 Apr 1;90(4):971–7.
C, Wu R. Incidence and risk factors for side effects
2. Richardson MG, Wissler RN. Densities of dextrose- of spinal anesthesia. Anesthesiology 1992;76:906–16.
free intrathecal local anesthetics, opioids, and
14. Sundarathiti P, Sangdee N, Sangasilpa I,
combinations measured at 37 degrees C. Anesthesia Prayoonhong W, Papoun S. Comparison of
and Analgesia. 1997 Jan 1;84(1):95–9. intrathecal bupivacaine, levobupivacaine for
3. Morrison SG, Dominguez JJ, Frascarolo P, Reiz S. A cesarean section. J Med Assoc Thai 2014;97:710–6.
comparison of the electrocardiographic cardiotoxic 15. Gautier P, De Kock M, Huberty L, Demir T,
effects of racemic bupivacaine, levobupivacaine, Izydorczic M, Vanderick B. Comparison of the
and ropivacaine in anesthetized swine. Anesthesia effects of intrathecal ropivacaine, levobupivacaine,
and Analgesia. 2000 Jun 1;90(6):1308–14. and bupivacaine for Caesarean section. Br J Anaesth
4. Huang YF, Pryor ME, Mather LE, Veering BT. 2003;91:684-9.

A Comparative Study of the Anesthetic Potencies and Hemodynamic

Changes of 0.5% Isobaric Levobupivacaine and 0.5% Hyperbaric
Racemic Bupivacaine for Spinal Anesthesia in Lower Abdominal
and Lower Limb Surgeries
P Sridhar1, V A Sabapathy2, Pratheba3, Poorna Uma4, C R Lakshmi Narayanan5
Author’s Affiliation: 1Associate Professor, Department of Anesthesiology, Dhanalakshmi Srinivasan Medical and Hospital,
Permabalur 621113, India, 2Professor, 3Senior Consultant, 4,5Post-Graduate, Department of Anesthesiology, Vinayaka Missions
Kirubananda Variyar Medical College and Hospital, Vinayaka Missions Research Foundation (Deemed To Be University) Salem,
Tamil Nadu 636308, India.
Corresponding Author: V A Sabapathy, Professor, Department of Anesthesiology, Vinayaka Missions Kirubananda Variyar
Medical College and Hospital, Vinayaka Missions Research Foundation (Deemed To Be University) Salem, Tamil Nadu 636308,
India.
E-mail: sabapathyv.appavoo@gmail.com

P Sridhar, V A Sabapathy, Pratheba, et al. A Comparative Study of The Anesthetic Potencies and Hemodynamic Changes
of 0.5% Isobaric Levobupivacaine and 0.5% Hyperbaric Racemic Bupivacaine for Spinal Anesthesia in Lower Abdominal and
Lower Limb Surgeries. Indian J Anesth Analg. 2020;7(6):1431–1438.
Abstract
Background and Objectives: Spinal anesthesia is widely used, providing a fast onset and effective sensory and motor
blockade. Systemic hypotension and bradycardia are the more common side effects seen during the central neuraxial
block. Levobupivacaine has been introduced into clinical practice because of its lower toxic effects for the heart and central
nervous system. We, therefore, performed this prospective randomized clinical study to compare the clinical efficacy and
hemodynamics of 3 ml of 0.5% intrathecal isobaric Levobupivacaine with 3 ml of 0.5% intrathecal racemic Bupivacaine for
lower abdomen and lower limb surgeries.
Methodology: 100 patients belonging to ASA physical status I and II scheduled for lower abdomen and lower limb
surgeries were randomly selected for the study and were divided into 2 groups of 50 each. Group L (Levobupivacaine
group) received 3ml of 0.5% isobaric Levobupivacaine (15mg) intrathecally Group B (Bupivacaine group) received 3ml 0.5%
of racemic Bupivacaine (15mg) intrathecally. Onset and duration of sensory block, onset duration and degree of motor block,
maximum dermatomal level of sensory block, hemodynamic parameters, and adverse effects if any were studied.
Results: There was a statistically significant difference between both the groups with regards to mean onset of sensory and
motor block which was significantly faster in group B when compared to group L. The mean time for peak sensory block
was 7.44 mins with Levobupivacaine and 6.84 mins with Bupivacaine (p-value 0.02). The mean onset time for the motor
block was 10.99 mins with Levobupivacaine and 10.48 mins with Bupivacaine (p-value 0.05). The maximum sensory height
attained ranged between T4 and T10 in both the groups, which was clinically and statistically not significant. The mean time
for 2 segment regression was 123.8 mins in group L and 126.5 mins in group B which was statistically not significant (p-value
0.23). The degree of motor block was comparable in both groups. The mean duration of sensory block was 257.4 mins in
group L and 259.9 mins in group B which was clinically and statistically not significant (p-value 0.17). The mean duration of
motor block was 283.2 mins in group L and the group was 286.3 mins with a p-value of 0.31 which clinically and statistically
was not significant. Hypotension and bradycardia were less common in group L than group B which was clinically and
statistically significant. 52% of patients in group B and 16% of patients in group L required the use of vasopressor with a
statistically significant p-value of <0.001. 30% of patients in group B had bradycardia compared to 8% in group L with a
p-value of 0.002. The incidences of other side effects were comparable in both the groups.
Conclusion: Levobupivacaine 15 mg (3ml of 0.5% Isobaric) has significantly a late onset of sensory and motor block but
had a similar duration of sensory and motor block compared to Bupivacaine 15 mg (3ml). However, Bupivacaine required
more often the use of a vasopressor and sympathomimetic drug compared to Levobupivacaine. So Levobupivacaine could
be advisable inpatient whose clinical history demandsthe cardiovascular impact of spinal anesthesia to be minimized.
Keywords: Levobupivacaine; Bupivacaine; Intrathecal; Isobaric.

Introduction and duration of sensory block, onset duration and

degree of motor block, maximum dermatomal level
Spinal anesthesia is widely used, providing a fast of sensory block, hemodynamic parameters, and
onset and effective sensory and motor blockade. adverse effects if any were studied.
It has many advantages like simplicity, easy to
perform, rapid onset of action, and good muscle Methods for Collection of Data
relaxation. It has an added advantage of preventing
complications of General Anaesthesia like airway 100 patients undergoing surgical procedures will
manipulation, Polypharmacy, the pressor response be randomly selected. Informed, written consent
from intubation, nausea, vomiting, sore throat, will be taken from patients. Result values will be
excessive sedation, etc. Systemic hypotension and
recorded using a preset proforma. Patients who
bradycardia are the most common side-effects
will be selected for the study will be randomly
seen during the central neural block. Marked
allocated to 2 groups of 50 each on an alternate
hypotension may be harmful, particularly in
basis, namely: a) Group B: Received 3ml of 0.5%
elderly patients with limited cardiac reserve. Age
intrathecal hyperbaric Bupivacaine (15 mg) b)
and a high level of the block are the two main
Group L: Received 3ml of 0.5% intrathecal Isobaric
factors known to play a role in the development of
Levobupivacaine (15 mg).
hypotension after spinal anesthesia.1 Bupivacaine
(1-butyl-2', 6'-pipercoloxylidine), is an amino amide Inclusion criteria: Age - 20 to 60 years of both
local anaesthetic.2 Racemic bupivacaine is the sex,◦ American Society of Anaesthesiologists (ASA)
most frequently used long-acting agent for spinal grade I and II,◦ Patients giving valid informed
anesthesia. The use of low dose racemic bupivacaine consent,◦ Patients undergoing elective general
is recommended to reduce its cardiovascular surgical/urological/gynecological/plastic and
side-effects3,4 Levobupivacaine (S-1-buty l-2 orthopedic lower limb operations.
piperidylformo-2‘, 6‘-xylazine hydrochloride) is a Exclusion Criteria: Patients' refusal to spinal
pure S(-)-enantiomer of racemic bupivacaine. It is anesthesia,◦ ASA grade III and IV,◦ Age < 20, and
a new long-acting local anesthetic.5 Owing to the > 60 years. Patients with a history of allergy/
lower affinity of the S (-) isomer to cardiac sodium hypersensitivity to the study drugs or any local
channels compared to the R isomer, it is associated anesthetic General contraindications for spinal
with fewer cardiac side effects.6,7 The objective of the anesthesia. A pre-anesthetic checkup was carried out
present study is to investigate the clinical efficacy with a detailed history, general physical examination,
and safety of isobaric solution of levobupivacaine and systemic examination. Airway assessment and
compared with racemic bupivacaine in spinal spinal column examination were done.
anesthesia for lower abdominal and lower limb surgery.
Procedure: The patient was shifted on the OT
Table, IV access was obtained on the forearm with
Methodology 18G IV cannula and the patient was preloaded
with 500 ml Ringers Lactate solution before the
This clinical study was conducted on 100 adult spinal block. The monitors connected included
patients of ASA physical status I and II in the non-invasive BP, Oxygen saturation using a pulse
age group of 20 to 60 years of either sex, posted oximeter, and ECG. Baseline Pulse rate, BP, and SpO2
for elective lower limb, lower abdominal, were recorded. Under strict aseptic precautions, a
gynecological, and urological surgeries under lumbar puncture was performed in the left lateral
spinal anesthesia after taking informed consent at position by midline approach by using a disposable
Vinayaka Mission’s Kirupananda Variyar Medical 25 G Quincke Babcock spinal needle at L2-L3 or L3-
College Hospital, Salem over 24 months. After L4 intervertebral space. After confirmation of the
approval from the hospital ethical committee, a free flow of CSF, the study drug was administered
comparative study was carried out on 100 adult at 0.1 ml/sec. The patient was turned supine
patients 100 patients belonging to ASA physical immediately after the injection with a pillow under
status I and II scheduled for lower abdomen and their head and was put in a neutral position. After
lower limb surgeries were randomly selected for the spinal block, Pulse rate, NIBP and SpO2 were
the study and were divided into 2 groups of 50 each. measured at 0, 1, 3, 5, 10, 15, 30, 60, 90, 120 and 180
Group L (Levobupivacaine group) received 3ml of mins. Hypotension was defined as a 20% decrease
0.5% isobaric Levobupivacaine (15mg) intrathecally in blood pressure from baseline values and was
Group B (Bupivacaine group) received 3ml 0.5% of treated with incremental IV boluses of ephedrine
racemic Bupivacaine (15mg) intrathecally. Onset 6mg. Bradycardia was defined as a pulse rate of less
P Sridhar, V A Sabapathy, Pratheba, et al. / A Comparative Study of The Anesthetic Potencies and 1433
Hemodynamic Changes of 0.5% Isobaric Levobupivacaine and 0.5% Hyperbaric Racemic
Bupivacaine for Spinal Anesthesia in Lower Abdominal and Lower Limb Surgeries
than 60bpm and treated with IV atropine 0.3mg. Table 2: Onset of Sensory and Motor Block.
Patients were monitored continuously using NIBP, Parameter Group L Group B t value p-value
SpO2, and ECG. After giving spinal anesthesia, Mean SD Mean SD
oxygen was given by facemask at 4 lts/min and the Sensory 7.44 0.97 6.84 1.61 2.26 0.02,ns
fluid therapy was with lactated Ringers solution block(min)
and DNS. Motor 10.99 1.19 10.48 1.37 1.99 0.05,ns
block(min)
Statistical Methods Table 2, Graph 1 The mean time for onset of

sensory block in group L was 7.44mins and in the
group, B was 6.84 mins with a p-value of 0.02 which
Descriptive and inferential statistical analysis
was statistically and clinically significant. Unpaired
has been carried out in the present study. Results
t-test, *P < 0.05, Significant.
on continuous measurements are presented on
Mean±SD (Min Max) and results on categorical
7.5
measurements are presented in Number (%). 7.4 7.44
Significance is assessed at a 5 % level of significance. 7.3
The following assumptions on data are made
Mean Onsetin
7.2
assumptions: 1. Dependent variables should be 7.1
Min
normally distributed, 2. Samples drawn from the 7
population should be random, Cases of the samples 6.9
6.8 6.84
should be independent. Student t-test (two-tailed,
6.7
independent) has been used to find the significance
6.6
of study parameters on a continuous scale between
two groups (Intergroup analysis) on metric
parameters. Chi-square/Fisher Exact probability Graph 1: Onset of Sensory Block.
test has been used to find the significance of study
parameters on a categorical scale between two or Graph 2 The mean time for onset of motor
more groups. The Statistical software namely SAS blockade (Bromage 3) was 10.99 mins for group L
9.2, SPSS 15.0, Stata 10.1,Med Calc 9.0.1,Systat 12.0, and 10.48 mins for group B with a p-value of 0.05
and R environment ver. 2.11.1 were used for the which was clinically and statistically significant.
analysis of the data, and Microsoft Word and Excel
have been used to generate Graphs, Tables, etc. 11 10.99
10.9
Observation and Results 10.8

Mean Onsetin
10.7
Min
A total of 100 ASA I and ASA II patients who 10.6

underwent lower abdominal and lower limb 10.5
10.48
surgeries under subarachnoid block were randomly 10.4
selected and were divided into 2 groups of 50 each. 10.3
Group L (Levobupivacaine group) received 3ml of
0.5% isobaric Levobupivacaine 15mg intrathecally.
Group B (Bupivacaine group) received 3ml of 0.5% Graph 2: Onset of Motor Block.
hyperbaric Bupivacaine 15mg intrathecally.
Table 1: Demographic Profile.
Parameter Group L Group B t value P-value
80
Mean SD Mean SD
Percentage of cases
Age (yrs) 39.0 10.5 37.5 7.9 0.82 0.42,ns 60

Height (cm) 163.6 5.8 161.5 5.0 1.94 0.06,ns
40
Sex (M:F) 31:19 29:21 - 0.68,ns
20
Table 1 The mean age in group L was 39 years
and the mean age in group B was 37.5 years. In 0
group L 31 were males and 19 were females and T4 T6 T8 T10
in group B 29 were males and 21 were females. Group L Group B
Unpaired t-test, *P < 0.05, Significant Graph 3: Highest Level Of Sensory Block.

Graph 3 The highest level of block achieved in significant.

group L was T4 with 2 (4%) patients achieving it and
in group B was also T4 with 3 (6%) patients achieving
286.3
Duration in Min
it. 68% of patients in group L and 44% of patients
in group B achieved a maximum sensory blockade
of up to T8 dermatomal level. These findings were
clinically and statistically not significant. 283.2
126.5 126.5
126 Group L Group B
125.5 Graph 7: Duration of Motor Block.
Mean Time in
125 Graph 7 The mean duration of motor block (time

Min
124.5 to recovery of complete motor block i.e, grade 0)

124 was 283.2 mins for group L and 286.3 mins for
123.8
123.5 group B. This was clinically and statistically not
123 significant (p 0.31).
122.5
Graph 4: Time For 2 Segment Regression.
Graph 4 The mean time taken for 2 segment

regression of sensory block was 123.8 mins in group
L and 126.5 mins in group B with a p-value of 0.40
which is clinically and statistically not significant.
260
259.8
259.5
Mean duration in
259
258.5 Group L Group B
Min
258 Graph 8: Comparison of Pulse Rate Between Two Groups.

257.5
257.4 Graph 8 The baseline heart rate was comparable
257
256.5 in both groups. In group B there was a significant
fall in pulse rate compared to baseline starting from
Group L Group B 1 min to 10 mins and there was the statistically
Graph 5: Duration Of Sensory Block. significant intergroup difference with a p-value of
< 0.05 when compared with group L. This was both
Graph 5 The mean value for the duration of clinically and statistically significant.
sensory block was 257.4 mins in group L and for
group B the mean duration was 259.8 mins. This 140
was not significant clinically or statistically with a 120
p-value of 0.17.
100
MM Hg
80
Percentage of Cases
60
40
20
0
Grade 1 Grade 2 1 3 5 10 15 30 60 90 120 180
Grade 3
Graph 6: Degree of Motor Blockade. Group L GroupB
Graph 9: Comparison of Systolic Blood Pressure Between Two
Graph 6 98 % of patients in group L and 96% of Groups.
patients in group B had grade 3 or complete motor
block. This was clinically and statistically not Graph 9 Baseline systolic blood pressures were

comparable in both groups. There was a slight 52

reduction in systolic blood pressure after spinal 60 30
anesthesia in both groups. The magnitude of fall 50 Nausea
18
however was significant only in group B (p-value 40 8
Vomitting
30
< 0.05) with the intergroup comparison. This fall Hypotension
20 0 2
in blood pressure was more pronounced from 1st 10
4 8
Bradycardia
minute up to 10 minutes after spinal injection. 0
Group L
90 Group B
80 Graph 11: Side Effects.

70 Graph 11 Nausea was seen in 2 patients of group
60 L (4%) and 4 patients of group B (8%). Vomiting
was seen only in 1 patient of group B. 52% of
mm Hg
50
40 patients had hypotension and 30 % of patients had
30 bradycardia in group B, whereas in group L 16% had
20
hypotension and 8% had bradycardia. Incidence
of hypotension (p-value <0.001) and bradycardia
10
(p-value 0.002) was higher in group B than group L
0
basal 1 3 5 10 15 30 60 90 120 180 which was clinically and statistically significant. No
case of allergy, respiratory depression, shivering
in min
and other side effects were reported.
GroupL Group B
Graph 10: Comparison of Diastolic Blood Pressure between two
groups. Discussion
Graph 10 The baseline diastolic blood pressure
values were comparable. Both groups showed a A subarachnoid block is a commonly employed
reduction in diastolic blood pressure after spinal anesthetic technique for performing surgeries of
anesthesia. Intergroup comparisons showed a more the lower abdomen and lower limb. It is a safe,
significant fall of diastolic blood pressure in group economical, and easy to administer a technique
B (p <0.05) and this was from 3rd minute up to 10 which also offers a high level of post-anesthesia
minutes after spinal injection. satisfaction for the patient. The technique is
Table 3: Oxygen Saturation. simple, has a rapid onset, and is reliable. The risk
of general anesthesia including mishaps due to
Time Interval (min) Group L Group B
airway management is avoided by this technique.
Mean SD Mean SD Systemic hypotension and bradycardia are the
Basal 98.5 0.5 98.3 0.6
most common side-effects seen during the central
neural block. Marked hypotension may be harmful,
1' 98.2 0.8 98.4 0.7 particularly in elderly patients with limited cardiac
3' 98.3 0.8 98.5 0.6 reserve. Bupivacaine is a local Anaesthetic used
5' 98.6 1.0 98.4 0.7 routinely for spinal anesthesia because of its high
potency and minimal neurologic symptoms.
10' 98.8 0.9 98.3 0.7
Racemic bupivacaine is the most frequently used
15' 98.7 1.0 98.2 0.9 long-acting agent for spinal anesthesia. The use
30' 98.6 0.9 98.4 0.5 of low dose racemic bupivacaine is recommended
to reduce its cardiovascular side-effects.3,4
60' 98.5 0.9 98.4 0.5
Levobupivacaine (S-1-butyl-2piperidylformo-2‘,6‘-
90' 98.7 0.7 98.4 0.5 xylazine hydrochloride) is a pure S(-)- enantiomer
120' 98.4 0.6 98.40 0.6 of racemic bupivacaine. It is a new long-acting local
180' 98.7 0.8 98.5 0.6
anesthetic.8 Owing to the lower affinity of the S (-)
isomer to cardiac sodium channels compared to the
Table 3 There was no significant change in oxygen R isomer, it is associated with fewer cardiac side
saturation (SpO2) following subarachnoid block in effects.9,10 Hence this study was conducted to assess
both the groups. The SpO2 values were comparable the anesthetic potency and hemodynamic effects
in both groups. of intrathecally administered Levobupivacaine
Unpaired t-test compared with intrathecal administered racemic
* P < 0.05, Significant Bupivacaine in patients coming for surgeries of
lower abdomen and lower limb. The equipotent study, the time for 2 segment regression of sensory
ratio between Levobupivacaine and Bupivacaine block was 123.8±10.4 mins for group L and in the
is considered to be 0.97 (Ying Y Lee et al).24 Since group, B was 126.5±12.1 mins with a p-value of 0.40
hyperbaric Levobupivacaine is not available in the which was statistically not significant. In our study,
market, we chose isobaric 0.5% Levobaupivacine there was no difference with the duration of sensory
15 mg and isobaric 0.5% Bupivacaine 15 mg as block among the 2 groups. Ashton D‘Souza et a[l27]
an equipotent dose for this study. In our study, found that the onset of motor block was quicker
the majority were middle-aged in both groups. In with the Bupivacaine group which was a mean
group L (Levobupivacaine group) there were 31 time of 4.5 mins and for the Levobupivacaine group
males and 19 females and in group B (Bupivacaine the meantime was 5.25 mins. Our study showed
group) there were 29 males and 21 females.11 The the mean duration for the onset of motor block in
mean heights in the group were also identical. group B was 10.48 mins and group L was 10.99
These parameters were kept identical in both the mins with a p-value of 0.05 which was statistically
groups to avoid variations in the intraoperative significant. The mean onset time-correlated with
and postoperative outcomes of the patients.13 The the study conducted by F. Fattorini et al17 showed
mean time for onset of peak sensory block in Group the mean onset time for the motor block in the
L was 7.44 mins and in Group B was 6.84 mins with Bupivacaine group was 9 ± 5 mins and in the
a p-value of 0.02 which was statistically significant. group,Levobupivacaine was 12 ± 6 mins. Glaser et
This observation was comparable to the study al12 noted that the duration of the motor block in the
done by Ashton D‘Souza et al, who compared levobupivacaine group was 280±84 mins and in the
the anesthetic efficacy and safety of Hyperbaric bupivacaine group was 284±80 mins. This correlated
0.5% Bupivacaine, Isobaric 0.75% Ropivacaine and with our study which showed the mean duration
Isobaric 0.5% Levobupivacaine. The mean sensory of the motor block for group L was 283.2 mins and
onset time for Bupivacaine was 5.25 mins and in the group, B was 286.3 mins with a p-value of
Levobupivacaine was 6 mins. It was found that 0.31 which was statistically not significant. There
hyperbaric bupivacaine produces a spinal block was a reduction in both systolic blood pressure
which has a sensory block with an earlier onset of and diastolic blood pressure in both the groups but
clinically significant sensory and motor block as the magnitude of fall was more in group B than in
compared to isobaric levobupivacaine. In another group L. The pronounced fall in blood pressure
study done by F. Erdil et al23 in their study of 80 was more from 1st minute after spinal injection
patients posted for TURP, Time to reach T10 and peak up to 15 minutes after the injection in group B.18,19
sensory block was significantly shorter in group The incidence of hypotension was more in group B
Bupivacaine compared to group Levobupivacaine (52% patients) which required more often the use of
(p <0.05) which was 6.4 ± 2 mins for Bupivacaine and vasopressor drug inj ephedrine IV bolus compared
7.8 ± 1.9 mins for Levobupivacaine which is similar to group L (16% patients) with a p-value of <0.001
to the observation in our study. So Bupivacaine which was clinically and statistically significant.
produced a clinically earlier onset of peak sensory This correlated in a study of one hundred-twenty
block compared to Levobupivacaine. A study of ASA I-III patients, conducted by M Mantouvalou,
one hundred-twenty ASA I-III patients, conducted et al20 who observed that 42.5% of patients of the
by M Mantouvalou et al[20] noted a similar trend Bupivacaine group had hypotension compared to
for maximum cephalad spread variation of the 17.5% patients of the Levobupivacaine group. In our
sensory block between the isobaric bupivacaine study, we noted that the incidence of hypotension
group and isobaric levobupivacaine. In our study, and bradycardia was significantly higher with the
the highest level of sensory blockade was similar Bupivacaine group than with the Levobupivacaine
in both groups. The highest level of block achieved group.21 Levobupivacaine was found to be more
in group B was T4 with 3 (6%) patients achieving it cardio stable amongst the two after spinal injection.
and in group L highest level achieved was also T4 This may be attributed to the lower affinity of the
with 2 (4%) patients achieving it. 68 % of patients in S (-) isomer to cardiac sodium channels compared
group L achieved a level of T8 and in group B 44 % of to the R isomer and thus is associated with fewer
patients achieved a sensory block upto T8. Glasser cardiac side effects.14,15 The incidence of nausea and
et al12 in their study noted the time for 2 segment vomiting were comparable between both groups in
regression was similar in between the 2 groups and our study. Nausea was seen in 2 patients of group
was 152±48 mins for the Levobupivacaine group L (4%) and in 4 patients of group B (8%) with a
and was 155±50 mins for the Bupivacaine group. p-value of 1.0 which was clinically not significant.
This correlates with the finding in our study. In our Vomiting was seen only in 1 patient of group B

(p-value 0.31). No other side effects were noted in 9. Magendie F. Experiences Sur Les fonctions des
the study.22,24 raciness des nerfsrachidian. J. PhysiolExper Path
1822;2:276–279.
10. Bier A. Versucheuber Cocainisirung des
Conclusion
Ruckenmarkes. Deutsche Zeitschrift fur Chirurgie.
1899;51:361–369.
Our study reveals that 15 mg of isobaric 11. Albright GA. Cardiac arrest following regional
Levobupivacaine (3ml of 0.5%) when administered anesthesia with etidocaine or bupivacaine.
intrathecally provides adequate anesthesia for Anesthesiology 1979; 51: 285–7.
lower abdomen and lower limb surgeries and is 12. Christian Glaser, Peter Marhofer, Gabriela Zimpfer,
an alternative to 15 mg of hyperbaric Bupivacaine. Marie T. Heinz, Christian Sitzwohl, Stephan Kapral,
(3ml of 0.5%). There is however a delayed onset et al; Levobupivacaine Versus Racemic Bupivacaine
of action of peak sensory and motor blockade for Spinal Anesthesia; AnesthAnalg 2002;94:194 –8.
with Levobupivacaine compared to Bupivacaine. 13. Alley, Elizabeth A., Kopacz, Dan J., McDonald,
Levobupivacaine is similar to Bupivacaine in two Susan B., Liu, Spencer S.: Hyperbaric Spinal
segments sensory block regression time, duration Levobupivacaine: A Comparison to Racemic
of sensory and motor block, and degree of motor Bupivacaine in Volunteers; AnesthAnalg
block. Bupivacaine required more often the use of 2002;94:188 –193.
vasoactive drug ephedrine and sympathomimetic 14. P Gautier, M De Kock, L Hubert, T Demir, M
drug atropine compared to Levobupivacaine. So Izydorczic, and B Vanderick; Comparison of the
Levobupivacaine could be advisable in patients effects of intrathecalropivacaine, levobupivacaine,
and bupivacaine for Caesarean section; Br J Anaesth
whose clinical history demands the cardiovascular
2003; 91: 684–9.
impact of spinal anesthesia to be minimized.
15. Y Y Lee, K Muchhal, C K Chan; Levobupivacaine
Versus Racemic Bupivacaine in Spinal Anaesthesia
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C, Wu R. Incidence and risk factors for side effects Levobupivacaine and Bupivacaine in Spinal
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amides. ActaChemScand 1957; 11: 1183-90. Pascarella, G. Pinto.Levobupivacaine versus
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Nimmo W. A comparison of the cardiovascular ActaAnaesth. Belg., 2008, 59, 65–71.
effect of Levobupivacaine and rac-bupivacaine
20. O Cuevas, A E Er, E Ongen, H Basar. Spinal
following intravenous administration to healthy
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Review Article November – December 2020;7(6)
Anesthesia for Brachytherapy: A Review
Kala1, Tanya Elizabeth2
Author’s Affiliation: 1Professor and Head, 2Junior resident, Department of Anesthesiology, Pain Medicine and Critical Care, Sree
Balaji Medical College and Hospital, Chennai, Tamil Nadu 600044, India.
Corresponding Author: Tanya Elizabeth, Junior Resident, Department of Anesthesiology, Pain Medicine and Critical Care, Sree
Balaji Medical College and Hospital, Chennai, Tamil Nadu 600044, India.
E-mail: tanyae235@gmail.com

Kala, Tanya Elizabeth. Anesthesia for Brachytherapy: A Review. Indian J Anesth Analg. 2020;7(6):1439–1444.
Abstract
Radiotherapy is a commonly employed and an important modality of treatment for cancer with about
50 % of the patients receiving radiotherapy during their course of treatment.1 Two major categories for the
application of radiation are external beam radiation and brachytherapy.1 Brachytherapy is derived from
the greek word brachys meaning “short distance”.2 Brachytherapy is administered by inserting a radiation
source inside a specific cancer site which needs anesthesia, analgesia and muscle relaxation. The theory
behind brachytherapy is to deliver low intensity radiation over an extended period to a relatively small
volume of tissue covering the tumour area and sparing the surrounding normal tissue. The demand for
anesthesia in brachytherapy is increasing nowadays. Anesthetic management is crucial because it poses a
number of challenges for the anesthesiologist. Patients for brachytherapy are often elderly and are high risk
patients with multiple co morbidities, brachytherapy for head and neck malignancy may pose the problem
of difficult airway, to achieve a stable position of the applicators and implants immobilization is essential.3
Brachytherapy often has an unpredictable procedural duration. Transportation of the anesthetized patients
to different radiological suite is a typical challenge.3 Various modalities of anesthesia employed include
general, spinal, combined spinal epidural anesthesia and local anesthesia with sedation. Anesthesiologist
play a major and an important role in the ongoing challenge to provide an optimal treatment conditions
for brachytherapy.
Keywords: Anesthesia; Brachytherapy; Radiotherapy treatment for cancer.
Introduction the surrounding normal tissue. The demand for

anesthesia in brachytherapy is increasing nowadays.
Radiotherapy is a commonly employed and an Anesthetic management is crucial because it poses
important modality of treatment for cancer with a number of challenges for the anesthesiologist.
about 50 % of the patients receiving radiotherapy Patients for brachytherapy are often elderly and
during their course of treatment.1 Two major are high risk patients with multiple co morbidities,
categories for the application of radiation are brachytherapy for head and neck malignancy may
external beam radiation and brachytherapy.1 pose the problem of difficult airway, to achieve a
Brachytherapy is derived from the greek word stable position of the applicators and implants
brachys meaning “short distance”.2 Brachytherapy immobilization is essential.3 Brachytherapy
is administered by inserting a radiation source often has an unpredictable procedural duration.
inside a specific cancer site which needs anesthesia, Transportation of the anesthetized patients to
analgesia and muscle relaxation. The theory behind different radiological suite is a typical challenge.3
brachytherapy is to deliver low intensity radiation Various modalities of anesthesia employed
over an extended period to a relatively small volume include general, spinal, combined spinal epidural
of tissue covering the tumour area and sparing anesthesia and local anesthesia with sedation.
Anesthesiologist play a major and an important stage liver disease are certain conditions associated
role in the ongoing challenge to provide an optimal with bone and soft tissue complications after an
treatment conditions for brachytherapy. implant. Also the location of the tumour, extent
of the tumour, size and function of the organ are
Indications4,5 also to be evaluated for the appropriateness of
the treatment. Any tumour eroding the bone is
considered as contraindication for brachytherapy
Radical Radiation because of potential risk of osteoradionecrosis.6
Similarly radiotherapy for very large tumour may
1. Skin malignancies( BCC, SCC) not also be feasible because of the poor coverage of
2. Head and neck malignancies. the tumour while placing implants and catheters.
3. Carcinoma cervix.
4. Carcinoma prostate. Different Types of Brachytherapy
After Surgical Excision with Cancer Chemotherapy 1. Based on the duration of implant
1. Head and neck malignancies Temporary- dose is delivered over a short
2. Carcinoma breast period of time and the source are removed after the
prescribed dose has been reached. The duration of
3. Carcinoma Esophagus treatment will depend on many factors including
4. Carcinoma Anal canal. rate and dose of delivery, type and location of the
tumour. Most of the brachytherapy treatments are
Postoperative temporary.
1. Carcinoma endometrium Permanent – also known as seed implantation.
2. Carcinoma cervix Involves placing small LDR radioactive seeds, or
pellets in the tumour or treatment site or leaving
3. Carcinoma breast them there permanently to gradually decay. Eg.
Prostate seed implants
Palliative
2. Based on the source position
1. Bronchogenic carcinoma
Interstitial- the sources are placed directly in the
2. Biliary duct malignancy target tissue of the affected site, such as prostate or
3. Carcinoma cervix breast.
4. Recurrent tumours. Contact- involves placement of the radiation
source in a space next to the target tissue.
Patient Selection Intracavitary- a body cavity such as cervix,
uterus or vagina.
The appropriate selection of patients determines Intraluminal- such as the trachea or oesophagus
the key success to brachytherapy treatment. Surface- externally such as the skin
Patients with multiple co morbid conditions
who have specific considerations and relative Intravascular- blood vessels.
contraindications are not considered ideal 3. Based on the dose rate
candidates for brachytherapy. Alcohol dependence,
Low dose rate (LDR)- emit radiation at a rate of
electrolyte abnormalities, neurological deficits, poor
cardiopulmonary reserve, poor mentation, anemia, 0.4-2gy/hour. Commonly used for cancers of the
thrombocytopenia are certain co morbidities oral cavity, oropharynx, sarcomas and prostate.
which pose real anesthetic challenges which may Medium dose rate (MDR) characterized by a
prolong post operative recovery2 and preoperative medium rate of dose delivery, ranging between
optimization and other modalities of treatment 2-12gy/hour.
should be offered to the patient. Patients should be
High dose rate (HDR)- when the rate of dose
explained about the procedure preoperatively and
delivery exceeds 12gy/hour.
should be taught about self careneeds to be given by
themselves including feeding through nasogastric Pulsed dose rate (PDR)- involves short pulses of
tube, tracheostomy stoma care etc. uncontrolled radiation typically once an hour, to stimulate the
diabetes, hypertension, vascular disorders and end overall rate and effectiveness of LDR treatment.

Kala, Tanya Elizabeth / Anesthesia for Brachytherapy: A Review 1441
Table 1: Sources of Radiation4,5

Symbol Half Life Energy Availability Others
Cesium137cs 30.17 yrs 0.662 mev Encapsulated in a stainless steel sheaths most
widely used for gynaecologicl cancers
Cobalt60co 5.26 yrs 1.17 mev In the form of wire encapsulated in a sheath of Available as pellets also
platinum
Iridum192ir 30.17 yrs 73.8 days Available in the form of seeds for LDR Also used in the form of a wire.
Iodine i
125
59.6 days 35.5 mev Only available as seeds. They are usually Only Used for permanent implants
inserted in the tumour volume using special
delivery guns.
Brachytherapy sources are usually encapsulated • To remember that the key to efficient and safe
contacting radioactivity, providing source rigidity, remote anesthetic management relies on open
absorbing any alpha and for photon emitting communication between the anesthesiologist
sources. Sources stores must provide protection and non-operating room personnel.
against environmental conditions, be only for • Realize that remote locations have different
radioactive materials, provide sufficient shielding, safety concerns, such as radiation and
be resistant to fire and be labelled. (Table 1) powerful magnetic fields.
Preoperative Assesment Special problem of NORA

• Limited working place, limited access to the
Careful and detailed present history, history of patient,
previous illness, associated comorbidities, drug • Use of outdated ,old equipment with minimal
therapy, radiation, chemotherapy, previous or no maintenance service
surgery,anesthesia complications and drug
allergy are very important. A thorough physical • Less familiar with the management of
examination of all the systems should be done. patients
All patients for head and neck brachytherapy may • Lack of skilled personnel, drugs and supplies.
have fibrosis of the tumour region due to previous
radiation or surgery and all such patients coming
ASA Guidelines7
for every sitting of brachytherapy are considered as
difficult airway and should be assessed each time
since the chance of fibrosis and necrosis may get a reliable oxygen source with backup
worsened with each radiation. Airway examination a suction source
including mallampati grading, lacation of trachea,
waste gas scavenging
presence of stidor guide the anesthesiologist in
deciding about the plan of anesthesia. sufficient space for the anesthesia care team
• adequate monitoring equipment to meet the
Investigations standards for basic anesthetic monitoring
• emergency drugs, and other emergency
Preoperative investigations include Hemoglobin, equipment
Random blood sugar, Platelet count, Chest xray, • a self-inflating hand resuscitator bag
ECG, Urine examination. Elderly patients with
co morbid conditions needs to be investigated • a means of reliable two-way communication
with liver function tests, renal function tests and to request assistance
pulmonary function test and echocardiogram. • sufficient safe electrical outlets
• compliance of the facility with all applicable
Non Operating Room Anesthesia Objectives (Nora) safety and building codes
• adequate patient and anesthesia machine
Understanding that the standards of anesthesia care illumination with battery- powered backup
and patient monitoring are the same regardless of • Appropriate postanesthesia management
location. should be provided.

• emergency cart with a defibrillator Anesthetic Techniques

• Adequately trained staff to support
anesthesia team 1. Carcinoma Cervix: Brachytherapy for ca cervix
plays a pivotal role and is mainly applied as
Equipments Check (Soapme)8 an intracavitary procedure in selected cases
complimented by interstitial implants. Tumours
which are confined to the cervix can be subjected
S (suction) – Appropriate size pre sterile to hysterectomy and patients who are unfit for
disposable suction catheters and functioning surgery can be treated with radiotherapy.9 For
suction apparatus. a long term many centers used the cervical
O (oxygen) – Reliableuninterrupted oxygen slit sleeve which had a plastic tube drainage
source with a functioning flowmeter. At least one with holes that is inserted through cevix into
spare E-type oxygen cylinder for back up In case of uterus and sutured with the sleeve the cervix
central supply failure. is dilated which is designed for fractionated
treatment and remains in place throughout the
A (airway) – Size appropriate airway equipment: course of treatment.10 Intracavitary applications
P (pharmacy) – Basic drugs needed for life are temporary that are left in the patient for a
support specified time to deliver prescribed dose and is
Drugs both for anesthesia and emergency drugs. generally carried out as an outpatient procedure.
General anesthesia, epidural or spinal
during emergency: anesthesia, consious sedation, paracervical
• Epinephrine (adrenaline) block are various anesthetic techniques that are
increasingly being applied. The advantage of
• Atropine
the regional anesthesia over general anesthesia
• Glucose is that it can be continued as post operative
• Naloxone (reversal agent for opioid drugs) analgesia and can be used for patients coming
for multiple sittings. Disadvantage includes
• Flumazenil (reversal agent for
hypotension, multiple punctures, technical
benzodiazepines) difficulties etc. the advantage of TIVA over
• Hydrocortisone other choices of anesthesia is that it can be done
• dexamathasone for patients coming on outpatient basis. The
etiology of pain in a patient with cancer cervix
• ephedrine coming for brachytherapy can be attributed to
• furosemide many. Due to the presence of applicators or
rods in the uterine cavity the T10-L1 sympathetic
• iv fluids(crystalloids and colloids)
9 fibres are stimulated causing pain. Cervical
M (monitors): dilatationand vaginal distension stimulates
• Pulse oximeter the parasympathetic fibres S2-S4 causing
lower back pain. Packing of the vagina and its
• NIBP
retaining suture through the labia stimulates
• End-tidal CO2 (capnography afferents via the pudendal nerve of S2-4. Patients
• Temperature(oropharyngeal, rectal and surface may have an indwelling urinary catheter and
probes) discomfort may be aggrevated while moving.
Inhalational anesthesia with nitrous oxide can
• ECG be given to relieve discomfort of the applicant
E (equipment): attachment or removal. Systemic opiods may
also be given as patient controlled analgesia.
• Defibrillator with paddles
Conscious sedation with fentanyl, midazolam
or dexmedetomidine. Since it’s a form of
Others Equipments gynaecological procedure it is associated with
increased incidence of PONV. NSAIDS can
Gas scavenging also be used as a part of multimodal approach
to post operative analgesia. Recently two
• Safe electrical outlets (earthed) methods have been described which curtails
• Adequate lighting (torch with battery backup) repeated anesthesia for subsequent treatments.
Kala, Tanya Elizabeth / Anesthesia for Brachytherapy: A Review 1443
First an indwelling cervical sleeve is inserted the standard of care. For the convenience
under anesthesia which remains in situ to allow of the patient the placement of the implants
subsequent introducation of uterine applicators days the procedure is being carried out under
without exposure to anesthesia. Secondly subcutaneous infiltration and also the pelvic
an osmotic dilator can also be used to dilate floor and prostate apex by infiltration.13 When
the cervix 10-12hrs before the insertion of the the needle tip reaches the prostatic base further
applicator. infiltration is done in the intraprostatictrack.
2. Head and Neck Implants: Patients airway must
be assessed preoperatively during each visit Conclusion
coming for head and neck brachytherapy or
implant placement since they can pose airway The successful anesthetic management of patients
problems due to prior radiation, or surgery scheduled for brachytherapy needs careful,
causing fibrosis of the area. They may also have cautious planning and preparation of equipment
disease related malnutrition and chemotherapy and availability of vital signs monitors in addition
related nausea, vomiting.11 Neck movements to preoperative assessment and optimization
might be restricted and everytime the airway and plan for individualized tailored anesthesia.
has to be examined. Emergency airway crash Adequate intraoperative and postoperative
cart should be kept ready. Patients should analgesia should be given meticulous attention.
be preoxygenated, premedicated, induced Post procedural monitoring also is mandatory for
and endotracheal intubation can be done. the successful outcome.
Some patients might require tracheostomy
preoperatively. Nasogastric tube should be
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Review Article November – December 2020;7(6)
Segmental Spinal: Is It Possible?
Naresh W Paliwal1, Sunil S Lawhale2
Author’s Affiliation: 1Associate Professor, 2Professor and HOD, Department of Anesthesiology, Dr. Panjabrao Deshmukh
Memorial Medical College, Amravati, Maharashtra 444601, India.
Corresponding Author: Sunil S Lawhale, Professor and HOD, Department of Anesthesiology, Dr. Panjabrao Deshmukh
Memorial Medical College, Amravati, Maharashtra 444601, India.
E-mail: tm

Naresh W Paliwal, Sunil S Lawhale. Segmental Spinal: Is It Possible? Indian J Anesth Analg. 2020;7(6):1445–1450.
Abstract
The name Segmental spinal anaesthesia is often widely used synonymously with Thoracic spinal
anaesthesia. But in real sense segmental spinal anaesthesia means “blocking of the required dermatomes
essential for the proposed surgical procedure with very low effective local anaesthetic drug dose “. This
often necessitates dural puncture at high lumber or thoracic levels apart from the conventional spinal.
Segmental spinal anaesthesia has been found to be feasible, safe, and effective alternative to conventional
general anaesthesia in abdominal and some thoracic surgeries. The objective of this special article is to
demonstrate the safety, benefits, risks and utility of this technique as a sole anaesthetic technique or
combined with epidurals.
Keywords: Segmental spinal; Combined segmental spinal epidural; Subarachnoid space; Continuous
segmental spinal anaesthesia.
Introduction demonstrated certain advantages like minimal

haemodynamic fluctuations, minimal motor
Anaesthetic management for patients with weakness, early recovery and voiding.
comorbidities undergoing major surgeries is
challenging, especially in patients with some History
respiratory issues when regional techniques are
a possible option. Neuraxial anaesthesia is one
In 1909 Thomas Jenessco proposed the term general
of the regional techniques that can provide good
spinal anaesthesia for surgeries of head,neck,
surgical fields with added benefits of postoperative
and thorax puncturing the subarachnoid space
analgesia and reduced postoperative pulmonary
complications. Apart from the conventional spinal between first and second thoracic vertebra. He also
anaesthesia done at lower lumber levels, segmental punctured the SAS at mid and lower thoracic levels
spinal performed at mid to lower thoracolumbar for thoracic and abdominal surgeries. It was in 2006,
levels has been found to be very useful for new era of studies on segmental spinal begun when
abdominal and some thoracic procedures. Spinal A Van Zundart gave spinal anaesthesia puncturing
anaesthesia till date is commonly used for lower SAS at T10 for laparoscopic cholecystectomy in a
abdominal surgeries with good effects. But for patient with severe obstructive lung disease.1 Since
upper abdominal surgeries when done under then there have been many studies about segmental
routine spinal anaesthesia requires a high dose spinal exploring its utility in many different surgical
of local anaesthetic drugs, producing great procedures like awake thoracic/ thoracoscopic,
haemodynamic changes and delayed recovery. laparoscopic / open abdominal surgeries, breast
Segmental spinal with low doses of drugs have surgeries etc.
Segmental spinal definition and feasibility the epidural space at lumber region because of the
lumber enlargement. Midline MRI of the spinal
The name segmental spinal anaesthesia is often column shows that the cervical enlargement of the
spinal cord fills almost the entire spinal canal at
widely used synonymously with thoracic spinal
that level. In the thoracic segments the spinal cord
anaesthesia. But in real sense segmental spinal
is positioned anteriorly leaving a significant space
anaesthesia means “blocking of the required
between the posterior dura and the spinal cord.
dermatomes essential for the proposed surgical
(Fig 1 and 4) At the lumber level the later space
procedure with very low effective local anaesthetic
disappears completely.
drug dose “. This often necessitates dural puncture
at high lumber or thoracic levels apart from the
conventional spinal anaesthesia at regular spaces. Major issues and queries related to segmental spinal
Lower the volume/dose of drug used, more likely
it to produce true segmental block. Is it possible? 1. Neurological injuries with dura punctured at
YES, practically all the abdominal surgeries be it an thoracic level: As mentioned above there are
upper abdominal or lower abdominal, laparoscopic many studies performed using myelography
or open, major or minor,day-care or not, all are and MRI which shows that at thoracic levels
possible with segmental spinal alone or combined the spinal cord lies more anteriorly leaving
with epidural (CSSE) anaesthesia. If that’s not all a sufficient space between posterior dura
then the option of continuous segmental spinal and the spinal cord. A possible anatomical
anaesthesia (CSSA) is also possible. In short explanation for the absence of spinal cord
“Subarachnoid block can be tamed according to lesion during accidental perforation of thoracic
need with the use of different drugs and techniques.2 dura mater was proposed by Imbelloni and
Gouveia through a study using MRI , which
showed following measurements - 5.19mm at
Important anatomical aspects
T2 , 7.75mm at T5 and 5.88mm at T10 vertebral
levels.3 (Fig. 2) A space sufficiently large to
Understanding of the anatomy of spinal canal is the allow the entrance of a needle during accidental
key to successful introduction of spinal medications perforation of dura ( a hazard - as we are not
at thoracic vertebral levels. There is a natural ready for it ) or intentional puncture of dura (
thoracic kyphosis at T7,6,5 levels. Amount of CSF lower risk , as we are ready for it ) with a fine
at thoracic levels is diminished as compared to needle. This distance is found to be more in all
lumber and cervical levels. Thoracic nerve roots are positions, more so in lateral and sitting positions,
slight and thin as compared to segments above and in which the patients are usually placed for
below. Thus there is less anaesthetic dilution per giving spinal anaesthesia. (Fig. 3) The angle
segmental unit of distance from the site of injection required to perform spinal anaesthesia at mid
and the roots are easily blocked due to their small thoracic levels, further increases the distance
size. Both factors producing efficient blockade of between posterior dura and spinal cord. It is
thoracic segments. Many studies performed using nearly double (8mm at mid thoracic level and
myelography shows that the thoracic cord lies 4.5 mm at thoracic-lumber level) at the mid
anteriorly in the theca, while the lumber spinal thoracic levels compared to levels below. (Fig.
cord is situated more dorsally. The space between 5 and 6) These are the possible explanations for
the dura mater and the mid to lower thoracic spinal the very low rate of neurological injuries after
cord on its width is actually greater than that of thoracic epidurals.
Fig. 1: Mid-line MRI of the spinal column. The cervical enlargement fills almost the entire spinal canal at the
level. In the thoracic segments, the spinal cord is positioned anteriorly leaving a significant space between the
posterior dura and the spinal cord. At the lumbar level the latter space disappears almost completely.

Naresh W Paliwal, Sunil S Lawhale / Segmental Spinal: Is It Possible? 1447
2. Respiratory embarrassment due to extensive

thoracic nerve blockade: The main inspiratory
muscle of respiration is diaphragm, which is
unaffected and expiration at rest is a passive
process. However forceful expiration and
coughing may get affected because of paralysis
of anterior abdominal wall muscles. However,
the low dose of drugs used for segmental
spinal preserves the coughing ability by
causing minimal motor weakness of expiratory
accessory muscles4.
3. Cardio-accelerator fibres T1 to 4 getting blocked,
causing bradycardia and hypotension: Heart Fig. 4: Diagrammatic representation spinal cord level at different
rate may decrease with high neuraxial blocks spine levels.
as a result of blockade of cardio-accelerator
fibres arising from T1 to T4. But as the right
atrial filling is maintained due to lumbosacral
sparing and less veno-dilatation in lower
limbs, that sustains the outflow from intrinsic
chronotropic stretch receptors located in the
right atrium and great veins. There is also less
hypotension because of low dose of drugs used
and less venodilatation in lower limbs.5
Fig. 5: MRI showing increased distance required to reach at

spinal cord and dura at mid thoracic levels.
Fig 2: Distances measured at different thoracic level.
Fig. 6: Angle required at mid thoracic level further increases the

distance between posterior dura and spinal cord.
Segmental spinal - indications, drugs, technique,

advantages and disadvantages
1. Indications: Till date segmental spinal was used

mainly in patients with multiple co-morbidities
for gall bladder surgeries either laparoscopic or
open method. But it can be a useful technique
in many thoracic and practically all the intra-
abdominal surgeries. Reports of its successful
Fig. 3: Distances measured in different positions- supine, lateral, use in awake thoracoscopic surgeries
and sitting.
(Thymectomy, lung volume reduction surgeries thoracic levels (7.5mg) as compared to doses at
and wedge resections) and breast surgeries is lumber levels (15mg).7
available. All the intra-abdominalsurgeries, be 3. Technique and doses: Depending on the type and
it upper abdominal or lower abdominal, open site of surgery, co morbidities of the patient,
or laparoscopic, major or minor, day care or whether combined with epidural or not, the
not, all are possible under segmental spinal dose of local anaesthetic agent and the site of
alone or combined with epidurals (CSSE). injection along the neuraxis can be varied. Tenth
Segmental spinal has certain advantages when thoracic intervertebral space being chosen
used in breast cancer surgeries, recurrence rate as lying in the centre of the surgical field for
is diminished as compared to when done under upper abdominal surgeries. For all abdominal
general anaesthesia.6 Patients chosen for this surgeries with adequate dose, thoracic spinal
technique need to be evaluated carefully and above T10 is hardly required. Space between
should be avoided in patients with coagulation T10 and L1 is usually sufficient for all abdominal
disorders and infection at the site of injection. surgeries. On and average a dose of 7.5 to 10mg
2. Drugs: Amongst the available drugs, isobaric of bupivacaine (either isobaric or hyperbaric)
drugs like Levobupivacaine, Ropivacaine, with some additive like fentanyl/clonidine/
or Chlorprocaine can be used for segmental dexmedetomidine works well for 90 to 120mins.
spinals. Hyperbaric bupivacaine can also be This is exactly half the dose required when spinal
used with good effects. Isobaric drugs are given at lumber levels.8
usually preferred as they are less sensitive
to position issues and when used in low Rough estimate of procedure specific dose and site of
doses, they have propensity to block sensory injection
nerves in preference to motor ones (labelled
as Selective A.) This tends to preserve the
muscle tone and power in the legs. Addition 1. For superficial chest wall procedures (breast
of small doses of fentanyl 25mcg, or clonidine surgeries etc.) or thoracoscopies, spinal needs
30mcg, or dexmedetomidine 10mcg causes to be at mid thoracic levels at T5/6/7 with
increased intensity of sensory blockade. Other isobaric levobupivacaine (preferred) in a
advantages of isobaric drugs are onset is dose range of 1 to 1.5 ml (max) with additive,
gradual, haemodynamic stability even with giving a duration of effects 60 to 70 mins. For
high levels of block, motor block time is shorter prolonged procedures it needs to be combined
leading to early ambulation and voiding. There with epidural rather than increasing the dose to
is no difference for time to onset at thoracic avoid side effects.
levels with isobaric and hyperbaric drugs,
2. For intra-abdominal surgeries spinal at T10
while isobaric drugs take little time for onset at to L1 (for upper abdominal and laparoscopic
lumber levels. -Chlorprocaine 1% is very short surgeries upper space, for lower abdominal
acting, useful for short duration (40 to 60 mins) and open surgeries lower space) with a dose
open or laparoscopic surgeries when used in of 10mg in females and 12.5mg in males with
the dose range of 3.5 to 5 ml. -Ropivacaine 0.75 additives is sufficient.
% and levobupivacaine 0.5 % are comparable,
but for intrathecal use ropivacaine in nearly
Positioning of patient for giving segmental spinal
half as potent as levobupivacaine because
of less lipid solubility. -Levobupivacaine 0.5
% being nearly isobaric, it is less sensitive to While using isobaric drugs for segmental spinal
position issues. Low dose technique blocks initial position of the patient for giving spinal does
sensory nerves in preference to motor ones not matter. Either sitting or lateral position (even
(selective). -Bupivacaine 0.5 % heavy - thoracic prone if necessary) can be used. When combined
segmental spinal anaesthesia can be produced with epidurals spinal can be given before placement
with just half the dose that is used in the lumber of epidural catheter. But if hyperbaric drugs are
region and onset time is reduced to reach the used for segmental spinal then lateral decubitus
T3 levels. Study of 140 patients by Imbelloni position with slight head low tilt (10 to 15 degrees)
et al,8 showed the values for time to reach T3 is better to avoid sacral pulling of drugs and
levels, duration of motor and sensory block inadequate levels with low dose of drug used. Also
and hypotensive events were significantly the epidural needs to be placed before the spinal to
lower with low dose hyperbaric bupivacaine at avoid unilateral effects.9

Naresh W Paliwal, Sunil S Lawhale / Segmental Spinal: Is It Possible? 1449
Type of spinal needle used modified by any change of position - - drugs need
to be placed at precise dermatomes required to be
If combined with epidural, then CSE kit is the safest blocked for proposed surgical procedure - - slightly
way to give segmental spinal. Either a quinke or less muscle relaxation, may need higher doses in
pencil point needle both can be used. In a study male muscular patients. - - sacral sparing is common
of 300 patients for giving lower thoracic spinals with low doses used at higher spaces, needs to be
using either cutting needle or pencil point needle, considered for pelvic manipulations - - time limit as
the incidence of paraesthesia and neurological with any low dose spinal technique
complications afterwards were evaluated by
Imbelloni et al.6 Paresthesia occurred in twenty Conclusion
patients, seven patients experienced paresthesia
with cut needle compared to thirteen patients with Low dose segmental spinal is associated with
pencil point. All paraesthesias were transient and remarkable cardiovascular stability. It is a useful
no neurological complications were observed. alternative in select patients for various thoracic
Procedure. and abdominal surgeries. Patients with multiple
After giving spinal with the preferred needle and comorbidities, cardiac and respiratory disease may
required dose the patient can be turned to supine be considered for day care surgeries. Advantages
position. For lateral position surgeries patient demonstrated are minimal haemodynamic
can be kept in same position if isobaric drugs are fluctuations, minimal motor block, faster sensory
used for spinal in lateral position with operative recovery, early ambulation and voiding. Above
side up. If hyperbaric drugs are used, then the all postoperative pulmonary complications are
tilt of the table can be adjusted according to level avoided.
achieved and desired. Using isobaric drugs patient
can be positioned to operative position once the Remarks
desired sensory level is set in, without worrying
for position dependant spread. Sensory block
usually sets in two to three minutes (tested by Patient safety takes precedence over the unnecessary
pin prick). Complete effects can be seen in five to risks to be taken for success of the procedure. This
seven minutes. With spinal given at thoracic levels, technique is reserved for experienced clinicians
minor and transient degrees of lower limb motor working in defined and approved evaluation
block is more likely to have been due to minimal programmes. Fact that anaesthetic technique is not
physical spread of some drug to lumbosacral roots. usual does not mean that it is wrong.
Whatever little haemodynamic fluctuations that Conflict Of interest: None
occur with low dose segmental spinal, they occur
within first ten minutes depending on the dose
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Subject Index
Title Page No
A Clinical Comparative Study of Dexmedetomidine and Buprenorphine as an Adjuvant to 0.5%

Bupivacaine for Ultrasound Guided Supraclavicular Brachial Plexus Block 903
A Clinical Study on Correlation of Ultrasonographic Measurement of Caval Index with

Central Venous Pressure 21

Paediatric I-Gel, Proseal LMA Vs Endotracheal Tube 1359
A Comparative Evaluation of the Characteristics of Recovery from Anesthesia

with Isoflurane and Halothane in Day-Care Surgery 889
A Comparative Study Between Bupivacaine and Ropivacaine Block in Paediatric

Age Group (0 To 8 Years) in Unilateral Unilateral Groin Surgeries 659
A Comparative Study between Thiopental Sodium and Etomidate on Hemodynamic

Response in Adult Treated Hypertensives Scheduled for Elective Surgery 143
A Comparative Study of 0.1% Ropivacaine with Fentanyl and 0.1% Bupivacaine with Fentanyl
for Epidural Labor Analgesia 41
A Comparative Study of 0.5% Levobupivacaine and 0.5% Bupivacaine in Spinal Anaesthesia

in Geriatric Patients Undergoing Lower Limb Surgeries 303
A Comparative Study of Attenuation of Hemodynamic Responses to Laryngoscopy

and Intubation with and without Oral Clonidine 15
A Comparative Study of Efficacy of Dexmedetomidine and Fentanyl As an Adjuvant

to Inrathecal Bupivacaine for Lower Limb and Lower Abdominal Surgeries 625
A Comparative Study of Fentanyl and Clonidine as an Adjuvant to Bupivacaine

for Spinal Anesthesia 155
A Comparative Study of Injection 0.5% Bupivacaine and Injection 0.75% Ropivacaine for
Their Duration of Anesthesia/Analgesia in Transversus Abdominis Plane Block
for Unilateral Inguinal Hernia Repair under Ultrasound Guidance 525
A Comparative Study of Intrathecal Clonidine with Hyperbaric Bupivacaine Administered

As A Mixture and Sequentially in Cesarean Section 606
A Comparative Study of Intravenous Dexmedetomidine Versus Intrathecal

Dexmedetomidine with Heavy Bupivacaine in Spinal Anaestheia 764
A Comparative Study of Intravenous Paracetamol Versus Intramuscular Diclofenac

For postoperative Pain Relief in Tonsillectomy Patients 1121
A Comparative Study of Laryngoscopic View and Intubation Response using Macintosh,

McCoy and AirTraq Laryngoscopes in Adults Undergoing Elective Surgeries 1011

A Comparative Study of Mixture of Clonidine - Fentanyl Compared to Clonidine Alone

as an Adjuvant to Intrathecal Hyperbaric Bupivacaine Under Spinal Anaesthesia for
Infraumbilical Surgeries 791
A Comparative Study of Neuromuscular Blocking Effects and Reversibility of

Cisatracurium and Vecuronium 58
A Comparative Study of Oral Clonidine and Intravenousesmolol for Attenuation of

Pressor Response During Laryngoscopy and Endotracheal Intubation 1155
A Comparative Study of The Anesthetic Potencies and Hemodynamic Changes of 0.5% Isobaric
Levobupivacaine and 0.5% Hyperbaric Racemic Bupivacaine for Spinal Anesthesia
in Lower Abdominal and Lower Limb Surgeries 1431
A Comparative Study of the Effects of Intravenous Esmolol and Sublingual Nitroglycerine

Spray on Hemodynamic Response Following Tracheal Extubation 473
A Comparative Study of the Efficacy of Dexmedetomidine and Clonidine as an Adjuvant to

Bupivacaine in Supraclavicular Brachial Plexus Block 562
A Comparative Study of Tramadol vs Butorphanol as An Adjuvant with Local Anaesthetic in

Supraclavicular Brachial Plexus Block in Upper Limb Surgeries 1283
A Comparative Study of Two Different Doses of Fentanyl 2mcg/kg and 4 mcg/kg in Attenuating
the Hemodynamic Stress Response During Laryngoscopy and Endotracheal Intubation 375
A Comparative Study on Efficacy of Intravenous Fentanyl Vs Ultrasonography (USG) Guided Fascia

Iliaca Compartment Block Prior to Subarachnoid Block in Patients Undergoing
Fracture Femur Surgeries 506
A Comparative Study on Ultrasound- Guided Supraclavicular Brachial Plexus Block Vs

Ultrasound Guided Nerve Stimulated Supraclavicular Brachial Plexus Block 400
A Comparative Study to Evaluate the Efficacy of Intravenous Dexmedetomidine versus Clonidine

for Post Spinal Anaesthesia Shivering in Caesarean Section 1309
A Comparison of Effect of Dexmedetomidine and Esmolol For Attenuation of

Haemodynamic Stress Response During Direct Laryngoscopy and Tracheal Intubation 1179
A Comparitive Evaluation of Propofol, Sevoflurane and Desflurane for Neuroanaesthesia in

Patients Undergoing Elective Supratentorial Craniotomies 1365
A Correlation of Preoperative Ultrasound Parameter to Cormack-lehane Classification in

Predicting Difficult Laryngoscopy 9
A Descriptive Study to Assess the Awareness and Acceptance of Labor Analgesia in

Pregnant Women Admitted for Safe Confinement 511
A Prospective Observational Study on Ultrasonographic Measurement of Optic Nerve Sheath

Diameter as a Bedside Tool in Detecting Findings of Increased Intracranial Pressure
in Neuro Critical Care Patients 99

1453
A Prospective Study of the Impact of Hot Climate on Polytrauma Patients 934
A Prospective, Randomized, Double-blinded Control Study on Comparison of Oral Midazolam

and Dexmedetomidine as Premedication in Children 441
A Randomized Controlled Study of The Efficacy of Addition of Clonidine to Bupivacaine as

Compared with Bupivacaine Alone used in Supracalvicular Brachial
Plexus Block for Upper Limb Surgeries 1107
A Randomized Double Blinded Comparative Study on Efficacy of Intraoperative

Dexmedetomedine versus Tramadol Intravenous Infusion in Prevention of
Postoperative Shivering Following Spinal Anaesthesia 1331
A Randomized Prospective Study to Compare Use of I-Geltm and Lma Prosealtm in

Patients undergoing Laparoscopic Cholecystectomy 1351
A study of efficacy and safety of Ropivacaine (0.5%) versus Levobupivacaine (0.5%) in

cervical epidural anaesthesia for upper limb surgery 780
A Study of Haemodynamic and Pharmacodynamic Effects of Cis-Atracurium and

Vecuronium in Patients Undergoing Laparoscopic 829
A Study on Complications of Magnesium Sulphate as an Adjunct to Ropivacaine

Versus Plain Ropivacaine in Local Subcutaneous Infiltration for Postoperative Analgesia 1391
A Study on Hemodynamic Changes in Dexamethasone 0.1 mg/kg When Combined with

0.15% Ropivacaine for Caudal Analgesia in Children 1319
A Study on Hemodynamic Response During Induction with Etomidate, Propofol or

Combination of Etomidate and Propofol in General Anaesthesia 368
A Study on the Effect of Lateral and Sitting Positions in Spinal Anesthesia for Cesarean Sections 33
A Survey of Intubation of Covid-19 Patients in The Critical Care Units to Assess Adherence to
Guidelines and Critical Events Encountered 1273
Absent Gastric Bubble: It’s Implications on Intra and Post-op Recovery in CABG Patients 1315
Addition of Dexamethasone to Bupivacaine for Brachial Plexus Block in Patients

Undergoing Upper Limb Surgeries 87
Adductor Canal Block: A Prospective Case Series Report in Unilateral Total Knee Arthroplasty 963
Adenosine as Perioperative Analgesia as an Adjuvent:A Comparative Study 1069
An Observational Study to Compare Supraglottic Airway Device I-Gel with

Classic LMA for Short Surgical Procedures 230
An Observational Study to Compare the Effects of Cisatracurium Verses Atracurium

During General Anaesthesia in Patients Posted for PCNL (Percutaneous Nephrolithotomy) 842

An Observational Study to Compare the Efficacy of Oral and Intranasal Midazolam

as Premedication in Children 743
Analgesic Efficacy of Addition of Clonidine to Bupivacaine in Transversus Abdominis

Plane Block for Postoperative Analgesia in Laparoscopic Appendicectomy 1209
Analysis of Delayed Extubation among Surgical Patients:A One-year

Prospective Observational Study 93
Anesthesia for Brachytherapy: A Review 1439
Anesthetic Management of a Rare Case of Primary Sjogren’s Syndrome for a Gynecological Surgery 191
Anesthetic Management of Severe Mitral Stenosis with Left Atrial Clot in a Known
Case of Hypothyroidism with Undetected Obstructive Sleep Apnoea Posted for
Mitral Valve Replacement 183
Antiemetic Efficacy of Dexamethasone in Prevention of Postoperative Nausea and Vomiting

after Laparoscopic Surgery 908
Axillary Approach Versus Infraclavicular Approach In Ultrasound-Guided

Brachial Plexus Block: A Comparative Study 720
Caudal Epidural Block for Transurethral Resection of Prostate in Patients with Comorbidities:
An Observational Study 1299
Changes in Hemodynamic Parameters in Patients Undergoing TURP and TURBT

Due to Additive Intrathecal Clonidine 1004
Clinical Study of Epidural Nalbuphine vs Tramadol for Postoperative Pain Relief in

Lower Limb Orthopedic Surgeries 578
Coccygodynia after Caudal Epidural Steroid Injection: A Case Report 1217
Comparative Assessment of Bupivacaine and Levobupivacaine in Elective Cesarian Section Cases 1427
Comparative Effect of Etomidate and Thiopentone on the Heart Rate and

Respiratory Rate for Induction of General Anaesthesia 1075
Comparative Effects of Supraclavicular Perivascular and Infraclavicular

Brachial Plexus Block for Upper Limb Surgeries 298
Comparative Evaluation of Clonidine and Nalbuphine for Control of

Post-Spinal Anaesthesia Shivering 235
Comparative Evaluation of Dexmedetomidine and Fentanyl as Adjuvants to

Ropivacaine for Epidural Anesthesia in Lower Limb Orthopaedic Surgeries 1019
Comparative Evaluation of Efficacy and Safety of Intravenous Propofol and Dexmedetomidine

for Intraoperative Sedation during Subarachnoid block: A Prospective Study 209

1455
Comparative Evaluation of Intrathecal Administration of Preservative free

Levobupivacaine Alone and with Clonidine in Different Doses in
Patients Undergoing Infraumbilical Surgeries 867
Comparative Evaluation of Ropivacaine and Ropivacaine with Dexamethasone in

Ultrasound Guided Brachial Plexus BlocK 816
Comparative Study of Dexmedetomidine and Clonidine as Adjuvants to Isobaric

Ropivacaine 0.75% for Epidural Anesthesia in Infraumbilical Surgeries 248
Comparative Study of Epidural Fentanyl versus Epidural Dexmedetomidine as

Adjuvants to Ropivacaine for Post Operative Analgesia 1203
Comparative Study of Granisetron and Ondansetron for the Prevention of

Post Operative Nausea and Vomiting in Patients Undergoing Total
Abdominal Hysterectomy Under General Anaesthesia 341
Comparative Study of Intravenous Dexmedetomidine (0.5 Microgram/Kg) Vs Intravenous

Midazolam (0.05 Mg/Kg) as Premedicant in Spinal Anesthesia with 0.5%
Bupivacaine for Gynecological Surgeries 540
Comparative Study of Isobaric Ropivacaine (0.75%) and Isobaric Ropivacaine(0.75%) with

Adjuvants Clonidine and Dexmedetomidine Administered Intrathecally in
Adult Patients Undergoing Lower Limb Surgeries 930
Comparative Study of Magnesium Sulphate Nebulization and Lignocaine Nebulization in

Prevention of Postoperative Sore Throat 114
Comparative Study of Nalbuphine and Fentanyl for Total Intravenous Anaesthesia

in Short Surgical Procedures 347
Comparative Study of Oral Clonidine, IV Fentanyl and IV Butorphanol in Attenuation of

Hemodynamic Stress Response to Laryngoscopy and Endotracheal Intubation 1343
Comparative Study of Preprocedural Anxiety in Patients Undergoing Interventional

Pain Management in Prone Position Under Monitored Anesthesia Care:
First Timer vs Experienced 948
Comparative Study of the Effect of Adding Dexmedetomidine versus Fentanyl to

Intrathecal Bupivacaine on Spinal Block Characteristics in Endo-Urological Procedures 671
Comparative Study of Three Techniques of Proseal Laryngeal Mask Airway (PLMA)

Insertion In Patients Undergoing Elective Surgeries 414
Comparative Study of Transdermal Patch of Fentanyl with that of Buprenorphine for

Postoperative Pain Management in Postthoracotomy Surgery Patients 459
Comparative Study of Two Different Doses of Fentanyl Citrate 2 mcg/kg and 4 mcg/kg in
Attenuation of Hemodynamic Responses During Intubation 174

Comparative Study of Ultrasound Guided PENG [Pericapsular Nerve Group] Block and FIB [Fascia
Iliaca Block] for Positioning and Postoperative Analgesia Prior to Spinal Anaesthesia
for Hip Surgeries: Prospective Randomized Comparative Clinical Study 798
Comparative Study to Evaluate Intravenous Dexmedetomidine as Bolus Versus Infusion with

Spinal Anaesthesia for Infra-Umbilical Surgeries 1149
Comparative Study to Evaluate the Efficacy of Intrathecal Clonidine Versus Clonidine with
Fentanyl in Laparoscopic Surgeries Under General Anaesthesia 354
Comparing ABG Analysis and Hemodynamics in Patients Undergoing Laparoscopic

Cholecystectomy with Either ProSeal Laryngeal Mask Airway or Cuffed Endotracheal
Tube as Airway Conduit: A Randomized Trial 554
Comparing Effect of 0.25% Bupivacaine and 0.5% Ropivacaine in Transversus

Abdominis Plane Block for Postoperative Analgesia in Lower Abdominal Surgeries 79
Comparing Macintosh, Miller and Truview Laryngoscopes for Evaluation of

Intubation Difficulty in Patients with Immobilized Cervical Spine 1265
Comparision of Dexmedetomidine and Fentanyl as Adjuvants to Hyperbaric Bupivacaine

0.5% in Gynacological Surgery 1028
Comparision of Dexmedetomidine Versus Clonidine as Anadjuvant To 0.5% Ropivacaine in

Supraclavicular Brachial Plexus Block: A Randomized Double Blind Prospective Study 808
Comparision of Effects of Fentanyl and Intravenous Paracetamol on Consumption of Sevoflurane 726
Comparison between Conventional Technique and Ultrasound Guided

Supraclavicular Brachial Plexus Block in Upper Limb Surgeries 267
Comparison between Dexmedetomidine and Midazolam for Postoperative Analgesia and

Sedation in Mechanically Ventilated Patients 547
Comparison of Baska Mask with I-GEL for Insertion Success Rate and Working Performance
in Laparoscopic Pelvic Surgery 584
Comparison of Bolus Phenylephrine, Ephedrine and Mephentermine for the Management

of Hypotension During Spinal Anaesthesia in Caesarean Section: A Clinical Study 361
Comparison of Caudal Block Using Ropivacaine with Clonidine and Ropivacaine with
Fentanyl for Post Operative Analgesia 241
Comparison of Clinical Performance of I-Gel With Proseal Laryngeal Mask Airway

in Surgical Procedures 787
Comparison of Conventional Central Venous Pressure with Peripheral Venous Pressure and
External Jugular Venous Pressure in Patients with Sepsis 979
Comparison of Conventional Dose versus Low-dose Infusion of Dexmedetomidine on

Hemodynamic Stress Response: A Prospective Institutional Based Study 621

1457
Comparison of Dexamethasone and Magnesium Sulphate with Plain Bupivacaine in Pectoral

Nerve Block for Postoperative Analgesia: A Randomised Double Blind Controlled Trial 774
Comparison of Dexmedetomidine as an Adjuvant to Levobupivacaine Versus

Levobupivacaine (Plain) in Supraclavicular Brachial Plexus Block: A Clinical Study 46
Comparison of Dexmedetomidine Propofol with Fentanyl Propofol for Laryngeal

Mask Airway Insertion in General Anesthesia Patients Undergoing Elective Surgeries 895
Comparison of Effects of Oral Ivabradine and Oral Clonidine as Premedicants on

Intraocular Pressure Changes Following Intubation with Succinylcholine 291
Comparison of Efficacy of Dexamethasone and Clonidine as an Adjuvant in Supraclavicular

Brachial Plexus Block Using 0.5% Bupivacaine in Upper Limb Surgeries 986
Comparison of Esmolol and Lidocaine for Attenuating Cardiovascular Stress Response to

Direct Laryngoscopy and Endotracheal Intubation 319
Comparison of Granisetron and Ondansetron on the Spinal Anesthesia Induced Hypotension,

Bradycardia and Fetal Outcome after Administration Intrathecal Hyperbaric
Bupivacaine in Patients Undergoing Cesarean Sections 137
Comparison of Hemodynamic Response in Direct and Video Laryngoscopy

in Hypertensive Patients 879
Comparison of Hemodynamic Response to Laryngoscopy and Tracheal Intubation in

Hypertensive Patients Using Macintosh, McCOY and Truview Video Laryngoscope:
A Clinical Study 750
Comparison of Insertion Techniques of Classical Laryngeal Mask Airway Regarding Ease of

Insertion and Complications 257
Comparison of Intrathecal 0.75% Ropivacaine-Fentanyl and 0.5% Bupivacaine-Fentanyl in Equipotent

Doses for Lower Abdominal and Lower Limb Surgeries Under Spinal Anesthesia 912
Comparison of Intravenous Lignocaine and Dexmedetomidine for Attenuation of

Hemodynamic Stress Response to Laryngoscopy and Endotracheal Intubation 873
Comparison of Ondansetron 4mg, Dexamethasone 8mg and Ondansetron 4 mg with

Dexamethasone 8mg in Preventing Nausea and Vomiting Post-Laparoscopic Cholecystectomy 1423
Comparison of Post Operative Sedation between Ultrasound Guided TAP Block with
the Standard Post-Operative Analgesic Regimen 1395
Comparison of Postoperative Analgesia by Intraperitoneal Infiltration of Bupivacaine versus

Bupivacaine with Dexmedetomidine in Laparoscopic Surgeries 482
Comparison of Ramosetron and Dexamethasone for Prophylaxis of Postoperative Nausea and

Vomiting in Patients Undergoing Middle Ear Surgeries 500
Comparison of Ropivacaine with MgSO4 versus Ropivacaine with Dexmeditomidine as Adjuvants

in Ultrasound-guided Supraclavicular Brachial Plexus Block in Upper Limb Surgeries 465
Comparison of Subclavian Vein Catheterization Using Supraclavicular Versus

Infraclavicular Approach with Ultrasound 279
Comparison of the Characteristics and Hemodynamic Effects of Infraclavicular Subclavian Central

Venous Catheterisation Done under Spontaneous Respiration versus Mechanical Ventilation 1193
Comparison of the Efficacy of Neuraxial Blockade Analgesic Effect between Intrathecal Clonidine
and Tramadol as An Adjuvant with 0.5% Bupivacaine 215
Comparison of the Upper Lip Bite Test (ULBT) with the Ratio of Height to Thyromental Distance
(RHTMD) for the Prediction of Difficult Laryngoscopy in Apparently Normal Patients 488
Comparison of Vasopressor Effects of Phenylephrine and Mephenteramine during Spinal

Anaesthesia for Ceasarian Section 804
Comparison of Volume Controlled Ventilation with Pressure Controlled Ventilation During

Lumbar Spine Surgery in Prone Position: A Randomized Controlled Study 70
Comparitive Evaluation of Crystalloid Preload and Crystalloid Coload on Hemodynamic

Parameters in Patients Undergoing Elective Cesarean Section under Spinal Anesthesia 449
Comparitive Evaluation of Dexamtheasone and Tramadol as An Adjuvant to 0.5% Ropivacaine

in Supraclavicular Brachial Plexus Block 223
Comparitive Study of Epidural Fentanyl and Bupivacaine with Epidural Clonidine and Bupivacaine for
Postoperative Pain Relief in Lower Abdominal and Lower Limb Surgeries: RCT 1323
Correlation between Interspinous Gap and the Ease of Spinal Anaesthesia: A Prospective
Observational Study 824
COVID 19 Severe Acute Respiratory tract infection and Pneumonia: Recommendations for Oxygen
Therapy in a Resource Limited setting 1050
Crystalloid Preload Vs Crystalloid Coloadfor the Prevention of Hypotension

During Spinal Anesthesia 106

Laparoscopic Cholecystectomy Cases 1305
Easy Method of Ryles Tube Insertion in Laparoscopic Surgeries under General Anesthesia:
A Simple, Non fussy and Practical Approach 64
Effect of Intraoperative Esmolol Infusion on Haemodynamics and Surgical Field in

Fess Under General Anaesthesia 1291
Effect of intrathecal Clonidine on subarachnoid Block Characteristics in

Patients Undergoing TURP and TURBT 835
Effect of Nalbuphine as Adjuvant to Bupivacaine for Ultrasound-Guided Popliteal Nerve Block:

A Prospective Randomised Comparative Clinical Study 664
Effect of Platelet Rich Plasma in Knee Osteoarthritis 969

1459
Effect of Preoperative Information on Perioperative Anxiety of the Patients Posted for

Elective Surgery: A Prospective Randomized Comparative Study 28
Effect of Spectral Entropy on the Requirement of Propofol During Induction of Anesthesia 1089
Effectiveness of 5% Lidocaine Patch in Post Mastectomy Cancer Pain –

A Randomized Controlled Trial 1187
Effectiveness of Usg Guided Axillary Ring Block in Reducing Tourniquet Pain in Patients
Undergoing Upper Extremity Surgery With Supraclavicular Brachial Plexus Block 1125
Effects of Adding Tramadol and Nalbuphine with Ropivacaine among Patients

Undergoing Upper Limb Orthopedic Surgeries in A Tertiary Care Hospital 601
Effects of Clonidine Versus Dexmedetomidine with Intrathecal Hyperbaric 0.5% Bupivacaine in

Patients Posted for Elective Lower Abdominal Surgeries 389
Effects of Magnesium Sulphate on Hemodynamic Response to Carbondioxide Pneumoperitoneum

in Patients undergoing Laparoscopic Appendicectomy 1405
Efficacy of Addition of Low Dose Oral Ketamine to Oral Midazolam Results in

Better Premedication Than Either Drugs Given Alone in Children 284
Efficacy of Dexamethasone 0.1mg/Kg when Combined with 0.15% Ropivacaine for

Caudal Analgesia in Children undergoing Infraumbilical Surgeries 1417
Efficacy of Dexmedetomidine in Supraclavicular Brachial Plexus Block with 0.5%

Ropivacaine hydrochloride 923
Efficacy of Intramuscular Ephedrine in Reducing the Incidence of Hypotension

After Spinal Anaesthesia 757
Efficacy of Magnesium Sulphate as an Adjunct to Ropivacaine in Local Subcutaneous Infiltration

for Postoperative Analgesia Following Lower Segmental Ceasfrean Section in
Parturents under Spinal Anesthesia 1401
Efficacy of Propofol-ketamine Over Propofol-butorphanol in Surgical Procedures

less than 60 Minutes 613
Efficacy of Seal of Proseal Laryngeal Mask Airway by Using Digital Insertion and
Bougie Guided Insertion Techniques 164
Efficacy of Tramadol and Butorphanol As Postoperative Rescue Analgesia: A Comparative Study 629
Efficacy of Ultrasound Guided TAP Block with The Standard Post-Operative

Analgesic Regimen, In Providing Post-Operative Analgesia for Patients Undergoing
Total Abdominal Hysterectomies 1373
Efficacy of Varying Doses of Dexamethasone with Lignocaine in Supraclavicular

Brachial Plexus Block in Upper Limb Surgeries 1381

Elastomeric Infusion Pump: Evaluation of Different Infusion Rates for

Postoperative Epidural Analgesia 124
Evaluation of Airway Blocks Vs General Anesthesia for Diagnostic Direct Laryngoscopy

and Biopsy for Carcinoma Larynx: A Comparative Study 593
Evaluation of Clonidine as an Additive to Bupivacaine for Central Neuraxial Blockade 311
Evaluation of Effect of Adding Dextrose to Levobupivacaine, Compared to Levobupivacaine

Plain in Subarachnoid Block for Lower Limb and Lower Abdominal Surgeries 999
Evaluation of Effectivenss of Intrathecal Bupivacaine with Adjuant Fentanyl and Clonidine

in Patient Undergoing Lower Segment Caesarean Section: A Randomised Control Trial 1036
Evaluation of Efficacy of Fentanyl as an Adjuvant to 1% 2-Chloroprocaine for

Subarachnoid Block in Ambulatory Surgery: A Prospective Study 1113
Evaluation of Predictors for Difficult Laryngoscopy and Intubation in Pediatric Population 918
Evaluation Safety and Efficacy of Chloroprocaine V/S Chloroprocaine with 20μg Fentanyl in
Subarachnoid Block in Participants Undergoing Lower Limb Ambulatory Surgery 739
Extra Pleural Pneumonectomy: Perioperative Anaesthetic Management in

Spindle Cell Sarcoma Patient – A Case Report 1221
Functional Outcome of Open Inguinal Hernia Repair: Nerve Block Versus Spinal 1139
General Anaesthesia Versus Paravertebral Anaesthesia with General Anesthesia in Mastectomy:

Comparative Surgical Outcome 1095
Haemodynamic Response To Fiberoptic Nasotracheal Intubation Under General Anaesthesia 697
Hemodynamic Stability of Dexmedetomidine in Laparoscopic Cholecystectomy Cases 1295
Incidence of Sore Throat with Endotracheal Intubation Using Mcintosh

Blade Versus Video Laryngoscope 53
Intravenous Dexamethasone as Adjuvant to Axillary Brachial Plexus Blockade for

Forearm Orthopedic Surgeries: A Randomized Controlled Trial 734
Intravenous Dexmedetomidine 0.6μg/kg and 1μg/kg for Attenuation of the Haemodynamic

Response to Laryngoscopy and Intubation: A Clinical Study 688
Intravenous Versus Epidural Dexmeditomidine: Comparison of Effect on Prolongation of

Analgesia after Subarachnoid Block with Bupivacaine in lower limb Surgery 957
Levobupivacaine vs Ropivacaine in Spinal Anesthesia for Lower Abdominal and

Lower Limb Surgeries: A Comparative Study 1411
Missing Epidural Catheter Fragment: Case Report and Review of Literature 1225

1461
Perioperative Positioning Concerns and Airway Management in Pediatric

Meningomyelocele Surgery: A Novel Innovation 636
Peripheral Nerve Stimulator for Obturator Nerve Block during Transurethral Resection of
Bladder Tumor Following Spinal Anesthesia: Initial Experience 1161
Postoperative Analgesia in Tympanomastoid Surgery with Great Auricular Nerve Block 408
Predictors of Difficult Airway Intubation A Prospective Observational Study of 202

Patients Undergoing General Anesthesia 515
Pretreatment with Three Different Doses of Lignocaine to Prevent Etomidate Induced Myoclonus 272
Prognosticators of Packed Red Blood Cell Transfusion in Patients Undergoing Off

Pump Coronary Revascularization 150
Propofol vs Sevoflurane for Laryngeal Mask Airway Insertion Under General

Anaesthesia in Day Care Surgeries 1277
Questionnaire to Assess the Knowledge, Attitude and Acceptance of Epidural

Labor Analgesia among Paramedical Staff 944
Revascularisation Surgeries in Pediatric Patients With Moyamoya Disease:

An Anesthesia Point of View (Implications) 710
Segmental Spinal: Is It Possible? 1445
Single-dose Intravenous Dexmedetomidine as an Adjuvant for Prolongation of Spinal Anesthesia 493
Sonoclot Analyzer Guided Transfusion Therapy in Patients Undergoing

On-Pump Cardiac Surgeries 703
Study Comparing the Effects of Fentanyl and Dexmedetomidine for Attenuation of the
Haemodynamic Response During Endotrcheal Extubation in
Patients Undergoing Elective Surgeries 679
Study of Intraperitoneal Bupivacaine-Tramadol with Bupivacaine-Magnesium Sulphate

for Pain Relief after Laparoscopic Cholecystectomy 330
The Effect of Endotracheal Tube Cuff Pressure Control on Postoperative Sore Throat in
Faciomaxillary Surgeries 953
The Effects of Intravenous Propofol and Intravenous Etomidate as Induction Agents on Blood
Glucose in Elective Surgeries Under General Anaesthesia: A Randomized Control Trail 420
The Relationship Between Body Mass Index and Incidence of Postdural Puncture Headache in
Female Patients Undergoing Infraumbilical Surgeries 716
Thoracic Epidural Anaesthesia for Upper Abdominal Surgery 1101
To Compare the Effectiveness of Non-Opioid Analgesics over Opioids in the

Intraoperative Pain Management 1081
To Determine The Efficacy of Prophylactic use of Ephedrine and Mephentermine in

Caesarean Section to Manage Hypotension under Subarachnoid Block 1247
To Study and Compare Induction Characteristics and Hemodynamic Effects of Sevoflurane

with Halothane for Inhalational Anesthesia in Pediatric Patients 570
To Study the Comparison of Ondansetron and Granisetron with Dexamethasone as

Adjuvant for Prevention of Post Operative Nausea and Vomiting in Middle Ear Surgery 1167
To Study the Efficacy and Heamodynamic Response to Dexmedetomidine as Hypotensive Agent

in Elective Spine Surgeries 382
Transdermal Diclofenac Patch versus Intra Muscular Diclofenac Injection for The Management
of Pain in the Post Operative Patients in a Teritiary Teaching Institute 1253
Ultrasound Guided Caudal Epidural: A Comparative Study of Ropivacaine Clonidine versus

Ropivacaine Dex Medetomidine for Perioperative Analgesia in Spine Surgery 1131
Use of Surgical Plethysmographic Index to Assess the Effect of Dexmedetomidine on

Hemodynamic Response to Intubation and Surgical Stress 531
Use of Truview Laryngoscope in Patients of Limited Mouth Opening Associated with

Panfacial Trauma 187
0.5% Lignocaine vs 0.5% Lignocaine with Dexmedetomidine for Bier’s Block:

A Comparative Study 1259

1463
Author Index
Name Page No Name Page No
A Anusha 873 Anurita Konnur 354

Aadesh Kumar 230 Arati Sharma 124
Aasim Ahmad 291 Archana Tripathi 41
AB Ashwin 798 Arish Sadaf 912
Abdul Azim Makandar 1411 Arjun 824
Abhishek K Manjunath 895 Arpit Shah 267
Abhishek Sharma 1265 Arushi Joshi 918
Abinaya SV 636 Arvind Kumar Gupta 1295
Aditya Agarwal 570 Arvind Kumar Gupta 1305
Aditya Agarwal 750 Asha G 1247
Ahsan Mustafa 889 Ashish Nair 1081
Ahsan Mustafa 908 Ashwini Khamborkar 235
Ajay Sharma 867 Ashwini Khamborkar 382
Akash Mukherjee 664 Ashwini Patil 87
Akash Mukherjee 903 Ashwini R 1423
Akhila L Arakkal 187 Asodariya Nidhi Chandreshbhai 780
Akhya kumar kar 1273 Atif Mohammed 889
Alagu Annamalai 21 Atif Mohammed 908
Amandeep Singh 1225 Avani Shah 9
Amandeep Singh 1277 Avni H Thacker 493
Amarnath Reddy Basavanapalli 710 Ayya Syama Sundar 1273
Amey Sable 382 B Keshavanarayana 15
Amit Jangir 1305 B Sowbhagyalakshmi 1381
Amith S 1247 B Sowbhagyalaxshmi 1365
Amogh Jagtap 1315 B Sunitha 15
Amol Shinde 1315 B Swathi 688
Amulya N 716 B Venkateswara Rao 1069
Anand P Math 420 B Venkateswara Rao 1089
Aneesh Rajan 500
Bachula Lavanya 1028
Anish K Singh 824
Balachander Hemavathy 311
Anjuna KC 465
Balachandran 183
Anshul Dahuja 1225
Balaji Ramamurthy 1107
Anupam Sharma 124
Balaji Thiyagarajan 21
Anupama Gill Sharma 1265
Balakrishna N 664
Anuradha Mitra 28
Balasubramanian Natarajan 441
Bhabananda Mukhopadhyay 209 Deepali Bansal 1277

Bhakti S Jain 58 Delcita Joyce Mathias 879
Bhat Ravindra R 311 Deshpal Singh 319
Bhavini B Shah 137 Deshpande SG 923
Bhavini Bhushan Shah 341 Dhananjaya Kumar SM 734
Bhavini Shah 375 Dhruvika Viradiya 739
Bhavini Shah 1155 Dinesh Chauhan 912
Bhumi Maru 488 Dinesh K Chauhan 842
Bipin M Patel 106 Dinesh Krishnamurthy 787
BN Seth 963 Dinesh Krishnamurthy 895
Britto Sabu 930 Dinesh Krishnamurthy 999
Bunty Sirkek 124 Dinesh Krishnamurthy 1011
C R Lakshmi Narayanan 1431 Dinesh Thakur 1291
Carolin Von Mullai A 400 Dipanjali Mahanta 341
CG Raghuram 64 Dipanjali Mahanta 375
CH Nagaraju 764 Dipika Patel 488
Chaitanaya 1253 Dipro Dey 1323
Chandrashekar E 1101 Divakar S Ramegowda 449
Chandrashekar Manjunatha 279 Divya Kavita 1277
Chandrashekar Manjunatha 1221 Divya N Kheskani 58
Chandrika Bhut 584 Divya N Kheskani 493
Chandrika Bhut 1167 Divyashree 1161
Chandy Mathew 1139 Firoz Satpathy 41
Chinnappan Kuppuswamy Swetha Ramani 441 Fumakiya Pooja Hasmukhbhai 780
Chiranji Lal Khedia 114 G Karthikeyan 1405
Chiranthkumar G Nelogal 511 G Srinivas Rao 1069
Chiranthkumar G Nelogal 726 G Srinivas Rao 1089
Chudasama Ankita 842 Garima Gupta 743
CM Suryawanshi 223 Gauri Satish Jahagirdar 248
Curpod G Srinivas Prasad 279 Gauri Varma 1217
D Dinesh Babu 33 Geethanjali S 1247
Darshan M S 1319 Girish Sharma 124
Darshan M S 1417 Gopal Sharma 114
Debanjali Ray 28 Gouthami M 593
Deepa Gautham 578 Gunaseelan Sivasamy 930
Deepak Devendran 53 Gurpreet Singh 1277
Deepak Malviya 948 Gurpreeti Kaur 934
Deepak Vijaykumar Kadlimatti 798 Guru Prasad Rai D 150
1465
Guruchannabasavaiah B 1221 Jinesha Chauhan 488

H K Mahajan 1265 Juhi Mattoo 1149
Haramritpal Kaur 1225 Juhi Mattoo 1291
Haramritpal Kaur 1277 Juluri Vamshi Krishna 284
Harish Hegde 1161 Jyothi B 272
Harsha Prakash BG 473 Jyoti V Kulkarni 957
Harsha Prakash BG 506 Jyotsna Bhosale 1209
Harshil Joshi 150 K Ravi Nayak 330
Hassaan Muhammed 46 K Shankar 798
Hassaan Muhammed 547 K Suresh Kumar 33
Heena S Chhanwal 58 K Udaya Bhaskar 562
Heena S Chhanwal 493 Kala 1439
Hemadip Tavethiya 482 Kalla Nagaraj S 944
Hemnath Babu Kotla 389 Kam Bala Krishna 1299
Himani Arya 963 Kanirajan Yogalakshmi 99
Himanshu Khanapurkar 697 Karande TK 923
Himanshu Kiran Khanvelkar 137 Karri Naga Venkata Harish 1253
Hitendra Kanzariya 9 Karthik Jain 53
Hukam Singh 319 Kavita S Lalchandani 408
Iram Ali 1050 Khaliq Ahmed 1028
Iramnaaz Sheikh 1283 Khan Afroz Shahana M 703
Ishita Saha 28 Kiran Nelamangala 895
J Hymavathi 143 Kiran Nelamangala 999
Jaipreet Singh Sidhu 1225 Kiran Nelamangala 1011
Jamadar NP 923 Kiranpreet Kaur 824
Janmejaya Sahoo 87 Kishore Keerthy N 500
Jatin Babubhai Patel 912 Komal S. Shah 1036
Jatin Gupta 1225 Komal Shah 1167
Jatin Lal 824 Kondikar Lohit 720
Jayshree Thakkar 488 Kota Raju 816
Jayshri Balkisan Desai 912 Krishna Diddi 606
JC Makwana 267 Krishna Diddi 835
JC Vasava 408 Krishna Diddi 1004
Jeevan Kumar 1161 Krishnamoorthy Karthik 99
Jenish Patel 488 Krishnamoorthy Karthik 441
Jigar Panchal 671 Kriti Nagar 291
Jignesh Govindbhai Makvana 1036 Kulkarni Dilip Kumar 64

KV Srinivasan 562 Marina Rajan Joseph 804

Lavanya Chetan 716 Mary Mammen 804
Laviena Mallela 531 Mathew Jibin Sam 311
Leno Ninan Jacob 1107 Md Ayathullah 284
Lopa Trivedi 584 Md Ayathullah 613
Lubna 368 Megha Rungta 473
M Archana 1381 Meshwa S Desai 493
M Dhakshinamoorthy 1405 Mihika Divatia 183
M Gouthami 688 Minal Chandra 1217
M Manjuladevi 70 Mishra Sandeep Kumar 311
M Paul Wilson 1139 Mohammed Afsal P 1193
M Prem Kumar 414 Mohammed Sadiq 525
M Santhi Sree 1365 Mohammed Yahya 1411
M Santhi Sree 1381 Mohammed Yahya 1259
M Sathyasuba 1323 Mohan Deep Kaur 1193
Madhava Reddy R 903 Mohan Kumar RM 279
Madhurima Singh 750 Mohandeep Kaur 636
Madhusmita Patro 1187 Mohandeep Kaur 1265
Madhusudhana Ravi 944 Mohanjeet Singh Juneja 963
Mahamad Javeedulla Baig 473 Mohd Asim Rasheed 291
Mahamad Javeedulla Baig 506 Moses Charles D ‘Souza 70
Mahesh Chandra 798 Mukesh Somvanshi 41
Mahesh KM 511 Munish Khurana 963
Mahesh KM 726 Muralidhar Joshi 710
Mahesh Kumar 1019 Myakala Siddartha 1391
Mahesh Verma 1075 Myakala Siddartha 1401
Mahesh Verma 1095 N K Nandanwankar 248
Mala Rani 934 N Kannan 525
Malini Mehta 743 N Vanaja Lakshmi 298
Mamatha Paturu 562 Nagaraj Gajagouni 764
Mamta Goda 1427 Nagaraj Sharanabasappa Kalla 757
Mamta Jain 824 Naik Harish S 720
Manan Shah 267 Nama Nagarjuna Chakravarthy 361
Manas Ranjan Panigrahi 209 Namrata Nair 303
Manjula Sudhakar Rao 1351 Narendra Babu MC 716
Manjunath SM 473 Narendra Kumar Vaniya 948
Manoj Kumar Panwar 867 Naresh Kumar Tyagi 1295

1467
Naresh Kumar Tyagi 1305 Pasham Abbaiah 679

Naresh W Paliwal 1445 Pasham Abbaiah1 Rontala Saraiah 659
Nataraj M Srinivasan 279 Pasupuleti Surender 64
Navaneetha Krishnan Srinivasan 953 Patil BM 923
Nazneen Makhbool 354 Patil Vishalakshi 720
Neena Jain 1113 Pavan Kumar 808
Neeta Bose 9 Phaneendra BV 389
Neha Garg 1155 Pinu Ranawat 1295
Neha Kanojia 710 Pinu Ranawat 1305
Nellimarala Appalaraju 1299 Pooja Bhosle 918
Nidhi Asodariya 1283 Pooja Fumakiya 1283
Nidhi Chitravanshi 957 Pooja R Mathur 1113
Nikhila Rajendra 1011 Poorna Uma 1431
Nimisha A Tank 829 Potlapelly Vasu Prakash 164
Nirmala Kumari 957 Prabhuvel Nandhini4 99
Nischala Dixit 53 Pradeep A Dongare 279
Nischith D Souza 1161 Pradeep Karunagaran 953
Nisha Sharma 774 Prajwal Venugopal 664
Nupur Moda 629 Prakash Rajkumar Sadhwani 671
Nupur Moda 1187 Prashant M Parmar 106
P Anand Vijaya Bhasker 79 Pratheba 1431
P Eniya 873 Pratibha Omkar 808
P G Raghavendra 1391 Pratishruti 272
P G Raghavendra 1401 Preethi Goutham C 1331
P Krishna Prasad 1365 Preethi Narendra B 664
P Manohar, G Uma 601 Preeti Lamba 1113
P R Chauhan 1265 Prerana Jogdand 459
P Sahithya 613 Prithi Jain 879
P Savanth Kumar 389 Priyadarshini M Bentur 1121
P Sridhar 215 Priyadarshini M Bentur 1423
P Sridhar 1431 Priyanka Priyadarshini C 816
Padmavathi Bodiga 593 Pujala Umapathy 284
Pallavi Huilgol 41 Pujala Umapathy 613
Papireddy Sujatha M 944 Puneet Rate SP 506
Parshotam Lal Gautam 934 Putta Vinod Kumar 606
Parth M Shah 1291 Putta Vinod Kumar 835
Parul Kamal 948 Putta Vinod Kumar 1004

Quazi Mohammed Azhar 703 Ravikumar Manchala 547

R Manickavasagan 824 Ravindra Kumar Arora 1351
R S Chendraya Perumal 903 Rayees Najib 1050
R Shankar 215 Rayees Najib 1125
Rachna Varma 1217 Reena Nayar 515
Raghavendra Biligiri Sridhara 1131 Reena Nayar 531
Raghuraman MS 930 Renuka R 191
Rahul Bankapur 1113 Riyaj Kalathil Jayaprakash 257
Rahul Kaiche 1315 Robin George 53
Raj Bahadur Singh 291 Rohit Singh 963
Raj Kumar Pradhan 87 Rontala Saraiah 679
Rajagopal Venkatraman 441 Rosly R Jacob 375
Rajashri Sonwane Virshid 187 Rosly R Jacob 347
Rajneet Kaur 554 Ruchi Gupta 1019
Rajprasath Rajaraman 33 Ruchi Gupta 1075
Ramachandraiah R 473 Ruchi Gupta 1095
Ramachandraiah R 506 Rukhsana Najeeb 1050
Ramachandraiah R 726 Ruksana Najeeb 1125
Ramachandraiah R 1309 Rupinder Kaur Kaiche 1315
Ramakrishna Shatagopam 79 S Arpitha Mary 787
Ramamurthy Balaji 241 S Bala Subramanian 33
Ramamurthy Balaji 257 S Mohideen Abdul Kadar 1139
Ramesh R 1203 S Navaneetha Krishnan 414
Ramsali Manjula V 64 S Sathyanarayanan 578
Rana Khatoon 889 S Selvamani 525
Rana Khatoon 908 S Selvamani 1323
Rangadhamaiah Sreenidi 979 Safiya Shaikh 272
Rashmi D Souza 1343 Sai Sowmya Garlapati 223
Rashmi Hegde 1221 Sakthi Abirami 400
Raveendra Ubaradka 93 Samarth S P 1319
Ravi Madhusudhana 757 Samarth S P 1373
Ravi Madhusudhana 1011 Samba Siva Rao Jupalli 330
Ravi Saravanan 99 Samba Siva Rao Jupalli 540
Ravikant Dogra 867 Sameer H Parmar 106
Ravikumar M Parmar 106 Sameer Kadam 183

1469
Sameer Parmar 1036 Shashank M 1179

Samhita Kalimireddy 1209 Sheetal Jaykar 375
Sampathila Padmanabha 1161 Sheetal Jaykar 1155
Sanchara M Paramesh 449 Sheikh Iramnaaz Ahmedhussain 780
Sandeep Khandelwal 230 Shewata G Khatri 923
Sandhya Kalappa 1131 Shilpa Doshi 739
Sandip Baheti 235 Shilpa G K Bhat 1161
Sanjay Kalani 114 Shilpa M Doshi 829
Santosh Gitte 459 Shipra 1167
Sara john 241 Shishir KR 46
Sara Mary Thomas 842 Shishir KR 547
Sarala HS 716 Shivakumar Gurulingaswamy 449
Sarala Mohan 1373 Shivakumar KP 465
Sarala Mohan 1395 Shivananda PT 1179
Saraswathi Nagappa 1131 Shreecharan P K 1373
Sarita S Swami 1081 Shreecharan P K 1395
Sarita Swami 1209 Shreyavathi R 986
Sarvesh B 420 Shridhar Devidasrao Yennawar 248
Sasidharan Nair M 1139 Shruthi R 420
Sathesha M 791 Shweta Birajdar 375
Sathish Kumar 791 Shweta Kalkutiginahal 1331
Sathish Kumar Bopparathi 540 Shweta Mahajan 774
Satish Kumar MN 473 Shweta Mahajan 867
Satish Kumar MN 506 Shyamli Jamwal 554
Satish Kumar MN 511 Sijo C Babu 124
Satish Kumar MN 726 Siri Kandavar 93
Saurabh Kapoor 330 Smita Joshi 347
Saurabh Kapoor 223 Smruti Govekar 375
Saurah Kapoor 375 Smruti Govekar 382
Savita Patil 511 Smurti Govekar 235
Sayyed M Omar 187 Sofia Jaswal 867
Shah Parth M 1149 Sonali Kaushal 774
Shaher Banu 889 Sonalika Tudimilla 223
Shaher Banu 908 Sonam Norbu 621
Shankara Narayana P 734 Sorathiya Prashant C 1343
Sharanu Patil 21 Soumya Garlapati 341
Shashank Gupta 1277 Soumya Nath Maiti 137

Soumya Samal 629 Sushil Kumar 1095

Spriha Mathur 1351 Sushma J Pattar 449
Sreenivas Reddy M 562 Sushma Ladi 482
Sri Harsha Merugu 389 Sushree Das 1187
Sridhara 1359 Swati Lad 87
Srinivasan Rangalakshmi 798 Swetha Rajoli 986
Subhasis Das 629 Syed Abid Ali 688
Subhasundari Visu 449 Tahir Ali Khan 570
Subrata Ray 28 Talikota Nagaraju 164
Sudharani P Halli 449 Tanya Elizabeth 1439
Sudheer Dara 1217 Tanya Gulia 1155
Sudheesh K 506 TC Balaraju 720
Sudheesh K 511 Tejalben A Chaudhari 408
Sudheesh K 726 Tejaswini Tadooru 361
Sugantharaj Anuradha 400 Thakur Dinesh 1149
Suhashini Talawar 625 Tushar D Bhavar 697
Suhit Natekar 697 TVL Tanuja 835
Sulochana Dash 629 TVL Tanuja 1004
Suman Choudhary 482 Uday Pratap 1019
Sumit Kumar 948 Uday Pratap 1075
Sunder Lal Negi 621 Uday Pratap 1095
Suneeth P Lazarus 33 Uma Aratikatla 389
Sunil Katyal 934 Uma B R 1359
Sunil Kumar Gupta 963 Uma G 578
Sunil Ninama 155 Uma Hariharan 636
Sunil Ninama 174 Umer Iqbal Peer 1125
Sunil S Lawhale 1445 US Arutselvan 873
Suranjith Sorake 1161 Usha Badole 459
Surbhi Gupta 70 Usha Nandhini 664
Surekha C 354 Usha Nandini 798
Surekha G 70 V A Sabapathy 1431
Surendra Kumar 319 V Praveen Kumar 143
Surendra Kumar Raikwar 570 VA Sabapathy 215
Suresh Kumar N 979 Vacha Patel 584
Surinder Singh 774 Vaishali A Mohod 703
Sushil Kumar 1019 Vanagondi Sivakumar 64
Sushil Kumar 1075 Vandana Hebballi 791

1471
Vankaylapatti Sarada Devi 64 Vikas Joshi 1411

Vasantha Kumar J 368 Vikas Kumar 1113
Vasantha Kumar KR 420 Vikram MS 531
Vatika Bhardwaj 554 Vinay Dandemmanavar 808
Vedang Vaidya 488 Vinayak Seenappa Pujari 21
Veena 1221 Vineeta Goda 1427
Venus Sharma 1427 Vinod C N 903
Vidhyalakshmi K 1203 Viraj Shah 515
Vidjai Vikram S 33 Virendra Kumar 948
Vigy Varghese 1309 Visharad Trived 174
Vijay Kumar Nagpal 1193 Visharad Trived 155
Vijay Kumar Nagpal 1265 Vishwajeet 272
Vijay V Katti 625 Vishwajeet Singh 554
Vijaya Kumara 150 Vishwas Sathe 183
Vijaykumar T Kalyanappagol 303 Vivek MP 1121
Vikas Gupta 750 VM Shibinath 1139
Vikas Jaswal 867 VRR Chari 382
Vikas Joshi 1259 Yoganarasimha 1247

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1473
Guidelines for Authors

Manuscripts must be prepared in accordance author@rfppl.co.in. Submission page: http://rfppl.
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The text of observational and experimental articles
Types of Manuscripts and Limits should be divided into sections with the headings:
Original articles: Up to 3000 words excluding Introduction, Methods, Results, Discussion,
references and abstract and up to 10 references. References, Tables, Figures, Figure legends, and
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references and abstract and up to 10 references.
Case reports: Up to 1000 words excluding
Title Page
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1474
Introduction in detail data or other material given in the

State the background of the study and purpose Introduction or the Results section.
of the study and summarize the rationale for the
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Reports of randomized clinical trials should [1] Flink H, Tegelberg Å, Thörn M, Lagerlöf F.
be based on the CONSORT Statement (http:// Effect of oral iron supplementation on unstimulated
www. consort-statement. org). When reporting salivary flow rate: A randomized, double-blind,
experiments on human subjects, indicate whether placebo-controlled trial. J Oral Pathol Med 2006; 35:
the procedures followed were in accordance with 540–7.
the ethical standards of the responsible committee
[2] Twetman S, Axelsson S, Dahlgren H, Holm
on human experimentation (institutional or
AK, Källestål C, Lagerlöf F, et al. Caries-preventive
regional) and with the Helsinki Declaration of 1975,
effect of fluoride toothpaste: A systematic review.
as revised in 2000 (available at http://www.wma.
Acta Odontol Scand 2003; 61: 347–55.
net/e/policy/l 7-c_e.html).
Article in supplement or special issue

Results
Present your results in logical sequence in the text, [3] Fleischer W, Reimer K. Povidone-iodine
tables, and illustrations, giving the main or most antisepsis. State of the art. Dermatology 1997; 195
important findings first. Do not repeat in the text Suppl 2: 3–9.
all the data in the tables or illustrations; emphasize
or summarize only important observations. Extra Corporate (collective) author
or supplementary materials and technical details [4] American Academy of Periodontology. Sonic
can be placed in an appendix where it will be and ultrasonic scalers in periodontics. J Periodontol
accessible but will not interrupt the flow of the 2000; 71: 1792–801.
text; alternatively, it can be published only in the
electronic version of the journal.
Unpublished article
Discussion [5] Garoushi S, Lassila LV, Tezvergil A,
Vallittu PK. Static and fatigue compression test
Include summary of key findings (primary outcome
for particulate filler composite resin with fiber-
measures, secondary outcome measures, results as
reinforced composite substructure. Dent Mater
they relate to a prior hypothesis); Strengths and
2006.
limitations of the study (study question, study
design, data collection, analysis and interpretation);
Interpretation and implications in the context of the Personal author(s)
totality of evidence (is there a systematic review to [6] Hosmer D, Lemeshow S. Applied logistic
refer to, if not, could one be reasonably done here regression, 2nd edn. New York: Wiley-Interscience;
and now?, What this study adds to the available 2000.
evidence, effects on patient care and health policy,
possible mechanisms)? Controversies raised by
this study; and Future research directions (for Chapter in book
this particular research collaboration, underlying [7] Nauntofte B, Tenovuo J, Lagerlöf F. Secretion
mechanisms, clinical research). Do not repeat and composition of saliva. In: Fejerskov O,

1475
Kidd EAM, editors. Dental caries: The disease Type or print out legends (maximum 40 words,
and its clinical management. Oxford: Blackwell excluding the credit line) for illustrations
Munksgaard; 2003. pp 7–27. using double spacing, with Arabic numerals
corresponding to the illustrations.
No author given
[8] World Health Organization. Oral health Sending a revised manuscript
surveys - basic methods, 4th edn. Geneva: World While submitting a revised manuscript, contributors
Health Organization; 1997. are requested to include, along with single copy of
the final revised manuscript, a photocopy of the
Reference from electronic media revised manuscript with the changes underlined
in red and copy of the comments with the point-
[9] National Statistics Online—Trends in suicide to-point clarification to each comment. The
by method in England and Wales, 1979–2001. www. manuscript number should be written on each of
statistics.gov.uk/downloads/theme_health/HSQ these documents. If the manuscript is submitted
20.pdf (accessed Jan 24, 2005): 7–18. Only verified online, the contributors’ form and copyright
references against the original documents should transfer form has to be submitted in original
be cited. Authors are responsible for the accuracy
with the signatures of all the contributors within
and completeness of their references and for correct
two weeks of submission. Hard copies of images
text citation. The number of reference should be
should be sent to the office of the journal. There
kept limited to 20 in case of major communications
is no need to send printed manuscript for articles
and 10 for short communications.
submitted online.
More information about other reference types
is available at www.nlm.nih.gov/bsd/uniform_
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or date after volume, etc.). a author copy is sent to the main author and
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1476
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For Authors The Indian Journal of Anesthesia and Analgesia

IJAA / Volume 7 Number 6 / November – December 2020

To Determine the Efficacy of Prophylactic use of Ephedrine and Mephentermine

0.5% Lignocaine vs 0.5% Lignocaine with Dexmedetomidine for Bier’s Block:

Comparing Macintosh, Miller and Truview Laryngoscopes for Evaluation of

A Survey of Intubation of COVID-19 Patients in The Critical Care Units to

Propofol vs Sevoflurane for Laryngeal Mask Airway Insertion Under General

A Comparative Study of Tramadol vs Butorphanol as an Adjuvant with Local

Effect of Intraoperative Esmolol Infusion on Haemodynamics and

Hemodynamic Stability of Dexmedetomidine in Laparoscopic Cholecystectomy Cases 1295

Caudal Epidural Block for Transurethral Resection of Prostate in Patients

Dexmedetomidine versus MgSo4 in Hemodynamic Stability in

A Comparative Study to Evaluate the Efficacy of Intravenous Dexmedetomidine

IJAA / Volume 7 Number 6 / November – December 2020

A Study on Hemodynamic Changes in Dexamethasone 0.1 mg/kg When Combined

A Randomized Double Blinded Comparative Study on Efficacy of Intraoperative

Comparative Study of Oral Clonidine, IV Fentanyl and IV Butorphanol in Attenuation

A Randomized Prospective Study to Compare use of I-GELTM and LMA ProsealTM

A Comparative Evaluation of Respiratory Parameters Spo2 and Etco2 with

A Comparitive Evaluation of Propofol, Sevoflurane and Desflurane for

Efficacy of Ultrasound Guided TAP Block with the Standard Post-Operative

Efficacy of Varying Doses of Dexamethasone with Lignocaine in Supraclavicular

A Study on Complications of Magnesium Sulphate as an Adjunct to Ropivacaine

Comparison of Post Operative Sedation between Ultrasound Guided TAP Block

Efficacy of Magnesium Sulphate as an Adjunct to Ropivacaine in Local Subcutaneous

IJAA / Volume 7 Number 6 / November – December 2020

Levobupivacaine vs Ropivacaine in Spinal Anesthesia for Lower Abdominal

Efficacy of Dexamethasone 0.1mg/Kg when Combined with 0.15% Ropivacaine

Comparison of Ondansetron 4mg, Dexamethasone 8mg and Ondansetron 4 mg

Comparative Assessment of Bupivacaine and Levobupivacaine in Elective

A Comparative Study of the Anesthetic Potencies and Hemodynamic Changes of 0.5%

Anesthesia for Brachytherapy: A Review 1439

Segmental Spinal: Is it Possible? 1445

Subject Index 1451

Author Index 1463

Guidelines for Authors 1473

IJAA / Volume 7 Number 6 / November – December 2020

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IJAA / Volume 7 Number 6 / November – December 2020

To Determine the Efficacy of Prophylactic use of Ephedrine and

Asha G1, Geethanjali S2, Amith S3, Yoganarasimha4