5th INTERNATIONAL SYMPOSIUM ON REGIONAL ANAESTHESIA AND PAIN THERAPY 5th Croatian Congress of Regional Anaesthesia and Analgesia

Dear Colleagues, Guests and Friends, On behalf of Croatian Society of Regional Anaesthesia and Analgesia – Croatian Medical Association (CSRAA-CroMA) and European Society of Regional Anaesthesia and Pain Therapy (ESRA) it is our great pleasure and honour to welcome you to the 5th International Symposium on Regional Anaesthesia and Pain Therapy and 5th Croatian Congress of Regional Anaesthesia and Analgesia in Zagreb, Croatia, June 14–15, 2013. 10 years Anniversary Jubilee The scientific programme is designed for anaesthesiologists and other physicians interested in regional anaesthesia for surgical procedures, acute and chronic pain as well. As in previous 10th years, the focus of the scientific programme is on state of the art presentations as well as on new insights into basic science, clinical research and therapeutic interventions. However, clinical practice holds an important position in regional anaesthesia and pain therapy and therefore workshops are important features of the Symposium. Your opinions and experience are important and we cordially invite you to actively participate in all discussions during the scientific sessions as well as the workshops. The industrial exhibition is an opportunity for you to network and to keep up-to-date with the latest pharmacological and technological developments as a specific Ultrasound. Each company is a supporter of the Symposium and we would like to thank them all for their commitment and contribution by visiting the exhibition. We are thankful that Zagreb, the capital of beautiful Croatia, will play host to this Symposium. It is a marvellous town with lot of heritage, culture dynamism and appeal and we sincerely hope that you will enjoy both, the educational value of the programme and the unique atmosphere of the charming city of Zagreb. We are looking forward to greeting you personally in Zagreb. Prof. Katarina Šakić, MD, PhD President CSRAA-CroMA Slobodan Gligorijevic, MD President of Eastern ESRA Past president ESR

Perspective Chapter: Epidural Administration-New Perspectives and Uses

Neuraxial techniques are commonplace in labor analgesia. Techniques for labor analgesia range from intrathecal and epidural anesthesia to peripheral nerve blocks, nitrous oxide, intravenous infusions, and acupuncture. The epidural approach is the most popular as it allows for local anesthetics to diffuse into the intrathecal space along with repeated or continuous doses of medication for labor and primary anesthetic for surgeries. The epidural technique affects differing spinal nerves (i.e., pain, autonomic, sensory, and motor) with varied effects depending on the concentration and volume of LA used. Adverse effects do exist following these techniques with hypotension being a major concern. A multitude of anesthetic agents can be given in the epidural; opioids are the most frequently used local anesthetic adjuvants. Alpha 2 adrenoreceptor agonists are also used as local anesthetic adjuvants. Although not performed routinely, peripheral nerve blocks play a complementary and supplementary role in epidural analgesia and anesthesia. There are absolute and relative contraindications to epidural anesthesia. Alternatives to neuraxial anesthesia that can be offered include infusion of ultrashort acting opioids, nitrous oxide, opioid agonist-antagonists, ketamine, TENS, and acupuncture. Local Anesthetic Systemic Toxicity may be more prevalent in the pregnant

5th INTERNATIONAL SYMPOSIUM ON REGIONAL ANAESTHESIA AND PAIN THERAPY 5th Croatian Congress of Regional Anaesthesia and Analgesia

Dear Colleagues, Guests and Friends, On behalf of Croatian Society of Regional Anaesthesia and Analgesia – Croatian Medical Association (CSRAA-CroMA) and European Society of Regional Anaesthesia and Pain Therapy (ESRA) it is our great pleasure and honour to welcome you to the 5th International Symposium on Regional Anaesthesia and Pain Therapy and 5th Croatian Congress of Regional Anaesthesia and Analgesia in Zagreb, Croatia, June 14–15, 2013. 10 years Anniversary Jubilee The scientific programme is designed for anaesthesiologists and other physicians interested in regional anaesthesia for surgical procedures, acute and chronic pain as well. As in previous 10th years, the focus of the scientific programme is on state of the art presentations as well as on new insights into basic science, clinical research and therapeutic interventions. However, clinical practice holds an important position in regional anaesthesia and pain therapy and therefore workshops are important features of the Symposium. Your opinions and experience are important and we cordially invite you to actively participate in all discussions during the scientific sessions as well as the workshops. The industrial exhibition is an opportunity for you to network and to keep up-to-date with the latest pharmacological and technological developments as a specific Ultrasound. Each company is a supporter of the Symposium and we would like to thank them all for their commitment and contribution by visiting the exhibition. We are thankful that Zagreb, the capital of beautiful Croatia, will play host to this Symposium. It is a marvellous town with lot of heritage, culture dynamism and appeal and we sincerely hope that you will enjoy both, the educational value of the programme and the unique atmosphere of the charming city of Zagreb. We are looking forward to greeting you personally in Zagreb. Prof. Katarina Šakić, MD, PhD President CSRAA-CroMA Slobodan Gligorijevic, MD President of Eastern ESRA Past president ESR

Education of Obstetrical Nursing Staff Regarding Regional Anesthesia and Possible Complications

Spinal and epidural anesthesia have long been a popular choice for anesthesia in the obstetrical population, whether for a laboring patient or a patient undergoing a cesarean delivery. Anesthesia providers caITy out the placement and delivery of these blocks. After the block is deemed successful and the patient is considered medically stable, the anesthesia provider may then leave the side of their patient, trusting that the care given by the labor and delivery nurse will be the best possible care available. However, it is a well know fact that risks are present anytime an invasive procedure takes place. Complications can arise with the placement of spinal or epidural anesthetics, and they may occur during, immediately after, hours after or even days after placement of a spinal or epidural anesthetic. If the obstetrical patient does experience complications, the obstetrical nurse must have an adequate knowledge base regarding regional anesthesia in order to provide the most competent care available The method used for this independent project was a review of literature utilizing PubMed, CINAHL and SCOPUS databases. Current thoughts on educating labor and delivery nurses on regional anesthesia and possible complications were organized according to a physiological framework. The plan for this independent project was implemented by educating labor and delivery nurses regarding regional anesthesia and possible complications using a Power Point presentation. Main topics of discussion included basics of spinals and epidurals and how they differ, complications that may arise from spinals and epidurals, and appropriate interventions that may either prevent or treat these complications. It was anticipated the nurses would have a better understanding of spinal and epidural anesthesia and possible complications after the Power Point presentation. Results from an evaluation proved the presentation was successful in increasing the labor and delivery nurses overall comprehension of spinal and epidural anesthesia in the obstetrical populatio

A study on analysis of fetal heart rate abnormalities comparing epidural analgesia ropivacaine 0.2% plus fentanyl 2 μg/ml with bupivacaine 0.1% plus fentanyl 2 μg/ml during labour

Title: A study on analysis of foetal heart rate abnormalities comparing epidural analgesia ropivacaine 0.2% with fentanyl 2ug/ml to bupivacaine 0.1% with fentanyl 2ug/ml during labour. Background and Objectives: Epidural analgesia effectively relieves labour pain and is widely chosen by parturients. Foetal well being is also important during labour as various neuraxial analgesia in labour is known to influence FHR tracings. Various studies focused on equipotent doses of local anesthetics and compared different techniques of labour analgesia in assessing foetal heart rate changes and its outcome on mode of delivery, effects on maternal haemodynamics and the neonatal outcome based on APGAR score. Therefore, this study was intended to analyze foetal heart rate changes using two different concentrations of epidural analgesia with opioids and its effect on the mode of delivery, maternal haemodynamics and neonatal outcome. Methodology: A total of 126 patients were recruited in this prospective randomized cross sectional study. Maternal haemodynamics and foetal heart rate monitoring is documented 15 minutes before epidural administration and 15 minutes after epidural administration and subsequently every 30 minutes till four hours. CTG interpretation is documented. The observed outcome in this study were foetal heart rate abnormalities post epidural, maternalhaemodynamics before and after epidural analgesia in labour, mode of delivery and the neonatal APGAR score. Result: Based on the mode of delivery between both the groups of epidural analgesia ropivacaine and bupivacaine, there were 48 (71.6%) in the ropivacaine group and 49 (83.1%) in the bupivacaine group who delivered spontaneously. 4 (6%) only delivered via instrumental in the ropivacaine group. Via caesarean section 15 (22.4%) in the ropivacaine group and 10 (16.9%) in the bupivacaine group. There were no significant changes in the mode of delivery between both the groups. 115 parturients had normal FHR, 96(83.5%) delivered spontaneously, 2 (1.7%) had instrumental delivery, 17 (14.8%) delivered via caesarean section. Whereas 11 patients had abnormal FHR, 1 (9.1%) delivered spontaneously, 2 (18.2%) via instrumental delivery and 8 (72.7%) via caesarean delivery. A higher percentage in caesarean delivery with abnormal CTG with a significant p value <0.001. Parturients for caesarean section were 27, 18 had normal CTG out of which 4 (22.2%) for secondary arrest, 2 (11.1%) for acute foetal distress, 12 (66.7%) for poor progress. 9 parturients had abnormal CTG, out of which 1 (11.1%) for secondary arrest, 8 (88.9%) for acute foetal distress with a significant p value=<0.001.There were no significant difference seen in maternal outcome and neonatal outcome. Conclusion: This study revealed that with epidural analgesia in labour using ropivacaine 0.2% and bupivacaine 0.1% with fentanyl 2ug/ml, there were no foetal heart rate changes. There were increased risk for caesarean delivery with abnormal CTG in the ropivacaine group due to acute foetal distress. There were no changes in the maternal and neonatal outcome

Comparing Efficacy of Epidural Dexamethasone Versus Fentanyl on Post Operative Analgesia: A Double Blinded Randomized study

INTRODUCTION: The perioperative period is usually associated with a variety of pathophysiologic responses that are initiated or maintained by nociceptive input. Uncontrolled postoperative pain may produce various acute and chronic effects which may be detrimental to the patient. The perioperative pathophysiological changes that occurs during surgery can be attenuated through reduction of transmission of nociceptive input to the central nervous system by providing perioperative analgesia. This also • Decreases complications, • Facilitate recovery during the immediate postoperative period, • Improves long term recovery, • Reduces the length of hospital stay, • Improves the quality of life. Post operative pain management should be planned and tailored to the needs of special population like ambulatory surgical patient, elderly, paediatric, opioid tolerant, obese patients and those with obstructive sleep apnea syndrome. AIM OF THE STUDY: To compare the efficacy of epidural dexamethasone versus fentanyl on post operative analgesia. MATERIALS AND METHOD: After getting Ethical committee approval from Goverment Kilpauk Medical College Hospital. Chennai 10, we conducted the study in our hospital in 60 adult male patients aged between 25 – 45 years belonging to ASA Physical status I and II undergoing elective hernioplasty under epidural anesthesia after obtaining written informed consent. Study Design: Double blinded randomized prospective study. Patients were randomly allocated into one of the three groups (20 patients per group) by lotting method. Method of Blinding: Patients and the person performing the epidural technique was unaware of the epidural drug composition. The drug solution was prepared by an anaesthesiologist assistant in the operating room and was labelled accordingly. Patient Selection: All the 60 patients were evaluated clinically, biochemically and assessed for hernioplasty under epidural anesthesia considering the inclusion and exclusion criteria. Then the patients were randomised into three groups. Study Period: From onset of epidural blockade to onset of postoperative pain with VAS > 5. Observation Period: For 24 hours postoperatively. Inclusion Criteria: 1. Adult male patients aged 25 – 45 years, 2. ASA physical status I & II, 3. For uncomplicated inguinal hernia surgery. Exclusion Criteria : 1. Patient unwilling for the procedure, 2. Obese, 3. Hypertension, 4. Diabetes mellitus, 5. History of peptic ulcer disease, 6. Those received corticosteroids or immune suppressive drugs in the last 6 Months, 7. Those with contraindications to steroids, 8. Patients on anticoagulants, 9. Patchy or inadequate blockade which required supplemental narcotics or general anesthesia. Patient Groups: 60 patients enrolled in the study were randomly allocated into three groups. Group 1: Patients receiving 11 cc of 0.5 % bupivacaine plus normal saline 1 cc epidurally. Group 2: Patients receiving 11 cc of 0.5 % bupivacaine plus 50 μg fentanyl epidurally. Group 3: Patients receiving 11 cc of 0.5 % bupivacaine plus 4 mg preservative free dexamethasone epidurally. All patients received a total volume of 15 ml of study drug including 3 ml of test dose plus 1 ml of adjuvant. The level of blockade was then noted. Materials Used: 1. 16 Gauge Tuohy needle, 2. 18 Gauge epidural catheter, 3. Loss of resistance syringe, 4. 10 ml syringe, 5. Local anesthetic solution ( 3 ml of 0.5 % bupivacaine with epinephrine 1 in 2,00,000 dilution ) for test dose. 6. 0.5% bupivacaine, 7. Inj. Fentanyl, 8. Inj. Dexamethasone sodium phosphate (preservative free), 9. 22 g needle for pin prick test. SUMMARY: After getting ethical committee approval the study was conducted in 60 patients undergoing elective hernioplasty belonging to ASA physical status I & II. The 60 patients enrolled in the study were divided into three groups.The data were statistically analysed , compared and discussed. The results obtained were summarised below: 1. The demographic data like age, weight, height were comparable to each other in all the three group. 2. The onset of analgesia was significantly earlier in group 2 patients receiving fentanyl 5.075 min and the onset was delayed in dexamethasone receiving group 6.525 min . 3. The duration of analgesia was significantly prolonged in group 3 patients receiving dexamethasone 373 min when compared to group 2 patients receiving fentanyl 347.25 min. 4. None of the patients in group 3 receiving dexamethasone had nausea. The incidence of nausea in group 1 was 3.55 % and in group 2 patients was 20%. 5. None of the patients in group 1 and group 3 had pruritus but the incidence of pruritus in group 2 patients receiving fentanyl was 15%. 6. There is nil incidence of sedation in group 1 and group 3.There was more incidence of sedation in group 2 patients receiving fentanyl ( 25 %.) 7. The incidence of initial hypotension followed by epidural bolus was 10, 15, 20 % in group 1, 2 and 3 respectively which were comparable. This initial hypotension was treated with fluid bolus and single dose of inj. Ephedrine 6 mg IV. 8. There is nil incidence of any complications in all the study group. CONCLUSION: We conclude that epidural administration of dexamethasone – bupivacaine admixture resulted in better postoperative analgesia in terms of lower postoperative pain score, prolonged postoperative analgesia and patient comfort with fewer side effects when compared with the other two groups. We also conclude that this epidural dexamethasone resulted in prolonged postoperative analgesia without any side effects like nausea, vomiting, pruritus, sedation except hypotension in few patients