Comparative Study Between Combined Spinal Epidural Analgesia (CSEA) and Pre-Emptive Multimodal Analgesia for Pain Control in Joint Replacement Surgeries of Lower Limbs

Background and aims: Epidural analgesia has been considerably used for postoperative analgesia in Orthopaedic surgeries, however, combination of opioid and non-opioid medications in the perioperative period seems to provide an effective alternative. Objectives: To compare the efficacy of pre-emptive multimodal analgesia with combined spinal epidural for postoperative analgesia in lower limb arthroplasties. Materials and methods: 50 patients scheduled for elective lower limb Arthroplasties were randomly divided into two groups. Spinal anaesthesia with 2.5ml of 0.5% Bupivacaine (heavy) plus 0.5ml (25µg) Fentanyl was given in both the groups for procedure. Group I received Cap. Pregabalin 150mg and Inj Paracetamol 1000mg IV 1 hour before surgery and 75mg 12 hourly and 1000mg IV 8 hourly respectively, while Group II received epidural top up with 10 ml of 0.125% bupivacaine 8 hourly, both for 3 days postoperatively. Perioperative haemodynamics, postoperative VAS, rescue analgesics requirement, and Patient satisfaction level were monitored for 72 hours. Results: Postoperative VAS score was significantly higher in Group II from 4th hour postoperatively, and, accordingly, more patients in this group required rescue analgesia (21 and 20 in Group II vs 10 and 1 in group I in 12-24 hrs and 24-36 hrs respectively with p value <0.001). Modified Bromage score, haemodynamics and side effect profiles were comparable in the groups, however, patient satisfaction level was more in Group I (p value <0.001) after 72 hours. Conclusion: Pre-emptive multimodal analgesia can be used as an effective alternative to epidural for postoperative analgesia in patients undergoing lower limb joint replacement surgeries. Keywords: Pre-emptive multimodal analgesia, Combined spinal epidural analgesia, Lower limb arthroplasties, Postoperative analgesi

A comparative study on sedative and cardiorespiratory effects of clonidine and dexmedetomidine added to ropivacaine in supraclavicular brachial plexus block in upper extremity surgery

Background: Supraclavicular brachial plexus block is widely used peripheral nerve block technique used for surgery of the upper extremity. Several drugs have been used with local anesthetic as adjuvants for rapid, dense, and prolonged analgesia. Aims and Objectives: The aims and objectives of the study are to compare the degree of sedation and cardiorespiratory effects of clonidine and dexmedetomidine added to ropivacaine in supraclavicular brachial plexus block. Materials and Methods: A double-blinded comparative study was done on eighty patients who were randomly allocated equally into two groups and received clonidine and dexmedetomidine added to ropivacaine 0.5%. Intraoperative degree of sedation and cardiorespiratory parameters were monitored in regular intervals and compared to find difference. Results: Heart rate was consistently lower with dexmedetomidine. Systolic, diastolic, and mean arterial pressures (MAPs) were comparable in both groups at all time points except at 45 min when diastolic and MAP were lower with dexmedetomidine and it was statistically significant. Sedation score in Group D was higher except at 5 min and difference was statistically significant. All patients in both groups were sedated and easily arousable. There was statistically significant difference in peroperative oxygen saturation between the groups although it was clinically not significant. Conclusion: There was more hemodynamic effect of dexmedetomidine than clonidine but these effects can be managed by medication easily. In addition to this, it was found that dexmedetomidine provides conscious sedation without any respiratory depression. Comparing the risk and benefit dexmedetomidine can be used with local anesthetic in supraclavicular brachial plexus block in upper extremity surgery

Comparing Propofol-Ketamine and Propofol-Fentanyl as Procedural Sedation and Postoperative Analgesia for Total Intravenous Anaesthesia in Adult Patients Undergoing Short Surgical Procedures- A Randomised Clinical Study

Introduction: Total Intravenous Anaesthesia (TIVA), an immensely popular procedure of recent times is most often conducted using propofol as the main anaesthetic agent. Ketamine or fentanyl has also been regularly used to compliment with their analgesic action, which propofol lacks. Aim: To compare the induction characteristics, maintenance of anaesthesia, awakening and recovery characteristics while performing TIVA with either propofol-ketamine or propofol-fentanyl combinations. Materials and Methods: This randomised, single blinded study was conducted, from March 2020 to August 2021, in a tertiary care centre of Kolkata, India. Total of 76 patients of either sex, aged between 18-45 years with an American Society of Anesthesiologists (ASA) physical status I and II, who were posted for short surgical procedures, with a duration of surgery less than 30 mins were equally divided into two groups. Group A received propofol ketamine (1:1), prepared by mixing 4 mL ketamine (50 mg/mL) with 20 mL of 1% Propofol (10 mL/kg), while group B received propofol-fentanyl solution (1:1) was prepared by mixing 4 mL (50 μg/mL) of fentanyl with 20 mL of 1% propofol (10 mg/mL). Induction was done with ketamine 10 mg/ kg+propofol 1 mg/kg in group A and fentanyl 1.5 μg/kg+propofol 1.5 mg/kg while maintenance of anaesthesia was achieved with continuous infusion of the prepared solutions for either group respectively at a rate of around 20 mL/hour or more, as per required to maintain the Ramsay Sedation Scale (RSS) score of 6. Intraoperative haemodynamic parameters, including respiratory rates, awakening time, recovery time and the possible the side effects were recorded at regular intervals. Student’s t-test was used for quantitative data and Chi-square test for qualitative data. A p-value of less than 0.05 was considered statistically significant. Results: Patients of group B developed significantly more incidents of bradycardia (20 in group B and 3 in group A) and hypotension (28 in group B and 2 in group A). Respiratory depression was also significantly more in group B (p-value<0.005).However, recovery, awakening, VAS score and other side effect profiles were all comparable in the two groups. Conclusion: Propofol-ketamine provides equipotent analgesia with better haemodynamic control and minimal side effects in comparison to propofol-fentanyl while used in TIVA for adult patients undergoing short surgical procedures

Role of nebulised dexmedetomidine, midazolam or ketamine as premedication in preschool children undergoing general anaesthesia—A prospective, double-blind, randomised study

Background and Aims: Preschool age children are psycho-biologically vulnerable to all surgical procedures. In this study, we investigated the effect of nebulised dexmedetomidine, midazolam and ketamine as sedative premedication for alleviating parental separation anxiety, facilitating face mask acceptance and reducing emergence agitation in paediatric patients undergoing general anaesthesia. Methods: A prospective, randomised, double-blind study was done involving 96 children of age 3–7 years, randomly allocated into three equal groups and pre-medicated with either nebulised dexmedetomidine 2 μg/kg (GroupD), midazolam 0.2 mg/kg (GroupM) or ketamine 2 mg/kg (Group K). The scores of sedation scale, parental separation anxiety scale, mask acceptance scale and emergence agitation scale were recorded along with haemodynamic parameters. Two-way repeated measures analysis of variance (ANOVA), post hoc test and Kruskal–Wallis test were used for statistical analysis. Results: A statistically significant difference in sedation score was seen between the different study groups, χ2(2) = 8.561, P = 0.014 with mean rank sedation score of 56.50 for Group D, 38.92 for Group M and 43.84 for Group K. Parental separation anxiety scale score and Mask acceptance scale score also showed statistically significant difference between the different study groups, χ2(2) = 9.369, P = 0.009 and χ2(2) = 11.97, P = 0.003, respectively. Conclusion: Nebulisation with dexmedetomidine produced easy parental separation, more satisfactory sedation and face mask acceptance with less postoperative agitation than nebulisation with midazolam or ketamine

Combination of self-report method and observational method in assessment of postoperative pain severity in 2 to 7 years of age group: A cross-sectional analytical study

Background: Postoperative pain management is based on assessment of severity of pain. Adult patients can express their pain accurately but difficulty occurs in paediatric population. Children between 2 and 7 years of age may give biased response to any scale of pain assessment as they belong to the preoperational stage of cognitive development. Objectives: To establish the agreement between two pain scale, namely Faces Pain Scale-Revised (FPS-R) and Face, Legs, Activity, Cry, Consolability scale (FLACC) regarding assessment of severity of postoperative pain and to find out true negative in terms of specificity of combination of scale for assessment of postoperative pain. Settings and Design: Postoperative recovery unit, cross-sectional analytical study. Materials and Methods: Four hours after short surgical procedure 95 children were assessed by two pain scale and by two observers simultaneously and data submitted to analyser. Statistical Analysis: IBM SPSS (Version 20.0). P < 0.05 was considered as statistically significant. Results: Combination of these two scales show high odds ratio (39%) and kappa coefficient (0.76) suggesting excellent agreement. Specificity of combination of these scales is very high (95.1%) than individual (FPS-R-17.85%, FLACC-2.2%). Spearman′s correlation coefficient (ρ) was computed to ascertain the correlation between two scales and a significant positive correlation was found (ρ = 0.727, P = 0.00). Conclusion: FPS-R and FLACC scale has excellent agreement to diagnose the severity of postoperative pain in 2-7 years of age group and combination of these two scales has high specificity to assess the severity of postoperative pain than individual