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Background and Aims: Genicular nerve block (GNB) is beneficial in early ambulation and faster patient discharge since it selectively blocks articular branches and is motor-sparing. This study aimed to compare the analgesic efficacy of ultrasound (US)-guided GNB with adductor canal block (ACB) in patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR). Methods: This randomised, double-blind study was conducted on 38 adults undergoing arthroscopic ACLR. Patients in Group GNB (n = 19) received US-guided GNB with 3 ml of 0.25% bupivacaine and 2 mg dexamethasone. Patients in Group ACB (n = 19) received US-guided ACB with 20 ml of 0.25% bupivacaine with 6 mg dexamethasone. Postoperative rescue analgesia was provided by intravenous Patient Controlled Analgesia (PCA) with morphine. The primary outcome was Numerical Rating Scale (NRS) pain scores over 24 h. The secondary outcome was the duration of analgesia and 24-h morphine consumption. The Chi-square test was used to test the statistical significance between categorical variables. Independent t-test or Mann–Whitney U test was used to compare continuous variables. Results: NRS scores at rest and physical activity at 24 h were similar in both the groups (P = 0.429 and P = 0.101, respectively). The mean time to rescue analgesia was comparable in both groups (Group GNB: 820.79 [483.65] min [95% confidence interval {CI}: 603.31–1038.27] and Group ACB: 858.95 [460.06] min [95% CI: 652.08, 1065.82], P = 0.805), and the mean 24-h morphine consumption was also comparable in both groups (P = 1.000). Conclusion: US-guided GNB has an analgesic efficacy similar to US-guided ACB for patients undergoing arthroscopic ACLR.

Background and Aims: There is limited literature wherein the hypotensive drugs have been compared to know the cerebral effects by monitoring regional cerebral oxygen saturation (rScO2). This study aimed to compare the effects of dexmedetomidine and nitroglycerin on rScO2 during controlled hypotensive anaesthesia using near-infrared spectroscopy (NIRS). The primary objective was to evaluate the non-inferiority of dexmedetomidine versus nitroglycerin in the occurrence of cerebral desaturation events (CDEs) during hypotensive anaesthesia. Methods: Adult patients scheduled to undergo head and neck surgery under general anaesthesia randomised to receive either dexmedetomidine or nitroglycerin infusion for controlled hypotensive anaesthesia. Cerebral oximetry was monitored with NIRS, and data regarding CDEs, bilateral rScO2, and peri-operative haemodynamics were collected. Continuous data were analysed using unpaired Student's t-tests except for intra-group analyses, which were analysed using paired t-tests. Categorical data were analysed using the Chi-square test. For comparison of time to CDEs, Kaplan–Meier survival analysis with log-rank test was performed. Results: Of the 82 patients in both groups, CDEs were observed in 15 patients each. A decrease from baseline by 20% was observed in three patients: one in Group N and two in Group D. Statistically, there was an equal risk of getting CDEs in the groups. The time to CDE was comparable (P > 0.05). The difference in heart rate was statistically significant (P < 0.001). Conclusion: Dexmedetomidine is non-inferior to nitroglycerin in terms of the occurrence of cerebral desaturation events when used for controlled hypotensive anaesthesia in head and neck surgeries.

Background and Aims: Single-shot erector spinae plane block (ESPB) provides excellent analgesia in mastectomy in the immediate post-operative period but is not sufficient to maintain for prolonged duration. This study compares the efficacy of programmed intermittent bolus (PIB) versus continuous infusion (CI) techniques after ESPB by placing a catheter for mastectomy. Methods: After ethical approval and patient consent, ESPB was performed at the T4 level in 50 patients with an initial bolus of 20 mL 0.375% ropivacaine and a catheter placed 30 min before surgery. In the postoperative period, they were randomised to Group I - intermittent bolus of 20 mL 0.2% ropivacaine every 4 h for 24 h and Group C - continuous infusion of 0.2% ropivacaine at 5 mL/h for 24 h. The primary outcome was the 24-h fentanyl consumption by patient-controlled analgesia device. Data was analysed using Stata 14.0. Results: Group I patients had reduced post-operative fentanyl consumption {mean [standard deviation (SD)]: 166 (139.17) μg vs 332 (247.96) μg, P = 0.002} and lower median NRS scores (1 h: 3 vs 5), (2 h: 3 vs 5), (4 h: 3 vs 5), (6 h: 4 vs 5) with a higher mean (SD) Quality of Recovery-15 score {134.4 (8.53) vs 127 (12.89), P = 0.020} compared to Group C, respectively. The 24-h dermatomal sensory coverage was more comprehensive in Group I compared to Group C. Conclusion: The PIB technique after ESPB provides decreased postoperative opioid consumption, better post-operative analgesia and quality of recovery compared to the CI technique in patients undergoing mastectomy.

Background and Aims: Laparoscopic trans abdominal preperitoneal (TAPP) repair of hernia is one of the most commonly performed surgeries and may cause significant postoperative pain. Among different truncal block techniques, quadratus lumborum (QL) and transversus abdominis plane blocks (TAP) are used during this abdominal surgery. We aimed to investigate whether, bilateral QL block by trans-muscular approach provided better analgesia as compared to posterior TAP block in these patients. Methods: Forty adult patients with American Society of Anesthesiologists physical status I and II, undergoing inguinal hernia repair were randomized to receive either QL or TAP block, with 20 mL of 0.25% ropivacaine bilaterally. The primary objective of the study was to compare the total fentanyl consumption (in μg) within 24 hours postoperatively. The secondary objectives studied were dermatomal spread, quality of recovery at discharge and at 3 months postoperatively. Results: There was a significant reduction in total 24-hour fentanyl consumption (552 ± 229.56 vs 735.5 ± 264 μg, P =0.01) in the QL group, with longer duration of analgesia [282.5 ± 89.9 min group TAP vs. 354.8 ± 107 min QL, (mean difference -72.34,95% confidence interval -135.516 to -9.024), P =0.03], as compared to TAP group. At T8 and T9 dermatomes, greater proportion of patients in the QL group attained analgesia. Quality of Recovery at 24 hours and at 3 months of follow-up were comparable. Conclusion: QL block provided better perioperative analgesia than TAP block, in patients undergoing laparoscopic hernia repair. It also leads to greater dermatomal spread but without any decrease in the incidence of chronic pain at 3 months postoperatively.

Background and Aims: Analgesia for hip surgery involves cutaneous anaesthesia at the site of the skin incision and the anterior hip capsule. This study aimed to compare continuous ultrasound (US)-guided transmuscular quadratus lumborum block (TQLB) with psoas compartment block (PCB) for analgesia in patients undergoing total hip arthroplasty (THA) under general anaesthesia (GA). Methods: This randomised, observer-blinded trial included 18–70-year-old American Society of Anesthesiologists physical status I–III patients undergoing THA under GA with either US-guided continuous TQLB or PCB. Primary objectives included a visual analogue scale (VAS; 0–100 mm) at rest and mobilisation at 6 h postoperatively (analysed by intention to treat and per protocol) using a non-inferiority margin of 20 mm. Secondary objectives included VAS at other time points, 24-h fentanyl consumption (analysed using the Wilcoxon rank-sum test), sensory dermatomes anaesthetised, motor weakness 30 min after block, and haemodynamic response to skin incision (analysed using the Chi-squared or Fisher's exact test). A P value less than 0.05 was considered statistically significant. Results: VAS (0-100 mm) score at 6 h on rest was 25.34 ± 14.25 and 27.3 ± 9.6, mean difference (MD) was 1.9 [−3.3, 7.1] and at movement was 35.1 ± 23.0 and 38.6 ± 17.0, MD was 3.5 [−5.2, 12.2], in the PCB (n = 29) and QLB (n = 30) groups, respectively (i.e. less than the non-inferiority margin). However, VAS (rest) at 1, 12, and 24 h postoperatively and median (IQR) 24-h fentanyl consumption was significantly higher in the QLB group (1212.5 [300–2345] μg] when compared to the PCB group (635 [100–1645] μg; P = 0.0004). Conclusion: Though statistically, continuous QLB was non-inferior to continuous PCB for pain at rest and mobilisation at 6-hours postoperatively, a higher 24-hour perioperative fentanyl consumption and VAS show that QLB was clinically inferior to PCB.

Background and Aims: Recovery from surgery and anaesthesia is usually observed through conventional indicators. The Quality of Recovery (QoR-15) score was specially designed to measure psychometric and functional recovery from the patient's perspective. This study aimed to evaluate QoR-15 following the administration of intravenous (IV) lignocaine or IV fentanyl in patients undergoing septoplasty surgery. Methods: This randomised, controlled trial was conducted on 64 patients of American Society of Anesthesiologists (ASA) physical status I and II, of either sex, of ages between 18 and 60 years, and who were scheduled for septoplasty. The primary end point was to compare the quality of recovery following the administration of IV lignocaine(group L) and IV fentanyl (group F) using the QoR-15 score in patients undergoing septoplasty. Secondary end points were to compare postoperative analgesia, recovery characteristics, and adverse effects in both groups. Statistical analysis was done using the Shapiro–Wilk test, paired t test/ Wilcoxon signed-rank test, and unpaired t test/Mann–Whitney U test. A P-value 9 and gastrointestinal recovery was shorter in group L compared to group F. Conclusion: Both IV lignocaine and IV fentanyl improved postoperative QoR-15 score; however, lignocaine had a higher postoperative QoR-15 score than fentanyl, in addition to showing early discharge readiness, better analgesia, and better recovery profile in patients following septoplasty surgery.

Background and Aims: Modified radical mastectomy (MRM) is associated with significant postoperative pain for which many blocks including thoracic paravertebral (TPV) block are being used. Erector spinae plane (ESP) block is a recently described technique. We planned to compare the efficacy and safety of ultrasound-guided continuous ESP and TPV blocks for postoperative analgaesia following MRM. Methods: Sixty-six patients belonging to American Society of Anaesthesiologists physical status I and II, aged 25–85 years, undergoing MRM were enrolled and randomly allocated into two groups. Ipsilateral block was given preoperatively at T3 or T4 level with 20 ml of 0.5% ropivacaine and 50 μg fentanyl. Infusion of 0.5% and 0.2% ropivacaine with fentanyl 2 μg/ml at a rate of 5 ml/hr was continued during intraoperative and postoperative period, respectively. Pain was assessed using visual analogue scale (VAS) till 24 hours. Block performance time, time to first rescue analgaesia, total amount of rescue analgaesic consumed, the incidence of procedure-related and postoperative complications, failure rate and patient satisfaction score were also recorded. Data collected were analysed using the Chi-square test or Student's t-test with the help of SPSS 22.0. Results: Demographics, baseline vitals, VAS scores both at rest and on movement, block performance time, time to first rescue analgaesia, the total amount of rescue analgaesia and patient satisfaction score were comparable in both groups (P value > 0.05). No complications were observed in either group. Conclusion: In patients undergoing MRM, continuous catheter technique ESP block is as efficacious and safe as TPV block for providing prolonged postoperative analgaesia.

Background and Aims: Sedation improves patient satisfaction, comfort and acceptance of regional anaesthesia. Propofol using bispectral index (BIS)/target-controlled infusion (TCI) system can be an optimal method of sedation, as it combines objective measurement of sedation using BIS along with maintenance of a steady plasma concentration of propofol with the TCI device. The aim of this study was to ascertain the dose and safety of propofol using BIS/TCI system for sedation in patients undergoing surgeries under neuraxial anaesthesia. Methods: One hundred and seven adult patients, undergoing elective surgical procedures under spinal or combined spinal epidural anaesthesia, were recruited. Propofol infusion was started with TCI at an initial target plasma concentration (Cpt) of 1.2 μg/mL, and after equilibration between Cpt and effect site concentration (Ce), propofol was then adjusted in increments and/or decrements of 0.2 μg/mL in order to maintain a BIS value between 60 and 80. The average time to reach BIS = 80 after starting infusion was 7.32 ± 3.13 minutes. The objective was to calculate mean Cpt value maintaining BIS between 60 and 80 and to observe recovery time and complications. Results: Mean Cpt value was 1.13 ± 0.17 μg/mL with 95% confidence interval (1.10–1.16 μg/mL). In 85% of patients, a BIS value of 60–80 was maintained at Cpt ≤ 1.2 μg/mL. No patient had severe complications requiring stoppage of infusion. Conclusion: Propofol sedation using BIS/TCI system can provide safe and convenient sedation during neuraxial anaesthesia at very low plasma concentration, Cpt ≤ 1.2 μg/mL in majority of patients. There were no periprocedural complications, and recovery was rapid.

Background and Aims: Serratus anterior plane (SAP) blocks can be given either superficial or deep to the serratus anterior muscle to block the branches of intercostal nerves providing analgesia to the anterolateral chest wall. This prospective randomised comparative study aimed to compare the analgesic efficacy of superficial and deep SAP block in breast surgeries. Methods: Forty female patients scheduled to undergo elective modified radical mastectomy under general anaesthesia (GA) were randomly assigned to receive ultrasound guided SAP block with 30 ml 0.375% ropivacaine either superficial (group S, n = 20) or deep (group D, n = 20) to the serratus anterior muscle, before the induction of GA. The primary outcome was post operative fentanyl requirement over 24 hours and secondary outcomes were comparison of numerical rating scale (NRS) scores for pain, sensory block mapping, time to perform the block, number of needle attempts, etc. Results: The post operative 24-hour fentanyl requirement was comparable between group S and D (318.75 ± 80.65 versus 272.5 ± 80.25 μg, P = 0.07). NRS pain scores were comparable between the groups. Sensory block mapping done at various levels showed T3–T7 block in most of the patients with no difference between the groups. Block performance time (6.05 ± 3.27 versus 8.35 ± 3.26 minutes, P = 0.034) and number of needle attempts was significantly lesser in group D. Conclusion: There was no difference in analgesic efficacy when SAP block was given superficial or deep to serratus anterior muscle for modified radical mastectomies. However, deep SAP block required less time and number of attempts to perform than superficial technique.

Background and Aims: Inferior vena cava (IVC) diameter and its respiratory variability have been shown to predict post-induction hypotension with high specificity in a mixed population of patients. We assessed whether these parameters could be as reliable in healthy adult patients as in a mixed patient population. Methods: In the present prospective observational study, 110 patients of either sex, aged between 18 and 50 years, belonging to American Society of Anesthesiologists class I and II, fasted as per the institutional protocol and scheduled for elective surgery under general anaesthesia were enroled. Prior to induction, ultrasound examination of IVC was done and variation in IVC diameter with respiration was assessed. Maximum and minimum IVC diameters [(dIVCmax) and (dIVCmin), respectively] over a single respiratory cycle were measured and collapsibility index (CI) was calculated. Vitals were recorded just before induction and at every minute after induction for 10 min. Episodes of hypotension (mean arterial pressure [MAP] 30% from baseline) during the observation period were recorded. The receiver operating characteristic (ROC) curve was constructed for determining optimum cut-off with sensitivity and specificity of IVC diameters and CI for development of hypotension. Results: IVC was not visualised in 22 patients. Out of the remaining 88 patients, 17 (19.3%) patients developed hypotension after induction. The dIVCmax, dIVCmin and CI were comparable between patients who developed and who did not develop hypotension. The area under curve of ROC for CI, dIVCmax and dIVCmin was 0.51, 0.55 and 0.52, respectively, with optimum cut-off value of 0.46, 1.42 and 0.73, respectively. Conclusion: Ultrasound-derived IVC parameters demonstrate poor diagnostic accuracy for prediction of hypotension after induction in healthy adult patients.

Background and Aims: Postoperative pain following laparoscopic donor nephrectomy (LDN) is significant and no suitable analgesic technique is described. Opioid analgesia in standard doses is often suboptimal and associated with numerous adverse effects. Transversus abdominis plane (TAP) block has been evaluated in various laparoscopic procedures. Intrathecal morphine (ITM) has been seen to provide long-lasting analgesia of superior quality in laparoscopic colorectal procedures. Methods: The present study was undertaken to evaluate the analgesic efficacy of single-dose ITM 5 μg/kg for LDN. After ethics approval, 60 adult patients scheduled for LDN were randomised to receive intravenous fentanyl, ultrasound-guided TAP block or ITM for postoperative analgesia. Postoperative 24-h patient-controlled analgesia (PCA) fentanyl consumption, visual analogue scale (VAS) score and intraoperative fentanyl and muscle relaxant requirements were compared. Statistical analysis was performed using appropriate statistical tests by using Stata 11.1 software. Results: Haemodynamic stability at pneumoperitoneum and in the post anaesthesia care unit was significantly better in patients receiving ITM. Intraoperative rescue fentanyl requirement (P = 0.01) and postoperative fentanyl requirement until 24 h (P = 0.000) were significantly lower in the morphine group. Postoperative VAS at rest and on movement was significantly lower in the morphine group at all points of assessment (P = 0.000). Conclusion: ITM 5 μg/kg provides better intraoperative and postoperative analgesia and reduces postoperative PCA fentanyl requirement in laparoscopic donor nephrectomy compared to TAP block or intravenous fentanyl.

Background and Aims: Intense bleeding during general anaesthesia (GA) is the major limitation during functional endoscopic sinus surgery (FESS). This study was aimed to compare the efficacy of dexmedetomidine and magnesium sulphate (MgSO4)for controlled hypotension in FESS. Methods: Sixty eight patients undergoing FESS were randomised to receive either dexmedetomidine 1 μg/kg over 10 min followed by infusion at 0.2 to 0.7 μg/kg/h (Group D) or MgSO440 mg/kg over 10 min followed by an infusion at 10 to 15 mg/kg/h (Group M). Anaesthesia and infusion rates for study drugs were maintained with sevoflurane to keep MAP between 60–70 mmHg throughout the surgery. The time to reach the target MAP, the number of patients requiring a minimum and maximum infusion doses of study drugs were noted. Results: The mean time to achieve target mean arterial pressure (MAP) was less in group D (10.59 ± 2.04) as compared with (21.32 ± 4.65 min) group M (P < 0.001). The target MAP was achieved between 5–15 min in 73.52% patients (Group D) with an infusion dose of 0.2–0.4 μg/kg/h of dexmedetomidine without the use of sevoflurane, while 82.35% patients in group M required 4% sevoflurane along with >12–15 mg/kg/hr infusion of MgSO4to achieve target MAP in 10–20 min. Conclusion: Dexmedetomidine is superior to MgSO4in achieving target MAP in lesser time with minimum infusion dose.

The corona virus disease 2019 (COVID-19) pandemic sweeping across the world has severely strained health care resources (equipment and personnel) forcing us to rethink strategies to provide obstetric care while judiciously using resources. We describe the anaesthetic management of a mildly symptomatic, COVID-19 positive, 28-year-old second gravida with term pregnancy who was taken up for an elective caesarean section under subarachnoid block in a standalone maternity facility. Challenges encountered and modifications of standard procedures so as to optimize patient care and minimize exposure of health care professionals are also discussed.

During pregnancy, the body goes through various anatomical and physiological changes to provide suitable environment for foetal development, to cater to the increased metabolic demands and to prepare for the childbirth. These changes have notable anaesthetic implications in determining the optimal anaesthetic technique, while also keeping in mind the gestational age, type of procedure and any coexisting medical condition. It is important to note that these changes revert to baseline (pre-pregnancy) levels at different time intervals during the postpartum period which is important while managing postpartum patients. None of the anaesthetic agents are known teratogens; however, there is concern regarding the effects of some agents on the developing brain.

Background and Aims: Intrathecal bupivacaine results in complete anaesthetic block of longer duration than ropivacaine. Fentanyl as an adjuvant may improve the quality of spinal block of ropivacaine while maintaining its advantage of early motor recovery. In this study, we proposed to compare the efficacy and safety of intrathecal ropivacaine-fentanyl (RF) with bupivacaine-fentanyl (BF) for major lower limb orthopaedic surgeries. Methods: Sixty patients were randomly allocated to receive either intrathecal 15 mg 0.5% ropivacaine with 25 mcg fentanyl (Group RF) or 15 mg 0.5% bupivacaine with 25 mcg fentanyl (Group BF). The onset, duration, spread of sensory and motor block, haemodynamic parameters and side effects were recorded. Statistical Package for Social Sciences 20 software was used for statistical analysis. Results: Time to reach highest sensory level and complete motor block were comparable. Sensory regression to L1 dermatome was 226 ± 46.98 min in Group RF and 229.33 ± 50.51 min in Group BF, P = 0.36. The motor recovery to Bromage scale 1 was faster in Group RF (242.8 ± 47.06 min) than Group BF (268 ± 49.9 min) P = 0.023. Time for rescue analgesia was prolonged in Group BF (263.33 ± 63 min) when compared to Group RF (234.44 ± 58.76 min), P = 0.021. The haemodynamic stability was better in Group RF than Group BF. Conclusion: Intrathecal RF provided satisfactory anaesthesia with haemodynamic stability for major lower limb orthopaedic surgery. It provided similar sensory but shorter duration of motor block compared to BF which is a desirable feature for early ambulation, voiding and physiotherapy.

A 42 - year-old diabetic and hypertensive male with good effort tolerance was administered peribulbar block for vitreo-retinal surgery. Ten millilitres of an equal mixture of 2% lignocaine and 0.5% bupivacaine was administered for the block after ascertaining negative aspiration for blood. Inadequate akinesia of the eye necessitated further supplementation with 4 mL of local anaesthetic (LA) mixture. Thirty minutes later, the patient complained of uneasiness, respiratory distress and desaturated despite oxygen supplementation. He was found to be in pulmonary oedema. He subsequently developed a weak thready pulse, became unresponsive, apnoeic and had generalized tonic clonic convulsions. Immediately, atropine 0.6 mg, followed by midazolam, intubation, mechanical ventilation, morphine and furosemide, were administered intravenously. Spontaneous respiration returned in 20 minutes and he started responding to verbal commands 90 minutes later. He was weaned off the ventilator the next morning. There was no evidence of an ischemic myocardial event and non-contrast computerized tomography scan of the head was normal. The reversible cardiorespiratory arrest, associated convulsions and loss of consciousness were suggestive of LA toxicity. Pulmonary oedema manifesting as respiratory distress and desaturation can be the initial manifestation of LA toxicity in patients with pre-existing cardiovascular disease undergoing eye surgery under peribulbar block.

Standardization of anaesthetic equipment is needed for safe anaesthetic practice. Various organizations and regulatory bodies have been made throughout world to formulate and control standards for anaesthesia equipment including endotracheal tubes. All endotracheal tubes must conform to ASTM standards. This has medico-legal importance also. Regulatory bodies should look after the whole process right from the manufacturers to the actual users. The Indian Society of Anaesthesiologists promotes safe anaesthetic practice, by establishing purchase guide-lines for equipments and drugs. It is working in collaboration with World Federation of Societies of Anaesthesiologists. Standards have made anaesthesia and critical care equipment much safer over the years. There is need to form standards for various equipment in India.

Indoxacarb is a broad-spectrum non-organophosphorus oxidiazine insecticide widely used in farming. Once absorbed it acts on sodium channels and blocks the flow of sodium ions. We report a case of indoxacarb poisoning in a farmer following suicidal consumption, manifested as unconsciousness, cyanosis and stationary SpO 2 values. Methemoglobinaemia was suspected on clinical presentation which was successfully managed with inj. methylene blue and other symptomatic and supportive treatment.

Post traumatic stress resulting from an intensive care unit(ICU) stay may be prevented by adequate level of sedation and analgesia. Aims of the study were reviewing the current practices of sedation and analgesia in our ICU setup and to assess level of sedation and analgesia to know the requirement of sedative and analgesics in mechani-cally ventilated ICU patients. This prospective observational study was conducted on 50 consecutive mechanically ventilated patients in ICU over a period of 6 months. Patient′s sedation level was assessed by Ramsay Sedation Scale (RSS = 1 : Agitated; 2,3 : Comfortable; 4,5,6 : Sedated) and pain intensity by Behavioural Pain Scale (BPS = 3 :No pain, to 16 : Maximum pain). BPS, mean arterial pressure(MAP) and heart rate(HR) were assessed before and after painful stimulus (tracheal suction). Although no patient had received sedative and analgesics, mean Ramsay score was 3.52±1.92 with 30% patients categorized as ′agitated′, 12% as ′comfortable′ and 58% as ′sedated′ because of depressed consciousness level. Mean BPS at rest was 4.30±1.28 revealing background pain that further increased to 6.18±1.88 after painful stimulus. There was significant rise in HR (10.30%), MAP (7.56%) and BPS (40.86%) after painful stimulus, P< 0.0001. The correlation between BPS and Ramsay Score was negative and significant (P< 0.01). We conclude that there should be regular definition of the appropriate level of sedation and analgesia as well as monitoring of the desired level, using sedation and pain scales as a part of the total care for mechanically ventilated patients.