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Catechol-O-methyl transferase (COMT), a catechol-dependent enzyme, plays pivotal role in the development of pain. In different ethnic populations, it is associated with chronic persistent surgical pain (CPSP). In this context, the present study is aimed to assess involvement of COMT allele (Val158Met) in the development of CPSP. The patients (n = 216) underwent cardiac surgery with median sternotomy were selected to assess the magnitude of the CPSP evaluated with pain questionnaires’ after 3 months from surgery. The exon 4 of COMT gene was PCR amplified and sequenced. The quantitative gene expression of COMT using RT-PCR corroborated the COMT enzyme activity. Among 216 patients who underwent sternotomy procedure, 54 patients showed CPSP even after 3 months from surgery. The sequence analysis revealed that, in 25% (54/216) patients having following one or more alleles: c.472G>A (Val158Met) (reported), and novel c.382C>G;c.383G>C (Arg128Ala), c.373C>G (Arg125Gly), c.370G>A (Val124Met), c.359G>C (Gly120Ala), c.349G>A, c.350G>A(Ala117Ser), c.349G>C, c.351C>A (Ala117Pro), c.349G>A (Ala117Thr), c.350G>C (Ala117Gly), and c.405G>C (Ala135Ser) were observed for the first time in Indian population. Distinct CPSP (≥ 4 NRS pain score) was observed in these patients correlating with COMT enzyme activity (7.80 ± 0.92 units/mg) which is 14 times lowered when compared with non-CPSP patient’s (n = 162) 110.15 ± 6.41 units/mg. The findings of COMT gene expression using quantitative RT-PCR corroborated the COMT enzyme activity. The dominant effect of mutant COMT alleles connecting with low enzyme activity resulted in CPSP, warrants COMT genetic analysis prior to surgery was useful to predict the occurrence of CPSP.

Background: Following general anaesthesia, post-operative shivering, apart from its physiological and haemodynamic effects, has been described as even worse than surgical pain. Methods: After ethical committee approval and informed consent, ninety patients were subjected to study. They were randomly divided into three groups. Just after intrathecal bupivacaine injection, all patients received prophylactically intravenous drug as normal saline (Group C, n = 30) or ketamine 0.5 mg/kg (Group K, n = 30) or tramadol 2 mg/kg (Group T, no = 30) for shivering. The incidence and degree of shivering and the effectiveness and side effects of ketamine and tramadol in preventing shivering during the post-operative period were recorded. Results: We compared the efficacy of tramadol and ketamine in the prevention of post-anaesthetic shivering in patients undergoing surgery under GA. The incidence of post-anaesthetic shivering was significantly less with tramadol and ketamine as compared to that of the control group (P < 0.01). Tramadol and ketamine were equally effective in controlling the severity of shivering as compared to that of the control group (P = NS). The prevention of shivering was comparable in the tramadol and ketamine groups (P > 0.05). Patients in the ketamine group had statistically significant sedation at 20 and 30 min compared to the tramadol and control groups (P < 0.05). In this study, we can assume that both intravenous tramadol 2 mg/kg and intravenous ketamine 0.5 mg/kg are highly effective and comparable in the prevention of post-anaesthetic shivering and the possible mechanisms is by lowering of shivering threshold.

Background: Unanticipated difficult tracheal intubation remains a primary concern of anaesthesiologists. The aim of the present study was to compare upper-lip bite test (ULBT) with other four predictors namely modified Mallampati test (MMT), thyromental distance (TMD), sternomental distance (SMD) and interincisor distance (IID) for predicting difficulty in intubation. Methods: Airway assessment indices were evaluated and compared in 60 American Society of Anesthesiologists physical status Grade I and II patients undergoing general anaesthesia at a tertiary care teaching hospital in South India. The cut-off points for defining the difficult intubation (DI) were as follows: for ULBT, Class III; MMT, Classes 3 and 4; TMD

Background: Various adjuvants were combined with local anaesthetic agents, either intrathecally or epidurally, to prolong the duration of a denser neuraxial block and achieve adequate intraoperative conditions. Methods: In this prospective randomised double-blind placebo-controlled study, 90 patients were randomly allocated into three groups of 30 each depending upon the intrathecal adjuvant used. Standardised anaesthetic technique and monitoring for subarachnoid block (and epidural catheter placement) with 3 mL of 0.5% hyperbaric bupivacaine was followed. In addition, Group K (n = 30) received 0.3 mg/kg of preservative-free ketamine, Group F (n = 30) received 25 μg (0.5 mL) of fentanyl and Group C (control group, placebo, n = 30) received 0.5 mL normal saline. Time of onset and duration of sensory and motor block and duration of analgesia, haemodynamic parameters, sedation scores intra-operatively and post-operatively and side effects were recorded and analysed. Results: The mean time (sec) to onset of sensory (P = 0.04) and motor (P = 0.02) blockade was prolonged, and the duration (min) of sensory (P = 0.003) and motor (P = 0.009) block and the duration of analgesia (min) (P = 0.022) were shorter in the Group K compared to other two groups. Fentanyl showed shorter onset time, longer duration of sensory and motor block and duration of analgesia in contrast to ketamine and placebo. Conclusions: Fentanyl (25 μg) was superior to 0.3 mg/kg of ketamine and placebo as an intrathecal adjuvant with minimal side effects.

We aimed to show that a single preprocedural dose of either dexmedetomidine or fentanyl reduces procedural pain and discomfort and provides clinically acceptable sedation. In this prospective, double-blind study, sixty patients scheduled for elective surgery and requiring planned central venous catheter insertion were randomized to receive dexmedetomidine (1 μg/kg), fentanyl (1 μg/kg), or 0.9% normal saline intravenously over ten minutes followed by local anesthetic field infiltration before attempting central venous catheterization. The primary outcome measures are assessment and analysis of pain, discomfort, and sedation level before, during, and after the central venous catheter insertion at five time points. The median (IQR) pain score is worst for normal saline group at local anaesthetic injection [6 (4–6.7)] which was significantly attenuated by addition of fentanyl [3 (2–4)] and dexmedetomidine [4 (3–5)] in the immediate postprocedural period (P=0.001). However, the procedure related discomfort was significantly lower in dexmedetomidine group compared to fentanyl group in the first 10 min of procedure after local anaesthetic Injection (P=0.001). Fentanyl is more analgesically efficient for central venous catheter insertion along with local anaesthetic injection. However, dexmedetomidine has the potential to be superior to fentanyl and placebo in terms of providing comfort to the patients during the procedure.

Context: Central venous catheter (CVC) insertion induces pain and discomfort to a conscious patient despite application of a local anesthetic (LA) field block and this pain can be greatly lessened by using additional analgesics. Aim: The aim of this study is to evaluate the efficacy of fentanyl along with LA field infiltration in controlling pain and discomfort associated with CVC insertion. Settings and Design: A prospective, randomized, double-blind, placebo-controlled trial was conducted at tertiary referral center. Materials and Methods: Fifty-four patients scheduled for planned CVC were randomly assigned to receive either fentanyl (2 μg/kg) or 0.9% normal saline. Pain and discomfort using a verbal numeric rating pain scale at 5 times points during CVC insertion were assessed and analyzed. Results: The median interquartile range pain score is worst for placebo group after LAI (5 [3-6]) and in the immediate postprocedure period (5 [4-5]) which was significantly attenuated by addition of fentanyl (3.5 [2-5] and 3 [2-4]) ( P = 0.009 and 0.001 respectively). Overall, fentanyl and placebo group were not statistically different with median discomfort score except at T10 ( P = 0.047). Conclusions: Preprocedural bolus fentanyl infusion provides adequate analgesia and can be safely used for alleviating pain during CVC insertion in conscious patients.

Background: Spinal anaesthesia with bupivacaine for lower limb and lower abdominal surgeries is limited by the fixed duration of action and cannot be prolonged except with usage of spinal catheters which increase the chance of infection and occurrence of haemodynamic instability when used in high doses. To minimize the instability in haemodynamics, several neuraxial adjuvants have been used. Methods: We carried out a prospective randomized double-blind study in 60 patients posted for lower abdominal and lower limb surgeries. Patients were divided into two groups of 30 each. Both groups received 3 mL of intrathecal hyperbaric 0.5% bupivacaine. In addition, ketamine group (Gr K) received ketamine 0.1mg/kg body weight intathecal (made to total volume of 0.5 mL); saline group (Gr S) received equal volumes of 0.9% normal saline intrathecally. The onset and duration of sensory and motor blockade and intraoperative haemodynamics were studied. Results: Addition of ketamine in comparison to saline administration produced significantly earlier onset (5.2±1Vs. 3.4±1; p=0.000), prolonged duration of sensory block (129.7±14.9 Vs. 111.3±11; p=0.000) and long duration of postoperative analgesia (150.8±11.7Vs. 127.8±12.8; p=0.000). Conclusion: Addition of ketamine to intrathecal hyperbaric bupivacaine provides better intraoperative spinal block characteristics, stable haemodynamics and longer duration of postoperative analgesia.

We report a 35-year-old gentleman who presented to us with respiratory distress. He was diagnosed to have a large anterior mediastinal mass and was and posted for debulking of mediastinal mass. Immediately after intubation, airway collapsed and there was difficulty in ventilating the lungs, followed by drop in oxygen saturation. After sternotomy, oxygen saturation and airway pressures improved. In this report we discussed in detail about the successful anaesthetic considerations for patients with large anterior mediastinal tumour including the management of airway obstruction.

Back ground: Laparoscopic surgeries have advantages like shorter stay and rapid return to normal activities because of small incision and les pain. Pain is an unpleasant sensation in the post-operative period. Methods: Fifty patients of American society Anesthesiologists (ASA) grade I and II, scheduled to undergo laparoscopic surgery, were randomized into butorphanol group (Group B) (n=25) and fentanyl group (Group F) (n=25). Four minutes before induction of anesthesia, Group B received inj. butorphanol 40 μg/Kg intravenously while Group F received Inj. fentanyl 2 μg/kg intravenously. All patients received general anaesthesia with controlled ventilation. Heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), end tidal carbon dioxide (ETCO2), and oxygen saturation were monitored at different intervals. Results: The demographic data was comparable in both groups (p

Background: Treatment of acute post-thoracotomy pain is particularly important not only to keep the patient comfortable but also to minimize pulmonary complications. Aim: This study was designed to test the effect of pre-induction administration of clonidine, given as a single intravenous dose, on post-operative pain scores and fentanyl consumption in patients after thoracic surgery. Setting and Design: Tertiary referral centre. Prospective, randomised, double-blind, placebo-controlled trial. Methods: Sixty patients were randomly allocated to receive clonidine (3 mcg/kg) or saline pre-operatively before induction of anaesthesia. The primary endpoint was pain on coughing (visual analogue scale (VAS) 0–100 mm) 120 min after surgery, time to first analgesic injection in the post-anaesthesia care unit (PACU) and 24-h fentanyl consumption. Statistical Analysis: For between-group comparisons, t-test and U-test were used as appropriate after checking normality of distribution. The incidence of complications between the groups was compared by Fisher's exact test. Results: The post-operative VAS for the first 120 min and the fentanyl consumption at 24 h was significantly greater in the placebo group compared with the clonidine group (P

Background and Aims: Intraperitoneal local anaesthetic instillation (IPLAI) reduces postoperative pain and analgesic consumption effectively but the timing of instillation remains debatable. This study aims at comparing pre-emptive versus post-surgery IPLA in controlling postoperative pain after elective laparoscopic cholecystectomy. Methods: Ninety patients belonging to American Society of Anesthesiologists physical status I or II were randomly assigned to receive IPLAI of either 30 ml of normal saline (C) or 30 ml of 0.5% bupivacaine at the beginning (PE) or at the end of the surgery (PS) using a double-dummy technique. The primary outcome was the intensity of postoperative pain by visual analogue scale score (VAS) at 30 minute, 1, 2, 4, 6, 24 hours after surgery and time to the first request for analgesia. The secondary outcomes were analgesic request rate in 24 hours; duration of hospital stay and time to return to normal activity. Data were compared using analysis of variance, Kruskal-Wallis or Chi-square test. Results: For all predefined time points, VAS in group PE was significantly lower than that in groups C (P < 0.05). The time to first analgesic request was shortest in group C (238.0 ± 103.2 minutes) compared to intervention group (PE, 409.2 ± 115.5 minutes; PS, 337.5 ± 97.5 minutes;P < 0.001). Time to attain discharge criteria was not statistically different among groups. Conclusion: Pre-emptive intraperitoneal local anaesthetic instillation resulted in better postoperative pain control along with reduced incidence of shoulder pain and early resumption of normal activity in comparison to post surgery IPLAI and control.

Background: Pain on injection with propofol is a well recognized problem sometimes very distressing to patient. Current study compared the effectiveness of intravenous dexmedetomidine and lignocaine pretreatment for the prevention of propofol pain during induction of general anaesthesia. Methods: Ninety, American Society of Anesthesiologists (ASA) grade I and II patients were randomised into three groups of 30 each, Group D, Group L and Group N. Group D, patients received dexmedetomidine 0.2 μg/kg diluted to 5 ml of normal saline, group L, patients received 0.5 mg/kg preservative free lignocaine diluted to 5 ml of normal saline and group N, patients received 5 ml of normal saline. Intravenous access was secured with 20 G cannula and venous occlusion was applied to forearm using a pneumatic tourniquet inflated to 90 mm of Hg for 1 minute. The study drugs were injected over 5 seconds and after 1 minute venous occlusion was released and 25% of total calculated dose of propofol (2 mg/kg) was given intravenously over a period of 60 seconds. Severity of pain was evaluated using McCrirrick and Hunter scale at 0 seconds, 30 seconds and 60 seconds respectively and then remaining propofol and neuromuscular blocking agent was given. Results: The groups were comparable demographically. There was significant difference in pain scores assessed at 0 seconds, 30 seconds and at 60 seconds between the three groups. Conclusions: Dexmedetomidine in a dose of 0.2 μg/kg before applying venous occlusion by tourniquet for one minute in the same vein before inducing the patient with propofol was effective in decreasing the propofol injection pain when compared to lignocaine in a dosage of 0.5 mg/kg and placebo.