Jasbir Kaur

Dexmedetomidine and clonidine in epidural anaesthesia: A comparative evaluation

Efforts to find a better adjuvant in regional anaesthesia are underway since long. Aims and objectives are to compare the efficacy and clinical profile of two α-2 adrenergic agonists, dexmedetomidine and clonidine, in epidural anaesthesia with special emphasis on their sedative properties and an ability to provide smooth intra-operative and post-operative analgesia. A prospective randomized study was carried out which included 50 adult female patients between the ages of 44 and 65 years of (American Society of Anaesthesiologists) ASAI/II grade who underwent vaginal hysterectomies. The patients were randomly allocated into two groups; ropivacaine + dexmedetomidine (RD) and ropivacaine + clonidine (RC), comprising of 25 patients each. Group RD was administered 17 ml of 0.75% epidural ropivacaine and 1.5 μg/kg of dexmedetomidine, while group RC received admixture of 17 ml of 0.75% ropivacaine and 2 μg/kg of clonidine. Onset of analgesia, sensory and motor block levels, sedation, duration of analgesia and side effects were observed. The data obtained was subjected to statistical computation with analysis of variance and chi-square test using statistical package for social science (SPSS) version 10.0 for windows and value of P < 0.05 was considered significant and P < 0.0001 as highly significant. The demographic profile, initial and post-operative block characteristics and cardio-respiratory parameters were comparable and statistically non-significant in both the groups. However, sedation scores with dexmedetomidine were better than clonidine and turned out to be statistically significant (P < 0.05). The side effect profile was also comparable with a little higher incidence of nausea and dry mouth in both the groups which was again a non-significant entity (P > 0.05). Dexmedetomidine is a better neuraxial adjuvant compared to clonidine for providing early onset of sensory analgesia, adequate sedation and a prolonged post-operative analgesia.

Comparative evaluation of dexmedetomidine and fentanyl for epidural analgesia in lower limb orthopedic surgeries

Background and Aims: Opioids as epidural adjunct to local anesthetics (LA) have been in use since long and α-2 agonists are being increasingly used for similar purpose. The present study aims at comparing the hemodynamic, sedative, and analgesia potentiating effects of epidurally administered fentanyl and dexmedetomidine when combined with ropivacaine. Methods: A total of one hundred patients of both gender aged 21-56 years, American Society of Anaesthesiologist (ASA) physical status I and II who underwent lower limb orthopedic surgery were enrolled into the present study. Patients were randomly divided into two groups: Ropivacaine + Dexmedetomidine (RD) and Ropivacaine + Fentanyl (RF), comprising 50 patie nts each. Inj. Ropivacaine, 15 ml of 0.75%, was administered epidurally in both the groups with addition of 1 μg/kg of dexmedetomidine in RD group and 1 μg/kg of fentanyl in RF group. Besides cardio-respiratory parameters and sedation scores, various block characteristics were also observed which included time to onset of analgesia at T10, maximum sensory analgesic level, time to complete motor blockade, time to two segmental dermatomal regressions, and time to first rescue analgesic. At the end of study, data was compiled systematically and analyzed using ANOVA with post-hoc significance, Chi-square test and Fishers exact test. Value of P<0.05 is considered significant and P<0.001 as highly significant. Results: The demographic profile of patients was comparable in both the groups. Onset of sensory analgesia at T10 (7.12±2.44 vs 9.14±2.94) and establishment of complete motor blockade (18.16±4.52 vs 22.98±4.78) was significantly earlier in the RD group. Postoperative analgesia was prolonged significantly in the RD group (366.62±24.42) and consequently low dose consumption of local anaesthetic LA (76.82±14.28 vs 104.35±18.96) during epidural top-ups postoperatively. Sedation scores were much better in the RD group and highly significant on statistical comparison (P<0.001). Incidence of nausea and vomiting was significantly high in the RF group (26% and 12%), while incidence of dry mouth was significantly higher in the RD group (14%) (P<0.05). Conclusions: Dexmedetomidine seems to be a better alternative to fentanyl as an epidural adjuvant as it provides comparable stable hemodynamics, early onset, and establishment of sensory anesthesia, prolonged post-op analgesia, lower consumption of post-op LA for epidural analgesia, and much better sedation levels.

Reduction in the incidence of shivering with perioperative dexmedetomidine: A randomized prospective study

Background and Aims: Shivering is distressing to the patient and discomforting to the attending anesthesiologist, with a varying degree of success. Various drugs and regimens have been employed to abolish the occurrence of shivering. The present study aims to explore the effectiveness of dexmedetomidine in suppressing the postanesthetic shivering in patients undergoing general anesthesia. Materials and Methods: The present study was carried out on 80 patients, in American Society of Anesthesiologists I and II, aged 22–59 years, who underwent general anesthesia for laparoscopic surgical procedures. Patients were allocated randomly into two groups: group N (n = 40) and group D (n = 40). Group D were administered 1 μg/kg of dexmedetomidine intravenously, while group N received similar volume of saline during peri-op period. Cardiorespiratory parameters were observed and recorded during the preop, intraop, and postop periods. Any incidence of postop shivering was observed and recorded as per 4 point scale. Side effects were also observed, recorded, and treated symptomatically. Statistical analysis was carried out using statistical package for social sciences (SPSS) version 15.0 for windows and employing ANOVA and chi-square test with post-hoc comparisons with Bonferronis correction. Results: The two groups were comparable regarding demographic profile (P > 0.05). Incidence of shivering in group N was 42.5%, which was statistically highly significant (P = 0.014). Heart rate and mean arterial pressure also showed significant variation clinically and statistically in group D patients during the postop period (P = 0.008 and 0.012). A high incidence of sedation (P = 0.000) and dry mouth (P = 0.000) was observed in group D, whereas the incidence of nausea and vomiting was higher in group N (P = 0.011 and 0.034). Conclusions: Dexmedetomidine seems to possess antishivering properties and was found to reduce the occurrence of shivering in patients undergoing general anesthesia.

Comparison of two drug combinations in total intravenous anesthesia: Propofol-ketamine and propofol-fentanyl.

Background and Aims: Keeping in consideration the merits of total intravenous anesthesia (TIVA), a genuine attempt was made to find the ideal drug combinations which can be used in general anesthesia. This study was conducted to evaluate and compare two drug combinations of TIVA using propofol–ketamine and propofol–fentanyl and to study the induction, maintenance and recovery characteristics following anesthesia with these techniques. Settings and Design: A case control study was conducted, which included 100 patients, in the department of Anaesthesiology and Intensive care, Government Medical College and Hospital, Patiala. Patients and Methods: A hundred patients between the ages of 20 and 50 years of either gender were divided into two groups of 50 each, and they underwent elective surgery of approximately 1 h duration. Group I received propofol–ketamine while group II received propofol–fentanyl for induction and maintenance of anesthesia. All the results were tabulated and analyzed statistically with students unpaired t-test and chi-square test. Results: Propofol–fentanyl combination produced a significantly greater fall in pulse rate (PR; 9.28% versus 0.23%) and in both systolic (7.94% versus 0.12%) and diastolic blood pressures (BP; 8.10% versus 0.35%) as compared to propofol–ketamine during induction of anesthesia. Propofol–ketamine combination produced stable hemodynamics during maintenance phase while on the other hand propofol–fentanyl was associated with a slight increase in both PR and BP. During recovery, ventilation score was better in group I while movement and wakefulness score was better in group II. Mean time to protrusion of tongue and lifting of head was shorter in group I. Conclusions: Both propofol–ketamine and propofol–fentanyl combinations produce rapid, pleasant and safe anesthesia with only a few untoward side effects and only minor hemodynamic effects.

Attenuation of pressor response and dose sparing of opioids and anaesthetics with pre-operative dexmedetomidine

Background and Aims: Alpha-2 agonists are being increasingly used as adjuncts in general anaesthesia, and the present study was carried out to investigate the ability of intravenous dexmedetomidine in decreasing the dose of opioids and anaesthetics for attenuation of haemodynamic responses during laryngoscopy and tracheal intubation. Methods: One hundred patients scheduled for elective general surgery were randomized into two groups: D and F (n=50 in each group). Group D were administered 1 μg/kg each of dexmedetomidine and fentanyl while group F received 2 μg/kg of fentanyl pre-operatively. Thiopental was given until eyelash reflex disappeared. Anaesthesia was maintained with 33:66 oxygen: nitrous oxide. Isoflurane concentration was adjusted to maintain systolic blood pressure within 20% of the pre-operative values. Haemodynamic parameters were recorded at regular intervals during induction, intubation, surgery and extubation. Statistical analysis was carried out using analysis of variance, chi-square test, Students t test and Mann–Whitney U test. Results: The demographic profile was comparable. The pressor response to laryngoscopy, intubation, surgery and extubation were effectively decreased by dexmedetomidine, and were highly significant on comparison (P<0.001). The mean dose of fentanyl and isoflurane were also decreased significantly (>50%) by the administration of dexmedetomidine. The mean recovery time was also shorter in group D as compared with group F (P=0.014). Conclusions: Dexmedetomidine is an excellent drug as it not only decreased the magnitude of haemodynamic response to intubation, surgery and extubation but also decreased the dose of opioids and isoflurane in achieving adequate analgesia and anaesthesia, respectively.

Palonosetron: A novel approach to control postoperative nausea and vomiting in day care surgery

Background: Postoperative nausea and vomiting (PONV) is one of the complications which hamper the successful implementation of day care surgical procedure in spite of the availability of so many antiemetic drugs and regimens for its prevention. The aim was to compare the prophylactic effects of intravenously (IV) administered ondansetron and palonosetron on PONV prevention in patients undergoing laparoscopic gynecological surgery under general anesthesia. Methods: A prospective double-blind study comprised of 60 ASAI/II female patients between the age group of 25 and 40 years was carried out in the Departments of Anesthesiology and Obstetrics and Gynecology of our institute. Patients were randomly divided into two groups of 30 patients each in a double-blind manner. Group I received 8 mg of inj. ondansetron IV while group II received inj. palonosetron 0.075 mg IV 5 minutes before the induction of anesthesia. The need for rescue antiemetics, episodes of PONV and other side effects were observed for 6 hours in the postanesthesia care unit and thereafter complaints were received on phone after the discharge. At the end of study, results were compiled and statistical data was subjected to statistical analysis using Student two-tailed ‘t’ and χ2 test and value of P<0.05 was considered significant. Results: The demographical profile of the patients was comparable. Twenty and 13.33% of the patients in group I had nausea and vomiting episodes postoperatively as compared to 6.67% and 3.33%, respectively, in group II which was statistically significant (P<0.05). Twenty percent of the patients in group I experienced significant post-op headache as compared to 6.67% in group II. The mean rescue dose of antiemetic was significantly higher (10.6 mg) in the group I as compared to group II (6.4 mg) (P=0.036). The rest of parameters were comparable and statistically nonsignificant. Conclusions: Palonosetron is a comparatively better drug to prevent the PONV in patients undergoing day care surgical procedures as compared to ondansetron as it has got a prolonged duration of action and favorable side-effects profile.

Prevention of hypotension and prolongation of postoperative analgesia in emergency cesarean sections: A randomized study with intrathecal clonidine

Background and Context: Different adjuvants been tried out for neuraxial anesthesia in emergency caesarean section so that the dose of the local anesthetic can be reduced and hypotension thereby prevented. Aims and Objectives: The present study was carried out in patients presenting for emergency lower segment caesarean section (LSCS) to establish the dose of intrathecal clonidine that would allow reduction of the dose of local anesthetic (thereby reducing the incidence and magnitude of hypotension) while at the same time providing clinically relevant prolongation of spinal anesthesia without significant side effects. Materials and Methods: This randomized clinical study was carried out in our institution among 100 pregnant females who underwent emergency caesarean section. The participants were divided randomly into four groups: A, B, C, and D, each comprising 25 parturients. Subarachnoid block was performed using a 26G Quincke needle, with 12 mg of hyperbaric bupivacaine (LA) in group A, 9 mg of LA + 30 μg of clonidine in group B, LA + 37.5 μg of clonidine in group C, and LA + 45 μg of clonidine in group D. The solution was uniformly made up to 2.2 mL with normal saline in all the groups. Onset of analgesia at T10 level, sensory and motor blockade levels, maternal heart rate and blood pressure, neonatal Apgar scores, postoperative block characteristics, and adverse events were looked for and recorded. Statistical analysis was carried out with SPSS® version 10.0 for Windows®, using the ANOVA test with post hoc significance, the Chi-square test, and the Mann-Whitney U test. P<.05 was considered significant and P<.0001 as highly significant. Results: One hundred patients were enrolled for this study. The four groups were comparable with regard to demographic data and neonatal Apgar scores. Onset and establishment of sensory and motor analgesia was significantly shorter in groups C and D, while hypotension (and the use of vasopressors) was significantly higher in groups A and D. Perioperative shivering, nausea, and vomiting were significantly higher in groups A and D, while incidence of dry mouth was significantly higher in group D. Conclusions: The addition of 45 μg, 37.5 μg, and 30 μg of clonidine to hyperbaric bupivacaine results in more prolonged complete and effective analgesia, allowing reduction of up to 18% of the total dose of hyperbaric bupivacaine. From the results of this study, 37.5 μg of clonidine seems to be the optimal dose.

Is intensive care the only answer for high risk pregnancies in developing nations

Background: Management of high risk obstetric patients. Aim: The present study was conducted to evaluate the primary causes of the admission of obstetric patients to Intensive Care Unit (ICU), the presence of co-morbid diseases, outcome of such patients, their survival rate as well as the factors which contribute to the maternal mortality. Settings and Design: A retrospective study was conducted in the Department of Obstetrics and Gynaecology and Anaesthesiology/ICU of our Institute. Materials and Methods: Sixty-one obstetric patients, who were admitted to ICU between 20 December 2006 and 31 January 2010, were evaluated for various factors responsible for their admission as well as their outcome. Statistical Analysis: At the end of study, the data were arranged systematically and subjected to statistical analysis using nonparametric tests and P value <0.05 was considered significant. Results: Majority of the 61 patients admitted in ICU were referred from the peripheral health centers, smaller nursing homes/hospitals and some even without proper primary care and mainly comprising uneducated and rural population. Hemorrhage, pregnancy induced hypertension, cardiac diseases, respiratory insufficiency and sepsis were the main causes for admission. A total of 18 patients among 61 died during their ICU stay in the hospital. Conclusions: In the developing countries, high risk pregnancy should be managed at peripheral centers with proper facilities, antenatal visits and timely referral. The intensive care help should be reserved for very high risk pregnancies with co-morbid diseases.

Caudal ropivacaine-clonidine: A better post-operative analgesic approach.

The aim was to determine qualitative and quantitative aspects of caudal block, haemodynamic effects, and post-operative pain relief of ropivacaine 0.25% versus ropivacaine 0.25% with clonidine for lower abdominal surgeries in paediatric patients. A double-blind study was conducted among 44 paediatric patients in the Department of Anaesthesiology and Intensive Care of our institute. A total of 44 ASA-I paediatric patients between the ages of 1 and 9 years, scheduled for elective hernia surgery, were enrolled in this randomised double-blind study. The caudal block was administered with ropivacaine 0.25% (Group I) and ropivacaine 0.25% and clonidine 2 µg/kg (Group II) after induction with general anaesthesia. Haemodynamic parameters were observed before, during and after the surgical procedure. Post-operative analgesic duration, total dose of rescue analgesia, pain scores and any side effects were looked for and recorded. All the results were tabulated and analysed statistically. The variables in the two groups were compared using the non-parametric tests. For all statistical analyses, the level of significance was P < 0.05. Forty-four patients were enrolled in this study and their data were subjected to statistical analysis: 22 patients in both the groups were comparable with regard to demographic data, haemodynamic parameters and other vitals and were statistically non-significant (P>0.05). The duration of analgesia was significantly prolonged in Group II (P<0.05). The dose requirement for post-operative pain relief was also significantly lesser in Group II. The incidences of side effects were almost comparable and non-significant. A caudal block with 0.25% of isobaric ropivacaine combined with 2 µg/kg of clonidine provides efficient analgesia intra-operatively and prolonged duration of analgesia post-operatively.

Comparison of epidural ropivacaine and ropivacaine clonidine combination for elective cesarean sections

Background and Aim: Neuraxial adjuvants augment the action of local anesthetics. The aim is to determine the qualitative and quantitative aspects of epidural block of ropivacaine 0.75% versus ropivacaine 0.75% with clonidine for elective cesarean section. Settings and Design: A randomized double-blind study was conducted among 51 healthy parturients, scheduled for elective cesarean section, at Gian Sagar Medical College and Hospital, Banur, Punjab, India. Materials and Methods: Epidural block was administered with 20 ml of ropivacaine 0.75% (group R) and ropivacaine 0.75% and clonidine 75 µg (group RC) and anesthetic level was achieved minimum until T6–T7 dermatome. Onset time of analgesia, sensory and motor block levels, maternal heart rate and blood pressure, neonatal Apgar scores, postoperative analgesic dose and adverse events were recorded. Results: Fifty one patients were enrolled in this study and were subjected to statistical analysis. Groups were comparable with regard to demographic data, neonatal Apgar scores and incidences of side effects except for the higher incidence of dry mouth in patients of RC group. Onset of analgesia was much shorter in RC group along with prolonged duration of analgesia. The incidence of bradycardia and hypotension was more in RC group as compared to R group which was statistically significant. The dose requirement for postoperative pain relief was significantly lesser in RC group. Conclusions: The addition of 75 µg clonidine to isobaric epidural ropivacaine results in longer, complete and effective analgesia with similar block properties and helped to reduce the effective dose of ropivacaine when compared with plain ropivacaine for cesarean delivery.