Reetu Verma

A Comparative study of intrathecal dexmedetomidine and fentanyl as adjuvants to Bupivacaine.

Background: Various adjuvants have been used with local anesthetics in spinal anesthesia to avoid intraoperative visceral and somatic pain and to provide prolonged postoperative analgesia. Dexmedetomidine, the new highly selective α2-agonist drug, is now being used as a neuraxial adjuvant. The aim of this study was to evaluate the onset and duration of sensory and motor block, hemodynamic effect, postoperative analgesia, and adverse effects of dexmedetomidine or fentanyl given intrathecally with hyperbaric 0.5% bupivacaine. Materials and Methods: Sixty patients classified in American Society of Anesthesiologists classes I and II scheduled for lower abdominal surgeries were studied. Patients were randomly allocated to receive either 12.5 mg hyperbaric bupivacaine plus 5 μg dexmedetomidine (group D, n = 30) or 12.5 mg hyperbaric bupivacaine plus 25 μg fentanyl (group F, n = 30) intrathecal. Results: Patients in dexmedetomidine group (D) had a significantly longer sensory and motor block time than patients in fentanyl group (F). The mean time of sensory regression to S1 was 476±23 min in group D and 187±12 min in group F (P<0.001). The regression time of motor block to reach modified Bromage 0 was 421±21 min in group D and 149±18 min in group F (P<0.001). Conclusions: Intrathecal dexmedetomidine is associated with prolonged motor and sensory block, hemodynamic stability, and reduced demand for rescue analgesics in 24 h as compared to fentanyl.

Dexmedetomidine as an intrathecal adjuvant for postoperative analgesia

Background: Spinal anaesthesia is the most common approach which is used for lower limb surgery. Dexmedetomidine is the recent drug which acts on α2-adrenergic receptors in the dorsal horn of the spinal cord to produce analgesic effects. Aim: Efficacy and safety of intrathecal dexmedetomidine added to ropivacaine. Setting and Design: Randomised double blind trial. Methods: Sixty patients were randomly allocated to receive intrathecally either 3 ml of 0.75% isobaric ropivacaine + 0.5 ml normal saline (Group R) or 3 ml of 0.75% isobaric ropivacaine + 5 μg dexmedetomidine in 0.5 ml of normal saline (Group D). Results: The mean time of sensory regression to S2 was 468.3±36.78 minutes in group D and 239.33±16.8 minutes in group R. Duration of analgesia (time to requirement of first rescue analgesic) was significantly prolonged in group D (478.4±20.9 minutes) as compared to group R (241.67±21.67 minutes). The maximum visual analogue scale score for pain was less in group D (4.4±1.4) as compared to group R (6.8±2.2). Conclusion: The addition of dexmedetomidine to ropivacaine intrathecally produces a prolongation in the duration of the motor and sensory block.

Savings, investment and growth in India: an application of the ARDL bounds testing approach

This article considers savings, investment and economic growth for India using annual time series data for the period 1950/51 to 2003/04. The analysis uses Perrons innovational outlier model to conduct unit root tests which endogenously determines structural break. The empirical results show that the null hypothesis of unit root cannot be rejected for gross domestic product. Moreover, the results show that the most significant structural breaks over the last five decades correspond to the wars, regime change and the nationalization of the banks. The study also utilizes the autoregressive distributed lag (ARDL) approach to test for cointegration. Whilst the results support the existing evidence for the Carroll-Weil hypothesis, the study also finds that saving unambiguously determines investment in both the short and long runs. No evidence is found to support the commonly accepted growth models in India, that investment is the engine of economic growth.

International Trade and Regional Income Convergence: The ASEAN-5 Evidence

This paper demonstrates that multilateralism and regionalism are complementary, and that regional income convergence is likely with a like-minded and committed regionalism that often has links culturally and geographically. The association between international trade, income per capita, regional income convergence in ASEAN-5 is explored by applying the Lumsdaine and Papell approach that allows two endogenous structural breaks. The causal relationships between the above variables are also studied using Granger causality tests. The conclusion is that global (non-discriminatory multilateral) reforms have had a large impact on increasing trade. There is also a two-way causal relationship between the flow from trade to regional income convergence, and vice versa.

Comparison between Thoracic Epidural Block and Thoracic Paravertebral Block for Post Thoracotomy Pain Relief

INTRODUCTION Postoperative pain after thoracotomy is being considered one of the most severe pain and if not treated well, can result in various respiratory and other complications. AIM Present study was conducted with the aim to compare continuous thoracic epidural infusion with continuous paravertebral infusion for postoperative pain using Visual Analogue Scale (VAS) score and four point observer ranking. The secondary outcomes measured were pulmonary functions and any complication like hypotension, bradycardia, nausea, vomiting, urinary retention and neurological complications if any. MATERIALS AND METHODS Sixty patients of age group 18-60 years posted for anterolateral thoracotomy surgery for lung resection were randomised either to epidural or paravertebral group in this randomised prospective double blind study. In Epidural group 7.5ml bolus of 0.125% Bupivacaine with 50μg Fentanyl and in Paravertebral group 15ml bolus of 0.125% Bupivacaine with 50μg Fentanyl was given 30 minutes before the anticipated end of surgery. Bolus dose was followed by infusion of 0.125% Bupivacaine with 2μg/ml Fentanyl at the rate of 5 ml/hr in both groups. Parameters noted were Mean Arterial Pressure (MAP), Heart Rate (HR), Oxygen Saturation (SpO2), Arterial Blood Gas (PaCO2, P/F ratio), Visual Analogue Scale (VAS) and Four Point Observer Ranking Scale (FPORS) for pain, number of sensory segments blocked (by checking for pinprick sensation), requirement of infusion top ups and rescue analgesia (Tramadol), pre and postoperative pulmonary function test {(Forced Expiratory Volume (FEV)1, Forced Vital Capacity (FVC), FEV1/FVC, Peak Expiratory Flow Rate (PEFR)} and complications from start of infusion till 24 hours in the postoperative period. RESULTS Both the techniques were effective in relieving pain but pain relief was significantly better with epidural. Postoperatively, HR, SpO2, P/F ratio and PaCO2 were comparable between group E and P. There was significant decline in FeV1, FVC, FeV1/FVC and PEFR in postoperative period as compared to preoperative value in both the groups. Hypotension and bradycardia were more in group E. CONCLUSION Both the techniques, continuous thoracic epidural block and continuous thoracic paravertebral block were effective for post-thoracotomy pain relief; however, epidural block provides better pain relief. The incidence of sympatholytic complications was more in epidural group. The effect on respiratory mechanics was equivalent. Hence, paravertebral block can be used in post thoracotomy pain relief in those patients where thoracic epidural is contraindicated.

Do External Shocks Have a Permanent or a Transitory Effect on Thailand's Tourism Industry?

Given the number and the frequency of external shocks encountered by Thailand in the last two decades, this study identifies the number and the location of the breaks and tests to determine whether the breaks have a transitory or a permanent effect on international tourist arrivals to Thailand for its top 10 source countries using both univariate and panel unit root tests with structural breaks. The findings suggest that break dates coincide with the Asian financial crisis, the September 11 attack, and the SARS and the bird flu outbreaks. The univariate unit root tests with structural breaks reject the null hypothesis of a nonstationarity in tourist arrivals from all countries. Furthermore, panel unit root tests with one and two structural breaks also reject the joint null hypothesis of a nonstationarity. These findings imply that external shocks have only a transitory effect on tourist arrivals and Thailands tourism sector will return to its long-run equilibrium path.

Saving and investment in Saudi Arabia: an empirical analysis

Purpose - This paper examines the long-term relationship between saving and investment as a criterion for assessing international capital mobility for the case of Saudi Arabia, the largest economy among the Middle Eastern and Arab nations. Design/methodology/approach - The approach is modeled on Feldstein and Horioka covering the period 1963-2007 for Saudi Arabia. We use the bounds testing approach and the Gregory and Hansen cointegration methods to test for the long-run relationship between saving and investment. Additionally, before testing for this relationship, we conduct unit root tests, including the additive outlier model developed by Perron with an endogenously determined structural break. Findings - The study finds no evidence of a long-run relationship between saving and investment and therefore concludes that capital is highly mobile in Saudi Arabia. This finding is plausible given the economic and financial reforms which have occurred in Saudi Arabia along with increased capital inflows into the country in the last few decades. Originality/value - Of the limited studies so far on developing countries, none has considered the capital mobility issue for an oil-dependent country.

Dexmedetomidine and propofol for monitored anesthesia care in the middle ear surgery

Context: Local anaesthesia with sedation is a well established approach used for tympanoplasty. Dexmedetomidine is a new drug which acts on α2-adrenergic receptors in the dorsal horn of the spinal cord to produce analgesic effects. Aims: Efficacy and safety of intravenous dexmedetomidine in comparison to propofol. Setting and Design: Randomized controlled trial. Materials and Methods: Eighty patients were randomly allocated to receive either dexmedetomidine or propofol as intravenous bolus followed by the same in infusion supplemented with local anaesthesia for tympanoplasty. Statistical Analyses Used: Statistical Package for Social Sciences version 15.0. Results: Dexmedetomidine and propofol provides adequate sedation but the use of propofol is associated with more requirements of rescue analgesia and poor patient and surgeon satisfaction. Conclusion: These results suggest that dexmedetomidine provides adequate sedation with analgesia and good surgical and patient comfort without any adverse effects for patients undergoing tympanoplasty under local anaesthesia

Selective nerve root blocks vs. caudal epidural injection for single level prolapsed lumbar intervertebral disc – A prospective randomized study

BACKGROUND Chronic lumbar radiculopathy has a lifetime prevalence of 5.3% in men and 3.7% in women. It usually resolves spontaneously, but up to 30% cases will have pronounced symptoms even after one year. AIMS A prospective randomized single-blind study was conducted to compare the efficacy of caudal epidural steroid injection and selective nerve root block in management of pain and disability in cases of lumbar disc herniation. METHODS Eighty patients with confirmed single-level lumbar disc herniation were equally divided in two groups: (a) caudal epidural and (b) selective nerve root block group, by a computer-generated random allocation method. The caudal group received three injections of steroid mixed with local anesthetics while selective nerve root block group received single injection of steroid mixed with local anesthetic agent. Patients were assessed for pain relief and reduction in disability. RESULTS In SNRB group, pain reduced by more than 50% up till 6 months, while in caudal group more than 50% reduction of pain was maintained till 1 year. The reduction in ODI in SNRB group was 52.8% till 3 months, 48.6% till 6 months, and 46.7% at 1 year, while in caudal group the improvement was 59.6%, 64.6%, 65.1%, and 65.4% at corresponding follow-up periods, respectively. CONCLUSIONS Caudal epidural block is an easy and safe method with better pain relief and improvement in functional disability than selective nerve root block. Selective nerve root block injection is technically more demanding and has to be given by a skilled anesthetist.

Dexmedetomidine as an anesthetic adjuvant in intracranial surgery

Background: The basic principle of neuroanesthesia is to provide hemodynamic stability, provision of optimal operative conditions, maintenance of cerebral perfusion pressure, and cerebral oxygenation. Aim: This study was undertaken to see the effect of dexmedetomidine infusion on hemodynamics and its ability to act as an anesthetic adjuvant in patients undergoing supratentorial tumor surgery. Setting and Design: Prospective randomized control double blind study. Subjects and Methods: In this study, we compared two groups with 25 patients in each group. Group C patients received saline infusion during surgery and 4 μg/kg of fentanyl intravenously (i.v.) at the induction and at pin head application. Group D patients received dexmedetomidine infusion during surgery at the rate of 0.4 μg/kg/h and 2 μg/kg of fentanyl i.v. at the induction and at pin head application Statistical Analyses Used: Parametric data were analyzed using Students t-test. The categorical data were studied using Chi-squared test or Fishers test as appropriate. Results: The vitals remained within 20% of baseline in both groups during the study period except at the time of extubation where the rise in heart rate was more than 20% in control group. The requirement of thiopentone for induction was significantly less in dexmedetomidine group. In dexmedetomidine group, less number of patients required intraoperative fentanyl (P < 0.05), and the time to rescue analgesic was also more in Group D (P < 0.05). Conclusion: Dexmedetomidine infusion started before surgery maintains hemodynamic stability intraoperatively and is effective in attenuating the cardiovascular responses to intubation, skull pin application, and extubation. It decreases the requirement of other anesthetic agents as well.