Background: The aim of this study was to evaluate the effect of combined lumbar plexus – para sacral nerve block (LP/NB) and spinal anaesthesia (SA) on the duration and intensity of postoperative pain in patients with Tibia fracture requiring surgery.
Methods: In this clinical trial, 40 patients with tibial fractures requiring surgery, who were admitted to a referral hospital in north-eastern Iran from 2020 to 2021, and randomly subjected to LP/NB or spinal anaesthesia. Pain intensity and duration of anaesthesia in the two groups were compared based on a numerical rating scale within 4, 6 and 12 hours from the induction of anaesthesia. Clinical demand for analgesics following surgery was also recorded. Data were statistically analysed with IBM SPSS.
Results: The mean age of participants was 37.4 ±14.4, with 29 (72.5%) and 11 (27.5%) male and female patients, respectively. There were no significant differences in age and sex ratio between the two groups. The mean pain intensity within 4 hours from surgery was lower in the LP/NB group, however, this difference was not statistically significant (p-value: 0.054). Likewise, there were also no significant differences between the values reported for 6 (p-value: 0.303) and 12-hour (p-value: 0.523) post-surgery pain intensity for each group. Overall, the mean pain intensity at any given time was not significantly different between the two groups of LP/NB and SA (p-value: 0.671).
Conclusion: There was no significant difference between the two groups in terms of mean pain intensity at 4, 6 and 12 hours after the onset of the block. No side effects were observed in any of the patients.

Background: Neuromuscular blocking drugs (NMBD) have paved the way for the conduct of every known surgical procedure. However, the hunt for optimum NMD with appropriate intubating circumstances is continuous. Rocuronium and cisatracurium are amongst the newer NMBDs. We aim to compare the onset of action, intubating conditions, duration of action, and recovery features in a dose twice the ED95 in patients having abdominal surgery.
Methods: A total 60 American Society of Anesthesiology (ASA) I and II adult patients were randomized equally into Group A and Group B. Group A received Inj. Rocuronium 0.6 mg/kg and Group B received Inj. Cisatracurium 0.10 mg/kg. We assessed the intubating conditions after ensuring jaw relaxation using both the clinical criteria and neuromuscular monitoring whereas onset time, duration of action and recovery time were assessed using neuromuscular monitoring only.
Results: In Group A, a significant rapid onset of action of muscle relaxant was seen compared to Group B (2.4±0.30 mins versus 4.0±0.09 mins, p= 0.00). 93% patients had excellent intubating conditions in Group A compared to 73% patients in Group B (p= 0.038). The duration of action in Group A was 36.73±1.05 mins and in Group B was 47.40 ±1.33mins (p=0.00). Similarly, early mean duration of recovery was found in Group A-45.30±1.29mins versus Group B -57.77±1.19 mins, p= 0.00).
Conclusion: Rocuronium provides rapid onset of action with excellent intubating conditions, and shorter duration of action with an early recovery time compared to cisatracurium.

Background: The pre-requisites to a successful awake fiberoptic intubation (AFOI) include adequate psychological and pharmacological preparation of the patient. This study aims to compare two pharmacological agents, dexmedetomidine and nalbuphine, in addition to nebulization and airway topicalization, for intubating conditions during AFOI.
Methods: Sixty consenting patients belonging to ASA I/II, MPC I/II, age-group of 18-60 years weighing between 40-70 kgs requiring general anaesthesia with endotracheal intubation were randomly allocated to one of the two groups. Patients received dexmedetomidine 1µg/kg i.v. (group D) or nalbuphine 0.2 mg/kg i.v. (group N) over 10 min before intubation. Fiberoptic intubation was attempted. Intubating conditions were assessed in terms of sedation score, cough score and post-intubation score. Hemodynamic responses, lignocaine and propofol requirement were also recorded. Repeated measure ANOVA, Tukey’s test, unpaired t test, Chi‑square test or Fisher’s exact test were used for data analysis. A P < 0.05 was considered significant.
Results: Sedation score (P = 1.000), cough score (P = 0.165) and post‑intubation score (P = 0.157) were comparable among the two groups. Hemodynamic responses, propofol and lignocaine requirements were also comparable.
Conclusion: Both intravenous dexmedetomidine and nalbuphine provide good intubating condition with minimal adverse effects on haemodynamic profile during awake fibreoptic intubation.

Background: Tonsillectomy and adenotonsillectomy are simple surgical procedures that can cause laryngospasm as complications which blocks airflow causing serious issues. The laryngospasm incidence decreases in patients undergoing deep extubation. Present study aimed to compare laryngospasm in innovative method of head down deep extubation with No Touch method.
Methods: Forty-two patients were enrolled in the study in (23 females and 19 males) between the ages of 5 up to 15 who were referred for tonsillectomy or adenotonsillectomy. The patients were divided into two randomized No Touch (n=21) and head down deep extubation (n=21) intervention groups according to permuted block randomization. All patients received standard general anesthesia. The first group received the no-touch extubation and the second group received head down deep extubation method. The duration of surgery, Time interval between the injection of reverse drugs and the return of spontaneous breathing (TRDRSB), time interval between anesthesia drug withdrawal and extubation (TIDWE), SPO2, incidence of laryngospasm, and cough were recorded and graded according to their severity at 0, 5, 10, 15 minutes and 2 hours after extubation, respectfully.
Results: The age, weight, gender and duration of surgery, TRDRSB was not statistically different between the two groups but TIDWE showed a significant difference between groups (P<0.001). The SPO2 levels in 0, 5, 10, 15 minutes, and 2 hours after surgery were not significantly different between the “no touch” and “head down deep extubation” groups as well as the severity of coughing and laryngospasm. However, the rate of laryngospasm and cough in "No touch" group was higher than " head down deep extubation " group.
Conclusion: HDDE is an innovative technique that it seems in comparison to No Touch method can reduce the incidence of laryngospasm. However, further comprehensive trials are needed to confirm these findings.

Background: Percutaneous cervical central venous cannulation is now common practice during Perioperative care in major surgical procedures, critically ill patients in intensive care units for long term hyperalimentation and for rapid restoration of blood volume in cases of acute blood loss. Proper route of insertion is essential for its success. The objective of this study is to compare procedural parameters and complications associated with anterior and posterior approaches for Internal Jugular Venous cannulation.
Methods: Our study was conducted as a prospective randomized interventional trail in 60 patients undergoing scheduled cardiac surgeries requiring Right internal jugular venous cannulation in a tertiary level hospital after obtaining clearance from ethics committee, patients were randomly allocated into two groups either Anterior approach (Group A; n=30) or Posterior Approach (Group B; n=30). Number of attempts, time for identification of IJV, duration of cannulation, ease of insertion, complications were compared in both the groups.
Results: The number of attempts (p value 0.036), mean time taken for vein identification (p value 0.0003), catheterization time (p value <0.001), incidence of arterial puncture and hematoma are less with posterior approach, ease of threading is comparable among both the group. There were no statistically significant intergroup differences with respect to the Age, Sex, ASA grade.
Conclusion: The posterior approach is better than anterior approach for Internal Jugular Vein Cannulation, as it improves the success rate, permits easy threading of catheter, reduces access time and duration of cannulation, complications like arterial puncture, hematoma, pneumothorax are lesser in posterior approach.

Background: Parturient health is a priority worldwide. In this regard, the promotion of natural childbirth has always been considered by health policy makers. However, the most important cause of parturient tendency to caesarean section is fear of labour pain and lack of information about surgery complications, leading to inappropriate rate of caesarean. Midwives, attending in prenatal visits and labour, may have a key role in encouraging pregnant patients through labour analgesia. In this study we evaluate midwives’ attitude through necessity of labour analgesia and their understanding of neuraxial analgesia for labour pain.
Methods: One hundred and five midwives working educational hospitals, participated in this observational study. All participants were asked to fill questionnaires. Each questionnaire consists of 15 questions, each answer had 1 to 3 points. Total score of 15 to 25 was considered as poor, score 26 to 35 as intermediate and 35 to 45 as good attitude.
Results: Forty-nine percent of midwives had experience with labour analgesia. Forty-one percent participated in relevant educational workshops. About 40% presumed these techniques would result in immobility, while 66% assumed it will lengthen the procedure. 63% believed labour analgesia will increase mother’s satisfaction. Overall, 73% of them agreed with regional analgesia. In regards to attitude score, 22% were scored poor, 65% intermediate and 13% good.
Conclusion: Midwives’ attitude was estimated low. Participating in workshops improved their attitude, yet the difference was not significant. Attitude of those who participated in labour analgesia was significantly better than others.

Background: To investigate the onset and duration of sensory and motor blockade in isobaric 0.75% Ropivacaine and isobaric 0.75% Ropivacaine - Clonidine in patients undergoing infra umbilical surgeries.
One year double-blinded randomized controlled trial.
Methods: A total of 70 patients undergoing infra umbilical surgeries were allocated into two groups namely, Group I (n=35; Patients received 3 ml of isobaric 0.75 % ropivacaine intrathecally) or Group II (n=35; Patients received 3 ml of isobaric 0.75 % ropivacaine + 15 mcg of clonidine intrathecally). Onset and duration of Sensory and motor block and hemodynamic parameters were noted and compared.
Results: The demographic parameters were comparable in both groups. The onset of sensory block was similar in both groups but the duration of sensory block was prolonged in group II (191.7±19.21 minutes) than in group I (180.8 ±13.08 minutes). The motor block onset was faster in group II (11.4±2.29 minutes) than in group I (13.6±2.29 minutes). Duration of motor block was prolonged in group II (271.3±18.32 minutes) than in group I (224.5±16.46 minutes).
Conclusion: The addition of clonidine to 0.75 % isobaric ropivacaine intrathecally prolonged the duration of sensory and motor block but with no effect on the sensory onset but the faster onset of the motor block with no significant hemodynamic changes.

Background: Adjuvants are added to intraperitoneal local anesthetics to prolong analgesia however no study compares Dexmedetomiditine with Ketamine as adjuvant to Ropivacaine for laparoscopic cholecystectomy.
To compare efficacy of intraperitoneal instillation of Ropivacine with Dexmedetomidine versus Ropivacaine with Ketamine for postoperative pain relief following laparoscopic cholecystectomy.
Methods: Sixty patients ASA I and ASA II undergoing laparoscopic cholecystectomy were  randomly allocated in three groups and received Ropivacaine 0.2 % (group R), Ropivacaine 0.2 % alongwith Dexmedetomidine 0.7 micogrms/ kg (group RD) and Ropivacaine with Ketamine 0.5 mg/kg (group RK) to a total volume of 40ml.The primary outcome measured was time to request of rescue analgesia while secondary outcomes were post op numeric rating scale, total dose of rescue analgesia required in 24 hours and haemodynamic parameters in postoperative period.
Results: The median time to request of rescue analgesia was shortest in R group 55 [42.5-70] minutes followed by RK group 60 [50.50-72.50] and maximum in the group RD the time being 900 [86.25 -1440] minutes while haemodynamics remained stable in all the groups. Similar findings were seen for total demand of analgesia in 24 hours as well as NRS scale both static and dynamic which was measured periodically in the first 24 hours.
Conclusion: Dexmedetomiditine 0.7 micrograms per kg when used as adjuvant with Ropivacine is effective combination that prolongs duration than Ropivacaine alone or when used with Ketamine 0.5 mg per kg body weight  however total dose of rescue analgesia was significantly less in Ketamine  group compared to Ropivacine alone and least when Dexmedetomiditine is used as adjuvant.

Background: Obtaining central venous access is the basic requirement in patients undergoing cardiac surgery. Use of ultrasound (USG) for accessing IJV cannulation, improves the success rate and reduces the number of complications that may arise due to blind approach. Through this study we aimed to compare landmark vs real time USG guided IJV cannulation techniques.
Methods: 190 adult patient’s undergoing cardiac surgery were randomly divided into two groups of 95 each. Patients in Group A (Landmark based approach) were being compared to Group B (USG based) in terms of – success rate, first attempt success rate, total cannulation time, number of attempts, complications and success rate among residents and consultants.
Results: Success rate obtained in Group A was 89.4% compared to 100% in group B (P = 0.001). First attempt success rate was 67.36% in group A and 91.57% in group B (P < 0.001). Group B showed less number of attempts. Total cannulation time in group A (252.2 ± 66.4) sec was significantly higher (P<0.001) than group B (182.5 ± 40.39) sec. Rate of complications such as hematoma formation and carotid artery puncture were also significantly higher in group A.
Conclusion: The real time USG guided IJV cannulation is better technique than Landmark guided approach as it has significantly higher success rate, reduces the number of attempts, reduces the total time for cannulation and decreases the rate of complications. Also, success rate even increases among junior residents with the use of USG.

Background: Sepsis is a serious condition that can be fatal and has become more common in recent times. The impact of diastolic dysfunction on the early mortality rate of septic patients has not been extensively researched. This study aimed to assess the accuracy of serum procalcitonin (PCT) levels and diastolic dysfunction in predicting the mortality rate of patients diagnosed with sepsis and admitted to the intensive care unit.
Methods: In this cross-sectional study, 40 sepsis patients admitted to the ICU were examined. Their characteristics were meticulously recorded using the APACHE II and SOFA score questionnaires, and only those who met the criteria underwent echocardiography. In order to evaluate the serum levels of PCT, it was required to take 40 ml of venous blood samples from the patients on the first and fifth days of admission.  
Results: Out of 40 patients, the average age was 63±17 years. Of these patients, 23 (57.5%) were discharged, while 17 (42.5%) unfortunately passed away. Results showed a notable correlation between diastolic dysfunction, CRP, SOFA score on days 1 and 2, APACHE II score, and PCT on day 5 (P˂0.05). However, when analyzed using logistic regression, only PCT on day 5 showed a significant association with mortality.
Conclusion: Based on our research, we found that PCT is an essential indicator in predicting the mortality rate of sepsis patients. While there was no significant correlation between diastolic dysfunction and mortality, it should still be considered a critical factor in determining the mortality rate.

Background: The quest for an ideal sedoanalgesic-combination exhibiting the triad of efficacy, safety and patient comfort has led to administration of several permutations and combinations of drugs (midazolam, fentanyl, remifentanil, dexmedetomidine, propofol, ketamine, pethidine, pentazocine). The ideal sedoanalgesic for CT-guided core-biopsy of spine, radiofrequency/microwave ablation of hepatic/pulmonary lesions, has hitherto been elusive. In the absence of any guidelines, we compared a ketamine-dexmedetomidine combination (Group-K) with fentanyl-dexmedetomidine (Group-F).
Methods: This prospective, interventional, single-centric, parallel-armed, randomized controlled study included 60 patients (ASA physical state I-II, either gender, aged 18-75y, weighing 35-85kg), undergoing CT-guided core biopsy/radiofrequency/microwave ablation in remote location, allocated to Group-K and Group-F. Independent/paired-sample t-tests were utilized and data expressed as box-whisker plots and trendlines, p-value<0.05 being statistically significant.
Results: There was a significant difference in intraprocedural pain-scores between both groups (p-values 0.0001, 0.0011, 0.0092 and 0.0201 at 0-10mins, 10-20mins, 20-30mins and 30-40mins respectively). More patients in Group-F required rescue-analgesic with reduced interventionist-satisfaction score versus Group-K. In Group-K, mean arterial pressure and heart rate (95.1mmHg;79.6/min) increased after initial ketamine bolus, but were maintained/decreased at intervention-initiation (93.2mmHg;79.4/min) and at 10min and 30min thereafter. In Group-F, MAP and HR decreased after initial fentanyl bolus (83.5mHg;71.9/min), increased with intervention-initiation (90.1mmHg;77/min), progressively decreasing at every time-point thereafter. VAS-scores (resting; on coughing) were lower in Group-K.
Conclusion: A ketamine-dexmedetomidine combination technique demonstrated a superior sedoanalgesic effect with reduced intra-procedural bradypnea, bradycardia, rescue-drug requirement and post-procedural complications with enhanced interventionist-satisfaction and may emerge as the ideal procedural sedoanalgesic for patients undergoing CT-guided core-biopsy, radiofrequency/microwave ablation.

Background: Pneumatic Balloon Dilation (PBD) as an achalasia treatment is painful procedure because of tearing the lower esophageal sphincter (LES) muscle fibres. Recently, two sedation methods including the moderate sedation and deep sedation are used for increasing the convenience of the patients and gastroenterologist.
Methods: To compare the efficacy of moderate and deep sedation in PBD in treatment of Idiopathic Achalasia (IA).
Results: We prospectively assessed 200 IA patients. The first 100 patients (group A) underwent PBD by the moderate sedation using diazepam or midazolam and meperidine injections. The patients in the group B (100 patients) received midazolam, fentanyl and propofol as a deep sedation.  The pulse rate (PR), systolic and diastolic blood pressure (SBP, DBP), respiratory rate (RR), and oxygen saturation were monitored before, during and after PBD and achalasia symptom scores (ASS) were collected before and 1.5 months after treatment.
The mean PR during and after procedures in the group B were significantly lower compared to the group A (p 0.001, 0.028). The patients in group B revealed less SBP and DBP after PBD versus group A (p 0.004, 0.002). The mean psi for 30 mm and 35 mm balloon dilators were significantly increased in group B compared to group (p 0.0001, 0.002).
Conclusion: We concluded that the deep sedation of achalasia patients in the PBD process can improved the efficacy of PBD and decreased the complications (transient chest pain) of the procedures. The patients with the deep sedation revealed less tachycardia and blood pressure rising and tolerated more pressure in balloon dilators.

Background: Postoperative nausea and vomiting (PONV) is one of the most common postoperative complaints of the patients that affects the surgical outcome, quality of life, length of hospital stay, and costs. The prevalence of nausea and vomiting is estimated at 52% and 25% within the first 24 hours after surgery. Many risk factors have been identified for PONV, including female gender, being a non-smoker, young age, general anesthesia, use of volatile anesthetics and Nitrous Oxide, and duration of anesthesia. Following receiving reports indicating an unusually high prevalence of PONV in the male orthopedic ward of Imam Khomeini Hospital Complex despite applying regional techniques, the present study was conducted to investigate its prevalence and possible reasons.
Methods: After obtaining informed consent, 300 patients admitted to male and female orthopedic wards of Imam Khomeini Hospital complex that had undergone surgery within the past 48 hours were interviewed in person and their medical records were reviewed.
Results: Of 300 patients, 61 (20.3%) had nausea and 39 (13%) had vomiting. Three patients (1%) experienced recurrence of PONV after treatment. The risk factors associated with PONV were female gender, history of motion sickness, general anesthesia with sodium thiopental, atracurium, IV lidocaine, isoflurane, neostigmine, and postoperative administration of ciprofloxacin.
Conclusion: The prevalence of PONV was lower than other studies, which was in contrast to reports received from the ward, indicating a reduction in PONV following the use of regional techniques.

Complex regional pain syndrome (CRPS), previously known as reflex sympathetic dystrophy syndrome, is a situation specified by persistent regional pain. The aberrant functioning of the neurological system is believed to be the root cause of an exaggerated reactivity to pain signals that are unable to switch off the sensation of pain. It is characterized by such symptoms as swelling, alterations in the color of the skin and tissues, along with edema. Although it most commonly affects the limbs, such as the arm, leg, hand, or foot, these symptoms can manifest themselves in any part of the body. The existence or nonexistence of nerve injury is used to classify patients into one of two subgroups, I or II, when referring to this illness. Since many medical professionals are unfamiliar with the diagnosis of CRPS and its etiology is not fully elucidated, the condition is frequently incorrectly diagnosed. The treatments available for CRPS focus on alleviating symptoms, regaining organ function, and cosseting a person's quality of life, despite the fact that no cure for the condition has been identified.

Pheochromocytoma is a challenging case for any anesthesiologist and a team approach is required throughout the perioperative period to prevent anticipated difficulties and best manage any unforeseen complications that develop. We discuss successful management of certain unique challenges, like multifocal arrhythmias and surgical rebleed during transport, during pheochromocytoma surgery in an adult, in addition to the usual perioperative problems.

Paediatric spine surgeries are quite frequently performed these days on patients with congenital spinal anomalies. Correction of congenital spinal deformities, at this early age of life can cause lifestyle modifying changes in young patients, which will help them to live a comparative healthy and disease free life. Spine surgeries are often performed in prone position with aid of Total Intra-Venous Anaesthesia which are better supplemented with Intra-Operative Neuro-Monitoring as they help in improving the desirable outcome of surgeries in children. Here, we report a case of Total Intra-Venous Anaesthesia for release of tethered cord aided with Intra-Operative Neuro-Monitoring, which was managed meticulously without any detrimental complications.

Parathyroid adenomas are usually an incidental finding and present more commonly in women. The parathyroid gland releases parathyroid hormone(PTH), which is essential to maintain calcium homeostasis. Hence, the removal of parathyroid glands will result in hypocalcemia and if not treated could be life threatening. We present the case of a young female patient who presented with vague complaints and was evaluated and diagnosed with primary hyperparathyroidism. She was optimized and taken for surgical removal of parathyroid glands. The anesthetic considerations in the perioperative period and an intraoperative event during positioning are mentioned herewith.

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