SIngle needle thoracic paravertebral block as an alternative to general anaesthesia for modified radical mastectomy operation: A randomised controlled study

Roy

Archana

Bhunia

Pratibha

Sadhukhan

Sampriti

Mukherjee

Dipankar

Nilratan Sircar Medical College, KOLKATA.

**Background and Aims:** Conventionally,surgery for breast carcinoma is done under general anaesthesia(GA).Recently thoracic paravertebral block(TPVB) is gaining popularity as it produces unilateral block and minimal haemodynamic changes.It also facilitates post-op analgesia,early ambulation,and reduces hospital stay. Aim was to evaluate efficacy of single needle TPVB with catheter using 0.5% bupivacaine as a sole anaesthetic approach for Modified radical mastectomy(MRM).

**Methods:** 60 consenting ASA I & II, females aged 30 -60yrs scheduled for modified radical mastectomy were randomly assigned into 2groups: Gr.P(n=30),Gr.G(n=30). Gr.P: TPVB was given using 18G touhy needle.Epidural catheter inserted 2-3cm inside the paravertebral space at T4 level.INJ BUPIVACAINE 0.5% isobaric 20ml injected through catheter.IV infusion of Dexmedetomidine started for sedation. Gr.G: GA with midazolam,fentanyl,propofol and atracurium. Measured parametres were Baseline, Intra-op haemodynamics,induction time,recovery time,fentanyl requirement,average blood loss and post-op pain score by VAS at 0,1/2,1,2,4,8,12,24hrs,duration of analgesia,patient and surgeon satisfaction scores(PSS,SSS),incidence of post-op nausea vomiting(PONV).

**RESULTS:**

  PARAMETERS                    Gr.P (*n*=28) mean±SD   Gr.G (*n*=30) mean±SD   *P*
  ----------------------------- ----------------------- ----------------------- -----------
  I.TIME (min)                  12.25±3.66              6.53±0.94               \<0.0001
  R.TIME (min)                  1.61±0.69               7.23±1.83               \<0.00001
  INTRA-OP Fentanyl (ug)        9.28±23.52              37.33±36.21             \<0.001
  Blood Loss (ml)               167.86±45.06            291.67±56               \<0.00001
  Duration of analgesia (min)   531.43±100.29           130±77.33               \<0.00001
  SSS                           96.96±4.78              97.83±4.09              0.23
  PSS                           95.36±4.7               95.67±5.21              0.41
  PONV                          2/28 (7.14%)            16/30 (53.3%)           \<0.0001

Induction was prolonged in Gr.P(2.25±3.66min),though recovery was faster(1.61±0.69min) in comparison to Gr.G. Also intraoperatively Gr.P required less fentanyl and had less blood loss. Post-op VAS scores,incidence of PONV were significantly more in GA patients. SSS,PSS were similar.

**Conclusion:** TPVB may be a reasonable alternative to GA for MRM as it provides adequate intra and post-op analgesia with minimal adverse events.

Ultrasound guided determination of optimal angle of needle insertion for successful caudal block in pediatric patients"

SY

Hulakund

C

AJAY B

Ganeshnavar

Anilkumar

S Nijalingappa Medical College, Bagalkot

**Background and Aims :** Caudal epidural block is one of the most common regional techniques in paediatric anesthesia. Failure rate of placement of needle into the caudal epidural space can be upto 25% with conventional method. In this study, our aim is to estimate the optimal angle of needle insertion for successful caudal block, and also to calculate number of puncture attempts, procedural time and other complications by ultrasound imaging.

**Methods:** After obtaining ethical committee clearance and written consent from guardian, ASA grade I&II patients aged between 6-72 months undergoing infra-umbilical surgeries were included in the study. After general anaesthesia with laryngeal mask airway placement caudal block was given using ultrasound. To estimate the optimal angle, an imaginary line was drawn parallel to the sacral base on the longitudinal view, and the angle between the imaginary line and the needle was measured. puncture attempts, procedural time and complications were noted. Data was entered in excel sheet and analysed using SPSS software version 19.

**Results:** Calculated median optimal angle was 19.22^0^ \[14--25\]. First attempt was taken in 34 / 37 (91.89%) and second attempt was taken in 3 / 37 (8.10%) children. Average time taken to insert needle is 14.25 seconds. and there were no complications.

                                            Minimum   Maximum   Mean       Standard deviation
  ----------------------------------------- --------- --------- ---------- --------------------
  Age in months                             8         72        44.67      26.799
  Weight in KGs                             6         23        15.167     5.7284
  Calculated needle angle                   14^0^     25^0^     19.22^0^   2.789
  Needling time or Procedural time in sec   9         20        14.25      2.931
  Number of puncture attempts               1         2         1.06       0.232

**Conclusion:** The optimal angle showed no significant correlation with age, weight & height. We conclude that the needle should be inserted at about 20^0^ to the skin to avoid puncture of the bone and potential intra-osseous and intravascular injection

Hyperthermic intraperitoneal chemotherapy (HIPEC): Anaesthetic implications & outcomes redefined

V

Finija Francis

Thomas

Mariam Koshi

Rajagopal

Rakesh

Babu

Akhil

Institution:Jubilee Mission Medical College, Thrissur

**Background and aims:** Cytoreductive surgery (CRS) combined with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) has emerged as a treatment modality for selected patients with peritoneal surface malignancies. This technique involves infusing chemotherapeutic agents heated to 42°C to 43°C into the peritoneal cavity following resection of visible tumor.Anaesthetic management of CRS with HIPEC are complex . It involves major surgical resection,perioperative fluid and blood loss, electrolyte and acid--base disturbances. There are variations in body temperature during cytoreduction and HIPEC . It requires proper planning, coordination with surgeons and vigilance in perioperative period for successful outcome . the present study tried to analyze the perioperative management of patients undergoing CRS with HIPEC

**Methods:** Retrospective analysis of 8 patients with ovarian carcinoma who underwent CRS with HIPEC during the year June 2018 to June 2019 in Jubilee mission medical college Thrissur was done after obtaining ethical committee clearance. Data was collected on patient characteristics, duration of surgery, changes of body temperature, heart rate, mean arterial blood pressure (MAP), need for vasopressor support, intraoperative fluid requirement, urine output, estimated blood loss and blood transfusion. Data also collected on metabolic derangements, length of post operative invasive ventilation, length of ICU stay. Descriptive statistical analyses using measures of central tendency (mean, median, mode) and variance(range ) was performed on all variables.

**Results:** A total of 8 patients were evaluated with median age being around 66 years.Median duration of surgery extended upto 7 hours during which intravenous fluid administered ranged between 3.5 L and 10.5 L(median-7 L). Significant blood loss of 0.7 L(0.5 -2 L ) was seen during cytoreduction phase. 6 out of 8 patients needed blood transfusion with median of 1 PRBC(0-3). The need for norepinephrine infusion was observed in 50% of patients to keep MAP of ±20% . Body temperature increased upto a median of 37.5°C during the HIPEC phase.Out of 8 patients 7 of them required post operative invasive ventilation of 19.5 hours.

**Conclusion:** CRS+HIPEC is a high risk procedure associated with major hemodynamic and metabolic changes. This study suggests that meticulous management and monitoring of different physiological systems help in successful outcome of patients who undergo demanding surgeries like CRS with HIPEC.

USG Guided Thoracolumbar Paravertebral Block As Sole Anaesthetic Technique For Inguinal Hernia Surgeries -- A Case Series.

Preya

R.

T

Sivashanmugam

Jha

Smriti

Nahar

Afreen

Mahathma Gandhi Medical College And Hospital, Pondicherry

**Abstract:** Locoregional techniques as sole anaesthetic technique are associated with less hemodynamic changes, prolonged analgesia, devoid of side effects like nausea, sore throat in the postoperative period, and better patient comfort compared to general anaesthesia and central neuraxial techniques. Quadratus lumborum block, transverse abdominis plane block, ilioinguinal-iliohypogastric nerve block are used for postoperative analgesia. They cannot be used as a sole anaesthetic technique as they are not able to cover all the nerves required for hernia surgeries. Landmark guided thoracolumbar paravertebral block was used as the sole anaesthetic technique for Hernioplasty.^1^In this case series, described a stepwise approach for identification of thoracolumbar paravertebral space using Ultrasound and the block dynamics in five patients. Using a systematic scanning technique, we identified the paravertebral space of T11, T12, L1, L2 vertebrae (Fig 1) and 20ml of the local anaesthetic mixture was injected as 5 ml aliquots in each space. The hernial sac was infiltrated with 10 ml of LA mixture under ultrasound guidance. The sensory loss was observed from midline umbilicus(T10 ) to 5cm below the inguinal region (L2) in both anterior and posterior aspect of the ipsilateral parietal wall of the abdomen. Out of 5 patients, the surgical anaesthesia was satisfactory in 4 patient, and one patient required General anaesthesia during the sac manipulation. The mean time required for the first analgesic requirement is 5.5±1.2 hours. We are proposing that Ultrasound-guided paravertebral block with spermatic cord injection is a feasible peripheral nerve block technique for hernioplasty.

![Shows the ultrasound guided thoracic paravertebral block. Fig 1Ai shows the ultrasound probe and its placement with the ultrasound machine. Fig 1Aii shows the cadaveric sagittal section and Fig 1B shows the ultrasound image at intervertebral foramen level of T12 vertebra](IJA-64-83-g001){#F1}

Catheter associated blood stream infections in the central intensive care unit.

Dey

Sandeep

Tarat

Abhijit

Deori

Amio Kumar

Assam Medical College and Hospital (AMCH), Dibrugarh, Assam.

**Background and Aims:** Catheter Related Blood Stream Infections (CRBSI) is a frequent complication of central venous cannulation and accounts for majority (around 14%) of hospital acquired infections in intensive care. Catheter related blood stream infections are also considered as the first and most preventable classes of nosocomial infections. This study was done to characterize the population profile and microbial characteristics of CRBSI in the Central ICU (CICU) of AMCH. Additionally the CRBSI rate, duration of catheterization for CRBSI to develop was also estimated.

**Methods:** A prospective observational study was conducted in the CICU of AMCH on 100 patients over a period of one year after taking approval from the Institutional Ethical Committee. Patients over 18 years with no other initial source of infection and where consent could be obtained were included. Data regarding the patients and disease, indication, infections, organisms isolated, ICU stay, events such as death were collected and analysed.

**Results:** CRBSI was seen after ≥ 11 days of CVC insertion. There was no statistically difference in the duration of ICU stay in patients with or without CRBSI (12 ± 4.6 days versus 12 ± 8 days, p=1). CRBSI was more common with internal jugular vein (IJV) catheterisation (n=1/8, 12.5%), when catheterization was done in emergency (n=2/13, 15.38%) tand amongst patients with history of polytrauma (42.85%, p=0.000009) or hollow viscus perforation (25%, p=001513).

  --------------------------------------------------------------------------------------------------------------------------------------------------
  %CRBSI (*n*/N)   CRBSI Rate (per 1000 catheter days)   Isolates (%)      Antibiotic sensitivity      Mean ICU duration for CRBSI   Mean ICU stay
  ---------------- ------------------------------------- ----------------- --------------------------- ----------------------------- ---------------
  4% (4/100)       3.48                                  MRSA\             MRSA:\                      ≥\                            12±4.6\
                                                         (*n*=1/4, 75%)\   Linezolid and vancomycin\   11 days                       days
                                                         Klebsiella\       Klebsiella\                                               
                                                         Pneumoniae\       Pneumoniae:\                                              
                                                         (*n*=3/4, 25%)    Tigecycline, meropenem                                    

  --------------------------------------------------------------------------------------------------------------------------------------------------

**Conclusion:** CRBSI rate was high in our institute which calls for the need of antibiotic stewardship program as well as tighter bundle care protocol and staff training.

Evaluation of analgesic efficacy of bupivacaine and ropivacaine given through landmark guided erector spinae plane block in laparoscopic choleycystectomy

Solanki

Nachiket

Korat

Reshma

Shah

Divyang

Institution: Smimer Medical College, Surat.

**Background & Aims:** Erector spinae plane block(ESPB) is emerging as effective method for post-operative analgesia. The main aim of the study is to assess analgesic efficacy of landmark guided ESP block in patients undergoing laparoscopic Cholecystectomy. Duration of post-operative analgesia between Ropivacaine and Bupivacaine is compared.

**Methods:** Thirty patients of ASA grading I,II & III aged between 18-60 years scheduled for elective laparoscopic cholecystectomy were selected. Prior to induction, under all aseptic precaution ESP block was given. Using C7 spinous process as reference, T9 spinous process was palpated. 3cm from midline from this point, 22G spinal needle was inserted and advanced perpendicular to skin in all planes to contact transverse process of T10 vertebra. Needle was withdrawn 1-2mm and 20cc local anaesthetic solution injected bilaterally.General anaesthesia was given and maintained as standard technique. After completion of surgery patient was extubated. VAS score was used for post-operative pain assessment.

**Results:** Landmark guided ESP block is less time consuming, does not need extra equipment with no added risk of local anaesthetic systemic toxicity. It reduces postoperative VAS score and additional analgesic requirement. Ropivacaine is better in terms of post-operative analgesia than Bupivacaine.

![Landmarks for Erector Spinae Block](IJA-64-83-g002){#F2}

**Conclusion:** Landmark guided ESP block is simple, safe and most effective supplemental technique as a part of the multimodal post-operative analgesic regimen.

The anaesthesiologist and eeg

Karthikadevi

N.

Jain

Shalini

K.K.Arora

Mahatma Gandhi Memorial Medical College, Indore.

**ABSTRACT:** Electroencephalographic (EEG) recordings present an opportunity to monitor changes in human brain electrical activity during changing states of consciousness like sleep or general anesthesia. Frontal EEG recordings during surgical interventions with anesthetic-induced unconsciousness help to estimate the patient\'s level of unconsciousness. Use of these monitors to assess depth of anesthesia are in increasing trends but their usage is suboptimal. These monitors record the frontal EEG and process it through algorithms that yield an index number. This index alone has proven unreliable. Brain function under anesthesia has now changed from depth of anesthesia to adequacy/quality of anesthesia. Technology advances in EEG will make us able to provide better care for our patients, allowing more refined control and better monitoring preventing Delirium, Postoperative Cognitive Dysfuction etc. With an example of a case showing inconsistent EEG findings.
