European Journal of Molecular & Clinical Medicine

Objective: Adjuvants prolong the action of intrathecal local anesthetic agents. They have shown to have significant analgesic effects in the postoperative period much after the regression of the sensory and motor blockade. Our objective of the current study was to compare the hemodynamic profile and adverse effects (nausea, pruritus, sedation and respiratory depression) in two groups of adult patients undergoing infra-umbilical and lower limb surgery under spinal anesthesia using either intrathecal clonidine or intrathecal fentanyl as an adjuvant to intrathecal bupivacaine (0.5% heavy).
 
Materials and Methods: It was a prospective randomized study in which eighty patients posted for lower limb orthopedic surgery were divided into two groups of forty each. Group A – Received intrathecal hyperbaric bupivacaine (2.5 ml) +50 µg clonidine (diluted to 0.5 ml). Group B – Received intrathecal hyperbaric bupivacaine (2.5 ml) + fentanyl 25 µg (diluted to 0.5 ml). Duration of postoperative analgesia, sensory and motor block characteristics, hemodynamic parameters, and side effects were recorded and analyzed.

Results: Both the groups were comparable in demographic data, hemodynamic parameters, but the duration of sensory and motor blockade and duration of analgesia was significantly longer in Clonidine group when compared with the Fentanyl group, with a mild increase in sedation score.
Conclusion: Addition of 50 μg clonidine to intrathecal bupivacaine offers longer duration of postoperative analgesia than 25 μg of fentanyl but with higher sedation. Both the drugs offer similar surgical conditions and prolongs postoperative analgesia (clonidine more than fentanyl), so we suggest fentanyl as better choice when sedation is not desirable and clonidine is recommended where sedation is acceptable.

Introduction: Spinal anaesthesia is one of the widely used anaesthetic techniques among obstetric patients due to its safety. Despite having high success, there are several instances where anaesthetists have found spinal anaesthesia difficult. Several factors influence the anaesthetic difficulty during the technique. We did this study to determine the anatomical factors influencing difficult spinal anaesthesia among women who underwent cesarean section
Methods: We included a total of 100 pregnant women who underwent spinal anaesthesia during the cesarean section. The women were enrolled consecutively during the study period using specific inclusion and exclusion criteria. Difficult spinal anaesthesia was determined based on the scores developed through various parameters. Adjusted analysis was done to determine the independent factors influencing difficult spinal anaesthesia.
Results: All women consented for the study. In multivariable logistic regression analysis, we observed that age group of >35 years, (aOR 1.3 95% CI 1.1 – 1.9), being overweight/obese (aOR 1.7 95% CI 1.2 – 2.3), with previous history of spinal anaesthesia (aOR 1.9 95% CI 1.2 – 2.3), having scoliosis (aOR 1.7 95% CI 1.1 – 2.4), lordosis (aOR 2.9 95% CI 1.7 – 5.3) and kyphosis (aOR 1.8 95% CI 1.2 – 2.7), non-palpable anatomical signs (aOR 1.7 95% CI 1.1 – 3.1) and less narrow non-palpable intervertebral space (aOR 1.9 95% CI 1.2 – 3.8) as independent risk factors for spinal anaesthesia.
Conclusion: Our study results highlight the importance of pre anaesthetic determination of anatomical indices among women who undergo C section to predict difficult spinal anaesthesia among them

The relationship between Post-Dural puncture headache (PDPH) and body mass index (BMI) in individuals who have just given birth has been the subject of contentious studies in the past. As a result, we decided to survey this complication in a group of patients who had cesarean sections performed under spinal anesthesia. It was predicted that people with greater BMIs would experience PDPH less frequently.The demographic data was retrieved and documented after looking over the patient files and phoning the patients. Additionally, a headache score based on a 0–10 verbal numeric rating scale (NRS) and the development of PDPH up to three days after a cesarean section in the present delivery were documented.At the Kakatiya Medical College in Warangal, 76 women who had undergone spinal anesthesia for a cesarean section participated in this study (March 2021 to February 2022). The subjects ranged in age from 20 to 40 years old (28.24 ± 3.27). The average BMI (kg/m2) before a cesarean section was 30.21 ± 2.82. 38 (50%) of the 76 parturient patients were not obese, and the remaining (50%) were (BMI > 30 kg/m2); 97.90% were non-smokers, and 92 percent had no prior history of PDPH during the previous neuro-axial anesthesia/analgesia. Only 13 participants (17.10 %) in this study experienced headaches following the current spinal anesthetic. 31 patients (81.57%) and 32 patients (84.21%) of the patients who did not develop PDPH had BMIs below 30 and over 30 respectively (P = 0.386). We concluded that increased BMI at the time of cesarean section decreased the incidence of PDPH. Increased BMI lowers the risk of PDPH because obese patients' increased intra-abdominal pressure reduces CSF leakage from the dural puncture point. Additionally, this study demonstrated that neither BMI nor weight gain during pregnancy, nor any other characteristics looked at, had a significant impact on the severity of PDPH.

Background: Shivering is a physiological response to core hypothermia to increase metabolic heat generation. Prolonged impairment of thermoregulatory autonomic function under anaesthesia, along with cool operating room temperatures and cold infusion fluids, causes shivering.
Methods: This prospective study included 90 individuals who shivered under spinal anaesthesia during abdominal or orthopaedic surgery. On shivering, patients received a 1 mL intravenous bolus dose of 50 mg tramadol, 1 mg butorphanol, or 150 mcg clonidine. All 3 groups were compared for shivering control, time to cessation, recurrence, hemodynamic changes, axillary temperatures, and side effects. Data was processed using statistical methods.
Results: Butorphanol and tramadol decrease shivering better than clonidine. Butorphanol, tramadol, and clonidine totally decreased rigours in 83%, 73%, and 53% of patients, respectively. Clonidine (3.3±0.9 minutes) took longer than butorphanol and tramadol (2.1±1.0 minutes and 1.8 ±0.5 minutes; P 0.001).
Conclusion: Butorphanol controlled shivering with fewer recurrences than tramadol, but both were better than clonidine with an early onset of action. Both opioids reduce rigours better than α-2 agonists.

Aim: To evaluate the incidence of spinal anesthesia failure necessitating conversion to general anesthesia in women presenting for caesarean section.
Methods: This research included 120 women who were scheduled for a caesarean section under regional anaesthetic, as well as women who were weighed and had their heights measured. Women scheduled for general anaesthesia, women who refused to participate, and women whose height and weight could not be obtained were all excluded from the research.
Results: We discovered that the majority of the patients (70.33%) were between the ages of 25 and 35, with the average age of the patients being 32.552.58 years. The patients' mean BMI was 29.122.33kg/m2. There were 21 elective cases (17.5%) and 99 emergency cases (82.5%). The frequency of spinal anaesthesia failure necessitating conversion to general anaesthesia. We discovered that 10% of all patients were converted to general anaesthetic owing to spinal anaesthesia failure. The outcome was statistically significant (p<0.05).
Conclusion: As a result of the failure of spinal anaesthetic during the c-section operation, we found that 10% of the patients in our research group required a change to general anaesthetic.

Background: Epidural labor analgesia (ELA) can be extended for use as epidural surgical anesthesia (ESA) for intrapartum caesarean section. The present study was conducted to compare spinal and epidural anesthesia for caesarean section following epidural labor analgesia.
Materials & Methods: 84parturients admitted for vaginal deliveries were divided into 2 groups of 42 each. In group I, epidural painless labor was maintained by continuous infusion and patient-controlled epidural analgesia (PCEA) using 0.125% bupivacaine with fentanyl 1.25 mg/mL.In group II, SA was performed, a standardized dose of hyperbaric bupivacaine 10-12 mg with or without 100-300 mg morphine was administered through a 26- gauge spinal needle.
Results: In group I and group II, parity found to be nullipara in 30 and 34 and multipara in 12 and 8, ASA status was I in 4 and 5, II in 32 and 30 and III in 6 and 7. Cervical oswas 2.9 cm and 3.0 cm, block levelT2-T3 was seen in 0 and 2 and <T4 in 42 and 40 respectively. Failure rate was seen in 4 in group I and 6 in group II. A to S time (min) was 17.4 and 13.2. Medicine given was Ephedrine (mg) as 1.26 and 10.2, Meperidine(mg) as 11.4 and 9.2, Fentanyl (mg) as 0.014 and 0.0052, Midazolam (mg) as 0.81 and 0.23, Propofol (mg) as 8.7 and 4.6 and Ketamine (mg) as 3.16 and 1.92 in group I and II respectively. The difference was significant (P< 0.05).
Conclusion: The failure rate of sequential SA and EA for CS following successful epidural painless labor was similar

Background:Transversus abdominis plane (TAP) block is a well-established analgesic
technique for postoperative analgesia in abdominal surgeries.In our study, we
compared the analgesic efficacy of adjuvant fentanyl and tramadol with Bupivacaine in
TAP block following percutaneous nephrolithotomy.
Methods:In this randomized, prospective, controlled study, 90 patients of ASA grade I
and II were divided into three groups; Group A, Group B, and Group C. Surgical
procedure was done under spinal anesthesia.At the end of surgery, we introduced TAP
block unilaterally in the triangle of petit by feeling two pop technique. Group A
received 28 ml of 0.25% bupivacaine with 50 μg of Fentanyl;1 ml normal saline was
added to make total 30 ml, Group B received 28 ml of 0.25% bupivacaine with 100 mg
of tramadol (2ml), and Group C received 28 ml of 0.25% bupivacaine with 2 ml of
normal saline. The primary outcome wasduration of analgesia (time to first rescue
analgesia) and the secondary outcomes were total dose of rescue analgesics and visual
analog scale (VAS) score recorded at 0,2,6,4,8,12, and 24 hr. If VAS score >4 or patient
complained of pain, then injection diclofenac 75mg intravenous was given as rescue
analgesic.
Results:Duration of analgesia was higher with fentanyl than tramadol & normal saline.
It was 7.01±0.176 hrs., 4.89±0.713 hrs. and 3.01±0.125 hrs. respectively with fentanyl,
tramadol, and normal saline. The total dose of rescue analgesic was lower with fentanyl
than tramadol and higher with normal saline. VAS score was also lower with fentanyl in
comparison to tramadol and normal saline.
Conclusion:Postoperatively many adjuvants were added in TAP block to improve the
quality of analgesia but fentanyl prolonged the postoperative analgesia effectively in
comparison to tramadol or plain TAP block.

Background: Neuraxial anaesthesia greatly expand the anaesthesiologist
armamentarium in many cases providing alternative to general anaesthesia. Spinal
anaesthesia is a popular technique for lower limb orthopaedic surgeries. Hyperbaric
bupivacaine in 8% glucose is often used. Unintended intravascular injection of
bupivacaine during regional anaesthesia may cause severe cardiovascular toxicity,
including left ventricular depression,atrioventricular heart block,life threatnig
ventricular tachycardia, fibrillation and sudden cardiac arrest which is difficult to
resuscitate However levobupivacaine has similar efficacy but better safety profile than
racemic bupivacaine.

Aim: Assessment of the prevalence and associated risk factors of post dural puncture
headache (PDPH) after cesarean section delivery under spinal anesthesia
Methods: This Cross Sectional study conducted in the Department of Anesthesia, Madha
Medical College Research Institute, Kovur, Chennai, Tamil Nadu, India for the period of 1
year. The entire procedures were performed at sitting position. The backside of the patients
was cleaned with Iodine and alcohol. Spinal anaesthesia was done using a midline approach
at the L2-3 or L3-4 interspaces by using different size of spinal needles and 0.5 % isobaric
bupivacaine 2.5-3.0ml was injected.
Results: The 100 Patients were included in this study with fulfilling the criteria. 8 patients
had a previous history of spinal anesthesia exposure and 3 of them complained a PDPH like
headache after the procedure. All patients had given spinal anesthesia on sitting position. 23
G needle is the most frequently used spinal needle. There were 1 cases (1%) diagnosed as
failed block which were converted to general anesthesia. Hosmer-Lemeshow test of goodness
of fit was performed to check the appropriateness of the model for analysis. Variables found
to be significant at a binary logistic regression were: needle size and number of attempts.
After analysis with multivariate logistic regression needle size and number of attempts were
found to be significant at p-value<0.05. Size of the needle used to administer spinal
anesthesia is significantly associated with the development of PDPH. In this study PDPH
was present in 43 patients (43%).
Conclusion: In conclusion, the prevalence of PDPH was higher, 43% compared with most
other studies.

Background: Dexmedetomidine has emerged as a wonder drug in regional anesthesia practice owing to its co-analgesic properties. However, there is a lack of literature for comparison of intrathecal with intravenous routes of dexmedetomidine administration on the effectiveness of subarachnoid block.
Methods: Prospective, randomized, double-blind study was carried out in 40 patients aged 18-60 years with ASA I and ASA II physical status scheduled for elective infraumbilical surgery under subarachnoid block. Participants were randomly divided into two groups. Subarachnoid block was administered with 3ml of hyperbaric Bupivacaine in both groups. Patients in Group 1 received intrathecal 5µg dexmedetomidine and intravenous infusion of normal saline during surgery. Patients in Group 2 received intravenous bolus dexmedetomidine infusion of 0.5 µg /kg followed by maintenance infusion of 0.5 µg/kg/hr. Block characteristics, Ramsay Sedation score and hemodynamic variables were recorded for all patients.
Results: The duration of motor block, the dermatomal level achieved and duration of analgesia was higher in group 1 compared to group 2. The groups were similar with respect to onset time of sensory and motor block, sedation score and hemodynamic variables. There were no significant side effects in either of the groups.
Conclusions: Dexmedetomidine by either intrathecal or intravenous route is an attractive adjuvant for infraumbilical surgical procedures performed under subarachnoid block. In cases where the requirement is to prolong duration of intraoperative anesthesia and postoperative analgesia intrathecal route is desirable. Whereas, in daycare surgeries where the requirement is only to intensify the block in the intraoperative period with early postoperative ambulation intravenous route is preferable.

Laparoscopy has revolutionised surgery and management of the patient with marked decrease in morbidity and post-operative complications. Initially, these procedures were done using only General Anaesthesia. However, now with the introduction of Spinal anaesthesia and after learning its advantages, surgeons are slowly beginning to gravitate towards this mode of anaesthesia. Sixty three patients who were admitted in the hospital for appendicitis participated in this Randomized controlled trial conducted in a tertiary care hospital in India. Thirty three patients were randomly included in Group A (undergoing laparoscopic surgery under Spinal Anaesthesia) and thirty patients in Group B (undergoing laparoscopic surgery under General Anaesthesia). The mean values of Systolic and diastolic pressure was found to be significantly higher in patients who were administered General anaesthesia and no change in the respiratory functions was observed following administration of either Spinal or General anaesthesia. Laparoscopic surgery under Spinal anaesthesia is a viable and safe alternative as compared to General anaesthesia. The recovery rates and the satisfaction reported by patients is also better. Spinal anaesthesia also helps in maintaining better haemodynamic stabilization.

Background:Spinal anesthesia is a common choice for patients undergoing orthopedic
surgeries.ondansetron was found to attenuate the incidence of SIH and bradycardia during
spinal anesthesia.
Aim of the study:This work was done to compare between the effects of prophylactic
intravenous of two different doses of ondansetron (4 mg) and (8 mg) in attenuating hypotension
in patients undergoing orthopedic surgeries under spinal anesthesia.
Patients and methods:This study wasa prospective comparative randomized controlled clinical
trial that have been carried out in Zagazig University Hospitals and included 66 patients, their
ages ranged from 21 to 60 years old patients for only unilateral orthopedic surgeries under
spinal anesthesia, duration of surgery less than 2 hours in the study.Patients were randomly
divided into three equal groups, 22 patients for each group, Group "O1" received IV
ondansetron (4mg) diluted in 10 ml saline, group "O2" received IV ondansetron (8mg) diluted
in 10 ml saline, and group C (control) received only 10 ml IV saline alone. Medications were
administrated 5 min before starting the subarachnoid block by an anesthesiologist blinded to
them, they were assessed for their cardiovascular effects including blood pressure, heart rate
(HR) before, throughout and after operation.
Results:There was difference between the prophylactic intra venous of the two different doses
of ondansetron in attenuating hypotension in patients undergoing orthopedic surgeries, under
spinal anesthesia compared with the control group. Mean Blood Pressure (MBP) and HR were
significantly, lower among the control group from 5 min tell the 10 minutes compared to (O1)
and (O2) groups.
Conclusion:
In patient undergoing orthopedic surgeries under spinal anesthesia, prophylactic intravenous
administration of 4mg ondansetron or 8mg ondansetron 5min before induction of spinal
anesthesia to reduce the severity of spinal-induced hypotension and bradycardia well
significantly.

Background & Aim: Phenylephrine induces maternal bradycardia in 50% of mothers when used for prevention and treatment of spinal anaesthesia-induced hypotension during caesarean delivery. Rapid fluid administration immediately after initiation of the spinal block (co-loading) may have a vasopressor sparing effect. Even though phenylephrine infusion was active as a vasopressor, there was a fall in heart rate occasionally as a reflex action, but it was not statistically significant. There was no incidence of bradycardia or change in rhythm. Aim of the study is to assess the efficacy of prophylactic and therapeutic phenylephrine when administered by different methods as a vasopressor.
Method: 60 mothers scheduled for elective caesarean section were recruited in this randomized controlled trial. The primigravida included in the study were divided into two groups; group 1 (n = 30) received intravenous prophylactic phenylephrine infusion at 100 micrograms/min for 3 minutes immediately after subarachnoid block and group 2(n = 30) received phenylephrine as boluses of 100 microgram for the treatment of hypotension following subarachnoid block. Vital signs (blood pressure, heart rate, and arterial oxygen saturation) were recorded throughout the surgery. Maternal and neonatal perioperative complications were also controlled and recorded.
Results: There was an insignificant difference in demographic data between the groups. In Group I, only 6.7% incidence of hypotension episodes, whereas in Group II, 96.7% incidence of hypotension episodes were seen, indicating phenylephrine infusion was more effective in preventing hypotension episodes. In both, the groups had similar pre-induction systolic blood pressure, but the mean systolic blood pressure was higher in the infusion group and was statistically significant. In both groups DBP was higher in the infusion group and was statistically significant. Mean arterial pressure pre-induction was similar in both the groups, but mean arterial pressure was higher in the infusion group and was statistically significant. Phenylephrine does much higher in Group I (infusion group) when compared to Group II (bolus group), which was statistically significant (P-value <0.001).No significant side effects were observed in the study (nausea, vomiting). There was no significant difference between the two groups in APGAR score.Conclusion: Administration of prophylactic phenylephrine infusion is more effective as vasopressor compared to therapeutic Boluses in elective caesarean section done under subarachnoid block. Prophylactic phenylephrine infusion was associated with lower heart rates occasionally when compared to bolus doses. There is no significant reduction in APGAR scores at 1st and 5th min in both groups. Prophylactic infusion of phenylephrine can effectively decrease spinal anesthesia related hypotension without any significant complication for mother or her fetus.

Background: Levobupivacaine is a long acting, amide-type local anaesthetic
that is the S(−) \3- isomer of the racemate bupivacaine. In general, in vitro, in vivo and
human volunteer studies of nerve block indicate that levobupivacaine is as potent as
bupivacaine and produces similar sensory and motor block. Dexmedetomidine is used as
an adjuvant in spinal anesthesia and is associated with prolonged motor and sensory block,
hemodynamic stability, and less requirement of rescue analgesia in 24 h as a result it
facilitates reduction in dose of local anesthetic. Aim of the study: To compare isobaric
levobupivacaine 0.5% versus isobaric levobupivacaine 0.5% with 3 mcg Dexmeditomidine
in spinal anaesthesia. Materials and methods: The present study was conducted in the
Department of Anesthesiology of the medical institution. For the study, we selected a total
of 50 patients in the age group of 20-65 years of physical status American Society of
Anesthesiologists (ASA) Classes I and II admitted for surgeries requiring spinal
anesthesia. An informed written consent was obtained from all the participants after
explaining them the protocol of the study. The patients were randomly grouped into two
groups, Group 1 and Group 2. Group 1 patients received 3 ml (15 mg) of 0.5% isobaric
levobupivacaine + 0.3 ml normal saline, whereas Group 2 patients received 3 ml (15 mg) of
0.5% isobaric levobupivacaine + 0.3 ml (3 μg) dexmedetomidine. Results: It was observed
that the number of male patients in group 1 and 2 was 12 and 14, respectively. The number
of female patients in group 1 and 2 was 13 and 11, respectively. The mean age of patients
in group 1 was 46.28 years and in group 2 was 47.12 years. It was observed that the mean
duration of sensory block in Group 2 was significantly higher than Group 1. The mean
duration of motor block in both the groups was similar and was statistically nonsignificant.
Conclusion: Within the limitations of the present study, it can be concluded
that the duration of sensory block increases with addition of 3 mcg of dexmedetomidine
with Levobupivacaine as compared to plain Levobupivacaine. The results were found to be
statistically significant.