Background: Pericapsular nerve group (PENG) block is a new ultrasound guided nerve block. It was used primarily to relieve pain in hip fracture; now, many new indications have been added. However, dependency on ultrasound guidance for this block limits its use where ultrasound facility is poor or not available. We have suggested a landmark based technique to increase the benefit of this novel nerve block. Aim and Objectives: To do a feasibility study to assess the successful placement of block needle, clinical efficacy of the block and block-related complications. Material and Methods: Total 10 patients (4 males and 6 females) with fracture hip and scheduled for hip surgery under spinal anaesthesia were selected for the study. In 4 patients ultrasound guided PENG block using out-of-plane approach and in 6 patients landmark based nerve stimulator guided block was given with 20ml 0.25% bupivacaine and 8mg dexamethasone. Pain relief before and after 30 minutes of block was assessed by numeric rating scale (NRS) and comfort during spinal position was assessed by ease of spinal position score (EOSP). Results: All 10 patients had successful block; NRS at rest was 6 (6-9) Vs 2 (0-2) and on 15 °limb elevation was 8 (8-10) Vs 3 (2-4). All patients could sit comfortably during spinal anaesthesia and median (range) EOSP sore was 3 (2-3). No complication was observed. Conclusion: Landmark based technique for PENG block is a feasible option and can be used safely where ultrasound facility is not available.

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Background and Aims: Oropharyngeal seal pressure (OSP) achieved by a supraglottic airway device holds due importance as it indicates the feasibility of positive pressure ventilation, the degree of airway protection from supra-cuff soiling and also relates to postoperative morbidity. The primary outcome measure was to assess and compare OSP in different head and neck positions with Baska mask^® and I-gel™. Secondary outcome measures were to compare peak inspiratory pressure (PIP), exhaled tidal volume (ETV), ease of insertion, time taken for insertion, number of attempts, intraoperative manipulations, and postoperative airway morbidity with both the devices. Materials and Methods: Seventy consenting adults scheduled for a variety of surgical procedures under general anesthesia were allocated to Group B and Group G using Baska mask^® and I-gel™ respectively. All statistical calculations were done using SPSS (Statistical Package for the Social Science). The comparison of quantitative variables between the study groups was done using Student t-test and within the variables was done by paired t-test. For comparing categorical data, Chi-square (χ²) test was performed. Results: OSP was significantly higher in group B than in group G in all head and neck positions (neutral 33 ± 2.8 vs. 23.2 ± 1.8, flexion 35.5 ± 2.5 vs. 25.2 ± 1.6, extension 30.6 ± 2.7 vs. 21.4 ± 1.7, right lateral 32.6 ± 2.8 vs. 23.0 ± 1.5. left lateral 32.6 ± 2.7 vs. 23.1 ± 1.7 cm H₂O, respectively) (P = 0.000). PIP increased significantly in group G as compared to group B in flexion. (P = 0.009). Baska mask^® had significantly higher ETV in flexion compared to I-gel™. (P = 0.009). Conclusion: Baska mask^® may provide a useful alternative to I-gel™ where the glottic seal has precedence over ease of insertion.

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Background: Quadratus lumborum block (QLB) provides somatic and visceral analgesia to the lower thoracic and abdominal wall. The aim was to investigate the analgesic effect of dexamethasone with levobupivacaine in QLB in patients undergoing unilateral inguinal hernia repair surgery. Methods: A total of 90 patients of American Society of Anaesthesiologists (ASA) I/II were randomly divided into two groups. Group L received 0.25% levobupivacaine (20 ml) + normal saline (1 ml) and group D received 0.25% levobupivacaine (20 ml) + 4 mg dexamethasone (1 ml) in QL plane on the operated side using ultrasound, after completion of surgery under spinal anaesthesia. The primary objective was to compare time for first rescue analgesia. The secondary objectives were total rescue analgesic consumption and numeric rating scale (NRS) in the first 24 h. Results: The demographic data age, sex, height, weight and ASA were comparable in both groups. The mean time to request for first rescue analgesia was longer in group D compared to group L (1016.02 ± 205.97 min versus 640 ± 132.96 min; P < 0.0001). The mean total tramadol consumption in the first 24 h was lower in group D compared to group L (233.55 ± 86.92 mg versus 328.22 ± 78.74 mg; P < 0.0001). Patients in group D had significantly lower NRS scores at rest and on movement as compared to group L. Conclusions: The addition of dexamethasone to levobupivacaine in QLB results in prolonged duration of postoperative analgesia, less rescue analgesic requirements and better quality of analgesia as compared to levobupivacaine in unilateral inguinal hernia repair surgery.

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Background and Aims: Evaluations of adverse heart rate (HR)-responses and HR-variations during anaesthesia in beach-chair-position (BCP) for shoulder surgeries have not been done earlier. We analysed the incidence, associations, and interpretations of adverse HR-responses in this clinical setting. Methods: We performed a meta-analysis of trials that reported HR-related data in anaesthetised subjects undergoing elective shoulder surgeries in BCP. Studies included prospective, randomised, quasi-randomised and non-randomised, controlled clinical trials as well as observational cohorts. Literature search was conducted in MEDLINE, EMBASE, CINHAL and the Cochrane Central Register of Controlled Trials of the 21^st century. In the first analysis, we studied the incidence and associations of bradycardia/hypotension-bradycardia episodes (HBE) with respect to the type of anaesthesia and different pharmacological agents. In the second, we evaluated anaesthetic influences, associations and inter-relationships between monitored parameters with respect to HR-behaviours. Results: Among the trials designed with bradycardia/HBE as a primary end point, the observed incidence of bradycardia was 9.1% and that of HBE, 14.9% and 22.7% [(for Interscalene block (ISB) ± sedation) subjects and general anaesthesia (GA) + ISB, respectively]. There was evidence of higher observed risk of developing adverse HR-responses for GA subjects over ISB (Risk Difference, P < 0.05). Concomitant use of β-agonists did not increase risk of HBEs (P = 0.29, I²= 11.4%) or with fentanyl (P = 0.45, I²= 0%) for ISB subjects (subgroup analysis). Fentanyl significantly influenced the HR-drop over time [meta-regression, estimates (standard error), 14.9 (5.4), 9.8 (4.3) and 17 (2.6); P = 0.007, 0.024 and <0.001; for early, mid and delayed periods, respectively] in GA subjects. With respect to number of subjects experiencing cerebral desaturation events (CDEs), total intravenous anaesthesia (TIVA)- propofol had higher risk over inhalational anaesthesia (P = 0.006, I² = 86.7%). Meta-correlation analysis showed relationships between the HR and rSO₂(regional cerebral oxygen saturation) or SjvO₂(jugular venous oxygen saturation) values (r = 0.608, 95%CI, 0.439 to 0.735, P < 0.001, I²= 77.4% and r = 0.397, 95%CI, 0.151 to 0.597, P < 0.001, I²= 64.3%, respectively). Conclusions: There is not enough evidence to claim the associations of adverse HR-responses with any specific factor. HR-fall is maximal with fentanyl and its variability is associated with changes in rSO₂. Fall in rSO₂could be the common link triggering adverse HR-responses in BCP.

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Background and Aims: Laryngoscopy and endotracheal intubation cause significant derangement of the haemodynamic parameters proving detrimental for some patients. Clonidine, an α-2 adrenoreceptor agonist, and melatonin, the pineal hormone, have been used for the attenuation of these haemodynamic responses. This study was designed to evaluate the effect of oral melatonin and clonidine in attenuating the haemodynamic responses to laryngoscopy and intubation. Materials and Methods: In this prospective randomised double-blind study, 60 American Society of Anaesthesiologists (ASA) grade I and II patients aged 20–60 years of either gender scheduled to undergo elective surgery under general anaesthesia were randomly divided into Group M and Group C and orally received 6 mg of melatonin and 0.2 mg of clonidine, respectively, 120 min before the induction of anaesthesia. The haemodynamic parameters-heart rate (HR), systolic blood pressure, diastolic blood pressure, mean arterial pressure and rate -pressure product(RPP) were recorded before and 120 min after the administration of the study drug, before induction, immediately after intubation and at 1, 3, 5 and 10 min following intubation. Sedation was assessed using the Ramsay Sedation Scale. The qualitative and quantitative variables were analysed using Chi square test and unpaired student t test, respectively. For intragroup comparison of quantitative data, paired t test was applied. A P value <0.05 was considered as statistically significant. Results: A significant difference was noted between the groups regarding HR and RPP 0, 1, 3 and 5 min after intubation. The Ramsay sedation score ranged between 2 and 3 at all time intervals. Conclusion: Although both the drugs are effective, oral melatonin proved superior to oral clonidine in attenuating the haemodynamic response to laryngoscopy and tracheal intubation without any side effects.

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Background and Aims: Airway management in obese patients is associated with increased risk of difficult airway and intubation. After failed intubation, supraglottic airway-guided flexible bronchoscopic intubation (SAGFBI) may be required. It is uncertain whether SAGFBI is best performed in the ramped versus conventional supine “sniffing air” position. We conducted a feasibility study to evaluate the logistics of positioning, compared glottic views, and evaluated SAGFBI success rates. Methods: We conducted a prospective, pilot study in patients with a body mass index (BMI) 30–40 kg/m² undergoing elective operations requiring tracheal intubation. All patients were placed in a ramped position. After induction, a supraglottic airway device (SAD) was inserted. A flexible bronchoscope was inserted into the SAD and a photograph of the glottic view taken. The patient was repositioned to the supine position. A second photograph was taken. SAGFBI was performed. Images were randomised and assessed by two independent anesthetists. Results: Of 17 patients recruited, 15 patients were repositioned successfully. There were no differences in glottic views observed in the two positions. SAGFBI was successful in 92.9% of patients (median time 91.5 s). Haemodynamic changes were noted in 42.7% of patients which resolved spontaneously. Conclusion: Our pilot study was completed within 5 months, achieved low dropout rate and protocol feasibility was established. SAGFBI was successfully and safely performed in obese patients, with a median time of 91.5 s. The time taken for SAGFBI was similar to awake intubation using FBI and videolaryngoscopy. Our study provided preliminary data supporting future, larger-scale studies to evaluate glottic views in the ramped versus supine positions.

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Background and Aims: Cytoreduction and hyperthermic intraperitoneal chemotherapy (CRS+HIPEC) cause numerous pathophysiological changes. The objective of this study was to compare the effect of two anaesthetic techniques on haemodynamic changes, inflammatory and coagulation parameters during this procedure. Methods: Twenty-one consenting adults undergoing CRS+HIPEC procedure, were block randomised to receive desflurane (V, n = 9) or TIVA (T, n = 12). After epidural catheter placement and intravenous induction of anaesthesia in both groups with fentanyl, propofol and rocuronium, anaesthesia was maintained with propofol or with desflurane, based on group allocation. Haemodynamic and temperature changes were assessed intra-operatively and variance was analysed. Inflammatory and coagulation markers were measured and compared at five time-points in the peri-operative period. Categorical variables were analysed using Chi square or Fisher exact test. Continuous variables were compared using t-test or Wilcoxon rank sum test. Results: Changes in core body temperature and haemodynamic variables during the hyperthermic intraperitoneal chemotherapy (HIPEC) phase were comparable between the two groups; except mean variance of mean arterial pressure, which was significantly higher (P = 0.0056) in group V (receiving desflurane) (58.98 ± 36.74) than TIVA group (27.51 ± 14.22). Inflammatory markers in both groups were comparable at five defined time points in the peri-operative period. On post-hoc analysis, pairwise comparisons with baseline, between levels of inflammatory markers within each group showed increased post-operative inflammation in group V. Mean prothrombin time was comparable. Conclusion: Desflurane group suffered greater mean arterial pressure (MAP) instability during the HIPEC phase. Inflammation in both groups was highest during the first 24 h after surgery. Prolonged inflammation was noted in patients receiving desflurane.

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Background and Aims: Various methods have been used to check vocal cord movements as a routine before awakening the patient at the end of thyroidectomy to rule out recurrent laryngeal nerve (RLN) palsy; out of which, fibreoptic-assisted visualisation via laryngeal mask airway (LMA) being the most desirable. Methods: Thirty patients of either sex, aged 18-65 years, American Society of Anaesthesiologists (ASA) grade I/II, scheduled for thyroidectomy under general anaesthesia (GA) were included and were randomised to receive either fibreoptic assisted (FB) or LMA CTrach-assisted (CT) visualisation of laryngeal structures at the end of thyroidectomy. The primary outcome was grade of view of laryngeal structures and secondary outcomes were time taken to achieve optimal view of laryngeal structures, ease of visualisation, hemodynamic parameters, and complications. Results: In the fibreoptic group, we obtained comparable optimal laryngeal view i.e., grade 1 and 2 in all (100%) patients in comparison to 14 (93.33%) in LMA CTrach group. The “time taken to achieve the optimal view” was significantly lower in the CTrach group when compared to Fibreoptic group (220.67 ± 95.98 vis-a-vis 136.67 ± 68.98). The ease of visualisation of laryngeal structures was comparable (P = 0.713) and the baseline haemodynamic parameters were comparable between the 2 groups and at various designated intervals. In total, 6.66% and 26.66% patients in group FB and CT group, respectively, required manoeuvres. However, difference was statistically significant (P < 0.05). Conclusion: Both Fibreoptic-assisted and LMA CTrach-assisted visualization of laryngeal structures in thyroidectomy are equally efficacious in terms of the optimal laryngeal view obtained and ease of visualisation. However, the time taken to achieve optimal laryngeal view was lesser with LMA CTrach.

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