Lower Limb Procedures Research Articles

ADJUNCTIVE USE OF CLONIDINE OR DEXMEDETOMIDINE WITH 0.25% ROPIVACAINE IN PNS GUIDED FEMORAL NERVE BLOCK FOR POST OPERATIVE ANALGESIA AFTER LOWER LIMB PROCEDURES : A RANDOMISED COMPARATIVE CLINICAL TRIAL

Background: The quality and duration of analgesia is improved when a local anesthetic is combined with alpha 2 adrenergic agonist. Though, the effects of clonidine on local anesthetics have been extensively studied, there are limited studies demonstrating the effects of epidural dexmedetomidine on local anesthetics. The aim of our study is to compare the effect of clonidine and dexmedetomidine when used as an adjuvant to ropivacaine for post operative analgesia after lower limb surgeries. Materials and Methods: Primary anesthetic technique in all the patients was spinal anesthesia. However femoral nerve block was placed at the completion of surgery by randomizing patients in two groups:Group C (20ml 0.25% Ropivacaine +1mcg/kg Clonidine) and Group D (20ml 0.25% Ropivacine +1mcg/kg Dexmedetomidine ) both containing 35 patients Onset of analgesia , duration of analgesia(It is time interval between administration of FNB & demand of rst resue analgesic ,total no of Rescue analgesics required in 24 hrs and quality of analgesia ,hemodynamic stability, post operative sedation scoring ,failure rate of technique and complications were recorded. Results: We found signicant difference in onset(9.41 ±0.73 mins) and duration(7.69±0.69 mins) of analgesia in group C as compared to onset(3.08 ±0.61 mins) and duration(11.16±0.58 mins) of analgesia in group D. No signicant complications were seen in either of the group.Conclusion: Dexmedetomidine at doses of 1 μg/kg is an effective adjuvant to ropivacaine for post operative analgesia after lower limb procedures .

Comparative evaluation of anesthetic efficacy and hemodynamic effects of intrathecal isobaric bupivacaine versus intrathecal isobaric levobupivacaine in the lower abdominal and lower limb surgeries

Background: The most frequently utilized approach in patients undergoing lower abdominal and lower limb procedures is spinal anesthesia with bupivacaine. Aims and Objectives: The aim of the study was to compare the anesthetic efficacy and hemodynamic effects of isobaric bupivacaine and isobaric levobupivacaine for spinal anesthesia. Materials and Methods: In our study, 80 patients (43 – male and 37 – female) between the ages of 18 and 70 years at Sri Venkateswaraa Medical College Hospital and Research Centre, Ariyur, Puducherry, were enrolled and split into Group I and Group II following approval by an ethical committee and written informed consent. Individuals in Group I were given 3 mL of preservative free 0.5% isobaric bupivacaine (Anawin™, bupivacaine hydrochloride, Neon laboratories, India), and Group II patients were given 3 mL of 0.5% isobaric levobupivacaine (Levoanawin™, levobupivacaine hydrochloride, Neon laboratories, India) for spinal anesthesia. A complete preanesthetic checkup was performed the day before surgery. Results: In this study, we observed no significant correlation between height, weight, and surgery duration. We discovered a statistically substantial distinction in motor and sensory blockade between the bupivacaine (Group I) and levobupivacaine (Group II) groups. In this study, Group I (50% of patients) had a lower occurrence of hypotension than Group II (20% of patients), indicating a statistically significant variation between the groups. Conclusion: When compared to levobupivacaine, individuals in the bupivacaine group required more administration of the vasoactive medicine ephedrine and the sympathomimetic drug atropine. Levobupivacaine is less cardiotoxic, neurotoxic, and equally potent local anesthetic compared to its racemate.

Comparison of Intrathecal Bupivacaine with Clonidine Versus Intrathecal Bupivacaine with Fentanyl for Post-operative Pain Treatment in Lower Limb Procedures

Background: One of the anaesthesiologist's key goals during spinal anaesthesia is to keep the body physiology as close to normal as feasible. As we all know, subarachnoid block causes significant hemodynamic changes, especially in trauma and elderly individuals. Sympathetic nervous system denervation, skeletal muscle weakness, or loss of proprioception are not linked to neuraxial opioids. They primarily operate on the receptors found in the substantia gelatinosa of the spinal cord to exert their synergistic analgesic impact on visceral pain. Opioids and local anaesthetics delivered intrathecally have a powerful synergistic analgesic effect. A 2 adrenergic agonist, Clonidine is sometimes used as a local anaesthetic adjuvant with mixed effects. The effects of intrathecal Clonidine vs Fentanyl with 0.5 percent hyperbaric bupivacaine on postoperative analgesic duration and adverse effects were compared.
 Objectives: The purpose of this study was to compare the efficacy of 0.5 percent hyperbaric bupivacaine with Clonidine (75 gs) vs Fentanyl (25 gs) for spinal anaesthesia in patients undergoing lower limb procedures, as well as the postoperative pain alleviation and adverse effects in both groups.
 Methods: This was a prospective study involving 80 patients who were scheduled for elective lower limb surgery under spinal anaesthesia. The participants were randomly assigned to one of two groups: Group C (15mg 0.5 percent bupivacaine + 75gs Clonidine) or Group F (15mg 0.5 percent bupivacaine + 25gs Fentanyl).
 Results: We discovered a time delay in the start of sensory and motor block in group C after assessing the outcomes of our investigation. Group C's sensory and motor block lasted significantly longer compared to group F. The average duration of analgesia in groups C and F was 234.7529.71 minutes and 170.8732.38 minutes, respectively. Compared to group C, the demand for rescue analgesics was higher in group F throughout 24 hours. Bradycardia affected 12 individuals in group C, while pruritus affected 12 patients in group F. Five of the patients in group F experienced nausea.
 Conclusion: In compared to 25gs Fentanyl, adjuvant use of Clonidine 75gs with hyperbaric bupivacaine prolongs the duration of both sensory and motor blockage, as well as the length of analgesia postoperatively, without generating substantial hemodynamic compromise or other side effects.

Effect of Injection Speed of Heavy Bupivacaine in Spinal Anesthesia on Quality of Block and Hemodynamic Changes.

Background and Aims:Spinal anesthesia is a technique widely used for gynecological, lower abdominal, pelvic and lower limb procedures. Even though it causes a profound nerve block, it is associated with profound hypotension.Aims of the Study:To assess the effect of the speed of injection of heavy bupivacaine on quality of block and hemodynamic changes in patients undergoing gynecological surgeries under spinal anesthesia.Methods:This was a prospective randomized study conducted on 40 patients. Group F patients were given 3.2 mL of 0.5% heavy bupivacaine intrathecally in 15 s and Group S patients were given the same drug over 60 s. The time to achieve T10 dermatomal block, maximum block height, block height at 5 min were recorded. Heart rate (HR), systolic, diastolic blood pressures, and mean arterial pressures (MAP) were also recorded at different time points.Results:HR, systolic BP, diastolic BP, and MAPs and mean block height at 5 min were comparable between the two groups at all time points. The time to achieve T10 dermatome block was significantly faster in Group F (1.85 ± 1.14 min) as compared to Group S (3.98 ± 1.58 min). Majority of patients in Group F (65%) had a maximum block up to T6 and those in Group S (45%) had a block upto T4. The usage of vasopressors was found to be significantly higher in Group F compared to Group S with P = 0.041.Conclusion:Using faster speed of injection of heavy bupivacaine during spinal anesthesia can lead to faster achievement of blockade but with significantly higher usage of vasopressors.

Spinal anaesthesia with Chloroprocaine HCl 1% for elective lower limb procedures of short duration: a prospective, randomised, observer-blind study in adult patients

BackgroundThis prospective, randomised, observer-blinded study has been conducted in patients undergoing procedures of the lower extremities to evaluate the time to complete block resolution of 2-chloroprocaine 1% at three intrathecal doses (30, 40 and 50 mg).MethodsAfter informed consent, we enrolled 45 male and female patients, aged 18–65 years, ASA score I-II, BMI 18–32 kg/m2, undergoing elective lower limb procedures lasting ≤40 min and with a requested dermatomeric level of sensory block ≥ T12.The patients were randomised in a 1:1:1 ratio to receive Chloroprocaine HCl 1% at one of the three different intrathecal doses (Group 30 = 30 mg, Group 40 = 40 mg or Group 50 = 50 mg). The progression and regression of both sensory and motor blocks were evaluated blindly. Urine and venous blood samples were collected for pharmacokinetic analysis.ResultsTimes to regression of spinal blocks were 1.76 ± 0.35 h, 2.13 ± 0.46 h and 2.23 ± 0.38 h, in Group 30, 40 and 50 respectively: the 30 mg dose showed a significantly faster resolution of spinal block than the 40 mg (p = 0.034) and the 50 mg (p = 0.006). Time to readiness for surgery was significantly reduced with the dose of 50 mg when compared to dose of 30 mg (p = 0.0259).ConclusionsThe doses of 50 mg and 40 mg yielded a longer resolution of spinal block than the dose of 30 mg. Nevertheless, the dose of 30 mg resulted in a higher secondary failure rate.Trial registrationRegistration of clinical trial: clinicaltrials.gov (NCT02481505).

Ultrasound-guided anterior iliopsoas muscle space block versus posterior lumbar plexus block in hip surgery in the elderly: A randomised controlled trial.

Ultrasound-guided posterior lumbar plexus block is widely used for hip fracture surgery but it requires a change of position, which may be painful. Our primary objective was to describe a new technique, the anterior iliopsoas muscle space block, which can be performed in the supine position, and to test the hypothesis that its analgesia for hip surgery was similar to that of the traditional posterior lumbar plexus block. Randomised, double-blind study. Shanghai 6th People's Hospital, China, from February to August 2019. Forty-eight patients scheduled for unilateral hip fracture surgery were included in the study. The exclusion criteria were infection at the puncture site, history of hip surgery, pre-existing neurological deficits of the lower extremity, contraindications for regional anaesthesia, allergy to local anaesthetics, coagulopathy, abuse of medicine or alcohol, or daily consumption of analgesics. Patients were randomised to receive a lateral sacral plexus block with either an anterior iliopsoas muscle space block or a posterior lumbar plexus block, using 0.33% ropivacaine (30 ml each). The main outcome was verbal numerical scale (VNS) pain intensity 1 h after surgery in the postanesthesia care unit, and the secondary outcome was the dose of intra-operative fentanyl. The differences in VNS scores and fentanyl use between the groups were analysed. Based on previous work, we considered a difference (confidence interval [CI]) of 1.6 on the VNS to be significant. The median [IQR] pain scores in postanesthesia care unit were similar in the anterior 0 [0 to 3] and posterior groups 1.5 [0 to 3]. The median scores for intra-operative fentanyl use were similar in the anterior 20 [10 to 42.5] μg and posterior groups 15 [0 to 50] μg (P = 0.34). The difference in the median pain score at-rest was NS: anterior group 0.5 [0 to 5], posterior group 0 [0 to 2], median difference -0.5 (95% CI -2 to 0). The median post to preblock difference in VNS was higher in the anterior -0.5 [-2 to 0] than in the posterior group 0 [-1.25 to 0], median difference 0.5 (95% CI 0 to 1). The median block onset time was longer in the anterior 11 [6 to 14.25] min than in the posterior group 6 [4.75 to 8] min (P = 0.002), median difference -5 (95% CI -7 to -1). The anterior iliopsoas muscle space block had the same effect as the posterior lumbar plexus block on peri-operative analgesia for hip surgery, but with a longer onset time. Therefore, anterior iliopsoas muscle space block can be recommended as a routine technique for hip and lower limb procedures. http://www.chictr.org.cn identifier: ChiCTR1900021214.

Factors predicting toxicity and response following isolated limb infusion for melanoma: An international multi-centre study

IntroductionIsolated limb infusion (ILI) is a minimally-invasive procedure for delivering high-dose regional chemotherapy to treat melanoma in-transit metastases confined to a limb. The aim of this international multi-centre study was to identify predictive factors for toxicity and response. MethodsData of 687 patients who underwent a first ILI for melanoma in-transit metastases confined to the limb between 1992 and 2018 were collected at five Australian and four US tertiary referral centres. ResultsAfter ILI, predictive factors for increased limb toxicity (Wieberdink grade III/IV limb toxicity, n = 192, 27.9%) were: female gender, younger age, procedures performed before 2005, lower limb procedures, higher melphalan dose, longer drug circulation and ischemia times, and increased tissue hypoxia. No patient experienced grade V toxicity (necessitating amputation). A complete response (n = 199, 28.9%) was associated with a lower stage of disease, lower burden of disease (BOD) and thinner Breslow thickness of the primary melanoma. Additionally, an overall response (combined complete and partial response, n = 441, 64.1%) was associated with female gender, Australian centres, procedures performed before 2005, lower limb procedures and lower actinomycin-D doses. On multivariate analysis, higher melphalan dose remained a predictive factor for toxicity, while lower stage of disease and lower BOD remained predictive factors for overall response. ConclusionILI is safe and effective to treat melanoma in-transit metastases. Predictive factors for toxicity and response identified in this study will allow improved patient selection and optimization of intra-operative parameters to increase response rates, while keeping toxicity low.

A study of dexmedetomidine as an adjuvant to hyperbaric bupivacaine in subarachnoid block

Background: No drug, used as adjuvant to spinal bupivacaine, has yet been identified that specifically inhibits nociception without its associated side-effects. Dexmedetomidines a novel alpha-2 agonist which holds promise as an intra-thecal adjuvant. Aims: This observational study was conducted to evaluate the onset and duration of sensory and motor block as well as perioperative analgesia and adverse effects of dexmedetomidine given intrathecally with 0.5% hyperbaric bupivacaine for spinal anesthesia. Materials and Methods: A total of 60 patients belonging to age group 18-60 yrs, urban population, classified as American Society of Anesthesiologists status I and II scheduled for lower abdominal and lower limb procedures were prospectively studied. Patients were randomly allocated to receive intrathecally either 12.5 mg hyperbaric bupivacaine plus 5 μg (0.5 ml) dexmedetomidine (group D, n=30) or 12.5 mg hyperbaric bupivacaine plus 0.5 ml NS (group B, n=30). Sensory and motor blockade charactersistics- The onset time to reach peak sensory and motor level, the regression time for sensory and motor block, time for rescue analgesia, hemodynamic changes and side-effects were recorded. Data collection was done by observation and measurement of various parameters. Results: The onset times to reach T10 dermatome, peak sensory level and onset time to reach modified Bromage 3 motor block were similar in both groups. We found that adding dexmedetomidine intrathecally significantly prolonged sensory and motor block time. time for first analgesic request was also significantly prolonged in group BD. Statistically there were no significant differences in hemodynamic alterations and other adverse effects between the groups. Conclusion: clinical advantage of dexmedetomidine is that it facilitates the spread of the block and offers prolonged post‑operative analgesia. The groups were similar with respect to hemodynamic variables and there were no significant side-effects in either of the groups. However, prolonged duration of motor blockade with dexmedetomidine may be undesirable for short‑term surgical procedures or ambulatory surgeries.

Comparative Study of Hyperbaric Bupivacaine and Isobaric Ropivacaine for Lower Limb Surgery under Spinal Anesthesia


 
 
 
 Introduction: Subarachnoid block is commonly employed technique for lower abdominal and lower limb procedures. Bupivacaine and ropivacaine are commonly used local anesthetics for subarachnoid block. The aim of this study is to compare the efficacy and safety of isobaric Ropivacaine over hyperbaric Bupivacaine.
 Methods: This was a prospective comparative study for a duration of six months. 60 ASA grade I-II adult patients between 16-60 years undergoing lower limb surgery under spinal anesthesia were randomized into two groups. Group I including patients who received 15 mg of hyperbaric bupivacaine 0.5% and group II including patients who received 22.5 mg of isobaric ropivacaine 0.75%. The onset and duration of sensory and motor block and hemodynamics including heart rate (HR), non invasive mean arterial blood pressure (MAP) and respiratory depression were recorded. Data were entered in Microsoft excel and statistical analysis was done by chi square test and T test using SPSS (version 23.0).
 Results: Both the groups were demographically statistically insignificant. Successful block was attained in all patients in both groups. The sensory onset and motor onset were significantly delayed in the Ropivacaine Group compared to the Bupivacaine Group P<0.001. There was no significant difference in the hemodynamics (heart rate and mean arterial pressure ).
 Conclusions: Though isobaric ropivacaine provided lesser degree of sensory and motor block with delayed onset compared to hyperbaric bupivacaine, it can effectively and safely used in subarachnoid block in lower limb surgeries without any major hemodynamic changes and adverse effects.
 
 
 

Analgesic strategies for day-case knee surgery.

Analgesic strategies for day-case knee surgery.

Contrast-Induced Nephropathy: A Fact or Fiction in Lower Limb Revascularization?

Contrast-induced nephropathy (CIN) is defined as an increase >25% of serum creatinine from baseline, occurring in 24-48hours after exposure to contrast, while alternative explanations for renal impairment have been excluded. The volume administered directly relates to risk, increasing by 12% per 100mL of contrast. According to the series, its incidence varies between 3.3% and 8% in patients without renal damage and 12-50% in patients with chronic kidney disease (CKD) and/or diabetes mellitus (DM). The purpose of this study is to determine the incidence of CIN in endovascular revascularization of lower limbs in our center, where we apply the ALARA concept (As Low As Reasonably Achievable) to the use of contrast. 163 patients who underwent endovascular revascularization procedures in lower limbs were included in this prospective observational study between February 2013 and April 2015. They were classified according to clinical stage and presence of DM and/or CKD. Data included serum creatinine values preoperative and postoperative, type and volume of contrast used. Patients on hemodialysis and those without sufficient analytical data were excluded. Chi-squared test and Student t-test were used for data analysis. P<0.05 was considered statistically significant. 109 patients were enrolled, with 67% of DM and 31.5% of CKD. CIN incidence was 3.7% in patients without DM neither CKD, in DM was 6.8% and 12.5% in CKD. Mean creatinine presurgery was 97.96 and postsurgery 97.07, finding no significant differences between them (P=0.753). Medium-contrast volume was 37.43mL ± 22.3. The worsening variable (creatinine postsurgery minus creatinine presurgery) was evaluated according to clinical stage, DM, or CKD, being not significant in either group. In our experience, the dose administered of contrast was not related to the existence of postprocedure CIN, due to the policy of optimizing the use of contrast.

Population pharmacokinetics of intravenous acetaminophen in Japanese patients undergoing elective surgery.

Intravenous (i.v.) acetaminophen is administered during surgery for postoperative analgesia. However, little information is available on the pharmacokinetics of i.v. acetaminophen in Japanese patients undergoing surgery under general anesthesia. The study was approved by the Institutional Review Board and registered at UMIN-CTR (UMIN000013418). Patients scheduled to undergo elective surgery under general anesthesia were enrolled after obtaining written informed consent. During surgery, 1g of i.v. acetaminophen was administered over 15, 60, or 120min. Acetaminophen concentrations (15 or 16 samples per case) were measured at time points from 0-480min after the start of administration (liquid chromatography-mass spectrometry/tandem mass spectrometry; limit of quantitation 0.1μg/mL). The predictive performance of three published pharmacokinetic models was evaluated. Population pharmacokinetics were also analyzed using a nonlinear mixed-effect model based on the NONMEM program. Data from 12 patients who underwent endoscopic or lower limb procedures were analyzed (male/female=7/5, median age 55years, weight 63kg). Anesthesia was maintained with remifentanil and propofol or sevoflurane. The pharmacokinetic model of i.v. acetaminophen reported by Würthwein et al. worked well. Using 185 datapoints, the pharmacokinetics of i.v. acetaminophen were described by a two-compartment model with weight as a covariate but not age, sex, or creatinine clearance. The median prediction error and median absolute prediction error of the final model were -1 and 10%, respectively. A population pharmacokinetic model of i.v. acetaminophen in Japanese patients was constructed, with performance within acceptable ranges.

Venous thromboembolism incidence in upper limb orthopedic surgery: do these procedures increase venous thromboembolism risk?

In 2005, the House of Commons (HoC) Health Committee stated deaths attributed to preventable, hospital-acquired venous thromboembolism (VTE) numbered upwards of 25,000 per annum. Nationwide prevention of VTE became the topic of a major health campaign. The HoC Health Committee stated there was an unstratified VTE risk of between 45% and 51% associated with orthopedic surgery. VTE research in orthopedic surgery has been concentrated on lower limb procedures. Experience suggests that this kind of relation does not hold true for upper limb orthopedic procedures. This project aimed to estimate the incidence of postoperative VTE in upper limb orthopedic surgery. The incidence of postoperative VTE was assessed in 3357 consecutive upper limb orthopedic operations performed by 4 surgeons in Lancashire Teaching Hospitals National Health Service (NHS) Trust (LTHTR) between July 1, 2009, and July 31, 2012. Four pulmonary embolisms and 2 deep vein thromboses occurred. Incidence of postoperative VTE was 0.0018%, significantly lower than rates reported in the literature. Five of 6 patients who developed a VTE reported a personal or family history of VTE. Three patients would not have been identified as at risk under the current VTE screening guidelines. Three of these patients received appropriate anticoagulation according to present guidelines, yet VTE events still occurred. These results indicate VTE risk in orthopedic upper limb surgery is much lower than reported in the literature. The necessity for screening for VTE in upper limb surgery is contested. The efficacy of VTE screening and current VTE prophylaxis is discussed, and an alternative and much simplified method of screening is suggested.

Australian multi‐center experience outside of the Sydney Melanoma Unit of isolated limb infusion chemotherapy for melanoma

Isolated limb infusion (ILI) is a minimally invasive alternative to isolated limb perfusion (ILP) for delivering high-dose regional chemotherapy to treat locally advanced limb melanoma. The current study aimed to evaluate the applicability of ILI in four Australian tertiary referral centers outside of its originating institution, the Sydney Melanoma Unit (SMU; currently known as the Melanoma Institute Australia). Data of 131 patients, treated between 1992 and 2008 were collectively analyzed. The ILI procedures were based on the Sydney Melanoma Unit protocol using melphalan. Response was determined using the WHO criteria and toxicity was assessed using the Wieberdink scale. The median patient age was 74 years (range 28-100). Fifty-six percent were female. Overall response (OR) rate to ILI was 63% (CR 27%; PR 36%). Wieberdink toxicity grade III or higher was seen in 13%. No toxicity-related amputations occurred. Median follow-up was 24 months; median survival was 58 months. In patients with a complete response (CR), median survival was 101 months; in patients with a partial response (PR) this was 41 months (P = 0.026). On univariate analysis a younger age, lower-limb procedures and a lower Breslow thickness of the primary melanoma were associated with a favorable response. On multivariate analysis Breslow thickness and lower-limb ILI remained significant predictors for response. In this, to date, largest multi-center study of ILI for melanoma the results are comparable to other reports and demonstrate that ILI can be widely implemented and safely applied across tertiary referral centers.

Intrathecal 1% 2-chloroprocaine vs. 0.5% bupivacaine in ambulatory surgery: a prospective, observer-blinded, randomised, controlled trial

This prospective, observer-blinded, randomised, multicentre study aimed at determining the non-inferiority of 50 mg of plain 1% 2-chloroprocaine vs. 10 mg of 0.5% plain bupivacaine in terms of sensory block onset time at T10 after spinal injection. The study hypothesis was that the difference in onset times of sensory block to T10 between the two drugs is ≤ 4 min. One hundred and thirty patients undergoing lower abdominal or lower limb procedures (≤ 40 min) were randomised to receive one of two treatments: 50 mg of plain 1% 2-chloroprocaine (Group C, n = 66) or 10 mg of plain 0.5% bupivacaine (Group B, n = 64). Times to sensory and motor block onsets, maximum sensory block level, readiness for surgery, regression of sensory and motor blocks, first analgesic requirements, unassisted ambulation, home discharge, and side effects after 24 h and 7 days were registered blindly. Chloroprocaine was comparable with plain 0.5% bupivacaine in terms of time to sensory block at T10 level. Group C showed faster onsets of motor block (5 vs. 6 min), maximum sensory block level (8.5 vs. 14 min), resolution of sensory (105 vs. 225 min) and motor (100 vs. 210 min) blocks, unassisted ambulation (142.5 vs. 290.5 min), first analgesic requirement (120 vs. 293.5 min), and home discharge (150 vs. 325 min) (all comparisons, P < 0.05). No chloroprocaine patient developed transient neurological symptoms. Spinal anaesthesia with 50 mg of plain 1% 2-chloroprocaine is similar to 10 mg of plain 0.5% bupivacaine in terms of onset of sensory block at T10 but shows quicker recovery from anaesthesia than with 0.5% bupivacaine.

English

BACKGROUND: Spinal anesthesia is the more commonly administered procedure for pelvic, lower abdominal and lower limb procedures. Hypotension is the most common complication of spinal anesthesia. It is a common practice to give intravenous fluids, usually crystalloids, prior to centro neuraxial block in order to prevent hypotension and this is usually referred as preloading. AIMS: Compare the efficacy of preloading with crystalloid to that of colloids in reducing the incidence and severity of hypotension in spinal anesthesia for lower abdominal surgery and also to find out if hydroxyl ethyl starch (HES) is a better colloid than polygelatin. STUDY DESIGN: The study population included 150 patients belonging to either sex undergoing elective lower abdominal surgeries under spinal anesthesia. METHODS AND MATERIAL: One hundred and fifty ASA I and II patients posted for lower abdominal surgeries under spinal anesthesia were randomly allocated to receive either 10mL/Kg of HES (Group A), 10mL/Kg of polygelatin (Group B) or 10mL/Kg of Ringer's lactate solution as preloading solution. Heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were recorded once in two minutes for the first ten minutes and once in five minutes for the next fifty minutes. The incidence of hypotension and the mean dose requirement of mephentermine were noted after spinal anesthesia. STATISTICAL METHODS: The analysis of variance to find the significance difference of pulse rate, SBP and MAP between the three groups of patients. The Post hoc test by Tukey to find the pair wise significance between the three groups. The Chi-square test to find the significance of proportions of mephentermine dose requirement between the three groups. RESULTS: The incidence of hypotension was 9 of 50 (18%) in Group A, 17 of 50 (34%) in Group B and 27 of 50 (54%) in group C. The mephentermine bolus requirements were also less in group A (9 times) when compared to group B (18times) and group C (32 times), which was statistically significant. INTERPRETATION AND CONCLUSION: HES reduced the incidence of hypotension after spinal anesthesia and required lesser mean dose requirements of mephentermine when compared to polygelatin and ringers lactate. It can be concluded from the present study that colloids offset hypotension and hypovolemia more effectively than crystalloids. Also it can be concluded that hydroxyethyl starch is a better

Brachial plexus anesthesia: A review of the relevant anatomy, complications, and anatomical variations

The trend towards regional anesthesia began in the late 1800s when William Halsted and Richard Hall experimented with cocaine as a local anesthetic for upper and lower limb procedures. Regional anesthesia of the upper limb can be achieved by blocking the brachial plexus at varying stages along the course of the trunks, divisions, cords and terminal branches. The four most common techniques used in the clinical setting are the interscalene block, the supraclavicular block, the infraclavicular block, and the axillary block. Each approach has its own unique set of advantages and indications for use. The supraclavicular block is most effective for anesthesia of the mid-humerus and below. Infraclavicular blocks are useful for procedures requiring continuous anesthesia. Axillary blocks provide effective anesthesia distal to the elbow, and interscalene blocks are best suited for the shoulder and proximal upper limb. The two most common methods for localizing the appropriate nerves for brachial plexus blocks are nerve stimulation and ultrasound guidance. Recent literature on brachial plexus blocks has largely focused on these two techniques to determine which method has greater efficacy. Ultrasound guidance has allowed the operator to visualize the needle position within the musculature and has proven especially useful in patients with anatomical variations. The aim of this study is to provide a review of the literature on the different approaches to brachial plexus blocks, including the indications, techniques, and relevant anatomical variations associated with the nerves involved.

Isolated Limb Perfusion and Isolated Limb Infusion for Malignant Lesions of the Extremities

Isolated limb infusion (ILI) is a minimally-invasive procedure for delivering high-dose regional chemotherapy to treat melanoma in-transit metastases confined to a limb. The aim of this international multi-centre study was to identify predictive factors for toxicity and response.Data of 687 patients who underwent a first ILI for melanoma in-transit metastases confined to the limb between 1992 and 2018 were collected at five Australian and four US tertiary referral centres.After ILI, predictive factors for increased limb toxicity (Wieberdink grade III/IV limb toxicity, n = 192, 27.9%) were: female gender, younger age, procedures performed before 2005, lower limb procedures, higher melphalan dose, longer drug circulation and ischemia times, and increased tissue hypoxia. No patient experienced grade V toxicity (necessitating amputation). A complete response (n = 199, 28.9%) was associated with a lower stage of disease, lower burden of disease (BOD) and thinner Breslow thickness of the primary melanoma. Additionally, an overall response (combined complete and partial response, n = 441, 64.1%) was associated with female gender, Australian centres, procedures performed before 2005, lower limb procedures and lower actinomycin-D doses. On multivariate analysis, higher melphalan dose remained a predictive factor for toxicity, while lower stage of disease and lower BOD remained predictive factors for overall response.ILI is safe and effective to treat melanoma in-transit metastases. Predictive factors for toxicity and response identified in this study will allow improved patient selection and optimization of intra-operative parameters to increase response rates, while keeping toxicity low.

Comparative study of intrathecal dexmedetomidine with intrathecal magnesium sulfate used as adjuvants to bupivacaine

Background:No drug, used as adjuvant to spinal bupivacaine, has yet been identified that specifically inhibits nociception without its associated side-effects.Aims:This prospective randomized double-blind study was conducted to evaluate the onset and duration of sensory and motor block as well as perioperative analgesia and adverse effects of dexmedetomidine and magnesium sulfate given intrathecally with 0.5% hyperbaric bupivacaine for spinal anesthesia.Materials and Methods:A total of 90 patients classified as American Society of Anesthesiologists status I and II scheduled for lower abdominal and lower limb procedures were prospectively studied. Patients were randomly allocated to receive intrathecally either 15 mg hyperbaric bupivacaine plus 0.1 ml (10 μg) dexmedetomidine (group D, n=30) or 15 mg hyperbaric bupivacaine plus 0.1 ml (50 mg) magnesium sulfate (group M, n=30) or 15 mg hyperbaric bupivacaine plus 0.1 ml saline (group C, n=30) as control. The onset time to reach peak sensory and motor level, the regression time for sensory and motor block, hemodynamic changes and side-effects were recorded.Statistical Analysis Used:All statistical analyses were performed using INSTAT for windows. Continuous variables were tested for normal distribution by the Kolmogorov-Smirnov test. Data was expressed as either mean and standard deviation or numbers and percentages. Continuous covariates (age, body mass index and height) were compared using analysis of variance (ANOVA). For the times to reach T10 dermatomes, Bromage 3 scale and the regression of the sensory block to S1 dermatome and Bromage scale 0, one-way ANOVA was used to compare the means. The level of significance used was P<0.05.Results:The onset times to reach T10 dermatome and to reach peak sensory level as well as onset time to reach modified Bromage 3 motor block were significantly different in the three groups. The onset time to reach peak sensory and motor level was shorter in group D as compared with the control group C, and it was significantly prolonged in group M. We also found that patients in group D had significant longer sensory and motor block times than patients in group M, which was greater than in the control group C.Conclusion:It was found that onset of anesthesia was rapid and of prolonged duration in the dexmedetomidine group (D). However, in the magnesium sulfate group (M), although onset of block was delayed, the duration was significantly prolonged as compared with the control group (C), but to a lesser degree than in the dexmedetomidine group (D). The groups were similar with respect to hemodynamic variables and there were no significant side-effects in either of the groups.

Effect of epidural or intravenous patient-controlled analgesia on stress response and blood coagulation in the elderly after orthopedic surgery of lower limb

Objective To explore the effect of epidural or intravenous patient-controlled analgesia on stress response and blood coagulation after orthopedic surgery of lower limb in the elderly.Methods Fony ASA Ⅲ-Ⅲ patients(15 males,25 females)aged 65-85 years undergoing elective orthopedic procedures of lower limb were randomized to one of two groups:epidural patient-controlled analgesia(EPCA)group(n=20)and intravenous patient-controlled analgesia(PCIA)(n=20).All the patients received combined spinal and epidural anesthesia.After surgery,the patients in PCEA group received PECA with a mixture of 100 ml,including 225 mg ropivacaine,8 mg morphine and 5 mg droperidol,and those in PCIA group received PCIA with a mixture of 100 ml,including 0.2 mg fentany1.1 g tramadol and 5 mg droperidol.The parameters,including blood cortisol concentration(COR),blood glucose concentration(BS),and the parameters of blood coagulation,including prothrombin time(PT),activated partial thromboplastin time(APTT),thrombin time(TT),and the concentration of blood fibrinogen(Fg),were determined at following time points:before anesthesia induction(T0),at the end of surgery(T1).24 h(T2)and 48 h (T3)after the operation.Pain intensity was tested using a visual analog seale(VAS)at 12.24 and 48 h after surgery.Results The demographic data,duration of operation.intraoperative transfusion volume and blood loss were comparable between the two groups.Pain relief was better at 12 and 24 h after surgery in PCEA group than in PCIA group(P＜0.05).The concentrations of COR and BS from T1 to 13 were decreased as compared with those before anesthesia induction(T0)in two groups(P＜0.05 or0.01).The concentrations of COR and BS were lower at T2 and T3 in PECA group than those in PCIA group(P＜0.05).TP,APTT and TT were prolonged from T1 to T3 as compared with those at TO in two groups(P＜0.05 or0.01).PT,APTT and TT at T2 were longer in PCEA group than in PCIA group(P＜0.05).The concentrations of Fg from T1 to T3 were decreased as compared with those at T0 in PCEA group(P＜0.05or0.01).In PCIA group,the concentrations of Fg were lower from T1 to T3 than those at TO,but the differenee was not significant(P＞0.05).The concentrations of Fg were lower only at T2 in PCEA group than those in PCIA group(P＜0.05).Conclusion After the surgery of lower limb in the elderly patient,patient-controlled analgesia,regardless of the route(epidural or intravenous),is effective,and decreases the stress response to surgery and impmves the blood coagulation.The epidural route provides better pain rehef,decreases the stress response to surgery,and improves the blood coagulation more preferably. Key words: Analgesia,epidural; Analgesia,intravenous; Stress; Blood coagulation