Perioperative Hemodynamic Stability Research Articles

Evaluating Intravenous Paracetamol And Dexmedetomidine For Peri-Operative Hemodynamic Stability, Post-Operative Delirium, And Pain In Laparoscopic Cholecystectomy

Objective: In order to manage pain, reduce post-operative delirium, and achieve peri-operative hemodynamic stability in patients having laparoscopic cholecystectomy, this study compared the efficacy of intravenous Paracetamol and Dexmedetomidine. Study Design: Cross sectional study Place and Duration of the Study: Study conducted at National Hospital Lahore in 6 months period of time.from March-2024 to Sep- 2024 Methodology: One hundred forty patients slated for elective laparoscopic cholecystectomy were randomly allocated to receive either Paracetamol (Group P) or Dexmedetomidine (Group D). Hemodynamic measures (heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure) were documented at intervals throughout the surgical procedure. Post-operative outcomes, such as the incidence of delirium, onset time, duration, pain scores on the Visual Analog Scale (VAS), and sedation levels, were evaluated at 4, 8, 16, and 24 hours post-operatively. Result: lower heart rate and blood pressure were consistently observed at various time intervals, with an HR of 91.25 ± 19.8 bpm compared to 103.12 ± 14.3 bpm (p < 0.05) and lower systolic and diastolic pressures of 114.35 ± 19.1 mmHg against 122.58 ± 17.3 mmHg (p < 0.05). Group D demonstrated improved pain management as evidenced by reduced pain scores on the VAS scale at 4 hours (1.90 ± 1.10 vs. 2.50 ± 1.25, p < 0.05) and 24 hours (1.40 ± 0.48 vs. 1.50 ± 0.92, p < 0.05). Group D had more consistent sedation levels, with lower levels at 4 hours (2.00 ± 0.60 vs. 2.20 ± 0.75) and 24 hours (1.80 ± 0.30 vs. 2.00 ± 0.45). Group D had a considerably lower rate of post-operative delirium (7% vs. 21%, p = 0.02), started later (15 ± 4 hours vs. 12 ± 3 hours, p = 0.04) and lasted shorter (4 ± 1 hours vs. 6 ± 2 hours, p = 0.01). In terms of post-operative pain management, sedation, and delirium reduction, Dexmedetomidine demonstrated superior efficacy, suggesting its potential benefits in this area of treatment. Conclusion: Dexmedetomidine (Group D) demonstrates superior efficacy compared to Paracetamol (Group P) in regulating vital signs, alleviating pain, and achieving sedation in post-operative management following laparoscopic cholecystectomy. Keywords: Dexmedetomidine, pain, Hemodynamic Stability, Laparoscopic Cholecystectomy, Delirium

Adequacy of Anesthesia Guidance for Combined General/Epidural Anesthesia in Patients Undergoing Open Abdominal Infrarenal Aortic Aneurysm Repair; Preliminary Report on Hemodynamic Stability and Pain Perception.

Background/Objectives: Hemodynamic instability and inappropriate postoperative pain perception (IPPP) with their consequences constitute an anesthesiological challenge in patients undergoing primary elective open lumbar infrarenal aortic aneurysm repair (OLIAAR) under general anesthesia (GA), as suboptimal administration of intravenous rescue opioid analgesics (IROAs), whose titration is optimized by Adequacy of Anaesthesia (AoA) guidance, constitutes a risk of adverse events. Intravenous or thoracic epidural anesthesia (TEA) techniques of preventive analgesia have been added to GA to minimize these adverse events. Methods: Seventy-five patients undergoing OLIAAR were randomly assigned to receive TEA with 0.2% ropivacaine (RPV) with fentanyl (FNT) 2.5 μg/mL (RPV group) or 0.2% bupivacaine (BPV) with FNT 2.5 μg/mL (BPV group) or intravenous metamizole/tramadol (MT group). IROA using FNT during GA was administered under AoA guidance. Systemic morphine was administered as a rescue agent in all groups postoperatively in the case of IPPP, assessed using the Numeric Pain Rating Score > 3. The maximum score at admission and the minimum at discharge from the postoperative care unit to the Department of Vascular Surgery, perioperative hemodynamic stability, and demand for rescue opioid analgesia were analyzed. Results: Ultimately, 57 patients were analyzed. In 49% of patients undergoing OLIAAR, preventive analgesia did not prevent the incidence of IPPP, which was not statistically significant between groups. No case of acute postoperative pain perception was noted in the RPV group, but at the cost of statistically significant minimum mean arterial pressure values, reflecting hemodynamic instability, with clinical significance < 65mmHg. Demand for postoperative morphine was not statistically significantly different between groups, contrary to significantly lower doses of IROA using FNT in patients receiving TEA. Conclusions: AoA guidance for IROA administration with FNT blunted the preventive analgesia effect of TEA compared with intravenous MT that ensured proper perioperative hemodynamic stability along with adequate postoperative pain control with acceptable demand for postoperative morphine.

Effect of Propofol and Isoflurane on Hemodynamic changes during Spinal Surgery Under General Anesthesia

Background: Hemodynamic stability are vital requirements of up-to-date anesthesia. Both propofol and isoflurane meet these criteria though the clinical effects like postoperative nausea vomiting after administering propofol and isoflurane have been studied in various surgeries but have not been much evaluated or studied in patients undergoing major surgical procedures like spine surgeries, There’ is definite advantage of one technique over the other. Isoflurane has a low blood gas partition coefficient, which contributes to rapid induction and emergence from anaesthesia than with other volatile anesthetics in current clinical use. Propofol has been established as the intravenous agent that provides faster and smoother recovery &amp; peri operative hemodynamic stability. Objective: To compare the effects of isoflurane and propofol regarding hemodynamic status in spinal surgery under general anaesthesia. Methods: After getting ethical approval, a randomized controlled trial study design was performed where patients were selected in the pre-anesthetic checkup room based on inclusion and exclusion criteria for those who were scheduled for spine surgeries under general anesthesia is admitted in the Department of Neurosurgery in East West Medical College from January 2023 – December 2024. A total number of 40 patients were selected. 20 patients were enrolled each in group A and group B by lottery method in a sealed envelope. They were divided into two groups by randomization; Group A and Group B. A written informed consent was taken from all selected patients. Patients were advised to fast for at least 8 hours before intervention. In Group A, anesthesia is maintained with propofol infusion, nitrous oxide (66%), and oxygen (33%) while in Group B, anesthesia is maintained with Isoflurane, nitrous oxide (66%), and oxygen (33%). All patients were given N2O in oxygen and 1.25% inspired concentration of Isoflurane (MAC -1.15). In Group A propofol infusion at rate of 80 μg/kg/min (fixed from the beginning). All data was collected at –Just after starting, 15 minutes, 30-minute, 1 hour, and &gt;1 hour interval per operatively. Data was compiled, edited and plotted in tabular and figure form. P value was determined as significant when it was &lt;0.05. Results: 40 patients yielded the following results. The mean age of Group A and B were 32.56±12.55 years and 34.6±12.5 years. Mean difference of heart rate was lower in Group A than that of Group B. Other parameters in both groups were confined to good and acceptable categories. But interestingly, there was a statistically significant difference found between Group A and Group B in Systolic Blood Pressure (SBP) &amp; Diastolic Blood Pressure (DBP). The scoring was far better in Group A than Group B. Mean SBP was higher in Group B than Group A (p= &gt;0.05). Similarly, mean DBP was also higher in Group B than Group A (p = &gt;0.05). Conclusion: Propofol is better for maintaining hemodynamic status than Isoflurane for Spine surgery under General anaesthesia. EWMCJ Vol. 12, No. 1&amp;2, January-July 2024: 21-26

Postoperative cognitive dysfunction in elderly patients with colorectal cancer: A randomized controlled study comparing goal-directed and conventional fluid therapy.

To investigate the impact of goal-directed fluid therapy (GDFT) on postoperative cognitive dysfunction (POCD) in elderly patients with colorectal cancer, we conducted a randomized controlled trial. Eighty elderly patients who underwent elective laparoscopic radical resection of colorectal cancer were randomly assigned to either the GDFT group or the conventional fluid therapy group. The primary outcome was the incidence of POCD during the initial 7 postoperative days, while secondary outcomes included inflammatory marker levels such as interleukin-6 (IL-6) and S100β protein, hemodynamics, level of lactic acid, postoperative functional recovery, and complications. Among 88 randomized patients, 80 were evaluable for the primary outcome. The incidence of POCD was significantly lower in the GDFT group (15.0%) compared to the conventional fluid therapy group (30.0%), with the highest occurrence observed on day 3 postoperatively in both groups (P < 0.05). IL-6 and S100β concentrations were consistently lower in the GDFT group than in the conventional fluid therapy group at the corresponding time points (P < 0.05). The GDFT group exhibited more stable perioperative hemodynamics and lower lactate levels (P < 0.05). Moreover, patients in the GDFT group exhibited better postoperative functional recovery indicators and a lower incidence of postoperative complications (P < 0.05). In summary, GDFT appears to reduce the incidence of early POCD, accelerate postoperative recovery, and enhance overall prognosis.

Reduction of Surgical Bleeding During Lumbar Laminectomy with Pedicular Screw Using Oral Clonidine as a Premedication: A Randomized Comparative Study

Background: Spinal fusion surgeries are often associated with major blood loss. The aim of this study was to investigate the effect of oral clonidine as premedication on the amount of blood loss and the need for blood transfusion during lumbar laminectomy spine surgery with pedicle screw insertion, achieved by controlled hypotension. Methods: In this double-blind randomized clinical trial, 100 patients scheduled for lumbar spine laminectomy with pedicle screw insertion (as a fusion procedure) were included. Patients were classified into two groups: The intervention group received a 0.2 mg clonidine tablet one hour before entering the operating room, and the control group received a placebo. The patients were compared with respect to hemodynamic variables, quality of the surgical field, duration of the surgery, estimated amount of blood loss, and any blood transfusion. Results: Oral clonidine was found to be significantly better in terms of maintaining stable dynamics and having a lower amount of blood loss, thereby requiring fewer blood transfusions compared to the control group. Conclusions: Premedication with 0.2 mg oral clonidine in patients undergoing lumbar spine laminectomy with pedicle screw insertion results in improved perioperative hemodynamic stability and a reduction in the amount of intraoperative blood loss, thereby reducing the need for blood transfusion.

Comparison of Opioid-Based Versus Opioid-Sparing Anesthesia in Patients Undergoing Glioma Surgery.

Background In the neurosurgical population, opioids may cause respiratory depression, leading to hypercapnia, increased cerebral blood flow (CBF), and ultimately increased intracranial pressure (ICP), which can mask early signs of intracranial complications and delayed emergence. This study was designed to compare perioperative hemodynamic stability, analgesia, and recovery parameters in opioid-based (fentanyl) general anesthesia versus opioid-sparing (dexmedetomidine) general anesthesia in patients undergoing glioma surgeries. Methodology This prospective observational comparative study compared 52 patients in two groups. Twenty-six (50%) patients in group F received Inj. fentanyl IV (intravenous; bolus 2 mcg/kg 10 minutes before induction and then infusion 1 mcg/kg/hour till 30 minutes before skin closure), whereas 26(50%) patients in group D received Inj. dexmedetomidine IV (0.5 mcg/kg infusion 10 minutes before induction and then maintenance with a 0.5 mcg/kg/hour infusion till 30 minutes before skin closure). Perioperative heart rate (HR), mean arterial pressure (MAP), Numerical Rating Scale for Pain (NRS) assessment and postoperative emergence time, modified Aldrete score,patient satisfaction, and surgeon satisfaction score were estimated and compared in both groups. Results The mean HR was less in group D compared to group F at following time points - 10 minutes after infusion (P= 0.006), laryngoscopy and intubation (P= 0.003), pinning of the skull (P< 0.001), one hour after dura opening (P= 0.007), two hours after dura opening (P = 0.006), five minutes after extubation (P< 0.001), and 30 minutes after extubation (P= 0.011). MAP was lower in group D compared to group F at the following time intervals: 10 minutes after infusion (P= 0.008), five minutes after extubation (P= 0.007), 30 minutes after extubation (P< 0.001), and one hour after extubation (P= 0.023). A significant decrease in emergence time in group D compared to group F (P< 0.001) was noted. NRS was lower in group D at eight hours (P= 0.005) and 12 hours (P< 0.001) post-extubation. Conclusions Dexmedetomidine can be used as an alternative to fentanyl in terms of perioperative hemodynamic stability, perioperative analgesia, smooth early recovery from anesthesia, patient satisfaction, and surgeon satisfaction.

Short anesthesia without intravenous fluid therapy in children: Results of a prospective non-interventional multicenter observational study.

The German guidelines recommend that intravenous fluid therapy should not be mandatorily performed in children with short fasting times undergoing short anesthesia, but there is a lack of clinical studies including a large number of pediatric patients. Therefore, we performed a prospective non-interventional multicenter observational study to evaluate the perioperative hemodynamic and metabolic stability of children undergoing short anesthesia without intravenous fluid therapy. The primary aim was to assess the incidence of hypotension and the secondary aim was to assess the real preoperative fasting times, the incidence of hypoglycemia and the impact on ketone bodies and acid-base balance. Children aged 1 month-18 years undergoing short anesthesia (<1 h) without intravenous fluid therapy were enrolled. Patient demographics, the surgical or diagnostic procedure performed, anesthesia, hemodynamic, laboratory data, and adverse events were documented using a standardized case report form. Four hundred and twenty seven children that were investigated at three pediatric centers from July 2021 to June 2022 (mean age 83.4 ± 58.9 months, body weight 27.9 ± 19.8 kg) were included in the analysis. The real preoperative fasting times were 14.2 ± 3.6 h for solids, 7.2 ± 3.5 h for milk and 5 ± 4.8 h for clear fluids. During the course of anesthesia, hypotension (<2.5th percentile) was detected in 3 of 427 cases (0.7%), hypoglycemia (glucose <3.0 mmol L-1) in 1 of 355 cases (0.3%), and ketosis (ketone bodies ≥0.6 mmol L-1) in 51 of 233 cases (21.9%). The occurrence of ketosis was associated with lower body weight (p <.001) and longer fasting times for solids or milk (p =.021), but not for clear fluids (p =.69). Our study supported the German guidelines recommendation that perioperative intravenous fluid therapy is not mandatory in children beyond the neonatal period with short pre- and postoperative fasting times undergoing short anesthesia (<1 h).

To study dexmedetomidine’s effect on intraocular pressure after succinylcholine and endotracheal intubation

Background: One of the most important preconditions for any anesthetic operation is perioperative hemodynamic stability during laryngoscopy and intubation, which has been the subject of extensive research and documentation. Numerous approaches have been proposed to protect the patient from the sympathetic reaction, intraocular pressure (IOP) response, and catecholamine response during laryngoscopy and intubation. Aims and Objectives: To study the efficacy of two doses of intravenous dexmedetomidine premedication given as a single bolus dose over 10 min, 0.4 μg/kg and 0.6 μg/kg, 10 min before induction in preventing the rise of intraocular pressure following succinylcholine administration and endotracheal intubation. Materials and Methods: A retrospective randomized study was conducted. Ethical committee permission and signed informed consent were obtained from 60 eligible patients before the trial began. Results: Premedication with either 0.4 mcg/kg I.V. or 0.6 mcg/kg I.V. of dexmedetomidine diluted in normal saline at a 2 mcg/mL concentration administered over 10 min before induction resulted in significant obtundation of the rise in IOP associated with succinylcholine administration and intubation. Sympathetic response to laryngoscopy and intubation was also significantly diminished. The dose of 0.4 mcg/kg I.V. produced the best hemodynamic stability. Conclusion: Therefore, from the above research it can be concluded that, before succinylcholine delivery and intubation, dexmedetomidine 0.4 mcg/kg I.V. can be used as a premedication in situations where an increase in IOP could be hazardous.

Effectiveness of the oral Clonidine as a pre-anesthetic medicine for thyroidectomy surgery; A randomized clinical trial.

Hemodynamic disturbance is a common problem in patients undergoing thyroid surgery. It may be due to episodic increases in thyroid hormones (thyroid storm) or stimulation of the carotid sinus baroreflex. The aim of the present study was to investigate effectiveness of the pre-operative oral Clonidine on reducing these hemodynamic changes during total thyroidectomy surgery. In a prospective, randomized, double-blind study, 80 patients scheduled for elective total thyroidectomy were randomized to receive either 0.2 mg Clonidine (n=40) or a matched placebo (n=40) orally sixty minutes before entering the operating room. Hemodynamic variables, the duration of surgery, estimated amount of blood loss and the dose of administered remifentanil were recorded for further analysis. Oral Clonidine was found to be significantly better in maintaining stable hemodynamics compared to the control group. Also, In the Clonidine group, the estimated amount of blood loss (110.4±10 ml vs. 182.2±11.4 mL, P=0.04), duration of the surgery (78.26±55.2 min vs. 105.16±61.75 min, P=0.027) and administered dose of remifentanil (26.67±6.6 μg vs. 216.2±14.8 μg, P=0.01) were also significantly lower than the control group. Pre-operative administration of 0.2 mg oral Clonidine in patients undergoing total thyroidectomy results in improved perioperative hemodynamic stability and reduced response to perioperative stress.

Peri-operative Outcomes of Dexmedetomidine as an Additive to Subtenon Block Compared with Intravenous Dexmedetomidine for Patients Undergoing Vitreoretinal Surgery under General Anesthesia

Background: Several medications such as dexmedetomidine can be used as adjuvants with anesthesia to reduce the stress response during surgery resulting in good post-operative outcomes and safe recovery times. Aims: To compare the peri-operative outcomes of subtenon block with or without dexmedetomidine versus dexmedetomidine infusion as adjuvants to general anesthesia in subjects undertaking retinal operations. Design: A prospective randomized double-blind controlled clinical trial Patients and methods: Through the use of sealed opaque envelopes, 120 participants were randomly divided into three groups. Group SB received subtenon bupivacaine and lidocaine and IV infusion of normal saline. Group SD received subtenon bupivacaine, lidocaine, and dexmedetomidine and IV infusion of normal saline, whereas Group DI received subtenon saline and IV infusion of dexmedetomidine. Peri-operative hemodynamics and intra-ocular pressure were measured and recorded. Intra-operative bleeding, recovery times, post-operative sedation and pain scores, first analgesic times, total analgesic requirements, and the incidence of PONV and OCR were also assessed and documented. Statistical analysis: A prospective analysis of the collected data was performed using the SPSS program for Windows (version 22). Results: The results showed that IV dexmedetomidine has decreased cardiovascular responses to surgery as signified by decreased HR and MAP with a significant drop in IOP measurements before induction and after intubation, in comparison to other groups. Administering dexmedetomidine either or IV in the subtenon block led to a significant reduction in pain scores of the first post-operative six hours, the total pethidine consumption, and the surgical bleeding. Conclusion: When used as a supplement to general anesthesia during retinal surgery, dexmedetomidine is effective at reducing the airway response to tracheal intubation and extubation and maintaining peri-operative hemodynamic stability. Dexmedetomidine is also an efficient method for lowering intraocular pressure, surgical bleeding, and postoperative analgesic consumption with a better recovery profile. It can be administered either through IV infusion or combined with local anesthetics in subtenon block.

Dexmedetomidine in Patients Undergoing Transsphenoidal Resection of Pituitary Adenoma: An Updated Systematic Review and Meta-Analysis of Randomized Placebo-Controlled Trials.

Dexmedetomidine has been widely studied in many surgical settings, with possible benefits in lowering anesthetic requirements, improving perioperative hemodynamic stability, and improving postoperative outcomes. This systematic review aims to evaluate the effects of dexmedetomidine in patients undergoing transsphenoidal resection of pituitary adenoma, shedding light on its potential as an adjunctive agent in anesthesiafor this specific surgical population. In this review, we searched PubMed, Cochrane Library, Scopus, Web of Science, and Google Scholar from inception to July 20, 2023. A total of six randomized clinical trials (RCTs) investigating the effects of dexmedetomidine versus placebo in patients undergoing transsphenoidal resection of pituitary adenoma were included in this review. The outcomes of interest were extracted from the included studies asmean difference (MD) and standard deviation (SD), then analyzed using the Review Manager (RevMan, RevMan International Inc., New York, USA) software. Our literature search process retrieved 274 records. Of them, six studies were included in the meta-analysis. There was a significant difference between the dexmedetomidine group compared to the placebo group in terms of heart rate at the end of the surgery (MD = -16.5; CI = [-25.36 to -7.64]; P value = 0.0003) and after extubation (MD = -16.81; CI = [-23.18 to -10.43]; P values < 0.00001). Furthermore, dexmedetomidine significantly reduced the mean arterial blood pressure (MAP) at after both intubation and extubation (MD = -9.11 and -21.5; CI = [-13.56 to -4.65] and [-30.93 to -12.06]; P values < 0.00001). This systematic review and meta-analysis demonstrated that dexmedetomidine appears to have several potential benefits in patients undergoing transsphenoidal resection of pituitary adenoma. The use of dexmedetomidine was associated with reductions in heart rate, mean arterial blood pressure, blood loss, and duration of surgery, while showing no significant difference in propofol dose or time to extubation of the trachea.

Fractionated dose of hyperbaric bupivacaine for hemodynamic stability and prolonged duration of anaesthesia in high-risk geriatric patients undergoing unilateral hip surgeries under subarachnoid block- A case series

Poor cardiopulmonary reserve, multiple comorbidities and polypharmacy in geriatric patients result in significant hemodynamic changes after the subarachnoid block (SAB) which are often unpredictable and requires administration of fluids, vasopressors, invasive monitoring and ICU admission leading to poor post operative outcome especially in patients belonging to American Society of Anaesthesiologists Physical Status (ASA PS) 3 &amp; 4. Fractionated dose of hyperbaric bupivacaine for preferential unilateral lower limb blockade is found to have excellent hemodynamic stability and more duration of action making it a better alternative to the bolus dose in unilateral hip surgeries in high-risk geriatric patients. Here is a case series of 20 high risk geriatric patients who successfully underwent unilateral hip surgeries under fractionated dose of spinal anaesthesia with a stable perioperative hemodynamics.

Prophylactic Administration with Methylene Blue Improves Hemodynamic Stabilization During Obstructive Jaundice–Related Diseases’ Operation: a Blinded Randomized Controlled Trial

ObjectivesPatients with obstruction jaundice are at a high risk of hypotension and need high volume of fluids and a high dose of catecholamine to maintain organ perfusion during operation procedure. All these likely contribute to high perioperative morbidity and mortality. The aim of the study is to evaluate the effects of methylene blue on the hemodynamics in patients undergoing surgeries associated with obstructive jaundice. DesignA prospective, randomized, and controlled clinical study. SettingThe enrolled patients randomly received 2 mg/kg of methylene blue in saline or saline (50 ml) before anesthesia induction. The primary outcome was the frequency and dose of noradrenaline administration to maintain mean arterial blood pressure over 65 mmHg or > 80% of baseline, and systemic vascular resistance (SVR) over 800 dyne/s/cm5 during operation. The secondary outcomes were liver and kidney functions, and ICU stay. PatientsSeventy patients were enrolled in the study and randomly assigned to receive either methylene blue or control (n = 35/group). ResultsFewer patients received noradrenaline in the methylene blue group when compared with the control group (13/35 vs 23/35, P = 0.017), and the noradrenaline dose administrated during operation was reduced in the methylene blue group when compared with the control group (0.32±0.57 mg vs 1.787±3.51 mg, P = 0.018). The blood level of creatinine, glutamic oxalacetic transaminase, and glutamic–pyruvic transaminase after the operation was reduced in the methylene blue group when compared with the control group. ConclusionsProphylactic administration of methylene blue before operation associated with obstructive jaundice improves hemodynamic stability and short-term prognosis. QuestionMethylene blue use prevented refractory hypotension during cardiac surgery, sepsis, or anaphylactic shock. It is still unknown that methylene blue on the vascular hypo-tone associated with obstructive jaundice. FindingsProphylactic administration with methylene blue improved peri-operative hemodynamic stability, and hepatic and kidney function on the patients with obstructive jaundice. MeaningsMethylene blue is a promising and recommended drug for the patients undergoing the surgeries of relief obstructive jaundice during peri-operation management.

Dexmedetomidine as an adjuvant to scalp block in patients undergoing elective craniotomy: A prospective randomized controlled trial.

Regional techniques minimize anesthetic requirements and their effects may be beneficial. There is a lack of consensus and evidence concerning alternative analgesia strategies for cranial neurosurgery. This study was designed to evaluate the effect of scalp block with or without dexmedetomidine combined with general anesthesia on hemodynamic stability, opioid consumption and postoperative pain in patients undergoing elective craniotomy. One hundred five patients undergoing elective craniotomy for tumor dissection were randomly divided into three groups to receive scalp block as an adjuvant to general anesthesia: with either 40ml ropivacaine 0.5% (Group R), 40ml ropivacaine 0.5% plus dexmedetomidine 1μg/kg (Group RD) or 40ml saline as a placebo (Group C). After a standard induction sequence using propofol, fentanyl and a single dose of rocuronium, patients were intubated. Bilateral scalp block was given immediately after induction. Anesthesia was maintained with propofol and remifentanil infusion. Five minutes before head pinning scalp block was performed by blocking the supraorbital, supratrochlear, auriculotemporal, occipital, and postauricular branches of the greater auricular nerves. All patients were monitored with electrocardiogram, invasive blood pressure, pulse oximetry and BIS monitoring. Primary outcomes measures were overall hemodynamic variables during surgery and intravenous fentanyl and remifentanil consumption. Mean arterial pressure (MAP) and heart rate (HR) were recorded at seven time-points: scalp block (T1-baseline), pin fixation (T2), skin incision (T3), drilling (T4), dura matter incision (T5), dura matter closure (T6) and skin closure (T7). For all time points it was recorded the mean value after 3 consecutive measures with 5min interval. Secondary outcome was postoperative pain intensity using visual analog scale 24 and 48h after surgery. VAS scores, fentanyl and remifentanil were evaluated using Kruskal-Wallis test. MAP and HR were compared by One-Way repeated measures Anova (GLMM) using time as random efect and by One-Way Anova using time as fxed efect. Mean arterial pressure was significant lower at skin closure compared to baseline in group R (p<0,001) and in group RD (p<0,001). Patients in group RD showed significant lower heart rate at dura matter incision, dura matter closure and skin closure compared to baseline, pin fixation and skin incision time points (p<0,001) and reported significantly less heart rate than group C (p<0,001) and group R (p<0,001) during dura matter incision, dura matter closure and skin closure time points. Patients in group RD receive significant lower fentanyl than group R (p<0,01). The intraoperative consumption of remifentanil was significant higher in control group compared to group R (p<0,01) and to group RD (p<0,001). Additionally, remifentanil consumption was significant lower in group RD as compared to group R (p<0,001). Postoperative pain had no statistically differences between the three groups at 24h and 48h after craniotomy (Preop VAS: p=0,915, VAS 24: p=0,284, VAS 48, p=0,385). No adverse effects were noted. Our study indicated that addition of dexmedetomidine to scalp block with ropivacaine 0.5% provided significantly better perioperative hemodynamic stability during elective craniotomy. Moreover, scalp block with or without dexmedetomidine reduced fentanyl and remifentanil consumption, but it didn't significantly prolonged analgesia in patients undergoing elective craniotomy.

Shiv-mix for perioperative hemodynamic stability and analgesia: A new paradigm for limited resource centres

Dear editor, A very interesting article has been published in your esteemed journal titled “Effect of pre-emptive intravenous paracetamol, magnesium sulfate, and lignocaine on hemodynamic variables during perioperative period in pre-eclampsia patients scheduled for lower segment cesarean section under general anesthesia: A prospective randomized study” by Kothari et al., (December 2022|Vol 13|Issue 12). Research is not complete unless it reaches to its potential audience. We, firstly, would like to congratulate the authors and the journal for publishing their research on such a very important topic. Authors have described their findings in a clear and scientific manner. Randomized and double-blinded studies provide inferences which are considered more authentic. Authors in this study used envelop method for allocating patient in the two groups; the intervention and the control. Findings of this study will definitely help readers and practitioners in providing safe and stable anesthesia to their patients. In this prospective randomized study, authors concluded that combination of paracetamol, magnesium sulfate, and lignocaine is effective in attenuating hemodynamic responses to laryngoscopy and intubation. They also found better hemodynamic stability during intraoperative and post-operative period in pre-eclampsia patients scheduled for lower segment cesarean section under general anesthesia. Finally, they opined that when paracetamol, magnesium sulfate, and lignocaine are given together effective and prolonged post-operative analgesia can be obtained. Authors discussed efficacy and safety of various medications (Lignocaine, fentanyl, esmolol, and magnesium sulfate) comparing with placebo and different combinations used to attenuate laryngoscopy and intubation response. However, in last paragraph of introduction and in discussion, authors wrote that they could not find any single study using all three drugs (intravenous paracetamol, magnesium sulfate, and lignocaine) simultaneously for attenuation of hemodynamic changes during laryngoscopy and intubation. We would like to draw your kind attention published work that have utilized the same combination with similar effects and this study support the conclusions of those studies. We do agree that these were nor RCTs but case series. Two related articles are discussed here. Khan and Singh in their narrative review described efficacy, safety, and patient satisfaction of various combinations of paracetamol, tramadol, magnesium sulfate, and lignocaine (Shiv-mix 1, 2, and 3). Authors found the described opioid free anesthesia (OFA) regimen (Shiv-mix) very effective in attenuating laryngoscopic and intubation response. In their case series, they also found stable intraoperative hemodynamics and absence of some commonly seen post-operative complications such as PONV and shivering. In another case series by Ansari et al., using similar OFA describing ten cases of laparoscopic cholecystectomy, the authors found that OFA using Shiv-Mix (A combination of paracetamol, tramadol, magnesium sulfate, and lignocaine) infusion preoperatively was a safe, opioid‑sparing, and feasible option that provide good perioperative analgesia, stable hemodynamics, and an uneventful recovery profile. We again support the findings of the study by Kothari et al. We hope that this discussion will help researchers and practitioners to provide effective and safe perioperative course of their patients and opening new horizons for multimodal analgesia.

Opioid-based Anaesthesia versus Opioid Free Anaesthesia in Laparoscopic Cholecystectomies: A Randomised Clinical Study

Introduction: Intravenous opioids have been frequently used to provide analgesia and supplemental sedation during general anaesthesia or monitored anaesthesia care. Opioid Free Anaesthesia (OFA) is a multimodal approach which combines different drugs likes lignocaine, dexamethasone, paracetamol and dexmedetomidine with different techniquessuch as hypnosis, sedation, analgesia and sympatholysis. Thus, reducing and avoiding opioids perioperatively will lead to decrease in opioid related adverse effects with better postoperative outcomes. Aim: To compare OFA and Opioid-based Anaesthesia (OBA) in terms of haemodynamic stability, speed and quality of recovery, postoperative pain score and analgesic requirement. Material and Methods: The present study was a randomised study conducted over a period from June 2021 to September 2022, in which 90 patients of American Society of Anaesthesiologists (ASA) Grade I,II, 20-60 years of age undergoing elective Laparoscopic Cholecystectomy (LC) were divided into OBA fentanyl and OFA-lignocaine and dexmedetomidine. A standard general anaesthesia protocol of the institute was followed. OBA group received fentanyl (2 μg/kg) over 10 minutes before induction of anaesthesia and OFA group received lignocaine (2 mg/kg) and dexmedetomidine (0.5 μg/kg) both intravenously over 10 minutes before induction of anaesthesia. In OFA group analgesia was maintained by infusion of lignocaine 2 mg/kg/hr and dexmedetomidine 0.5 μg/kg/hr whereas in OBA group fentanyl 0.5 μg/kg was given whenever required till the gallbladder was resected. Postoperative intraperitoneal instillation of gallbaldder fossa was done with 20 mL 0.5% bupivacaine. Intraoperative mean Heart Rate (HR) and Mean Arterial Pressure (MAP) were recorded. Postoperative speed and quality of recovery, pain score, analgesic requirements and incidence of Postoperative Nausea and Vomiting (PONV) were noted. Paracetamol 15 mg/kg was given intravenously whenever Numerical Rating Scale (NRS) score was ≥6. Comparison of means between the two groups was done using unpaired t-test, association between two non parametric variables was done using Pearson Chi-square (χ2 test) test. Results: The mean age, sex, weight, ASA and duration of surgery were comparable in both the groups. The mean HR and mean MAP were significantly lower in OFA group compared to the OBA group at all the time points (p-value=0.001). Although postoperative speed of recovery was slower in OFA group, the overall quality of recovery was better (p-value=0.001). The postoperative pain score, analgesic requirement and incidence of nausea and vomiting were all significantly less in OFA group as compared to OBA group with p-values of 0.02, 0.001 and 0.02, respectively. Conclusion: OFA is new anaesthetic approach that provides better perioperative haemodynamic stability, postoperative pain control with less PONV and thus can be used safely and successfully

Effect of Dexmedetomidine on Maintaining Perioperative Hemodynamic Stability in Elderly Patients: A Systematic Review and Meta-analysis

ObjectiveDexmedetomidine is a highly selective alpha-2 adrenergic receptor agonist with sedative and analgesic properties but without respiratory depression effect and has been widely used in perioperative anesthesia. Here we performed a systematic review and meta-analysis to evaluate the effect of dexmedetomidine on maintaining perioperative hemodynamic stability in elderly patients. MethodsPubMed, Web of Science, the Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang Data were searched for randomized-controlled trials (RCTs) on the application of dexmedetomidine in maintaining perioperative hemodynamic stability in elderly patients from their inception to September, 2021. The standardized mean differences (SMD) with 95% confidence interval (CI) were employed to analyze the data. The random-effect model was used for the potential clinical inconsistency. ResultsA total of 12 RCTs with 833 elderly patients (dexmedetomidine group, 546 patients; control group, 287 patients) were included. There was no significant increase in perioperative heart rate (HR), mean arterial pressure (MAP), and diastolic blood pressure (DBP) in the dexmedetomidine group before and during the operation. In addition, the variations of hemodynamic indexes including HR, MAP, SBP (systolic blood pressure), and DBP were significantly lower in the dexmedetomidine group compared with the control group (HR: SMD = −0.87, 95% CI: −1.13 to −0.62; MAP: SMD = −1.12, 95% CI: −1.60 to −0.63; SBP: SMD = −1.27, 95% CI: −2.26 to −0.27; DBP: SMD = −0.96, 95% CI: −1.33 to −0.59). Subgroup analysis found that with the prolongation of 1.0 μg/kg dexmedetomidine infusion, the patient's heart rate declined in a time-dependent way. ConclusionDexmedetomidine provides more stable hemodynamics during perioperative period in elderly patients. However, further well-conducted trials are required to assess the effective and safer doses of dexmedetomidine in elderly patients.

Recovery and post-operative analgesic efficacy from fentanyl- versus dexmedetomidine-based anesthesia in head and neck cancer surgery: A prospective comparative trial.

Opioids such as fentanyl are being used frequently in the management of postoperative period, whereas non-opioid drugs such as dexmedetomidine are now commonly being used as adjuvants during the perioperative period to hasten the fast recovery and better outcome in the post-operative period because of their anesthetic and analgesic property. The recovery profile was measured by the emergence of anesthesia and pain characteristics. We aimed to evaluate and compare the efficacy of dexmedetomidine and fentanyl in the surgery of head and neck cancer patients. Prospective double-blind study on 60 patients with the American Society Anesthesiologists (ASA) grade I and II were randomly divided into two groups. Group DM received a loading dose of dexmedetomidine 1 µg/kg over 10 min followed by a maintenance dose of 0.5 µg/kg/h and Group FM received a loading dose of fentanyl 2 µg/kg/h for over 10 min followed by 1 µg/kg/h maintenance dose. Data were analyzed using a Chi-square test or Student's 't' test. The group DM was hemodynamic stable as compared to group FM. The perturbation during extubation emergence was significantly lower in group DM as compared to that in group FM. A total of four patients were severely agitated in group FM, whereas it was absent in group DM. Severe agitation was significantly different between Group FM and Group DM. The visual analog scale (VAS) was lower among patients of Group DM as compared to Group FM at all times except at 4 h. The infusion of dexmedetomidine was better in controlling emergence agitation, postoperative pain, and achieving peri-operative hemodynamic stability as compared to fentanyl.

Comparative Study Between Intravenous Clonidine and Preservative Free Intravenous Lignocaine in Attenuation of Pressor Response to Laryngoscopy and Endotracheal Intubation

Objectives To compare the attenuation of pressor responses by intravenous clonidine and preservative-free lignocaine to laryngoscopy and endotracheal intubation. Materials and Methods A randomized, prospective, comparative, double-blinded study was conducted in 80 adult patients who were randomized into two groups of 40 each, group clonidine (Group C) and group lignocaine (Group L). Group C patients were given 2 µg/kg clonidine in 20 ml of normal saline as a slow infusion over 10 min prior to intubation. Group L patients were given 1.5 mg/kg of preservative-free 2% lignocaine in 20 ml of normal saline as a single-dose infusion over 3 min prior to intubation. Baseline vital and hemodynamic parameters were monitored during the perioperative period at 1-, 5-, and 10-min post-intubation. Results The attenuation of heart rate (HR) after intubation was much better with clonidine than lignocaine as there is statistically significant difference in the mean HR between the two groups at 1, 5, and 10 min after intubation with the HR significantly lesser in the Group C than the Group L at all times after intubation. Both clonidine and lignocaine were effective in attenuating systolic blood pressure response after intubation, but clonidine was more effective than lignocaine as systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) in the Group C remained much lower than the Group L and the difference between the two groups was statistically significant at all times after intubation. Conclusion Premedicating with a single slow infusion of 2 µg/kg i.v. clonidine has been proven to be effective in maintaining perioperative hemodynamic stability at 1, 5, and 10 min post-intubation than lignocaine.

Opioid Free Anesthesia (OFA) for Laparoscopic Cholecystectomy in Low Resource Settings

Laparoscopic Cholecystectomy is a common minimally invasive surgical procedure done under general anesthesia using an opioid-based regimen. Although laparoscopic cholecystectomy is a minimally invasive surgical procedure, some patients may have significant discomfort in the postoperative period in the first 24 to 72 hours. Inadequate pain control, PONV, and delayed recovery are common postoperative issues. This case report shows that OFA is a safe, opioid‑sparing, and feasible option that provide stable perioperative hemodynamics, good analgesia, and an uneventful recovery profile to patients undergoing laparoscopic cholecystectomy.