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Background and Aims:Hypotension following spinal anaesthesia for caesarean section is common in spite of adequate fluid loading. Phenylephrine is the recommended drug to treat spinal hypotension during caesarean section. Recently, norepinephrine boluses are being suggested as an alternative to phenylephrine boluses. The aim of our study was to compare the effectiveness of bolus doses of norepinephrine with phenylephrine to treat spinal hypotension during caesarean section.Methods:Fifty patients undergoing elective caesarean section under spinal anaesthesia were randomly assigned into two groups. Group P patients received phenylephrine 50 μg as an intravenous bolus and group N received 4 μg of norepinephrine as intravenous bolus to treat spinal hypotension. The primary objective of our study was to compare the number of bolus doses of norepinephrine or phenylephrine required to treat spinal hypotension. The secondary objectives were to compare the incidence of bradycardia, hypertension, nausea and vomiting in mother and foetal outcomes.Results:The number of boluses of vasopressors required to treat hypotension was significantly lower in group N (1.40 ± 0.577 vs. 2.28 ± 1.061, P = 0.001). The frequency of bradycardia was high in group P, but this difference was not statistically significant (4%vs. 20%, P = 0.192). Maternal complications such as nausea and vomiting and shivering were comparable between the groups. The foetal parameters were also comparable between the two groups.Conclusion:Intermittent boluses of norepinephrine are effective in the management of spinal-induced hypotension during caesarean section. The neonatal outcomes were similar in both the groups. Norepinephrine boluses can be considered as an alternative to phenylephrine boluses.

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Background: Over concerns of vasoconstriction leading to free flap failure, it has been a common practice to avoid vasopressors for the maintenance of blood pressure during reconstructive microvascular surgeries. Aims: The aim of this study was to assess the impact of use of noradrenaline in the perioperative period on outcome of free flaps in patients who underwent reconstructive surgeries as compared to those who did not receive noradrenaline. Settings and Design: Retrospective analysis was conducted at a tertiary care institute. Materials and Methods: A total of 120 patients who underwent free flap surgeries were included in the study, of which 102 patients who did not require noradrenaline perioperatively formed the control group (Group C), whereas those who required noradrenaline infusion constituted the study group (Group N). Data regarding flap outcome at discharge, intraoperative hemodynamics and temperature were documented. Statistical Test Used: Chi-square test, Mann–Whitney test, Independent sample t -test, and paired t -test were used for statistical analysis. Results: Out of 120 patients, 15% ( n = 18) patients required noradrenaline (Group N). In Group N, 27.78% ( n = 5) patients and in Group C, 22.55% ( n = 23) were re-explored. Four patients in Group C and none in Group N had a poor flap outcome (3.92% vs. 0%). There was no significant difference in surgical duration and the volume of crystalloids received in both groups. Preoperative hemoglobin levels were lower in Group N; intraoperatively, they were more hypothermic and needed more colloids, blood, and plasma. Conclusion: Perioperative use of noradrenaline did not adversely affect free flap survival in patients who underwent microvascular reconstructive surgeries. Although re-exploration rate was marginally increased with use of noradrenaline, the final flap outcome was unaffected.

Context:Medical guidelines advise perioperative continuation many antihypertensives, but discontinuing angiotensin antagonists before surgery.Aims:This study is aimed to determine the effect of preoperative discontinuation of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor antagonists (ARA) on intra-operative blood pressure after induction of general anesthesia.Settings and Design:The study was a randomized, prospective and double blinded one done in 60 hypertensive patients, receiving these drugs.Materials and Methods:Patients were randomized into two equal groups. In Group A, ACEI or angiotensin II receptor antagonist was stopped the day before surgery, but in Group B it was continued. Anesthetic management was standardized by a study protocol. Systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were measured just before induction and after induction at 1 min, 3, 5, 10, 15, 30, 45 and 60 min.Statistical Analysis:Difference between means and difference between two proportions was analyzed using Normal test for means and corresponding P values were calculated.Results:Pre-induction SBP, DBP and MAP were comparable between groups. However when the pre-induction values were compared with subsequent readings at 3, 5, 10, 15, 30, 45 and 60 min, it was found that there was a significant reduction in SBP, DBP and MAP in Group B up to 60 min.Conclusions:Intraoperative hemodynamics can be safely managed when ACEI or ARA are withheld on the day of surgery.

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Context: Various intravenous (i.v.) adjuvants have been used along with spinal anesthesia to delay the onset of postoperative pain. Aims: To compare effects of i.v. dexmedetomidine with midazolam on duration of spinal anesthesia. Settings and Design: This prospective randomized control trial was conducted in a tertiary care institution. Subjects and Methods: Forty-three patients presenting for elective infraumbilical surgery under spinal anesthesia were randomly allocated into two groups. Group A received a loading dose of 0.5 μg/kg followed by 0.5 μg/kg/h of i.v. dexmedetomidine. Group B received a loading dose of 0.03 mg/kg followed by 0.03 mg/kg/h of i.v. midazolam. Two dermatomal regressions, regression to S 1 level, and sedation score were noted. Statistical Analysis Used: To test the statistical significance of duration of sensory blockade, Mann–Whitney U-test was applied. The incidence of bradycardia and hypotension was analyzed using Pearson's correlation coefficient test. Results: The mean time for two dermatomal regressions was significantly prolonged in Group A (2.3 ± 0.4 h) than Group B (1.6 ± 0.5 h, P = 0.001). Mean time for sensory regression to S 1 dermatome was also prolonged in Group A (5.2 ± 0.83 h) than in Group B (4.4 ± 0.87 h, P = 0.01). Glycopyrrolate was administered in 45% of patients in Group A and 21% in Group B, which was statistically significant ( P = 0.039). Conclusion: Conscious sedation with i.v. dexmedetomidine at a loading dose of 0.5 μg/kg followed by 0.5 μg/kg/h prolongs duration of spinal anesthesia than i.v. midazolam at a loading dose of 0.03 mg/kg followed by 0.03 mg/kg/h in patients undergoing infraumbilical surgeries. However, dexmedetomidine is associated with higher incidence of hemodynamic instability.