Sir,A 62-year-old, 76-kg male, with a bilateral osteoarthritis knee, scheduled for right knee replacement was a known hypertensive for 4 years, controlled on tablet amlodipine 10 mg and clonidine 100 mg once daily. History, examination and investigations revealed no abnormality. Combined spinal epidural anesthesia was accomplished with an 18 G epidural catheter inserted at L 2-3 level and 2.5 ml of 0.5% heavy bupivacaine injected intrathecally at L 3-4 level, using a 27 G sprottee-type spinal needle. Maximum sensory loss up to T 10 dermatome was achieved after 7 min.A tourniquet was applied over the right thigh and pressure was maintained at 230 mmHg. After 90 min, the surgeon was reminded of the tourniquet time every 10 min. Throughout the surgery (including the cementing with methyl-methacrylate), the patient remained hemodynamically stable. Inspite of repeated reminders, the surgery lasted 155 min and then the tourniquet was released.Before tourniquet deflation, his pulse rate was 72/min, regular, blood pressure 130/76 mmHg and 97% SpO 2 . Immediately after deflating the tourniquet, his heart rate came down to 18/min and blood pressure declined to 70/42 mmHg and then became unrecordable with a complaint of uneasiness. Instantly, he was given 0.6 mg atropine intravenously and 100% oxygen by a mask. His heart rate increased to 102/min and blood pressure to 140/84 mmHg and his complaint of uneasiness subsided. The patient remained hemodynamically stable post-operatively. There was no sensory loss or motor weakness.Tourniquet deflation causes the release of blood that has low pH, low pO 2 , high pCO 2 , high lactate and K 1 into systemic circulation, which leads to a decline in blood pressure. This decline could be further aggravated by volume shift back to the limb on deflation of tourniquet, a post-ischemic reactive hyperemia (vasodilatation) and a decrease in peripheral vascular resistance. This leads to a decrease in mean systemic blood pressure of 14-19 mmHg and a mean increase in heart rate of 6-12 beats per minute (1) and can cause severe myocardial depression (as in our case) and rarely cardiac arrest. As the duration of tourniquet inflation increases, the pH and pO 2 of blood in the limb decrease significantly and adenosine, lactate and pCO 2 increase (Po0.05) (2). The maximum recommended time of tourniquet inflation is 2 h for lower limb surgery (1).Previous studies have shown that factors contributing to tourniquet-induced ischemia-reperfusion injury are activation of granulocytes (3), release of oxygen-free radicals (4) and tumor necrosis factor-a (5). The patient had taken oral clonidine pre-operatively, which has been shown to accentuate the hypotension following tourniquet deflation by inhibiting noradrenaline release (6). The release of tourniquet leads to hypotension more commonly in older patients (57 AE 8 years) vs. 50 AE 4 years (Po0.005), patients with underlying cardiovascular disease and longer duration of surgery [120 AE 14 vs. 60 AE 27 min (Po0.001) (7)]. Even our patient was elderly (62 y...

Background: Regional anaesthesia has always been an attractive option for laparoscopic surgeries in patients who are not fit for general anaesthesia. Also, regional anaesthesia has certain advantages over general anaesthesia like lesser oropharyngeal morbidity, lesser blood loss and decreased chances of thrombosis. Lumbar spinal anaesthesia has been synonymous with the term regional anaesthesia for laparoscopic surgeries for quite some time now. In the light of recent works by Imbelloni and Zundert, thoracic spinal anaesthesia has been shown to be a promising alternative not only for healthy patients but for high risk patients as well. Baricity defines the density of the drug with respect to CSF density. This undoubtedly makes it is one of the most important factors that influence drug distribution in the subarachnoid space. Drugs of differing baricities have been studied previously in lumbar spinal anaesthesia. We aimed at studying the behaviour of isobaric and hyperbaric bupivacaine using a different approach which in this study was thoracic combined spinal epidural anaesthesia. Authors evaluated the haemodynamic changes as well as neurological and any other post operative complications that occurred in any of the patients.Methods: There were 60 ASA I and II patients undergoing elective laparoscopic cholecystectomy who were chosen for this study. They were randomly divided into two equal groups - group I and group H. Thoracic combined spinal epidural anaesthesia (CSE) was performed at T9-T10 / T10-T11 interspace. Patients in group I received 1.5ml of isobaric bupivacaine 0.5% (5mg/ml) + 25µg (0.5ml) of fentanyl and group H patients were given 1.5ml of hyperbaric bupivacaine 0.5% (5mg/ml) + 25µg (0.5ml) of fentanyl.Results: There was no significant difference among the haemodynamic variables between the two groups and no neurological complication was seen in any patient.Conclusions: Thoracic combined spinal epidural anaesthesia allows haemodynamic stability in laparoscopic cholecystectomies with minimal neurological and post operative complications irrespective of baricity of the drug used.

BACKGROUNDPostoperative Nausea and Vomiting (PONV) are the most unpleasant side effects after surgery. The incidence of PONV after laparoscopic surgery is high (40-75%). The purpose of this study was to prospectively evaluate the efficacy of granisetron, ramosetron and palonosetron for the prevention of PONV in patients undergoing laparoscopic surgery.

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