A 1 year prospective analysis of all critically ill obstetric patients admitted to a newly developed dedicated obstetric intensive care unit (ICU) was done in order to characterize causes of admissions, interventions required, course and foetal maternal outcome. Utilization of mortality probability model II (MPM II) at admission for predicting maternal mortality was also assessed. During this period there were 16,756 deliveries with 79 maternal deaths (maternal mortality rate 4.7/1000 deliveries). There were 24 ICU admissions (ICU utilization ratio 0.14%) with mean age of 25.21±4.075 years and mean gestational age of 36.04±3.862 weeks. Postpartum admissions were significantly higher (83.33% n=20, P<0.05) with more patients presenting with obstetric complications (91.66%, n=22, P<0.01) as compared to medical complications (8.32% n=2). Obstetric haemorrhage (n=15, 62.5%) and haemodynamic instability (n=20, 83.33%) were considered to be significant risk factors for ICU admission (P=0.000). Inotropic support was required in 22 patients (91.66%) while 17 patients (70.83%) required ventilatory support but they did not contribute to risk factors for poor outcome. The mean duration of ventilation (30.17±21.65 h) and ICU stay (39.42±33.70 h) were of significantly longer duration in survivors (P=0.01, P=0.00 respectively) versus non-survivors. The observed mortality (n=10, 41.67%) was significantly higher than MPM II predicted death rate (26.43%, P=0.002). We conclude that obstetric haemorrhage leading to haemodynamic instability remains the leading cause of ICU admission and MPM II scores at admission under predict the maternal mortality.

Context and Aims:Spinal anesthesia though gaining popularity in children, the misconceptions regarding its safety and feasibility can be better known with greater use and experience. The objective of this study was to evaluate the success rate, complications and hemodynamic stability related to pediatric spinal anesthesia.Materials and Methods:In this 1-year prospective study, 102 pediatric patients aged 6 months to 14 years undergoing infraumbilical and lower extremity surgery were included. Spinal anesthesia was administered using hyperbaric bupivacaine 0.5% in a dose of 0.5 mg/kg (for child < 5 kg), 0.4 mg/kg (for 5-15 kg), 0.3 mg/kg (for >15 kg) in L4-L5 space under all aseptic precautions after sedation. Demographic data, vital parameters, supplemental sedation, number of attempts for lumbar puncture, sensory-motor block characteristics, and complications were noted.Results:Spinal anesthesia was successful in 98 (97.1%) patients. Remaining 4 (3.9%) were failures and were given general anesthesia. Lumbar puncture was successful in first attempt (60 [58.82%]) or 2nd attempt (42 [41.18%]). There was no significant change in vital parameters. Mean peak sensory level was T 6.35 ± 1.20 (T4-T8). Mean sensory level at the end of surgery was T 8.11 ± 1.42 (T6-T10). Modified Bromage score was 3 in 98 (96.08%) patients. Sensory and motor block recovery was complete in all patients. Mean time to two segment regression was 43.97 ± 10.72 (30-70) min. Mean time to return Bromage score to 0 was 111.95 ± 20.54 (70-160). Mean duration of surgery was 52.5 ± 16.056 (25-95) min. Incidence of complications was minimal with hypotension occurring in 2 (2%) and shivering in 3 (2.9%) patients.Conclusion:Pediatric spinal anesthesia is a safe and effective anesthetic technique for lower abdominal and lower limb surgeries of shorter duration (<90 min) with high success rate. Owing to, its early motor recovery, it can be a preferred technique for day case surgeries in the pediatric population.

Background and Aims:The American College of Obstetricians and Gynecologists (ACOG) committee on professional standards and the National Institute of Clinical Excellence (NICE) guidelines suggest that decision-to-delivery interval (DDI) and emergency cesarean section (CS) should not be more than 30 min, and a delay of more than75 min in the presence of maternal or fetal compromise can lead to poor outcome. This prospective 1-year study was conducted on emergency CS in a tertiary care hospital to evaluate the DDI, factors affecting it and to analyze their effects on maternal and neonatal outcome.Material and Methods:A structured proforma was used to analyze the data from all women undergoing emergency CS, during a 1-year period, included in Category 1 and 2 of NICE guidelines for CS.Results:A total of 453 emergency CSs were evaluated, with a mean DDI of 36.3 ± 17.2 min for Category 1 CS and 38.1 ± 17.7 min for Category 2 CS (P > 0.05). Only 42.4% emergency CSs confirmed to the 30 min DDI while 57.6% had a DDI of more than 30 min. Reasons of delay were identified as a delay in shifting the patient to operation theater (22.1%), anesthesia factors (18.1%), and lack of resources or manpower (16.1%). Maternal complications occurred in 15 (3.3%) patients with 3 (0.7%) nonsurvivors having a DDI of 91.0 ± 97.0 min as compared to survivors with a DDI of 36.8 ± 15.7 min, P = 0.001. There was no significant association between DDI and occurrence of neonatal complications.Conclusion:Failure to meet the current recommendations was associated with adverse maternal outcomes, but not with adverse neonatal outcome.

BACKGROUND: Effect of adding intrathecal tramadol and nalbuphine to local anaesthetics in spinal anaesthesia is not much studied. STUDY DESIGN: A prospective, randomised double blind placebo controlled study. METHODS: 90 adult patients of ASA grade I-II scheduled for lower limb orthopaedic surgery under spinal anaesthesia were randomised to three groups of 30 each destined to receive 2.5ml (12.5mg) hyperbaric bupivacaine (0.5%) along with 1 ml of either normal saline (Group C) 50mg tramadol (Group T) or 2mg nalbuphine (Group N), making intrathecal drug volume to 3.5ml in each group. Sensory-motor block characteristics, postoperative analgesia in terms of VAS score, time to first rescue analgesic (duration of analgesia) and rescue analgesic consumption (tramadol) in 24 hours were compared in three groups. RESULTS: All three groups were comparable regarding onset and extent of sensory and motor block, (p>0.05). However, time to two dermatomal regression and time for complete motor recovery were significantly longer in Group N than in Group T than in Group C,(p<0.05). Duration of analgesia was significantly longer in Group N (378.0±35.72 min ≈6.3hr) as compared to Group C (234.0±24.10min ≈3.9) (p=0.000) and Group T (260.0±26.52 min ≈4.3hr) (p=0.00) while Group C and Group T were comparable. CONCLUSION: We conclude that addition of intrathecal nalbuphine 2mg is effective in enhancing postoperative analgesia as compared to when bupivacaine was used alone or along with tramadol.

Hence, the present study was conducted to evaluate objectively, the efficacy of intraperitoneal instillation and rectus sheath block using ropivacaine for postoperative pain relief after laparoscopic cholecystectomy and to assess the supremacy of either of these techniques over administration of tramadol 'on demand'-a conventional technique used in our institution. MATERIALS AND METHODSAfter taking approval from the institutional ethical committee and informed consent from the patients, a prospective, single blind, randomized, controlled trial was conducted on 75 ASA grade Keywords: Cholecystectomy pain, Local anaesthetics, Prince henry hospital pain score (PHHPS) Aim:To compare the efficacy of preemptive administration (initiated before the surgical procedure) of intraperitoneal instillation and rectus sheath block using ropivacaine for postoperative analgesia after laparoscopic cholecystectomy. Materials and Methods:A total of 75 selected patients were randomly assigned to three equal groups as Group R, who received bilateral RSB with 0.25 % ropivacaine 15 ml on either side; Group I, who received intraperitoneal instillation of 0.25% ropivacaine 50 ml and Group C (Control group), who received only rescue analgesic on pain. These were compared regarding postoperative analgesia in terms of Visual Analog Scale (0-10 cm), Prince Henry Hospital Pain Score (0-3), time to first dose of rescue analgesic (tramadol), total rescue analgesic consumption in 48 hours, patient satisfaction scores (1-7) and adverse effects.

Background and Aims:The role of nitro-glycerine (NTG) lingual spray for attenuation of the hemodynamic response associated with intubation is not much investigated. We conducted this study to evaluate the efficacy of NTG lingual pump or pen spray in attenuation of intubation induced hemodynamic responses and to elucidate the optimum dose.Material and Methods:In a prospective randomized controlled trial, 90 adult patients of ASA I, II, 18-60 year posted for elective general surgery under general anesthesia with intubation were randomly allocated to three groups as Group C (control) - receiving no NTG spray, Group N1 – receiving 1 NTG spray and Group N2 – receiving 2 NTG spray one minute before intubation. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate were recorded at baseline, just before intubation (i.e., 60 s just after induction and NTG spray), immediately after intubation, at 1, 2, 5 and 10 min after intubation.Results:Incidence of hypertension was significantly higher in Group C (60%, n = 18) as compared to Group N1 and N2 (10%, n = 3 each), P < 0.01. Mean value of SBP, DBP and MAP showed a significant rise as compared to baseline, following intubation in control group (15.31% in SBP, 12.12% in DBP, 17.77% in MAP) that persisted till 5 min, while no significant rise was observed in Group N1 and N2. There was a trend toward fall in blood pressure in Group N2 (4.95% fall in SBP, 4.72% fall in MAP) 1-min following spray, which was clinically insignificant. Mean value of SBP, DBP and MAP was significantly higher in Group C than in Group N1, which was in turn greater than Group N2 (Group C > N1> N2), P < 0.05. However, incidence of tachycardia was comparable in three groups (70% in group C, 63.33% in Group N1 and 67.77% in Group N2, P > 0.05).Conclusions:We concluded that the NTG lingual spray in dose of 0.4 mg (1 spray) or 0.8 mg (2 sprays) was effective in attenuation of intubation induced hemodynamic response, in terms of preventing significant rise in SBP, DBP and MAP compared to control group.

Background and Aims:Effect of intrathecal dexmedetomidine as an adjuvant to isobaric ropivacaine in spinal anesthesia for abdominal hysterectomy is not much investigated. The objective was to assess the dose dependent effect of dexmedetomidine (3 mcg vs 5 mcg) as an adjunct to isobaric ropivacaine in spinal anesthesia.Materials and Methods:Forty selected female patients were randomized to receive intrathecal 0.5% isobaric ropivacaine (15 mg) with dexmedetomidine 3 mcg (Group D3) or 5 mcg (Group D5) in spinal anesthesia for abdominal hysterectomy. Block characteristics, hemodynamic changes, postoperative analgesia, and adverse effects were compared.Results:Both groups were comparable regarding sensory-motor block characteristics and postoperative analgesia (P > 0.05). Four (10%) patients of Group D5 and 5 (12.5%) of Group D3 could not achieve desired T6 sensory level and Bromage score of 3(complete motor block) hence were converted to general anesthesia at the outset. Nine (22.5%) patients each in both groups required ketamine supplementation (0.5 mg/kg) for intraoperative pain at the time of uterine manipulation. Incidence of hypotension was comparable (55.56% in Group D5 and 37.14% in Group D3, P = 0.11), but this occurred significantly earlier in Group D5, P < 0.001. Sedation was also significantly more in Group D5 as compared with Group D3, P < 0.01.Conclusion:We conclude that spinal anesthesia with isobaric ropivacaine (15 mg) with dexmedetomidine (3 mcg or 5 mcg) did not show much promise for abdominal hysterectomy as one third cases required analgesic supplementation. Both doses of dexmedetomidine produced a similar effect on block characteristic and postoperative analgesia; however, a dose of 5 mcg dose was associated with more hypotension and sedation.

Non-cardiogenic pulmonary oedema (NCPE) is a clinical syndrome characterized by simultaneous presence of severe hypoxemia, bilateral alveolar infiltrates on chest radiograph, and no evidence of left atrial hypertension/congestive heart failure/fluid overload. The diagnosis of drug-related NCPE relies upon documented exclusion of other causes of NCPE like gastric aspiration, sepsis, trauma, negative pressure pulmonary oedema, etc. We describe two cases (45-year male and 6-year male), who had undergone elective surgery under general anaesthesia. They developed NCPE within 3-5 minutes after administration of ‘neostigmine-glycopyrrolate’ used to reverse residual neuromuscular blockade. Both patients were treated successfully with mechanical ventilatory support, and adjuvant therapy, viz., frusemide, dopamine, steroids. This report emphasizes that this fatal complication may be seen with neostigmine, the pathogenic mechanism remains unknown, and it probably is a drug-related NCPE.