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Background and Aims: The stress response to pneumoperitoneum can be deleterious due to its effects on haemodynamics, thereby increasing the morbidity. We intended to compare different doses of nitroglycerine nasal spray to obtund these responses and to look for any side effects. Methods: After ethical committee clearance and clinical trials registration, 70 patients scheduled for laparoscopic cholecystectomy were recruited. Random allocation was done into two groups by a computer generated randomisation table. Group N4 (n = 35) received 400 μg nitroglycerine and group N8 (n = 35) received 800 μg nitroglycerine with an intranasal spray 2 min prior to pneumoperitoneum. All the haemodynamic parameters were monitored at regular intervals. Results: The heart rate was comparable between the groups except at 6 and 10 min of pneumoperitoneum but showed significant increase from baseline within the groups. Mean arterial pressure (MAP) was statistically significant between the groups, being higher in group N4. Within group N4, MAP was significantly low only at 2 min, 4 min of pneumoperitoneum (101.69 ± 12.34 at baseline versus 93.31 ± 8.07 at 2 min and 97.54 ± 9.07 mm Hg at 4 min) and increased significantly at 30 min of pneumoperitoneum (101.69 ± 12.34 at baseline versus 105.66 ± 12.35 mm Hg) and hence, MAP was observed to be around baseline throughout the rest of intraoperative period. Within group N8, there was a significant decrease in mean, systolic and diastolic blood pressure from baseline at most of the time intervals. Conclusion: 800 μg of intranasal nitroglycerine effectively obtunds the hypertensive response associated with pneumoperitoneum as compared to 400 μg without significant side effects.

BACKGROUND Scoliosis, a major surgery conducted under general anaesthesia causes significant neuroendocrine stress response. Conduct of the wake-up test may further exaggerate the stress response due to the uncomfortable prone position during surgery and also presence of an endotracheal tube in situ during conduct of the test. Dexmedetomidine causes modulation of catecholamine release, which minimises the neuroendocrine and haemodynamic stress response. MATERIALS AND METHODS50 cases of NF-1 coming for scoliosis repair were studied over 4 years prospectively for quality of wake-up test, control of blood loss and haemodynamic stability due to administration of Dexmedetomidine infusion. Dexmedetomidine was started intravenously as a bolus 1 ug/ kg over 10 minutes followed by 1 ug/ kg/ hour infusion. HR, ECG, SpO2, IABP, temperature and urine output was monitored. Wake-up test: Surgeons requested for wake-up test half an hour in advance. Atracurium infusion was stopped. Isoflurane was stopped 15 mins later. Dexmedetomidine was continued at 0.5 µg/ kg/ hr. Study Design-Descriptive Study. RESULTSIn our study, we did not see any of these complications and all 50 patients had good quality of wake-up test. The patients were calm due to the hypnotic and anxiolytic actions of dexmedetomidine. They responded to commands equivalent to a Ramsay sedation scale of 2. They were pain free, haemodynamically stable with good spontaneous respiration. Intraoperative period was characterised by haemodynamic stability (Heart rate was maintained between 80 -120/mins, ABP-70/ 40 -100/ 60 mmHg, P-max 20 -24 mmHg). Average blood loss was around 15 mL/kg body weight. Major blood loss requiring massive blood transfusion was not seen; 1 unit of packed cells was transfused in each of the 50 cases. CONCLUSIONIntraoperative dexmedetomidine use has multiple advantages in NF-1 patients undergoing scoliosis corrective surgery. A randomised controlled study is necessary to statistically evaluate the multiple benefits of dexmedetomidine.

BACKGROUNDIn adults, extraperitoneal lower abdominal and lower limb procedures are performed under epidural or spinal anaesthesia without supplemental general anaesthesia. However, similar procedures in paediatric population to be performed under regional anaesthesia require additional sedation, analgesia to immobilise the child during institution of the regional anaesthetic technique and continued sedation during the surgical procedure to ensure cooperation of the child. Aims and Objectives-To evaluate the efficacy and safety of a combination of intravenous infusion of dexmedetomidine and fentanyl for sedation during surgeries done under regional anaesthesia in children. MATERIALS AND METHODS22 children, ranging in age from 2 to 12 years of both sexes posted for lower limb deformity correction, lower abdominal, extraperitoneal and hypospadias repair were selected continuously for this study. Sample size since there were no previous similar studies, we selected continuously all patients who met the eligibility criteria during the study period. Pharmacological Interventions: Intravenous access was secured and the loading dose of intravenous Dexmedetomidine and Fentanyl, both at the rate of 1 ug/kg /hr was infused over 10 minutes using a syringe pump. At the end of 10 minutes, a maintenance dose of 1 ug/kg of the same was continued. Lumbar epidural catheter was inserted using 19-G epidural Tuohy needle (PORTEX) and 0.5% Bupivacaine 0.5 mL/kg up to a maximum dose of 2.5 mg/kg was deposited and the catheter was secured. Surgical procedure was conducted with the child breathing spontaneously with supplementation of oxygen 3 L/minute through a face mask. Inj. Propofol 1mg/kg was used as rescue sedation. The perioperative monitoring to evaluate the efficacy of sedation under the study regimen and need to opt for rescue sedation included ECG, Heart rate, NIBP, SPO2, EtCO2, the Respiratory rate, level of sedation and time to achieve Ramsay score of 2 in recovery room. Design-Descriptive. Setting-250 bedded paediatric referral hospital offering tertiary care to South Asian population. RESULTSEffective sedation in all 22 patients was achieved intraoperatively with intravenous infusion of Fentanyl 1 ug/kg/hour and Dexmedetomidine 1 ug/kg/hour combined with epidural block with Bupivacaine 0.5%. Primary outcome measured was the need for rescue sedation which was required in 3 out of 22 cases, i.e. 13.6%. The vital parameters were as follows. The maximum change in mean heart rate from baseline was during the intraoperative period (P4), being 28.4 ± 28.7 (p < 0.001). The lowest recorded value was 58/m. Blood pressure changes showed a maximum mean change from baseline seen in both the systolic as well as diastolic pressures at the end of 10 minutes of bolus and was -7.7 ± 18 and -7.8 ± 16 mmHg. No patient's respiratory rate decreased to less than 12 breaths/min or increased above 28 breaths/min during the procedural sedation. The highest EtCO2 was 30 mmHg. Oxygen saturation remained between 97 to 100% during the study in all pati...

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