INTRODUCTIONSubarachnoid (spinal) block is a safe and effective form of anaesthesia when the surgical site is located on the lower extremities or perineum. It is simpler, cheaper and offers better physiological benefits with lesser complications than general anaesthesia. 1 It can be given by either median or paramedian approach. For the midline approach, the desired interspace is palpated and local anaesthetic is injected into the skin and subcutaneous tissue. The introducer is placed with a cephalad angle of 10 to 15 degree followed by passing of the spinal needle through the introducer. The needle goes through the subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum, epidural space, dura mater, and subarachnoid mater in order to reach the subarachnoid space. If the patient has a heavily calcified interspinous ligament (as seen in elderly patients) or difficulty in flexing the spine, a paramedian approach is used for spinal anaesthesia.After identifying the correct level for spinal anaesthesia placement, the spinous process is palpated. The needle is inserted 1 cm lateral to this point and directed toward the middle of the interspace. The ligamentum flavum is usually the first resistance felt. When the spinal needle goes though the dura mater, a pop is often appreciated. Accurate identification of the subarachnoid space is very important as multiple attempts at needle ABSTRACT Background: Spinal anaesthesia in elderly patients is frequently associated with significant technical difficulties. Spinal anaesthesia can be given by either paramedian or median approach. Paramedian approach has been used as an alternative in case of failure with median approach. The goal of this study is to determine which of these two approaches should be preferred as a first choice of spinal anaesthesia in elderly patients. Methods: The study included 100 patients of either sex, aged 50 years and above, who received spinal anaesthesia either with the midline approach (group M, n=50) or paramedian approach (group PM, n=50). Results: The success rate of paramedian group was 100% as compared to 96 % in median group. The first attempt success rate was 90% in group PM and 70% in group M. Paraesthesia was felt in 5 patients (10%) in midline group and in 2 patients (4%) in paramedian group. Hemorrhagic tap was seen in 2 patients each in both the groups . None of the patients in Group M had postdural puncture headache (PDPH) as opposed to 2 patients in Group M. Conclusions: Thus the study conclude that paramedian approach is a better approach for spinal anaesthesia in elderly patients in terms of success rate, success at first attempt, complications like paraesthesia, PDPH and failure of subarachnoid block. Thus study recommends the routine use of paramedian approach for sub-arachnoid block in elderly patients as first choice.

We present the first case of a posttraumatic pseudoaneurysm of the axillary artery successfully treated with a stentgraft.A 89-year-old woman with a conservatively treated subcapital humeral fracture developed a pseudoaneurysm of the left axillary artery which was percutaneously successfully treated with a stentgraft. Endovascular repair of a traumatic axillary artery pseudoaneurysm should be considered especially in unfit patients.

Background: Pain after breast surgeries is a major problem which costs both in patient comfort and duration of hospital stay. Uncontrolled post-operative pain may produce a range of detrimental acute and chronic effects. Optimal pain relief and minimal side effects following surgery have a major impact on patient outcome, including patient satisfaction and earlier mobilization, as well as fulfilling the needs for streamlined surgical services with lower costs. Aims and Objectives: The aim of the study was to assess for the pain score during the first 24 h with time of the first request for rescue analgesic and total analgesic requirement and also to assess the patient‘s satisfaction for post-operative pain relief and consequences if any during the first 24 h. Materials and Methods: This prospective study was conducted in 60 patients of ASA status I or II considering for mastectomy categorized into two groups, the first group with 30 patients who received Bupivacaine drug and second group with 30 patients who received normal saline. In the PACU, each patient’s VAS score and tramadol use were evaluated. The pectoral nerve block is a less invasive interfacial plane block used for post-operative pain relief in breast surgeries that involves deposition of local anesthetic between the pectoralis major and minor muscles, in addition to the serratus anterior and pectoralis minor muscles and the intercostal muscles, blocking the lateral branches of the intercostal nerves and the long thoracic nerve. Results: We found a significant difference in total rescue analgesia intake among control and PECS II block groups, in an initial 24 h of surgery. In the control group, mean VAS score and total rescue analgesia intake in 24 h were statistically significant greater (P<0.05). Conclusion: We concluded that pectoral nerve block is an effective and easy technique for pain control and fast recovery in post-operative period following breast surgeries.

INTRODUCTION:Spinal anesthesia for below umbilical surgery causes almost inevitable sympathetic block and decreased venous return to the heart. It results in hypotension and decreased cardiac output. The prevention of spinal hypotension appears more likely to decrease the frequency and severity of associated adverse symptoms than the treatment of established hypotension. Physical intervention as lower limb elevation is used for prevention of hypotension and may act by minimizing venous pooling of blood in the lower limbs and lower abdomen. AIMS: To compare the effects of lower limb elevation as a tool for prevention of hypotension during spinal anesthesia for below umbilical surgeries. METHODOLOGY: Our study was conducted in department of Anesthesiology, S.S. Medical College, Rewa. Hundred patients scheduled for elective below umbilical surgeries were randomized into two groups. In group A patients, lower limbs were elevated to approximately 30 degrees and no intravenous fluid was given preoperatively, while in group B patients 10-20 ml/kg of intravenous crystalloid was given as preloading and patient was in neutral position. RESULTS: There was less hypotensive episodes, intravenous fluid requirement, urinary retention; nausea & vomiting in group A patients. Also there was less subjective blood loss in group A patients.

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