Lower Limb Surgeries

I, DR.K. SURESHKUMAR hereby declare that the Dissertation titled on “COMPARISON OF POST OPERATIVE ANALGESIA FOLLOWING EPIDURAL BUPIVACAINE AND EPIDURAL BUPIVACAINE WITH VERAPAMIL IN ORTHOPAEDIC LOWER LIMB SURGERIES” was entirely done by me, under the guidance of PROF. Dr. R.MEENAKSHI, M.D. D.A., Prof. & HOD, Department of Anaesthesiology, Government Stanley Medical College and Hospital, in partial fulfillment of regulations for MD (Anaesthesiology) Degree Examination of the Tamil Nadu Dr.M.G.R. Medical University to be held in March 2008.

BACKGROUND: Major lower limb surgeries are often painful and require aggressive analgesic management postoperatively. So, we used psoas compartment block and Femoral Three in One block for postoperative analgesia. We performed prospective randomized study in 60 patients of ASA grade I and II scheduled for lower limb surgeries using psoas compartment block and Femoral Three in One block. Our main aim of study was to compare the efficacy of psoas compartment block with Three in One block at rest and at physiotherapy while minimizing the requirement of rescue analgesics and complications. MATERIALS AND METHODS: 60 patients were randomly allocated into two groups of 30 each group P received Psoas compartment block and group F received Femoral three in one block. Both the grops received Inj. Bupivacaine 0.25 % postoperatively . We observed onset, peak effect, duration of effective analgesia and no. of rescue analgesics required in first 24 hours, VAS score at rest and VAS score at physiotherapy postoperatively.Results were compared using the students unpaired „t‟ test after calculation of mean, standard deviation, and standard error of mean in both the groups. RESULTS AND DISCUSSION : The time taken to achieve peak effect in group P and group F was 18.9±2.8 mins and 23.23±3.5 mins respectively (P<0.05).The mean duration of analgesia in group P was 13.4±1.9 hrs and in group F was 9.2±2.2 hrs. (P<0.05). The no. of rescue analgesia required in 1st 24 hrs in group P was 1.2±0.37 and in group F was 2±50.63 (P<0.05). CONCLUSION: We observed that though both the blocks provide good postoperative analgesia, Group P offered better pain relief than group F during rest and physiotherapy.

Forty patients posted for orthopaedic lower limb surgeries of ASA I and ASA II were taken up for the study. They were allocated randomly into two equal groups of 20 each. Group P receieved 1 ml of placebo along with the first dose of epidural 0.5% bupivacaine and Group C received 50 µg of clonidine diluted with normal saline to 1 ml along with first dose of epidural 0.5% bupivacaine. A standard anaesthetic technique was followed in all patients. The patients were assessed by the same observer in the postoperative period.

I Dr. M.S. LAKSHMI SREE solemnly declare that the dissertation titled “COMBINED PSOAS COMPARTMENT BLOCK AND SCIATIC NERVE BLOCK FOR ELECTIVE LOWER LIMB SURGERIES” is a bonafide work done by me in the Department of Anaesthesiology , Chengalpattu Medical College& hospital , Chengalpattu , under the able guidance of Prof. DR. J . REVATHY, M.D, D.A, Professor and HOD, Department of Anaesthesiology , Chengalpattu Medical College, Chengalpattu, after getting approval from ethical committee.

A Mehta, V. Gupta and colleagues used 15 mg of isobaric Ropivacaine, Bupivacaine and Levobupivacaine intrathecally to 75 patients of 3 groups, n=25 in patients undergoing lower limb surgeries. Onset time,duration of the sensory and motor blocks and hemodynamics were noted. The onset of block was significantly shorter for Bupivacaine and Levobupivacaine as compared to Ropivacaine. The duration of sensory and motor block was shorter for Ropivacaine. Ropivacaine was better hemodynamically stable than Bupivacaine and Levobupivacaine. It concluded that Ropivacaine produce adequate spinal blockade of short duration with early ambulation and faster home discharge when compared with Bupivacaine and Levobupivacaine.

The detail of the study has been explained to me in writing and the details have been fully explained to me. I am aware that the results of the study may not be directly beneficial to me but will help in the advancement of medical science. I confirm that I have understood the study and had the opportunity to ask questions. I understand that my participation in the study is voluntary and that I am free to withdraw at any time, without giving any reason. Without the medical care that will normally be provided by the hospital being affected. I agree not to restrict the use of any data or results that arise from this study provided such a use is only for scientific purpose(s). I have been given an information sheet giving details of the study. I fully consent to participate in the study titled “Dexmedetomidine and Clonidine as an adjuvant to 0.75% Ropivacaine for epidural anaesthesia in lower abdominal and lower limb surgeries in a tertiary care centre- Comparitive study.”

This is to certify that this dissertation work titled “COMPARATIVE STUDY OF ORAL PREGABALIN VS GABAPENTIN FOR POST OPERATIVE ANALGESIA IN LOWER LIMB SURGERIES PERFORMED UNDER SPINAL ANAESTHESIA” of the candidate Dr.S.SANDEEP with registration Number 201520201 for the award of DOCTOR OF MEDICINE in the branch of ANAESTHESIOLOGY ( BRANCH X). I personally verified the urkund.com website for the purpose of plagiarism Check. I found that the uploaded thesis file contains from introduction to conclusion pages and result shows 1 percentage of plagiarism in the dissertation.

Forty patients posted for orthopaedic lower limb surgeries of ASA I & II were taken up for the study. They were allocated randomly in a double - blind fashion into two groups in equal number of 20 each. Group P (placebo) received a tablet of alike looking placebo(Vitamin C), Group G (Gabapentin) received 300mg tablet of gabapentin 90 minutes prior to anaesthesia .A standard anaesthetic technique was followed in all patients. The patients were assessed by an observer in the postoperative period who was blinded for the group assignment.

effects. The present prospective, randomized, double blind study was conducted after approval by the ethical committee, in the Department of Anaesthesiology, King George's Medical University, Lucknow, UP to find out appropriate concentration of Ropivacaine with Clonidine for Epidural anesthesia in elective lower limb surgeries in patients of ASA grade I-II, age between 18-60 years. This study was conducted on 60 patients, who were randomly divided into two groups with 30 patients each. Mean Time of onset of analgesia in patients of Group I was found to be 16.22+3.49 minutes while that in Group II was 12.28+3.49 minutes and this difference was found to be statistically significant (p<0.001). So, onset is earlier in Ropivacaine 0.75%, shows higher concentration of drug has rapid onset of action.

stability and the incidence of post dural puncture headache is not there as the dura is not pierced. Bupivacaine is the widely used local anaesthetic in regional anaesthesia. Stereoisomers of the agent are being developed for use instead of the isomers, in order to avoid the toxic effects of local anaesthetic agents as much as possible. Bupivacaine is available in a commercial preparation as a racemic mixture (50:50) of its two enantiomers, Levo-Bupivacaine, S (-) isomer and Dextro- Bupivacaine, R (+) isomer. Several central nervous system and cardiovascular adverse reactions reported in the literature have been linked to the R (+) isomer of Bupivacaine. The levorotatory isomers were shown to have a safer pharmacological profile with less cardiotoxic and neurotoxic effects and it is attributed to its faster protein binding rate. S forms of the isomers are less toxic and provide longer lasting analgesia (Casati and Putzu, 2005: Foster and Markham, 2000). The pure S (-) enantiomers of Bupivacaine, i.e., Dextro- Bupivacaine and Levo-Bupivacaine were thus introduced into clinical anaesthesia practice. This study aims to compare the clinical efficacy of 0.5% Levo-Bupivacaine and 0.5% Bupivacaine without adjuvant medication in patients undergoing elective lower abdominal and lower limb surgeries under epidural anaesthesia with respect to the onset & highest level of sensory block, duration of sensory analgesia, onset, degree & duration of motor blockade, hemodynamic changes like heart rate, blood pressure, and oxygen saturation at various time intervals. Intraoperative and postoperative complications such as nausea, vomiting, hypotension, bradycardia and respiratory depression.

I, Dr. MANGAL SWATHI.V, solemnly declare that this dissertation, entitled “A Comparative study of Epidural 0.5% Isobaric Levobupivacaine and Epidural 0.5% Isobaric Levobupivacaine with Dexmedetomidine for patients undergoing elective infraumbilical and lower limb surgeries” has been prepared by me, under the expert guidance and supervision of PROF.Dr.T.MURUGAN,M.D.,D.A., Professor & HOD, Department of Anaesthesiology, Government Kilpauk Medical College ,Chennai and submitted in partial fulfillment of the regulations for the award of the Degree M.D.(Anaesthesiology) by The Tamil Nadu Dr. M.G.R. Medical University and the examination to be held in April 2015.

lower limb. They also stated that the average surgery duration for patients in the three groups was comparable. Author found that in terms of loss of pinprick sensation at T10, patients in the three groups were comparable. Chaudhary AK et al, observed that this time was 5.25+1.21 min in the ropivacaine+clonidine group while it was 4.60±1.04 min in the plain ropivacaine group. 15

An onset profile for motor block can be represented as a “Myotomes score- time” diagram. An apparatus (Axelsson) that measures maximal isometric strength by a force transducer at ankle, knee and hip can be used for research purposes which provide objective, reproducible measurements of muscle power. Abdominal muscle power may be assessed by the rectus abdominis muscle (RAM) test. This is useful in abdominal surgery when abdominal muscle blockade is required rather than lower limb muscle blockade.

Adjuvant agents are pharmacological drugs that, when co-administered with local anaesthetic agents, may improve the speed of onset, the quality and / or duration of analgesia with desirable sedation. A wide range of drugs has been assessed for both neuraxial and peripheral nerve blocks. α-2 adrenergic agonists have both analgesic and sedative properties when used as an adjuvant in regional anaesthesia [5] . Dexmedetomidine is a highly selective α2 adrenergic agonist with an affinity of eight times greater than clonidine. There is no such study which has compared the dose equivalence of these drugs but the observations of various studies have stated that the dose of clonidine is 1.5−2 times higher than dexmedetomidine when used in epidural route [6] . The anaesthetic and the analgesic requirement get reduced to a huge extent by the use of these two agents. The aim of this study is to compare dexmedetomidine and clonidine as an adjuvant to ropivacaine for epidural anaesthesia in lower abdominal and lower limb surgeries.

Ropivacaine a new long-acting amide local anaesthetic agent, is a pure S-enantiomer, with a high pKa and relatively low-lipid solubility. [1] Ropivacaine provides effective spinal anesthesia for lower limb and hip surgeries. [2] Plain solutions are less reliable for surgery above a dermatomal level of L1. [3] the objective of the current study is to establish the reliability and efficacy of plain 0.5% and 0.75% intrathecal ropivacaine in patients undergoing lower limb surgeries.

4. Sarabjit Kaur,et al (26) ( 2014) conducted a prospective study to compare analgesic effects of epidurally administered ropivacaine and dexmedetomidine when compared with plain ropivacaine in undergoing lower limb surgeries . They randomized 100 patients into two groups as group A and B . Group A (n = 50) patients received plain ropivacaine in the epidural and Group B (n = 50) patients received dexmedetomidine as adjuvant to epidural ropivacaine . They had compared the two groups with respect to time to onset of sensory level at T10, time to maximum sensory and motor block and time of rescue analgesia . They had observed that significant difference was seen in relation to the duration of sensory block prolonged in group group B (535.18 ± 19.85 min) than group A (375.20 ± 15.97 min ),p=0.000 and similarly duration of motor block prolonged in group B( 385.92 ± 17.71 min) than group A (259.80 ± 15.48) p=0.000 , prolonged duration of post-operative analgesia seen in group B (312.64 ± 16.21 min versus 496.56 ± 16.08 min in Group B ) and low doses of rescue analgesia needed in Group B as compared to Group A . Better sedation score was seen in Group B . Finally, they had concluded that epidural dexmedetomidine as a better adjuvant to Ropivacaine when compared to plain Ropivacaine.

You are invited to take part in this research study. We have got approval from the IEC. Your are asked to participate because you satisfy the eligibility criteria .We want to compare and study the safety and efficacy of epidural buprenorphine and dexmedetomidine with 0.5% bupivacaine in lower limb surgeries What is the Purpose of the Research:

Body weights were measured using a body composition meter (MC-190; TANITA, Japan) at baseline and 4 months. Body composition parameters (bone mineral content, fat mass, and muscle mass) were measured using dual-energy X-ray absorptiometry (DXA; QDR- 4500A; Hologic, Japan) at baseline and 4 months. DXA measurements were conducted following overnight fast and 24-h absence of strenuous exercise. Participants wore typical athletic clothing and removed all metal jewelry. Participants were laid on their back on the DXA table with their arms at their sides and feet together. The same investigator conducted all analyses, and the second measurement was performed as a comparable mode. The investigator checked the setting of analysis region. Lower limb were separated from the trunk by a horizontal line just below the lower pelvic. Analysis pro- vided data on lean body mass, fat mass, and bone

scheduled for discharge on the basis of clinical assessment of psychotic symptoms; be taking antipsychotic agents (haloperidol, olanzapine, quetiapine, risperidone, clozapine, amisulpride, aripiprazole) in therapeutic doses. We also enrolled healthy first-degree adult relatives of patients with schizophrenia and a control group of healthy volunteers. The exclusion criteria for all groups were: age ,18 years and .40 years; taking analgesic, antidepressive, or anti- convulsive drugs in last 8 weeks; drug intoxication in the past; use of a psychoactive substance currently or in the past; mental disorders other than schizophrenia; presence of depressive symptoms upon clinical examination and on the Hamilton Depression Rating Scale (score .7); peripheral neuropathy; limb trauma in the past; a current diagnosis of diabetes or cancer; degenerative diseases of the musculosk- eletal system. In all, 43 patients with schizophrenia (aged 19–40 years) were enrolled on study. The female-to-male ratio was 31:12. All patients met the ICD 10 criteria for a diagnosis of schizophrenia, and the duration of psychosis was no lon ger than 6 years. All patients were in a stable mental state and chronically received antipsychotic agents (haloperidol, olanzapine, quetiapine, risperidone, clozapine, amisulpride, aripiprazole) in therapeutic doses. Five healthy first-degree relatives (three female, two male; aged 18–29 years) of patients with schizophrenia were also included in the study. The control group comprised 34 healthy volunteers (seven male, 27 female; aged 20–40 years).

At present, the number of patients with multifocal atherosclerosis and critical ischemia of the lower extremities in the Russian Federation has increased. This is due to the increase of elderly and senile persons among the population 1, 5, 6, 7, 8 .