Journal of the Bangladesh Society of Anaesthesiologists

Development of sub or super specialties in Anesthesiology- Bangladesh perspective

Debabrata Banik — 2022-07-31

Abstract not available

JBSA 2022; 35 (2) : 1-2

Comparative Study between Dexmedetomidine and Nalbuphine for prevention of post spinal shivering in Obstetrics cases- A randomized controlled trial

Md Abu Kawsar — 2022-07-31

Background: Shivering is a physiological response to core hypothermia in an attempt to raise themetabolic heat production. The main causes of intra/post-operative shivering are temperature loss,increased sympathetic tone, pain, and systemic release of pyrogens. Spinal anaesthesia significantlyimpairs the thermoregulation system by inhibiting tonic vasoconstriction, which plays a significant rolein temperature regulation. It also causes a redistribution of core heat from the trunk (below the blocklevel) to the peripheral tissues. These factors predispose patients to hypothermia and shivering. Severalpharmacological agents are used for control of Post spinal shivering. Nalbuphine has become afavoured and commonly used drug for post-spinal shivering. However, it has many adverse effects likenausea, vomiting, dizziness etc. Dexmedetomidine is another agent which has gained popularity duringthe last few years. Dexmedetomidine is an α2-adrenergic receptor agonist, has been used as a sedativeagent and is documented to increase the shivering threshold.

Objectives: To assess the superiority of Dexmedetomidine over Nalbuphine in prevention of post spinalshivering.

Materials & method: This prospective, randomized clinical trial was conducted in Department ofAnaesthesia, Analgesia, Palliative and Intensive Care Medicine, Dhaka Medical College Hospital, from18th October 2019 to 17th April 2020. Total 120 patients were selected and allocated into two groups,group N (Nalbuphine) and group D (Dexmedetomidine). Patients of Group N was given intravenousNalbuphine 0.07 mg/kg mixed with 0.9% normal saline to a volume of 10ml. Patients of Group D wasgiven intravenous Dexmedetomidine hydrochloride 1 μg/kg mixed with 0.9% normal saline to a volumeof 10ml. Then shivering grade and haemodynamic status were recorded at different follow-up time andcompared between groups.

Result: Majority of the patients i.e. 58.33% (n=70) were between 25-30 years, mean age was found to26.7±8.4 years and 26.7±8.4 years in Group D & N respectively. The heart rate after 5 min (56, 62beat/min respectively), after 10 min (58, 68 beat/min respectively) and 15 min (63, 72 beat/min respectively)after of anaesthesia were statistically significant. Shivering grade 3 or 4 was existed in bothgroups, but more in group N. Rescue medication for shivering (Inj. Pethedine 25 mg) requirement washigher in Group-N & difference was statistically significant. Shivering was controlled within 15 minutein maximum 13(21.66%) of patients in group D. Comparison of sedation, 45 minute after mean sedationscore was found 2.03±0.07 in group D, but in group N score is reduced and found 1.43±0.127. Meansedation score difference was statistically significant (p<0.05) between two groups.

Conclusion: Post spinal shivering is very distressing for patients and may induce a variety of complications.Present study concluded that Dexmedetomidine was more effective compared to Nalbuphineinattenuating the post spinal shivering.

JBSA 2022; 35 (2) : 3-11

A Dose Response Study Of Oral clonidine as premedication in patients undergoing abdominal gynaecological surgery

Sharmin Mahbub — 2022-07-31

Background: The current study was designed to investigate the safe and effective dose of oral clonidine onpost-operative analgesia in patients undergoing gynaecological laparotomy. The objective of the study was to see theeffectiveness of oral Clonidine as a preanesthetic medication and to determine which dose of oral Clonidine givesbetter analgesic effect.

Method: In this prospective, randomized, double-blind, controlled study sixty adult female patients of ASA physicalstatus I & II aged 18-40 yrs, undergoing gynaecological laparotomy received low dose clonidine 2-2.5mcg/kg (n=30)and high dose clonidine 4-4.5mcg/kg (n=30).These drugs were administered 105 min before the estimated time ofinduction of anesthesia. Heart rate & arterial pressure were recorded prior to induction, 5 min intervally upto 20 minin peroperative time and 2 hour intervally upto 6 hours in postoperative period. In the Group-A (clonidine2-2.5mcg/kg) mean heart rate ranged from73.80 ±8.69 to 71.45±5.80, in Group-B mean heart rate decreased morefrom 70.85±7.64 to 67.85±6.47. Systolic blood pressure in Group-A (low dose clonidine) was 113.00±7.32, inGroup-B (high dose clonidine) was 120.00±10.38 and where p=0.024. Diastolic blood pressure of Group-A (low doseclonidine) was 76.15±5.29, in Group-B(high dose clonidine) was 80.10±5.3. Postoperative pain was assessed by ablinded observer using a VAS scale. This study was done in the department of anesthesiology of Apollo HospitalsDhaka over a period of six months.

Results: Patients in group A (low dose) and group B (high dose) showed no significant hemodynamic changesbetween groups. Five patients in group B showed marked hypotension and bradycardia and treatedaccordingly.Group B patients (high dose clonidine) showed more post operative analgesia compared to group A.

Conclusion: These data suggest that low dose clonidine (100mcg/kg) premedication is safe and effective to facilitatepost-operative analgesia with stable haemodynamics & without any side effects. On the other hand,.high doseclonidine showed more post op analgesia &.marked hypotension and bradycardia.

JBSA 2022; 35 (2) : 12-16

Premedication of Oral Clonidine 2mcg/kg and 4mcg/kg for Analgesic and Pressure Response During First Twenty-four Hours After Upper Abdominal Surgery: A Comparative Study

Mohammmad Shaddam Hoshain Mondol — 2022-07-31

Traditionally postoperative period analgesia was maintained by opoids and which frequently increasethe hospital stay time and cost by delayed bowel movement and others side effects. on the other handupper abdominal surgery is very much painful, usually Opiods are used as good analgesic, but havesome adverse effect and addiction effect; anaesthesiologists want to reduce its requirements. In upperabdominal surgery adequate analgesia, stable haemodynamic, early bowel movement, free from nauseaand vomiting is wanted, as a part of multimodal analgesic approach, premedication by clonidine is veryimportant for it analgesic, angiolytic and sedative properties. Alpha two (α–2) adrenoreceptor agonist,Clonidine exerts central sympatholytic effect for 8 to 10 hours as its half life is 9-12 h. So thatpremedication with oral clonidine causes reduction of anxiety, reduction of perioperative analgesicdrugs and also reduction of anaesthetic doses. In addition, clonidine increases cardiac baroreceptorreflex sensitivity to increase in systolic blood pressure, and thus stabilizes blood pressure. Clonidine israpidly and almost completely absorbed after oral administration with a time to maximum plasmaconcentration of between 1.5 and 2 hr and elimination half-life of 8 to 12 hr. But clonidine producesanalgesia in a dose dependent manner, achieving complete pain relief for up to 5 hours without sensoryor motor block at large doses (oral 7000 to 900 mcg) however large doss were associated withdisadvantage including hypotension, bradycardia and transient sedation. It also reported thatclonidine 150mcg intravenous (I/V) produce a similar analgesic effect to morphine 5mg in patient afterorthopedic surgery. Because of its dose, route, and surgical variation it is very much important tospecify the dose for upper abdominal surgery.The primary aim of this study to compare the effects of clonidine premedication at different doses (2 &4mcg/kg) on postoperative analgesia and hemodynamic status in upper abdominal surgery with largeincision area. (like- hepatobiliary surgery, gastrectomy, esophagectomy, hepatictomy, and whipplesoperations).

JBSA 2022; 35 (2) : 17-21

Effectiveness of platelet rich plasma versus corticosteroid in the treatment of plantar fasciitis: a double-blind randomized controlled trial

Shukha Ranjan Das — 2022-07-31

Background: Plantar fasciitis is a common cause of heel pain. This condition is caused bydegenerative changes resulting in repetitive microtears of the plantar fascia, which are in turn causedby biomechanical overuse from prolonged standing or running. Several nonoperative treatments havebeen employed, such as stretching, physical therapy, nonsteroidal anti-inflammatory drugs,extracorporeal shock wave therapy, needling and night splints, relative rest, etc. But clinical outcomesof these methods are controversial. Corticosteroid is also effective but provides only short-term painrelief with disappointing long-term results. This procedure is also associated with complications,including localized infection, fat pad atrophy, and plantar fascia rupture. In recent years, platelet-richplasma (PRP) has been investigated as a treatment option for plantar fasciitis. PRP is a bioactiveconcentrate of various growth factors and cytokines that modulate cell proliferation and differentiation,angiogenesis, and chemotaxis.

Objectives: To evaluate the effectiveness of platelet rich plasma versus corticosteroid in the treatmentof plantar fasciitis.

Materials & method: This Quasi-experimental study was carried out on adult patients with chronicPlantar Fasciitis attended in Dhaka Medical College Hospital, during the period of October 2021 toMay 2022. The patients were randomly assigned to one of the two groups; group A (patients treated withPRP); group B (patients treated by with corticosteroid). After providing the allocated treatment, allpatients were undergone follow-up examination at 1st week, 1st month, 3rd month and at 6th month forclinical improvement. Visual Analog Scale (VAS), Roles and Maudsley (RM), and Foot Function Index(FFI) scoring systems were used as outcome measures.

Result: Mean ± SD of age was calculated to be, 42.31 ± 7.6 for Group A and 42.29 ± 8.0 for Group B.Most of the participants in Group A [13 (72.1)] & in Group B [15 (65.2)] were females. Mean VAS scoreat different follow up time reveals, after 1 week of intervention, score was turn down or pain reduced inboth groups, but comparatively better in group B. At 3rd month (Mean VAS 3.05 & 4.82 in group A &B respectively) and 6th month later (Mean VAS 1.67 & 4.12 in group A & B respectively) follow upperiod, significant improvement was found in group A. Use of corticosteroid (Group B) showedimprovement in symptoms immediately at 1st week to one month (short duration), which did not lastlong. But PRP effective in prolong time. RM score shows that a significant difference among two groupsat 1 and 3 months with P = 0.051 and P = 0.001, respectively. Mean FFI scores in Group A weresignificantly lower than Group B. No adverse events were noticed in any of the groups.

Conclusion: Platelet-rich plasma (PRP) injection is better than steroid injection in relieving the painof planar fasciitis and improvement function of the patient foot.

JBSA 2022; 35 (2) : 22-29

Comparison between effects of Clonazepam and Dexmedetomidine as sedative in elective Caesarean section under Subarachnoid anaesthesia

Md Enayet Karim — 2022-07-31

Background: Regional anaesthesia has become an important anaesthetic technique now a days. Theuse of spinal (subarachnoid) anaesthesia is often limited by the unwillingness of patients to remainawake during surgery. Pharmacologically induced tranquility improves acceptance of regionaltechnique. This study compares Clonazepam and Dexmedetomidine in terms of onset and recovery ofsedation, haemodynamic effects, respiratory effects and adverse effects of both the drugs during electiveCaesarian section under spinal anaesthesia.

Materials and Methods: This randomized clinical trial included 60 ASA (American Society ofAnaesthesiologists) grade I patients between age 20-40 years undergoing elective Caesarean sectionsunder Subarachnoid anaesthesia during the period January 2022 to June 2022. Patients wererandomly allocated to one of two groups: Clonazepam group (Group C, n=30), who received Clonazepamin a single dose of 0.015mg/kg and Dexmedetomidine group (Group D, n=30), who receivedDexmedetomidine in a single dose of 2mcg/kg. Spinal anaesthesia was conducted by injecting ahyperbaric solution of 0.5% bupivacaine 3ml through a 25G spinal needle at L3-4 level. All parameterswere documented at 5 min intervals until arousal of the patient. The onset of sedation i.e. time from iv(intravenous) injection of Clonazepam or Dexmedetomidine to closure of eye lids (OAA/S score of 3) andthe arousal time from sedation i.e. time from closing of the eye lids to OAA/S score of 5 ( patient isawake clinically) were noted. Any complication during operation was documented. The patient’ssatisfaction with the sedation was assessed by the 5 point ‘Likert verbal rating scale.’

Results: There was no significant difference of mean blood pressure and mean heart rate between thetwo groups at different time intervals (P>0.05). Time of onset of sedation was significantly delayed inDexmedetomidine group (P<0.05). Duration of sedation was comparable between the two groups (Pvalue 0.326). Incidence of peroperative complications were comparable between the two groups (P>0.05).

Conclusion: Although onset of sedation was significantly delayed in Dexmedetomidine group,duration of sedation was not significantly different between Clonazepam and Dexmedetomidine insingle dose technique for sedation during Caesarean section. Haemodynamic effects and adverse effectsof two drugs were comparable. Thus it is recommended that either Clonazepam or Dexmedetomidinecan be used for sedation during subarachnoid block for Caesarean section.

JBSA 2022; 35 (2) : 30-36

Postoperative pain relief in pediatric surgery patients: Effect of intravenous paracetamol in comparison with diclofenac suppository

Zikrul Bashir — 2022-07-31

Background: Pain is a major problem regarding quality of life in children undergoing surgicaloperation.Pain assessment is the most important and critical component of pain management. Oral andrectal paracetamol formulations are associated with a slower onset of action and more variableanalgesic activity than IV acetaminophen, making them less useful in preoperative and acute caresettings.

Objective: To find out the effect of intravenous paracetamol in releiving postoperative pain in pediatricpatients.

Settings and study design: This randomized clinical trial study was conducted in theAnaesthesiology department of Sir Salimullah Medical College Mitford Hospital,Dhaka fromFebruary' 2014 to August' 2014. A total of 100 cases were taken, they were randomly divided into twogroups in which one group received intravenous paracetamol and another group received diclofenacsuppository for the same operation performed on them, age of the children were between 4-12 years, andall were ASA grade I. Pain relief was assessed with VAS score from 30 minutes after surgery up to 6hours with regular follow up and comparison made between the two groups.

Results: In this study, comparisons by mean visual analog scale between intravenous paracetamolwith diclofenac suppository groups were done. VAS score showed both analgesic reduces pain, butdiclofenac suppository was found better post operative pain reliever than intravenous paracetamolwithin observed 30 min to 2 hours. However observed after 6 hours, diclofenac suppository group issignificantly better than intravenous paracetamol group in relieving post operative pain by measuringVAS.

Conclusion: Our study showed that diclofenac suppository is more effective than IV paracetamol inrelieving postoperative pain. However paracetamol is definitely a viable alternative to the NSA IDs,especially because of the lower incidence of adverse effects, and should be the preferred choice inhigh-risk patients. It may be appropriate to combine paracetamol with NSAIDs,but future studies arerequired especially after major surgery.

JBSA 2022; 35 (2) : 37-42

Blood Glucose Variability as a Predictor of Mortality for Septic Patients in Intensive Care Unit

Shamima Akter — 2022-07-31

Background: One of the ways of modulation of septic response is glycaemic control. Increased Bloodglucose variability rather than mean glucose level in critically ill patients is an important factorassociated with sepsis.

Objective: Objective of this study was to find out whether the increased blood glucose variabilitypredicts mortality for septic patients in Intensive Care Unit.

Methods: Purposively allocated 40 septic patients in Intensive Care Unit of Dhaka Medical CollegeHospital, Bangladesh were observed prospectively from January 2012 to July 2013. Glucose variabilitywas assessed within first twenty four hours of recruitment of septic patients. By considering a targetblood glucose level (5 - 8 m mol/L), the assigned patients were separated into three groups (accordingto blood glucose variability). Group I (mild variable group) included those patients having less than twoblood glucose values not within the target blood glucose level. Group II (moderate variable group)included those patients having more than two to four blood glucose values not within the target range.Group III (more variable group) included those patients having more than four blood glucose values outof range of target glucose level. Chi- square test along with a p-value (< 0.05) was done to assess whichgroup of blood glucose variability best reflects the association of mortality. Logistic regression was usedto determine the odds ratio of ICU death in relation to blood glucose variability.

Results: Out of all the septic patients, the more blood glucose variability group (37.5%) more reflectedthe blood glucose variability than the others. Using the Chi-square, it was found that a highlysignificant difference (x2-14.56, p-value 0.001) was existed between three blood glucose variabilitygroups with respect to mortality. Logistic regression analysis demonstrated that more glucosevariability group had predicted higher mortality rate with a p- value of 0.007 and an odds ratio of 16.0.Result is significant. On the other hand, significant effect of moderate glucose variability group onmortality was not found with a p-value of 0.665 and an odds ratio of 0.667.

Conclusions: The septic patients having more blood glucose variability had predicted higher mortalityrate than that of moderate and less blood glucose variability in Intensive Care Unit. This observationindicates that blood glucose variability should be included as a future approach to glucose managementof septic patients as a target for therapeutic intervention.

JBSA 2022; 35 (2) : 43-50

Maternal and Foetal Outcome in Routine versus Selective Use of Episiotomy

Farida Khan — 2022-07-31

Introduction: An episiotomy is a surgical incision of the perineum made to increase the diameter ofthe vulval outlet during child birth.

Aim of the study: To evaluate the maternal and foetal outcome in routine versus selective use ofepisiotomy.

Material & Methods: This prospective interventional study was conducted at the Department ofObstetrics and Gynaecology, Sir Salimullah Medical College and Mitford Hospital during January 08to June 08. A total of 160 patients were included for the study. The patient of group I were givenepisiotomy with all aseptic precaution after infiltration of 10 ml of 1% solution of lignocaine. For groupII patients episiotomy was restricted and w. only given for specific indications. Statistical analysis wereperformed using computer- based software, statistical package for social science (SPSS).

Results: In the study, 65(40.6%) cases received episiotomy, 86(53.8%) not received episiotomy and only9(5.6%) needed episiotomy. Maximum number was found in the age group of 20-25 years in both groups.Most of the study patients were primi. Regarding the duration of second stage of labour of maximumnumber belongs to 30 - 90 minutes in all groups. In group I there was 2° tear in 61(93.8%), 3rd degreetear 4(6.2%) and none had 1° perineal tear, whereas in group II it was observed that 45(52.3%) had notear. In group I, 24(36.9%) patients complained difficulty in defecation and 30(46.2%) felt difficulty insitting. But in patients needing episiotomy in group II 4(44.4%). There was no still birth found in anygroup. The mean± (SD) head circumference of the baby was 36.4±6.05 cm and 34.7±1.26 cm in group Iand group II respectively.

Conclusion: In a poor country like ours, where pregnancy rate is very high, reducing episiotomy ratecan eliminate morbidity associated with episiotomy and can ensure early resumption of women to theirnormal life.

JBSA 2022; 35 (2) : 51-57

Anaesthetic Management of a Morbidly Obese Parturient Undergoing Cesarean Section

Abdullah Al Maruf — 2022-07-31

An increasing number of women with a morbid obesity are requiring anaesthetic care for labour anddelivery. Management of these patients presents obstetric, anesthetic, and logistical challenges. Wereport our experience in the management of elective Caesarian section of a morbidly obese (BMI 61.6kg/m2) parturient under epidural anaesthetictechnique. Despite the increased risk of morbidity andmortality, our patient had an optimal outcome. An awareness of the hemodynamic and respiratorystability during anaesthetic management, postoperative analgesia and careful thromboprophylaxiswillbenefit parturient with morbid obesity.

JBSA 2022; 35 (2) : 58-62