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 COMPARATIVE STUDY OF THE EFFECTS OF INTRAOPERATIVE INFUSION OF LOW DOSE KETAMINE AND MAGNESIUM ON CONTROLLING POST OPERATIVE PAIN AND POST OP OPIOID CONSUMPTION AMONG THE PATIENTS UNDERGOING ORTHOPAEDIC SURGERIES AT DGH TRINCOMALEE SUPERVISOR Dr. Herath R. M. H. M. A. I. Consultant Anaesthetist. DGH Trincomalee INVESTIGATORS Dr. Rimaz S. N. A. Dr. Nusra M. A. F Dr. Amarasooriya S.C. Dr. Cowshika K.TABLE OF CONTENTS1. INTRODUCTION 1.1 Background Pain is defined as “An unpleasant sensory and emotional experience associated with actual orp otential tissue damage”. Postoperative pain is the commonest reason for delayed discharge and unanticipated hospital admission after ambulatory surgery.1 When pain is not treated accordingly it will become persistent, a vicious cycle of increasing disability and distress can occur2.Therefore alleviating the surgical pain from perioperative period will break the vicious cycle. Provision of multimodal analgesia with conventional opioids, non-steroidal an

 Anesthetic considerations for urologic surgeries Chang-Hoon Koo1, Jung-Hee Ryu1,2 Department of Anesthesiology and Pain Medicine, 1Seoul National University Bundang Hospital, Seongnam, 2Seoul National University College of Medicine, Seoul, Korea Review Article Korean J Anesthesiol 2020;73(2):92-102 https://doi.org/10.4097/kja.19437 pISSN 2005–6419 • eISSN 2005–7563 Urologic surgeries are widely performed, and the cases have increased owing to the fact that the elderly population is growing. The narrow and limited surgical space is a challenge in performing most urologic surgeries. Additionally, the elderly population is exposed to the risk of perioperative complications; therefore, a comprehensive understanding and approach are required to provide optimized anesthesia during surgery. We have searched the literature on anesthesia for urologic surgeries and summarized the anesthetic considerations for urologic surgeries. Received: November 11, 2019 Revised: December 12, 2019 Accepted: D

 Background Several techniques for infraclavicular nerve blocks have been described. The coracoid approach was first described by Whiffler in the British Journal of Anaesthesia in 1981. This technique was most commonly used with nerve stimulation. The use of ultrasound offers more flexibility in approaches, giving the provider different choices for needle insertion depended on patients’ anatomy and best ultrasound image. [1, 2] All upper extremity blocks involve the brachial plexus. The brachial plexus arise from the anterior rami of C5-8 and T1 with some contribution from C4 and T2. The rami unite to form superior, middle, and inferior trunks. They occupy the space between the anterior and middle scalene muscles. Each trunk divides into anterior and posterior divisions, which rejoin to form 3 cords: the lateral, posterior, and medial. The medial brachial cutaneous and medial antebrachial cutaneous nerves come off the medial cord. The cords then pass into the axilla and divide into ner

 Infraclavicular plexus block: vertical approach COMPLEXITY: Indications • Anaesthesia and analgesia for upper arm, lower arm, and hand surgery • Analgesia for physiotherapeutic treatment • Treatment of pain syndrome • Sympathicolysis. Specifi c contraindications • Thorax deformity • Foreign bodies in the needle insertion area (e.g. pacemaker) • Clavicular malunion. Side effects and complications • Intravascular injection • Pneumothorax • Horner’s syndrome. See Figures 3.20, 3.21, and 3.22. Single injection technique Patient position: supine. Landmarks: acromion (ventral process) and clavicle. Technique: palpate the ventral process of the acromion. Make a mark 2 cm caudad and 2 cm medial to this point. Direct the needle sagittally, and advance approximately 3 cm (or to the same depth as the middle of the head of the humerus, depending on patient habitus). Correct placement of the needle will elicit fl exion of the fi ngers (median nerve) at a stimulating current of 0.3 mA/0.1 ms. Injec

 Sciatic nerve block: subgluteal to popliteal fossa COMPLEXITY: The sciatic nerve is a large structure and may be blocked at different levels to provide regional anaesthesia and analgesia for a wide range of indications. Consideration must be given to both the indication for the nerve block and the location where the sciatic nerve is best visualized with ultrasound to determine the best location to perform a block. Refer to Scanning tips for the lower extremities for a more detailed description of scanning the sciatic nerve. Indications • Hip surgery (proximal) • Surgery of the sciatic distribution • Leg surgery, when combined with a lumbar plexus block • Analgesia (proximal for above the knee; distal for below the knee) • Sympathicolysis (achillodynia, diabetic gangrene, circulatory or wound-healing disorders, complex regional pain syndrome) • Foot or ankle surgery. See Figures 4.42 to 4.52. Ultrasound-guided technique Patient position: the patient may be positioned semi-prone, with t

  Background The popliteal fossa has the semitendinosus and semimembranosus medially and the biceps femoris laterally. The sciatic nerve divides into the tibial and common peroneal nerve about 5–12 cm proximal to the popliteal crease. The sciatic nerve has a common epineural sheath that envelops the nerve trunks of the tibial and common peroneal nerve from their origin in the pelvis. The sciatic nerve is formed by the union of the first 3 sacral spinal nerves and the fourth and fifth lumbar nerves (see the image below). It is the largest nerve supplying the leg. It leaves the pelvis through the greater sciatic foramen and runs toward the posterior aspect of the thigh between the greater trochanter and the ischial tuberosity. It separates into its terminal branches about 6 cm proximal to the popliteal crease into the tibial nerve and the common peroneal nerve.  The tibial nerve supplies the heel and the sole of the foot. The common peroneal, also known as the common fibular nerve, inner

Caudal Anaesthesia Positions 1. Lateral position with hips and knees flexed (foetal position) 2. Prone position with the pelvis raised on a pillow and feet turned medially Drugs 15-20 ml (0.5% bupivacaine or 1.5% lignocaine or mixture) will fill the sacral canal of an adult, and provide a perinea! block. Increasing the volume further will push the fluid into the lumbar canal. Add fentanyl 50µg for quick onset, and better quality of block. Add morphine (preservative free) 2mg to provide post operative analgesia for 12-24h. Anatomy • The dural sac ends at S2 in adults and lower in children. • The sacral hiatus is identified with the non dominant hand by moving the finger down along the midline of the sacrum till a give is felt which is usually just above the natal cleft and bordered by the two sacral comua. It forms an equilateral triangle with the posterior superior ilac spines. The sacral hiatus is covered by the sacro-coccygeal membrane. Injection 1. Clean the area with antiseptic. Av

 Epidural Anaesthesia (EDB) The epidural space is a potential space between the ligamentum flavum and the dura mater, occupied by areolar tissue, loose fat and the internal vertebral venous plexus. The ligamentum flavum and the epidural space are both widest (5mm) at L3/4. TECHNIQUE Needle Use 18G Tuohy needles (8, 9 or 11 cm length) as the curved Huber tip decreases the possibility of dural puncture and facilitates passage of the catheter. Note the 1 cm markings on the needle. Injection 1. Raise a wheal with 2% lignocaine ( 27G needle) at the selected point. 2. Infiltrate the expected path of the epidural needle via a moving needle to avoid intravenous injection. Wait 30 seconds for lignocaine to act. 3. Insert the epidural needle through the supra-spinous ligament. 4. Attach a syringe with 7ml of saline. Steady the back of the non-dominant hand against the back of the patient. Hold the hub of the needle firmly, and push the needle inwards steadily and continuously. (a) Needle in:tene

 THE POST-ANESTHESIA CARE UNIT General Management All children should be transported to the post-anesthesia care unit (PACU) in the lateral decubitus position with the head extended to provide an unobstructed airway; all children—other than absolutely healthy children having minor surgery—should receive oxygen or be monitored with SpO 2 during transport to PACU. Evidence suggests that decreases in SpO 2 during transport are most likely due to airway obstruction; be alert to this possibility. However, administering oxygen while monitoring SpO 2 renders the oximeter an insensitive metric of hypopnea; respiration should be monitored by observing chest movements, mist in the facemask, or by feeling exhaled breathing. The anesthesiologist walks at the head of the bed facing forward to continuously observe and monitor the child. If the airway is in doubt, do not leave the OR. If the airway becomes precarious while on route to the PACU, apply digital pressure to the condyle of the mandible be