Jubilee Anaesthesia

Role of subarachnoid adjuvants for caeserian/ laprotomies:

The problem of spinal with any laprotomies including caeserians, hystrectomies, or bowel surgeries is:-
the LA alone cannot block the visceral pain and discomfort thereof. The visceral pain is transmitted through
(1) the splanchnic nerves (sympathetic) and also through
(2) the cranial nerve Vagus (parasymathetic) .
The splancnichs may be blocked with a high spinal extending up to T6, but does not occur with the small volume LA like 2 ml of Bupivacaine administered for a Caesarian. So the patient will have disturbing visceral pain, especially if the obstretician exteriorize the uterus. The levels start receding over time.

Vagus being a cranial origin,can't be blocked with a Subarachnoid block..

Adjuvants -- opioids, Alpha 2 agonists(Clonidine, Dexmedetomidine) or Ketamine administered subarachnoid can extend the visceral analgesia; with its neuraxial as well as systemic effects. The effects after these adjuvants are not segmental, but global.
Though visceral pain is not an issue with the lower limb surgeries, these adjuvants are useful here also, by reducing LA dose and thus minimising the haemodynamic impact.

These adjuvants also extend post op analgesia to varying periods.

Intravenous administration of these drugs also will provide the necessary visceral analgesia, though at a higher dose and frequency.

“Jubilee Anesthesia Insight -2024”
Ultrasound Guided Regional Anaesthesia Programs.

Sunday, 30 June 2024; 8 AM to 5PM

Venue: Jubilee Mission Medical College, Thrissur, Kerala

This event is convened by
“Jubilee Anesthesia Insight", Academic initiative of the Department of Anaesthesia, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India;
in association with ISA Thrissur City Branch.

Two workshops are conducted simultaneously in two different halls.
A delegate can attend only one.

1 JAI Basic Course USG Regional Anaesthesia.

Target Audience:
This Basic Certificate course is for those Anaesthesiologists and trainees who wants to be initiated to the Ultrasound Guided Regional Anaesthesia, from the basic principles to scanning and needling.
What to expect:
The common upper limb, lower limb and truncal blocks are presented and demonstrated. Hands on experience to scanning is provided for all candidates in this group.
Registrations: Limited to 40. Fee Rs 2200/-
The tickets for the regular program is fully booked. A few more seats are created on Limited hands-on basis on popular requestsat a fee of Rs. 2100

Click the URL for Details and Registration
https://www.townscript.com/e/jai-basic-certificate-course-in-ultrasound-guided-regional-anaesthesia-332203

2 JAI Recent Advances in USG RA
Target Audience:- Those who are already introduced into Ultrasound Guided Regional Anaesthesia.
Recent Advances in the field of Ultrasound Guided Regional Anaesthesia in the knowledge and skill domain is discussed by the experts in the field in their master classes and demonstrations on the volunteers.
Discussions and demonstrations on:-
Analgesia for TKR. New Insights into Adductor Canal block, IPACK and LIA.
Truncal approach to brachial plexus block, the game changer.
PENG block- uses and limitations.
Erector Spinae Plane Blocks and Thoracic paravertebral blocks.
Sciatic block in a supine patient at various levels
POCUS -Heart & Lung,
USG Caudal epidurals for safety and efficiency.
Use of Ultrasound in Pain Medicine, Coeliac and Hypogastric Plexus Blocks.

Registrations: Limited to 50 Fee: Rs.2200/-

Click the URL for Details and Registration
https://www.townscript.com/e/jai-recent-advances-in-ultrasound-guided-regional-anaesthesia-243443

Photographs from the 2023 JAI USG RA Basic and Recent Advances Program held on 21 May.
The enthusiasm the delegates was huge and was the greatest reward to the organizers.
Thank you all

The annual USG Regional Anaesthesia programs by “Jubilee Anaesthesia Insight” (JAI) were on the hold for three years due to the Covid 19 pandemic.
We are happy to announce these much awaited programs now..
Date- Sunday 21 May 2023.
Venue: Mother Theresa Hall, Jubilee Mission Medical College, Thrissur, Kerala.
There are two USG RA Programs:
(1) Basic Certificate Course in USG RA.
Target audience: Beginners in USG RA.
For details and registration, click the link below-
https://www.townscript.com/e/jai-basic-certificate-course-in-ultrasound-guided-regional-anaesthesia-402130

(2) Recent Advances in USG RA.
Target audience: Those who are already initiated to USG RA and want to refine and upgrade the skills.
Click the link for details-
https://www.townscript.com/e/jai-recent-advances-in-ultrasound-guided-regional-anaesthesia-431442

Dr. Christina Jose from Aster Medicity Kochi recieving certificate after successful completion of Fellowship in Ultrasound Guided Regional Anaesthesia.
Wish Christina all the best.

Dr Ligiya Febin from Little Flower hospital Angamaly recieving recieving Certificate after successful completion of a Fellowship program in Ultrasound Guided Regional Anaesthesia.
She is the third candidate to undergo this training program after the Covid lockdown.

Low Dose Ketamine (LDK)
Today we had an elderly psychiatric patient (agitated depression) with many other systems affected by mild to moderate levels.. diabetes, chronic bronchitis, hypertension, cardiac dysfunction.
He was for a bilateral inguinal hernia repair.

Wanted to give a small volume spinal, so that the systems are least affected.
On the table patient became delirious and unrudy and will not lie for a spinal, and was fighting.

Ketamine 20 mg IV rapidly çontrolled the delirium and was followed by 8 mgs of Dexmedetomidine. A combination called Dexaket or Ketadex!

Spinal could be done safely.

Ketamine is currently recommended for quick control of delirium even in psychiatric, ischaemic heart, CKD, or neuro patients.
A Low Dose Ketamine (LDK) to the tune of 0.2- 0.4 mg / kg is enough. This dose is also known as a Sub-Discociative Dose of Ketamine (SDDK).
LDK is also useful for rapid control of any severe pain.. post operative, or after trauma in an emergency unit.
It rapidly control pain without causing airway compromise or respiratory depression unlike narcotics.
It's anti hyperalgesic effect is useful in the post op pain control.
Works for more than 30 minutes, when if necessary, a top up dose may be given or other drugs may be utilised for pain control.
It's high time we change the concept of Ketamine being contraindicated in "Psychiatric illness", hypertension, IHD and head injury.
Ketamin also has shown rapid antidepressant effects even in Treatment Resistant Depression (TRD) and used as a rescue from suicidal tendencies.
The patient was sedated throughout nthe surgery, and calm in the post op.

Post operative analgesia: how to prevent hyperalgesia.

Most of the anaesthetics we currently use for anaesthesia are ultra short acting... Eg. Sevoflurane, Fentanyl. When we stop these agents at the end of the surgery, there is a rapid withdrawal of analgesic effect, leading to hyperalgesia.. they feel more pain than would have been otherwise!
Paracetamol and NSAIDs can dampen the somatic pain component to various levels in different patients, and can definitely reduce the narcotic requirements. But it do not adequately contain visceral pain. As we all know paracetamol is not useful for angina pectoris!? We need a longer acting narcotic analgesic as a weaning agent for this purpose. Morphine, Tramadol, butrophanol or nalbifine may be good enough for this purpose and should be good enough and should be administered before a problem pain starts.
I prefer to use Buprenorphine in small doses, 0.5- 2 mcg/ Kg (30-120mcg) on smaller alequots according to the physical condition and response. Buprenorphine is a potent partial agonist, which has a consistent and prolonged analgesic effect in all patients. Tramadol and nalbufine do not have this; analgesia is inadequate in many patients even with heavy doses. Morphine, a pure agonist, produces good analgesia in all, but there is an unacceptable delay in the onset. Histamine release and hypotension is another drawback.
Using potent narcotic analgesics in lower doses is better than using a weak analgesic in higher doses.. side effects are definitely lower, and good and predictable analgesia always.

Intraoperative use of Dexmedetomidine, Magnesium and lignocaine are known to reduce the incidence of hyperalgesia. Now it is established and recommended that the NMDA antagonist Ketamine can reduce the pain sensitisation and incidence of hyperalgesia and chronic post operative pain. Low Dose Ketamine (LDK) in the dose of 0.2 mg/kg (just 10 mg!) is recommended. The same dose is also useful to contain post operative effectively and rapidly.
Regional analgesia is a definite was of preventing hyperalgesia and chronic post operative pain. RA may be in the form of neuraxial through peripheral nerve and plexus blocks to local anaesthetic infiltration. But we should not forget that regional analgesia will wear off at a certain point of time, and we should always have a rescue plan for that..

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