Indian Journal of Anaesthesia

: 2020  |  Volume : 64  |  Issue : 13  |  Page : 8--14

KOPS Award Abstracts: Neuroanaesthesia


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 Abstract ID: ISAP068: A prospective randomized controlled study to analyse the efficacy of scalp block in providing analgesia for supratentorial craniotomies using surgical pleth index, response entropy and haemodynamics.

Manchala Ravi Kumar, Manohar Nitin

Yashoda hospitals, Secunderabad, Telangana, India

Background and Aims: Supplementing general anesthesia with scalp block has markedly improved intraoperative haemodynamics and analgesia during supratentorial craniotomies. We compared the effects of Scalp block (Study group) and No scalp block (control group) on intraoperative haemodynamics and correlated surgical plethysmographic index with other variables like Response entropy, state entropy and mean arterial pressure to assess depth of analgesia. The aim of the study was to compare the effect of Scalp block and non Scalp block in providing analgesia for supratentorial craniotomies using Surgical pleth index, Response entropy as depth of analgesia monitors. Primary objective was to compare intra-operative haemodynamics between scalp block group and non scalp block group. Secondary objective was to compare the quality of analgesia between the two groups using surgicalplethindex, Response entropy and difference between RE and SE as depth of analgesia monitors at different points of maximum nociception like intubation, pin, incision, craniotomy and durotomy during supratentorial craniotomies and to compare opioid consumption between two groups.

Methods: 30 ASA grade 1 and 2 patients, satisfying the inclusion criteria, undergoing supratentorial craniotomies were double blinded, prospectively studied and divided into 2 groups. Study group received 0.2% Ropivacaine 20ml for scalp block and Control group received 20ml normal saline for scalp block and both the groups received IV fentanyl infusion at 1microgram/kg/hr. Intraoperatively whenever there was >20% raise in haemodynamic parameters above baseline IV Fentanyl (1microgram/kg) was given as rescue analgesia. Quality of analgesia was assessed by using Surgical plethysmographic index(SPI), Response entropy(RE) and State entropy(SE) at different time points (Induction, Postinduction, Intubation, Postintubation, Pin, PostPin, Incision, Postincision, Craniotomy, Postcraniotomy, Durotomy, postdurotomy).

Results: We found stable intraoperative haemdynamics, decreased number of patients requiring intraoperative fentanyl and decreased fentanyl consumption in study group (0.06± 0.04) compared to Control group (1.73± 0.52). We found that surgical plethysmographic index, response entropy, state entropy and mean arterial pressure positively correlated intraoperatively as depth of analgesia monitors.

{Table 1}

Conclusion: We conclude that scalp block along with general anesthesia can offer better intraoperative haemodynamic stability and decreased intraoperative fentanyl requirement. Surgical plethysmographic index, Response entropy and State entropy correlated well as depth of analgesia monitors.

Key words: Surgical pleth index, Response entropy, State entropy.


Lakshman K,GanneS,Umamaheshwarrao et al. Analgesia nociception monitoring during supratentorial craniotomy. J Neurosurg Anesthesiol 2017;00:00.Osborn I, Sebeo J. Scalp block during craniotomy: a classic technique revisited. J Neurosurganaesthesiology. 2010; 22:187-94

 Abstract ID: ISAP222: Comparison between ketofol 1:1 (Ketamine and propofol) and etomidate in electro convulsive therapy: A double blinded randomized controlled trial.

Thapi Srija, Chhaya Joshi , Hulakund S Y, Narayan Mutalik

S. Nijalingappa medical college and Hanagal Shri Kumareshwar Hospital and Research centre, Bagalkot

Background and aims: In this study we compared ketofol with etomidate as induction agent in ECT, with respect to the seizure duration as there is paucity in the literature available till date comparing these drugs. Aim was to study the drug which causes increase in SD.

Methods: We performed this study in a prospective, randomized, double blind manner after obtaining institutional ethical clearance & informed consent from patient. The sample size calculated was 60 in each group with 95% confidence level and 80% power of the study. Group A: ketofol 1:1. Group B: Etomidate. Glycopyrrolate 0.2mg iv was given as premedicant. One group was given etomidate 0.2mg/kg, other group was given ketofol 1:1 (ketamine 0.5mg/kg + propofol 0.5mg/kg) as an induction agent, muscle relaxant succinylcholine 0.5 mg/kg was given. Ventilation was accomplished with 100% oxygen via bag and mask. Adequate size bite block was inserted and ECT was delivered. seizure duration, seizure threshold and hemodynamic parameters were assessed in both the groups.

Result: There is a significant difference in seizure duration between two groups with group A having less mean time (38 ± 14.9) compared to group B (45.3 ± 17.5), with P-value of 0.014. Seizure threshold, hemodynamic parameter differences were not statistically significant in this study.


Conclusion: In our study we found that etomidate is better than ketofol with respect to seizure duration, which ultimately helps in better clinical outcome of the patient.


Tan HL, Lee CY. Comparison between the effects of propofol and etomidate on motor and electroencephalogram seizure duration during electroconvulsive therapy. Anaesth Intensive Care. 2009;37(5):807–14.Zavorotnyy M, Kluge I, Ahrens K, Wohltmann T, Köhnlein B, Dietsche P, et al. S-ketamine compared to etomidate during electroconvulsive therapy in major depression. Eur Arch Psychiatry Clin Neurosci. 2017;1–11.

 Abstract ID: ISAP317: Efficacy and safety of etomidate with or without fentanyl on hemodynamics and seizure duration during modified electroconvulsive therapy

Kavita Verma, Sanjeev Palta, Richa Saroa

Government medical college and hospital,Chandigarh

Background and aims: Opioids have been added to induction agents in Modified Electroconvulsive Therapy (MECT) in order to achieve maximum hemodynamic stability, prolong seizure duration and minimize side-effects. However, efficacy and safety of Etomidate with or without fentanyl on hemodynamics and seizure duration during MECT has not been studied so far.

Methods: 32 patients belonging to American society of anesthesiology (ASA) 1 and II, scheduled for MECT were enrolled in this prospective double blinded randomized crossover trial. For initial MECT, Patients were randomized to receive either fentanyl (1.5mcg/kg) with etomidate (0.2mg/kg) or etomidate (0.2mg/kg) alone as induction agent, on subsequent MECT crossover of drugs was done. The effect of etomidate and fenatnyl on heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, oxygen saturation, motor seizure and EEG seizure was compared with etomidate alone during MECT.

Results: No group difference was observed in Mean Motor seizure duration. Although Mean EEG seizure duration was found to be longer in patients receiving etomidate and fentanyl anesthesia (66.06 +- 33.573 s) s) as compared with etomidate anesthesia (57.72 _ 26.55 s) but was statistically insignificant ( p value = 0.274). HR, SBP, DBP, MBP and spO2 were similar in both the groups.

Conclusions: Addition of fentanyl to etomidate during modified electroconvulsive therapy do not alter seizure duration and had no effect on any of the hemodynamic parameters analysed.

 Abstract ID: ISAP380: The intubation in cervical spine surgery patient through ilma: a comparison between intubation under fiberoptic guidance & without fiberoptic guidance

Neelam Chandna, Harsha Patel, Neeta Kavishvar

Government medical college, Surat

Background & aims: Endotracheal intubation is gold standard to ensure airway safety in patient undergoing GA. ET tube intubation requires neck flexion & A-O joint extension with conventional laryngoscopy, but in cervical spine injury patient difficulty of inability to flex neck makes intubation difficult. So to overcome this problem ILMA is used to intubate patients with neck in neutral position. Aim was to compare success rate for intubation, ILMA insertion time, ETT insertion time, total induction time, hemodynamic response & incidence & severity of sore throat after 2hrs postoperatively.

Methods: Prospective comparative study performed on 40 patients posted for cervical spine surgery, 2 groups of 20 each. After induction with inj propofol and muscle relaxant & confirming correct position of ILMA. Intubation through ILMA-

FOB group: - under fiberoptic guidance; Blind group: - without fibreoptic guidance. Success rate, time to intubation and complications if any were noted.

Results: Overall intubation success rate high in FOB group. Total induction time & ILMA insertion time similar in 1st attempt in both groups, while both time longer in FOB group in 2nd attempt. ET tube insertion took longer time in FOB group in 1st & 2nd attempt. Hemodynamic parameters increased in both groups during intubation & returned toward baseline after intubation. Sore throat incidence similar in both groups


Conclusion: ILMA is a useful device for intubation in patients with difficult airway (cervical spine injury). Its success rate can be increased with the aid of fiberoptic bronchoscope.


Ryu Komatsu,Osamu Nagata, Kotoe Kamata, Katsuyuki Yamagata, Daniel I. Sessler and Makoto Ozaki ; The Intubating Laryngeal Mask Airway Allows Tracheal Intubation When the Cervical Spine Is Immobilized by a Rigid Collar, Br J Anaesth. 2004 November ; 93(5): 655–659.S Saini, R Bala & R Singh (2017) Evaluation of the Intubating Laryngeal Mask Airway (ILMA) as an intubation conduit in patients with a cervical collar simulating fixed cervical spine, Southern African Journal of Anaesthesia and Analgesia, 23:2, 40-44, DOI: 10.1080/22201181.2017.1295630

 Abstract ID: ISAP419: To evaluation of variations in blood sugar and inflammatory markers following dexamethasone in neurosurgical patients: An observational study

Seema, Renu Bala, Jyoti Sharma

Pandit Bhagwat Dayal Sharma Post graduate Institute of Medical Sciences, Rohtak

Background & aims: Improvement in neurological status following dexamethasone administration is dramatic, however it has potential to cause hyperglycemia and anti inflammatory effects. The present study was planned to evaluate the variations in blood glucose levels and anti inflammatory mediators in response to single dose of dexamethasone in neurosurgical patients.

Methods: The present prospective, non-randomized study was conducted in sixty four adult patients of either sex,scheduled to undergo craniotomy under GA. Induction was done under standard protocol. 8mg dexamethasone was administered after consultation of operating surgeon by consultant anesthesiologist accrording to need. Three groups were made:

DD - Patients already on dexamethasone and recieving intraoperatively,

ND - Not on dexamethasone but recieving intraoperatively,

NN - Neither on dexamethasone nor recieving intraoperatively.

Venous sample was taken for blood sugar estimation at 1hr, 2hr, 3hr,4hr after administrating dexamethasone, then every 4 hrs till 24 hrs. WBC count with neurophil percentage, haematocrit, serum lactate and CRP were measured at baseline, 12 hours and 24 hours.

Results: All groups showed rise in blood glucose with peak at 4hours and returning to baseline values at 24 hours. On comparing groups DD and NN, there was significant difference of blood glucose values at all times. On comparing group ND and NN, blood glucose levels were higher in group ND at all times, although statistically significant difference was found at 4 hours only. Significant difference in anti-inflammatory mediators was seen in group DD.

Conclusion: Single dose of dexamethasone administered intraoperatively induces increase in blood sugar levels and changes in anti- inflammatory mediators.

 Abstract ID: ISAP548: Evaluation of cardiac functions in patients undergoing craniotomy after administration of different dose of mannitol used for brain relaxation

Deepti Sharma, Pawan Kumar Ray, Deepak Malviya

Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow

Background & aims: Anaesthesia for supratentorial tumour requires an understanding of the pathophysiology of raised intracranial pressure (ICP), regulation and maintenance of cerebral perfusion; the effect of anaesthesia on intracranial pressure, perfusion and metabolism and the therapeutic options to decrease ICP, brain bulk perioperatively. On the basis of current scenario, the study was designed for comparing the two dose of 20% mannitol on brain relaxation along with their effect on cardiac functions. Effect of various doses of mannitol on brain relaxation and various cardiac functions.

Methods: 60 patients undergoing supratentorial tumor resection were randomly allocated by using computer generated table to 2 groups. Group A received 20% mannitol of dose 0.7g/kg over 20 minutes and Group B received dose 1.4g/kg over 20 minutes. FloTrac transducer and pressure transducer was connected to Vigileo TM system. Brain relaxation was assessed by attending neurosurgeons by using Brain Relaxation Score. Heart rate(HR), mean arterial pressure (MAP), central venous pressure (CVP), stroke volume (SV), cardiac output (CO) and cardiac index (CI) were recorded at baseline and at different time intervals after mannitol infusion.

Results: Brain relaxation was better in group B than group A and there was no significant difference in heart rate or MAP while there was significant difference in CVP, stroke volume, cardiac output and cardiac index at some intervals in group B.

Conclusion: Higher dose of mannitol provide better brain relaxation intraoperatively despite of more alteration in hemodynamics and cardiac functions in relation to time and dosing in patients undergoing supratentorial craniotomy.

 Abstract ID: ISAP565: Post-operative analgesic effect of bupivacaine alone and in combination with dexmedetomidine in wound instillation technique for lumbar laminectomy: A randomised controlled trial

Sanket Agrawal, Urvashi Yadav, Swati Srivastava

UPUMS,Saifai,Etawah UP,India

Background and aims: Studying the effects of addition of Dexmedetomidine as an adjuvant to bupivacaine in wound instillation for post operative analgesia. Aim was comparing postoperative analgesic effect of bupivacaine alone and in addition of dexmedetomidine to bupivacaine in wound instillation for lumbar laminectomy.

Methods: Prospective, randomised, double blind study conducted on Sixty adults of ASA I-II scheduled for elective lumbar laminectomy under GA were randomly allocated into two groups. Group B (control group) patients received wound instillation with 20ml of 0.25% bupivacaine at the end of surgery and Group D patients received 2μgm/kg dexmedetomidine diluted in 20 ml 0.25% bupivacaine as instillation over incision site. If the NRS exceeded '4' at any point of time, rescue analgesia with inj. Diclofenac 75 mg deep intramuscular was administered. Post- operative pain score, duration of analgesia, total rescue analgesic required in 24 h, incidence of side effects such as bradycardia, hypotension, sedation, nausea and vomiting were compared between the groups.

Results: Demographic character and duration of surgery were comparable.Time to first analgesic required or duration of analgesia was more in group D{19.93±3.2 hr} than group B{12.13±1.8 hr}(p=<0.0001).Total consumption of analgesia were less in study group D{62.51±39.13mg} than group B{95.68±33.5mg}(p=0.0129).Total number of analgesic demands(0/1/2 times) were less in group D{6/22/0} than group B{0/20/10}(p=0.0098). Group D had lower pain score, longer duration of analgesia,lower demands of rescue analgesic and lower rescue doses required in first 24 h.

{Table 2}

Conclusion: Dexmedetomidine 2μg/kg is an effective adjuvant to bupivacaine for wound instillation in terms of quality and duration of postoperative analgesia following lumbar laminectomy.


Oza VP, Parmar V, Badheka J, Nanavati DS, Taur P, Rajyaguru AM. Comparative study of postoperative analgesic effect of intraperitoneal instillation of dexmedetomidine with bupivacaine and bupivacaine alone after laparoscopic surgery. J Min Access Surg 2016;12:260-4.Deshwal R, Kumar N, Sharma JP, Kumar R. Efficacy of Dexmedetomidine Added to Ropivacaine Infiltration on Postoperative Pain following Spine Surgeries: A Randomized Controlled study. Anesth Essays Res. 2018;12(3):700-704.

 Abstract ID: ISAP848: Effect of intravenous magnesium sulphate on patients undergoing craniotomy for meningioma excision: A randomised controlled study

Premkumar D, Yashwant Dhawale, Aditya Agarwal

Gandhi Medical College & Hamidia Hospital,Bhopal

Background & aims: Meningioma is one of the most common tumor of the central nervous system. Meningioma surgeries are associated with a high incidence of intraoperative bleeding and seizures. Various modalities such as hypotensive agents and antiepileptic drugs have been used in the management of meningioma surgery. Magnesium sulphate is an NMDA receptor antagonist with analgesic, hypotensive and anti-seizure effects, hence this study aimed to determine the effect of magnesium sulphate on patients undergoing craniotomy for meningioma excision.

Methods: After obtaining institutional ethical committee clearance and valid informed consent, 60 patients of age 18 to 60 years, undergoing elective craniotomy for meningioma excision under GA and satisfying inclusion criteria were randomly divided into two groups of 30 each.

GROUP M – 30 patients received 30 mg/kg of magnesium sulphate diluted up to 20 ml with 0.9% NS over 15 mins preinduction, followed by infusion of 10 mg/kg/hr. till dura closure.

GROUP C- 30 patients received 20 ml of 0.9% NS preinduction, followed by infusion till dura closure.

The vitals (HR, BP, MAP, SPO2) of the patient were recorded prior to induction, pre intubation, post intubation at 5th, 10th, 15th minute and then at 30 minutes interval later till the end of the surgery and also in the postoperative period at 3rd, 6th, 12th and 24th hour. The total requirement of inhalational agents, opioid and neuromuscular blockers and incidence of early postoperative seizures were recorded. Adverse effects if any were recorded.

Results: Demographic characters, baseline vitals & duration of surgery were comparable. Intraoperative HR, MAP, Inhalational agent,opioid & Neuromuscular blocker requirement were significantly lesser in group M(p<0.005)


Conclusion: Magnesium sulphate is a good anaesthetic adjuvant in patients undergoing craniotomy for meningioma providing an hypotensive anaesthesia, with decreased requirement of inhalational agents ,opioids(Intra-operative)and neuromuscular blockers, however there was no significant decrease in incidence of early postop seizures.


Essam M. Manaa1, and Amro F. Alhabib.Effect of Magnesium Sulfate on the Total Anesthetic and Analgesic Requirements in Neurosurgery. Journal of neurology and neurophysiology 2012, s11,DOI: 10.4172/2155-9562.S11-001Lysakowski C, Dumont L, Czarnetzki C, Tramèr MR: Magnesium as an adjuvant to postoperative analgesia: Asystematic review of randomized trials. Anesth Analg 2007;104:1532–9

 Abstract ID: ISAP771: Evaluation of optic nerve sheath diameter as a guide for raised intracranial pressure in patients undergoing robot assisted surgeries in steep trendelenburg position

Shashikant Reddy, Anita Pramod, G Parameswara, Chandan N

Manipal Hospitals, Bangalore

Background and aim: Steep Trendelenburg (ST) position offers surgical technical advantage for robotic pelvic surgeries which however may result in raised intracranial pressures. We aimed to study increase in optic nerve sheath diameter (ONSD) as a surrogate for raised ICP in robotic surgeriesperformed in ST position.

Methods: After ethical clearance and informed consent, a prospective nonrandomized, observational study was done on 30 patients aged 20-60 years of ASA1 and 2 category, undergoing robotic pelvic surgeries. Ultrasound ONSD measurements were doneafter induction (baseline), after pneumoperitonium, 3minutes after ST position and at the endafter desufflation of pneumoperitoneum. Hemodynamics, airway pressures, EtCO2and duration of ST position were recorded. SPSS 22.0 was used for statistical analysis.

Results: Mean age of patients was 54±8years. There was a significant increase in ONSD at desufflation of pneumoperitoneum compared to baseline (0.47±0.07 vs 0.53±0.07). Patients were in ST for 218±47 minutes during surgery.We found no significant correlation between duration in STposition and rise in ONSD.


Conclusion: ONSD increased significantly in prolonged ST position during robot assisted pelvic surgeries and was not affected by the duration of ST position.


Major R, Girling S, Boyle A: Ultrasound measurement of optic nerve sheath diameter in patients with a clinical suspicion of raised intracranial pressure. Emerg Med J. 2011;28(8):679–81.Kim MS, Bai SJ, Lee JR, Choi YD, Kim YJ, Choi SH.Increase in intracranial pressure during carbon dioxide pneumoperitoneum with steep Trendelenburg positioning proven byultrasonographic measurement of optic nerve sheath diameter.J Endourol. 2014 Jul;28(7):801-6.

 Abstract ID: ISAP312: The effects of levobupivacaine scalp block versus dexmedetomidine infusion on hemodynamic response to skull pin insertion in patients undergoing elective craniotomy: A randomized blinded clinical comparative study

Neelam Thakuria, Chandita Konwar

Gauhati Medical College and Hospital, Guwahati, Assam

Background & aims: The application of skull pin holder elicits an adverse hemodynamic response that can have deleterious effects, which can be attenuated by various drugs. This study was aimed at comparing the effects of levobupivacaine scalp block versus intravenous dexmedetomidine infusion on hemodynamic response to skull pin insertion in patients undergoing elective craniotomy.

Methods: This randomized, prospective, double blind, single hospital study was carried out after Institutional Ethics Committee Clearance. Seventy nine patients aged 18 to 65 years belonging to ASA classes I and II undergoing elective craniotomy surgeries were randomly allocated into 2 groups - Group A (n=39): 20mL of 0.5% levobupivacaine scalp block and Group B (n=40): infusion dexmedetomidine 1mcg/kg over 10 mins followed by 1mcg/kg/hr for 30 minutes after scalp pin insertion. Intraoperative hemodynamics such as Heart rate (HR), Systolic blood pressure (SBP), Diastolic Blood pressure (DBP), Mean arterial pressure (MAP) were recorded at specific intervals.

Results: The demographic and baseline hemodynamic parameters were comparable. After pinning, the HR, SBP, DBP and MAP were all increased in both the groups which was non significant (p>0.05). At later time intervals the parameters decreased and it was found to be lower in scalp block group. Significant differences in HR and SBP at 10 minutes and 15 minutes (p<0.05) were seen, while for DBP and MAP it was seen at 10 mins after scalp pin insertion.

Conclusion: We conclude that though both scalp block with 0.5% levobupivacaine and dexmedetomidine infusion is effective in attenuating hemodynamic response to scalp pin insertion, scalp block provided superior results.


Arshad A ,Shamim MS ,Waqas M, Enam SA. How effective is the local anesthetic infiltration of pin sites prior to application of head clamps:A prospective observational cohort study of hemodynamic response in patients undergoing elective craniotomy. Surg Neurol Int 2013;4:93.Pinosky ML,Fishman RL,Reeves ST, The effect of bupivacaine skull block on the hemodynamic response to craniotomy.Anesth Analg 1996; 83: 1256-1261

{Figure 1}