i

SEGMENTAL EPIDURAL ANAESTHESIA FORINGUINAL HERNIA REPAIR

ByDr. B.DHARMENDER REDDY

A Dissertation Submitted toThe Rajiv Gandhi University of Health Sciences Karnataka, Bangalore

in partial fulfilmentof the requirements for the degree of

DOCTOR OF MEDICINEIn

ANAESTHESIOLOGY

Under the guidance of

Dr. S. GOWRI KUMARI

Professor and HOD, ANAESTHESIOLOGY.

DEPARTMENT OF ANAESTHESIOLOGY,MVJ MEDICAL COLLEGE AND RESEARCH HOSPITAL,

HOSKOTE, BANGALOREAPRIL 2011

ii

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,KARNATAKA, BANGALORE

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “SEGMENTAL EPIDURAL

ANAESTHESIA FOR INGUINAL HERNIA REPAIR” is a bonafide and genuine

research work carried out by me under the guidance of Dr. S. GOWRI KUMARI,

Professor and Head, Department of Anaesthesiology, MVJ Medical College and

Research Hospital, Hoskote, Bangalore.

Dr. B.DHARMENDER REDDY,Date: Postgraduate in Anaesthesiology,Place: Hoskote MVJ Medical College and Research

Hospital.Hoskote, Bangalore.

iii

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “SEGMENTAL EPIDURAL

ANAESTHESIA FOR INGUINAL HERNIA REPAIR” is a bonafide research

work done by Dr. B.DHARMENDER REDDY in partial fulfilment of the

requirement for the degree of Doctor of Medicine in Anaesthesiology.

Date: Dr. S. GOWRI KUMARI.Professor and Head

Place: Hoskote Department of Anaesthsiology,MVJ Medical College andResearch Hospital,Hoskote, Bangalore

iv

ENDORSEMENT BY THE HEAD OF THE DEPARTMENT,

DIRECTOR / DEAN

This is to certify that the dissertation entitled “SEGMENTAL EPIDURAL

ANAESTHESIA FOR INGUINAL HERNIA REPAIR” is a bonafide research

work done by Dr. B.DHARMENDER REDDY, under the guidance of

Dr. S. GOWRI KUMARI, Professor and Head, Department of Anaesthesiology,

MVJ Medical College and Research Hospital, Hoskote, Bangalore.

Dr. S. GOWRI KUMARI. Dr. T. RAJESHWARI.Professor and Head Dean / DirectorDepartment of Anaesthesiology MVJ Medical College andMVJ Medical College and Research Hospital, Research Hospital, HoskoteHoskote, Bangalore. Bangalore.

Date : Date:

Place: Hoskote Place: Hoskote

v

COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka, shall

have the rights to preserve, use and disseminate this dissertation in print or electronic

format for academic/research purpose.

Date: Dr. B.DHARMENDER REDDYPostgraduate in Anaesthesiology,

Place: Hoskote MVJ Medical College andResearch Hospital,Hoskote, Bangalore

@ RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

vi

ACKNOWLEDGEMENT

It is most appropriate that I begin expressing my indebtedness gratitude to my beloved

parents and family members for being supportive in all my endeavours.

It gives me great pleasure in preparing this dissertation and I take this opportunity to

thank everyone who has made this possible.

It gives me greatest pleasure to express my deep sense of gratitude and profound

thanks to my most revered teacher Dr. S. GOWRI KUMARI, Professor and HOD of

the Department of Anaesthesiology, MVJMC&RH, Hoskote, Bangalore, for her

valuable guidance, constant encouragement, constant efforts in fine tuning my

practical skills, timely expert advice with prospective comments and suggestions,

which she always rendered in every step of my work. Without her valuable guidance,

this dissertation would not have come in its present form. My sincere thanks to her for

being my guide.

I am highly indebted and consider myself very fortunate to have

Dr.T.RAJESHWARI, Dean-cum-Director and the pillar of this MVJMC & RH, for

having inculcated in me a sense of determination and courage, for her constant

support and invaluable guidance with her superb talent and professional expertise

throughout this dissertation work. I find no words to express my heartfelt thanks to

her.

vii

It gives me immense pleasure to extent my sincere thanks to Professors

Dr. A.V. PAI, Dr.PRASAD KULKARNI and Associate Professor

Dr. B. NARASIMHA REDDY whose authoritative knowledge of practical skills has

guided and inculcated in me a sense of confidence. I am thankful to them for their

valuable teaching and guidance.

My sincere thanks are due to Assistant Professor Dr.NIRMALA B.C. for her words

of encouragement and constant and timely support in completing my dissertation

work.

My heartful thanks to other consultants Dr.GAYATHRI, Dr. GIRISH.K.N.,

Dr.GIRISH BABU and Dr.SHASHIDHARA Dept. Of Anaesthesiology,

MVJMC&RH, Hoskote, Bangalore, for their valuable guidance and constant

encouragement.

I thank management MVJ MC & RH for being supportive in every stage of study.

I thank all my post graduate colleagues, members of department of surgery and OT

staff for their whole hearted cooperation.

My heartfelt thanks to all patients who have been the backbone of this study without

whom this study would not have been complete.

Date: Dr. B.DHARMENDER REDDY

Place: Hoskote

viii

ABSTRACT

BACKGROUND AND OBJECTIVES: Inguinal hernia repair is one of the most

commonly encountered surgical corrections in men worldwide. Epidural anaesthesia

is widely used for these surgeries. As inguinal hernia is usually seen in elderly age

group, so as to avoid or reduce the complications which could occur in the

conventional dosages this clinical study of segmental epidural anaesthesia was

undertaken where the extent of block is limited to only few segments involved in the

field of surgery.

METHODS: Study was conducted on 100 patients of ASA I and II posted for

elective inguinal hernia repair. Segmental epidural block was performed with

ing.Bupivacaine 0.5% 5-6ml. Patients were observed for onset, duration and quality

of analgesia. Level of analgesia preoperatively and post operatively. Hemodynamic

stability with heart rate, systolic and diastolic blood pressure.

RESULTS: In the present study, the mean onset of analgesia was 8.08 minutes. The

quality of analgesia was excellent in 53 cases, good in 34 cases, fair in 10cases and

poor in 3 cases. The mean duration of analgesia was 167.42 minutes (120 min to 240

min). All patients were haemodynamically stable throughout the surgery. Shivering

was seen in 5 cases and sweating in 9 cases.

INTERPRETATION AND CONCLUSION: Segmental epidural block with 5-6 ml

of 0.5% Bupivacaine is found to be safe and fulfils the surgical requirement. Could be

successfully employed for inguinal hernia repair with limited spread of analgesia

ix

involving only few segments. Fall in blood pressure and other complications were

very minimal. This technique can be safely used in elderly patients.

KEY WORDS: Epidural anaesthesia; Segmental epidural anaesthesia; Hemodynamic

stability; Excellent alangesia.

x

LIST OF ABBREVIATIONS

Sup : Superior.

Inf : Inferior.

CSE : Combined spinal epidural.

SA : Spinal anaesthesia.

EA : Epidural anaesthesia.

PNOV : Post operative nausea and vomiting.

ECG : Electro cardio graph.

MIN : Minutes.

SAB : Subarachnoid block.

xi

TABLE OF CONTENTS

Sl.No Contents PAGE NO

1 Introduction 1

2 Objectives 4

3 Review of Literature 34

4 Methodology 48

5 Results 57

6 Discussion 77

7 Conclusion 85

8 Summary 86

9 Bibliography 90

10 Annexures

i. Proforma

ii. Consent form

iii. Master Chart

iv. Key to Master Chart

96

98

99

103

xii

LIST OF TABLES

S.NO. TITLE PAGE NO.

1 Characteristics of ligamentum flavum at differentvertebral levels 7

2 Size of epidural space at different vertebral levels 12

3 Pressures in epidural space at different vertebral levels 13

4 Age Distribution 57

5 Sex Incidence 59

6 Weight Distribution 60

7 Height Distribution 61

8 Type of Hernia 62

9 Volume of Drug 63

10 Quality of Analgesia 64

11 Duration of Analgesia 66

12 Level of Analgesia Pre-operatively 68

13 Level of Analgesia Post-operatively 69

14 Side Effects 70

15 Success Rate 71

16 Mean heart rate changes 72

17 Mean blood pressure changes 74

18 Summary of results 76

xiii

LIST OF FIGURES

S.NO TITLE PAGE NO.

1 Vertebral column 8

2 Lateral view of Lumbar vertebrae 9

3 Median section of Lumbar vertebrae 9

4 Fourth Lumbar vertebra ventral view 9

5 Cross section of epidural Space 10

6 Loss of resistance technique 14

7 Site of action of epidural drug 18

8 Anatomy of inguinal canal 21

9 Structure of bupivacaine 27

10 Epidural tray 54

11 Position of the patient 54

12 Loss of Resistance 55

13 Catheter insitu 55

14 Dermatomes 56

xiv

LIST OF GRAPHS

S.NO. TITLE PAGE NO.

1 Age Distribution 58

2 Sex Incidence 59

3 Weight Distribution 60

4 Height Distribution 61

5 Type of Hernia 62

6 Volume of Drug 63

7 Quality of Analgesia 64

8 Duration of Analgesia 67

9 Level of Analgesia Pre-operatively 68

10 Level of Analgesia Post-operatively 69

11 Side Effects 70

12 Success Rate 71

13 Mean heart rate changes 73

14 Mean blood pressure changes 75

1

INTRODUCTION

"I esteem it the office of the physicians not only to restore health, but to mitigate

pain". SIR FRANCIS BACON.

"Divine is the task to relieve pain". HIPPOCRATES.

Most common symptoms for which a patient seeks medical advice are pain and

structural deformity and whatever may be the basic cause they demand a relief.

In general, relief of pain is one of the most tangible roles to be played by the medical

practitioner and as such it merits careful attention. Relief of pain is by far the most

frequent indication of surgical intervention.

The surgeon in his mission induces pain, which at times is more severe than the

original complaint.

Medical profession has attempted various methods of pain relief from ancient times.

The development of epidural analgesia and anaesthesia played a small but significant

role in man’s triumph over pain, which undoubtedly is one of the most fascinating

chapters in the history of medicine.

The rationale of epidural analgesia in surgery is simple. The technique is used to

prevent afferent impulses from reaching the central nervous system and to prevent

transmission of inappropriate efferent signals to the target organs such as muscle,

2

blood vessels and viscera. In doing so, epidural blockade fulfils the central aim of

anaesthesia that is, prevention of pain, overall control of patient and his reflexes and

preservation of physical well being.

Epidural analgesia managed to escape the general decline in regional techniques when

it was given a fresh impetus by introduction of Touhy needle and an indwelling

epidural catheter. With these technical refinements it became possible to maintain

analgesia continuously for even weeks if necessary.

Hernia is the word derived from Greek words “Herons” an offshoot or bulge.

It is defined by Sir Astley Cooper (1804) as “protrusion of any viscous or part of the

viscous through an abnormal opening in the walls of its containing cavity.1

Inguinal hernia repair is one of the most commonly encountered surgical corrections

in men representing 12.5% of total surgical repair in Britain. In the international

classification of diseases 9th division clinical manifestation, the number was 9 for

hernias with relative value guide of 6.2 In providing anaesthesia for inguinal

herniorraphy, the technique chosen must be cost effective with respect to speed of

recovery, patient comfort, and associated incremental costs.3

Inguinal hernia repair is one of the common treatments performed. Which can be

performed under spinal, epidural, general and inguinal field block.

3

Epidural anaesthesia is suitable as a sole agent for lower abdominal surgery and on

lower limbs. It has some definite advantages over spinal anaesthesia like avoidance of

post spinal headache, minimal chances of meningitis, and minimal chances of nausea

and vomiting in post operative period.4 But administration of conventional dosage of

local epidural anaesthetics(15ml and above) for surgical anaesthesia frequently results

in multiple hemodynamic changes, including decreases in chronotropism, inotropism,

dromotropism, systemic vascular resistance, cardiac output, and myocardial oxygen

consumption.5 The economic consequences of these hemodynamic changes are far

from being calculated.

As inguinal hernia is usually seen in elderly age group, the above mentioned

complications will be more severe.

For a simple inguinal hernia repair, which is located at the level of the 12th thoracic

and 1st lumbar dermatomes, an upper analgesic level of the 8th to the 10th thoracic

dermatomes is satisfactory.6

The practice of the technique whereby, the block extends only to the segments

involved in the surgical field is said to have the following advantages.

1. Accurate limitation of the area of analgesia.

2. Minimal or no depression of blood pressure.

3. Small doses of local anaesthetics required and toxic doses are avoided.

4. Minimal incidence of complications.

Hence to meet the above requirements the present study of segmental epidural

anaesthesia for inguinal hernia repair is undertaken.

4

OBJECTIVES

This study is undertaken to evaluate the advantages of segmental epidural anaesthesia

for inguinal hernia repair.

1. To reduce the conventional dosage of epidural anaesthesia to block only the

segments involved in the field of surgery.

2. Hemodynamic effects.

3. To minimise the complications, which could occur in conventional dosage.

5

ANATOMY AND PHYSIOLOGY OF EPIDURAL SPACE

Epidural space is the potential space between the spinal duramater and the periosteum

and ligaments lining the vertebralcanal.7

The duramater is made of two layers, the endosteal and the meningeal layer. The two

layers are closely fused within the cranium. Below the foramen magnum, these two

layers are separate.

The outer layer forms the periosteum lining the spinal canal.

The inner layer forms the spinal duramater. Between these two layers is the epidural

or the peridural space.

The epidural space is widest in the midline posteriorly with an average of 5mm

between ligamentum flavum and the posterior surface of the spinal dura. The depth is

slightly more, proximal to the inferior border of the lamina due to the obliquity of the

vertebral lamina.

Boundaries:8

Above: The foramen magnum, where the periosteal and the spinal layers of the

dura fuse together.

Below: The sacrococcygeal membrane.

In front: The posterior longitudinal ligament covering the posterior aspect of

the vertebral bodies and intervertebral discs.

Behind: The anterior surface of the vertebral lamina and ligamentum flavum.

6

Laterally: The pedicles of the vertebrae and the intervertebral foramina.

The epidural space is not a closed space. It communicates with the paravertebral space

through the intervertebral foramina. It is shallowest anteriorly where it fuses at some

places with the posterior longitudinal ligament. It is deepest posteriorly. The depth

varies as it is obliterated by contact between the duramater and the ligamentum

flavum or vertebral lamina. Laterally, the space is interrupted by contact between

duramater and pedicles.

Thus the epidural space is composed of a series of discontinuous compartments that

become continuous when the potential space separating the compartments is opened

up by injection of air or liquid.

According to a study dorsomedian fibrous tissue connects the duramater and the

ligamentum flavum in the lumbar region fairly frequently.9 Due to these

fibrous strands, the injected fluid distends the space laterally rather than in the

midline.

This has been confirmed anatomically through epiduroscopy and epidurography.

These fibrous strands are responsible for occasionally unilateral anaesthesia following

apparently adequate epidural technique.

Ligamentum flavum: The ligamentum flavum is an important landmark for

technical identification of epidural space during the introduction of epidural

analgesia.

7

It is made of tough elastic fiber disposed in a vertical direction connecting the upper

and lower bodies of adjacent lamina. It is thinnest in the cervical region becoming

progressively thicker down the spine and is thickest in the lumbar region.

Table-1 Characteristics of ligamentum flavum at different vertebral levels10

Site (mm) Skin to ligament (cm)Thickness of ligament

(mm)

Cervical1.5

3.0

Thorasic 3.05.0

Lumbar 3.0-8.0 5.0-6.0

Caudal 2.0-6.0 Variable

The epidural space is entered most safely and easily in the mid lumbar region. The

lumbar spine and the interspinous ligaments are widest in the mid-lumbar

region making an easy land mark for insertion of the epidural needle.

8

Fig-1 Vertebral column

9

Fig-2, 3, 4 4th Lumbar vertebra ventral aspect

10

Fig-5 Cross section of epidural space

Contents of epidural space:

1) Fat: It is a ubiquitous material in the space and is highly vascular. The

fat competes with the nervous tissue of the spinal roots, cord and blood vessels

within the spinal cord for the drug. Drugs with high lipid solubility and lipoprotein

binding characteristics tend to enter the fat phase and remain there for a period of

time, depending on their pharmacodynamics and briskness of local blood flow

competing for uptake. .

11

2) Spinal arteries: The arteries that traverse the space arise from the

vertebral, ascending cervical, deep cervical, intercostals, lumbar and ileo-lumbar

arteries. They anastamose with those above and below and across the midline and

lie mainly in the lateral parts of the epidural space

3) Epidural veins: The venous plexus of the vertebral canal which drain the

adjacent structures and the spinal cord lie in the anterolateral parts of the epidural

space. They form a network, which runs vertically within the epidural space. It can

be subdivided into a pair of anterior venous plexus which lie on either side of

the posterior longitudinal ligament into which basivertebral veins empty and

a posterior venous plexus. These are valveless (Batson’s plexus) and afford

a connection between the pelvic veins below with the intracranial veins above. These

veins become distended during coughing and straining and also when the inferior

venacava is obstructed by large abdominal tumors or in late pregnancy. When these

epidural veins engorge, the epidural space is markedly reduced. Aspiration tests may

not always indicate intravenous position of a needle or catheter and subsequent

injections of air or local anaesthetic will be carried directly to the heart. The

appropriate dose of the drug should preclude this problem.

4) Lymphatics: The lymphatics run anteriorly from each intervertebral

foramen. They drain the dural cul-de-sacs of the dural root sleeves and empty in

the longitudinal channels in front of the vertebral column.

Connections between epidural space and paraspinal tissue space:

The epidural space is not a closed space. Many of the tissue planes around the spinal

canal connect to form an extended system of tracks.

12

There are 58 foramina in all. The areolar tissue around these foramina varies in

density according to age. As age advances the soft and tenuous tissue

undergoes increasing condensation to form the fibrous tissue which thickens and

blocks the intervertebral foramina with aging. This confines the solutions injected into

the epidural space within the spinal canal and they escape less rapidly along the

neurovascular bundles into the paravertebral spaces. Thus dosage should be reduced.

The spread is greater in pregnant females.

Size of the epidural space:

The distance across the circular peridural space is variable. It is negligible or almost

non-existent in the anterior region. It is more and readily measurable in the posterior

region, especially in the midline.

Table –2 Size of epidural space at different levels

Level Epidural space (mm) Thickness of dura (mm)

Cervical 1.0-1.5 2.0-1.5

Upper thoracic 2.5-3.0 1.0

Lower thoracic 4.0-5.0 1.0

Lumbar 5.0-6.0 0.66-0.33

13

PHYSIOLOGY

Haldt and Moloney were the first to describe negative pressure in the epidural space

in 1928. This negative pressure is maximum at points of firm attachments. It

is maximum in the thoracic region, less in the lumbar region and least or absent in

the sacral region.

Table 3 Pressures in the epidural space at different levels

Level Pressure (cm H2O)

Lower lumbar - 0.5

Upper lumbar - 1.0

Thoracic -1.0 to - 3.0 (Average -2.0)

Three theories have been put forth to explain the negative pressure.

1) The Cone Theory: 11

Jonzen, 1926, Eaton in 1938 and Lawrence in 1948 put forward this theory.

According to this theory, the needle introduced into the epidural space depresses the

dura, creating a larger space. This theory was reviewed in the studies conducted by

Aitkenhead in 1979 in experiments on dogs.

2) Transmission Theory: 11

According to Macintosh and Bryce-Smith the negative pressure in the epidural space

is caused by the transmission of the intrapleural negative pressure

through intervertebral foramina to the epidural space. It varies with the depth of

14

respiration. i.e., clinically this negative pressure will be diminished or absent if the

patient is not relaxed or straining.

3) Flexion theory: 11

This theory states that the negative pressure is directly proportional to the flexion of

the spine. Marked flexion at the spinal column increases the negative pressure. A rise

in negative pressure may favour the spread of local anaesthetic solution in the

epidural space.

Fig-6 Loss of resistance technique

15

Thus a good knowledge of the anatomy of the epidural space and nearby structures

goes a long way in proper performance of the technique of epidural block.

Identification of epidural space is by:

Negative pressure technique

Hanging drop sign.

Capillary tube method.

Manometer technique.

Disappearance of resistance techniques

Syringe technique.

Spring loaded syringe.

Balloon technique.

Brooke’s device.

Vertical tube of Dawkins.

Local anaesthetic injected into the epidural space acts on the dorsal root ganglia and

spinal roots with their dural cuffs in the extradural space.11

Leakage by vascular absorption.

Leakage through intervertebral foramina.

Diffusion through dural root sleeves.

Diffusion through dura mater.

16

Factors affecting the spread of epidural analgesia:

1. Volume of the solution:

The spread of analgesia in the epidural space depend on the volume of drug injected.

During his experimental study in the dogs and human cadavers by injecting coloured

solution through the sacro coccygeal membrane.12

Larger volumes will travel farther and remains in situ longer than smaller volumes.

When different volume of solution has been used vertical spread has been expressed

as a ratio obtained by dividing the volume of solution injected by the number of

vertical segments involved. The ratio is expressed in millilitres per segment, varies

inversely with the vertical spread, so the lower its value the greater the degree of

spread for a given volume. 13

2. Speed of injection:

spread of solution depend upon the speed of injection.12 With rapid injection fluid is

dispersed widely but thinly throughout the epidural space, so that the resulting block

is extensive and is of short duration. With the slow injection there is time for the

solution to pool evenly in larger amounts in any given area with the result that block

tendts to be more localised and lasts longer.14

3. Gravity:

X-Ray studies of the flow of solution in the epidural space injected via the lumbar

route of living subjects were first carried out by Sicard and Forestier in 1921 using

lipidol. In their study they described the passage of the heavy oil outward through the

17

intervertebral foramina and the influence of gravity in determining the direction of

spread.

Solution flow under the influence of the gravity and will diffuse cephaled in the

trendelenberg position and caudal in sitting up position .13

4. Site of Injection:

The site of injection is one of the extrinsic variables in the spread of analgesic

solution. To keep the dose to minimum, injection should be made at the level

corresponding to the middle of the area to be blocked. The solution injected spreads

equally in cephalad and caudal direction from the site of the injection provided the

solution is injected slowly.13

5. Age:

Small volumes of solution will travel relatively farther in old ages where

intervertebral foraminae are stenosed by calcified processes. Exaggerated spread of

epidural analgesia is seen in patients with atherosclerosis, the degenerative changes in

connective tissue associated with atherosclerosis produce increased permeability of

neural coverings.15 Marked reduction in volume is required clinically in older patients

is due to the much greater degree of neuraxial spread and greater permeability of the

perineurium. The dose requirement decreases as age increases.15

The diffusion gradient is very important when compared to volume because small

volume of high concentration can produce wide spread block, which is due to

18

neuraxial spread which is in turn due to high concentration gradient and greater

permeability of the perineurium.

The mechanism of action of epidural analgesia is complex. The site of action of the

drug injected in the epidural space could be summarised as per figure below. FIG- 7

Longitudinal spread in epiduralspace

Leakage by vascularabsorbtion

Systemic effects

Leakage throughintervertebral

foramina

Paravertebral block innerve trunks

Centripetalsubperineural spread

Subpial spread &uptake in piamatter

18

neuraxial spread which is in turn due to high concentration gradient and greater

permeability of the perineurium.

The mechanism of action of epidural analgesia is complex. The site of action of the

drug injected in the epidural space could be summarised as per figure below. FIG- 7

Epidural injection

Longitudinal spread in epiduralspace

Leakage throughintervertebral

foramina

Paravertebral block innerve trunks

Centripetalsubperineural spread

Subpial spread &uptake in piamatter

diffusion throughduralroot sleeves via

arachnoid villi &perivascularspaces

Sub dural spread

Spinal root block

Uptake in epidural fat

Diffusion in epiduralfat Spinal subdural space

cerebrospinal fluid

18

neuraxial spread which is in turn due to high concentration gradient and greater

permeability of the perineurium.

The mechanism of action of epidural analgesia is complex. The site of action of the

drug injected in the epidural space could be summarised as per figure below. FIG- 7

Diffusion throughspinal cord dura

Spinal subdural space

cerebrospinal fluid

19

Epidural analgesia is not simple as spinal root or ganglion blockade, but rather of

action on several sites after passing through labrynth of diffusion pathways as

outlined in figure.

Solution spread in the epidural space will depend on the volume injected. Within the

extradural space the drug will be taken up and removed by blood flow, or it will be

stored and perhaps spread in the extradural fat.

In young patients with freely patent intervertebral foramina, some solutions will

passout of the spinal canal into the paravertebral spaces and along the spinal nerves,

producing a form of paravertebral block. From these diffusion through the epineurium

and perineurium into subperineural space will allow some degree of centripetal spread

backward towards the neuraxis with subsequent access to the contiguous subpial

space and from these to the surface of the roots and cord.

The epidural neural blockade may affect various systems as described below.

1. Cardiovascular system: The possible cardiovascular influences may be classified

according to the following scheme

a) Neural b) Pharmacological

Neural:

Segmental sympathetic efferent blockade with resultant dilution of resistance

and capacitance vessels.

20

Paralysis of cardiac sympathetic fibers from the upper 4 to 5 thorasic segments

with loss of chronotropic or inotropic drive to the myocardium, resulting in

bradycardia and reduction of ejection force.

Pharmacological:

Vascular absorption of local anaesthetic from the epidural space leading to high

concentration of local anaesthetic in the circulation causes consequent distant effects

on smooth muscle and fall in the cardiac output from beta blockade. The depressant

effects of circulating local anaesthetics are PH dependent and are likely to be most

severe in the presence of renal and respiratory acidosis. If the epidural solution

contained epinephrine, its absorption would lead to increase in cardiac output and fall

in peripheral resistance.

2. Liver: Hepatic flow is largely dependent on mean systemic blood pressure. Under

epidural analgesia hepatic blood flow is significantly decreased if the systolic blood

pressure is allowed to fall below 60-70 mm Hg.

3. Renal system: Decrease in blood pressure causes proportionate decrease in renal

blood flow and GFR effect on bladder.

4. Bladder: Lumbar and sacral epidural anaesthesia results in atonic bladder with

large volume of residual urine, sometimes catheterisation is needed. In segmental

thoracic epidural anaesthesia lower parts of spinal cord are left intact and bladder

function may not be affected.

5. Respiratory System: Depends upon the segmental blockade. There is no effect on

the vital capacity, forced expiratory volume, FRC and gas distribution.

21

ANATOMY OF INGUINAL CANAL

a

bFig-8 Anatomy of inguinal canal

22

No disease of human body, belonging to the province of the surgeon, requires in its

treatment a better combination of accurate anatomical knowledge with surgical skill

than hernia in all its varieties. (Sir Astley Paston Cooper, 1804)16

The inguinal canal is 4cm long and extends from internal inguinal ring laterally to the

external inguinal ring medially. It lies above the inner half of the inguinal ligament.17

The canal gives passage to spermatic cord in male, and the round ligament of the

uterus in the female.18

The deep ring, an oval opening in fascia transversalis, lies about 0.5 inches (1.3cm)

above inguinal ligament midway between the anterior superior iliac spine and the

symphysis pubis. Just medial to it is the inferior epigastric artery. The margin of the

ring gives attachment to the internal spermatic fascia. The superficial inguinal ring, is

a triangular defect in the aponeurosis of the external oblique muscle and lies

immediately above and medial to pubic tubercle. The margins give attachment to the

external spermatic fascia.19

The mid inguinal point is the midpoint of the line between anterior superior iliac spine

and the symphysis pubis. Hence it is just medial to the midpoint of the inguinal

ligament.

23

Boundaries of inguinal canal19 :

1) The anterior wall of the canal: Formed along its entire length by aponeurosis

of the external oblique muscle. It is reinforced in its lateral third by the origin

of the internal oblique.

2) The posterior wall of the canal: Formed along its entire length by fascia

transversalis. It is reinforced in its medial third by conjoint tendon and

reflected part of inguinal ligament.

3) The floor of the canal: It is formed by grooved surface of the inguinal and

lacunar ligaments.

4) The roof of the canal: Formed by arching lowest fibers of the internal oblique

and transversus abdominis muscles.

Contents of inguinal canal:18

1) Spermatic cord in males and round ligament of uterus in female.

2) Ilioinguinal, iliohypogastric and genitofemoral nerves.

24

Protective mechanism for the development of hernia: 18

1) Canal is an oblique passage with weakest areas namely superficial and deep

rings lying some distance apart.

2) Anterior wall is reinforced by the fibers of internal oblique

3) Posterior wall is reinforced by strong conjoint tendon.

4) On coughing and straining, the arching lowest fibers of the internal oblique

and transverses abdominis muscle contracts so the canal is virtually closed.

Nerve supply:

1) Ilioinguinal nerve: 20

Origin: From L1 ventral ramus

Course: It emerges from the lateral border of psoas major, with or just inferior to

iliohypogastric nerve. It passes obliquely across quadratus lumborum and the upper

part of iliacus and enters transversus abdominis near the anterior end of the iliac crest.

It pierces internal oblique and supplies it and then traverses the inguinal canal below

the spermatic cord. It emerges with the cord from the superficial inguinal ring to

supply skin. Occasionally this nerve is completely absent, when the iliohypogastric

nerve supplies its territory.

Motor: Transeversus abdominis and internal oblique.

Sensory: Supplies sensory fibers to transeversus abdominis and internal oblique.

Medial skin of thigh and skin over the root of the penis and upper part of scrotum in

males or skin covering the mons pubis and adjoining labium majus in females.

25

2) Iliohypogastric nerve: 20

Origin: L1 ventral ramus

Course: It emerges from the upper lateral border of psoas major, crosses obliquely

behind the lower renal pole, and in front of quadratus lumborum. Above the iliac

crest, it enters the posterior part of transeversus abdominis. Between transverses

abdominis and internal oblique, it divides into lateral and anterior cutaneous branches.

The lateral cutaneous branch runs through internal and external oblique above the

iliac crest and is distributed to the posterolateral gluteal skin. The anterior cutaneous

branch runs through internal oblique 2cm medial to anterior superior iliac spine, and

through external oblique aponeurosis 3cm above superficial inguinal ring.

Motor: It supplies a small motor contribution to transeversus abdominis and internal

oblique, including conjoint tendon.

Sensory: Supplies sensory fibres to transeversus abdominis, internal oblique and

external oblique, and innervates the posterolateral gluteal and suprapubic skin.

3) Genitofemoral nerve:20

Origin: Ventral rami of L1 and L2

Course: It is formed within the substance of psoas major and descends obliquely

forwards through the muscle to emerge on the abdominal surface near its medial

border, opposite the third or fourth lumbar vertebrae. It descends beneath the

peritoneum on psoas major, crosses obliquely behind the ureter and divides above

inguinal ligament into genital and femoral branches. The genital branch, crosses the

lower part of external iliac artery, enters the inguinal canal by the deep ring. The

femoral branch descends lateral to external iliac artery, then crosses deep circumflex

26

iliac artery passes behind inguinal ligament and enters femoral sheath lateral to

femoral artery.

Motor: Cremaster muscle via genital branch of genitofemoral nerve.

Cutaneous:

Genital branch: skin of scrotum in males or monspubis and labium majus in females

via genital branch.

Femoral branch: Anteromedial skin of thigh.

27

PHARMACOLOGY

Local anaesthetics are chemical compounds which are capable of producing reversible

conduction blockade of impulses along central and peripheral nerve pathways after

regional anaesthesia.

Classification:

Clinically local anaesthetic agents can be classified into two groups depending on the

link between the aromatic portion and the intermediate chain. The amino ester group

have an ester link and include procaine, chloroprocaine and amethocaine. The amino

amides have an amide link between the aromatic head and the intermediate chain and

include lignocaine, bupivacaine, mepivacaine, prilocaine, etidocaine and

ropivacaine21.

Bupivacaine Hydrochloride:

History: Bupivacaine belongs to homologous series of mepivacaine and was

synthesized in Sweden (1957) by Boafekenstan. First reports of its use were made in

1963 by Televard. Since then it has been widely used in Scandinavia.

Structural Formula:

1-N-Butyl-DI-piperidine-2-carboxylicacid-2,6-dimethyl-anilide hydrochioride.

Fig-9 Structure of bupivacaine

28

The only difference from mepivacaine is that the butyl group replaces the methyl

group in piperidine ring. Both are being used as hydrochloride salts.

Bupivacaine, Lignocaine and mepivacaine contain linkages between the aromatic

nucleus and the amino or piperidine group. They differ from procaine, which has an

ester linkage.

Physical and Chemical Properties

It is a poorly water-soluble, long acting amide local anaesthetic. It is a salt of white,

odourless, crystalline powder with a bitter, numbing taste. It is prepared by chemical

synthesis. Its molecular weight is 324.9, freely soluble in water and alcohol in its

hydrochloride form, with its melting point of 258 oc. The pKa is 8.2 and pH is 3.5.

The solution is available in the form of 0.25%, 0.5% and 0.75% in isotonic sodium

solution with or without adrenaline, 1: 200,000 concentrations. A preparation

marketed specifically for intrathecal use contains dextrose.22

Mechanism of action:

Bupivacaine, like other local anaesthetics prevents the generation and the conduction

of the nerve impulse. Their primary site of action is the cell membrane. Conduction

block can be demonstrated in squid giant axons from which the axoplasm has been

removed.

Local anaesthetics block conduction by decreasing or preventing the large transient

increase in the permeability of excitable membranes to Na+ that normally is produced

by a slight depolarization of the membrane. This action of local anaesthetics is due to

their direct interaction with voltage-gated Na+ channels. As the anaesthetic action

29

progressively develops in a nerve, the threshold for electrical excitability gradually

increases the rate of rise of the action potential declines, impulse conduction slows,

and the safety factor for conduction decreases. These factors decrease the probability

of propagation of the action potential, and nerve conduction eventually fails 23.

Pharmacokinetics of Bupivacaine:

Bupivacaine is rapidly absorbed from the site of injection, the rate of rise in plasma

concentration and the peak plasma concentration depending on the particular local

anaesthetic technique being used. There is also some inter individual variation, and

peak systemic concentrations may occur between 5 and 30 min after administration.

1. Absorption:

The site of injection, dose, age of the patient and addition of a vasoconstrictor

determine systemic absorption of bupivacaine. The maximum blood level of

bupivacaine is related to the total dose of the drug administered from any particular

site.

2. Distribution:

This can be described by a two compartment model. The rapid distribution (phase A)

is believed to be related to uptake by rapid equilibrating tissue (i.e., tissues that have

high vascular perfusion). The slow distribution (phase B) is mainly a function of

distribution to slowly equilibrating tissue, biotransformation and excretion of the

compound.

30

More highly perfused organs show higher concentrations of the drug. Bupivacaine is

rapidly extracted by lung tissue. Though skeletal muscle does not show particular

affinity for bupivacaine it is the largest reservoir of the drug.

Distribution characteristics of Bupivacaine.

1. T1/2 A (min) – 2.7

2. T1/2 B (min) – 28

3. Volume of distribution at steady state (ltrs) – 72.

4. Clearance (ltrs/min) – 0.47.

3. Biotransformation and excretion:

Bupivacaine undergoes enzymatic degradation primarily in the liver. The excretion

occurs via the kidney. Renal perfusion and factors affecting urinary PH affect its

excretion. Less than 5 percent of unchanged drug is excreted via the kidney through

urine. The major portion of injected agent appears in urine in the form of 2, 6,

pipecolyloxylidine (PPx) which is an N-dealkylated metabolite of bupivacaine. Renal

clearance of this drug is related inversely to its protein binding capacity and pH of

urine.

Dosage:

The dosage varies upon the area to be anaesthetised.

1. The vascularity of the tissue

2. The number of segments to be blocked

3. The individual tolerance

4. Site of injection

31

In recommended doses, bupivacaine produces complete sensory block, but the motor

block depends on the concentration.

1) 0.25% incomplete motor blockade

2) 0.5% motor blockade is produced but muscle relaxation may be inadequate for

surgery.

3) 0.75% causes complete motor blockade.

Maximal dose is 2mg/kg body weight (25-30 ml 0.5% solution) and the strength used

is 0.125% - 0.75%. 24, 25

Advantages:

1. More powerful drug.

2. Prolonged duration, 4-5 times that of lignocaine or mepivacaine.

Toxicity of Bupivacaine:

It is relatively free of side effects if administered in an appropriate dosage. It is more

cardiotoxic than lignocaine and this is made worse by hypoxia, hypercapnia and by

pregnancy.

1. Central nervous system toxicity:

CNS is more susceptible to bupivacaine. The initial symptom involves feeling of light

headedness and dizziness followed by visual and auditory disturbance. Disorientation

perioral numbness and occasional feeling of drowsiness may occur. Objective signs

are usually excitatory in nature which includes shivering, muscular twitching and

tremors; initially involving muscles of the face and part of extremities. At still higher

32

doses cardiovascular or respiratory arrest may occur. Acidosis increases the risk of

CNS toxicity from bupivacaine, since an elevation of PaCO2 enhances cerebral blood

flow, so that more anaesthetic is delivered rapidly to the brain.

2. Cardiovascular system toxicity:

Bupivacaine depresses rapid phases of depolarization (Vmax) in purkinge fibres and

ventricular musculature to a greater extent than lignocaine. It also decreases the rate

of recovery from a dependent block than that of lignocaine. This leads to incomplete

restoration of Vmax between action potential at high rates, in contrast to complete

recovery by lignocaine. This explains why lignocaine has antiarrhythmic property

while bupivacaine has arrhythmogenic potential. High level of bupivacaine prolongs

conduction time through various parts of heart and extremely high concentration will

depress spontaneous pacemaker activity, resulting in bradycardia and arrest. Cardiac

resuscitation is more difficult following bupivacaine induced cardiovascular collapse

and hypoxia along with acidosis which markedly potentiates cardiac toxicity.

Bretylium but not lignocaine could raise the ventricular tachycardiac threshold that

was lowered by bupivacaine.

3. Respiratory system:

Respiratory depression may be caused if excessive plasma level is reached which in

turn results in depression of medullary respiratory center. Respiratory depression may

also be caused by paralysis of respiratory muscles as may occur in high spinal or total

spinal anaesthesia.

33

4. Autonomic nervous system:

Myelinated preganglionic beta fibres have a faster conduction time and are more

sensitive to the action of local anaesthetic including bupivacaine. Involvement of

preganglionic sympathetic fibres is the cause of widespread vasodilatation and

consequent hypotension that occurs in epidural and paravertebral block. When used

for conduction blockade all local anaesthetic particularly bupivacaine produces higher

incidence of sensory blockade than motor fibres.

Adverse effects and precautions

The safety and effectiveness of local anaesthetic depend upon proper dosage, correct

technique, adequate precautions and readiness for emergencies. The lowest dosages

that produce effective anaesthesia should be used, to avoid high plasma levels and

serious systemic side effects. Injection of repeated doses of bupivacaine may cause

significant increase in blood levels with each dose, due to accumulation of the drug or

its metabolites or due to slow degradation. Tolerance varies with the general condition

of the patient. Debilitated elderly patients and acutely ill patients should be given

reduced doses commensurate with age and physical condition.

34

REVIEW OF LITRETURE

Corning has been credited with being the first to use epidural analgesia in 1885.26

In 1901 Jean Enthuse Sicard and Fernand Cathelin independently introduced cocaine

through the sacral hiatus, becoming the first practitioners of caudal epidural analgesia.

They popularised this caudal approach for epidural analgesia.27

Arthur Lawen successfully used caudal anaesthesia with large volumes of procaine for

pelvic surgery.28

After the favourable reports of Sicard and Cathelin, Tuffier attempted epidural analgesia

by lumbar approach. But his lack of success and natural difficulties of locating a narrow

space of 2-4 mm width at a depth of 20 times that amount discouraged all further

attempts for many years.

In 1906 Forestier independently described the interspinous approach to the peridural

space utilizing a loss of resistance technique and thus, is considered as the co-originator

of the method of locating the peridural space with Sicard, who in 1906 demonstrated the

feasibility of the interspinous approach to the epidural space.28

In 1921 Fidel Pages, a Spanish military surgeon devised a technique to introduce

epidural procaine at all the levels of neuraxis. His method was to use a blunt needle and

then feel and hear the entry of the needle through the ligamentum flavum. He had

produced a segmental anaesthesia through epidural injections, avoiding some of the side

35

effects of complete neuraxial block, which occurred after high subarachnoid

administration of local anaesthetics. He published an article “Anaesthesia Metamerica”

in which he described satisfactory anaesthesia for abdominal surgery obtained by

utilising the interspinous approach to the peridural space.27, 28

In 1926 Janzen first described existence of negative pressure in the epidural space.29

A catheter passed through a needle into epidural space was first used in obstetrics by

Aburel in 1931.

In 1931 Achille Mario Dogliotti described epidural injections of local anaesthetics,

apparently without prior knowledge of the work of Pages. In 1933 in his article “A new

method of block anaesthesia” has mentioned about anatomy, physiology and

identification of epidural space by loss of resistance technique by using a continuous

pressure on the plunger of a saline filled syringe as the needle advanced through the

ligamentous structures. Subsequently this method became known to be as Dogliotti

method.27

A.Gutierrez of Argentina developed the hanging drop sign, which is still being used by

some anaesthesiologists to identify the epidural space.30

In 1936 B.Odom of New Orleans published 285 cases of lumbar epidural anaesthesia

and introduced the concept of test dose to detect intrathecal injection.31

36

William Lemmon used a 17-gauge, malleable, silver needle that was connected through

a hole in the operating table to rubber tubing and a syringe. Injections could then be

made at intervals to maintain the block for several hours.32

Edward Tuohy in 1945 used a ureteral catheter threaded through a large Huber-tipped

spinal needle to provide continuous anaesthesia.33 Later in 1949 this was modified to

give continuous epidural analgesia by Martinez Curbelo.34 A fresh impetus was given

by the introduction of Tuohy’s needle for epidural analgesia.

The marked increase in the use of epidural analgesia followed the introduction of

reliable, relatively non-toxic and fast acting local anaesthetics.

Philip Bromage and John Bonica performed several studies on epidural dose-response

relationships and the hemodynamic changes that followed initiation of the block. Whose

text books on the subject have made them thus the world’s authority of epidural

space.35,36

In 1951 Rudin D.O. working upon live dogs found that it is possible to recover in

CSF up to 10percent of local analgesic drug placed in the epidural space and behaves

as a true spinal analgesic acting either on nerve roots or dorsal root ganglia and that

the drug spreads from the epidural space through the intervertebral foramina and

produces block at the paravertebral space.

37

In 1966 Ekblon and Widman during 640 extradural lumbar blocks gave on an average

1.29+/- 0.03 mg/kg body weight of local anaesthetic without the appearance of any

appreciable side effects.37

In 1972 a study on the relation of age and length of vertebral column and volume of

solution for lumbar epidural anaesthesia was done by Dr. Mandappa. Approximately

up to age of 60 years the relationship between dose in volume to length of vertebral

column could be established. For higher age group a volume to age relationship is

observed which could be due to narrowing of the inter vertebral foramina limiting the

flow of injected fluid away into paravertebral space and also atherosclerosis of blood

vessels which limits absorption of injected fluid. The procedure of approximating

length of the vertebral column, age of the patient has greatly reduced the

complications. Further it is interesting to note that older age group requires only about

half the volume of drug required for younger age group for same operation. Sticking

to this regime, many protect the aged patients from complications.

In 1972, Philip R.Bromage Studied the incidence of missed, unblocked segments

during continuous epidural analgesia for relief of pain in labour and vaginal delivery

in 433 patients. Six different local anaesthetic agents were tested: the carbonated salts

of lignocaine and prilocaine, and the hydrochloride salts of lignocaine, prilocaine,

bupivacaine and amethocaine. The incidence of painful or unblocked segments ranged

from 1 per cent with carbonated lignocaine, to 12.8 per cent with amethocaine

hydrochloride, and it was four times higher with lignocaine hydrochloride than with

carbonated lignocaine.38

38

In 1974 P. R. Bromage studied lower limb reflex changes in segmental epidural

analgesia where sensory changes and lower limb reflexes were observed in 35 patients

receiving segmental epidural analgesia in the mid-thoracic region. Sensory blockade

was confined to the thoracic and upper lumbar segments. The lower limb reflexes

changed to an "upper motor neurone" pattern, with the onset and development of

segmental blockade. With regression of analgesia the reflexes returned to normal in

the reverse order. The significance of these findings is discussed in relation to the

anatomy of descending spinal pathways, and to the pattern of penetration of local

anaesthetics into the substance of the spinal cord.39

In1975 Maltau JM, gave selective lumbar epidural anaesthesia with 0.25% or 0.5%

bupivacaine without adrenaline in doses of 5 ml to 8 ml in 35 patients and monitored

the foetal heart rate changes. In 33 parturients the FHR changes observed were

insignificant. In one case a period of marked bradycardia was seen. One parturient

developed acute hypotension with a synchronous foetal bradycardia while lying in the

supine position. He concluded that continuous lumbar epidural anaesthesia with low

dose bupivacaine without adrenaline does not precipitate foetal bradycardia during the

first stage when care is taken to avoid maternal hypotension.40

In 1977, Hollman A, Jouppila R, Pihlajaniemi R, Karvonen P and Sjostedt conducted

a study of segmental (T10-T12) epidural analgesia in 418 parturient, using 4-6 ml

dose of 0.5% bupivacaine with or without adrenaline. Seventy percent of parturients

were primi paras and 30% had history or signs of possible uteroplacental

insufficiency. The analgesia during the opening phase was of good quality in 89% of

primiparas and 84% of multi. The onset of analgesia was rapid (3-5min) and duration

39

was on average 2 ½ hr. Slight but rapidly correctable hypotension occurred in 16.5%,

and in 2 cases the hypotension led to more serious complications. There was no

maternal or neonatal mortalities.41

In 1978 Jouppila R, Pihlajaniemi R, Hollman A and Jouppila P conducted a study

‘Segmental epidural analgesia and postpartum sequel’. Where the incidence of the

postpartum sequel of headache, backache, pain in the legs and difficulties in

micturition, was studied in 219 normal vaginal deliveries after segmental epidural

analgesia at the level of T10-T12 for pain relief during the first stage of labour. The

results showed that segmental epidural analgesia did not increase the occurrence of

postpartum sequel either in primiparous or in multiparous parturients.42

In 1979 Jouppila R, Jouppila P, Karinen JM and Hollman studied the effect of low-

dose continuous segmental epidural analgesia given during the first stage of labour on

the progress of labour, the frequency of foetal malpositions and the rate of vacuum

extractions was studied in 100 parturients (epidural group). The results were

compared with 100 parturients given none or conventional analgesia (control group).

The results showed that in the primiparous epidural group the progress of labour was

slower than in the control group. After the block, however, the subsequent course of

the labour was of equal duration in both groups. The duration of the second stage of

labour did not differ significantly between the groups. The differences in foetal

malpositions at delivery were statistically insignificant. Nor did the rate of vacuum

extractions, 8% in the primiparous and 0% in the multiparous epidural group, differ

statistically from the corresponding rate in the control groups. The results signify a

normal progress and outcome of labour after low-dose segmental epidural analgesia.43

40

In 1979 Willdeck-Lund G, Lindmark G and Nilsson BA, conducted segmental

epidural block for vaginal delivery to 242 women. Of these, 178 with a spontaneous

start of labour and vaginal delivery were studied with respect to the effect of epidural

block with bupivacaine-adrenaline on the course of labour and the condition of the

infant in women with normal uterine activity and women with primary uterine inertia

treated with oxytocin infusion. On an average, the 178 women had already had a

longer course of labour before the block was applied than women in control groups.

The block per se had only a slight effect on the first stage of labour, but the effect on

the second stage was more obvious, leading to outlet extraction in 50% of the

primiparous women, compared to 12% of the controls.44

In 1979 Gal D, Choudhry R, Ung KA, Abadir A and Tancer ML conducted a study to

evaluate segmental epidural analgesia . Bupivacaine (0.25 per cent) was used during

the first stage of labor and for the second stage, either 3 per cent - Chloroprocaine

delivered through the catheter (Group I) or 1 per cent Lidocaine as a perineal infiltrate

(Group II) was used. There were 124 full term patients of whom, 36 were nulliparous

and 88 were multiparous. The effects of segmental epidural analgesia on maternal

blood pressure, pain relief, preservation of lower limb motor power, duration and

progress of labor, and foetal outcome were evaluated. Pain relief during the first stage

of labor was satisfactory in 114 (92 per cent) of the patients. There were no significant

changes in maternal blood pressure, motor power in lower limbs, efficiency of uterine

contractions and internal rotation of the presenting part when analgesia was effective.

The use of 2-Chloroprocaine for second stage pain relief required low forceps

delivery in 84 (91 per cent) patients, as compared to 14 (44 per cent) patients that had

1 per cent Lidocaine local infiltration. Foetal outcome, was excellent in all cases.45

41

In 1982,Pentti Jouppila, RiittaJouppila, Arno Hollman and Antero Koivula measured

intervillous blood flow using a Xe133 clearance technique during the first stage of

labour in 9 parturients with severe preeclampsia before and after lumbar epidural

analgesia. Analgesia was produced with 10 ml of 0.25% bupivacaine. After the lumbar

epidural block the intervillous blood flow significantly improved, suggesting that

epidural analgesia is the obstetric analgesic method of choice in cases of severe

preeclampsia.46

In 1983 Kanto J, Erkkola R, Mansikka M and Aärimaa L, Studied the effect and

safety of segmental epidural analgesia (SEA) in three groups of parturients totalling

250. In 50 primigravidae, the analgesic effect was good in 90%, moderate in 8%, and

poor in only 2%. The SEA did not lead to more malpositions than were present in the

nonepidural groups. Nevertheless, the rate of instrumental deliveries was

approximately three times higher in the SEA groups than in nonepidural groups.47

In 1993 Anthony C. Webster, J. D. McKishnie, J. T. Watson and W. Donald Reid

evaluated lumbar epidural anaesthesia (LEA) to assess its technical feasibility,

effectiveness and incidence of complications in infants. Using a standard loss of

resistance technique and a 4.0 cm 20 G epidural needle. Epidural analgesia was

achieved in all 16 cases with bupivacaine 0–25% with and without 1:200,000

epinephrine, 0.75 ml/ kg for the first two cases, and subsequently 1.0 ml/ kg. In 15

patients, good operating conditions were achieved with epidural analgesia alone.

Inhalational anaesthesia supplementation was necessary in three cases. In the first two

patients, the level of analgesia (T8) was insufficient to control the response to traction

on the hernial sac. In one infant, analgesic to T4, whose surgery was inadvertently

42

delayed for four hours, inhalation anaesthesia was needed to control restlessness

rather than pain. Ten infants were analgesic to T2, four to T4, two to T9 and two to

T9. No adverse hemodynamic effects were seen. And there were no postoperative

complications. They concluded that lumbar epidural anaesthesia was technically easy,

and provided good operating conditions for most neonates in this study.48

In 1993 Peutrell JM and Hughes DG, in order to avoid complications of high doses of

local anaesthetics, injected the local anaesthetics at appropriate segmental level

through epidural catheter in awake ex-premature babies who were undergoing

inguinal herniotomies. The anaesthesia was excellent in six babies. Two babies cried

briefly with peritoneal or spermatic cord traction. One other baby needed

supplementation with nitrous oxide in oxygen in order to complete the surgery. The

majority of babies slept throughout surgery. There was no reported postoperative

complications.49

Studies conducted by Dr.M.H.Rao, Prof. Dept. Of Anaesthesiology, Thirupathi and

Dr.Phani Thota, Head Dept. Of Anaesthesiology KMC Mangalore in 1995 on

segmental dose requirement of epidural lignocaine and the effects on age, height,

body weight and body surface area. In their study a negative correlation is seen

between the age and segmental dose requirement of epidural lignocaine in adults.

Correlated moderately with height and body weight but correlated best with body

surface area. Dose required to block each segment in males was about 22.3

mg/segment and in females about 19.7 mg/segment.50

43

In 1995 William M. Splinter, Juan Bass and Lydia Komocar conducted a study where

they compared the effect of local anaesthesia with that of caudal anaesthesia on

postoperative care of children undergoing inguinal hernia repair. This was a

randomized, single-blind investigation of 202 children aged 1–13 yr. Anaesthesia was

induced with N2O/O2 and halothane or propofol and maintained with

N2O/O2/halothane. Local anaesthesia included ilioinguinal and iliohypogastric nerve

block plus subcutaneous injection by the surgeon of up to 0.3 ml/kg bupivacaine

0.25% with 5 μg/kg adrenaline. The dose for caudal anaesthesia was 1 ml/kg up to

20 ml bupivacaine 0.2% with 5 μg/kg adrenaline. Postoperative pain was assessed in

the anaesthesia recovery room. The postoperative pain scores and opioid usage were

similar; however, the local anaesthesia group required more acetaminophen in the day

care surgical unit. The local anaesthesia patients had a shorter recovery room stay.

The postoperative stay was prolonged in the caudal anaesthesia group. They conclude

that Local anaesthesia and caudal anaesthesia have similar effects on postoperative

care with only slight differences.51

In 1996 Cedric Prys-Roberts and Andrew M.S.Black stated that segmental epidural

block with local anaesthetic is far more satisfactory when placed at correct vertebral

level and in more than 90% patients undergoing lower abdominal surgeries where

block required is between T10-L2 the volume of local anaesthetic required is 5ml.

Duration of block with Bupivacaine 5ml (0.5%) is limited to 3-4 hours, whereas

continuous infusion, with 0.25%(3-7ml/hr) after bolus dose of 5ml maintains

satisfactory analgesia for a variable period of time.52

44

In 2000 Della Rocca G, Giampalmo M, Giorni C, Di Marco PA, Monaco S, Romboli

D, Gossetti F, Negro P, Carboni M and Pietropaoli P conducted a study comparing

different anaesthetising techniques for inguinal hernia repair, where 405 patients

undergoing inguinal hernioplasty were studied. Four different anaesthetic techniques

were used: (i) surgical field infiltration (SFI) with 0.5% carbonated lidocaine +

0.125% bupivacaine (193 pts.) in which monitored anaesthesia care was administered

with propofol (3 to 4 mg/kg/h) when necessary; (ii) epidural anaesthesia with 2%

lidocaine + fentanyl 100 mcg (137 pts.); (iii) general anesthesia with isoflurane and

fentanyl in N2O:O2 (48 pts.); and (iv) intrathecal anaesthesia with 1% hyperbaric

bupivacaine 1-2 ml (25 pts.). Intra- and postoperative complications, intraoperative

sedation, postoperative supplemental drugs for analgesia and postoperative length of

hospital stay were recorded. Intraoperative hypotension/bradycardia were observed in

4 patients (2%) in the SFI group and in 6 patients (4%) in the epidural group. Sedation

was required in 29.5% of patients in the SFI group and in 15.3% in the epidural group

(P < 0.05). Postoperative supplemental analgesic drugs administered and length of

hospital stay were similar in the 4 groups. No difference in intra- and postoperative

complications was observed among the 4 groups. In conclusion, both SFI and epidural

anaesthesia are safe and suitable for the inguinal hernioplasty procedure, without

intra- or postoperative complications.53

In 2002 Günal O, Arikan Y and Celikel conducted a study where they compared the

effect of spinal and epidural anaesthesia on surgical outcome measures of inguinal

herniorrhaphy. Ninety-eight male patients undergoing inguinal hernia repair were

randomized to either spinal or epidural anaesthesia. Anaesthesia onset time (AOT),

postoperative stand-up time (SUT), first pain sensation time (FPT), operation time

45

(OT), analgesic requirement (AR), hospital stay (HS), visual analogue scores of pain

(VAS), per- and postoperative complications, and post anaesthesia complications

were recorded and compared with each other. No statistically significant difference

was found between the SA and EA groups with respect to the other outcome measures

that were considered. Concluded as spinal and epidural anaesthesia show some

differences from each other with respect to outcome measures such as OT, SUT, FPT,

and 12- and 24-h VAS scores.54

In 2005,Todorovic Dragana, Konstatinovic Slavko, Jankovic Radmilo studied the

efficiency and safety of administration of minor anaesthetic concentrations in epidural

anaesthesia for operations of inguinal hernia .Half of the patients were given 20 ml

2% lidocaine and half patients were given 20 ml 1.5% lidocaine. In patients with 2%

lidocaine motor blockade occurred after 14.37+-1.04 mins and duration

110.45min.Only 20 % of the patients on whom 1.5% lidocaine was given had motor

blockade after 11.16+-2.02 mins and duration 100.3 mins. Systolic pressure

significantly decreased after 20ml of 2% lidocaine administration compared to the

group to whom 1.5% was given. The first group had to stay longer in the post

operative ward than the second group, and concluded stating that minor

concentrations of anaesthetics can be efficient and safe in epidural analgesia and they

achieve adequate amount of analgesia for surgical interventions.55

In 2007 Srivastava U, Kumar A, Saxena S, Neeraj and Sehgal conducted a

prospective randomized study in 92 adult male patients to compare the local

anaesthesia with conventional spinal and general anaesthesia for elective unilateral

inguinal hernia repair. The operative conditions were excellent in majority of the

46

patients in local anaesthesia group similar to other two groups. The main disadvantage

of local anaesthesia was dome pain or discomfort at the operative site during

dissection of sac but this did not affect the satisfaction by the patients and its use

again. 87 percent of surgeons and 90 percent of patients were satisfied with the local

anaesthesia. The main advantages of this method were excellent operative conditions,

quick recovery, long analgesia and minimal postoperative complications.56

In 2007 A. A. J. Van zundert, G. Stultiens, J. J. Jakimowicz, D. Peek, W. G. J. M.

Van der ham, H. H. M. Korsten and J. A. W. Wildsmith studied laparoscopic

cholecystectomy under segmental thoracic spinal anaesthesia where twenty ASA I or

II patients undergoing elective laparoscopic cholecystectomy received a segmental

(T10 injection) spinal anaesthetic using 1 ml of bupivacaine 5 mg/ml mixed with 0.5

ml of sufentanyl 5 µg/ml. Other drugs were only given to manage patient anxiety,

pain, nausea, hypotension, or pruritus during or after surgery. The block was effective

for surgery in all 20 patients, six experiencing some discomfort which was readily

treated with small doses of fentanyl, but none requiring conversion to general

anaesthesia. Two patients required midazolam for anxiety and two ephedrine for

hypotension. Recovery was uneventful and without sequelae, only three patients (all

for surgical reasons) not being discharged home on the day of operation. This

preliminary study has shown that segmental spinal anaesthesia can be used

successfully and effectively for laparoscopic surgery in healthy patients.57

In 2008 Yang B, Liang MJ and Zhang Y, conducted a randomized trial to investigate

the efficacy and safety of local anaesthesia and epidural anaesthesia in tension-free

repair of inguinal hernia. 269 patients underwent inguinal hernia repair were

47

randomly divided into two groups, receiving local anaesthesia (143 cases) and

epidural anaesthesia (126 cases). The clinical data from the two groups were analyzed

retrospectively. The operation time, ambulation time, length of hospital stay and cost

of hospitalization in local anaesthesia group were significantly less than those in

epidural anaesthesia group. No significant differences were found in intra-operative

use of ancillary sedation drugs, postoperative recovery situation, pain scores and

operation-correlated complications between the two groups. 58

48

METHODOLOGY

A clinical study was undertaken for anaesthetising 100 patients aged between 18-70

years posted for elective inguinal hernia repair, agreeing and co-operative for epidural

anaesthesia. Study was conducted at MVJ Medical College and Research Hospital

Hosakote, Bengaluru during the period of September 2008 to August 2010.

Selection of patients:

Inclusion criteria:

1. Patients undergoing inguinal hernia repair.

2. Age 18– 70 years.

3. Normal adults belonging to ASA Grade I and ASA Grade II

Exclusion criteria:

1. Patients below 18 and above 70 years.

2. Patients with ASA Grade III and ASA Grade IV.

3. Patients allergic to local anaesthetics.

4. Presence of ischemic heart diseases, hypertension, symptomatic asthma,

inability to climb a flight of stairs, uncontrolled diabetes, epilepsy, renal

problems, bleeding disorders, patients on chronic drug medications such as

MAO inhibitors, acute substance abuse, previous problem with anaesthesia,

obesity, neurological deficit, infection at injection site and patients unwilling

to comply with instructions.

49

Pre-anaesthetic evaluation:

Pre-anaesthetic evaluation was done a day prior to the elective surgery. History of

present complaints, duration of swelling and any co-existing disease, previous surgery

were noted. A thorough physical, systemic examination was done which included the

size of the swelling, type of hernia, weight of the patient, vital signs and airway

assessment.

The following investigations were carried out in all patients:

BLOOD: Haemoglobin percentage, bleeding time, clotting time and random blood

sugar.

URINE: Urine for routine examination, urine albumin and urine sugar were done.

ECG & chest x-ray for patient above 45 years.

All patients were assessed and they were graded according to the ASA physical status

I and II. They were educated regarding the anaesthetic technique. Consent for the

same was obtained. Local anaesthetic test dose was carried out on the previous day of

surgery. Patients were premedicated with oral Alprazolam 0.5 mg and Oral Ranitidine

150 mg on the night prior to surgery and 2 hours before the surgery.

Regional anaesthetic equipment:

There are several important requisites for optimal results in regional anaesthesia. In

order to have consistently good results, the anaesthesiologists must have a genuine

interest in and be convinced of the advantages of regional anaesthesia. After attaining

the necessary skill and clinical application, thorough knowledge of the pertinent

anatomy and landmarks, familiarising with the pharmacology of the local anaesthetic

50

agents as well as the physiological changes that accompany these anaesthetics. He can

thus anticipate any changes and be prepared to institute immediate treatment if

necessary (i.e. intravenous fluids, vagolytics and possible vasopressors). Equally

important is the careful preparation and management of the individual patient and the

availability of appropriate anaesthesia equipment, as well as equipment for

resuscitation and the treatment of adverse reactions.

The department of anaesthesiology in which regional anaesthesia is to be performed

in a sophisticated fashion must have a significant inventory of regional anaesthetic

technique must be kept ready.

Needles:

A wide selection of high quality disposable epidural (Tuohy) needles 16 and 18G.

Syringe:

Disposable and glass barrel syringes with close fitting plungers and various sizes

ranging from 2ml, 5ml, 10ml, 20ml are kept ready.

Drugs:

Inj.Bupivacaine 0.5% isotonic.

Resuscitation:

To perform epidural analgesia, equipments and drugs for resuscitation and treatment

of complications should be kept ready.

51

This should include a means of administering oxygen by positive pressure, such as an

anaesthesia machine or an resuscitation bag and mask connected to a source of

oxygen, airway equipment, working laryngoscope, oro-pharyngeal airways of several

sizes, cuffed endotracheal tubes of appropriate sizes, a suction apparatus and labelled

syringes that contain atropine and a dilute solution of vasopressors.

Monitors:

In the operation theatre an IV line was secured with no. 18 or 20 G IV cannula.

The monitors – pulse oxymeter, ECG, NIBP were connected.

Segmental epidural block denotes the use of local anaesthetic solution enough to

cover only the segments involved in the field of surgery by injecting a low volume

and selecting site of puncture of epidural space, so it becomes the midpoint of

segments involved.

Procedure:

Each patients selected for the study was positioned laterally (on affected side) on the

operation theatre table. With all aseptic precautions the epidural space was identified

at L1-L2 space , with 18G epidural needle 5ml of 0.5% Bupivacaine is injected very

slowly only to block the segments(T12-L2) involved in the field of surgery. Later

epidural catheter was inserted and secured and patient positioned back to supine

position.

Level of analgesia was checked by needle prick. After conforming the adequacy and

level of analgesia, the surgery was commenced. If the patient complained of pain

52

during needle prick, then injected local anaesthetic (0.5% Bupivacaine) with an

incremental dosage of 1ml at a time, till the complete onset of analgesia.

Pulse Rate and Blood Pressure were recorded at an interval of 1 minute for first 5

minutes and then every 5 minutes till the end of the surgery. Oxygen saturation and

ECG monitoring was done continuously.

Onset of analgesia, level of analgesia (pre & post operatively), duration of analgesia,

total dosage of local anaesthetic used were recorded.

Complications like bradycardia, hypotension, respiratory depression, shivering,

nausea and vomiting, sweating and inadvertent dural puncture were recorded.

Criteria for hypotension was taken as a fall in systolic Blood pressure more than 20%

of patients basal reading and treated with vasopressors like Inj.Ephedrine 3-5 mg IV.

Bradycardia as heart rate less than 60 and treated with Inj.Atropine 0.6 mg IV.

If any inadvertent dural puncture occured, those cases were excluded from the study

and was given homologous epidural blood patch to prevent post dural puncture

headache.

After confirming the onset of analgesia patient was sedated with Inj.midazolam 1 mg

IV.

53

In the present study the following scale was adopted to grade quality of analgesia and

relaxation.

1. Excellent: Patient comfortable, analgesia and surgical relaxation adequate, no

supplementation required during surgery.

2. Good: Analgesia and relaxation adequate, minimal discomfort present during

surgical procedure. Additional top-ups of local anaesthetic at an incremental

dose of 1 ml are given.

3. Fair: Analgesia and relaxation adequate, discomfort present even after

additional top-up of epidural local anaesthetic, this was alleviated by analgesic

dose of Ing.Fentanyl 1 Mcg/kg IV.

4. Poor: Patients complaining of severe intolerable pain during surgery without

relaxation. These cases were supplemented with general anaesthesia.

Statistical analysis:

Descriptive data included mean, standard deviation and percentage which were

determined for the study group.

54

Fig-10 Epidural Tray

Fig-11 Postion of The Patient

55

Fig-12 Loss of Resistance

Fig-13 Epidural Catheter Insitu

56

a

b

Fig-14 a, b Dermatomes

57

RESULTS

Segmental epidural anaesthesia was given to one hundred patients undergoing

inguinal hernia repair at MVJ Medical College and Research Hospital, during the

period of September 2008 to August 2010 and these cases were taken up for study as

outlined in the methodology.

AGE DISTRIBUTION:

TABLE – 4

Age Group No. Of Cases

18-30 21

31-40 30

41-50 22

51-60 17

61-70 10

Total 100

58

GRAPH - 1

Age of these patients ranged from 18 to 70 years and this incidence is shown in Table

– IV.

Mean Age 42.65 years

STD Deviation 12.85

Majority of the patients were in 31-40 Age group.

0

5

10

15

20

25

30

18-30 31-40

21

30

58

GRAPH - 1

Age of these patients ranged from 18 to 70 years and this incidence is shown in Table

– IV.

Mean Age 42.65 years

STD Deviation 12.85

Majority of the patients were in 31-40 Age group.

31-40 41-50 51-60 61-70

30

2217

10

58

GRAPH - 1

Age of these patients ranged from 18 to 70 years and this incidence is shown in Table

– IV.

Mean Age 42.65 years

STD Deviation 12.85

Majority of the patients were in 31-40 Age group.

61-70

10

59

SEX INCIDENCE:

TABLE – 5

Sex No. of Cases

Male 97

Female 3

Total 100

GRAPH – 2

Regarding the sex incidence it is the male who predominates as compared to females,

which is shown in the Table- V

97

3

SEX INCIDENCE

MALE

FEMALE

60

WEIGHT DISTRIBUTION:

TABLE – 6

Weight in Kgs No. Of Cases

31-40 3

41-50 27

51-60 32

61-70 32

71-80 6

GRAPH - 3

TABLE VI shows the weight distribution of patients.

Maximum weight was 85 Kgs

Minimum weight was 37 Kgs

Mean weight 57.65 Kgs with a standard deviation of 9.1

3

27

32 32

6

0

5

10

15

20

25

30

35

31-40 41-50 51-60 61-70 71-80

WEIGHT INCIDENCE

61

HEIGHT DISTRIBUTION:

TABLE - 7

Height in cms No. of Cases

141-150 5

151-160 30

161-170 36

171-180 29

GRAPH - 4

TABLE VII shows the Height distribution of patients.

Maximum Height 180 cms

Minimum Height 148 cms

Mean Height 165.16 cms with a standard deviation of 8.24.

0

5

10

15

20

25

30

35

40

141-150 151-160 161-170 171-180

Height

Height

62

TYPE OF HERNIA:

TABLE – 8

Type of Hernia No. Of Cases

Indirect 73

Direct 27

Total 100

GRAPH - 5

Incidence in type of hernia is shown in the Table- VIII

Direct hernia 27 cases

Indirect hernia 73 cases

73

27

TYPE OF HERNIA

INDIRECT

DIRECT

63

VOLUME OF BUPIVACAINE USED:

TABLE - 9

Volume of drug No. Of Cases

5ml 53

6ml 22

7ml 16

8ml 9

GRAPH - 6

Volume of Bupivacaine required, ranged from 5 ml to 8 ml. with a mean volume of

5.8 ml.

53

22

16

9

VOLUME OF DRUG

5 ml

6 ml

7 ml

8 ml

64

QUALITY OF ANALGESIA:

TABLE – 10

No. Of Cases

Excellent 53

Good 34

Fair 10

Poor 3

Cases excluded from study 2

Total 102

GRAPH - 7

53

34

0

10

20

30

40

50

60

EXCELLENT GOOD

64

QUALITY OF ANALGESIA:

TABLE – 10

No. Of Cases

Excellent 53

Good 34

Fair 10

Poor 3

Cases excluded from study 2

Total 102

GRAPH - 7

34

10 3 2

GOOD FAIR POOR CASESEXCLUDED

64

QUALITY OF ANALGESIA:

TABLE – 10

No. Of Cases

Excellent 53

Good 34

Fair 10

Poor 3

Cases excluded from study 2

Total 102

GRAPH - 7

CASESEXCLUDED

65

Table X shows the quality of analgesia and relaxation in patients.

53 patients had an excellent type of analgesia and relaxation. Patients were

comfortable no supplementation required during surgery.

In 34 patients analgesia and relaxation was adequate, minimal discomfort was present

during surgical procedure. Additional top-ups of local anaesthetic at an incremental

dose of 1 ml were given.

In 10 patients, discomfort was present even after additional top-up of epidural local

anaesthetic, this was alleviated by analgesic dose of Ing.Fentanyl 1 Mcg/kg IV.

3 patients had no analgesia at all, Patients were complaining of severe intolerable

pain during surgery without relaxation. These cases were converted to general

anaesthesia.

2 cases were withdrawn from the study as there was an inadvertent dural puncture.

66

DURATION OF ANALGESIA:

TABLE – 11

Time range in minute Number of patients

120-130 12

131-140 11

141-150 11

151-160 13

161-170 12

171-180 15

181-190 4

191-200 9

201-210 7

211-220 0

221-230 1

231-240 2

67

GRAPH - 8

TABLE XI shows the Duration of analgesia in minutes. The patients who received general

anaesthesia, had no analgesia.

Mean duration 167.42 min

Minimum duration 120 min

Maximum duration 240 min

In 3 patients who had poor quality of analgesia and converted to general anaesthesia,

duration of analgesia could not be recorded.

1211 11

1312

15

4

9

7

01

2

0

2

4

6

8

10

12

14

16

DURATION

68

LEVEL OF ANALGESIA PRE-OPERATIVELY:

TABLE – 12

LEVEL NO. OF CASES

T8 2

T9 16

T10 54

T11 22

T12 3

GRAPH - 9

TABLE XII shows the sensory level of analgesia pre operatively.

In majority of the patients (54) level of analgesia was up to T10

In 22 patients T11

In 16 patients T9

In 3 patients T12

In 2 patients T8

In 3 patients who had poor quality of analgesia and converted to general anaesthesia,

level of analgesia could not be appreciated.

2

16

54

22

30

10

20

30

40

50

60

T8 T9 T10 T11 T12

69

LEVEL OF ANALGESIA POST OPERATIVELY

TABLE – 13

LEVEL NO. OF CASES

T7 2

T8 33

T9 43

T10 17

T11 1

T12 1

GRAPH - 10

TABLE XIII Shows the sensory level post operatively

In majority of the patients (43) level of analgesia was up to T9

In 33 patients T8

In 17 patients T10

In 2 patients T7

In 2 patients T11 & T12

2

33

43

17

1 10

5

10

15

20

25

30

35

40

45

50

T7 T8 T9 T10 T11 T12

70

SIDE EFFECTS:

TABLE – 14

SIDE EFFECTS NO. OF CASES

Inadvertent dural puncture 2

Shivering 5

Sweating 9

Hypotension NIL

GRAPH - 11

TABLE XIV Shows the incidence of side effects.

Sweating is seen in 9 patients.

Shivering in 5 patients.

Inadvertent dural puncture in 2 patients.

No cases of Hypotension.

9

70

SIDE EFFECTS:

TABLE – 14

SIDE EFFECTS NO. OF CASES

Inadvertent dural puncture 2

Shivering 5

Sweating 9

Hypotension NIL

GRAPH - 11

TABLE XIV Shows the incidence of side effects.

Sweating is seen in 9 patients.

Shivering in 5 patients.

Inadvertent dural puncture in 2 patients.

No cases of Hypotension.

2

5

0

SIDE EFFECTS

IDP

SH

SW

HYPOTENSION

70

SIDE EFFECTS:

TABLE – 14

SIDE EFFECTS NO. OF CASES

Inadvertent dural puncture 2

Shivering 5

Sweating 9

Hypotension NIL

GRAPH - 11

TABLE XIV Shows the incidence of side effects.

Sweating is seen in 9 patients.

Shivering in 5 patients.

Inadvertent dural puncture in 2 patients.

No cases of Hypotension.

IDP

SH

SW

HYPOTENSION

71

ANALGESIA AND RELAXATION SUCCESS RATE

TABLE 15

QUALITY OF ANALGESIA NO. OF CASES

EXCELLENT 53

34

1097 %

GOOD

FAIR

POOR 3

GRAPH - 12

SUCCESS RATE 97%

97

3

NO.OFCASES

SUCCESS

FAILURE

72

MEAN HEART RATE CHANGES

TABLE- 16

MINUTES MEAN HEART RATE

PREOP 83.8

0 87.22

1 86.58

2 86.44

3 86.72

4 85.9

5 85.06

10 85.24

15 85

20 84.32

25 83.8

30 84.44

35 84.14

40 84.03

45 83.48

50 83.76

55 83.36

60 83.08

END 83.42

73

GRAPH- 13

81

82

83

84

85

86

87

88

HR

74

MEAN BLOOD PRESSURE CHANGES

TABLE- 17

MINUTES MEAN SYST.BP. MEAN DIAST.BP.

PREOP 130.26 80.44

0 132.84 82.6

1 132.3 82.18

2 130.56 81.56

3 130.56 80.9

4 129.62 81.12

5 126.55 80.66

10 127.76 79.98

15 127.87 79.88

20 127.7 79.46

25 127.82 79.5

30 128.26 79.66

35 128.92 79.48

40 128.42 78.82

45 128.3 79.66

50 128.58 79.9

55 128.36 79.48

60 129.08 80.06

END 130.48 81

75

GRAPH –14

0

20

40

60

80

100

120

140PR

EOP 0 1 2 3 4 5 10 15 20 25 30 35 40 45 50 55 60

END

SYSTOLIC

DIASTOLIC

76

TABLE – XVIII

SUMMARY OF RESULTS ( AGE GROUPS)

AGEGROUP(YEARS)

NO.CASES MEANAGE

(YEARS)

MEANWEIGHT

(Kg)

MEANHEIGHT

(cm)

MEANDRUGVOL

(ml)

MEANONSET

(Min)

MEANDURATION

(Min)

MEANBP

FALL

MEAN% BPFALL

18-30 21 26.19(STD DEV 3.31)

55.66(STD DEV 8.77)

164.90(STD DEV 8.08)

6.81(STD DEV 1.07)

8.11(STD DEV 1.24 )

171.42(STD DEV 30.21)

8.76 6.69

31-40 30 36-63(STD DEV2.95 )

56.23(STD DEV9.05 )

166.57(STD DEV 7.24)

5.60(STD DEV 0.85)

8.03(STD DEV 1.19)

162.03(STD DEV 26.24)

8.74 6.64

41-50 22 46.09(STD DEV 2.88)

60.50(STD DEV 9.63)

167.09(STD DEV 7.43)

5.59(STD DEV 0.73)

7.88(STD DEV 0.90)

166.67(STD DEV 24.56)

9.90 7.36

51-60 17 55.47(STD DEV 3.28)

59.47(STD DEV 8.90)

162.56(STD DEV 10.55)

5.53(STD DEV 0.79)

8.36(STD DEV 1.17)

174.11(STD DEV 34.65)

14 10.20

61-70 10 65.9(STD DEV 2.51)

56.17(STD DEV 9.10)

161.3(STD DEV 8.40)

5.3(STD DEV 0.94)

8.17(STD DEV 1.09)

163.89(STD DEV 28.26)

15.56 13.38

77

DISCUSSION

Inguinal hernia repair is one of the most commonly encountered surgical corrections

in men representing 12.5% of total surgical repair in Britain. In providing anaesthesia

for inguinal herniorraphy, the technique chosen must be cost effective with respect to

speed of recovery, patient comfort, and associated incremental costs.

Inguinal hernia repair is one of the common treatments performed. Which can be

performed under spinal, epidural, general and inguinal field block.

Epidural anaesthesia is suitable as a sole agent for lower abdominal surgery and on

lower limbs. It has some definite advantages over spinal anaesthesia like avoidance of

post spinal headache, minimal chances of meningitis, and minimal chances of nausea

and vomiting in post operative period.

Segmental epidural block, though introduced by Fidel Pages (1921) and Dogliotti

(1931), clinically its use has been advocated by Massey Dawkins (1971) for thoracic

epidural for upper abdominal surgery and Doughty (1969) and Steel (1972) in labour

analgesia for uterine and perineal pain and have recommended that this technique to

be a very safe and satisfactory procedure to all concerned.

These works have given a useful suggestion for extending the technique as

“Segmental Epidural Block” for Inguinal hernia repair as the nerve supply to this area

is very suitable for carrying out this procedure and also has some attractive

advantages over the conventional epidural block using larger doses.

78

The study of Segmental Epidural Analgesia for inguinal hernia repair was carried out

with an intension of administering limited quantity of drug required to make the

procedure precise and safe.

Segmental or conventional block can be performed at any region like cervical,

thoracic, lumber or caudal. However the volume used in the segmental block is very

small so that the block covers only the particular segments concern. Whereas in

conventional block, the volume used is large enough to spread widely giving rise to

complications like arterial hypotension, bradycardia etc.

Advantages claimed with segmental epidural analgesia are:

1. Small quantity of local anaesthetic drug enabling to use an effective dose or

higher concentration without the fear of complications like extensive muscular

paralysis and toxic effects.

2. Complications like hypotension and bradycardia are reduced.

3. Even in accidental subarachnoid block the cardio-respiratory involvement is

minimal, as these small doses used will act as subarachnoid block.

4. Economical.

In our study the following parameters were studied.

1. Volume of local anaesthetic used.

2. Level of sensory blockade achieved pre-operatively (using standard

dermatome map).

3. Level of sensory blockade achieved post operatively.

4. Effectiveness of block or quality of analgesia.

79

5. Onset and Duration of analgesia.

6. Complications encountered.

In our study site of puncture for epidural space is fixed (L1-L2) so as to block only

the segments involved in the field of surgery and keep the dose to minimum.

Along with the site of injection, posture of the patient was also important so as to get

a denser block on the operative side.13 Hence with the patient on the side of surgery

the slow injection of small volume of drug permits gravity to deposit all the solution

on the dependent side to block the nerves which supplies the region involved in the

surgical procedure thereby minimising the complications associated with large

volume.59

Volume of the drug used:

Sicard stated that spread of analgesia depends upon the volume of the drug injected.12

Cedric Prys-Roberts and Andrew M.S.Black stated that segmental epidural block with

local anaesthetic is far more satisfactory when placed at correct vertebral level and in

more than 90% patients undergoing lower abdominal surgeries where block required

is between T10-L2 the volume of local anaesthetic required is 5ml.52

Studies conducted by Dr.M.H.Rao, and Dr.Phani Thota, on Segmental dose

requirement of epidural lignocaine stated that dose required to block each segment in

males was about 22.3mg/segment and in females about 19.7 mg/segment.50

Based on these studies volume of the drug injected by us was 5 ml, so as to limit the

spread to only the segments involved in the field of surgery.

80

In this study, a majority of patients (53 patients) who received 5ml the analgesic

effect was found to be satisfactory. 22 patients received 6 ml, 16 patients 7 ml and 9

patients received 8ml. It is observed that the majority of patients who required the

additional topups upto 7 and 8 ml were younger age group. This can be explained by,

in younger age group the spread is minimal due to spillage of drug through the patent

intervertebral foraminae. But escape of fluid is reduced to minimum in the elderly

patients due to the stenosed intervertebral foraminae which can be observed by the

largest spread of volume as seen in two patient aged 70 and 65 years, where the

spread was upto T8 with 5ml of drug.

The mean volume of drug is 5.8 ml. The TABLE XVIII shows that, with the increase

in age the volume required decreases.

Level of sensory blockade achieved pre-operatively and post operatively:

While using the minimal quantity of local anaesthetic drug of 5 ml, the extent of

spread of analgesia was tested 5-10 minutes after the block was given and at the end

of surgery. The extent of analgesia was elicited with the help of pin prick.

Bromage in 1954 demonstrated that there are two mechanisms in the spread of

analgesia, one by the longitudinal spread and the other by neuraxial spread. Diffusion

gradient appears to be important in relation to solutions of small volume but of high

concentration. With these small volumes of concentrated solution longitudinal spread

in the epidural space is presumeably confined to a fewer segments but neuraxial

spread is extensive owing to the concentration gradient blocking more segments

which was seen at the end of surgery. The same has been corroborated in this study

81

after the block and before starting of the surgery the longitudinal ascent of analgesia

with the small volume was minimal, affecting only few segments. Whereas at the end

of surgery the spread was definitely wider than what it was in the beginning which

was probably due to the neuraxial spread owing to the diffusion gradient with higher

concentration solution of 0.5% Bupivacaine.

Bromage in 196215 has also drawn attention to the exaggerated spread of epidural

analgesia in atherosclerotic patients. 56 patients who were severely atherosclerotic

reacted to 2% ligocaine as if they had received the drug of higher concentration than

that. It is probable that the degenerative changes in the connective tissue associated

with atherosclerotic disease produces increased permeability of neural coverings.

Furthermore sclerosis of vasa nervosium hastens the neural degeneration of myelin

sheaths which occur with increasing age, thus bringing the solution more readily into

contact with the axons of the posterior nerve roots.

In our study, even with 5 ml of local anaesthetic when injected at L1-L2 in elderly

patients (60 years and above) it has been found that the spread has been usually high

(T8).

Effectiveness of block or quality of analgesia:

In the present study we graded 53 patients as excellent analgesia and relaxation, i.e.

patient comfortable, analgesia and surgical relaxation adequate no supplementation is

required during surgery.

82

34 patients had good analgesia and mild discomfort during surgical procedure, which

required Additional top-ups of local anaesthetic at an incremental dose of 1 ml.

10 patients had analgesia graded as fair where mild discomfort was present even after

additional top-up of epidural local anaesthetic; These patients were given an analgesic

dose of Inj.Fentanyl 1 μg/kg IV to alleviate the pain.

3 patients had severe intolerable pain during surgery, requiring conversion to general

anaesthesia.

It has been observed by various authors that at the time of traction on the sac, patients

often complain of discomfort.60 This finding was observed in 9 patients in our present

clinical study.

Onset and Duration of analgesia:

Many studies did not mention about duration of analgesia.

A study conducted by Hollman A et al. In 418 parturients, the onset of analgesia was

rapid that is 3-5 mins and the duration was on average 150 mins.41

In a study by Prys Roberts and Andrew Black, stated that in 90% of the patients

undergoing lower abdominal surgeries where block required is between T10-L2 the

volume of local anaesthetic required is 5 ml and the duration of block with

Bupivacaine 0.5% is limited to 3-4 hours.52

83

In the present study mean onset of analgesia was 8.09 minutes and mean duration of

analgesia was 167.42 minutes (120 min – 240min).

In the present study onset of analgesia was relatively late and duration of analgesia

correlates with studies done by Hollman A et al.

Complications encountered:

Hypotension: Criteria for hypotension was taken as a fall in systolic blood pressure

more than 20% of patient’s basal reading.

Odom (1936), Guiterrez (1939), Doglitotti (1939) and Dawkins (1954) claimed that

the hypotension in epidural block is less than that from spinal analgesia. But the

works of Bromage (1954) and Bonica et al (1957) found that the extent of fall in

blood pressure is similar in both the techniques, speed of onset is slow in epidural

analgesia.

Factors contributing to the hypotension in epidural block have been enumerated as the

advanced age of the patient, high volume of the drug and height of the block.

In our study as the volume of the drug used is minimal and height of the block is

limited, thereby the incidence of hypotension is nil.

Only 4 patients had a 15-17% fall in blood pressure, in 20 patients 10-15%, in 50

patients 5-10% and in 24 patients 1-5% fall in blood pressure. TABLE XVI Shows

that percentage of fall in blood pressure increases with the increase in age.

84

Inadvertent Dural Puncture: The incidence of dural puncture was claimed to be low

with thoracic epidurals than with lumbar epidurals. Dawkins and Steel (1971) claimed

to be as 1.6% in 282 cases of thoracic epidurals as against 2.6% in 397 cases of

lumbar epidurals. This is because of the obliquity of the anatomy of spinous

processes.

In this present study there were 2 cases of dural puncture. These cases were

withdrawn from the study as the epidural puncture site was fixed at L1-L2.

In 9 cases symptoms of sweating are seen, majority of these cases were under fair or

poor quality of analgesia groups. So poor quality of analgesia may be the reason for

sweating. The symptoms were decreased after the analgesic dose of Inj.Fentanyl IV.

5 patients complained of shivering, was relieved by sedation.

Other complications like massive subarachnoid block, massive extradural block, toxic

reaction to local analgesic drug, bradycardia, respiratory depression, nausea and

vomiting, retention of urine and any neurological complications were not encountered

in the present study.

85

CONCLUSION

It can be concluded that

Segmental epidural block with 5-6 ml of 0.5% Bupivacaine is found to be safe

and fulfils the surgical requirement.

Could be successfully employed for inguinal hernia repair with limited spread

of analgesia involving only few segments.

Fall in blood pressure and other complications were very minimal.

This technique can be safely used in elderly patients.

In respiratory and cardiac cripple, this segmental epidural analgesia is safest

mode of regional anaesthesia.

In fit patients ideal as a day care anaesthesia.

86

SUMMARY

A clinical study “SEGMENTAL EPIDURAL BLOCK FOR INGUINAL HERNIA

REPAIR” was undertaken at the Department of Anaesthesiology, M.V.J. Medical

College and Research Hospital, Bangalore during the period of September 2008 to

August 2010.

This study includes a brief outline of the historical events in the development of

Epidural analgesia, the physiological and pharmacological aspects including the site

of action of the drug and the factors affecting the spread of the epidural block.

The segmental epidural block denotes the use of a small volume enough to block only

the segments involved in the field of surgery. This was achieved by selecting the site

of puncture, position and speed of injection of the local anaesthetic drug.

The study population consisted of 100 patients undergoing Inguinal hernia repair of

ASA class I and II. All the patients were explained about the procedure and

anaesthetic technique and consent for the same obtained. Local anaesthetic test dose

was carried out on previous day. Patients were premedicated with oral Alprazolam 0.5

mg and Oral Ranitidine 150 mg on the night prior to surgery and 2 hours before the

surgery.

Each patients selected for the study was positioned laterally (on herniated side) on the

operation theatre table. With all aseptic precautions the epidural space was identified

at L1-L2 space , with 18G epidural needle 5ml of 0.5% Bupivacaine is injected very

87

slowly only to block the segments(T12-L2) involved in the field of surgery. Later

epidural catheter was inserted and secured and patient positioned back to supine

position.

Level of analgesia was checked by needle prick. After conforming the adequacy and

level of analgesia, the surgery was commenced. If the patient complains of pain

during needle prick, then injected local anaesthetic (0.5% Bupivacaine) with an

incremental dosage of 1ml at a time, till the complete onset of analgesia.

Irrespective of discomfort during hernia repair, Inj. Medazolam 1mg was given as a

sedative. Pulse Rate and Blood Pressure were recorded at an interval of 1 minute for

first 5 minutes and then every 5 minutes till the end of the surgery. Oxygen saturation

and ECG monitoring was done continuously.

Onset of analgesia, Level of analgesia (pre & post operatively), Duration of analgesia,

Total dosage of local anaesthetic used were recorded.

If the patient complained of discomfort even after additional top-up of epidural local

anaesthetic, an analgesic dose of Ing. Fentanyl 1 Mcg/kg IV was given.

The following observations were made from the present study:

Total study population 100 patients

Mean Age 42.65 years (18-70 years)

Sex M/F 97/3

Mean weight 57.65 Kgs (37-85 Kgs)

88

Mean height 165.16 cms (148-180 cms)

ASA Physical status I and II

Type of Hernia Direct / Indirect 27 / 73

Volume of Drug 5.8 ml (6-8 ml)

Duration of Analgesia 167.42 minutes

Quality of Analgesia

1) Excellent 53

2) Good 34

3) Fair 10

4) Poor 3

53% of patients had excellent quality of analgesia and relaxation. 34% patients had

good quality analgesia and relaxation, mild discomfort while handling sac. 10% of

patients had fair quality of analgesia and relaxation only. In 3% patients the epidural

block failed, in whom general anaesthesia was given. Overall success rate was 97%.

Complications

Intraoperative and post operative complications were very minimal. No cases of

hypotension, bradycardia, nausea vomiting, total spinal block and respiratory

depression were seen.

2 cases of inadvertent dural puncture, which were excluded from the study.

89

9 patients complained of sweating and 5 patients complained of shivering, which may

be due to inadequate analgesia or anxiety and successfully treated with Inj.Fentanyl 1

mcg/Kg IV.

From the present study it can be inferred that 0.5% Bupivacaine 5-6 ml is effective for

segmental epidural block for inguinal hernia repair. Segmental epidural block is safe

anaesthesia with minimal physiological alterations.

90

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96

ANNEXURE – I

“SEGMENTAL EPIDURAL ANALGESIA FOR INGUINAL HERNIA

REPAIR” – A CLINICAL STUDY

PROFORMA

Name: I.P.No: Age/Sex: Wt:

Kg Ht: cms

Diagnosis: Surgery: Date of

Operation:

Pre Anaesthetic Evaluation:

Cardiovascular system: PR: BP: Heart:

Respiratory system: RR: Lungs: Airway:

MP: MO: cm

Central nervous system:

Investigations:

BLOOD: Hb: TC: DC: CT: BT:

Bl.Urea: Sr.Creatinine: FBS/RBS:

HIV: HbSAg:

URINE: Albumin: Sugar: Microscopy:

OTHERS : ECG: CXR:

97

INTRA OP VITAL SIGNS:

Drug used:

Dosage:

Time of injection:

Level of injection:

Observations

mins

0 1 2 3 4 5 1

0

1

5

2

0

2

5

3

0

3

5

4

0

4

5

5

0

5

5

6

0

END of

surg

Heart rate

B.P.

Systolic

diastolic

Respiratory rate

SpO2

MONITORING SENSORY BLOCK

Onset of Analgesia:

Height of Analgesia pre op: Height post op :

Duration of Analgesia : Quality of Analgesia: E / G / F / P

SEDATION GIVEN:

SIDE EFFECTS DURING SURGERY:

1. Bradycardia

2. Hypotension: Fall in systolic: diastolic:

3. Respiratory Depression 4. Shivering 5. Nausea & vomiting 6.

Sweating

7. Inadvertent dural puncture

98

ANNEXURE – II

CONSENT FORM FOR ANAESTHESIA/OPERATION

I ……………….. Hosp. No……………..in my full senses hereby give my complete

consent for ………………..or any other procedure deemed fit which is a / and

diagnostic procedure / biopsy / transfusion / operation to a be performed on me / my

son / my daughter / my ward ………………age ………under any anaesthesia deemed

fit. The nature and risk involved in the procedures have been explained to me to my

satisfaction. For academic and scientific purpose the operation / procedure may be

televised or photographed.

Date:

Signature / Thumb Impression of

the Patient / Guardian

Name:

Place:

Guardian

Relationship

Full Address

103

KEY TO MASTER CHART

A Serial number

A1I.P. No.

A3Name

A4Sex

A5Weight in kilograms

A6Height in centimetres

A7ASA grade

A8Type of hernia : Direct- D : Indirect- IN

A9Volume of bupivacaine in millilitres

A10Injection level

A11Onset of analgesia in minutes

A12Preoperative sensory level

A13Postoperative sensory level

A14Duration of analgesia in minutes

A15Quality of block (Analgesia)

E-Excellent; G-Good; F-Fair; P-Poor

HEART RATE

A16Preoperatively

A17At 0 minute (immediately after block)

A18At 1 minute

104

A19At 2 minutes

A20At 3 minutes

A21At 4 minutes

A22At 5 minutes

A23At 10 minutes

A24At 15 minutes

A25At 20 minutes

A26At 25 minutes

A27At 30 minutes

A28At 35 minutes

A29At 40 minutes

A30At 45 minutes

A31At 50 minutes

A32At 55 minutes

A33At 60 minutes

A34At the End

BLOOD PRESSURE

A35Preoperatively

A36At 0 minutes

A37At 1 minutes

A38At 2 minutes

A39At 3 minutes

105

A40At 4 minutes

A41At 5 minutes

A42At 10 minutes

A43At 15 minutes

A44At 20 minutes

A45At 25 minutes

A46At 30 minutes

A47At 35 minutes

A48At 40 minutes

A49At 45 minutes

A50At 50 minutes

A51At 55 minutes

A52At 60 minutes

A53At the End

A54Fall in Systolic Blood Pressure

A55Percentage of fall in Blood Pressure

A56Side effects

A57Remarks

A A1 A2 A3 A4 A5 A6 A7 A8 A9 A10 A11 A12 A13 A14 A15 A16 A17 A18 A19 A20 A21 A22 A23 A24 A25 A26 A27 A28 A29 A30 A31 A32 A33 A34

SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST

1 63449 Munishammappa 65 M 60 167 1 IN 5 L1-L2 8 T8 T8 190 E 64 56 56 58 56 54 52 58 58 60 62 66 64 68 60 60 64 62 58 126 82 130 80 126 80 122 80 122 82 124 80

2 64077 Shanthamma 63 F 41 156 2 D 5 L1-L2 8 T12 T11 200 E 84 82 84 88 86 84 86 82 88 96 76 98 96 80 88 86 80 76 74 130 80 126 80 124 80 122 78 126 78 128 78

3 64737 Lakshmana 18 M 46 152 1 IN 8 L1-L2 6 T11 T10 240 G 78 86 82 82 84 86 80 80 78 72 76 68 80 78 76 82 80 74 74 124 80 128 84 130 80 124 80 128 74 126 82

4 64455 Fayaz Khan 48 M 64 168 1 D 5 L1-L2 7 T11 T9 180 E 70 80 78 76 78 80 82 88 88 90 86 88 86 86 84 84 88 86 84 110 72 120 80 122 82 116 80 118 80 116 80

5 64557 Salmath Khan 52 M 65 164 1 D 5 L1-L2 7 T10 T8 210 E 88 90 88 88 90 90 88 92 90 88 86 88 84 82 80 78 80 86 82 128 72 132 78 132 78 134 76 130 78 124 70

6 64522 Venkatesh 38 M 40 158 1 IN 8 L1-L2 0 0 0 P 70 84 86 86 88 90 86 88 88 90 98 96 106 110 98 78 72 76 78 110 70 138 80 136 78 138 78 142 78 148 78

7 64800 Govindappa 52 M 58 156 1 D 5 L1-L2 7.3 T10 T9 150 E 82 88 90 90 92 90 86 88 88 88 86 86 84 82 80 88 82 86 86 128 80 138 90 136 88 124 82 128 80 126 84

8 64300 Shivappa 37 M 57 160 1 IN 7 L1-L2 8.3 T10 T9 170 G 86 82 82 82 82 86 84 86 86 88 88 84 82 84 78 82 80 80 80 124 84 130 86 128 84 128 86 126 82 134 88

9 66429 Venkataravanappa 41 M 73 169 1 IN 6 L1-L2 7 T11 T10 180 G 84 110 112 116 112 112 110 108 110 98 104 98 102 100 98 94 98 92 96 136 90 122 74 120 72 118 72 120 70 116 70

10 65837 Manjunath 26 M 49 158 1 IN 8 L1-L2 9 T12 T10 200 F 86 88 86 86 84 82 80 82 80 82 86 88 88 78 80 82 84 84 82 110 70 124 78 128 76 120 76 126 78 128 80

11 65444 A.Nagaraj 25 M 60 168 1 IN 5 L1-L2 7 T11 T10 180 E 86 86 82 82 84 86 80 80 86 72 76 62 70 62 64 66 60 62 70 126 80 128 84 128 82 128 82 126 80 122 80

12 66411 Venkataswamy 25 M 58 166 1 IN 7 L1-L2 9 T11 T10 210 F 92 98 96 96 92 94 94 92 94 92 92 88 90 94 86 92 88 92 96 128 90 138 88 140 94 136 96 128 90 130 92

13 66620 Nagarj 38 M 75 166 1 D 5 L1-L2 12 T9 T7-8 180 E 88 86 88 84 84 82 82 86 88 88 86 88 88 82 86 88 86 86 88 120 86 122 90 124 88 126 86 124 88 124 84

14 66885 Chikkanna 48 M 58 154 1 IN 5 L1-L2 8 T12 T10 180 E 86 90 92 90 88 86 88 86 84 84 86 78 76 84 78 76 78 78 76 120 82 122 80 120 80 122 80 124 86 120 80

15 66890 Anjanappa 49 M 62 160 1 IN 5 L1-L2 7 T10 T8 140 E 86 88 88 90 86 92 88 94 90 92 88 92 90 88 86 86 88 84 82 128 90 132 94 128 92 130 94 126 92 128 90

16 67763 Nagappa 55 M 49 158 1 IN 5 L1-L2 9 T11 T10 150 E 84 78 78 80 78 76 76 78 74 82 78 80 82 78 80 80 78 74 72 100 70 118 76 116 76 116 74 114 72 116 72

17 68226 Rudrappa 51 M 57 156 1 IN 6 L1-L2 8 T10 T8 210 G 86 90 88 92 94 92 90 90 90 82 88 86 82 88 88 88 86 86 88 150 86 148 92 148 90 148 90 148 90 140 90

18 68261 Prabhakar 46 M 46 164 2 D 5 L1-L2 9 T11 T10 190 E 86 82 82 82 84 84 84 86 86 82 84 84 80 84 92 82 90 80 78 124 82 132 80 134 80 132 78 130 80 128 80

19 69641 Bhavani 27 F 46 150 1 IN 7 L1-L2 7 T11 T10 200 F 88 90 88 92 94 90 86 82 86 88 86 80 84 90 88 86 84 84 92 136 82 136 84 138 86 136 84 136 84 134 84

20 69951 Sudharani 22 F 37 158 1 D 5 L1-L2 6.3 T10 T8 130 E 74 88 86 88 90 92 90 94 90 86 88 86 82 88 80 86 84 86 92 128 72 134 78 134 78 132 78 130 72 132 72

21 68640 Kiran 29 M 68 172 1 IN 6 L1-L2 8 T10 T9 180 G 86 86 88 88 88 88 90 86 88 84 82 88 86 88 86 90 84 94 92 130 82 136 84 136 84 130 82 128 78 128 78

22 69680 Venkateshmurthy 32 M 64 164 1 IN 5 L1-L2 7 T10 T8 130 E 96 106 100 100 98 96 92 106 98 100 98 98 98 94 96 98 94 98 96 126 84 130 90 128 92 130 90 138 94 138 90

23 71056 Machaiah 46 M 53 168 2 D 5 L1-L2 7.3 T10 T8 120 E 90 92 90 90 94 90 86 88 84 94 88 90 92 88 86 84 84 86 90 138 80 140 86 138 86 138 86 140 88 136 86

24 71203 Kodappa 65 M 56 164 2 IN 8 L1-L2 0 0 0 P 86 86 84 84 82 84 84 90 98 106 108 100 102 98 90 88 88 86 88 150 86 146 86 138 84 140 88 142 88 146 90

25 71416 Kodandaram 40 M 64 174 1 IN 5 L1-L2 7 T10 T9 140 E 88 82 78 76 76 76 78 74 74 74 72 76 78 76 78 76 76 78 82 126 82 130 72 128 64 122 60 118 60 122 64

26 71641 Narayanappa 40 M 63 178 1 D 6 L1-L2 8 T10 T9 200 F 98 100 100 94 98 98 100 92 90 92 90 92 92 92 94 94 88 96 96 120 78 128 80 126 80 120 74 118 72 120 78

27 67183 Lakshmanna 50 M 55 156 1 D 5 L1-L2 7.3 T10 T8 170 E 76 90 92 92 100 88 92 90 94 86 88 88 86 80 84 88 90 86 88 132 84 138 88 138 90 130 82 130 80 128 80

28 71553 Subramani 36 M 50 164 1 D 5 L1-L2 8 T9 T8 160 E 70 80 78 82 84 82 80 86 86 90 88 88 86 82 80 82 80 88 84 110 72 120 80 122 80 116 80 118 80 116 80

29 71890 Sudhakar 35 M 50 160 1 IN 6 L1-L2 8.3 T9 T8 200 G 82 88 86 88 82 84 82 84 84 80 82 80 78 82 80 86 80 88 84 136 80 140 80 138 80 136 82 138 82 136 84

30 72352 Rajanna 43 M 63 172 1 IN 5 L1-L2 7 T10 T8 170 E 78 88 88 82 84 82 80 80 84 86 84 84 82 86 88 84 86 86 88 132 80 138 80 138 78 138 82 136 80 136 82

31 72363 Nagesh 38 M 49 164 1 IN 5 L1-L2 7.3 T10 T9 180 E 78 86 88 86 84 86 84 86 88 82 80 82 82 86 84 84 88 80 84 130 80 134 82 132 82 130 80 130 80 130 80

32 72444 Murthy 45 M 58 171 2 IN 5 L1-L2 7.3 T11 T9 180 E 78 86 90 84 82 80 80 84 84 90 86 88 88 88 90 82 86 82 86 128 74 130 76 132 74 124 74 132 78 130 76

33 72593 ChanneGowda 47 M 68 178 1 IN 7 L1-L2 8 T10 T9 210 F 70 88 86 84 82 84 82 86 88 86 86 84 82 84 80 82 80 78 80 118 76 126 84 124 82 128 80 130 74 128 72

34 73002 Nandan 32 M 54 172 1 D 5 L1-L2 8.3 T10 T8 140 E 86 88 90 86 82 80 78 76 70 70 72 82 80 82 88 82 80 80 86 126 80 132 80 132 78 130 78 130 78 130 78

35 73130 Abhishek 29 M 51 161 1 IN 5 L1-L2 7.3 T10 T9 150 E 90 100 98 100 102 100 98 98 100 82 90 86 92 86 90 90 96 90 88 126 80 124 70 122 74 124 72 128 74 126 76

36 73174 Yuvraj 36 M 53 174 1 IN 6 L1-L2 7.3 T10 T8 180 G 86 88 86 88 88 86 80 80 76 84 78 82 80 82 86 88 86 88 86 128 80 132 90 130 90 130 90 132 88 132 86

37 73343 Nagendra 39 M 39 168 1 IN 5 L1-L2 6.3 T9 T8 130 E 86 90 88 86 84 82 82 82 80 84 80 88 88 84 82 88 86 88 88 136 78 132 80 132 84 132 80 130 80 130 78

38 73555 Ramaiah 55 M 50 160 2 D 5 L1-L2 6 T10 T9 120 E 96 110 116 112 114 112 110 126 124 136 120 130 128 116 118 108 112 104 100 150 90 150 90 148 90 146 90 148 88 138 98

39 73861 Mallikarjun 46 M 50 164 1 IN 7 L1-L2 9 T10 T8 180 G 86 90 88 90 92 86 84 86 84 86 82 88 84 84 86 88 88 86 84 136 82 140 82 140 84 138 82 136 80 132 78

40 74178 Muniraj 53 M 64 170 1 D 8 L1-L2 7.3 T11 T10 170 G 86 90 90 88 90 88 88 86 88 84 86 84 86 84 82 90 90 88 86 128 76 130 78 132 78 128 76 128 78 132 80

42 73901 Narayanappa 70 M 68 158 1 D 5 L1-L2 6.3 T10 T9 140 E 68 88 80 80 86 82 86 84 82 80 76 76 78 82 80 80 78 82 80 144 88 140 88 140 86 138 86 132 80 136 82

43 75395 Ravikumar 42 M 65 172 1 IN 6 L1-L2 7 T11 T10 150 G 92 90 92 92 96 90 90 84 86 88 86 82 88 88 86 84 82 84 86 134 80 136 88 138 88 132 86 136 84 138 88

44 75750 Rajesh 43 M 72 176 1 IN 5 L1-L2 7.3 T10 T10 130 E 78 80 78 84 82 80 82 84 80 76 78 82 80 80 76 80 78 78 84 136 80 136 80 136 78 132 76 134 78 130 76

45 75967 Varun 38 M 49 158 1 IN 6 L1-L2 9 T10 T9 135 G 86 90 88 82 86 84 80 82 78 82 80 88 82 88 78 86 78 86 88 128 80 130 80 132 80 134 80 132 78 130 76

46 75958 Shammi 37 M 49 168 1 IN 7 L1-L2 7.3 T9 T9 140 G 94 94 92 94 96 96 98 92 94 92 90 92 88 92 92 90 90 90 88 136 84 136 84 138 84 140 88 134 80 136 82

47 75383 Ravindraraj 55 M 64 178 2 IN 6 L1-L2 8 T10 T9 150 G 74 72 74 78 68 72 76 76 78 68 74 60 64 70 70 72 78 76 70 128 80 136 86 132 82 134 84 130 80 128 80

48 76846 Ravichari 40 M 58 164 1 IN 5 L1-L2 7.3 T10 T9 160 E 94 90 96 94 96 94 92 92 90 92 88 92 90 88 96 90 90 86 84 128 70 136 78 134 76 136 78 138 82 136 84

49 76831 Girish 30 M 62 168 1 IN 7 L1-L2 7.3 T10 T9 150 G 86 88 86 88 82 84 82 80 78 78 76 82 80 84 88 86 88 84 90 128 80 132 80 132 82 132 82 136 82 130 80

50 77114 Gangaraj 32 M 60 172 1 IN 6 L1-L2 8 T10 T8 140 G 92 92 90 90 88 84 80 92 90 92 88 86 86 82 80 84 84 88 86 134 86 130 78 128 80 120 86 142 100 140 94

A35 A36 A37 A38 A39 A40

99

A54 A55 A56 A57

SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST

122 80 120 80 120 78 120 76 118 76 122 76 118 72 118 68 118 70 112 72 110 68 110 68 116 74 20 15.38 NIL

126 76 120 78 124 80 128 80 128 80 126 80 128 82 128 80 130 82 130 84 130 84 130 86 130 84 6 4.76 NIL

124 86 128 80 132 88 136 82 130 80 132 78 128 84 126 82 136 80 130 78 128 78 134 76 132 82 4 3.13 NIL

112 78 110 82 110 76 118 74 112 72 114 72 114 74 120 82 122 78 118 78 118 76 116 74 118 76 10 8.33 NIL

126 72 124 74 122 78 124 76 126 72 128 72 126 76 124 70 120 70 122 72 126 74 124 74 126 74 12 9.09 NIL

129 80 126 78 145 88 146 90 136 80 130 78 128 78 128 80 126 88 130 88 132 80 132 82 128 82 SW INADEQUATE BLOCK-CONVERTED TO GA

130 86 132 88 138 94 136 92 136 90 136 88 136 88 134 88 136 90 138 92 130 84 132 88 136 88 14 10.14 SH

130 88 128 86 132 88 124 82 120 80 124 82 120 80 120 80 122 80 118 80 120 80 120 82 122 86 12 9.23 NIL

118 70 116 68 118 68 118 70 118 72 122 72 120 76 124 78 128 82 132 78 130 86 130 84 132 88 6 4.92 NIL

130 80 130 80 128 80 126 76 130 78 132 76 136 76 140 74 132 78 128 80 128 76 128 80 136 76 4 3.23 SW

124 82 122 77 124 74 118 72 118 70 120 68 120 68 124 66 118 68 118 70 124 68 124 70 124 74 10 7.81 NIL

138 92 136 84 136 88 134 86 136 86 130 86 130 84 128 84 130 86 130 86 130 84 132 88 132 86 10 7.25 SW

122 88 116 86 112 90 112 82 116 86 118 84 116 84 118 82 118 84 120 86 122 82 120 80 120 86 12 9.84 NIL

118 76 116 76 116 76 118 78 114 76 114 76 114 70 110 70 112 72 112 72 112 76 112 74 110 78 10 8.2 NIL

126 88 128 86 128 88 122 86 124 88 126 86 124 88 126 86 130 90 130 92 128 90 132 88 128 90 10 7.58 NIL

118 78 116 78 110 78 110 70 112 70 112 74 112 72 114 72 120 78 118 76 118 76 114 78 112 76 8 6.78 NIL

138 86 140 92 142 90 144 92 142 94 136 82 142 88 146 86 144 84 136 82 138 82 140 88 142 90 14 9.46 NIL

130 80 126 76 126 82 128 74 126 70 120 68 128 72 128 76 130 70 128 76 128 76 126 70 120 68 4 3.03 NIL

136 82 132 78 126 80 126 80 132 82 130 82 132 82 130 84 132 82 130 80 128 80 136 82 138 84 10 7.35 SW

132 72 138 74 140 78 130 80 132 78 132 78 128 70 126 70 126 72 128 74 128 72 130 74 130 78 8 5.97 NIL

130 78 130 84 132 84 126 82 128 80 136 82 130 82 132 82 134 84 130 80 126 78 128 82 126 80 10 7.35 NIL

140 96 136 92 138 88 134 90 138 94 136 92 136 88 134 88 136 90 138 92 130 86 132 88 136 88 2 1.54 NIL

136 86 146 82 138 82 138 82 154 82 150 78 148 78 150 82 134 82 136 84 136 84 136 86 136 90 12 8.57 NIL

134 84 130 88 138 82 128 80 130 86 136 88 142 90 128 84 132 86 136 84 132 82 138 90 142 86 18 12.32 SW INADEQUATE BLOCK-CONVERTED TO GA

120 62 120 64 126 64 130 66 136 66 142 74 142 74 142 76 144 76 150 76 146 74 146 76 148 72 12 9.23 NIL

122 76 124 76 124 76 124 74 124 74 122 70 122 70 116 68 116 68 116 70 116 70 128 76 126 76 12 9.38 SW

130 80 132 82 130 84 130 80 122 78 124 80 132 80 128 82 126 80 128 82 130 80 128 80 126 82 16 11.59 NIL

112 78 110 82 110 76 118 74 112 72 114 72 114 74 120 82 120 82 118 78 122 78 116 74 118 76 10 8.33 NIL

134 88 132 78 134 74 126 72 132 72 128 70 134 72 132 74 130 72 134 74 132 76 136 74 138 76 14 10 NIL

130 84 128 82 128 80 124 72 128 80 128 80 130 82 132 82 128 80 126 80 126 78 126 74 128 78 12 8.7 NIL

128 80 120 78 120 72 122 72 120 70 124 72 128 74 126 76 130 76 132 78 128 80 126 78 134 86 14 10.37 NIL

126 74 128 76 124 72 126 76 126 76 126 76 124 72 124 72 128 76 128 76 128 74 128 74 126 72 6 4.62 NIL

128 70 128 80 128 82 126 84 128 82 126 80 128 82 126 84 124 82 122 80 120 78 124 80 122 82 6 4.76 SH

124 76 118 68 120 80 128 82 132 86 126 74 124 80 126 90 124 86 122 84 124 86 128 82 132 74 14 10.61 NIL

130 74 132 72 128 74 124 76 126 72 124 74 126 72 122 70 124 72 126 78 128 78 126 76 132 74 2 1.61 NIL

132 88 130 82 128 80 124 80 122 78 124 76 120 84 118 82 122 80 120 78 120 80 122 78 128 84 12 9.09 NIL

128 76 126 76 128 78 122 72 124 72 128 72 124 74 122 74 122 70 128 72 122 72 124 74 128 74 10 7.58 NIL

142 88 140 86 140 88 128 86 132 88 132 94 138 94 138 92 138 92 138 90 130 90 138 92 146 92 20 13.33 NIL

132 76 134 80 136 84 132 76 136 78 136 74 136 74 138 76 138 76 132 78 134 80 136 82 134 78 8 5.71 NIL

130 80 132 82 132 80 130 80 124 78 122 76 126 74 124 72 128 78 134 84 128 80 132 86 130 84 8 6.15 NIL

128 84 120 80 118 76 124 80 138 86 138 88 138 86 136 84 136 84 138 88 140 88 136 86 138 88 22 15.71 SH

136 88 132 82 132 82 130 80 130 80 132 82 132 82 126 74 126 74 134 82 134 82 130 80 136 80 10 7.35 NIL

134 78 132 76 132 76 132 72 132 72 130 72 130 70 134 74 134 74 138 76 138 76 140 80 136 78 6 4.41 NIL

130 76 130 74 130 76 134 80 132 82 134 80 132 76 134 78 132 76 136 78 130 72 132 74 136 78 0 0 NIL

132 82 134 84 132 82 134 80 134 82 134 86 132 82 136 86 132 80 132 80 130 82 134 84 132 80 6 4.41 NIL

120 72 124 76 120 72 122 74 124 72 122 72 124 74 120 70 122 74 128 76 136 86 128 82 134 88 16 11.76 NIL

134 80 132 70 132 70 134 72 124 74 126 72 124 74 122 72 122 70 126 68 126 70 128 72 130 70 6 4.41 NIL

128 82 120 84 122 82 126 82 128 84 132 86 128 82 130 84 132 82 130 80 128 88 120 78 132 78 12 9.09 NIL

128 92 158 106 148 106 156 110 158 106 148 116 156 110 128 80 148 116 132 88 128 80 140 98 142 96 10 7.69 NIL

A44 A45 A46A41 A42 A43 A53A47 A48 A49 A50 A51 A52

99