The anesthetic procedure will be standardized. Pre anaesthetic evaluation and relevant investigations will be advised with standard nil per oral instructions. In the preoperative area patient will be connected to monitors and baseline Systolic Blood Pressure (SBP), Diastolic blood pressure (DBP) , Respiratory rate (RR) ,Heart rate(HR),Oxygen saturation (SPO2) will be monitored and study drug will be prepared by the nurse not involved in the study.  In the pre operative room, intravenous line of 18 G are established. Patient is started with 500ml of Ringer lactate solution.A brief explanation of the procedure and the type of anaesthesia to be given is explained to the patient.  Once the patient gets shifted inside the OT, all the monitors are connected.Patient’s basal parameters –Heart rate, saturation, blood pressure and ECG, will be monitored using pulse-oximetry, non invasive blood pressure and ECG monitor. Under sterile aseptic precautions parts painted and draped patient in sitting or lateral position, under local anaesthesia,using midline approach, Lumbar puncture is done under the L3-L4 intervertebral space using 25G Quinckes spinal needle, once the clear and free flow of CSF is noted ,Inj.Bupivacaine 0.5% (H )of 2ml without additive agents is given, after the spinal injection patient is repositioned.
Pudendal nerve block was performed after the spinal Anaesthesia, a low- frequency 2–5-MHz curved array ultrasound Probe allowed the visualization
of important landmarks: the Ischial spine, pudendal artery, sacrospinous ligament, Sacrotuberous ligament, and pudendal nerve. After sterile skin And probe preparation within a transparent plastic sheath,Scanning is performed in transverse planes to visualize the Ischium forming the lateral border of the sciatic notch. By Moving the ultrasound probe in a cephalad-caudal direction,The ischium appears as a progressively lengthening Hyperechoic line that is widest at the ischial spine level. The Ischium is initially seen as a curved
line as it forms the Posterior aspect of the acetabulum. When the probe is at The ischial spine level, the ischium will appear as a straight Line. At this level, a color Doppler is used to localize the Internal pudendal artery pulsations in close proximity to the Ischial spine. The inferior gluteal artery is often seen as another arterial pulsation lateral to the tip of the ischial spine and is Accompanied by the sciatic nerve—mistaking this artery for The pudendal artery could result in sciatic nerve block. The Sacrospinous ligament will appear as a hyperechoic line in continuity with the ischial spine, with lower echogenicity than Bone. Similarly, the sacrotuberous ligament is seen as a light Hyperechoic line deep within the gluteus maximus muscle and appeared parallel and superior to the sacrospinous ligament. The localization of the pudendal nerve is targeted in the Plane between these two ligaments. Under ultrasound guidance, a peripheral nerve–stimulating needle is inserted and Advanced in line with the ultrasound probe, medial to the Internal pudendal artery. Once the needle passes through the Sacrotuberous ligament, a “click†is usually felt and a small Volume (1–2 mL) of local anesthetic is injected. The solution appeared as a hypoechoic collection, in order to identify The plane between the sacrotuberous and the sacrospinous ligaments and to accentuate the pudendal nerve appearance.The needle is inserted medially toward the pudendal artery, as the pudendal nerve is generally located medial to this artery. Ten Milliliters of ropivacaine 0.75% was injected within this fascial plane, after negative aspiration. The procedure was then Repeated identically on the contralateral side.Thirty minutes later, if the sensation of the skin around the anus and the contractility of the anus is decreased this indicates that the pudendal nerve is successfully blocked
. After the completion of the surgical procedure patient gets shifted into the post Anaesthesia care unit where the vitals of the patients including the post operative pain will be monitored using the visual analogue scale (VAS) ( Annexure 4). Post operative pain on the visual analogue scale at 6 hours , along with opioid, NSAIDs administration and length of hospital stay is recorded. |