All sensory and motor assessments were made at 0,2,4,6,8,10,12,15,20,25 and 30 min and then every 15 min until the block was regressed completely unless sedation, anesthesia, or surgery prevented assessment. A single observer performed all assessments.
Assessments of parameters include:

1. Onset of sensory block ( time from epidural injection to the occurrence of sensory block at dermatome level T6)

2. Duration of sensory block (time for two segment regression).

3. Onset of motor block (time from completion of epidural injection to the time when

   Bromage grade 0 changed to grade 1)

4. Duration of motor block was assessed every 30min using Modified Bromage scale and

   RAM (rectus abdominis muscle) test.76

5. Duration of analgesia (time for rescue analgesia)

6. Hemodynamic changes - heart rate, blood pressure, respiratory rate and pulse oximetry

   saturation on every 5 minutes for first 30 minutes and thereafter measurement has been taken for every 10 minutes till the end of surgery.

7. Obvious side effects – nausea and vomiting, hypotension, pruritus, retention of urine, respiratory depression.
Sedation by fentanyl was assessed by modified Ramsay sedation score.

Modified Ramsay sedation score:

Score Clinical response

0. 0  Paralyzed, unable to evaluate

1. 1  Awake

2. 2  Lightly Sedated

3. 3  Moderately sedated, follows simple commands

4. 4  Deeply sedated, responds to non-painful stimuli

5. 5  Deeply sedated, responds only to painful stimuli

6. 6  Deeply sedated, unresponsive to painful stimuli

   All patients received balanced salt solution.

   Bradycardia, defined as heart rate (HR) <50/min, was managed by Inj. Atropine 0.6mg IV

bolus (may require repeatation). It was aimed to maintain the MAP between 65 and 85 mm Hg. Hypotension, defined by decrease in mean arterial blood pressure more than 20% below baseline or in normotensive patients, fall in systolic pressure below 90 mm Hg was treated with IV crystalloid fluid bolus and subsequently IV phrenylephrine and IV mephentermine bolus (titrated to patient response) as necessary. Persistent hypotension was treated with a bolus of 100-200ml crystalloids and maximally infused three boluses per hour according to clinical situation.

Analgesia was assessed by VAS pain score which is a linear pain scoring tool ranging from 0 to 100 mm where 0 means no pain and 100 means worst possible pain.

63

Rescue analgesia was administered postoperatively in the form of 8ml of either 0.125% solution of racemic bupivacaine or 0.2% ropivacaine respectively in group B and group R when VAS score > 40 or patient requested for analgesia.

Timing of first rescue analgesia and total analgesic doses within first 24 hours were noted. Analgesia was assessed by a trained research assistant with the visual analogue pain score (VAS), at rest and at coughing. Post-operatively VAS was noted two hourly till 24 hour of surgery. Top-up rescue drug (epidural local anesthetic) was given if patients complained of pain or when

VAS score was >40.