#i have 200000 different endings to this written

[dreaming-of-the-end]

lessons in fire, lessons in hate: Marella

A/N: this has been sitting in my drafts for too long. Comments/reblogs are better than the satisfaction that comes with being right!

Summary: Marella was fourteen when she began to hate fire.

What happened was this: she woke up engulfed in it.

TW: self hate, fire, swearing, tell me if I should add more!

Taglist: @steppingonshatteredglass @real-smooth @sunset-telepath   @stardustanddaffodils @jaxtheoraliestanner  @song-tam @turquoise-skyyyy @skycourthouse @silveredviolets @wu-marcy  @b-blurryyfacee  @rune-and-rising @lavender-and-rainy-days @chasteliac @confusedamphibian @hellomyfriends @cadence-talle @kai-i-guess @callas-starkflower-stew @a-harmless-poison @professionalwhalewatcher @theogony @keeper-of-the-jew-jew @gay-otlc  @confuzzled-fox @almostfullnerd  @athenswrites @synonymroll648

Marella was nine when she learned to fear fire.

The lesson was this: fire burns, and so do you.

Simple enough when everything in her life was so complicated. Complicated like when you take a step too far and feel your body start falling; complicated like how lemon juice squirts in your eye when you try to make lemonade; complicated like watching your mom cry from the staircase when she doesn't know you're looking.

So this was a simple rule.

Fire burns, and you will with it.

(unless...)

She learned to fear it, scribbling down the lesson in her mind, taking notes on what not to do and what to do. She learned so well that it was written into her very being. DNA is unchangeable? Well, she changed it to be afraid of fire, like everyone told her to, because every else didn't really have to learn to hate it.

Lack of self-preservation was a shitty side effect of being unique.

Yes, she memorized, watching her father's lips move as he taught his lessons and rules. Yes, fire is bad.

(...unless you're smart enough to avoid it. unless you're quick enough to run. unless you know not to love it, not to like it, not to look at it like that, Marella stop looking at it like that—)

...

Marella was eleven when she decided to fear fire.

She'd learned her lesson two years ago (about how things are complicated, and fire is simple), but never once had she believed it.

Rules were hard, and not following them was easy. Rules were hard, like when you shake out your clothes after a night on the floor because your mother isn't there to tell you to pick them up, like when you give up on lemonade and sprinkle sugar directly on the lemons wedges and eat them like that to savor the puckering sweetness, like when the girls at school make fun of you for having messy hair and messy braids and a messy life.

Rules were hard, especially the ones about fire and how she had to stay away.

She'd learned to follow the easy rules: show up to class, don't talk to the Vackers (especially the youngest), help your mother on her hard days (even if she couldn't quite adjust to letting her mother help her), and don't complain.

The last one was the hardest. But she learned well.

But this was worse than that. This wasn't a rule, this was a fact: fire is bad, and so is anyone who can use it, anyone who loves it, (anyone who looks at it like that Marella please stop looking at it like that—)

So, she decided, it was time to fear it.

First, she lit a match. Then, she set her favorite shirt on fire.

It burned faster than she'd expected. There was more smoke than she'd planned for, fanned into her face and making her eyes water, swallowed with the gulp of air she tried to take, sending her into a coughing fit. By the time she remembered to pour water on it, it had already spread to her carpet, growing until she drowned it with her ready bucket.

More smoke went up. She coughed. The fire went out. The smoke drifted out the window lazily, turning the pure sky briefly gray.

Her shirt (pink, with sparkles around the edges) was crumbled to ashes. A portion of her carpet (blue, fluffy, with a pattern of scattered purple petals) was blackened with fire.

Marella sat down in the middle of her ruined carpet and let her tears clear the smoke from her eyes. She waited for the smell in her room to go back to normal. Then she shoved the ruined remains of her favorite shirt into a bag and threw it away, cleaned her floor as well as she could with the water and towels from her bathroom, cut away the burned part of her carpet, and went downstairs like nothing happened.

Another thing she learned that day was that fire was hungry. It spread faster than water could reach it.

That was the day she decided to fear fire.

...

Marella was fourteen when she began to hate fire.

What happened was this: she woke up engulfed in it.

That was the simple answer, the easy answer. The complicated, the hard, the dangerous answer took longer to say. It's the danger of not looking before you leap, the danger of tilting your face to the sky and staring straight at the sun as long as you dare, the danger of taking a breath and another and another and smelling smoke instead of air. The danger of fire.

So the answer was dangerous, and it was that Marella imagined herself crumbling into dust like the shirt she'd burned. She imagined the carpet catching (she had a new one now, one that didn't have a big section at the ends cut away) and spreading to her parents and the rest of her house without her bucket of water there to stop it. She would be ash. She would be burned. She would be—

Warm.

She was so warm.

The only thing she could do was roll around her room to put out her fire, and scream. Scream from the pain that didn't exist, scream at the top of her lungs, the ones that weren't giving out from the smoke.

Something thudded, and then she was choking, losing her air, clutching at her throat, burning and dying and she couldn't breathe—

Air flooded her lungs and tears flooded her eyes as she gulped down air, knees stinging on her ruined carpet.

Her clothes were steaming.

"Marella—" Arms encircled her, flinched back. "Marella, you're burning hot. Boiling. Are you all right?"

"Does it look like I'm all right?" she forced out, a tear dripping down her cheek. She tried to wipe it away, but it had already evaporated. Her skin didn't feel hot to her. Her throat was the only part of her still on fire.

Her dad's face appeared in front of her, creased. "Look around you."

She did.

Her room was ruined. Blackened, charred, smoky. Her bedsheets, her closet, her carpet. The door to her bathroom had blackened, but was far enough away to be fine. Everything on her desk was in ashes. She would have to think of new excuses for her half-finished homework.

Heat swirled around her.

She could feel it in the air, in her very blood. It wanted her to touch it, wanted her to let it spill from her hands, to dance and twirl around her destroyed room with her. Hungry, hungry, hungry.

"Where did the fire come from?" Marella asked dully, staring at her hands.

Durand brushed a finger down her cheek, wiping away a tear. He winced like she'd burned him. Maybe she did. "I don't know."

But he did.

He did know.

And so did she.

"Your mother called a Regent when we realized there was a fire, Mare. They're coming now." Durand placed a hand on her knee, protected by a layer of still-hot pajama pants. They were an old pair, sparkly and pink from when she liked that sort of thing. His eyes searched hers, matching blue finding each other in the remnants of smoke. "They're coming here."

She sucked in a quick breath, choked, coughed. "Can you get rid of the smoke?"

"I took away your fire's air to put it out. I could blow away the smoke, but they're still coming here. It wouldn't dissipate in time."

Your fire, he said. Yours.

The doorbell rang from the end of a tunnel. "Where's Mom?"

"Waiting," he answered softly. Waiting for you to be safe. Waiting for the Regents to arrive. Waiting, waiting, waiting for it to be okay.

Marella stood on shaky legs. Durand stood with her.

The Regent had dark, deep eyes, like staring into an ocean. Dark skin, curls flopping around her head. Her ears were curved, but angled ever so slightly in a way that showed her age.

"What was the issue?" she was saying as Marella got close enough to hear.

"A fire," Caprise said, her voice strong. So this was a good day. Not a dangerous one. Not a hard one. Not a complicated one.

"Was it an accident?" This one knew who Caprise was. Knew what she was.

Was it an accident?

Marella started forward, but Durand placed a hand on her shoulder. "Yes."

"Of course. Where did it occur?"

Caprise looked at Durand, at Marella, her windblown hair, her unmarked skin. Her mouth tightened. "I set it. It was an accident, but it's out now."

Marella's eyes widened.

"How did you set it?" The woman wasn't surprised. Marella decided then and there that she hated her.

"During one of my moods." Caprise emphasized the last word too much, widening her eyes, making her bottom lip move when it shouldn't have.

Crazy Caprise. Where's your mom? Why isn't she here, Marella? Big talk from someone with a crazy mother, Redek. Why don't you let us come over to your house anymore? My dad says your mom is dangerous to be around. He says I can't sleep over unless she's not there. She might hurt me because she doesn't know what she's doing.

The woman nodded.

That was when Marella began to hate fire.

...

Marella is sixteen, and she doesn't know how she ended up here.

Here: hating herself like this.

Of course, she can trace every step that got her to this point.

She knows that Caprise falling off that balcony wasn't at fault any more than the person who pushed her. She knows that Sophie Foster didn't make Stina bully her after their friendship tore apart, and she didn't make Marella ostracize herself and hate every girl for being who she couldn't. She knows that Forkle didn't make her a pyrokinetic and Fintan isn't the reason she's dangerous and it isn't Biana's fault that she's too fucking beautiful.

Making everyone else at fault was an accident, and accidents happen all the time.

Accidents that she can count. Accidents like her mother's tumble, like Stina tripping her in the hall, like forgetting to flatten her uncombed hair before class or setting another fire or Gisela getting away for the millionth time or Keefe getting taken because Marella convinced Linh to take him underground.

If she burns the world down, it won't be an accident. It'll be the kind of burn that comes when lemon juice gets into a cut, when the sugar you tried to add turns out to be salt, when you aren't trying to catch yourself anymore because you fall down the stairs and land running, when you hear your mom crying and leave the house so you don't have to remember that you can't help anymore.

(she's crying because of you. because she found your plans to burn the world down. why'd you leave them out like that?)

She counts everything in her life, so why not mistakes? Why not dreams that never came true? Why not faults and blames, fires and flames, burned plans and lemons squeezed dry and flamed to charred bits of fragrant peel?

Fintan tells her that she shouldn't hate the fire erupting from her skin, that he doesn't hate his power even after everyone he's killed.

She can see it in him. How unafraid he is of himself, how proud he is of her power. Sometimes, she doesn't know if his satisfaction is in her or in the power constantly simmering in her veins.

"Don't be afraid of it, Marella!" he shouts constantly at her whenever they train. "Don't be angry! Fear and anger, this is how you lose control, of the fire and of yourself."

But fear and anger are all she has ever known. Fire burns, and she has to be ready to burn with it—

"It's everywhere!" she screams back, something in her voice breaking. The smoke is making her eyes tear up, and she's too afraid of crying to keep going. She puts out the flame with a twist of her wrists and falls to her knees on the ground, clothes steaming. She wishes Linh were here. "It's everywhere. All the fucking time. It's all over me."

"That's your burden. And your gift." Fintan's anger is clear in his voice. She's failed again. No fake pride today. "Start feeling the sun instead of wishing it was night."

"The sun shouldn't feel like fire ants when I use it." Her nails dig into the skin on her arms. "I can't forget it. I can't ignore it. I can't use it. Fintan, it hurts so bad. It hurts so bad."

"If you can't ignore it, then stop trying to. You are not afraid of your gift, you are not afraid of me." He's stone-cold like she's not on fire. "What are you afraid of?"

Her tears steam up as they fall. "Everything."

[urupotter]

I’ve been staring at your icon for like five minutes trying to puzzle it out and I’m just gonna bite and ask who’s your header and icon. (I love your blog btw! You always bring such refreshing takes to the HP fandom and it’s always nice to see someone else who’s a Snape fan but doesn’t hate the Marauders. Your philosophy posts are always interesting too, I might not understand some of them but your discussions are always pretty intriguing) Anyways! Hope you have a pleasant rest of your day man

Thank you for the kind words!

As for who are the people in my header and icons, that’s a very interesting question, which I’ll happily answer :) The answer is quite long however, so I’ll add a cut.

All the men represented are related to South American football, specifically Uruguayan and Argentine football. Football is my favorite sport to watch and among my favorites to play (even though I’m very bad at it hehe), and since football is the most important sport in our country by far I enjoy reading about its history here. I chose both pictures because they are in some way relevant to that and I think they look cool. 

The men in my icon are the Uruguayan Oscar Washington Tabárez and argentine Gabriel Batistuta, with the man in the suit being the former and the man in the jersey the other. Tabárez is a famous coach, who has been coaching the Uruguayan national team for around 15 years. He revolutionized it, and the team is now back to a respectable level, if not quite its glory days in the first half of the XX century. The picture depicts an event in 1991 in Santiago, Chile where Tabárez got involved in a fight that had broken out between the players of the team he coached at the time (argentine club Boca Juniors) and the chilean club Colo Colo. He was hit with a camera which left his face bloody. Nothing too out of this world for South American football, but still pretty cool. 

The header is more interesting. It shows Obdulio Varela, the most revered and legendary figure in Uruguayan football history. He was the captain of the nation team during the 1950 world cup, where Uruguay won the cup for the second time, in what is considered by many to be the greatest final (and achievement) in the history of the sport. The “Maracanazo” as it came to be know, coined after the name of the stadium in which the final was played, the Maracaná. 

If I said that it was something out of a movie it would be understating it. It is so ridiculously epic that if a movie included it you would laugh at the forced drama. 

In the prelude to the world cup, Brazil was desperate to win their first world cup. While football was already extremely important, Brazil had not yet won the titles that would establish it as the premiere football country in the world, and was desperate to be crowned. So, it decided to host it, as being host gives the host a considerable advantage and increases the chances of victory, and makes victory that much sweeter since the team can celebrate with the whole country.

The tournament was not structured the way it is now, and after the group stages instead of the teams being bracketed, an additional group was made for the four teams who had won classified out of the group stages. They would all play against each other, and whoever won the most points would be champion.

While not officially a final, the last game of the group stages became a final de facto, because the outcome of that game would decide the champion between the teams playing. It was played on the 16th of July in 1950, in front of approximately 200000 spectators, the highest number in any football game before or since. The favored team to win was Brazil, who had won the previous two games and had a total of four points (at the time victories gave two points instead of three). Not only had they won, but they had amply demonstrated their superiority over the other teams, winning 7-1 and 6-1, against Sweden and Spain respectively. Uruguay on the other hand had three points, having tied 2-2 against Sweden and squeaked a 3-2 victory against Spain. This meant that for Uruguay to win the cup the only acceptable result was victory, as a tie would crown Brazil on goal difference.

The atmosphere in Brazil was unbelievable. Not just the stadium being ridiculously packed, but the Brazilian media had created such an aura of victory that most everyone took Brazil’s victory as a foregone conclusion. 

The main newspapers of Rio de Janeiro (the city where the final was played) already had covers proclaiming Brazil as world champion, before the game had even began. 500000 shirts with the inscription “Brazil - 1950 world champion” had already been sold. The Maracaná even had banners that said: “Glory to the world champions”. A band had been hired and instructed to play the national anthem of the winning team, but had only been given the Brazilian anthem, as They believed that knowing the Uruguayan one was unnecessary. On their own initiative the band had even made an additional song, titled “Brazil Champions!” The Brazilian government had even minted celebratory coins with the image of the players of the Brazilian team. FIFA also got swept up in the atmosphere, as the president at the time, Jules Rimet, had even written a speech in portuguese (he was French) in honor of the Brazilian champions.

The favoritism even reached the Uruguayan authorities. A few hours before the beginning of the game, the national team where visited by the embassy, who said that all they asked was that they “lose in a dignified manner”, so as to not shame the country. Even the team coach was pessimistic, believing victory impossible, and he had asked his team to play defensively to avoid being crushed.

Obdulio however, knew that this wasn’t they could play if they ever wanted to win. After the coach had left, he gathered his team and said “Juan is good man, but he’s wrong this time. If we play defensively, they’ll destroy us like they did Spain and Sweden.” 

The game began. While the Brazilian side was dominant, they didn’t manage to score any goals, and so the first half ended without incident. However, once the second half began, disaster struck, as Brazil scored the first goal of the match at 2′. The celebration from the locals was unbelievable, and there were even a couple fireworks. Varela realized that something was necessary to disrupt the game, since if this was allowed to continue the Uruguayans would lose confidence, while the Brazilians would even more motivated. So he went to complain to ref about a supposed off-side in the Brazilian goal, even though he explicitly knew that the goal had been perfectly valid. Since the referee was English and didn’t speak Spanish, and he didn’t speak English, this devolved into an absurd discussion which lasted several minutes. This effectively killed the Brazilian team’s momentum. 

The result of this tactic made themselves known in the 21′ minute, when Juan Alberto Schiaffino scored to tie the game. Will this cooled the audience somewhat, as they hadn’t been expecting it, they were still optimistic, as tying would still give Brazil the title.  

Finally, in the 34′ minute, Varela started a play that ended with the ball at Alcides Ghiggia’s feat at the right wing, who fainted that he was going to centre the ball, and instead tried for the goal. He scored. Years later, Ghiggia would say, when recalling the game: “Only three people have ever silenced the Maracaná. The Pope, Sinatra and me.”

Now desperate, the Brazilian team tried everything in it’s power to turn back the result, but it wasn’t enough, and 11 minutes later the game ended and Uruguay were crowned champions. 

To say that the result was unexpected would be an understatement. All celebrations were cancelled, the marching band played no songs and there was no award ceremony, but rather the FIFA president discretely handed the World Cup trophy to Varela, who was captain. 

Jules Rimet’s recollection of the game is striking. 

“Everything was already accounted for, except for Uruguay’s victory. At the end of the game, I was supposed to hand the cup to the captain of the winning team. A showy guard of honor would form form the tunnel to the center of the pitch where the captain of the winning team would be waiting (naturally Brazil). I prepared my speech and went to the locker rooms shortly before the end of the game (they were tied 1-1 and a tie would crown the locals). But as I was walking down the halls, the infernal screaming of the crowd was interrupted. Coming out of the tunnel, a desolate silence dominated the stadium. No honor guard, no national anthem, no speech, not even a solemn award ceremony. I found myself alone, with the cup in my arms, and no idea what to do. In the tumult, I ended up finding the Uruguayan captain, Obdulio Varela, and almost secretly giving him the golden statue, shook hands, and I left without being able to say even a single word in congratulations to his team.”

The event was... traumatic for Brazil. In the days that followed, over 20 suicides were reported. The media didn’t quite now what to do. While Brazil is now famous for it’s yellow shirt, it was not the original color of their sports kit. Rather, the color was white. After the match, the shirt was practically abandoned, and has since been used in only a few games, mostly friendlies or special occasions. And that’s how Uruguay won the world cup for the second and last time. And how Obdulio Varela, became the greatest icon in Uruguayan sporting history. However, while his sporting achievement was already remarkable, it is what he did after the end of the game that makes him even more remarkable. At the end of the game, he was accosted by journalist who bombarded him with questions. When asked how they had won, he murmured “It was luck”, and showed them his back when they tried to photograph him. Instead of celebrating, he spent the night drinking in the bars of Rio, consoling the devastated and crying Brazilians. None of them recognized him.  

Brazil’s self-confidence was struck a huge blow by this event, and most feared it would never recover. It eventually did however, and Brazil managed to move past this event, with the help of a certain 17-year-old footballing prodigy. A boy by the name of Pelé. But that’s a story for another time

[juniperpublishersanesthesia]

Dexmedetomidine V/S Fentanyl with 0.75% Ropivacaine for Epidural Anaesthesia in Lower Abdominal Surgeries - A Comparative Study-Juniper Publishers

Abstract

Background: Opioids as epidural adjunct to local anaesthetics have been in use since long and a-2 agonists are being increasingly used for similar purpose. This study was done to compare the effects of epidurally administered dexmedetomidine and fentanyl in combination with Ropivacaine 0.75% in lower abdominal surgeries.

Methods: 80 patients of either sex, aged 18-55 years, ASA grade I-II posted for elective lower abdominal surgery were divided into two groups (n=40) by open label randomization chit method. Group RD received 1^g/kg Dexmedetomidine and group RF received 1^g/kg Fentanyl along with 15 ml Ropivacaine 0.75%. Onset and time of complete sensory and motor blockade, two segmental dermatomal regression, duration of analgesia, first 24 hour total LA consumption and complications were recorded. Data were compiled and analysed using Chi-square test and Fisher's exact test.

Results: Onset of complete sensory and motor block was significantly earlier in the RD(9.375 ± 0.2256 min and 14.65 ± 0.3588 min) as compared to group RF (11.45 ± 0.3281 min and 17.1 ± 0.4294 min) (p<0.0001). Postoperative analgesia was significantly prolonged in group RD as compared to group RF (374.3 ± 6.793Vs283.5 ± 5.576 min) (p<0.0001).Total duration of motor and sensory block was longer in group RD (276.6 ± 5.668 and 140.9 ± 3.602 min) as compared to group RF (198.4 ± 4.509 and 117.8 ± 2.715 min) (p<0.0001). Total LA consumption was lesser in group RD as compared to group RF (112.5 ± 7.869 mgVs 132.5 ± 8.758 mg) (p<0.0001). Hypotension, bradycardia and dry mouth was significant in group RD while nausea and vomiting was significant in group RF.

Conclusion: Dexmedetomidine is better alternative to fentanyl as an epidural adjuvant, due to comparatively faster onset of blockade, prolonged postoperative analgesia and lower consumption of post-op LA.

Keywords: Dexmedetomidine; Fentanyl; Epidural anaesthesia

Introduction

Epidural anaesthesia is an integral part of today's practice of anaesthesia, as it gives the anaesthesiologist the opportunity to place it at any level of the vertebrae to provide anaesthesia and analgesia, to supplement general anaesthesia, decrease the need for deep levels of general anaesthesia and therefore provide haemodynamically stable operative course. As early postoperative mobilization and rehabilitation with minimally associated pain and discomfort is the most desirable feature for modern orthopaedic and general surgeries so epidural becomes desirable technique of anaesthesia [1]. It not only provides perioperative surgical anaesthesia but also post-op analgesia in lower abdominal and limb surgeries [2].

Epidural bupivacaine was used since long but it is highly cardiotoxic. Recently ropivacaine became better alternative in choice of LA, due to long duration and less cardiovascular effects [3]. Very slow reversal of Na+ channel blockade after a cardiac action potential, which is the hallmark of bupivacaine, is considerably faster with ropivacaine, also the negative inotropic potency of ropivacaine on isolated cardiac tissue appears to be considerably less than that of bupivaicaine [4]. Adding adjuvants to LA have proven better and faster onset of blockade, prolonged duration of action and postoperative analgesia with lower consumption of local anaesthetic. Adjuvants like opioids can perform these activities but as to their certain side effects like pruritus, urinary retention, nausea and vomiting, newer adjuvants are been considered.

Fentanyl, a highly lipophilic opioid, has relatively rapid onset of action following administration. It has become very popular additive in recent times. However, it has side effects like pruritus, nausea and vomiting, hence, there was need for an alternative which was deprived of these side effects but has same or better qualities like opioids when used as adjuvant.

Dexmedetomidine is a new addition of a-2 agonist which has got numerous beneficial effects when used through epidural route. It does cause manageable hypotension and bradycardia but the striking effect of it is lack of opioid related side effects. Because of paucity of comparative studies between fentanyl and dexmedetomidine as an adjuvant to ropivacaine for epidural anaesthesia, we decided to compare both these drugs in our institute in terms ofonset and time of complete sensory and motor blockade, two segmental dermatomal regression, duration of analgesia, first 24 hour total LA consumption and complications.

Methods

Present study was conducted in the Department of Anaesthesiology and Critical care, Pt. J.N.M. Medical College and Dr. B.R.A.M. Hospital Raipur (C.G) after approval from the institutional ethics committee. It was a prospective randomizeddouble blind study, 80 patients of ASA I-IIaged 18-55 years of either sex undergoing lower abdominal surgeries were randomly allocated by chit method into 2 Groups (n=40). Group RD received dexmedetomidine 1μg/kg and Group RF received fentanyl 1μg/kg along with ropivacaine 0.75% 15 ml. Before the study, power of study was calculated by using software G power 3.0.10, taking mean value for onset of sensory blockade from Bajwa S, et al. [5] and considering a probability level of 0.05 (α-error) and power of 0.80 (1-β) yielded a sample size of 40 patients in each group.

Patients with history of drug allergy, gross spinal abnormality, localized skin sepsis, hemorrhagic diathesis, neurological disease, hepatic and renal diseases, peripheral neuropathy and psychiatric diseases were excluded from the study.

After preoperative assessment, written informed consent was taken from all patient and kept nil orally for 8 hrs before surgery. On the day of surgery, intravenous line was secured and preloaded with Ringer Lactate solution 10 ml /kg over 20 minutes prior to the procedure, all patients were premedicated with i.v. 50 mg Ranitidine and i.v. Ondensatron 4 mg 15 min prior to epidural anaesthesia.

Epidural anaesthesia was performed in sitting position and under all aseptic precautions, L3-L4 or L2-L3 interspace was identified and local infiltration by 2 ml 2% lignocaine with adrenaline was done at one of the interspaces. An epidural needle (Tuohy's) 18G was inserted through the midline approach and epidural space was located by loss of resistance to air method. Direction of the bevel was kept cephalad in all the cases. A disposable sterile multi hole epidural catheter was threaded 3-5 cm cephalad in the epidural space and was secured with adhesive tape. Test dose of 3 ml 2% lignocaine with adrenaline 1:200000 was injected, followed by total volume of 15 ml of either of the study drug were injected through the epidural catheter.Epidural supplementation was done on requirement of analgesia in postoperative period by 0.2% ropivacaine 10ml.

Sensory block was assessed by pin prick method at every 2 min interval till 30 min and then every 15 min until the return of normal sensation at dermatome levels S3, S1, L5, L3, L1, T12, T10, T8 and T6and the maximal sensory blockade level was noted. Onset and end of all degrees of motor blocks were assessed bilaterally according to the Modified Bromage scale [6] until the return of Bromage 1. [0= No motor block (ability to move hips, knees and ankles), 1 = inability to raise extended leg (able to flex knee); 2 = inability to flex knee (able to flex foot only); 3 = inability to flex ankle joint (unable to flex foot or knee)].

Onset of sensory blockade (time interval from epidural injection of drugs to sensory blockade at T10), onset of motor block (time interval from epidural injection of drug to achieve modified Bromage scale grade I), extent of block (highest dermatomal level of sensory block achieved), duration of sensory block (time to two segmental dermatome regression), duration of motor block (time interval fromachievement of Bromage I to regression of motor blockade to Bromage I), duration of analgesia (time from onset of sensory block to first complain of pain), sedation score was observed and recorded. Hemodynamic parameters like PR, SBP, DBP, MBP, RR, and SpO2 were recorded before induction and at every 5 minutes intervals for 30 minutes and later at 15 minutes intervals lasting for the entire duration of surgery.

Sedation score5was assessed by Ramsay Sedation Score and recorded just before the initiation of surgery and thereafter every 20 minutes during the surgical procedure (1-alert and wide awake, 2-arousable to verbal command, 3-arousable with gentle tactile stimulation, 4-arousable with vigorous shaking, 5-unarousable). Total dose consumption of local anaesthetic over 24 hours (total dose required till 24 hours including surgery and post-operative period) was recorded.

Fall in SBP and DBP ≥ 20% of baseline was considered as significant hypotension. It was managed with fast fluid administration and i.v. mephentermine 6 mg. Heart rate <50/ min was considered as bradycardia and treated with atropine 0. 5 mg i.v. Supplement O2 via face mask was given when SpO2 fell below 95%. Nausea and vomiting was treated with inj. metaclopramide 10mg.

Throughout the procedure, patients were observed for any side effects and complications related to technique and anaesthetics drugs by lumber epidural anaesthesia and recorded. Statistical analysis was done using Graph pad prism 7 Software. Data were analyzed by student t unpaired test and chi square test. The results were analyzed by various statistical techniques like percentage, mean and standard deviation. P-value <0.05 was considered significant and p-value <0.0001 was considered highly significant.

Results

The two groups were statistically comparable with regard to demographic data (Table 1). Onset of sensory and motor blockade in group RD was significantly faster as compared to group RF, andthe difference was statistically highly significant (p< 0.0001) (Table 2).

The highestlevel of sensory block achieved was T5-T6 level in group RD which was higher than group RF i.e. T6-T7 level. The number of patients who achieved grade III and grade II motor blockade was 36 and 04 in group RD as compared to 34 and 06 in Group RF. This difference between both the groups proved higher level of block was achieved in group RD compared to group RF.

Duration of sensory blockwas significantly prolonged in group RDas compared to group RF, and the difference was statistically highly significant (p< 0.0001) (Table 2). Duration of motor blockade and duration of analgesia was also significantly prolonged in group RD as compared to group RF, and the difference was statistically highly significant (p< 0.0001) (Table 2). Total LA dose consumption over first 24 hours was 112.5 ± 7.869 mg in group RD and 132.5 ± 8.758 mgin group RF. This was significantly low in RD group (p<0.0001).

Maximum number of patients in both groups had grade II sedation score i.e. 20(50%) in Group RD and 22 (55%) in Group RF. Higher number of patients in Group RD had grade III of Ramsay Sedation Score i.e. 14 (35%) as compared to 02 (05 %) in Group RF (Table 3).

The fall in HR and mean SBPfrom baseline was significant at 5 min and 10 min interval after injecting epidural drug in both the Groups (p < 0.0001). But the change in HR and mean SBP was statistically comparable between two at various other time intervals (p>0.05) (Figure 1 & 2). The fall in mean DBP from the baseline was significant at 5 min, 10 min, 15 min, 20 min and 25 min in Group RD while it was significant at 15 min and 20 min in Group RF after injecting epidural drug (p< 0.0001). But the change in DBP was statistically comparable between two Groups RD and RF at various other time intervals (p>0.05). Figure 3 Mean RR and SPO2 was comparable in both the groupsRDand RF during our entire study period, respectively (p>0.05). Comparison between the groups showed statistically no significant difference in the complications/side effects (p >0.05). Incidence of hypotension, bradycardia and dry mouth was significantly high in Group RD, while nauseaand vomiting was significantly high in Group RF (p <0.05) (Table 4).

Discussion

The aim of this study is to evaluate and compare the efficacy of 0.75% ropivacaine and fentanyl with 0.75% ropivacaine and dexmedetomidine in epidural anaesthesia in patients undergoing lower abdominal surgeries.

I. The primary objective of this study is to compare the onset of sensory block between dexmedetomidine and fentanyl.

II. The secondary objective of this study is to compare the onset of motor blockade, extent of block, duration of sensory and motor block, duration of analgesia, sedation score, total LA consumption and occurrence of side effects in the intraoperative period between the two drugs.

In our study onset of sensoryand motor block was earlier in group RD as compared to group RF, and the difference was statistically highly significant (p<0.0001). It correlated with findings of Vasupalli R et al. [6] and Agrawal S et al. [7]. The amount of study drug and adjuvants used in both the studies were similar to the amount of drugs used in our study.

Highest level of sensory block achieved was T5-T6 in group RD (34 patients) and T6-T7 in group RF (35 patients). This showed the block was higher in group RD in maximum number of patients compared to group RF. Similar results were observed in group RD as compared to group RF in Bajwa S, et al. [5] and in Vashisth, et al. [8] where highest level was T5 in group RD and T6 in group RF. The result of Bajwa S et al. [5] and Vashisth, et al. [8] was similar as the study and adjuvants dexmedetomidine, clonidine and fentanyl used was 1 |ig/kg which is similar to our study.

Duration of sensory block wasprolonged in group RD compared to group RF andthe difference was statistically highly significant.(p<0.0001)Similar results were seen in study of Bajwa SJ, et al. [9] when same amount of drug was given as in our study. Duration of motor block and duration of analgesia was also longer in group RD as compared to group RF, and the difference was also statistically highly significant (p<0.0001). Similar results were seen in study of Singh R et al. [10] where duration of motor block was prolonged in group RD as compared to group RF and in Mittal AA et al. [3] where duration of analgesia was prolonged in group RD compared to group RF.

Total LA consumption was significantly lesser in group RD as compared to group RF.This was similarly seen in study of Mittal AA, et al. [3] and Baglur S, et al. [11], where dexmedetomidine was given in same dose as in our study proving dexmedetomidine a better alternative to fentanyl.

In our study maximum number of patients in both the groups had grade II sedation score and higher number of patients in group RD had grade III and grade II score as compared to group RF. This showed dexmedetomidine provided better sedation scores compared to fentanyl, similar results were shown in study of Singh R, et al. [12] where 36% and 46% patients had grade II and grade III sedations scores compared to 18% and 4% in patients of group RF.

Mean RR was comparable in both the Groups and was statistically insignificant throughout the surgical procedures (p>0.05). Mean RR was above 12/min in both the Groups throughout whole duration of procedure. SpO2 was above 95% in all the patients of Group RD and Group RF throughout the study period and the difference was statistically insignificant (p>0.05).

Significant decrease in mean HR and SBP from the baseline was observed in group RD and RF was observed after 5 min and 10 min of injecting study drug but was comparable after 10 mins to throughout the procedure, this correlated with the studies of Bajwa SJ, et al. [9] and Singh RB, et al. [12] as same adjuvant and study drug was used. The fall in mean DBP in group RD correlated with studies of Rastogi B et al. [13] and Singh RB, et al. [12] while in group RF correlated with Singh RB, et al. [12].

Incidence of nausea was higher and significant in Group RF as compared to Group RD and vomiting was slightly higher in Group RF as compared to Group RD. The findings of our study that fentanyl when used as adjuvant causes nausea and vomiting correlates with Singh RB, et al. [12] and Harinath G et al. The incidence of hypotension and bradycardia was higher in Group RD patients as compared to and patients in Group RF. The difference was comparable and stastically significant (p<0.05). The findings observed in Baglur S, et al. [11] and Singh RB, et al. [12]) that there was comparable difference in hypotension and bradycardia as clonidine was used, which is also an alpha 2 agonist, correlates with our study. The incidence of shivering in Group RD and Group RF was comparable and statistically not significant. (p>0.05) The incidence of dry mouth was statistically significantin Group RD as compared to in Group RF (p <0.05). The incidence of headache was not significant in both the groups while none of the patients had urinary retention in either Group (p >0.05) (Table 3).

Conclusion

Our study shows faster onset, prolonged duration and excellent sensory and motor blockade along with better sedation, stable hemodynamics following epidurally administered dexmedetomidine with ropivacaine compared to fentanyl with ropivacaine. Thus it could be concluded that dexmedetomidine is better alternative to fentanyl as an adjuvant for epidural anaesthesia with ropivacaine for lower abdominal surgeries.

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[bapofficial]

I have to admit that when it comes to bap fics I'm weak for daejae. Unfortunately I've been pretty busy lately and the last really good fic I finished was steps to infinity by iwantsushi but it's over 200000 words long :| really well written though! Realistic take on a heavy subject matter. It's Complicated by i wantsushi is shorter, a completely different genre and HILARIOUS. A bit older though. I LOVE open-ended by inertial but it's 60000 words :((

omg i completely forgot to reply, sorry! oh my god....how do people even write that much lmao i get to 3k and I'm wiped out haha. maybe when i have more time? oooh that sounds fun! thank you!! and ahhh I've already read open-ended hehe i love their writing style :'(((