You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


INTRODUCTION {#sec1-1}
============

In lower limb surgical procedures, the regional anesthesia technique has gained popularity because of the absence of biochemical and metabolic changes consequent to the stress of general anesthesia for surgery. Introduction of cocaine (Karl Koller 1884) as a local anesthetic was a stepping stone in the development of spinal analgesia.\[[@ref1]\]

Spinal anesthesia with bupivacaine is administered routinely for lower limb surgeries. The ensuring nerve block is sufficient to ensure painless surgery to the patient, while motor block facilitates the surgeons' work. To prolong the duration of spinal anesthesia, a number of adjuvants have been added to local anesthesia, but these are associated with side-effects.

Spinal anesthesia can be prolonged in many ways, i.e., by using adjuvant like adrenaline, opioids, midazolam, neostigmine, etc., to the local anesthetic. Clonidine, either intrathecal or orally, can prolong spinal anesthesia and is free of the opioid-related side-effects. Clonidine hydrochloride, an imidazoline derivative, is a centrally acting α2 adrenergic agonist and was introduced more than two decades ago as an antihypertensive agent.

The present study was undertaken to evaluate the effects of intrathecal clonidine when administered together with hyperbaric bupivacaine 0.5% in unilateral spinal anesthesia for lower limb below-knee orthopedic surgery.

METHODS {#sec1-2}
=======

With the approval of the institutional ethical committee, 60 ASA I and ASA II patients of the age group of 1855 years undergoing elective surgery with time duration up to 90 min were studied. Patients were randomised into two equal groups of 30 patients each by the lottery method.

Group A:Patients were given Inj. bupivacaine (hyperbaric) 0.5% - 12.5 mg (2.5 ml) + 0.5 ml of normal saline intrathecally.Group B:Patients were given Inj. bupivacaine (hyperbaric) 0.5% - 12.5 mg (2.5 ml) + 50 mcg clonidine in 0.5 ml volume intrathecally.

Patients were kept nil orally for 68 h prior to surgery. Sedatives and hypnotics were avoided in pre-medications as well as intraoperatively.

Spinal anesthesia was given in a sitting position. Depending upon the groups, the respective agents were given intrathecally. After this, the patient was made to lie down in the lateral position for 10 min. The lateral position, right or left, was given with the operative side downwards planned for surgery.

Pulse rate, blood pressure, respiratory rate and oxygen saturation were noted every 5 min for the first 30 min and then, thereafter every 15 min for the next 30 min, at the end of surgery and post-operatively at two segment regressions of sensory block.

Sensory block was tested by pinprick at the left mid-clavicular line till the block reached the T10 level and then surgical incision was allowed. The degree of motor blockade was assessed using the modified Bromage scale \[[Table 1](#T1){ref-type="table"}\].

###### 

Modified Bromage scale

![](SJA-8-384-g001)

The following observations were made:

T0 - Time of spinal anesthesia.

T1 - Time of onset of sensory block.

T2 - Time of onset of motor block.

T3 - Time of peak sensory block.

T4 - Time of peak motor block.

T5 - Time of two-segment regression of sensory block.

T6 - Time to first dose of post-operative rescue analgesia.

The two-segment regressions were noted. Post-operative analgesic drugs were given when the patient\'s VAS score reached \>7 (this time it was taken as the time of wear-off of analgesia). Inj. diclofenac 75 mg was given intramuscularly as rescue analgesia.

Patients were assessed for quality of sedation and scoring was performed using the Campbell score \[[Table 2](#T2){ref-type="table"}\].

###### 

Campbell score

![](SJA-8-384-g002)

Any side-effects such as hypotension, bradycardia, shivering and hypoxia were noted and treated with appropriate drugs.

The VAS score was calculated \[[Table 3](#T3){ref-type="table"}\]. "0" mark means "no pain" at all while "10" represents the "worst pain" he/she had ever felt. Patients rated the degree of pain by making a mark on the scale. Thus, the pain score was obtained by measuring the distance from the "0" end to the indicated mark.

###### 

0-10 VAS Numeric Pain Distress Scale

![](SJA-8-384-g003)

At the end of the study, the results in the two groups were tabulated and statistically analyzed using SPSS software version 10 by the *t*-test.

RESULTS {#sec1-3}
=======

Onset of sensory block was earlier in the clonidine group (49±9.65 s) as compared with the control group (76.67±16.51 s). Onset of motor block was earlier in the clonidine group (71.83±10.29 s) as compared with the control group (86.7±14.41 s). The difference was insignificant, both statistically and clinically.

The peak sensory block \[[Table 4](#T4){ref-type="table"}\] was earlier in the clonidine group (4.7±1.32 min) as compared with the control group (6.27±1.51 min). The peak motor block \[[Table 5](#T5){ref-type="table"}\] was also faster in the clonidine group (6.17±1.2 min) as compared with the control group (8.63±1.71 min), and this was statistically significant.

###### 

Comparison of peak sensory block

![](SJA-8-384-g004)

###### 

Comparison of onset of peak motor block

![](SJA-8-384-g005)

Time for two-segment regression of sensory level \[[Table 6](#T6){ref-type="table"}\] was prolonged in the clonidine group (116.23±9.17 min) as compared with the control group (104.43±17.75 min). The duration of analgesia \[[Table 7](#T7){ref-type="table"}\] in the clonidine group (450.33±95.10 min) was significantly prolonged as compared with the control group (220±36.36 min), and this was statistically significant.

###### 

Comparison of two-segment regressions of sensory block

![](SJA-8-384-g006)

###### 

Comparison of time for requirement of rescue analgesia (duration of effective analgesia)

![](SJA-8-384-g007)

The mean heart rate in the clonidine group, pre-operatively, was 83.13±10.93 min. It declined after 10 min to 71.63±9.93 min, and remained almost same thereafter. At the end of the surgery, it was 73.37±8.07 min. The mean heart rate in the two groups was compared by applying the unpaired *t*-test at various time intervals, and this showed a statistically significant difference between the two groups after 10 min.

The mean systolic and diastolic blood pressures in the two groups was compared at various time intervals, and showed no statistically significant difference in the two groups.

In the present study, sedation was higher in patients in the clonidine group (12 patients) as compared with patients in the control group, where no patient was sedated.

In the control group, there was no bradycardia in any patient as compared with the clonidine group, in which one patient had bradycardia that required intervention.

DISCUSSION {#sec1-4}
==========

Intrathecal a2-agonists are used as adjuvant drugs to local anesthetics.\[[@ref2][@ref3][@ref4]\] They potentiate the effect of local anesthetics and allow a decrease in the required doses.\[[@ref3][@ref5]\] Clonidine is a partial a2-adrenoreceptor agonist used intrathecally, and has a well-established record of efficacy and safety.\[[@ref6]\] Its addition to local anesthetics prolongs the duration of both motor and sensory spinal blockade.\[[@ref2][@ref3][@ref4]\]

The mechanisms by which intrathecal a2-adrenoceptor agonists prolong the motor and sensory block of local anesthetics is not well understood. It is not a result of altered systemic absorption, as the plasma level of bupivacaine was not altered after the addition of intrathecal clonidine to bupivacaine spinal injection.\[[@ref7]\] It may be an additive or synergistic effect secondary to the different mechanisms of action of the local anesthetic and the a2-adrenoceptor agonist.

The local anesthetic acts by blocking sodium channels, whereas the a2-adrenoceptor agonist acts by binding to the pre-synaptic Cfibers and the post-synaptic dorsal horn neurons. Intrathecal a2-adrenoceptor agonists produce analgesia by depressing the release of C-fiber transmitters and by hyperpolarization of post-synaptic dorsal horn neurons.\[[@ref8][@ref9][@ref10][@ref11][@ref12]\] This anti-nociceptive effect may explain the prolongation of the sensory block when added to spinal anesthetics.

On the other hand, Yaksh\[[@ref13]\] has shown that intrathecal a2-adrenoceptor agonists can cause a dose-dependent decrease in motor strength in animals. The prolongation of the motor block of spinal anesthetics may result from the binding of a2-adrenoceptor agonists to motor neurons in the dorsal horn.\[[@ref14]\] Most of the clinical experience gained in the use of intrathecal a2-adrenoceptor agonists has been described with clonidine. The use of intrathecal clonidine has a well-established synergistic effect with local anesthetics.\[[@ref2][@ref3][@ref4][@ref5]\]

Clonidine is now an acceptable adjuvant to local anesthetics for the epidural route. Clinical trials provide evidence that less clonidine is needed intrathecally than epidurally to produce a nearly similar analgesic effect with fewer side-effects. The rationale behind the intrathecal administration of clonidine is to achieve a high drug concentration in the vicinity of a2-adrenoreceptors in the spinal cord. Clonidine produces analgesia at the spinal and supra-spinal sites. The other benefits are antiemetic effect, reduced post-spinal shivering, anxiolysis and sedation.

CONCLUSION {#sec1-5}
==========

Thus, it is concluded that a combination of 0.5% hyperbaric bupivacaine 12.5 mg (2.5 ml) with clonidine 50 mcg for producing unilateral spinal anesthesia for lower limb below-knee surgery of medium duration (\<90 min) prolongs the sensory and motor block along with significantly longer-lasting post-operative analgesia without any clinically significant adverse effects.

**Source of Support:** Nil

**Conflict of Interest:** None declared