Context and Aims: Little is known about onset and duration of sciatic block after 0.5% levobupivacaine (Levo) versus 0.5% ropivacaine (Ropi) for ultrasound-guided technique. We assessed these parameters in the ultrasound-guided block, to know for the practice. Setting and Design: A comparative randomized double-blind study was conducted in the University Hospital. Materials and Methods: Were included 35 adults of ASA I-II, scheduled for foot surgery, presenting clear imaging of their sciatic nerve at mid-thigh. A volume of 20 mL of either 0.5% Levo or 0.5% Ropi were injected around the sciatic nerve at mid-thigh using ultrasound guidance (out of the plane) followed by placement of a catheter to use, if necessary, for perioperative analgesia. A femoral single shot block was systematically performed to block the saphenous nerve. The onset times until complete foot block (primary outcome) and the sensory and motor block duration (secondary outcome) were assessed using Wilcoxon test. Values were expressed as medians (1 ^st -3 ^rd quartile). Results: Except for two delayed sciatic blocks in each group, the onset time otherwise was 35 min (20-60) in Ropi versus 40 min (30-60) in Levo, P = 0.5. Sensory block lasted longer in Levo, 17 h (14-27) compared with 15 h (10-17) in Ropi, P = 0.04. No significant between-group difference was found with motor block durations, 15 h (12-18) in Levo and 15 h (12-16) in Ropi, P = 0.3. Conclusion: No difference of onset times was found in ultrasound-guided sciatic block whether using Levo or Ropi. Levo induced a longer-lasting sensory block.

Background: Tramadol is an atypical analgesic agent. It has been shown that intramuscular or intravenous injection tramadol is able to inhibit M3 muscarinic receptors. Tramadol is able to mediate smooth muscles contraction and glandular secretions. We have evaluated the effects of single oral dose of tramadol given preoperatively on gastric juices pH in patients electively scheduled for laparoscopic cholecystectomy. Materials and Methods: Sixty adult, American Society of Anesthesiologist I and II patients scheduled for laparoscopic cholecystectomy were included in the study. Patients were randomly assigned to receive either placebo (n = 30) or oral tramadol 50 mg (n = 30). General anesthesia was induced using propofol, fentanyl and cisatracurium. After induction of anesthesia 5 ml of gastric fluid was aspirated through orogastric tube. The gastric fluid pH was measured using pH meter. Result: There was no significant difference in the pH between the groups. Gastric pH of the placebo and tramadol groups was 1.97 versus 1.98 (P = 0.092) respectively. Conclusion: Preoperatively single oral dose of tramadol was unable to elevate the desired level of gastric acid secretions pH (>2.5). This may be due to pharmacokinetic disparity between the analgesic and pH elevating properties of tramadol.

Introduction: Modulating the stress response and perioperative factors can have a paramount impact on the neurodevelopmental outcome of infants who undergo cardiac surgery utilizing cardiopulmonary bypass. Materials and Methods: In this single center prospective follow-up study, we evaluated the impact of three different anesthetic techniques on the neurodevelopmental outcomes of 19 children who previously underwent congenital cardiac surgery within their 1 ^st year of life. Cases were done from May 2011 to December 2013. Children were assessed using the Stanford-Binet Intelligence Scales (5 ^th edition). Multiple regression analysis was used to test different parental and perioperative factors that could significantly predict the different neurodevelopmental outcomes in the entire cohort of patients. Results: When comparing the three groups regarding the major cognitive scores, a high-dose fentanyl (HDF) patients scored significantly higher than the low-dose fentanyl (LDF) + dexmedetomidine (DEX) (LDF + DEX) group in the quantitative reasoning scores (106 ± 22 vs. 82 ± 15 P = 0.046). The bispectral index (BIS) value at the end of surgery for the -LDF group was significantly higher than that in LDF + DEX group (P = 0.011). For the entire cohort, a strong correlation was seen between the standard verbal intelligence quotient (IQ) score and the baseline adrenocorticotropic hormone level, the interleukin-6 level at the end of surgery and the BIS value at the end of the procedure with an R ² value of 0.67 and P < 0.04. There was an inverse correlation between the cardiac Intensive Care Unit length of stay and the full-scale IQ score (R = 0.4675 and P 0.027). Conclusions: Patients in the HDF group demonstrated overall higher neurodevelopmental scores, although it did not reach statistical significance except in fluid reasoning scores. Our results may point to a possible correlation between blunting the stress response and improvement of the neurodevelopmental outcome.

Background: The aim of this study was to evaluate the safety and efficacy of sevoflurane-based sedation technique for colonoscopy in geriatric patients as compared with that using propofol. Materials and Methods: Sixty elderly patients, who were scheduled for colonoscopy, participated in this controlled prospective study and were randomly allocated into two groups; P and S. The patients were sedated using either propofol in P group or sevoflurane in S group. Complications (including apnea, the need for airway intervention, occurrence of general anesthesia [GA], hemodynamic instability and others), the fentanyl requirement and the times of the procedure, recovery, and discharge were recorded in both groups. Results: The patients in P group had more frequent apnea attacks, need for airway intervention and occurrence of GA compared to the patients in S group. However, both groups were comparable regarding the other measured variables. Conclusion: For geriatric colonoscopy, sevoflurane can provide safe and effective sedation alternative to propofol.

Background: The aim of this study was to determine the frequency of patients admitted to Intensive Care Unit (ICU) after elective interventional neuroradiology (INR) procedures under general anesthesia. Materials and Methods: We retrospectively evaluated 121 patients underwent INR procedures performed with general anesthesia within a 5-year period. Information including demographics, aneurysm/arteriovenous malformations pathology (ruptured or un-ruptured), preoperative neurological status, co-morbidities, complications during procedure and postoperative admission in ICU were recorded on a predesigned form. Results: Elective INR procedure for both ruptured (n = 29, 24%) and un-ruptured (n = 85, 70.25%) aneurysms was performed. Rate of postoperative admission in ICU was significantly high in patients with preoperative ruptured aneurysm (P < 0.01). High rate of neurological deficit, sub-arachnoid hemorrhage (SAH) and hypertension in patients were significant factors of postoperative admission in ICU (P < 0.05). Out of 24 patients, 12 were admitted to ICU postoperatively because of procedure-related complications and 11 were sent due to preexisting significant co-morbidities with added complication of SAH. Conclusion: The authors conclude that patients without major co-morbidities, intraoperative complications, or complex aneurysm morphology can be safely observed in a regular ward rather than being admitted to the ICU.

Background: Quantification of the depth of desflurane anesthesia required for laryngeal mask airway (LMA) removal in children has been done with the use of intravenous fentanyl or caudal anesthesia. This study aimed to determine the end-tidal concentration of desflurane required for LMA removal in children without the use of caudal or opioid analgesia in children undergoing elective cataract surgery. Materials and Methods: Our study enrolled 25 American Society of Anesthesiologists I and II children aged 2-10 years, undergoing elective cataract surgery. Anesthesia was induced with sevoflurane and oxygen/nitrous oxide using face mask and a size 2 LMA inserted. A subtenon block was administered in all children before surgical incision. Desflurane was used for maintenance of anesthesia. Predetermined end tidal concentration of desflurane was maintained for 10 min at the end of surgery before LMA removal was attempted. End tidal concentrations were increased/decreased using the Dixon up-down method (with 0.5% as a step size) in the next patient depending on the previous patient's response. Patient responses to LMA removal were classified as "movement" or "no movement." Results: 50% effective dose (ED ₅₀ ) for successful removal of the LMA with desflurane in the presence of subtenon block was 3.6% (3.20-3.97%) and that the 95% ED ₉₅ was 4.648% (4.15-6.47%). Conclusion: Laryngeal mask airway removal can be successfully accomplished in 50% and 95% anesthetized children at 3.6% and 4.65% end-tidal desflurane concentration.

Context: Anxiety and distress regarding dental treatment is a major issue for dental patients and can be exaggerated in pediatric dental patients. Aims: The aim was to investigate how different methods of induction for general anesthesia affect children's distress for dental procedures such as extraction of teeth. Subjects and Methods: This was an observational clinical study conducted at Manchester University Dental Hospital. The induction of anesthesia in children was achieved with either intravenous (I.V.) or a gaseous induction. The Modified Child Smiley Faces Scales were completed for children at various times intervals. Statistical Analysis Used: There were statistically significant differences between the mean distress scores for the I.V. and inhalation groups (P values from independent t-test: P < 0.001) was applied. Results: In gaseous induction group, the number of children who scored severe and very severe distress was greater than those who were in I.V. group. Gaseous induction was used for 23 children. Preoperatively, 56.5% children were in very severe distress, 17.4% in severe distress, 13% in moderate distress, 8.7% in mild distress and only one (4.3%) showed no distress. For I.V. induction, 11.2% children were in very severe distress, 9% in severe distress, and 9.6% in moderate distress, 24.2% in mild distress and 46.1% showed no distress. Conclusions: Gaseous induction anesthesia for extractions of teeth does produce high levels of distress than I.V. induction in children for dental extractions. There was no significant difference between both induction methods in terms of distress levels at the time of recovery and 15 min postoperatively.

Background: Fiberoptical assisted intubation via a placed laryngeal mask airway (LMA) has been described as save and easy procedure to manage a difficult airway. The laryngeal tube (LT) is a promising alternative to the LMA as supraglottic airway device. Fiberoptical assisted intubation via LT is possible, however considered more difficult. The aim of this study was to compare the fiberoptical assisted intubation via LT and LMA. Materials and Methods: A total of 22 anesthesiologists with different levels of experience participated in the study performed on an adult airway model. Primarily the supraglottic device was placed and correct position was confirmed by successful ventilation. A 5 mm internal diameter tracheal tube was loaded onto a flexible 3.6 mm fiberscope and the so prepared device was inserted into the proximal lumen of the LMA or the LT. The glottis was passed under visual control and the tube advanced into the trachea. After removal of the fiberscope, ventilation was examined clinically by inspection. Success rates, procedure time and observed complications of LMA versus LT were compared (U-test; P < 0.05). Results: Placement of the endotracheal tube was successful in all attempts using both the LMA and LT. There was no difference in the time needed for the placement procedure (33 [26-38] s LMA; 35 [32-38] s LT). Only minor technical complications were observed in both groups. Conclusion: A fiberoptical assisted intubation via LT can be considered as a relevant alternative in advanced airway management.

Background: Blood loss is often a major complication in neurosurgery that requires transfusion of multiple units of blood. The purpose of this study was to assess the effect of tranexamic acid (TXA) on intraoperative blood loss and the need for blood transfusion in patients undergoing craniotomy for tumor excision. Materials and Methods: A total of 100 patients aged 18-60 years, with American Society of Anesthesiologists physical Status 1 and 2 scheduled to undergo elective craniotomy for tumor excision were enrolled. Patients received 10 mg/kg bolus about 20 min before skin incision followed by 1 mg/kg/h infusion of either TXA or saline. Hemodynamic variables, intravenous fluid transfused, amount of blood loss and blood given were measured every 2 h. Laboratory parameters such as serum electrolytes and fibrinogen values were measured every 3 h. On the 5 ^th postoperative day hemoglobin (POD Hb5), Hb estimation was done and the estimated blood loss (EBL) calculated. Patients were also monitored for any complications. Results: The Mean heart rate in TXA group was significantly lower compared with the saline group. Mean arterial pressure and fibrinogen levels were higher in TXA group. The mean total blood loss in the TXA group was less than in the saline group. Blood transfusion requirements were comparable in two groups. The EBL and POD5 Hb were comparable in two groups. Conclusion: Even though, there is a significant reduction in the total amount of blood loss in TXA group. However, there was no reduction in intraoperative transfusion requirement.

Background: Organophosphorus poisoning (OPP) is a major global public health problem. Pralidoxime has been used in a complimentary role to atropine for the management of OPP. World Health Organization (WHO) recommends use of pralidoxime but studies regarding its role have been inconclusive, ranging from being ineffective to harmful or beneficial. Materials and Methods: The present study was undertaken to evaluate the effectiveness of pralidoxime. Eddleston's study was the most compelling factor for our study, as he showed worst outcomes using pralidoxime. Our practice of continuous use of pralidoxime was based on the WHO guidelines and the study by Pawar (2006), which showed better outcome with higher doses of pralidoxime. These conflicting results suggested that a re-evaluation of its use in our clinical practice was indicated. Results: There was no difference in mortality rates, hemodynamic parameters and atropine requirements between the AP and A groups. Mean duration of ventilation (3.6 ± 4.6 in AP group vs. 3.6 ± 4.4 in A group) and Intensive Care Unit stay (7.1 ± 5.4 in AP group vs. 6.8 ± 4.7 in A group) was comparable. Serum sodium concentrations showed a correlation with mortality, with lower concentrations associated with better outcomes. Conclusion: The study suggests that add-on WHO-recommended pralidoxime therapy does not provide any benefit over atropine monotherapy. Adding pralidoxime does not seem to be beneficial and at the same time does not result in increased mortality rates. Our practice changed after completion of this study, and it has proven to be of significant benefit to patients who had to bear the expense of treatment.

Background: Procedural discomfort is experienced by patients during the establishment of subarachnoid block even after good preoperative counseling and adequate premedication. To enhance comfort, procedural sedation that would provide good analgesia, faster recovery, and amnesia is necessary. Materials and Methods: Patients with American Society of Anesthesiologists Status I and II posted for elective surgeries under subarachnoid block were premedicated with injection midazolam 0.05 mg/kg and preloaded with 10 ml/kg ringer lactate solution. They were randomized into three groups of 30 each. Group K0.3 received ketamine 0.3 mg/kg, Group K0.4 received ketamine 0.4 mg/kg and Group K0.5 received ketamine 0.5 mg/kg intravenously. University of Michigan sedation score, ease of positioning, prick response, verbal response, hallucinations, recall of procedure, and patient satisfaction were evaluated. Results: There was statistically significant difference in sedation among the three groups. Increased dose necessitated help of two persons to position the patient, which showed statistically significant difference. Verbal response was seen early in Group K0.3 (4.67 ± 2.84 min). There was no recall of experience of subarachnoid block procedure in any of the groups in spite of back muscle contraction or patient movement. Hence, all patients in all three groups were satisfied and were willing to undergo subarachnoid block, if the situation arises. Conclusion: Ketamine in the dose of 0.3 mg/kg provided sufficient sedation for allaying procedural discomfort due to less sedation, less positional difficulty, early verbal response, no hallucinations, no recall of performance of procedure, and good patient satisfaction.

Background: Stylomastoid foramen is an important site for Nadbath facial nerve block. Exact localization of foramen holds the key to success, thus decreasing the complications. Wide racial variation exists in position of stylomastoid foramen in different population groups. Aim: The aim was to study the morphometry of stylomastoid foramen and its location with respect to nearby anatomical landmarks. Materials and Methods: A total of 100 dry skulls (60 male and 40 female) were studied to locate the position of center of stylomastoid foramen (CSMF) with respect to tip and anterior border of the mastoid process and jugular foramen (JF). Along with this angle between antero-posterior line passing through the tip of the mastoid process and line joining the tip with stylomastoid foramen was also measured. Result: In 83.51% sides of skulls, the most common position of foramen was found to be anterior to the line passing through anterior border of the mastoid process. The mean distance of center of foramen from the tip of the mastoid process was 15.26 ± 1.4 mm on right and 14.32 ± 1.8 on the left side (P < 0.001) and from JF was 12.28 ± 1.9 mm and 12.96 ± 2.1 mm on the right and left sides, respectively (P < 0.01). The position of CSMF was found at an angle of 66.57° ± 2.6° and 65.96° ± 1.8° on the right and left sides, respectively from the tip of the mastoid process. Conclusion: This study makes possible the identification of the exact position of stylomastoid foramen and its application in facial nerve block.

Background: Anesthesia is a specialized branch of medicine with a very narrow margin of error. Incorporation of problem-based learning (PBL) in anesthesia post-graduate (PG) teaching enhances the critical thinking and problem-solving skills. It also helps in developing a broader prospective of clinical case scenarios. Case based discussions (CBD) are most widely practiced out of all PBL methods in anesthesia PG teaching. Materials and Methods: We conducted an anonymous questionnaire based, cross-sectional survey among 62 anesthesia residents from various medical institutions in a city of Delhi, India. We aimed to assess the current status of PBL by assessing the student satisfaction with CBD in anesthesia PG teaching, educational objectives accomplished with CBD and effectiveness of teaching curriculum in PG teaching with suggested modifications, if any. Result and Conclusion: We observed that CBD is lacking in many important key areas of PBL e.g., formulation of objectives, communication on the content and direction of PBL, facilitation skills, supplementation of inadequacies of CBD. However, CBD seems to be a valid method of PBL in terms of the educational objectives accomplished with it but increased motivation for learning is required. Majority of the students felt that PG teaching curriculum should be centralized, with increased emphasis on open interactive sessions regarding its effectiveness.

Since the first clinical application of analgesia following spinal anticholinesterase by 1940's, several clinical double-blind studies have been conducted to date, where intrathecal doses of neostigmine in humans ranged from 750 to 1 μg, due to side-effects. Conversely, epidural neostigmine has been evaluated in proportionally higher doses and represents an alternative, but still deserves more investigation concerning both acute and chronic pain, as it seems devoid of important side-effects.

Intraoperative management of a known acute intermittent porphyria patient is a challenge requiring awareness of factors, which trigger an acute crisis, clinical features of a porphyric attack, knowledge of safe pharmacologic intervention, and preparedness for reintubation and ventilatory support. The classical signs of a porphyric crisis such as pain abdomen, vomiting and neuropsychiatric symptoms are masked under general anesthesia and can be confused with postoperative pain and vomiting and postoperative cognitive dysfunction, especially for intra-abdominal surgeries. Eternal vigilance for onset of an acute crisis is imperative. After a crisis of acute intermittent porphyria, residual paresis may persist for years in the absence of further attacks.

Recurrent respiratory papillomatosis (RRP) is a rare, chronic disease of viral etiology affecting most commonly larynx. A 5-year-old child with stridor was posted for microlaryngoscopic excision of laryngeal papilloma. We discuss the perioperative management of case with the various ventilation strategies. In child with stridor intubation remains the safest option. It is suggested to maintain spontaneous ventilation until intubation as mask ventilation could be difficult.

Armored brain is condition, which occurs due to calcification in a chronic subdural hematoma (SDH). Here, we are reporting a case of armored brain due to chronic SDH as a complication of vetriculoperitoneal shunt (VP shunt). Patient had undergone major surgery for removal of calcified hematoma. VP shunt is a simple surgery, but can lead to catastrophic complications like this. In this report, we had described this condition and its aspects.

We report a case of a female having systemic lupus erythematosus and antiphospholipid antibodies syndrome, who was on immunosuppressant therapy. We discussed the preoperative evaluation and perioperative management who underwent nephrectomy and cholecystectomy.

Airway pressure monitoring is critical in modern day anesthesia ventilators to detect and warn high or low pressure conditions in the breathing system. We report a scenario leading to unexpectedly very high peak inspiratory pressure in the intraoperative period and describe the mechanism for high priority alarm activation. We also discuss the role of a blocked bacterial filter in causing sustained display of increased airway pressure. This scenario is a very good example for understanding the unique safety feature present in the Dräger ventilators and the attending anesthesiologist must have an adequate knowledge of the functioning and safety feature of the ventilators they are using to interpret the alarms in the perioperative to prevent unnecessary anxiety and intervention.