Background and Aims: Protection of anaesthesiologists from contaminated aerosols of COVID 19 patients during endotracheal intubation has spurred the development of barrier devices like aerosol boxes and clear transparent plastic sheets and usage of videolaryngoscopes in COVID 19 patients. However, the efficiency, feasibility and difficulties faced by anaesthesiologist while performing endotracheal intubations under barrier devices require scientific validation. This manikin-based pilot study aims to assess the laryngoscopic performances of experienced anaesthesiologists under two different barrier enclosures. Methods and Materials: 53 anaesthesiologists (14 Consultants and 39 Senior Residents) who were undergoing an airway training module as a part of preparedness for handling the COVID 19 pandemic were recruited. Using an aerosol box over a manikin, the participants attempted intubation using a Glidescope Videolaryngoscope and Macintosh laryngoscopes (GA and MA Groups). Subsequently, intubation was attempted under a transparent plastic sheet using both laryngoscopes (GP and MP groups). Time required for intubation, first pass success rates, subjective ease of intubation and the feedback obtained from the participants were recorded and analysed. Results: Time required for accomplishing successful intubation was 38.55 ± 12.16 seconds, 26.58 ± 5.73 seconds, 46.89 ± 15.23 seconds and 37.26 ± 8.71 seconds for GA, MA, GP and MP groups respectively. Time for intubation and difficulty (VAS) was least for Macintosh group with aerosol box (MA) and maximum time was taken in Glidescope group with transparent polythene drape (GP). First attempt success rate for Glidescope groups (GP and GA) were 100% and in MA and MP group was 98% and 96% respectively. Restriction in hand movement and stylet removal were the major difficulties reported Conclusion: Longer intubation times were observed while using Glidescope Videolaryngoscopes with either of the two barrier devices in place compared to Macintosh laryngoscopes.

Background: Coronavirus disease 2019 is an infectious disease caused by severe acute respiratory syndrome virus coronavirus 2 (SARS-COV-2). Many aspects of its pathology and pathogenesis are not well understood. Material and Methods: We describe a series of spontaneous air leak cases we found in our coronavirus disease 2019 (COVID-19) positive 1086-patient cohort. Results: Two out of six patients eventually required mechanical ventilation and succumbed to COVID-19. We presume that acute lung injury leading to SARS-CoV-2 with associated acute respiratory distress syndrome predisposes patients to this complication. Conclusion: This series is presented to highlight the emerging association of COVID-19 with spontaneous air leaks leading to pneumomediastinum, pneumothorax, and subsequent subcutaneous emphysema even in patients who have never received invasive mechanical ventilation and this may be more likely with the institution of high flow nasal cannula.

Context: Medical malpractice is a leading cause of morbidity and mortality worldwide. Analyzing the current number of lawsuits and comparing it to previous years will help assess the status of medical malpractice litigations in Saudi Arabia. Subjects and Methods: A review and analysis of the annual statistics book of the Medico-Legal Committees (MLCs) in Saudi Arabia over the years (1437–1439 H) was conducted. Results: Over the 3-year study period, the total number of lawsuits was 3,684. The percentage of increase of malpractice lawsuits from 1437 until 1439 Hijri (2016–2018) was 26% (1,097–1,379 lawsuits). Obstetrics and Gynecology consistently had the highest number lawsuits compared to other specialties (25.6%), followed by dentistry (13.5%). Similarly, the rate of compensation after a lawsuit was highest in Obstetrics and Gynecology claims (62.7%), followed by dentistry (60%). The private healthcare sector consistently showed the highest number of lawsuits when compared to other healthcare providers, with a 73% increase over 3 years. The Ministry of Health showed an overall reduction in the number of lawsuits by 6.6% over the course of the study period. Conclusions: The number of lawsuits in Saudi Arabia is increasing rapidly. Understanding the reason for this is very important especially given the high rates of lawsuits for certain specialties and healthcare sectors. A root cause analysis cannot be conducted without a detailed reporting system for malpractice lawsuits; the development of which would help in research and the generation of solutions in this field.

Background: Obstructive sleep apnea (OSA) is prevalent in the surgical patient population and is associated with high risk of perioperative complications. There are limited guidelines and wide practice variations regarding the perioperative care of obese and OSA patients. This is a study of European anesthesiologists' clinical practice of perioperative care of OSA patients. Methods: This survey evaluated United Kingdom anesthesiologists' clinical practice of the perioperative care of OSA patients. Outcomes and variables were compared between 4100 anesthesiologists of different clinical experience and hospital settings. Results: Approximately 45% of respondents manage OSA patients rarely, 42% occasionally, and 13% regularly. Most respondents order OSA screening tests if patients have tonsillar hypertrophy, head/neck tumor, BMI >35, increased neck circumference, craniofacial anomaly, and right-sided electrocardiography (ECG) anomaly. Majority request preoperative polysomnography, ECG, overnight pulse oximetry, and arterial blood gas analysis. Majority recommend preoperative weight loss, optimisation, smoking cessation, reduction of substance use, and regular mask-CPAP use. Majority consider endoscopy, and ophthalmology as appropriate day case procedures, but not laparoscopy. Majority postpone elective airway, laparoscopic, laparotomy, and head/neck surgery; if patients are not optimized preoperatively. For major surgery, combined general + neuraxial anesthesia was ranked as 3^rd option. For major limb surgery, neuraxial anesthesia without sedation was ranked as 1^st option, nerve block without sedation was ranked 2^nd, and general anesthesia + nerve block was ranked 3^rd or 4^th. At anesthesia emergence, majority ensure that patients have normal consciousness, respiration and neuromuscular function. Majority ensure postoperative oximetry, telemetry, and oxygen supplementation. Conclusion: This study highlights variations in anesthesiologists' perioperative care of OSA patients; even in developed countries with advanced medical training and standards. The study outcomes will improve perioperative care of OSA patients.

Background: Trigeminal neuralgia present an incidence rates ranging between 5.9 and 12.6 per 100.000 persons; although not frequent, it is a pathology often characterized by intense pain, an extremely significant reduction in quality of life and medical therapy is not always effective or tolerated. In these cases, the patient can undergo interventional treatments including radiofrequency thermocoagulation. There are still doubts regarding the effectiveness over time, the injury parameters and the repeatability of the procedure. Materials and Methods: We analyze patients with trigeminal pain undergo retrogasserian radiofrequency in a single center over a period of 8 years. The procedure was performed with the following parameters: Lesion time 60 sec, lesion temperature 70°C for first thermolesion 72°C for subsequent thermolesions. Duration of benefit, number of repetitions of the maneuver, and incidence of adverse events were assessed. Results: Totally, 122 patients with essential trigeminal neuralgia and 20 patients with trigeminal neuralgia secondary to multiple sclerosis were analyzed; almost all patients (96.5%) showed a significant reduction in pain after one or more procedures over time; 96.5 of the patients showed excellent pain relief after 1 (40%) or more procedures (60%). The average time between one procedure and the next was 26 months. Conclusion: The use of time and temperature parameters chosen shows excellent efficacy, in line with the literature, with very low incidence of adverse events. The pain-free time between one procedure and the next does not seem to be a significant prognostic criterion which may or may not indicate the repetition of the procedure.

Purpose: We evaluated the effects of postoperative administration of (ONSs) on the liver function and the outcome of cirrhotic patients using ultrasound (US) assessment of rectus femoris (RF) and anterior tibialis (AT) muscles. Patients and Methods: Forty-three malnourished adult hepatic patients who underwent major liver resections were recruited in this study. In the conventional diet (CD) group, the patients took water at postoperative day (POD) 0 and routine soft diet starting from POD1. In the ONS group, a commercially elemental diet was started from POD1 for 7 days postoperatively, with a target endpoint of 35-40 kcal/kg and 1.2-1.5 g/kg of protein per day. US assessment of the RF and AT muscles was done preoperatively and at POD3 and 7, including anterior-posterior (AP) diameter, lateral–lateral (LL) diameter, and cross-sectional area (CSA). Muscles' echogenicity was defined by the Heckmatt scale. The outcome of the patients was also recorded. Results: Consumption of ONS preserved the measured RF and AT characteristics (AP and LL diameters and CSA) in the ONS group at POD3 and 7 compared to the CD group. Heckmatt scale was significantly increased at POD3 and 7 in the CD group compared to the ONS group. Both total protein and albumin levels at POD3 and 7 were significantly lower in the CD group compared to the ONS group [P = (0.02, 0.03) and (0.05, 0.04), respectively]. Serum phosphate was significantly lower at POD7 in the ONS group than the CD group (p = 0.04). There were significant decreases in the ICU stay and time of passing flatus (h) in the ONS group comparing with the CD group (P = 0.045 and P = 0.00, respectively). Conclusions: ONS maintains muscle mass and echogenicity of RF and AT along with better liver function and intestinal function recovery.

Background: Anesthesia has an influence on early postoperative cognitive function. This is specifically relevant in ambulatory surgery. At discharge, patients must return to their normal life and manage simple tasks. Goal was to detect influencing factors of early postoperative cognitive dysfunction after ambulatory anesthesia. Methods: With approval of the local ethics committee, 102 individuals scheduled for ambulatory anesthesia were examined with a specific test battery. Cued and uncued reaction time, divided and selective attention were tested prior to anesthesia and at the time of discharge. Differences between the two examinations and potential influencing factors including age, premedication, type and duration of anesthesia were evaluated with the Student t-test and linear regression. P < 0.05 considered significant. Results: In all, 86 individuals completed the study. Both reaction times were reduced after anesthesia compared to before. No differences were seen for divided and selective attention. Age influenced on the post-anesthesia reaction time while all other factors did not. Conclusion: Reaction time but not attention as more complex cognitive function is influenced by anesthesia. Age seems to be an important factor in early postoperative cognitive dysfunction.

Background: Adequate preoperative information can lessen patient anxiety. Delivering sufficient information during a personal interview, however, is time consuming, and therefore a relevant economical aspect. We investigated whether video information given to the patient before the pre-anesthetic interview has an influence on the patient's anxiety and the duration of the interview. Method: We randomized 302 patients undergoing different types of anesthesia. In all, 151 patients watched a short video with general information about the anticipated anesthesia procedure. Afterward, all patients had a standard pre-anesthetic interview. Patients' anxiety and satisfaction with pre-anesthesia care were assessed after the interview using a visual analogue scale. The duration of the interview was documented. Student t-test and P < 0.05 for differences between the groups. Results: There was no difference in gender, age, ASA physical status, previous anesthesia experience, and the planned anesthesia procedure between the two groups. No difference in anxiety and satisfaction with pre-anesthesia care was observed. The duration of the pre-anesthetic interview was also not different between the groups. Discussion: Preoperative multimedia information did not reduce anxiety or increase the patient satisfaction undergoing anesthesia. The video containing general information did not save time in the pre-anesthetic interview.

Introduction: Intubation in COVID patients is challenging. Various guidelines suggest the use of video-laryngoscope (VL) as the first device to aid intubation in a COVID patient. The best VL to facilitate intubation in such a setting especially by novices is not ascertained. We compared intubation characteristics by two VL's (McGrath-MAC and C-MAC) for intubation in a COVID simulated mannequin by novices. Methodology: This prospective randomized manikin-based crossover study was done in thirty medical professionals with no previous experience of intubation with VL. All participants were trained on Laerdel airway management trainer and were allowed 5 practice sessions with each scope with an intubation box while wearing face protective personal protective equipment (PPE). Participants were randomized into two groups of 15 each, one group performed the intubation first with McGrath and the other with C-MAC before crossing over. Results: The mean (S. D.) time to intubation was similar with both McGrath-VL and CMAC VL [31.33 (14.72) s vs 26.47 (8.5) s, P = (p-0.063)]. POGO score [mean (S. D.)] was better with CMAC [81.33 (16.24) vs 60.33 (14.73), p-0.00. The majority of the users preferred C-MAC VL for intubation (93.33%). The incidence of failed intubation and multiple attempts at intubating were similar with the two scopes. Conclusion: The time to intubation was similar with both VL's but the majority of novices preferred CMAC probably due to a bigger screen that helped them to have a better view of glottis in the COVID simulated mannequin.

Introduction: The ultrasound (US)-guided erector spinae plane (ESP) block is a new regional anesthetic technique that offers significant advantages over paravertebral block as it is easy and safe to perform. We aim to compare the efficacy of US-guided paravertebral block with ESP block for postoperative analgesia in modified radical mastectomy (MRM). Methods: Eighty female patients of age group 18–70 years, belonging to physical status American Society of Anesthesiologists (ASA) I and II, undergoing MRM were included in the study. In Group P, patients received paravertebral block and in Group E, patients received ESP block before induction of general anesthesia. Both the groups received 0.5% 20 mL ropivacaine. The time to first rescue analgesia and total doses of rescue analgesics were recorded in the postoperative period. Numeric Rating Scale (NRS) scores at 0 min, 30 min, 1 h, 2 h, 6 h, 12 h, and 24 h were noted, and patient satisfaction was evaluated at 24 h. Unpaired t-test or the Mann–Whitney U test was used to compare quantitative variables while Chi-square test or Fisher's exact test was used to compare qualitative variables. Results: The time for the first analgesic request was 232.5 min (140-1200) in ESP group as compared to paravertebral group in which the duration was 205 min (135-1190) (P value = 0.29). The total dose of rescue analgesics and NRS scores in postoperative period were comparable. However, the time to perform ESP block was significantly shorter than that of paravertebral block. Conclusion: ESP block can be used as a safe and easy to perform alternative analgesic technique over paravertebral block in breast cancer surgeries.

Context: Mentorship is an integral part of the professional and academic growth; however, the position of mentorships in anesthesia is still yet to be understood. As an attempt to understand this phenomenon, we targeted Riyadh Anesthesiology residents and program directors to explore their perception of mentorship relationships. Aims: The aims of this study were to assess the prevalence of mentorship in anesthesiology training and to assess the perspective of mentorship from anesthesiology residents. Settings and Design: This was a cross-sectional study. Methods and Material: We administered a 20-item validated cross-sectional survey to program directors and anesthesia residents to all Riyadh SCFHS anesthesiology departments. Residents were asked about their perceptions of barriers and benefits to effective mentoring. Statistical Analysis Used: IBM SPSS version 23 and Microsoft Office Excel version 2010. Results: Fifty anesthesiology residents and three program directors responded to our survey. The majority of residents agreed that mentorship was beneficial to the overall success as an anesthesiologist (36 of 50, 72%). Although all three program directors reported that a formal mentorship program is part of their residency program (3 of 3, 100%), only (25 of 50, 50%) responded with access to a mentor. Difficulties reported included lack of formalized meeting times, insufficient times with mentors, and mentor-mentee incompatibility. Conclusions: In conclusion, the study indicated the positive perspective and high principles to mentorship held by anesthesiology residents in Riyadh, Saudi Arabia. It evidenced the beneficial, professional, and social impact that mentoring hails to the development of future anesthesiologists, and despite all that, it remains underutilized.

Aims: To detect the prevalence and the most significant sources of occupational burnout syndrome among anesthetic technicians in Saudi Arabia and draw recommendations that can reduce the level of this syndrome. Settings and Design: A cross-sectional descriptive survey was conducted in a central hospital in Saudi Arabia. Methods: Maslach Burnout Inventory and a self-created questionnaire was utilized to survey seventeen anesthesia technicians in order to capture the prevalence and most significant sources of burnout. Statistical Analysis Used: Descriptive statistics were utilized to conduct the statistical analysis. Results: Occupational burnout syndrome has been found in 29%. A level of emotional exhaustion was critically high in 41.2%. Likewise, a level of depersonalization was extremely high in 58.8%, while 76.5% of anesthetic technicians lacked personal accomplishments. There are several sources perceived by anesthetic technicians as the most significant sources of their occupational burnout syndrome. These sources include staff shortage, high workload, occupational hazards, and poor teamwork. However, the limited career pathway of anesthesia technicians seems to be the main predictor. Conclusions: A critically high prevalence of occupational burnout syndrome was found among anesthetic technicians, which is the highest among all studies reviewed worldwide. Several recommendations have been made which require urgent implementation into practice in order to protected practitioners' wellbeing and decrease their rate of turnover. These recommendations include implementing physician-led team-based care, provision of training and resources, fostering equity in a workplace and provision of hazard pay.

Background: COVID-19 pandemic was declared a worldwide crisis, as a response the community established new protocols and clinical pathways to prepare the health system in adapting to the expected surge of cases. Objectives: In this study, we aim to assess the effect of the pandemic on the anesthesia training program residents from their own view. Identification of gaps in training programs will help to overcome the challenge like pandemic in order to have competent anesthesia practitioners. Methods: We deployed an online survey in early May 2020 targeting the anesthesia residents in Saudi Arabia. We used mixed methods, containing both quantitative and qualitative questions. Our survey had 3 main sections: demographics, pandemic effect on the training, and pandemic effect on the trainees. Results: Our survey showed that in the first 2 months of the pandemic there was a vast decrease in educational activities and clinical activities. However, after that both the Saudi Commission for Health Speciality (SCFHS) and local hospitals employed alternative education methods like electronic learning and simulation to adopt these changes. We also found the average stress level among residents was 6.5 out of 10 with number one stressor is transmitting Covid-19 to family or self. Finally, Wellbeing resources were available to residents however were not used sufficiently by residents. Conclusion: During times of pandemic, assessment and gap identification in postgraduate training programs are necessary to help overcome challenges of training anesthesiologists. Other than the clinical competency residents' wellbeing needs to be monitored and make available resources easy to reach for the residents.

Background: Obesity is a major global public health problem. Observational studies have shown an increasing incidence of syncope and pre-syncope following bariatric surgery in obese patients. However, there is paucity of the true incidence of syncope following bariatrics sugary in the literature. Methods: We have randomly surveyed 200 patients who underwent bariatric surgery between 2016-2018 using Calgary Syncope Score (CSS). Results: Of the 200 patients enrolled, 107 (53.5%) were female with 167 patients (83.5%) between 18 and 50 years of age. The most-reported comorbidities were diabetes mellitus 26 (13%) hypertension 25 (12.5%) and pulmonary disease 18 (9%). The majority 98 (49%) of the patients had pre-operative body mass index (BMI) of 40–50 kg/m², and most of them had laparoscopic sleeve gastrectomy (LSG). Sixty-two (31%) patients had vasovagal syncope (VVS), 52 (26%) patients had non-VVS and 86 (43%) had no syncope. Conclusion: Vasovagal syncope in patients following bariatric sugary is quite common and affects 15% of bariatric patients in our series in the first year postoperatively. Further randomized controlled trials are required to prove our results.

Background and Aims: Pain assessment requires an extensive practice in diagnosis coupled with proficiency in recognizing health factors that lead to its occurrence. Nurses' education and training could be the main factor influencing pain perception and diagnosis. This study aims at comparing nurses' academic qualifications and relevant training courses that may impact their assessment skills toward patients in pain. Methods: A descriptive cross-sectional design using a Knowledge and Attitudes Survey Regarding Pain questionnaire was administered to a total of 247 nurses. In this survey, the nurses were asked to answer specific questions related to correctly diagnosing and assessing patients' pain, as well as answer questions about their previous training in pain assessment. Results: A total of 247 nurses answered the questionnaire, with an overall response rate of 82%. Questionnaires revealed that more than half (50.6%) of the nurses involved in this study have not received any pain education related to pain management in the 5 years following their initial nursing licensure or supervision under a nurse supervisor. Conclusions: The results of the paper show that nurses' experiential level has the highest impact on their knowledge of pain relief management and medications necessary for treating it. Also, nurses' pain education following their initial licensure and during their professional practice has the second highest impact on their pain relief management knowledge, whereas their primary nursing education had the lowest.

As of 22 April 2020, there are 6 countries with >100,000 cases, 21 countries with 1000 to 10,000 confirmed cases and 53 countries with between 1000 and 10,000 confirmed cases of COVID-19. Six articles (5 research articles and 1 review article) with a total of 159 cases delineating the equipment, protocol, techniques, indications and follow-up management of COVID-19 were identified in a PUBMED search evaluating the role of lung Ultrasound. In the current review article, 55%-60% of the patients with COVID-19 were male; the median age has been reported between 34 and 59 years. Lung Ultrasound features of COVID-19 are related to the stage of the disease, the severity of lung injury, and comorbidities. This review article provides a summary of lung Ultrasound findings in COVID-19 and clinical guidance for the use and interpretation of lung ultrasound for patients with moderate, severe and critical COVID-19-related pulmonary syndrome.

Context: Fraudulent publication is a scourge of scientific research. Objectives: This scoping review was aimed at characterizing retracted publications for fraud or plagiarism in the field of anesthesia. Does the reputation of the journal (Quartile and Impact Factor, IF) protect the reader from the risk of having the manuscript he read withdrawn for fraud/plagiarism? Methods/Design: This scoping review was planned following the Joanna Briggs Institute recommendations. Data sources: PubMed and the Retraction Watch Database (http://retractiondatabase.org/RetractionSearch.aspx?). Study selection: All types of publications retracted. Data extraction: Year, first author nationality, journal name, journal category, IF, Quartile, H index. Data analysis: The association with Quartile and IF was investigated. Results: No significant association between retraction of papers published in no-Quartile journals and retractions published in journals placed in the highest quartile. Conclusions: The quality of the surveillance in paper submission is not higher in journals of the first Quartile than in journals not placed in other Quartiles. (The protocol was prospectively registered in the Open Science Framework https://doi.org/10.17605/OSF.IO/TGKNE)

Hypertrophic cardiomyopathy (HOCM) is the most common genetic heart disorder and the most common cause of sudden cardiac death among young population and a major cause of disability for patients of any age. An extended transaortic septal myectomy is the definitive treatment. It is very important to have a good knowledge of the characteristic pathophysiology of the disease in order to optimize intraoperative treatment of these patients. We present a case of a 68-year old woman who underwent hypertrophic elective cardiomyopathy surgery. Anesthetic management is crucial to guarantee maximum safety, since HOCM has the capacity to produce hemodynamic events of such severity that put patient's life at risk. The use and combination of intraoperative transesophageal echocardiography (TEE) and direct measurement of the left ventricular outflow tract gradient provides vital information to ensure successful surgical outcome in patients with HOCM.

Foreign body ingestion is a common event among pediatric patients, especially in children less than 6 years of age. Although most cases are relatively benign, with the foreign body passing spontaneously or requiring a brief endoscopic procedure for removal, button battery ingestion is known to cause significant morbidity with the potential for mortality. Although aorto-esophageal fistula (AEF) is a rare complication following button battery ingestion, its clinical manifestations are significant and outcomes are poor. Early diagnosis and aggressive treatment are key in preventing fatal complications. We describe the successful management of an AEF which presented with hematemesis 8 days after removal of a button battery in a 17-month-old female. The literature regarding button battery ingestion and AEF is reviewed and treatment options including intraoperative anesthetic care discussed.

Massive hematemesis could be challenging situation requiring emergency airway control and urgent surgical treatment. We report a case of difficult airway management with blind intubation through Laryngeal Mask Airway in a 56-year-old patient with massive hematemesis. After failed endoscopic attempts to stop bleeding, worsening of hemodynamics called for emergency intubation and surgery. After failed intubation attempts and face-mask ventilation worsening, a classic LMA was used for rescue ventilation and decision was made to intubate through LMA. The airway exchange was aided by a nasogastric tube (NGT) through LMA, confirmed with capnography and surgery was started successfully and uneventfully. Unexpected difficult airway can be extremely challenging situation, especially in emergency settings with no possibility to delay surgery. In those cases, literature suggests different intubating techniques through LMA. Blind intubation through LMA aided by NGT showed to be a suitable option in resources-limited settings, where advanced supraglottic devices and/or optical devices are not available.

A 35-year-old female presented with headache in the third week postpartum period following uneventful cesarean delivery. She had left sided ptosis, pain, and numbness over left face since third trimester. Post-delivery magnetic resonance imaging revealed invading left sphenoid sinus meningioma. She was planned for combined endonasal and pterional craniotomy. Her preoperative investigations including sodium, glucose, and liver functions were normal. Intraoperatively during endonasal phase a high urine output (UO) with rising sodium were noticed which continued with worsening sodium (156 mEq/L after 3 h). Desmopressin 1 mcg IV administered which normalized UO for the rest of surgical duration with trends of declining sodium (149 mEq/L at the end of procedure). Her postoperative MRI was normal however desmopressin could not be discontinued because of increasing sodium and UO without it. She was discharged on oral desmopressin, hydrocortisone and levothyroxine. On her follow-up 3.5 months later she had normal sodium and normal UO.

Cardiac Sympathetic Denervation (CSD) has been shown to reduce shocks and subsequent pain of implantable cardiac defibrillator (ICD) in patients with heart diseases and recurrent Ventricular Tachycardia (VT) who did not respond properly to oral therapy and ablation. A 68-year-old man who presented an idiopathic dilated cardiomyopathy with impaired ejection fraction was treated for VT. A bilateral cardiac sympathetic denervation was performed under general anesthesia. Patient was extubated in the operating room and transferred to ICU where he presented hypotension. He was discharged after five days and remained symptom-free without any incident of VT during hospital stay. Currently no definite anesthetic management is available to treat such patients. This report discusses an approach that made heart rate control and safe patient discharge possible.

Technological advances in mechanical circulatory support have enabled more patients with end-stage heart failure to benefit from left ventricular assist devices (LVAD). Indications for LVAD implantation have evolved to include patients who are deemed unsuitable for cardiac transplantation, otherwise known as destination therapy. This case report describes such patient with multi-organ failure who underwent LVAD insertion after nine days of extra-corporeal membrane oxygenation, intra-aortic balloon pump and maximal inotropic support. Strategies for perioperative management, as well as intra-operative monitoring and interventions are discussed.

Medium-chain acyl-CoA dehydrogenase deficiency can cause symptoms resulting from β-oxidation disorder during preoperative fasting. Tight perioperative glucose monitoring is needed to avoid these symptoms. We report the first pediatric case using continuous tissue glucose monitoring devices. The patient was a 9-year-old boy with medium-chain acyl-CoA dehydrogenase deficiency for whom femoral osteotomy and selective muscle release of the hip and knee was planned to treat hip dislocation and joint contracture. To monitor tissue glucose levels continuously during preoperative fasting, a percutaneous sensor was attached to the right upper extremity, 2 days before the operation. Anesthetic management using Ringer's acetate containing 5% glucose, an inhalational agent, and epidural anesthesia without a muscle relaxant or propofol was performed without complications. The device achieved tight perioperative glucose monitoring. Continuous tissue glucose monitoring devices helped perioperative glucose monitoring of the pediatric patient with medium-chain acyl-CoA dehydrogenase deficiency.

Aarskog Scott syndrome is a rare genetic disorder characterised by facial, limb and genital abnormalities first described in 1970. Its evolving nature in terms of associated features and increased surgical interventions necessitates anaesthesiologists to have a thorough knowledge about this syndrome for a better preparedness. Although multiple case reports have been published in literature since its discovery, no case report regarding its anaesthetic considerations and challenges have been described in literature till now. We report challenges encountered and successful anaesthetic management of a seven-year-old girl with Aarskog Scott Syndrome posted for a corneal repair in view of traumatic corneal perforation.

As the motivation to potentially allow for a more expansive role of opioid-sparing anaesthesia in various surgical specialities transpire with new zeal, promising evidence needs to be accumulated to substantiate the same. Appropriate to this context, the index case series highlight the beneficial effects of an intraoperative magnesium sulphate infusion on perioperative hemodynamic profile and postoperative recovery in patients undergoing intracranial cerebral aneurysm surgery.

The erector spinae plane block (ESPB) has recently been described as an effective analgesic strategy for various surgeries at ventral and dorsal parts of body. The block has been utilized for postoperative pain relief in hip surgeries. Cadaveric and clinical studies performed at the lumbar level depict a dorsal spread and minimal ventral spread in the lumbar plexus. So far to our knowledge there is one case report which has described reduced quadriceps strength in a parturient after caesarean section. We report two patients who presented with absent knee reflexes (decreased quadriceps strength) and one patient with absent ankle reflex (foot drop) following continuous ESPB at the level of L3. The initial bolus was with 30 ml of 0.1% bupivacaine followed by a continuous infusion of 0.1% ropivacaine at 8ml/hour. The loss of knee reflexes in two patients and diminished reflexes in one patient suggested spread of local anaesthetic (LA) to the lumbosacral plexus. The LA infusion were stopped in all 3 patients. The average duration of motor block was 18 hours. These complications should be considered if early ambulation is mandatory for patients.