Background and Objectives: Awake "no touch" extubation requires performing extubations only when the patient spontaneously wakes up without any kind of stimulation during emergence from general anesthesia. The aim of this study was to evaluate absolutely awake extubation "no touch" technique in adult patients, scheduled for elective nasal and paranasal sinus surgeries under general anesthesia as regard to emergence airway complications. Methods: A total of 60 adult patients were randomly allocated into one of two equal groups according to the method of extubation: Group I: Standard fully awake, Group II: Absolutely "no touch" awake extubation (absolutely no stimulation "no touch" was allowed until patients were able to open their eyes). The incidence of laryngospasm and its grade according to a four-point scale was reported. Occurrence of airway events (excessive secretions, breath-holding, coughing, hoarseness, biting, as well as the number and severity of any desaturation episodes), oozing from the wound, and postoperative sore throat were also recorded. The heart rate (HR), systolic (SBP) and diastolic (DBP) blood pressure measured at the end of surgery served as baseline values, and subsequent measurements were taken within 30 minutes after the end of surgery. Results: There was absolutely no case of laryngeal spasm or episode of desaturation among patients who were extubated with the "no touch" technique. On the other hand, there were 3 cases of laryngeal spasm in standard fully awake group. Severity of coughing, excessive secretions and breath holding, hoarseness, biting, and occurrence of non-purposeful movements of the limbs were significantly less in the absolutely "no touch" awake technique. The changes in HR, SBP, and DBP during emergence extubation were significantly less in "no touch" technique group. However, oozing from the wound was significantly higher with standard fully awake extubation. However, there were no significant differences between the two groups regarding the incidence of postoperative sore throat (39 and 36%, respectively). Conclusion: The results of the present study showed that awake "no touch" technique for tracheal extubation produces less airway-related complications, as well as minimal hemodynamic response during emergence from general anesthesia in nasal and paranasal surgeries. It could be a safe alternative for tracheal extubation in airway surgery.

Introduction: The infraclavicular brachial plexus block (ICB) is designed to deposit anesthetic high in the plexus, achieving anesthesia of the hand, forearm, elbow, and distal arm. Adenosine is a metabolic intermediate that is involved in nearly all aspects of cell function, including neurotransmission and signal transduction.This study was aimed to show whether addition of adenosine to bupivacaine in ultrasound-guided ICB had an analgesic effect. Methods: Sixty adult patients were divided into two equal groups, each group included 30 patients. Group I received infraclavicular bupivacaine 0.325% in a volume of 30 ml. Group II received 30 ml of 0.325% bupivacaine + 12 mg adenosine. The block was maintained with an infusion of 10 ml/h. The following parameters were assessed: Success rate, time of the sensory onset, motor block, visual analog scale (VAS), and amount of i.v. pethidine needed. Results: This study showed an analgesic effect of infraclavicular adenosine as evidenced by a statistically significant shorter mean time of onset of the sensory block (16 vs. 20 min, P < 0.05), lower mean VAS score over 48 h (1.7 vs. 2.7, P < 0.05), longer mean time of first parenteral analgesic requirement (299 vs. 255 min, P < 0.05), and lower mean total dose of pethidine needed over 48 h after surgery (25.5 vs. 56.6 mg, P < 0.05). All patients got successful infraclavicular block and recovered uneventfully without any sensory or motor deficit. Conclusion: Adenosine may provide valuable addition to the therapeutic options in anesthesia and pain management. Further research is required to figure out its exact role .

Purpose: This study compared the efficacy of single-injection percutaneous peribulbar anesthesia (PBA) with a short needle with sub-Tenon's anesthesia (STA) to produce optimal operating conditions for cataract extraction in patients with complicated cataract. Methods: Two hundred patients with complicated cataract were enrolled in this prospective, double-blinded, randomized study. Adequate akinesia was a surgical requisite for all cases included in the study because of the expected difficult surgery. The patients were divided into two equal groups to receive either peribulbar anesthesia (PBA) with a 16-mm needle or sub-Tenon's anesthesia. Surgical akinesia (as a primary end point), analgesia, incidence of complications, as well as patient and surgeon satisfaction (as secondary end points) were assessed. Results: Both techniques provided similar analgesia during the operation and similar rates of incidence of chemosis with no serious complications; while the PBA group provided higher degree of akinesia 10 minutes after injection of the local anesthetic, a lower incidence of subconjunctival hemorrhage (SCH) and higher patient and surgeon satisfaction compared to the STA group. Conclusion: We concluded that when globe akinesia is necessary during surgery, the single-injection technique for percutaneous peribulbar anesthesia with a short needle proved to be more suitable than the STA in providing akinesia for cataract surgery. Also, this PBA technique demonstrated a lower incidence of SCH and was preferred to STA by the patients and surgeon.

Background and Objectives: Neuraxial anesthesia in the elderly is associated with exaggerated responses to conventional doses of local anesthetics, thereby increasing the incidence of hemodynamic complications. A double-blind prospective study was carried out in our institute with an aim to compare the hemodynamic stability and quality of the conventional dose of hyperbaric bupivacaine (LA) with low dose of LA and sufentanil in elderly patients scheduled for lower limb surgery, randomized to receive combined spinal epidural anesthesia. Methods: A total of 50 elderly patients of ASA grade I and II, divided randomly into groups I and II, of either sex undergoing lower limb surgery under combined spinal epidural anesthesia at our institute attached to a Government Medical College were enrolled for study. Group I received 2.5 ml of intrathecal hyperbaric bupivacaine (LA), while group II received 1.5 ml of intrathecal LA+0.1 ml sufentanil (5 μg). Both initial and postoperative subarachnoid block characteristics, hemodynamic and respiratory parameters, duration of analgesia, and side effects were observed and recorded. Statistical analysis was carried out using Chi-square and paired t test. Results: Demographic profile was comparable in both groups. Group I had a greater incidence of hypotension and, consequently, higher use of vasopressors (P<0.05). Onset of sensory analgesia, time to achieve peak sensory level, and recovery from motor blockade were significantly earlier in group II (P<0.05). Postoperative consumption of LA through epidural route was significantly higher in group I (P<0.05). The side effect profile was similar, except for a significantly higher incidence of shivering in group I (P<0.05). Conclusions: The study established that the dose of a local anesthetic can be safely and significantly lowered by 40%, with addition of low-dose sufentanil, thereby avoiding the hemodynamic fluctuation and providing a stable perioperative and postoperative period in the geriatric population. In addition, duration of sensory analgesia is prolonged and postoperative requirement for the epidural top-up also decreases.

Background: Dexmedetomidine is an alpha ₂ -adrenergic agonist with sedative and analgesic properties. This study aimed to investigate if the use of a continuous dexmedetomidine infusion with i.v. morphine patient-controlled analgesia (PCA) could improve postoperative analgesia while reducing opioid consumption and opioid-related side effects. Methods: In this prospective randomized, double-blinded, controlled study, 39 patients with obstructive sleep apnea syndrome undergoing uvulopalatopharyngoplasty were assigned to two groups. Group D (dexmedetomidine group) received a loading dose of dexmedetomidine 1 μg.kg^-1 i.v., 30 minutes before the anticipated end of surgery, followed by infusion at 0.6 μg.kg^-1 h^-1 for 24 hours. Group P (placebo group) received a bolus and infusion of placebo. In both groups, postoperative pain was initially controlled by i.v. morphine titration and then PCA with morphine. Cumulative PCA morphine consumption, pain intensities, sedation scores, cardiovascular and respiratory variables and opioid-related adverse effects were recorded for 48 hours after operation. Results: Compared with placebo group, patients in the dexmedetomidine group required 52.7% less PCA morphine during the first 24 hours postoperatively, with significantly better visual analogue scale scores, less incidence of respiratory obstruction (5 vs. 12 patients, respectively; P = .037) and longer time to first analgesic request (21 (11) vs. 9 (4) minutes; P = .002). Fewer patients in group D experienced nausea and vomiting than those in group P (7 vs. 24 patients, respectively; P < .05). Conclusion: Continuous dexmedetomidine infusion may be a useful analgesic adjuvant for patients susceptible to opioid-induced respiratory depression.

Introduction: This study was designed to evaluate the pre- vs. post-incisional analgesic efficacy of bupivacaine administered caudally in children undergoing unilateral hernia repair. Methods: Fifty children aged 6 months to 6 years were included in the study. Children were divided blindly between the two groups to receive pre- vs. post-incisional caudal bupivacaine. The preincisional group received 1 ml/kg of 0.125% bupivacaine caudally after induction of anesthesia and the postincisional group received the same dose caudally at the end of surgery. Heart rate, SaO ₂ , end tidal CO ₂ , and noninvasive arterial blood pressure were recorded every 10 min. The duration of surgery, extubation time, and duration of recovery period were also recorded. The pain scores were measured with using an Oucher chart in the recovery room, 2, 4, 6, 12, and 24 h after surgery. Time to first analgesia, numbers of supplementary analgesics required by each child in a 24-h period and total analgesic consumptions were recorded. Any local and systemic complications were recorded. Quantitative data were compared using a two-tailed t-test. Sex distribution and frequency of acetaminophen consumption were measured using χ² test. P<0.05 was considered statistically significant. Results: The Oucher pain scale at 4, 6, 12, and 24 h after surgery, the total analgesic consumption and the numbers of demand for supplemental acetaminophen were lower statistically in preincisional group ( P<0.05). Extubation time and duration were higher in preincisional group ( P<0.05). Mean changes of heart rates were statistically lower during the anesthesia period and recovery time in preincisional group (P<0.05). Conclusion: Preincisional caudal analgesia with a single injection of 0.125% bupivacaine is more effective than the postincisional one for postoperative pain relief and analgesic consumption in unilateral pediatric herniorrhaphy.

Objective: The objective was to compare the ability of norepinephrine and dopamine in reversing the hemodynamic and metabolic abnormalities of septic shock using Edwards Vigileo Monitor with Flotrac Sensor. Design: Prospective randomized control study. Methods: Fifty consecutive patients presenting with hyperdynamic septic shock who fulfilled the inclusion criteria were randomly allocated to either group I or group II. The goal of therapy was to achieve and maintain for 6 hours, all of the following - systolic blood pressure (SBP) >90 mmHg, systemic vascular resistance index (SVRI) >1800 dynes.s/cm ⁵ m ² ,cardiac index (CI) >4.0 lt/min/m ² , index of oxygen delivery >550 ml/min/m ² , index of oxygen uptake >150 ml/min/m ² . The patients in group I were started on dopamine infusion at 10 μg/kg/min which was increased by 2.5 μg/kg/min, every 15 minutes till the goals were achieved. The patients in group II received norepinephrine infusion started at a dose of 0.5 μg/kg/min with a dose increment of 0.25 μg/kg/min, every 15 minutes till the goals were achieved. Results: Post-treatment heart rate showed an increase in the mean value in group I patients and a decrease in group II patients. The post-treatment mean SBP and SVRI in group II was significantly higher than that in group I. Patients in group I showed a significantly higher increase in post-treatment CI and index of oxygen delivery compared to patients in group II. Nineteen out of 25 patients responded to the treatment in group II while only 10 out of 25 responded in group I. Conclusion: Norepinephrine was more useful in reversing the hemodynamic and metabolic abnormalities of hyperdynamic septic shock compared to dopamine.

Background: Prolonged mechanical ventilation is an important recognized complication occurring during cardiovascular surgery procedures. This study was done to assess the perioperative risk factors related to postoperative pulmonary complications and tracheostomy in women undergoing coronary artery bypass graft with cardiopulmonary bypass. Methods: It was a retrospective study on 5,497 patients, including 31 patients with prolonged ventilatory support and 5,466 patients without it; from the latter group, 350 patients with normal condition (extubated in 6-8 hours without any complication) were selected randomly. Possible perioperative risk factors were compared between the two groups using a binary logistic regression model. Results: Among the 5,497 women undergoing coronary artery bypass graft (CABG), 31 women needed prolonged mechanical ventilation (PMV), and 15 underwent tracheostomy. After logistic regression, 7 factors were determined as being independent perioperative risk factors for PMV. Discussion: Age ≥70 years old, left ventricular ejection fraction (LVEF) ≤30%, preexisting respiratory or renal disease, emergency or re-do operation and use of preoperative inotropic agents are the main risk factors determined in this study on women undergoing CABG.

Background: The role of the anesthesiologist is often unknown among patients. But, the situation where the anesthesiologist is uncertain of his/her function gives more cause for concern. Methods: A questionnaire survey on the appraisal of anesthetic practices was carried out over 5 months using the style of clinical practice. Results: One-third of the anesthesiologists who responded to the survey attached little importance to the work they did by not communicating the same to their patients while 45.2% did not discuss the intraoperative findings with the surgeons. Although 57 (59.4%) of the respondents usually visit their patients on the ward preoperatively, only 16 (21.6%) discussed the proposed anesthetic procedure with the patients. Thirty-nine (40.2%) respondents claimed that they do not wear ward coats to the ward at the preoperative visit. Less than 20% consistently conducted a postoperative visit. The majority of the respondents would treat all patients as important, irrespective of social status, while 74.5% of them considered obtaining informed consent for anesthesia from patients as significantly important. Conclusion: The current practice of anesthesia has been found wanting in several aspects. Knowledgeable discussion by anesthesiologists with surgeons as well as enlightenment of patients and their relatives about their work will improve the quality of anesthesia care remarkably. Changes in the anesthesia training curriculum to reflect these deficiencies would be helpful.

Background: The cardiopulmonary bypass (CPB)-associated atelectasis accounted for most of the marked post-CPB increase in shunt and hypoxemia. We hypothesized that pressure-regulated volume-control (PRVC) modes having a distinct theoretical advantage over pressure-controlled ventilation (PCV) by providing the target tidal volume at the minimum available pressure may prove advantageous while ventilating these atelactic lungs. Methods: In this prospective study, 36 post-cardiac surgical patients with a PaO ₂ /FiO ₂ (arterial oxygen tension/Fractional inspired oxygen) < 300 after arrival to intensive care unit (ICU), (n = 34) were randomized to receive either PRVC or PCV. Air way pressure (P_aw ) and arterial blood gases (ABG) were measured at four time points [T1: After induction of anesthesia, T2: after CPB (in the ICU), T3: 1 h after intervention mode, T4: 1 h after T3]. Oxygenation index (OI) = [PaO ₂ / {FiO ₂ × mean airway pressure (P_mean )}] was calculated for each set of data and used as an indirect estimation for intrapulmonary shunt. Results: There is a steady and significant improvement in OI in both the groups at first hour [PCV, 27.5(3.6) to 43.0(7.5); PRVC, 26.7(2.8) to 47.6(8.2) (P = 0.001)] and second hour [PCV, 53.8(6.4); PRVC, 65.8(7.4) (P = 0.001)] of ventilation. However, the improvement in OI was more marked in PRVC at second hour of ventilation owing to significant low mean air way pressure compared to the PCV group [PCV, 8.6(0.8); PRVC, 7.7(0.5), P = 0.001]. Conclusions: PRVC may be useful in a certain group of patients to reduce intrapulmonary shunt and improve oxygenation after cardiopulmonary bypass-induced perfusion mismatch.

Background: Hemodynamic responses of laryngoscopy and laparoscopy should be attenuated by the appropriate premedication, smooth induction, and rapid intubation. The present study evaluated the clinical efficacy of oral premedication with pregabalin or clonidine for hemodynamic stability during laryngoscopy and laparoscopic cholecystectomy. Methods: A total of 180 healthy adult consented patients aged 35 to 52 years with American Society of Anesthesiologist (ASA) physical status I and II of both gender, who met the inclusion criteria for elective laparoscopic cholecystectomy, were randomized to receive placebo Group I, pregabalin (150 mg) Group II, or clonidine (200 μg) Group III, given 75 to 90 minutes before surgery as oral premedication. All groups were compared for preoperative sedation and anxiety level along with changes of heart rate and mean arterial pressure prior to premedication, before induction, after laryngoscopy, pneumoperitoneum, release of carbon dioxide, and extubation. Intraoperative analgesic drug requirement and any postoperative complications were also recorded. Results: Pregabalin and clonidine proved to have sedative and anxiolytic effects as oral premedicants and decreased the need of intraoperative analgesic drug requirement. Clonidine was superior to pregabalin for attenuation of the hemodynamic responses to laryngoscopy and laparoscopy, but it increased the incidence of intra-and postoperative bradycardia. No significant differences in the parameters of recovery were observed between the groups. None of the premedicated patient has suffered from any postoperative side effects. Conclusion: Oral premedication with pregabalin 150 mg or clonidine 200 μg causes sedation and anxiolysis with hemodynamic stability during laryngoscopy and laparoscopic cholecystectomy, without prolongation of recovery time and side effects.

Objective: To compare the three common methods of endotracheal tube cuff inflation (sealing pressure, precise standard pressure or finger estimation) regarding the effective tracheal seal and the incidence of post-intubation airway complications. Methods: Seventy-five adult patients scheduled for N ₂ O free general anesthesia were enrolled in this study. After induction of anesthesia, endotracheal tubes size 7.5 mm for female and 8.0 mm for male were used. Patients were randomly assigned into one of three groups. Control group (n=25), the cuff was inflated to a pressure of 25 cm H ₂ O; sealing group (n=25), the cuff was inflated to prevent air leaks at airway pressure of 20 cm H ₂ O and finger group (n=25), the cuff was inflated using finger estimation. Tracheal leaks, incidence of sore throat, hoarseness and dysphagia were tested. Results: Although cuff pressure was significantly low in the sealing group compared to the control group (P<0.001), the incidence of sore throat was similar in both groups. On the other hand, cuff pressure as well as the incidence of sore throat were significantly higher in the finger group compared to both the control and the sealing group (P<0.001 and P=0.008). The incidence of dysphagia and hoarseness were similar in the three groups. None of the patients in the three groups developed air leak around the endotracheal tube cuff. Conclusions: In N ₂ O, free anesthesia sealing cuff pressure is an easy, undemanding and safe alternative to the standard technique, regarding effective sealing and low incidence of sore throat.

Background: Interscalene brachial plexus block (ISBPB) is an effective technique for shoulder surgery and postoperative pain control. The aim of this study is to compare the analgesic efficacy of 0.1% vs 0.2% bupivacaine for continuous postoperative pain control following arthroscopic shoulder surgery. Methods: A total of 40 adult patients divided into two groups (each 20 patients) undergoing arthroscopic shoulder surgery were randomized to receive an ultrasound-guided ISBPB of either 0.1% or 0.2% bupivacaine 10 ml bolus plus 5 ml/h infusion through interscalene catheter. Standard general anesthesia was given. Both groups received rescue postoperative PCA morphine. Pain, sensory, and motor power were assessed before for all patients, 20 minute after the block, postoperatively in the recovery room, and at 2, 6, 12, and 24 hours thereafter. The patient and surgeon satisfaction and the analgesic consumption of morphine were recorded in the first 24 hours postoperatively. A nonparametric Mann-Whitney was used to compare between the two groups for numerical rating scale, morphine consumption in different time interval. Results: Group 1 (0.1% bupivacaine) patients had significantly received more intraoperative fentanyl and postoperative morphine with higher pain scores at 24 hours postoperatively vs group 2 (0.2% bupivacaine) patients. Conclusions: The use of ultrasound-guided ISBPB with 0.2% bupivacaine provided better intra- and post-operative pain relief vs 0.1% bupivacaine in arthroscopic shoulder surgery.

Introduction: Measurement of respiratory quotient (RQ) and resting energy expenditure (REE) has been shown to be helpful in designing nutritional regimens. There is a paucity of the literature describing the impact of a feeding regimen on the energy expenditure patterns. Therefore, we studied the effect of continuous vs. intermittent feeding regimen in head-injured patients on mechanical ventilation on RQ and REE . Methods: After institutional ethical approval, this randomized study was conducted in 40 adult male patients with head injury requiring controlled mode of ventilation. Patients were randomly allocated into two groups. Group C: Feeds (30 kcal/kg/day) were given for 18 h/day, with night rest for 6 h. Group I: Six bolus feeds (30 kcal/kg/day) were given three hourly for 18 h with night rest for 6 h. RQ and REE were recorded every 30 min for 24 h. Blood sugar was measured 4 hourly. Other adverse effects such as feed intolerance, aspiration were noted. Results: Demographic profile and SOFA score were comparable in the two groups. Base line RQ (0.8 vs. 0.86) and REE (1527 vs. 1599 kcal/day) were comparable in both the groups (P>0.05). RQ was comparable in both groups during the study period at any time of the day (P>0.05). Base line RQ was compared with all other RQ values measured every half hour and fluctuation from the base line value was insignificant in both groups (P>0.05). REE was comparable in both the groups throughout the study period (P>0.5). Adequacy of feeding as assessed by EI/MREE was 105.7% and 105.3% in group C and group I, respectively. There was no significant difference in the blood sugar levels between the two groups (P>0.05). Conclusion: We found from our study that RQ, REE, and blood sugar remain comparable with two regimens of enteral feeding - continuous vs. intermittent in neurosurgical patients on ventilator support in a ICU setup.

Background: The objective of the present study was to compare the onset, degree and recovery time of sensory and motor block and hemodynamic effects of intrathecal bupivacaine alone and bupivacaine with sufentanil or butorphanol in endoscopic urological surgeries. Methods: In a randomized, double-blind study, 90 patients of either sex and age, belonging to ASA Grades I and II, scheduled for elective endoscopic urological surgeries under spinal anesthesia, were allocated into three groups of 30 each. Patients received either 2.5 ml of 0.5% hyperbaric buypivacaine 12.5 mg (Group A), 1.5 ml of 0.5% hyperbaric bupivacaine 7.5 mg with 10 μg sufentanil (Group B) or 1.5 ml of 0.5% hyperbaric bupivacaine 7.5 mg with 25 μg butorphanol (Group C). Vital parameters, level, duration and regression of sensory block and motor block and side-effects were recorded and compared. Statistical Analysis Analysis of variance (ANOVA), post hoc test and Chi-square test were used. Results: Intrathecal addition of sufentanil/butorphanol prolonged the duration of sensory block (DOSB) compared with bupivacaine alone (DOSB being 156.83±23.83 min, 170.87 ± 22.21 min and 171.17 ± 23.99 min in groups A, B and C, respectively) without altering the duration of motor blockade. Bromage score 3 was achieved in 100%, 90% and 54.4% patients in groups A, B and C, respectively. The time to first request for analgesia was 112 ± 46.3 min, 323 ± 65.0 min and 299 ± 73.9 min in groups A, B and C, respectively. Complications were reduced by the addition of butorphanol, which also has a lower tendency than sufentanil to produce pruritus (60%). Conclusions: The analgesia was significantly prolonged in groups B and C; group C had a less-intense motor block. Complications were reduced by the addition of butorphanol, which also has a lower tendency than sufentanil to produce pruritus. Thus, this combination of butorphanol with low-dose bupivacaine is especially beneficial in the geriatric group of patients who have multiple co-morbid conditions.

Ultrasound has added a feather in the cap of the anesthesiologists as real-time nerve localization and drug deposition around the nerve structure under real-time guidance is now a reality, as the saying "seeing is believing" has been proven true with the advent of ultrasound in anesthesia. Pediatric patients are a unique group regarding their anatomical and physiological features in comparison with adults; regional blocks in adults with the anatomical landmark and surface marking are almost uniform across the adult population. The landmark technique in pediatric patients is not reliable in all patients due to the variability in the age and size; the advent of ultrasound in assisting nerve localization has changed the way regional blocks are achieved in children and the range of blocks performed on adults can now be performed on pediatric patients; with advances in the technology and dexterity of ultrasound equipment, the chances of success of blocks has increased with a smaller dose of the local anesthetic in comparison to the traditional methods. Anesthesiologists are now able to perform blocks with more accuracy and avoid complications like intravascular injection and injury to the pleura and peritoneum during routine practice with the assistance of high-frequency transducers and top of the range portable ultrasound machines; catheters can be inserted to provide a continuous analgesia in the postoperative period. This review article describes the common peripheral blocks in pediatric patients; the readers are encouraged to gain experience by attending workshops, hands-on practice under supervision, and conduct random controlled trials pertaining to ultrasound-guided blocks in the pediatric age group. The recent literature is encouraging and further research is promising; a wide range of blocks being described in detail by many prominent experts from all over the world.

The practice of regional anesthesia is getting more popular after the introduction of ultrasound technology in anesthesia practice. The biggest obstacle in conducting regional anesthesia is the delay in operation room time. This brief report focuses on the set up of the so called "block room".

Sedation during invasive procedures not only provides appropriate humanitarian care for patients, but also facilitates the completion of invasive procedures. Although generally safe and effective, adverse effects may occur especially in patients with co-morbid diseases. We present the successful use of a combination of dexmedetomidine and ketamine to provide sedation and analgesia in a 21-year-old patient with Duchenne muscular dystrophy (DMD) undergoing bone marrow aspiration and biopsy. Co-morbidities included both depressed myocardial function and impaired respiratory function. Dexmedetomidine was administered as a loading dose of 1 μg/kg over 5 min followed by an infusion of 1 μg/kg/h. Ketamine (20 mg) was administered along with the dexmedetomidine loading dose. An additional 10 mg of ketamine was administered to treat the pain experienced during the placement of the local anesthetic agent prior to the procedure. No clinically significant hemodynamic or respiratory changes were noted. The patient tolerated the procedure well and was discharged home. A review of previously published reports of dexmedetomidine and ketamine for procedural sedation are reviewed.

This report relates how tracurium was given by mistake, intrathecally, during spinal anesthesia, to a 38-year-old woman, who was a candidate for abdominal hysterectomy. When no analgesia was observed, the mistake in giving the injection was understood. She was evaluated postoperatively by train of four ratio, measuring her breathing rate, eye opening, and protruding of tongue at one, two, twenty-four, and forty-eight hours, and then at one and two weeks, with the final evaluation the following month. The patient had normal timings during the operation and postoperation periods, and no abnormal findings were observed through the first month. This finding was contrary to several studies, which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs.

Airway management is considered one of the most difficult and challenging procedures among the various anesthetic procedures. It becomes tougher when there is a diseased temporomandibular joint (TMJ) due to inadequate mouth opening. In the current scenario there are only a few methods that ensure a safe, uneventful intubation in a TMJ ankylosis patient with a difficult airway. These include techniques ranging from minimally invasive techniques like blind nasal intubation, retrograde intubation using a guide wire, the latest technique of intubating with the help of a fiberoptic laryngoscope and the time tested tracheostomy. All these techniques have got their own disadvantages. So we report a case series of five patients with TMJ ankylosis who underwent fluoroscopic-assisted intubation for airway management. We found that this technique is 100% successful in managing the airway in these patients. To the best of our knowledge, this is the first case series detailing this novel technique in the entire English medical literature.

An otherwise healthy 13 year old developed hypercarbia and increased temperature during anesthesia with sevoflurane. Discontinuation of sevoflurane, surface cooling, and hyperventilation resulted in prompt resolution. However, hyperkalemia continued to raise the suspicion for malignant hyperthermia, which was ultimately confirmed by ryanodine receptor gene sequencing. The case underlines the importance of intraoperative monitoring of end-tidal CO2 and temperature and the potential benefits of early discontinuation of inhalational anesthetics in the presence of signs and symptoms suspicious for malignant hyperthermia. The severe hyperkalemia suggests that standard guidelines for diagnosis and treatment of malignant hyperthermia, including dantrolene treatment, should be followed whenever malignant hyperthermia is suspected.