Background: The objective of this study is to investigate the effect of intracuff alkalized lidocaine on sedative/analgesic requirements for mechanically ventilated patients and its consequence on patient-ventilator interaction. Materials and Methods: A total of 64 patients who expected to require ventilatory support for a period of more than 48 h were randomly assigned to groups S and L. In group S, the endotracheal tube (ETT) cuffs were inflated with normal saline. In group L, the ETT cuffs were inflated with lidocaine 2% and sodium bicarbonate 8.4%. The investigator and the surgical intensive care unit staff were blinded to the nature of cuff-filled solutions. Sedation was maintained with propofol and fentanyl infusions. The total requirements for propofol and fentanyl, frequency and severity of cough and number of ineffective triggering during the first 24 h of mechanical ventilation were recorded. Results: There was a significant reduction (about 30%) in the requirements for propofol and fentanyl in patients who received intracuff alkalinized lidocaine; P < 0.001. The frequency and severity of cough were significantly lower in group L compared with group S and the frequency of ineffective triggering was significantly lower in group L; P < 0.001 for both comparisons. Conclusion: Intracuff alkalized lidocaine increases ETT tolerance and hence, decreases sedatives/analgesics requirements for mechanically ventilated patients. This results in improved patient-ventilator synchronization.

Background: Spinal anesthesia has replaced general anesthesia in obstetric practice. Hemodynamic instability is a common, but preventable complication of spinal anesthesia. Preloading the circulation with intravenous fluids is considered a safe and effective method of preventing hypotension following spinal anesthesia. We had conducted a study to compare the hemodynamic stability after volume preloading with either Ringer's lactate (RL) or tetrastarch hydroxyethyl starch (HES) or succinylated gelatin (SG) in the patients undergoing cesarean section under spinal anesthesia. Materials and Methods: It was a prospective, double-blinded and randomized controlled study. Ninety six ASA-I healthy, nonlaboring parturients were randomly divided in 3 groups HES, SG, RL (n = 32 each) and received 10 ml/kg HES 130/0.4; 10 ml/kg SG (4% modified fluid gelatin) and 20 ml/kg RL respectively prior to SA scheduled for cesarean section. Heart rate, blood pressure (BP), oxygen saturation was measured. Results: The fall in systolic blood pressure (SBP) (<100 mm Hg) noted among 5 (15.63%), 12 (37.5%) and 14 (43.75%) parturients in groups HES, SG, RL respectively. Vasopressor (phenylephrine) was used to treat hypotension when SBP <90 mm Hg. Both the results and APGAR scores were comparable in all the groups. Lower preloading volume and less intra-operative vasopressor requirement was noted in HES group for maintaining BP though it has no clinical significance. Conclusion: RL which is cheap, physiological and widely available crystalloid can preload effectively and maintain hemodynamic stability well in cesarean section and any remnant hypotension can easily be manageable with vasopressor.

Background: Various adjuvant are being used with local anesthetics for prolongation of intra operative and postoperative analgesia in epidural block for lower limb surgeries. Dexmedetomidine, the highly selective α₂ adrenergic agonist is a new neuroaxial adjuvant gaining popularity. The aim of the present study was to compare the hemodynamic, sedative and analgesia potentiating effects of epidurally administered dexmedetomidine when combined with ropivacaine. Materials and Methods: The study was conducted in prospective, randomized double-blind manner in which 100 patients of American Society of Anesthesiologist Grade I and II in the age group of 20-65 years of either sex under going lower limb surgeries were included after taking informed consent. The patients were randomly allocated into two groups of 50 each. Epidural anesthesia was given with 150 mg of 0.75% ropivacaine in Group A (n = 50) and 150 mg of 0.75% ropivacaine with dexmedetomidine (1 μg/kg) in Group B (n = 50). Two groups were compared with respect to hemodynamic changes, block characteristics which included time to onset of analgesia at T10, maximum sensory analgesic level, time to maximum sensory and motor block, time to regression at S1 dermatome and time to the first dose of rescue analgesia for 24 h. At the end of study, data was compiled and analyzed statistically using Chi-square test, Fisher's exact test and Student t-test. P < 0.05 was considered to be significant and P < 0.001 as highly significant. Results: Significant difference was observed in relation to the duration of sensory block (375.20 ± 15.97 min in Group A and 535.18 ± 19.85 min in Group B [P - 0.000]), duration of motor block (259.80 ± 15.48 min in Group A and 385.92 ± 17.71 min in Group B [P - 0.000]), duration of post-operative analgesia (312.64 ± 16.21 min in Group A and 496.56 ± 16.08 min in Group B [P < 0.001]) and consequently low doses of rescue analgesia in Group B (1.44 ± 0.501) as compared to Group A (2.56 ± 0.67). Sedation score was significantly more in Group B in the post-operative period. Conclusion: Epidural Dexmedetomidine as an adjuvant to Ropivacaine is associated with prolonged sensory and motor block, hemodynamic stability, prolonged postoperative analgesia and reduced demand for rescue analgesics when compared to plain Ropivacaine.

Background: One of the methods proposed in cases of difficult airway management in children is using a supraglottic airway device as a conduit for tracheal intubation. The aim of this study was to compare the efficacy of the Air-Q Intubating Laryngeal Airway (Air-Q) and the Cobra Perilaryngeal Airway (CobraPLA) to function as a conduit for fiber optic-guided tracheal intubation in pediatric patients. Materials and Methods: A total of 60 children with ages ranging from 1 to 6 years, undergoing elective surgery, were randomized to have their airway managed with either an Air-Q or CobraPLA. Outcomes recorded were the success rate, time and number of attempts required for fiber optic-guided intubation and the time required for device removal after intubation. We also recorded airway leak pressure (ALP), fiber optic grade of glottic view and occurrence of complications. Results: Both devices were successfully inserted in all patients. The intubation success rate was comparable with the Air-Q and the CobraPLA (96.7% vs. 90%), as was the first attempt success rate (90% vs. 80%). The intubation time was significantly longer with the CobraPLA (29.5 ± 10.9 s vs. 23.2 ± 9.8 s; P < 0.05), but the device removal time was comparable in the two groups. The CobraPLA showed a significantly higher ALP (20.8 ± 5.2 cmH ₂ O vs. 16.3 ± 4.5 cmH ₂ O; P < 0.001), but the fiber optic grade of glottic view was comparable with the two devices. The CobraPLA was associated with a significantly higher incidence of blood staining of the device on removal and post-operative sore throat. Conclusion: Both the Air-Q and CobraPLA can be used effectively as a conduit for fiber optic-guided tracheal intubation in children. However, the Air-Q proved to be superior due to a shorter intubation time and less airway morbidity compared with the CobraPLA.

Aims: In our group, after a study showing that spinal anesthesia is safe when compared with general anesthesia, spinal anesthesia has been the technique of choice for this procedure. This is a prospective study with all patients undergoing LC under spinal anesthesia in our department since 2007. Settings and Design: Prospective observational. Materials and Methods: From 2007 to 2011, 369 patients with symptoms of colelithiasis, laparoscopic cholecystectomy were operated under spinal anesthesia with pneumoperitoneum and low pressure CO ₂. We compared 15 mg of hyperbaric bupivacaine and lumbar puncture with 10 or 7.5 mg of hyperbaric bupivacaine thoracic puncture, all with 25 μg fentanyl until the sensory level reached T ₃ . Intraoperative parameters, post-operative pain, complications, recovery, patient satisfaction, and cost were compared between both groups. Statistical Analysis Used: Means were compared by ANOVA or Kruskal-Wallis test, the percentages of the Chi-square test or Fisher's exact test when appropriate. Time of motor and sensory block in spinal anesthesia group was compared by paired t test or Mann-Whitney test. Differences were considered significant when P ≤ 0.05, and for comparisons of mean pain visual scale, we employed the Bonferroni correction applied to be considered significant only with P ≤ 0.0125 Results: All procedures were completed under spinal anesthesia. The use of lidocaine 1% was successful in the prevention of shoulder pain in 329 (89%) patients. There were significant differences in time to reach T ₃ , obtaining 15 mg > 10 mg = 7.5 mg. There is a positive correlation between the dose and the incidence of hypotension. The lowest doses gave a decrease of 52.2% in the incidence of hypotension. There was a positive correlation between the dose and duration of sensory and motor block. Sensory block was almost twice the motor block at all doses. With low doses, 60% of patients went from table to stretcher. Satisfaction occurred in 99% of patients. Conclusions: Laparoscopic cholecystectomy can be performed successfully under spinal anesthesia with low-pressure pneumoperitoneum of CO ₂ . The use of thoracic puncture and low doses of hyperbaric bupivacaine provided better hemodynamic stability, less hypotension, and shorter duration of sensory and motor blockade than lumbar spinal anesthesia with conventional doses.

Objectives: The objective of this study is to evaluate the efficacy and safety of sealing pressure as an inflation technique of the Microcuff pediatric tracheal cuffed tube. Materials and Methods: A total of 60 children were enrolled in this study. After induction of anesthesia and intubation with Microcuff pediatric tracheal tube, patients were randomly assigned, to one of the three groups. Control group (n = 20) the cuff was inflated to a cuff pressure of 20 cm H ₂ O; sealing group (n = 20) the cuff was inflated to prevent the air leak at peak airway pressure of 20 cm H ₂ O and the finger group (n = 20) the cuff was inflated to a suitable pressure using the finger estimation. Tracheal leak, incidence and severity of post-extubation cough, stridor, sore throat and hoarseness were recorded. Results: The cuff pressure as well as the volume of air to fill the cuff was significantly low in the sealing group when compared with the control group (P < 0.001); however, their values were significantly high in the finger group compared with both the control and the sealing group (P < 0.001). The incidence and severity of sore throat were significantly high in the finger group compared with both the control and the sealing group (P = 0.0009 and P = 0.0026). Three patients in the control group developed air leak around the endotracheal tube cuff. The incidence and severity of other complications were similar in the three groups. Conclusion: In pediatric N ₂ O, free general anesthesia using Microcuff pediatric tracheal tub, sealing cuff pressure is safer than finger palpation technique regarding post-extubation morbidities and more reliable than recommended safe pressure in prevention of the air leak.

Background: Transesophageal echocardiography (TEE) in the cardiac lab is usually performed in pediatric patients under general anesthesia with an endotracheal intubation (ET). This study was performed to investigate the safety and efficacy of using the laryngeal mask airway (LMA) as an alternative to ET to maintain pediatric airway during the general anesthesia for TEE. Materials and Methods: A total of 50 pediatric patients undergoing TEE in the cardiac lab were randomized to have their airway maintained during the procedure with either LMA (LMA group) or ET (ET group). Hemodynamic, respiratory parameters, time to extubation, recovery time, the incidence of complication and operator satisfaction were compared between the two groups. Results: There were no differences between both groups in hemodynamic and respiratory parameters. Laryngeal spasm was reported in one patient in the LMA group and two patients in the ET group. TEE operators were equally satisfied with the procedure in groups. The time to extubation was shorter in the LMA group (P < 0.01). The mean recovery time was also significantly shorter in the LMA than in the ET group (44 ± 8 min and 59 ± 11 min, respectively; P < 0.001). Conclusion: The LMA is safe and effective in securing the airway of children undergoing diagnostic TEE.

Objective: To ascertain the awareness regarding global warming and the anesthesia practices contributing to it in the city of Delhi. Materials and Methods: A questionnaire was circulated amongst the qualified anesthesiologists (consultants and senior residents) in the city of Delhi. The initial contact was made through e-mail and the questionnaire was required to be filled and returned electronically. The questionnaire was also made available online at http://sites.google.com/site/surveydelhi. After 1 month, the forms were distributed physically. Assuming that at least 50% of the approximately 1200 practising anesthesiologists would be able to recognize the greenhouse gases correctly, the target number of responses was 150 with 99% confidence limit. Results: Of the 831 anesthesiologists contacted, only 184 responded. Ninety-eight percent were aware of the greenhouse effect, but only 15.8% (29) could correctly identify all the greenhouse gases. However, 47.28% (87) could identify nitrous oxide and inhalational agents as a cause of greenhouse effect. Ninety percent of the respondents use circle system and 87% use low flows frequently. Ninety-three percent (171) of respondents routinely use nitrous oxide, and 32.1% (59) would, however, not use air even if made available. Seventy-nine percent (145) advocated total intravenous anesthesia as an alternative to reduce the menace. Conclusion: Only 22% were motivated enough to respond to the survey. More than half of these anesthesiologists were not aware about the anesthetic agents contributing to the greenhouse effect. However, their clinical practices inadvertently do not add to the environmental pollution.

Context: Spinal anesthesia (SA) was combined with general anesthesia (GA) for achieving hemodynamic stability in laparoscopic hysterectomy. Aims: The aim of our study was to evaluate the impact of SA combined with GA in maintaining hemodynamic stability in laparoscopic hysterectomy. The secondary outcomes studied were requirement of inhaled anesthetics, vasodilators, and recovery profile. Settings and Design: We conducted a prospective, randomized study in ASAI/II patients posted for laparoscopic hysterectomy, who were willing to participate in the study. Materials and Methods: Patients were randomly assigned to receive SA with GA (group SGA) or plain GA (group GA). Group SGA received 10 mg bupivacaine (heavy) for SA. GA was administered using conventional balanced technique. Maintenance was carried out with nitrous oxide, oxygen, and isoflurane. Comparison of hemodynamic parameters was carried out during creation of pneumoperitoneum and thereafter. Total isoflurane requirement, need of vasodilators, recovery profile, and regression of SA were studied. Statistical analysis used: Descriptive statistics in the form of mean, standard deviation, frequency, and percentages were calculated for interval and categorical variables, respectively. One-way analysis of variance (ANOVA) was applied for noting significant difference between the two groups, with chi-square tests for categorical variables and post-hoc Bonferroni test for interval variables. Comparison of heart rate (HR), mean arterial pressure (MAP), SPO2, and etCO2 was done with Student's t-test or Mann-Whitney test, wherever applicable. Results: Patients in group SGA maintained stable and acceptable MAP values throughout pneumoperitoneum. The difference as compared to group GA was statistically significant (P < 0.01). Group GA showed additional requirement of metoprolol (53.33%) and higher concentration of isoflurane (P < 0.001) to combat the increased MAP. Recovery was early and quick in group SGA as against group GA (P = 0.000). There were no adverse/residual effects of SA. Conclusion: The hemodynamic repercussions during pneumoperitoneum can be effectively attenuated by combining SA and GA, without any adverse effects.

Background: Sickle cell disease (SCD) in children with a history of repeated hospitalization is distressing for children as well as their parents leading to anxiety and has negative effects on the psychological state of children and their families. Objective: The aim of the study was to determine the overall effect of SCD on the behavior of young children age 1½ to 5 years old who had repeated history of hospitalization, compared to a control group of healthy children attended a vaccination clinic. Patients and Methods: Thirty-five children of age 1½ to 5 years who have SCD and repeated history of hospitalization were recruited from pediatric clinic as the study group and matched with same number of healthy children who attended vaccination clinic, as a control group. Both groups were administered the child behavior checklist (CBCL) 1½ to 5 years and diagnostic and statistical (DSM)-oriented scale. Behavior data were collected through a semi-structured questionnaire. Results: Children who have SCD had statistically significant behavioral changes on CBCL compared to the control group: Anxiety/depression (65.2 vs. 55.1; P < 0.001), somatic complaint (66.7 vs. 54.4; P < 0.001) withdrawn (63.4 vs. 53.2; P < 0.001), aggressive behavior (60.4 vs. 56; P=0.04), and internalizing symptoms (64.7 vs. 51.5; P < 0.001), respectively. The DSM scale showed that children with SCD scored significantly higher in pervasive developmental disorder compared to the control group (60.9 vs. 53.9; P < 0.001) respectively. Conclusion: Children with SCD who had history of repeated hospitalization are at an increased risk of developing behavioral problems. Psychological counseling, social support, and proper pain management could minimize these behavioral consequences.

Objective: Our study compared the discharge time after pediatric magnetic resonance imaging (MRI) following sedation with propofol infusion dose of 100, 75 and 50 mcg/kg/min given after a bolus dose of ketamine and propofol. Materials and Methods: One hundred children of American Society of Anesthesiologists status 1/2, aged 6 months to 8 years, scheduled for elective MRI were enrolled and randomized to three groups to receive propofol infusion of 100, 75 or 50 mcg/kg/min (Groups A, B, and C, respectively). After premedicating children with midazolam 0.05 mg/kg intravenous (i.v.), sedation was induced with bolus dose of ketamine and propofol (1 mg/kg each) and the propofol infusion was connected. During the scan, heart rate, noninvasive blood pressure, respiratory rate, and oxygen saturation were monitored. Results: The primary outcome that is, discharge time was shortest for Group C (44.06 ± 18.64 min) and longest for Group A (60.00 ± 18.66 min), the difference being statistically and clinically significant. The secondary outcomes that is, additional propofol boluses, scan quality and awakening time were comparable for the three groups. The systolic blood pressure at 20, 25 and 30 min was significantly lower in Groups A and B compared with Group C. The incidence of sedation related adverse events was highest in Group A and least in Group C. Conclusion: After a bolus dose of ketamine and propofol (1 mg/kg each), propofol infusion of 50 mcg/kg/min provided sedation with shortest discharge time for MRI in children premedicated with midazolam 0.05 mg/kg i.v. It also enabled stable hemodynamics with less adverse events.

Background: The aim of this retrospective study is to test the hypothesis that the use of spinal analgesia shortens the length of hospital stay after partial nephrectomy. Materials and Methods: We reviewed all patients undergoing partial nephrectomy for malignancy through flank incision between January 1, 2008, and June 30, 2011. We excluded patients who underwent tumor thrombectomy, used sustained-release opioids, or had general anesthesia supplemented by epidural analgesia. Patients were grouped into "spinal" (intrathecal opioid injection for postoperative analgesia) versus "general anesthetic" group, and "early" discharge group (within 3 postoperative days) versus "late" group. Association between demographics, patient physical status, anesthetic techniques, and surgical complexity and hospital stay were analyzed using multivariable logistic regression analysis. Results: Of 380 patients, 158 (41.6%) were discharged "early" and 151 (39.7%) were "spinal" cases. Both spinal and early discharge groups had better postoperative pain control and used less postoperative systemic opioids. Spinal analgesia was associated with early hospital discharge, odds ratio 1.52, (95% confidence interval 1.00-2.30), P = 0.05, but in adjusted analysis was no longer associated with early discharge, 1.16 (0.73-1.86), P = 0.52. Early discharge was associated with calendar year, with more recent years being associated with early discharge. Conclusion: Spinal analgesia combined with general anesthesia was associated with improved postoperative pain control during the 1 ^st postoperative day, but not with shorter hospital stay following partial nephrectomy. Therefore, unaccounted practice changes that occurred during more recent times affected hospital stay.

Objective: The aim was to evaluate general anesthesia (GA) plus ilioinguinal nerve block (IIB) versus spinal anesthesia (SA) in patients scheduled for ambulatory inguinal hernia repair regarding pain management, anesthesia recovery and reducing potential complications. Materials and Methods: A double-blind, prospective, randomized, controlled study in patients American Society of Anesthesiologists I-III randomized into two groups: GA plus IIB group, induction of anesthesia with propofol, maintenance with sevoflurane, airway management with laryngeal mask allowing spontaneous ventilation and ultrasound-guided IIB; SA group, patients who underwent spinal block with 2% mepivacaine. The study variables were pain intensity, assessed by visual analog scale, analgesic requirements until hospital discharge, time to ambulation and discharge, postoperative complications-related to both techniques and satisfaction experienced. Results: Thirty-two patients were enrolled; 16 patients in each group. The differences regarding pain were statistically significant at 2 h of admission (P < 0.001) and at discharge (P < 0.001) in favor of the GA plus ilioinguinal block group. In addition in this group, analgesic requirements were lower than SA group (P < 0.001), with times of ambulation and discharge significantly shorter. The SA group had a higher tendency to develop complications and less satisfaction. Conclusion: General anesthesia plus IIB is better than SA regarding postoperative analgesia, time to mobilization and discharge, side-effect profile and satisfaction experienced by the patients.

Neurosurgery in awake patients incorporates newer technologies that require the anesthesiologists to update their skills and evolve their methodologies. They need effective communication skills and knowledge of selecting the right anesthetic drugs to ensure adequate analgesia, akinesia, along with patient satisfaction with the anesthetic conduct throughout the procedure. The challenge of providing adequate anesthetic care to an awake patient for intracranial surgery requires more than routine vigilance about anesthetic management.

Although propofol has been the backbone for sedation in gastrointestinal endoscopy, both anesthesiologists and endoscopists are faced with situations where an alternative is needed. Recent national shortages forced many physicians to explore these options. A midazolam and fentanyl combination is the mainstay in this area. However, there are other options. The aim of this review is to explore these options. The future would be, invariably, to move away from propofol. The reason is not in any way related to the drawbacks of propofol as a sedative. The mandate that requires an anesthesia provider to administer propofol has been a setback in many countries. New sedative drugs like Remimazolam might fill this void in the future. In the meantime, it is important to keep an open eye to the existing alternatives.

Ventricular septal rupture (VSR) is a life threatening complication of myocardial infarction (MI). The incidence of post-MIVSR varied from 1% to 3% in the pre-thrombolytic era. There is almost a 10-fold decrease in the reported incidences (0.2-0.3%) of MIVSR today. The mortality in such an event is as high as 50-90%. Prognosis of post-MIVSR depends on prompt echo diagnosis and proactive surgical therapy. The peri-operative challenges during management of such a case can be enormous.

Diagnosis of a pneumothorax in the immediate post-operative area can be difficult. Traditional gold-standard modalities may not be available or feasible to institute. Ultrasound (US) guidance allows the anesthesia provider a method of quickly detecting this potentially life-threatening complication especially when it's least expected. We encountered such a case when a 40 years male patient posted for video assisted thoracic surgery for drainage of empyema on left side of chest developed pneumothorax on right side post-operatively. Timely diagnosis with the help of US saved time and his life. We thus want to emphasize the importance of this simple but useful skill to the anesthesiologist.

Laryngeal mask (LM) airway is commonly used for securing airway in day-care surgeries. Various problems have been described while using LM airway. Out of those, mechanical obstruction causing airway compromise is most common. Here, we describe a case report of 4-year-old child who had partial upper airway obstruction due to LM manufacturer's defect. There was a silicon band in upper one-third of shaft of LM airway. This band was made up of the same material as that of LM airway so it was not identifiable on external inspection of transparent shaft. We suggest that such as non-transparent laryngeal mask, a transparent LM airway should also be inspected looking inside the lumen with naked eyes or by using a probe to rule out any manufacturing defect before its insertion.

Anterior mediastinal mass is a rare pathology that presents considerable anesthetic challenges due to cardiopulmonary compromise. We present a case that was referred to us in the third trimester of pregnancy with severe breathlessness and orthopnea. An elective cesarean delivery was performed under combined spinal epidural anesthesia with a favorable outcome. We discuss the perioperative considerations in these patients with a review of the literature.

Complex regional pain syndrome (CRPS) type 1 of the upper limb is a painful and debilitating condition. Interscalene brachial plexus block (ISB) in conjugation with other modalities was shown to be a feasible therapy with variable success. We reported a case of CRPS type 1 as diagnosed by International Association for the Study of Pain criteria in which pharmacological approaches failed to achieve adequate pain relief and even were associated with progressive dysfunction of the upper extremity. Single injection ISB, in combination with physical therapy and botulinum toxin injection, was successful to alleviate pain with functional restoration.

Magnesium sulfate is used frequently in the operation room and risks of wrong injection should be considered. A woman with history of pseudocholinesterase enzyme deficiency in the previous surgery was referred for cesarean operation. Magnesium sulfate of 700 mg (3.5 ml of 20% solution) was accidentally administered in the subarachnoid space. First, the patient had warm sensation and cutaneous anesthesia, but due to deep tissue pain, general anesthesia was induced by thiopental and atracurium. After the surgery, muscle relaxation and lethargy remained. At 8-10 h later, muscle strength improved and train of four (TOF) reached over 0.85, and then the endotracheal tube was removed. The patient was evaluated during the hospital stay and on the anesthesia clinic. No neurological symptoms, headache or backache were reported. Due to availability of magnesium sulfate, we should be careful for inadvertent intravenous, spinal and epidural injection; therefore before injection must be double checked.