Background: We tested the hypothesis that nebulized budesonide would improve lung mechanics and oxygenation in patients with early acute lung injury (ALI) and/or acute respiratory distress syndrome (ARDS) during protective mechanical ventilation strategy without adversely affecting systemic hemodynamics. Methods: Patients with ALI/ARDS were included and assigned into two groups; budesonide group (30 cases) in whom 1 mg–2 ml budesonide suspension was nebulized through the endotracheal tube and control group (30 cases) in whom 2 ml saline (placebo) were nebulized instead of budesonide. This regimen was repeated every 12 h for three successive days alongside with constant ventilator settings in both groups. Hemodynamics, airway pressures, and PaO₂/FiO₂were measured throughout the study period (72 h) with either nebulized budesonide or saline. Furthermore, tumor necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1β), and interleukin-6 (IL-6) were analyzed serologically as markers of inflammation at pre- and post-nebulization sessions. Results: We found a significant difference between the two groups regarding PaO₂/FiO₂ (P = 0.023), peak (P = 0.021), and plateau (P = 0.032) airway pressures. Furthermore, TNF-α, IL-1β, and IL-6 were significantly reduced after budesonide nebulizations. No significant difference was found between the two groups regarding hemodynamic variables. Conclusion: Nebulized budesonide improved oxygenation, peak, and plateau airway pressures and significantly reduced inflammatory markers (TNF-α, IL-1β and IL-6) without affecting hemodynamics. Trial Registry: Australian New Zealand Clinical Trial Registry (ANZCTR) at the number: ACTRN12615000373572.

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Background: The main advantages of video assisted thoracoscopic surgery (VATS) include less post-operative pain, rapid recovery, less postoperative complications, shorter hospital stay and early discharge. Although pain intensity is less as compared to conventional thoracotomy but still patients experience upto moderate pain postoperatively. The objective of this study was to assess the efficacy and morphine sparing effect of intercostal nerve block in alleviating immediate post-operative pain in patients undergoing VATS. Materials and Methods: Sixty ASA I-III patients, aged between 16 to 60 years, undergoing mediastinal lymph node biopsy through VATS under general anaesthesia were randomly divided into two groups. The intercostal nerve block (ICNB group) received the block along with patient control intravenous analgesia (PCIA) with morphine, while control group received only PCIA with morphine for post-operative analgesia. Patients were followed for twenty four hours post operatively for intervention of post-operative pain in the recovery room and ward. Results: The pain was assessed using visual analogue scale (VAS) at 1, 6, 12 and 24 hours. There was a significant decrease in pain score and morphine consumption in ICNB group as compared to control group in first 6 hours postoperatively. There was no significant difference in pain scores and morphine consumption between the two groups after 6 hours. Conclusion: Patients receiving intercostal nerve block have better pain control and less morphine consumption as compared to those patients who did not receive intercostal nerve block in early (6 hours) post-operative period.

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Epidural blocks are a very important part of the anesthetic armamentarium. Among some of the known complications, fracture of epidural catheter, though is extremely rare, is a well-established entity. When it happens, it leaves the anesthesiologist puzzled and worried. We describe the occurrence of such an event where epidural catheter broke during insertion since it will also add to such an under-reported complication of a very commonly performed procedure. A brief review is also done which will delineate the recommendations for the prevention and management of such an event.

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Introduction: Electroconvulsive therapy (ECT) is a well-established psychiatric treatment in which seizures are electrically induced in patients for therapeutic effects. ECT can produce severe disturbances in the cardiovascular system and a marked increase in cerebral blood flow and intracranial pressure. These cardiovascular changes may be altered using various anesthetic drugs. Aim and Objectives: This study was undertaken to compare the effects of intravenous (IV) sodium thiopentone, propofol, and etomidate, used as IV anesthetic agents in modified ECT as regards, induction time and quality of anesthesia, alteration of hemodynamics, seizure duration, and recovery time. Materials and Methods: A total of 90 patients in the age group of 16–60 years of either sex, who had to undergo ECT therapy were divided randomly into three equal groups. Group A received propofol 1% - 1.5 mg/Kg, Group B received etomidate - 0.2 mg/Kg, and Group C received thiopentone 2.5% - 5 mg/Kg. All the patients were monitored for changes in heart rate, systolic blood pressure, diastolic blood pressure, and oxygen saturation at basal, after induction and 1 min, 2 min, 3 min, 5 min, 10 min, 20 min, and 30 min following ECT. Quality of anesthesia, seizure duration, and recovery times were also recorded. Conclusion: We found that propofol had the advantage of smooth induction, stable hemodynamic parameters and rapid recovery as compared to etomidate and thiopentone. Thiopentone had the advantage over propofol of having longer seizure duration at the cost of a relatively prolonged recovery period. Etomidate had a definite advantage of longer seizure duration.

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Background: Shivering is a common postanesthesia adverse event with multiple etiologies. At present tramadol is a widely used drug for the control of shivering. However, tramadol may cause a lot of nausea and vomiting. Hence, the need to find a better drug with less of side effects. The aim of this study was to compare the efficacy of dexmedetomidine and tramadol in the treatment of post-spinal anesthesia (SA) shivering as well as to compare their side-effect profile. Materials and Methods: This prospective, double-blind, randomized controlled trial was conducted in a tertiary care hospital. A total of 100 patients having shivering after SA were enrolled, out of which fifty received dexmedetomidine (Group A) and 50 received tramadol (Group B). The response rate, time to cessation of shivering and side effects (if any) was noted. All the results were analyzed using Student's t-test and Chi-square test. Results: All patients who received dexmedetomidine as well as tramadol had cessation of shivering. The time to cessation of shivering was significantly less with dexmedetomidine (174.12 ± 14.366 s) than with tramadol (277.06 ± 23.374 s) (P < 0.001). The recurrence rate of shivering with dexmedetomidine was less (6%) as compared to tramadol (16%). Nausea and vomiting was found to be higher in the case of tramadol. On the other hand, dexmedetomidine caused moderate sedation (modified Ramsay sedation score = 3–4) from which the patient could be easily awoken up. Conclusion: Dexmedetomidine offers better results than tramadol with fewer side effects.

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Background and Aims: Ultrasound imaging before neuraxial blocks was reported to improve the ease of insertion and minimize the traumatic trials. However, the data about the use of ultrasound in thoracic epidural block are scanty. In this study, pre-insertion ultrasound scanning was compared to traditional manual palpation technique for insertion of the thoracic epidural catheter in abdominal operations. Subjects and Methods: Forty-eight patients scheduled to midline laparotomy under combined general anesthesia with thoracic epidural analgesia were included in the study. Patients were divided into two groups with regard to technique of epidural catheter insertion; ultrasound group (done ultrasound screening to determine the needle insertion point, angle of insertion, and depth of epidural space) and manual palpation group (used the traditional manual palpation technique). Number of puncture attempts, number of puncture levels, and number of needle redirection attempts were reported. Time of catheter insertion and complications were also reported in both groups. Results: Ultrasound group showed lower number of puncture attempts (1 [1, 1.25] vs. 1.5 [1, 2.75], P = 0.008), puncture levels (1 (1, 1) vs. 1 [1, 2], P = 0.002), and needle redirection attempts (0 [0, 2.25] vs. 3.5 [2, 5], P = 0.00). Ultrasound-guided group showed shorter time for catheter insertion compared to manual palpation group (140 ± 24 s vs. 213 ± 71 s P = 0.00). Conclusion: Preprocedural ultrasound imaging increased the incidence of first pass success in thoracic epidural catheter insertion and reduced the catheter insertion time compared to manual palpation method.

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Background: Emergence agitation, vomiting, and oculocardiac reflex (OCR) in children undergoing strabismus surgery under general anesthesia are common problems. The purpose of this study was to determine whether the effect of analgesia can reduce the incidence of these problems. We compared the effects of sub-Tenon's injection versus intravenous (IV) and rectal paracetamol in this surgery. Methods: In a prospective, randomized, double-blind study, ninety patients ranging in age from 4 to 8 years scheduled for extraocular muscle surgery for strabismus were included in this study. After induction of anesthesia, just before the surgery, children were divided into three groups (n = 30 for each group) Group A received sub-Tenon's anesthesia with 2.5% bupivacaine (0.08 ml/kg). Group B received IV paracetamol (20 mg/kg). Group C received paracetamol rectal suppository (40 mg/kg). The occurrence of oculocardiac reflex (OCR) intraoperatively was recorded. Then, in the Postanesthesia Care Unit, patients were assessed for their emergence behaviors. Vomiting was also noticed. Results: The OCR developed in few patients, and there was no significant difference between the groups. The highest number of patients with agitation was in Group C followed by Group B then Group A. Vomiting was significantly low in Group A followed by Group B then Group C. Conclusion: Sub-Tenon block in strabismus surgery in children decreased the incidence of postoperative agitation and vomiting compared with IV paracetamol then rectal paracetamol. There was no difference between sub-Tenon block and paracetamol in the incidence of oculocardiac reflex.

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Background: The primary failure rate for arteriovenous fistula (AVF) creation under local anesthesia for hemodialysis is about 30%. Axillary brachial plexus block (BPB) may improve blood flow through blood vessels used in fistula creation; it may improve the AVF blood flow and thus may reduce the primary failure rate after 3 months. Methods: Hundred and forty patients with chronic renal failure scheduled for AVF creation for hemodialysis were divided into two equal groups; Group 1 (AxBP-G) received ultrasound (US) guided axillary BPB, and Group 2 (LI-G) received local infiltration. We recorded the measurements of the brachial and radial arteries before and after anesthesia and the AVF blood flow in both groups at three different time points. Furthermore, the primary failure rate was recorded in each group and compared. Results: After anesthesia, the mean radial artery blood flow in the AxBP-group was 3.52 ml/min more than the LI-group, and the brachial artery diameter was also 0.68 mm more than in the LI-group, both differences were statistically significant (P < 0.05). There were significant increases (P < 0.05) in the AVF blood flow in the AxBP-group more than the LI-group with mean differences of 29.6, 69.8, and 27.2 ml/min at 4 h, 1 week, and 3 months, respectively. The overall mean of AVF blood flow was 42.21 ml/min more in the AxBP group than the LI-group a difference which is statistically significant (P < 0.001). The primary failure rate was 17% in the AxBP group versus 30% in the LI-group; however, this difference is not significant statistically (P = 0.110). Conclusion: The US-guided axillary block increases AVF blood flow significantly more than local infiltration and nonsignificantly decreases the primary failure rate of the AVF after 3 months.

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Background: Radiofrequency ablation (RFA) is a minimally invasive technique of tumor destruction for patients with hepatic cancer who are not candidates for conventional therapy. The therapy required general anesthesia (GA) or sedation to ensure patient safety and comfort. The study is aimed to report and evaluate factors that influenced the periprocedural anesthetic management, drugs used, and complications during and immediately after RFA procedure for hepatocellular carcinoma. Methods: For this retrospective study, we included 46 patients who underwent percutaneous RFA under GA or conscious sedation from January 2010 to June 2013 in Aga Khan University Hospital, Pakistan. The patients' characteristics, hepatic illness severity (Child-Pugh classification), anesthetic techniques, drugs, and complications of procedure were collected on a predesigned approved form. The data were assessed and summarized using descriptive statistics. Results: The majority of patients were female (57%) and mostly classified as American Society of Anesthesiologist III (65.2%). The preoperative hepatic illness severity in most patients was Child-Pugh Class A (76.10%). Thirty-eight patients (69.09%) had only single lesion and majority number of lesions were <3 cm (65.45). GA was the main anesthetic technique (87%) with laryngeal mask airway as an airway adjunct predominantly (70%). The mainly used anesthetic agents for hypnosis and analgesia were propofol and fentanyl, respectively. Pain was the only significant complaint in postoperative period but only in nine (19%) patients and mild in nature. Conclusions: Percutaneous RFA is a safe treatment of hepatocellular cancer. The procedure required good anesthetic support in the form of sedation-analgesia or complete GA that ensures maximum patient comfort and technical success of the procedure.

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Background: In certain medical applications, it is necessary to be able to determine the position of a needle inside the body, specifically with regards to identifying certain tissue types. By measuring the electrical impedance of specific tissue types, it is possible to determine the type of tissue the tip of the needle (or probe) is at. Materials and Methods: Two methods have been investigated for electric impedance detection; bipolar and monopolar. Commercially available needle electrodes are of a monopolar type. Although many patents exist on the bipolar setups, these have not as yet been commercialized. This paper reports a comparison of monopolar and bipolar setups for tissue type determination. In vitro experiments were carried out on pork to compare this investigation with other investigations in this field. Results: The results show that both monopolar and bipolar setups are capable of determining tissue type. However, the bipolar setup showed slightly better results; the difference between the different soft tissue type impedances was greater compared to the monopolar method. Conclusion: Both monopolar and bipolar electrical impedance setups work very similarly in inhomogeneous volumes such as biological tissue. There is a clear potential for clinical applications with impedance-based needle guidance, with both the monopolar and bipolar setups. It is, however, worth noting that the bipolar setup is more versatile.

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Septo-optic dysplasia (SOD)/de Morsier's syndrome is characterized by optic nerve hypoplasia, pituitary endocrine dysfunction, and midline brain abnormalities. Hypopituitarism, hypothyroidism, hypogonadism, and adrenal insufficiency can lead to severe hypoglycemia, adrenal crisis, seizures, and sudden death. Anesthetic management of SOD was associated with high perioperative mortality. A 9-year-old male child proposed for dental treatments/extractions. Medical history of SOD with hypopituitarism, hypothyroidism, and delayed psychomotor development was observed. Anesthetic induction with sevoflurane and intravenous administration of hydrocortisone plus dexamethasone were given. An infusion of 5% glucose in sodium chloride 0.9% was started. Anesthesia with sevoflurane and air, combined with local infiltration with 2% lidocaine, was maintained. During the procedure, the patient was breathing spontaneously, hemodynamically stable, with normal glucose levels measured every 30 min. The patient received 750 mg of paracetamol for analgesia and was discharged from the hospital 24 h after the procedure without complications. The mortality related to general anesthesia in such patients put us some challenges. The procedure was imperative for improving the health and quality of life of the patient, so we opted for inhalational anesthesia combined with local infiltration. We think that combined anesthesia contributed to the abolition of pain and avoided adrenal suppression contributing for the success of the procedure.

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Background: Ultrasound-guided transversus abdominis plane (TAP) block has recently come up as a modality to take care of postoperative pain. It can somewhat avoid the use of intravenous opioid analgesics and hence to avoid its complications. We have performed a prospective, double-blinded, randomized study to assess the analgesic effect of adding dexmedetomidine to local ropivacaine on TAP block for patients undergoing lower abdominal surgeries. Aim: The aim is to assess whether addition of dexmedetomidine to ropivacaine may bring some improvements to the analgesic efficacy of TAP blocks in patients undergoing lower abdominal surgeries. Materials and Methods: The study was conducted on forty patients undergoing lower abdominal surgeries under general anesthesia. The patients were divided into two groups: one receiving plain ropivacaine (Group 1) and other receiving ropivacaine with dexmedetomidine (Group 2) during TAP block. The patients in the two groups were compared for age, sex, body mass index, incidence of postoperative nausea, and vomiting and pain as measured on visual analog scale (VAS). Results: There was significantly lower pain score on VAS at 1, 3, 6, 12, and 18 h in Group 2 than in Group 1. Conclusion: The addition of dexmedetomidine to ropivacaine during TAP block improves analgesic effect of TAP block and prolongs the duration of analgesia as well.

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Background: There are many adjuvant used along with bupivacaine for subarachnoid block, but fentanyl and clonidine are commonly used as adjuvant to intrathecal bupivacaine for prolonging both sensory and motor blockade as well as postoperative analgesia in patients undergoing lower abdominal surgeries. Objective: There is a paucity of studies comparing the efficacy of fentanyl and clonidine as adjuvant to intrathecal bupivacaine for improving intraoperative effect and postoperative analgesia in lower abdominal surgeries instigated us compare the effect of these drugs. Methods: This prospective, randomized study is conducted on 100 American Society of Anesthesiologists I or II patients between 18 and 65 years of age divided into two groups of 50 each. The patients were given 2.5 ml of 0.5% hyperbaric bupivacaine with either 50 μg of clonidine (BC Group) or 25 μg of fentanyl (BF Group) intrathecally. The onset and duration of sensory and motor block, sedation score, hemodynamic parameters, total analgesia time, and potential side effects were recorded and compared. Results: Both the groups were comparable in demographic data, onset and duration of sensory and motor blockade, hemodynamic parameters, but the duration of analgesia is significantly longer in clonidine group when compared with fentanyl group. Sedation score is more in clonidine group. Conclusion: Addition of clonidine to intrathecal bupivacaine offers longer duration of postoperative analgesia than fentanyl but with higher sedation.

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Although the major mechanism of complex regional pain syndrome (CRPS) involves dysfunctional central or sympathetic nervous system activation, the peripheral nervous system also contributes significantly to its clinical manifestations. Pulsed radiofrequency (PRF) is a recently developed treatment option for neuropathic pain syndromes. Here, we report a case of CRPS Type II after a femur fracture and sciatic nerve injury, in which the pain was treated successfully with ultrasonography-guided selective sciatic nerve PRF application.

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The usage of epidural infusion for intraoperative and postoperative pain relief is widely used in certain pediatric anesthetic practice because of the effectiveness and advantages. However, there is drawback for these techniques due to its potential complications such as inadvertent intrathecal placement, local anesthetic toxicity, catheter migration, infection, and breakage of epidural catheter. Though occur infrequently, epidural catheters have been known to snap during insertion or removal. The retained catheter tip may lead to multiple complications, including nerve injury, infection, and even catheter migration. Although there are literatures recommend options for management of removal of retained catheter, there are limited reports of these occurrences, especially among children. We report a case of sequestrated sheared epidural catheter segment in a child, aiming to share this experience for the future management of patients under similar condition.

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Gilbert's syndrome (GS) is an autosomal inherited disorder characterized by relative deficiency of glucuronyl transferase and poor uptake of unconjugated bilirubin by hepatocytes. Cardiac surgery on cardiopulmonary bypass (CPB) in these patients triggers further hepatic dysfunction. Transesophageal echocardiography (TEE) and Doppler assessment of hepatic vein help in assessing hepatic blood flow (HBF) during cardiac surgery. Here, we discuss anesthetic management and role of TEE in maintaining HBF perioperatively in a 25-year-old male patient with GS undergoing double valve replacement with tricuspid valve plasty. TEE-guided HBF monitoring and management of hepatic perfusion by modifying anesthetic and CPB protocol resulted in the favorable outcome.

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Subglottic stenosis is a known complication of a traumatic and prolonged intubation. In a child, subglottic area is narrower and more prone to damage by an oversized or overinflated endotracheal tube. The stenosis can present with complaints of change in voice, croup, or respiratory obstruction. Those presenting with respiratory obstruction require immediate diagnosis under direct laryngoscopy and timely corrective intervention under general anesthesia. A 4-year-old child came to the emergency department with severe respiratory obstruction. His medical history revealed invasive ventilatory management for aspiration pneumonitis 2 months back. Under direct laryngoscopy, we found severe narrowing of the subglottic area due to subglottic web. Since the subglottic area was so stenosed, intubation was impossible. Hence, emergency tracheostomy was performed to secure patient airway, followed by microlaryngeal surgery to remove the subglottic web. Acquired subglottic stenosis in a child can be a life-threatening situation which requires immediate airway management. It should be suspected in any child in severe respiratory obstruction with a history of prolonged intubation.

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Subcostal transverse abdominis plane (TAP) block anesthetizes area of the abdomen with cutaneous innervation of T6–T10 dermatomes. These abdominal field blocks become very advantageous when cardiac patient presents for noncardiac surgeries as sole anesthetic or as a part of multimodal anesthesia. A 58-year-male came for open surgical repair of subxiphoid incisional hernia developed post coronary artery bypass grafting (CABG). Echocardiography showed hypokinesia of left ventricle (LV) in the left anterior descending (LAD) artery territory, dilated LV, and ejection fraction of 30%, and coronary angiography after 6 months of CABG showed 70% stenosis of LAD. Surgery was successfully accomplished under ultrasound-guided bilateral subcostal TAP block except for a brief period of pain and discomfort when hernia was being reduced which required narcotic supplementation. The patient remained comfortable throughout the procedure as well as 24 h postoperatively without any analgesic supplementation. Thus, subcostal TAP block can be a safe alternative to neuraxial or general anesthesia for epigastric hernia repair in selected patients.

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We report a case of transient hyperkalemia during hysterectomy after cesarean section, due to preoperatively undiagnosed placenta accreta that caused unforeseen massive hemorrhage and required rapid red cell transfusion. Hyperkalemia-induced by rapid red cell transfusion is a well-known severe complication of transfusion; however, in patients with sudden massive hemorrhage, rapid red cell transfusion is necessary to save their life. In such cases, it is extremely important to monitor serum potassium levels. For an emergency situation, a system should be developed to ensure sufficient preparation for immediate transfusion and laboratory tests. Furthermore, sufficient stock of preparations to treat hyperkalemia, such as calcium preparations, diuretics, glucose, and insulin is required. Moreover, a transfusion filter that absorbs potassium has been developed and is now available for clinical use in Japan. The filter is easy to use and beneficial, and should be prepared when it is available.

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For labor pain management epidural analgesia is a popular and an effective method. Difficult removal of epidural catheters occasionally occurs, and several maneuvers have been recommended. The purpose of this article is to raise awareness of the problem of retained epidural catheter fragments and identify the potential impact of complications.

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Purpose: To compare the outcomes such as postoperative nausea/vomiting, analgesic requirements, and hospital stay following the use of topical oxybuprocaine hydrochloride 0.4% or intravenous (IV) fentanyl in children undergoing strabismus surgery. Methods: This was a prospective cohort study. Children operated under general anesthesia for strabismus were given topical oxybuprocaine hydrochloride 0.4% (Group T) and IV fentanyl (Group F) before surgery. The episodes of nausea/vomiting, pain score, requirement of additional analgesia during postoperative period, and duration of hospital stay were compared in two groups. Results: There were 47 children in Group T and 59 children in Group F. The median pain score in two groups were 2.38 (25% quartile; 2.0) and 3.00 (25% quartile; 3.00), respectively. The difference was significant (K W P < 0.03). The episodes of nausea/vomiting in two groups were in 2 and 6 children in Group T and Group F, respectively. The median hospital stay of children of Group T and Group F were 242 and 285 min, respectively. The difference was not statistically significant (P = 0.22). Conclusions: Using intraoperative topical oxybuprocaine drops, one can achieve better analgesic outcomes and reduce risk of nausea and vomiting compared to intravenous opioid analgesics and therefore, the hospital stay could also be marginally reduced.

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Background: Multiple studies claim that caudal administration of ketamine causes effective postoperative analgesia. The aim of this study was to assess the clinical effectiveness of ketamine after caudal or topical administration in pediatric patients undergoing inguinal herniotomy. Patients and Methods: This randomized, comparative, double-blind study included eighty children (aged 6 months to 6 years) received either 1 ml/kg of 0.25% bupivacaine/ketamine 0.5 mg/kg for caudal analgesia (caudal group) or 0.3 ml/kg of 0.25% bupivacaine/ketamine 0.5 mg/kg sprayed by the surgeon around the spermatic cord and upon the ilioinguinal nerve before wound closure for topical analgesia (topical group). The duration of postoperative analgesia, pain scores, rescue analgesic consumption, sedation score, hemodynamic monitoring, and side-effects were evaluated 48 h postoperative. Results: Kaplan–Meier survival analysis of analgesia free time demonstrated a significant advantage of topical ketamine (TK) group over caudal ketamine (CK) group. The duration of postoperative analgesia was longer in TK group than in CK group (28.74 ± 2.88 vs. 21.43 ± 5.01 h, P < 0.000). Fewer children asked for oral analgesics in the topical group (24 of 36, 66.7%) than in the caudal one (28 of 32, 87.5%; P < 0.01). Postoperative pain scores at the 6^th till 48^th h were lower in topical group with comparable analgesic consumption between two groups. In the caudal group, four subjects suffered from retention of urine: Two presented with a residual motor block and two had photophobia. Conclusion: Wound instillation of bupivacaine/ketamine is a simple, noninvasive, and effective technique that could be a safe alternative to CK for postoperative analgesia in children undergoing inguinal hernia repair.

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Electrocardiographic (ECG) artifacts may arise due to interference, faulty earthing, and current leakages in biomedical equipment which might create clinical dilemmas in the perioperative settings. Piezoelectric signals generated by ultrasonography probe are another uncommon source which might be sensed by the ECG electrodes and produce tracings similar to pathological arrhythmias triggering false alarms and avoidable therapies. Anesthesiologists should be familiar with these uncommon sources which might produce these artifacts and they should be identified swiftly.

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Acute renal failure is associated with increased mortality in the Pediatric Intensive Care Unit. When anuric or oliguric renal failure occurs, the associated fluid overload may compromise respiratory function and has been shown to be associated with worse outcomes. Renal replacement therapy using continuous venous-venous hemofiltration (CVVH) allows for fluid, solute, and nitrogenous waste removal. However, large bore vascular access with placement of a double-lumen dialysis catheter is necessary to ensure effective flow rates to allow for CVVH. We present a technique to facilitate exchange of a 4 Fr double-lumen central venous catheter to an 8 Fr double-lumen dialysis catheter for CVVH in a 2-year-old toddler who developed acute renal failure following surgery for congenital heart disease. This technique may be particularly valuable in patients with associated conditions including fluid overload and coagulation disturbances which may increase the morbidity of vascular access techniques.

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A 25-year-old male patient who was infected with human immunodeficiency virus (HIV) underwent a condyloma excision under spinal anesthesia. The patient complained of suspicious postdural puncture headache. The patient did not respond to conservative management. Subsequently, the subdural hematoma (SDH) was found through magnetic resonance imaging. In response, an epidural blood patch was used to improve the symptoms and inhibit the enlargement of the SDH. The patient was discharged after it was confirmed that a headache had subsided without increasing SDH. Anesthesiologist should be aware of other causes of headaches after spinal anesthesia in HIV-infected patients and should carefully and accurately identify the cause.

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Background: Acoustic puncture assist device (APAD™) is a pressure measurement combined with a related acoustic signal that has been successfully used to facilitate epidural punctures. The principal of loss of resistance (LOR) is similar when performing paravertebral block (PVB). We investigated the usefulness of APAD™ by comparing it with the conventional LOR techniques for identifying paravertebral space (PVS). Subjects and Methods: A total of 100 women who were scheduled for elective breast surgery under general anesthesia with PVB were randomized into two equal groups. The first group (APAD group) was scheduled for PVB using APAD™. The second group (C group) was scheduled for PVB using conventional LOR technique. We recorded the success rate assessed by clinical and ultrasound findings, the time required to identify the PVS, the depth of the PVS and the number of attempts. The attending anesthesiologist was also questioned about the usefulness of the acoustic signal for detection of the PVS. Results: The incidence of successful PVB was (49) in APAD group compared to (42) in C group P < 0.05. The time required to do PVB was significantly shorter in APAD group than in C group (3.5 ± 1.35 vs. 4.1 ± 1.42) minutes. Two patients in APAD group needed two or more attempts compared to four patients in C group. The attending anesthesiologist found the acoustic signal valuable in all patients in APAD group. Conclusion: Using APAD™ compared to the conventional LOR technique showed a lower failure rate and a shorter time to identify the PVS.

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Background: The composite variability index (CVI), derived from the bispectral analysis (BIS), has been designed to detect nociception; however, there is no evidence that bilateral BIS and CVI show intrapatient reproducibility or variability. Methods: We conducted an observational study in patients who underwent for total knee arthroplasty. A BIS Bilateral Sensor was applied and continuously recorded at different points of the anesthesia procedure. Bland–Altman limits of agreement and dispersion for BIS and for CVI were applied. Results: Forty-nine right-handed patients were studied. There were differences between the right and left BIS values after tracheal intubation (which was higher on the right side) and at surgical stimulus (higher on the left side). The maximum BIS and minimum, mean, and maximum CVI scores were higher on the left side for left-side procedures, but there were no differences in any indexes for the right-side procedures. Except for the baseline measurements, both CVI and BIS scores presented high interpatient variability. Although the right to left bias was < 3% for the BIS index, dispersion was large at different stages of the anesthesia. The right to left bias for the CVI was 3.8% at tracheal intubation and 5.7% during surgical stimulus. Conclusions: Our results indicate that the large interindividual variability of BIS and CVI limits their usefulness. We found differences between the left and right measurements in a right-handed series of patients during surgical stimuli though they were not clinically relevant.

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