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Background and Aims: This study was designed to compare the effectiveness of the combination of dexamethasone–ondansetron with oral aprepitant alone and triple combination therapy with all three agents (dexamethasone-ondansetron and oral aprepitant) in the prevention of postoperative nausea and vomiting (PONV) in day care gynaecologic laparoscopy. Methods: This was a randomised clinical trial conducted at a university teaching hospital. A total of 105 female patients were randomised into the aprepitant (A), dexamethasone-ondansetron (DO) and aprepitant-dexamethasone-ondansetron (ADO) groups. The patients in the A group received only 80 mg oral aprepitant 1 h before surgery. The patients in the DO group, received dexamethasone 8 mg at induction with ondansetron 4 mg before extubation. Patients in the ADO group received 80 mg oral aprepitant 1 h before surgery, dexamethasone 8 mg at induction and ondansetron 4 mg before extubation. Incidence of nausea and vomiting was compared between groups using the Chi-square test/Fisher's test. Bellville score for severity of PONV was analysed using the Kruskall-Wallis test. P value < 0.05 was regarded as significant. Results: The incidence of PONV did not show a statistically significant difference between the three groups, with a P value of 0.13 (12.5%, 30.3% and 32.3% in groups ADO, DO and A, respectively). The severity of PONV measured using Bellville score was also not significantly different among the groups [median values (IQR) of 0 (0-0), 0 (0-1), and 0 (0-1)]. Conclusion: The combination of aprepitant, dexamethasone and ondansetron failed to demonstrate a statistically significant superiority over the other two antiemetic regimens.

The topics for postgraduate teaching-learning tools are Journal club in-house with one speaker and a moderator, Seminars- with multiple speakers and a co-ordinator, and Webinars- online seminars with one or multiple speakers choosing multiple mediums of communication. They largely affect the working mechanism of a clinician as they help us upgrade with the recent development in our fields. Making them interesting for us as well as our colleagues is necessary. This article presents a few facts as well as tips and tricks to compile the literature in a manner, which includes all the necessary points for better learning.

Background and Aims: Dexmedetomidine is a drug that is being widely used as an adjuvant to anaesthesia because of its unique pharmacodynamic and pharmacokinetic properties. We aimed to assess the recovery of psychomotor function from balanced anaesthesia including intravenous dexmedetomidine infusion as adjunct. Methods: Ninety American Society of Anesthesiologists I and II patients were randomised to group D (n = 45), to receive 1 μg/kg of dexmedetomidine loading dose over 10 min, with maintenance infusion of 0.5 μg/kg/h, and group S (n = 45), to receive an equal volume of 0.9% normal saline. Objective parameters were recovery of psychomotor function assessed by Trieger dot test (TDT), digit symbol substitution test (DSST) and intraoperative opioid requirement. the total fentanyl used intraoperatively in the two groups. Statistical analysis was performed using unpaired Student's t-test, Chi-squareor Fisher's exact test. Results: Psychomotor recovery assessed by TDT showed statistically significant early recovery in group D compared with group S. This was seen in the maximum distance of dots missed at 30 min, 60 min, 90 min and 120 min as well as in the average distance of dots missed at identical time points. Similarly, DSST revealed early recovery at 30 min (12.4 ± 5.3 vs. 10.4 ± 3.9 P = 0.04) postoperative interval but not at other time intervals. There was significant decrease in the intraoperative opioid requirement in group D compared with group S. Conclusion: The addition of dexmedetomidine to balanced anaesthetic technique significantly hastened the psychomotor recovery compared with placebo.

Adherence to established standards of care is important for anaesthesiologists to avoid undesirable legal consequences of their actions. The judiciary lays stress on the need to perpetuate healthy doctor-patient correspondence, good documentation, and to bestow a justifiable standard of care. But what defines standard of care and who delineates such standards is something that lacks clarity. The American Society for Gastrointestinal Endoscopy (ASGE) has recently released updated guidelines on the use of sedation and anaesthesia for gastrointestinal endoscopic procedures. Almost simultaneously, the American Society of Anesthesiologists (ASA) has brought out practice guidelines for moderate sedation and analgesia. In contrast to the ASA recommendations, ASGE does not view capnography as an essential monitoring modality for endoscopic procedures with moderate sedation because it has apparently not been shown to improve patient safety. However, they do agree that evidence supports its deployment during deep sedation. These differences in views between guidelines published by societies of substantial academic and clinical standing can confuse the agreement over what constitutes standard of care for the particular speciality. It is the expectation that guidelines and consensus statements in anaesthesiology be preferably issued by national or international organizations of the same speciality.

Background and Aims: Ambu® AuraGain™ laryngeal airway (AuraGain) is one of the newer supraglottic airway device introduced in 2014. Cervical spine stabilisation with hard cervical collar makes insertion of supraglottic airways and tracheal intubation difficult. This study was conducted to investigate whether the presence of a cervical collar affects the oropharyngeal sealing pressure (OSP) and fibreoptic view of the glottis (Brimacombe score) in airways secured with the AuraGain. Methods: The study was a randomised crossover trial. Thirty five ASA 1-3 patients undergoing elective surgery under general anaesthesia were recruited for the study. In each patient AuraGain was inserted twice in a crossover manner once with and once without a hard cervical collar in situ, with the sequence of insertion randomised. During each insertion of AuraGain the OSP, fibreoptic view of the glottis, insertion parameters, ventilator data and complications were noted. Results: The mean OSPs in both the groups were similar with no significant difference (29.6 ± 3.7 cmH2O without collar and 30.1 ± 3.1 cmH2O with collar [P = 0.310]). The fibreoptic view of glottis was also similar in both groups. The insertion with collar was more difficult than without collar. The number of attempts for successful insertion was same in both the groups. The time taken for appropriate placement of LMA was significantly prolonged in patients with collar. Conclusions: We conclude that the Ambu AuraGain can be used to provide effective ventilation in patients whose cervical spine is immobilised with a hard cervical collar.

Cardiac anaesthesia is a demanding, but fulfilling speciality which challenges the skills, knowledge, professional and personal competence of cardiac anaesthesiologists on a daily basis. This article outlines the brief history of the subspecialty of cardiac anaesthesia in India, its growth and progress over the decades, reasons for choosing it as a career option, variations in practice standards and how the speciality has been affected by the coronavirus 2019 pan?demic.

Background and Aims: Evidence and utility of the individual steps of the rapid sequence induction and tracheal intubation protocols have been debated, especially in the setting of traumatic brain injury. The purpose of this survey was to determine preferences in the current approach to rapid sequence intubation ( RSI) in head injury patients among a population of anaesthesiologists from South India. Methods: A questionnaire was E-mailed to all the members of the Indian Society of Anaesthesiologists' South Zone Chapter to ascertain their preferences, experience and comfort level with regard to their use of rapid sequence intubation techniques in adult patients with head injury. Participants were requested to indicate their practices for RSI technique for a head-injured patient upon arrival at the Emergency Medical Services department of their hospital. Results: The total response rate was 56.9% (530/932). Of the total respondents, 35% of the clinicians used cricoid pressure routinely, most respondents (68%) stated that they pre-oxygenate the patients for about 3 min prior to RSI, thiopentone (61%) and propofol (34%) were commonly used prior to intubation. Rocuronium was the muscle relaxant of choice for RSI among the majority (44%), compared to succinylcholine (39%). Statistical analyses were performed after the initial entry onto a spreadsheet. Data were summarised descriptively using frequency distribution. Conclusion: In a rapid sequence intubation situation, the practice differed significantly among anaesthesiologists. Owing to disagreements and paucity of evidence-based data regarding the standards of RSI, it is apparent that RSI practice still has considerable variability in clinical practice.

Cardiac tachyarrhythmias are encountered commonly during the perioperative period and need to be promptly identified and appropriately managed by the anaesthesiologist. This review intends to highlight important aspects of these tachyarrhythmias and explore a temporal relationship between common medications employed in the perioperative period and their causation. Mechanisms of initiation of tachyarrhythmias, drugs that can trigger those, as well as their diagnosis and management, are also parts of the current review. Cardiac tachyarrhythmias may not always require treatment, and sometimes, aggressive management can trigger more serious types of arrhythmias. A thorough understanding of these tachyarrhythmias and their pathogenesis enables adopting a more objective approach, eschewing risks of inappropriate or unnecessary management strategies. We performed a MEDLINE search using combinations of MeSH terms such as 'cardiac', 'arrhythmias', 'anaesthesia', 'perioperative', 'tachyarrhythmias' and 'anaesthetic implications'. We reviewed the relevant publications with regard to cardiac tachyarrhythmias occurring in the perioperative period.

Background and Aims: Doppler renal resistive index (RI) has been studied to find its association with postoperative acute kidney injury (AKI). This study was conducted to evaluate the usefulness of preoperative RI, postoperative RI and RI variation before and after surgery expressed as a percentage (% RI) for early AKI detection in major abdominal surgery. Methods: This was a single-centre, prospective observational trial performed in the critical care unit of an academic hospital. Eligible patients posted for major abdominal surgery under general anaesthesia using intraperitoneal approach with at least two predefined risk factors for AKI were included in the study. Renal RI was measured preoperatively and on postoperative day zero. Statistical comparisons were performed for various parameters between the AKI and the non-AKI groups. Pre- and postoperative RI receiver operating characteristics (ROC) curves were drawn and areas under the curves computed. Positive and negative predictive values, sensitivity, specificity and positive and negative likelihood ratios were calculated. Results: A total of 69 subjects were enrolled, of which 14 developed AKI in the postoperative period. The mean resistive indices measured were 0.65 ± 0.09 and 0.74 ± 0.09 in the pre- and postoperative periods, respectively. The area under the ROC curve in the postoperative RI was 0.732 with 95% confidence intervals of 0.592–0.871. This most accurate cut-off value to detect postoperative AKI with sensitivity 57.1% and specificity of 85.5% was 0.77. Conclusion: Postoperative RI can detect early AKI after major abdominal surgery.

Background and Aims: Anaesthetics are implicated in cognitive dysfunction, taste and odour deficits in the postoperative period. We aimed to assess the effect of isoflurane, sevoflurane, propofol and regional anaesthesia on the olfactory threshold, olfactory identification and endocrine regulation of associative memory in the postoperative period. Methods: In this observer-blinded randomised controlled study, 164 patients (>50 years) with the American Society of Anesthesiologists I and II status were randomised into one of four groups to receive regional anaesthesia, general anaesthesia with sevoflurane, general anaesthesia with isoflurane and total intravenous anaesthesia with propofol. Hindi Mental State Examination, olfactory threshold and olfactory identification were tested at 12 h preoperatively (T0), at 3 h postoperatively (T1) and at the time of discharge or postoperative day 3 (T2). In addition, serum melatonin levels were estimated at T0 and T1. The olfactory threshold was tested with n-butyl alcohol and olfactory identification with the University of Pennsylvania Smell Identification Test (UPSIT). Data were analysed using the one-way analysis of variance, Kruskal-Wallis or Mann-whitney tests. Results: The olfactory identification scores were lower with patients receiving sevoflurane-based anaesthesia at 3 h postoperatively (T1) when compared to preoperative (T0) (median 19.5 vs. 22; P = 0.01). This was accompanied by a significant postoperative reduction of plasma melatonin levels in sevoflurane group when compared to other groups (17.34 ± 4.8 pg/ml vs 23.2 ± 3.5 pg/ml; P < 0.001). Conclusion: Sevoflurane was associated with short-term olfactory identification impairment with a concomitant reduction in melatonin levels illustrating a possible humoral mechanism.

Recent technologic advances have enabled high-dose rate and pulsed-dose rate brachytherapy techniques to minimise radiation exposure hazards while offering the physical and biological advantages of brachytherapy.[1] Brachytherapy implant insertion procedures present the anaesthesiologist with numerous challenges since patients are often elderly with coincidental diseases. Second, the implant insertion procedures are extremely painful and require both analgesia and immobilisation. Third, the patients presenting for these procedures for head-and-neck cancers have a very high incidence of difficult airways. This study intends to review the anaesthesia records of 32 procedures of brachytherapy for head-and-neck cancer over a period of 2 years and report the experience at the author's institution.

Background and Aims: We conducted a prospective, randomised, double-blind, controlled clinical trial to examine (1) whether a single preoperative dose of 800 mg gabapentin would be as effective as 2 μg/kg of intravenous (IV) fentanyl in blunting the haemodynamic response to tracheal intubation and (2) whether a combination of both would be more effective in this regard. Methods: Seventy-five patients (American Society of Anaesthesiologists physical status I), aged 20-50 years were allocated into one of three groups: 2 μg/kg IV fentanyl, 800 mg oral gabapentin or a combination of both. Gabapentin was administered 2 h and fentanyl 5 min before induction of anaesthesia, which was achieved with 5 mg/kg thiopentone, and tracheal intubation facilitated with 0.1 mg/kg vecuronium. Laryngoscopy lasting a maximum of 30 s was attempted 3 min after administration of the induction agents. Serial values of mean arterial pressure (MAP) and heart rate (HR) were compared among the three groups and with the respective preinduction measurements. Results : Patients receiving gabapentin 800 mg alone showed remarkable increases in HR and MAP in response to tracheal intubation (P < 0.05). The increases were similar for the other two regimens. These haemodynamic changes were lesser in patients receiving fentanyl and the combination of gabapentin and fentanyl. Conclusion: Oral gabapentin does not produce significant reduction in laryngoscopy and tracheal intubation induced sympathetic responses as compared to IV fentanyl or the combination of gabapentin and fentanyl.

Background and Aims: Previous studies suggest that administration of vecuronium based on total body weight rather than ideal body weight (IBW) in obesity results in overdosing with prolonged recovery times. We hypothesised that larger doses of neostigmine could result in faster recovery in obese patients administered vecuronium based on total body weight. Methods: Forty-five obese American Society of Anesthesiologists' II patients undergoing elective surgery under general anaesthesia were randomised into 3 groups to receive neostigmine 30, 40 and 50 μg/kg. Following induction, patients were paralysed with vecuronium 0.1 mg/kg based on total body weight. Reversal was achieved with neostigmine based on the patient's group, and time to train-of-four (TOF) ratios of 0.5, 0.7 and 0.9 measured. The primary outcome variable was time to achieve TOF ratio >0.9. Results: Neostigmine 50 μg/kg achieved faster recovery to TOF 0.7 than neostigmine 30 and 40 μg/kg. There was no significant difference in recovery times to TOF 0.7 in patients receiving either 30 or 40 μg/kg of neostigmine. However, neostigmine 40 μg/kg attained TOF ratio 0.9 faster than 30 μg/kg. We did not note a significant difference between the 40 and 50 μg/kg dose with regard to recovery of TOF to 0.9. Conclusion: Facilitated recovery from neuromuscular blockade to TOF of 0.7 was faster with neostigmine 50 μg/kg compared to 40 or 30 μg/kg. Recovery to TOF ratio of 0.9 was not significantly different with 40 or 50 μg/kg doses although such time was faster as compared to 30 μg/kg dose.

We report a case of temporomandibular joint dislocation occurring in the postoperative period in a patient, who developed catatonia following administration of a single dose of epidural morphine. The catatonic response to epidural morphine was delayed by several hours in the postoperative period, and might have resulted from intrathecal migration of the drug, through an initial dural puncture while locating the epidural space. The temporomandibular joint dislocation was diagnosed only after reversal of the effects of morphine with naloxone, when the patient complained of inability to fully close her mouth.

The results and management of penetrating thoracic trauma are largely dependent upon the extent of injury to internal organs as well as the skills of the attending clinicians. Thoracic trauma in children may be associated with rib fractures, flail chest, soft tissue injury, intrapleural lesions such as haemothorax and pneumothorax, parenchymal lung injuries such as pulmonary contusion and lung laceration as well as mediastinal lesions, including cardiac injury,[1,2] and yet our patient fortuituously had none of these, despite suffering a major, and what could potentially have been a life-threatening accident. The sources of perioperative morbidity and mortality in subjects suffering penetrating thoracic injuries include airway obstruction, respiratory failure and haemorrhage. Clinicians need to be adequately trained to deal with these problems. Trauma mainly affects the younger population and happens to be the most common cause of mortality in patients in the first three decades of life. The technical difficulties encountered during the perioperative management of the patient with severe penetrating thoracic injury are highlighted here.

Epidural infusion of local analgesic and opioid are commonly used for postoperative pain relief. This combina-tion gives excellent anlgesia but nausea and vomiting remains a major concern. Low dose epidural naloxone prevents PONV induced by spinal opioids like morphine, fentanyl and sufentanil. However, it is not known that epidural naloxone administration prevents PONV induced by epidural buprenorphine. We have reported three cases of major abdominal operation in which lowdose epidural infusion of naloxone releived the symptom of buprenorphine induced severe PONV and improved the quality of analgesia.