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Microsurgical aneurysm clipping under general anesthesia is considered a definitive procedure for the obliteration of unruptured and ruptured aneurysms. Aneurysm clipping can present with postoperative neurological complications, which can be missed under general anesthesia even with intraoperative neurophysiological monitoring. Real-time monitoring with awake patients can help prevent and treat these complications very early. The anesthesiologist has a vital role in awake aneurysm surgery from providing adequate surgical conditions to patient satisfaction and managing intraoperative complications. We report the first-hand experience as a neuroanesthesiology team managing awake craniotomy and aneurysm clipping.

Study Design Prospective randomized double-blind study. Purpose To assess the analgesic effects of the combination of a low-dose ketamine and dexmedetomidine (ketodex) infusion and compare it with that of fentanyl for postoperative analgesia after spine surgeries. Overview of Literature Adequate pain management following spine surgeries is crucial. Approximately 57% of patients experience inadequate pain control in the first 24 hours following elective spine surgery, which is attributable to the extensive soft tissue and muscle damage. Methods The study included 60 patients graded American Society of Anesthesiologists I and II and scheduled for thoracolumbar spine surgery involving >3 vertebral levels. The patients were divided into two groups: group KD (ketodex) and group F (fentanyl). The primary objective was to compare the postoperative analgesic requirements among the groups. The secondary objectives included a comparison of the intraoperative anesthetic requirements, postoperative pain scores, hemodynamic parameters, side effects of the study drugs, and the duration of post-anesthesia care unit stay of both the groups. Results Ketodex use prolonged the mean time to first rescue analgesia (22.00±2.30 hours vs. 11.69±3.02 hours, p0.05). The postoperative pain scores were significantly lower in the group KD than in group F at most timepoints (p3 vertebral levels to achieve prolonged analgesia without any opioid-related side effects.

Background A questionnaire-based survey was conducted to determine the preanesthetic evaluation (PAE) practices among the members of the Indian Society of Neuroanesthesiology and Critical Care (ISNACC). The survey aimed to assess the current clinical practice of PAE and optimization of neurosurgical patients in India. Methods An online questionnaire was designed by the working group of ISNACC and circulated among its active members. Response to individual questions was considered significant if 50% or more respondents concurred. The survey questions to which less than 50% of respondents concurred were identified as inconclusive results. Results Out of 438 active ISNACC members, 218 responded. Responses were obtained from various parts of the country. The majority of participants were practicing neuroanesthesiology. Questions asked were regarding clinical assessment, preoperative optimization, prognostication, and airway management in neurosurgery. More than 50% of practitioners acceded to most of the questions; however, the percentage of responses varied across different questions (50–100%). The questions related to preoperative duplex scanning in chronically immobilized patients, preoperative cognitive testing, and risk stratification during neurosurgical procedures received an inconclusive response (< 50%). Conclusion The survey highlights the variable PAE practices perused by ISNACC members across the country. A guideline for uniform PAE practices may help to enhance research and improve perioperative care.

Study Design This was a prospective, randomized, and double-blind study. Purpose Thoraco-lumbar spine surgery is associated with severe postoperative pain and can cause chronic pain. We aimed to compare the impact of epidural ropivacaine with and without dexmedetomidine on postoperative analgesia after thoracolumbar spine instrumentation wherein an epidural catheter was placed by the surgeon intraoperatively. Overview of Literature Very few studies have reported the use of epidural dexmedetomidine in spine surgeries. When used via the epidural route, dexmedetomidine is safe and efficacious and is associated with reduced rescue analgesia consumption, increased duration of analgesia, reduced pain scores, but not with major hemodynamic adverse effects. Methods Total 60 American Society of Anesthesiologists I–III adult patients aged 18–65 years who were scheduled to undergo thoraco-lumbar spine instrumentation were randomly allocated into group RD (epidural ropivacaine+dexmedetomidine) or group R (epidural ropivacaine plus saline). We aimed to compare the total rescue analgesic consumption on postoperative day 0, 1, and 2. Moreover, we studied the time to first rescue analgesia with visual analogue scale score

Purpose: Oral Triclofos is widely used as a sedative agent in children. However, the role of Triclofos as a sedative agent in children undergoing ophthalmological procedures has not been adequately studied. The aim of this study was to determine the safety and efficacy of oral Triclofos in children suffering from pediatric glaucoma who were undergoing ocular examination. Methods: 80 children aged less than 5 years were assessed for eligibility for the trial after taking hospital ethical committee approval. The children were administered 80 mg/kg of oral Triclofos and Ramsay sedation score was measured every 5 min starting from 20 min after administration of the drug. If the child was not adequately sedated after 30 min, additional dose of 05 mg/kg was administered every 5 min till 60 min of drug administration. The procedure was considered a failure and general anesthesia (GA) administered if Ramsay sedation score was ≤4 after 60 min of initial drug administration. Heart rate and arterial oxygen saturation were measured throughout the period of sedation. The duration of sedation and incidence of side effects was also noted. Results: A total of 73 patients underwent the study. The mean age of children was 23.4 months (SD – 14.72) and mean weight was 12 kg (SD – 3.84). The mean dose of Pedicloryl (Triclofos) used was 83.8 mg/kg and the median duration of onset was 25 min. 64 children completed examination successfully, 2 children had to be administered GA during the procedure. There were no major side effects. Conclusion: Administration of oral Triclofos in a dose of 80 mg/kg body weight was safe and effective in children less than 5 years of age undergoing ocular examination.

Background: Prevision of a potentially difficult airway in the preoperative period is imperative. The available tools are evaluation of mouth opening, Mallampati test; atlanto-occipital extension; hyomental, thyromental, and sternomental distances; and upper lip bite test; thyromental height test (TMHT) is a new indicator. Aims: To compare the effectiveness of preoperative anaesthetic airway evaluation methods of TMHT and Modified mallampati test (MMT) to predict the difficulty in intubation. Materials and Methods: A prospective observational study was aimed to compare the effectiveness of preoperative anesthetic airway evaluation methods of TMHT and modified Mallampati test (MMT) to predict the difficulty in intubation. A total of 150 subjects were included in this study. MMT and TMHT were compared, and sensitivity, specificity, predictive values, and accuracy were calculated. Results: On comparison, we found TMHT to be more sensitive (93.33%) than MMT (77.78%); both tests have high specificity (TMHT 91.43%; MMT 81.90%). Positive predictive value was 82.35% for TMHT and 64.81% for MMT. Similarly, negative predictive value was 96.97% for TMHT and 89.58% for MMT. Accuracy was 92.00% for TMHT and 80.66% for MMT. Conclusions: TMHT can predict difficult intubation better than MMT (high positive predictive value). However, both TMHT and MMT predict easy intubations effectively, their negative predictive values being high.

Cardiac disease is an important cause of mortality in pregnancy. It has the potential to remain undiagnosed and may present with cardiovascular decompensation during pregnancy, at the time of delivery, or immediately postpartum. It can have long-term implications to the life of the affected women and their families. This review summarises the current knowledge of the incidence, prevalence, and management of pregnancy-related cardiovascular disease in women presenting preconceptionally or during pregnancy.

We describe our experience of management of a young hypertensive male taken up for coiling of an unruptured intracranial aneurysm whom we diagnosed to be a case of coarctation of aorta during preanesthetic check-up. This diagnosis changed the treatment of the patient completely. We report this to emphasize the need to do a thorough preoperative check-up in every case. We also touch upon the important anesthetic considerations to be observed while managing such cases.

Unilateral recurrent pleural effusions are commonly encountered in critical care practice. Relevant clinical history, physical examination, radiology, and diagnostic thoracentesis usually identify the cause of pleural effusion in most cases. Thoracoscopy or video-assisted thoracic surgery may be required in selective cases. We report a case of 32-year-old female with recurrent unilateral hemorrhagic pleural effusion that was the presenting feature of thoracic endometriosis syndrome.

The patient profile undergoing neurosurgery varies from neonates to elderly, and from patients undergoing elective surgery to patients undergoing emergency surgeries. The goals of postoperative management include prevention of secondary brain injury and taking care of the major organ systems till the time patient recovers from the primary insult. Postsurgery, patients may be shifted to a neurosurgical intensive care unit or managed in a neurosurgical ward. As a general rule, all patients should be nursed 30-degree head up. We will be discussing the basic principles of postoperative management of neurosurgical patients.

Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, introduced into clinical practice six decades ago, has often been the worst fear of a neuroanesthesiologist due to its concerns of causing a rise in intracranial pressure and increasing cerebral blood volume. However, the recent literature clarifies that it may have a beneficial role, even in neurosurgical patients, because of its propensity to cause neuroprotection through antiglutamatergic action on the NMDA receptors in the ischemic brain. Apart from having an anticonvulsive role in refractory status epilepticus, its inherent property of increasing blood flow to the ischemic areas offers protection to the penumbral zone, thus preventing secondary brain injuries. Also, it has been widely used as an analgesic at subanesthetic doses post spine surgeries. Recently, enough scientific evidence has been published in favor of ketamine establishing the fact that it does not cause a rise in intracranial pressure when the patient is mechanically ventilated and normocarbia is maintained. It has also been used during evoked potential monitoring as it amplifies signals even under general anesthesia and proves to be quite effective during neuromonitoring. However, its adverse effects of increasing muscle tone, excessive salivation, emergence delirium, agitation, and “out of body” experiences with long-term psychomimetic effects and potential to cause addiction have precluded its widespread use. This review on ketamine summarizes the benefits of using it in neurosurgical anesthesia with the aim of removing the fears we had in the past, which did not seem to be evidence based.

Management of pregnant women with heart disease remains challenging due to the advancement of innovations in cardiac surgery and correction of complex cardiac anomalies, and more recently, with the successful performance of heart transplants, cardiac diseases are not only likely to coexist with pregnancy, but will also increase in frequency over the years to come. In developing countries with a higher prevalence of rheumatic fever, cardiac disease may complicate as many as 5.9% of pregnancies with a high incidence of maternal death. Since many of these deaths occur during or immediately following parturition, heart disease is of special importance to the anesthesiologist. This importance arises from the fact that drugs used for preventing or relieving pain during labor and delivery exert a major influence – for better or for worse – on the prognosis of the mother and newborn. Properly administered anesthesia and analgesia can contribute to the reduction of maternal and neonatal mortality and morbidity.

Immunoglobulin G4 (IgG4)-related disease is a relatively newly coined term for a disease which affects various body organs. There is tissue invasion of IgG4-positive plasma cells into tissues leading to various manifestations like lymph node enlargement, autoimmune pancreatitis, pulmonary manifestations, hepatic disease, and others. We describe the anesthetic management of a pediatric patient suffering from IgG4-related disease with systemic manifestations who underwent a ventriculoperitoneal shunt revision.

Hysteroscopy is becoming fairly common in most centers these days, both as a diagnostic and therapeutic tool especially for short day-care procedures, reducing unnecessary hospital admissions and overuse of resources. However, these procedures are not without complications, and some could be delayed and potentially fatal if a high index of suspicion is not maintained. One such rare yet one with a high mortality among urological patients is the transurethral resection syndrome on which there is a cornucopia of literature in the form of articles and chapters. There are very few highlighting a similar syndrome of sorts called the operative hysteroscopy intravascular absorption syndrome. Here, we describe one such case, and in brief, the anesthetic management options for hysteroscopic procedures to prevent such a complication.

Distant site hematoma formation may complicate an otherwise uneventful surgery. The authors describe three cases of such unexpected complications, while operating upon infratentorial lesions in prone position. Pathophysiology behind such complications and changes in intraoperative monitoring is discussed, along with all the previously reported cases. Of the three cases, there was one death, while rest of the two cases made eventless recovery. Meticulous hemostasis, isolation of operative site, avoidance of cerebrospinal fluid over-drainage during surgery may prevent such a complication. Careful interpretation of vital-monitoring may indicate the occurrence of such a complication.