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INTRODUCTION General anaesthesia is associated with higher maternal morbidity and mortality when compared with regional anaesthesia, related mainly to failure of intubation, hypoxia and aspiration. The aim of this retrospective review was to define the incidence of failed and difficult intubation in parturients undergoing general anaesthesia for Caesarean delivery at a high-volume obstetric hospital in Singapore. METHODS All parturients who underwent Caesarean delivery under general anaesthesia from 2013 to 2016 were identified and their medical records were reviewed to extract pertinent data. Difficult intubation was defined as ‘requiring more than one attempt at intubation or documented as such, based on the opinion of the anaesthetist’. A failed intubation was defined as ‘inability to intubate the trachea, with subsequent abandonment of intubation as a means of airway management’. RESULTS Records of 660 Caesarean sections under general anaesthesia were extracted. The mean age of the parturients was 32.1 ± 5.5 years and the median body mass index was 27.5 (interquartile range 24.6–31.1) kg/m2. Rapid sequence induction with cricoid pressure was employed for all patients, with thiopentone and succinylcholine being administered for 91.2% and 98.1% of patients, respectively. There were 33 difficult intubations among 660 patients, yielding an incidence of 5.0%. Junior trainees performed about 90% of all intubations and 28 (84.8%) out of 33 difficult intubations. Repeat intubations were performed by senior residents/fellows (57.1%) and consultants (14.3%). No instance of failed intubation was reported. CONCLUSION The local incidence of difficult obstetric intubation was one in 20. No failure of intubation was observed.

INTRODUCTION Children with solid organ tumours often present for curative surgery. Even with the best surgical technique, micrometastases can occur. Preclinical studies support the postulation that neuraxial anaesthesia maintains the body’s immune and inflammatory milieu against metastasis. However, human retrospective adult studies showed varying results, and no study has been done in children. We aimed to find out if intraoperative epidural, perioperative opioid and volatile dose are associated with relapse-free survival (RFS) in children with solid organ tumours. METHODS This is a retrospective cohort study of 126 children from a tertiary paediatric unit who were diagnosed with solid organ tumours (neuroblastoma, hepatoblastoma or sarcoma) over a 16-year period. RFS, stratified by tumour subtypes, was estimated using the Kaplan-Meier method. Adjusted hazard ratios (aHRs) were obtained from multivariable Cox regression models after taking potential covariates into account. RESULTS Of 126 children with solid organ tumours (51.6% neuroblastoma, 34.9% sarcoma and 13.5% hepatoblastoma), 53.2% received combined general anaesthesia (GA)/epidural. A total of 21 (31.3%) and 20 (33.9%) patients relapsed during the study period in the combined GA/epidural group and the GA alone group, respectively. Patients with sarcoma receiving combined GA/epidural had a clinically meaningful lower risk of relapse compared to patients receiving GA alone (aHR 0.51, 95% confidence interval 0.14–1.79), although this was not statistically significant. CONCLUSION Our study demonstrated some clinically meaningful associations, especially in paediatric sarcoma patients. Overall, however, there was no statistically significant association between epidural use and an improved RFS.

INTRODUCTION: The use of neuromuscular blocking agents (NMBAs) is common during general anaesthesia. Neuromuscular monitoring with a peripheral nerve stimulator (PNS) is essential to prevent postoperative residual neuromuscular block (PRNB), defined as a train-of-four (TOF) ratio < 0.9. PRNB remains a common complication and may contribute to morbidity in the postoperative anaesthetic care unit (PACU). METHODS: An online survey was sent to anaesthesiologists in our department to assess their knowledge and clinical practices related to neuromuscular blockade. Next, a study was conducted on adult patients scheduled for elective surgery under general anaesthesia requiring NMBAs. Upon admission to the PACU, TOF monitoring was performed. RESULTS: A large proportion of anaesthesiologists showed a lack of knowledge of neuromuscular blockade or non-adherence to the best clinical practices associated with it. The majority (98.7%) stated that they did not routinely use PNS monitoring. In the clinical study, TOF monitoring was only used in 17.9% of the 335 patients who were assessed. The prevalence of PRNB was 33.4% and was associated with the elderly (age ≥ 65 years), a higher dose of NMBA used, a shorter duration of surgery, and a shorter duration between the last dose of NMBA and measurement of PRNB in the PACU. The incidence of adverse symptoms in the PACU was observed to be higher in patients with PRNB. CONCLUSION: PRNB remains a clinically significant problem, but routine PNS monitoring is rare in our institution. This is compounded by inadequate knowledge and poor adherence to best clinical guidelines related to neuromuscular blockade.

Regional anaesthesia is emerging either as a sole anaesthetic technique or as an adjunct to general anaesthesia in different surgical conditions. With increasing incidence of systemic illnesses coming for operative procedures, the value of addition of nerve blocks to a routine anaesthetic technique assumes more significance in terms of decreasing morbidity. Usually, the anaesthesiologists are familiar with abdominal, chest and extremity blocks. As ultrasound is not friendly with head and face with bony prominences, the progress in this field is further hampered. In this narrative review, we will try to elaborate on a few useful nerve blocks of the head and face, the importance of ultrasound in viewing those nerves in the bony gaps will be discussed. The use of such techniques as either a perioperative analgesic or as an independent anaesthetic method along with the precautions to be followed in their administration will be highlighted.

INTRODUCTION: The use of electroconvulsive therapy (ECT) in Singapore dates back to 1947. However, there is little local information on the clinical practice of ECT and its standards. We aimed to conduct a comprehensive national survey of ECT practice in Singapore. METHODS: A cross-sectional structured questionnaire assessing the types of ECT (e.g. electrode placement, stimulus parameters), indications, anaesthetic technique, dosing methods, monitoring of outcomes and credentialing was sent in 2015 to all ECT centres in Singapore via email to collect qualitative and quantitative data regarding ECT. RESULTS: Data was obtained from all ECT centres (n = 6), which represented that ECT was available in 23.1% of all hospitals and 50.0% of all psychiatric specialist centres. The rate of ECT was 5.89 treatments per 10,000 residents per year, and each patient received an average of 5.4 ECT per course. Only 7.0% of ECT was administered for continuation/maintenance ECT. The most common indication for ECT was depression in 5 (83.3%) out of six centres, with schizophrenia being the second most common. In 5 (83.3%) out of six centres, ECT was brief (0.5 ms) bitemporal ECT with age-based dosing, and 93.0% of the sessions were conducted in an inpatient setting. All ECT was conducted under general anaesthesia, with propofol (66.7%) being the most common type of anaesthetic used. CONCLUSION: The practice of ECT in Singapore was highly uniform. The rates and indications for ECT were consistent with those of other developed countries, with greater use of ECT for schizophrenia. Future advances for ECT in Singapore include the use of individualised dosing based on empirical seizure threshold titration, expanded electrode placements and increased utilisation of continuation/maintenance ECT.

Bilateral proximal fibular head prominence is a rare case of chronic knee pain and can befound in isolation or as a part of multiple ligamentous or bony knee injuries. There is prominence of proximal fibula on clinical examination with tenderness on palpation. Radiological investigation can confirm the diagnosis;in the case of our patient, both plain radiograph and MRI magnetic resonance imaging (MRI) were performed. MRI helps in the assessment of the intrinsic knee ligament, as well as the course of common peroneal nerve. The prominent proximal fibular head excision was performed successfully under general anaesthesia in different sittings.

Introduction Adductor canal block (ACB) is hypothesised to provide superior analgesia to femoral nerve block (FNB) for total knee arthroplasty (TKA) while preserving quadriceps strength. Methods 30 patients undergoing TKA were randomised to receive either ACB or FNB. Baseline tests of quadriceps strength were performed. Ultrasound-guided blocks with 30 mL of 0.5% ropivacaine were administered before induction of general anaesthesia. Patient-controlled analgesia (morphine) was prescribed for postoperative analgesia. The primary outcome of this prospective, double-blinded, randomised controlled trial was morphine consumption (mean ± standard deviation) in the first 24 hours. Secondary outcomes were pain scores using a numeric rating scale (median and interquartile range [IQR]), quadriceps strength (% of baseline) and functional outcomes at 24 hours and 48 hours postoperatively. Results There was no statistically significant difference in morphine consumption at 24 hours between the ACB and FNB groups (21 ± 11 mg vs. 20 ± 12 mg; p = 0.85). No statistically significant differences were observed between the ACB and FNB groups in pain scores at 24 hours (at rest: 0 [IQR 0-2] vs. 0 [IQR 0-2]; on movement: 5 [IQR 4-8] vs. 5 [IQR 3-8]) and quadriceps strength (24 hours: 28.8% ± 26.1% vs. 26.8% ± 19.6% of baseline; 48 hours: 31.5 ± 23.1% vs. 33.7% ± 20.1% of baseline). There were also no statistically significant differences in functional outcomes and length of stay. Conclusion We found no statistically significant differences in analgesic effects, quadriceps strength or functional recovery postoperatively between ACB and FNB.

Respiratory tract foreign bodies are most dangerous emergencies in children. There are various types of foreign bodies removed from airway like-peanuts, metallic foreign bodies, sharp foreign bodies, led bulbs and different part of toys. Most commonly they present with proper history of aspiration and symptoms of respiratory distress, but not always. It should be diagnosed immediately either with the history and clinical examination or with the help of radiological investigations. High resolution computed tomography of chest gives the exact location of the foreign body. These patients should be managed promptly to reduce the morbidity and mortality. Rigid bronchoscopy with optical forceps under general anaesthesia is the procedure of choice to retrieve the foreign bodies. We are presenting a case of 2 months old child which has aspirated a safety pin into her airway accidentally. The location was confirmed by HRCT chest and it was removed using optical forceps. Child was discharged under stable conditions.

Introduction Difficult airway is a calamitous incident as it can lead to airway or oesophageal mucosal tear, leading to aspiration, severe hypoxaemia and finally death. The aim of the study is to measure thyromental distance, sternomental distance, ratio of height to thyromental distance and neck circumference to anticipate difficult intubation as defined by Cormack-Lehane grading and to evaluate anatomical predictors of neck for difficult direct laryngoscopy in adult Indian population. Methods The study is conducted in Teerthanker Mahaveer Medical College & Research Centre, Moradabad for the period of one year on 200 patients undergoing general anaesthesia. Following parameters like Thyromental distance, Sternomental distance, Neck circumference and Ratio of height to thyromental distance were measured and prediction of difficult laryngoscopy was done by Cormack-Lehane grade. Results The cut-off points of neck parameters in both the genders in Indian population were TMD ≤ 9.7 / ≤ 7.6 cm, STMD ≤ 18.6 / ≤ 15.8 cm, NC ≥ 40.3 / ≥ 38.2 cm and RHTMD ≥ 18.2 cm /≥ 21.5 cm. There was significant difference (p value Discussion TMD and NC has good agreement with kappa value of 0.7 and 0.72 respectively. STMD and RHTMD with kappa values of 0.57 and 0.45 (Moderate agreement) shows that they are not good predictors of difficult intubation.

INTRODUCTION Airway management during anaesthesia has potential difficulties and risks. We aimed to investigate the utility of routine airway assessment for predicting difficult tracheal intubation, review the prevailing practice of videolaryngoscope use amongst anaesthetists in a teaching hospital and determine the incidence of intraoperative and postoperative airway-related complications. METHODS A prospective observational study of 1,654 patients undergoing general anaesthesia with endotracheal intubation over a seven-month period was performed. Data regarding airway and anaesthetic management was collected and analysed. RESULTS Videolaryngoscopes were used as the first-choice equipment in 60.5% of the cohort. The incidence of difficult intubation was 2.1%, of which 45.7% of cases were unanticipated. The sensitivity of airway assessment was 54.3%, with a positive predictive value of 8.1%. When difficult intubation was anticipated, more videolaryngoscopes were used as the first equipment of choice compared to the Macintosh laryngoscope (p < 0.001). In the Macintosh group, more patients required a change of airway equipment (p = 0.015), but the number of intubation attempts was similar (p = 0.293). The incidence of intraoperative (p = 0.920) and postoperative complications (p = 0.380) were similar in both groups. CONCLUSION Using the current predictors of difficult intubation, half of the difficult airways we encountered were unanticipated. Videolaryngoscopes were preferred when difficulty was anticipated and were also used in routine tracheal intubation.

Introduction We developed an accelerated clinical pathway involving outpatient surgery for patients undergoing total knee arthroplasty (TKA) who are healthy enough for early discharge. Methods Between March 2014 and April 2015, 89 TKAs were performed at a single institution by a single orthopaedic surgeon. 31 patients met the inclusion criteria for the study. All patients received 2 g tranexamic acid and 750 mg cefuroxime sodium intravenously 30 minutes prior to surgery. A multimodal protocol for perioperative pain management was used for all patients. Results 31 patients (three male, 28 female), with a mean age of 67 (range 49-78) years, who underwent TKA were enrolled in this study. The mean length of hospital stay was 28.7 (range 16-49) hours and mean duration of surgery was 92 (range 75-128) minutes. Combined spinal epidural anaesthesia was performed for 23 (74.2%) patients and general anaesthesia was used in 8 (25.8%) patients. Among the 31 patients, 23 (74.2%) patients were discharged within 23 hours of surgery. Conclusion Early discharge of patients following outpatient surgery for TKA was not associated with any procedure-related complications among the selected patients up to three months postoperatively.

Electroconvulsive therapy (ECT) is a highly effective treatment for patients with psychotic disorders that do not respond to medication. Usually, many psychotropic drugs have a teratogenic effect on the foetus. ECT seems to be a relatively safe and effective choice of treatment in pregnant patients. Adverse events such as foetal heart rate reduction, uterine contractions and premature labour do occur during ECT. We report our experience with ECT in the treatment of first episode of mania with psychosis in a patient in second trimester of pregnancy.

Tracheal injury associated with thyroidectomy is rare. We report the case of a 41-year-old lady who underwent total thyroidectomy for multinodular goitre. The surgery was uneventful. On postoperative day (POD) 8, she complained of cough followed by a ‘give-way’ sensation over her neck. On POD 10, she presented with dyspnoea after a sudden bout of cough with blood-tinged sputum, stridor and swelling over the surgical site. Computerised tomographic (CT) scan showed a defect on the right anterolateral wall of the trachea at the level of C6 vertebra and subcutaneous emphysema. She underwent emergency tracheostomy under general anaesthesia. Intraoperatively, a 5 mm × 10 mm tracheal rent was visualised between the first and second tracheal rings over the right side with surrounding unhealthy tracheal cartilages. The defect was closed with strap muscles and surgical tracheostomy performed between the 4th and 5th tracheal rings. In patients presenting with respiratory distress and subcutaneous emphysema following thyroid, mediastinal or anterior cervical approach surgery, a high index of suspicion of delayed tracheal injury must be entertained. An X-ray, and more importantly a CT imaging, may be conclusive to identify the site of tracheal rupture. The decision to follow conservative management or consider urgent surgery will depend on patient presentation.

Background: Introduction of the laryngeal mask airway (LMA) has revolutionised the practice of anaesthesia. This study compares the clinical performance of Ambu Aura40 LMA with Classic LMA in anaesthetised spontaneously breathing patients in terms of its ease of use and side effects. Patients and Methods: In this prospective randomised controlled study, 176 patients were allocated to either the Classic LMA or Ambu Aura40 LMA group according to a pregenerated block randomisation number sequence with concealment method. The allocated LMA was placed under general anaesthesia without muscle relaxant. The time and ease of insertion were noted in addition to any adverse events. Results: It was observed that Ambu Aura40 LMA and the Classic LMA were positioned successfully in the first attempt in 94% and 81% of patients respectively. The Ambu Aura40 LMA was placed in

Background: Propofol is commonly used as a sole induction agent during laryngeal mask airway (LMA) insertion, and additional doses are often required with systemic consequences. Objective: Our study evaluated the effect of 0.1 mg/kg suxamethonium on the dose of induction of propofol when used during insertion of LMA. Methodology: Eighty patients aged between 18 and 60 years were included in this prospective study. Patients undergoing elective procedures under general anaesthesia with LMA and spontaneous ventilation were randomized into two groups. Patients in both groups were induced with an initial dose of 2.5 mg/kg of propofol; the control group (group P) and the second group (group S) received 5 ml of normal saline and 0.1 mg/kg of suxamethonium made up to 5 ml, respectively. The need for additional doses of propofol following insertion of LMA was then assessed based on insertion conditions (ease of insertion, severity of airway response in terms of coughing, gagging, laryngospasm, and patient movement). The total dose of propofol required before successful insertion was recorded, as well as the incidence and duration of apnea post-induction. The pulse rate (PR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were assessed at 0, 1, 3 and 5 min after insertion of LMA for each group. Results: The total dose of propofol required for successful LMA insertion was significantly lower in group S (2.82 ± 0.39 mg/kg) compared to group P (3.13 ± 0.49 mg/kg), P = 0.002. Haemodynamic parameters (SBP, DBP, MAP, PR, and SpO2) were well-controlled post-LMA insertion and were comparable between the two groups. Furthermore, no incidence of hypotension or bradycardia requiring intervention was observed at different time intervals, throughout the study period, in both groups. Conclusion: The dose of propofol is lesser when low-dose suxamethonium (0.1 mg/kg) precedes its use for induction during LMA insertion, and there is a reduction in the duration of apnea; however, it causes a higher apnea incidence. Vital signs were similar in the two study groups.

Background and Aims: Severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) is a highly infectious disease and healthcare workers are at constant risk for contracting it. Nowadays, aerosol box is used in conjunction with WHO-recommended safety kits, to avoid health workers from getting SARS-CoV-2 infection during aerosol-generating procedures. In our study, we compared the ease of oral intubation with C-MAC video laryngoscope and direct laryngoscopy, when the aerosol box was used. The secondary objectives were to compare the incidence of airway loss, haemodynamic changes, number of attempts, and time required for intubation between these two techniques. Methods: This prospective randomised controlled study was conducted on 60 non-coronavirus disease (COVID) patients presenting for elective surgery under general anaesthesia. Patients were randomly assigned into two groups:C and D using a computer-generated random sequence of numbers by closed envelope technique. In group D, laryngoscopy was performed with Macintosh blade and in group C, with Storz® C-MAC video laryngoscope. Results: The ease of intubation was better (grade 1) in group C than D (68.6% vs. 31.4% respectively) with a P value of < 0.001. 10% of patients required more than one intubation attempt in group D compared to none in group C, but this difference was not statistically significant. The intubation time was comparable between the two groups. There were no incidences of loss of airway or failure to intubate in both groups. Conclusion: The use of C-MAC video-laryngoscopy resulted in easier orotracheal intubation as compared to intubation with direct laryngoscopy when the aerosol box was used.

Granulomatosis with polyangiitis, earlier known as Wegener's granulomatosis, is an autoimmune vascular disorder in which small- and medium-sized vessels are affected. Anaesthetic management depends on the extent to which various organs are involved. Subglottic stenosis can complicate this autoimmune vascular condition which can become a challenging airway situation for anaesthesiologists, particularly when administering general anaesthesia.

Context: Most often, young children with early childhood caries (ECC) may need oral rehabilitation under general anaesthesia (GA) as treatment cannot be done chairside. A procedure under GA can be traumatic and stressful for both the parents and the children. Hence, it becomes necessary to understand the parents' opinions and address their concerns to provide better treatment. Aims: This qualitative study was conducted to explore the parental issues and concerns for their children treated under GA for ECC. Qualitative research approach was used so that it would enable us to address these issues better and prepare parents by counselling them in advance. Settings and Design: An in-depth interview was conducted with the parents of children who underwent oral rehabilitation under GA for ECC in the M.S. Ramaiah Memorial Hospital, admitted under the Department of Pedodontics and Preventive Dentistry. Participants and Methods: Data were audio-recorded and transcribed. Statistical Analysis Used: Data collected were analysed using thematic analysis. Results: The themes derived were 'Concerns and Issues of GA Procedures and Improved Oral-health-related Quality of Life'. Conclusions: The parents of children who underwent oral rehabilitation under GA initially had a few concerns and were reluctant about the procedure but were happy with the improvement post-operatively.

One-lung ventilation provided by double-lumen tube intubation under general anaesthesia has conventionally been considered necessary for thoracoscopic major pulmonary resections. Recently, regional anaesthesia techniques have been used to avoid complications of tracheal intubation and general anaesthesia. Although paravertebral block (PVB) comes to the fore as a safe and useful regional anaesthesia technique for intra-operative and post-operative analgesia for a wide variety of surgeries involving the thoracic and lumbar regions, it is sometimes used for anaesthesia. Here, we aimed to demonstrate that biportal video-assisted thoracoscopic surgery can be performed in a right upper lobectomy while maintaining spontaneous ventilation in a 55-year-old, awake patient who was not intubated under ultrasound-guided PVB.

Insulin Resistance syndromes (IR's), are a group of genetic disorders caused due a functional defect in chromosome 19p13. It is an autosomal recessive condition. Donohue Syndrome was initially described by Donohue and Uchida in 1948 and 1954, a case of sisters born to parents with a first-degree consanguineous marriage. Infants presented with typical facial features that resembled the Leprechaun elves of Irish fairy tales. The following is a report of a rare case of dental complications of Severe Insulin Resistance Syndrome. An eight year old female child, with characteristic features of severe insulin resistance syndrome, reported to the Department of Pediatric and Preventive Dentistry, Pravara Institute of Medical Sciences, Loni, presenting with cariously destructed molars and a previous history of dental treatment under local anaesthesia. Given her condition, it was decided to reduce the multiple appointments, to one appointment with all procedures done under general anaesthesia. The following case report discusses the advantages, disadvantages and post operative complications faced when forming a treatment strategy for Severe Insulin Resistance Syndrome.

Background and Aims: The paravertebral block (PVB) is an effective alternative to thoracic epidural analgesia for post-operative analgesia in thoracic surgeries. Despite the use of ultrasound in PVB, the search for a safer approach continues. This study was conducted to compare the analgesic efficacy of conventional and mid-transverse process to the pleura (MTP) approach of the PVB. Methods: Forty patients aged between 18-60 years, posted for video-assisted thoracoscopic surgery, were enroled for this study. Patients were randomised into two groups using a random number table, and group allocation was done by the sealed opaque envelope method. One group received PVB by conventional approach (group CP). In contrast, patients in the other group (group MP) received PVB by the mid-transverse process to pleura (MTP) approach before induction of general anaesthesia under ultrasound guidance. The study's primary aim was to compare analgesic consumption in the first 24 hours. Secondary aims were comparing the Visual Analogue Scale (VAS) score, block performance time, dermatomal spread, haemodynamic parameters such as heart rate (HR), oxygen saturation (SpO2), and non-invasive blood pressure (NIBP), patient satisfaction scores, and complications observed. Data were analysed using Statistical Package for the Social Sciences version 23. Results: Demographic parameters, block performance time, and dermatomal distribution were comparable in both groups. We did not find any statistical difference in the analgesic consumption in the first 24 hours (P = 0.38), VAS at rest or on movement, complication rates, and patient satisfaction scores between the groups. Conclusion: The MTP approach of the PVB is as effective as the conventional thoracic paravertebral approach for post-operative analgesia in video-assisted thoracoscopic surgeries.

We report a 38-year-old female, post-oesophagectomy with transposed colon, presenting with dysphagia for oesophageal dilatation. General anaesthesia was requested for as the patient did not tolerate previous dilatation attempts under local anaesthesia. Endoscopic images provided by the otorhinolaryngologists and gastroenterologists showed a good view of the glottis, suggesting a possible easy intubation. But direct laryngoscopy after sedation and airway topicalisation revealed an airway with extensive adhesions that would have been impossible to intubate. The patient was awakened and planned for the procedure after tracheostomy. Endoscopic images done by non-anaesthesiologists should be interpreted with caution.

Crouzon syndrome (CS) is an autosomal dominant disorder seen in about 1 in 60000 live births. The affected individuals are found to have facial dysmorphism, cranial synostosis and exophthalmos among other systemic involvement involving the heart and lungs. The primary concern for an anesthesiologist during administration of general anaesthesia for a patient with CS is the airway management. We report the successful anesthetic management of a pediatric case of CS who underwent a neurosurgical procedure.

Background: The concern about massive haemorrhage associated with placenta accreta spectrum (PAS) prompts the routine use of general anaesthesia (GA) at many centres. We aimed to describe the effects of establishing a fixed multidisciplinary team (PAS team) on anaesthetic practices and clinical results. Methods: In this before-and-after study, we included patients with prenatal PAS suspicion treated between December 2011 and December 2019. We evaluated the anaesthetic techniques used before (Group 1) and after (Group 2) a PAS team was established. Results: Eighty-one patients were included. Neuraxial anaesthesia (NA) was used in 23.3% of group 1 patients and 76.4% of group 2 patients. Likewise, the frequency of conversion to GA after initial management with NA decreased from 14.3% in group 1 to 7.7% in group 2. Conclusions: The establishment of a PAS team is related to increased use of NA during the management of PAS patients.

Introduction A Postanaesthesia Care Unit (PACU) is a specifically assigned area where patients receive pertinent postanaesthesia care after general anaesthesia, regional anaesthesia or local anaesthesia. Anaesthesiologists play an extensive role in monitoring for improving the safety of patients and are thus obligated to audit their practices. Aims and objectives To evaluate knowledge regarding standards of postanaesthesia care among post-graduates and senior residents working at a tertiary care referral centre in Delhi. Material and methods A structured, self-administered questionnaire was administered to post-graduates and senior residents working in the hospital during August 2015. Results Of the 78 resident doctors, 43.6% post-graduates (PGs) and 38.20% senior residents (SRs) agreed that vital signs should be checked every 15 min in the PACU. However only 48.7% PGs and 61.5% SRs agreed that patients are not required to pass urine and 66.7% PGs and 74.4% SRs were aware that patients are not required to drink and retain clear liquids prior to discharge. Conclusion There were certain gaps in knowledge of resident doctors and these lacunae in awareness were identified and recommendations were made to pave the way for executing these guidelines in routine practice.

Introduction The LMA Supreme™, i-gel® and LMA ProSeal™ are second-generation supraglottic airway devices. We tested the hypothesis that these devices differ in performance when used for spontaneous ventilation during anaesthesia. Methods 150 patients who underwent general anaesthesia for elective surgery were randomly allocated into three groups. Data was collected on oropharyngeal leak pressures, ease and duration of device insertion, ease of gastric tube insertion, and airway safety. Results Leak pressure, our primary outcome measure, was found to be higher for the i-gel than the Supreme and ProSeal (mean ± standard error of the mean: 27.31 ± 0.92 cmH2O, 23.60 ± 0.70 cmH2O and 24.44 ± 0.70 cmH2O, respectively; p = 0.003). Devices were inserted on the first attempt for 90%, 82% and 72% of patients in the i-gel, Supreme and ProSeal groups, respectively (p = 0.105); mean device placement times were 23.58 seconds, 25.10 seconds and 26.34 seconds, respectively (p = 0.477). Gastric tubes were inserted on the first attempt in 100% of patients in the Supreme group, and 94% of patients in the i-gel and ProSeal groups (p = 0.100). There was blood staining on removal in 9 (18%) patients in each of the Supreme and ProSeal groups, with none in the i-gel group (p = 0.007). The incidence of postoperative sore throat, dysphagia and hoarseness was lowest for the i-gel. Conclusion The three devices were comparable in terms of ease and duration of placement, but the i-gel had higher initial oropharyngeal leak pressure and lower airway morbidity compared with the ProSeal and Supreme.

Introduction Pain after wisdom teeth surgery can be moderate in severity and is compounded by preoperative anxiety in young patients. We studied the effect of melatonin premedication on postoperative pain and preoperative anxiety in patients undergoing wisdom teeth extractions. Methods This randomised controlled trial recruited 76 patients at Khoo Teck Puat Hospital who were American Society of Anesthesiologists physical status I and II, aged 21 to 65 and scheduled to undergo elective extraction of all four wisdom teeth under general anaesthesia. Patients with a history of long-term use or allergy to melatonin were excluded. The patients received either 6 mg melatonin or a placebo 90 minutes before surgery. Visual analogue scale (VAS) scores at multiple time intervals for postoperative pain and preoperative anxiety, patient satisfaction and first-night sleep quality scores were obtained. Mixed-effects regression models were used for longitudinal analysis of VAS pain, anxiety and satisfaction scores. Results Maximum VAS scores for pain and anxiety were 18.6 ± 19.1 mm at 60 minutes postoperatively and 26.2 ± 23.4 mm at 90 minutes preoperatively, respectively. After adjusting for gender, female patients who received melatonin had a faster rate of reduction of VAS pain (p = 0.020) and anxiety scores (p = 0.003) over time compared to the placebo group. No such effect was demonstrated in male patients. There was no significant difference in sleep quality or satisfaction scores. Conclusion Melatonin use did not consistently contribute to pain and anxiety amelioration in all patients. Our study demonstrated a positive effect in female patients, suggestive of sexual dimorphism.

Background and Aims: Endotracheal intubation is the predominant cause of airway mucosal injury, resulting in post-operative sore throat (POST), with an incidence of 20-74%, which brings immense anguish to patients. This study was conducted to evaluate and compare the efficacy of nebulised dexmedetomidine and ketamine in decreasing POST in patients undergoing thyroidectomy. Methods: Patients were randomly allocated into two groups of 50 each; Group 1 received ketamine 50mg (1mL) with 4mL saline nebulisation, while Group 2 received dexmedetomidine 50μg (1mL) with 4mL saline nebulisation for 15 min. GA was administered 15 min after completing nebulisation. POST monitoring was done at 0,2,4,6,12 and 24h after extubation. POST was graded on a four-point scale (0-3). The statistical analysis were performed using Statistical Package for Social Sciences (SPSS) software version 17.0. Fisher Exact-t-test, Chi square test, Student t-test, Paired t test and repeated measure analysis of variance (ANOVA) were used for analysis. Results: The overall incidence of POST in this study was 17%: POST was experienced by seven patients (14.3%) in ketamine and 10 patients (20.4%) in dexmedetomidine group (P = 0.424). There was no statistically significant difference in the incidence of POST between the two groups at 0,2,4,6,12 and 24h post-operatively. Severity of sore throat was also significantly lower in both groups at all time points. A statistically significant increase in heart rate, systolic and diastolic blood pressure was noted in ketamine group, post nebulisation. Conclusion: Pre-operative dexmedetomidine nebulisation can be utilised as a safe and ideal alternative to ketamine nebulisation in attenuating POST, with less haemodynamic derangement.

Intraoperative hypotension (IOH) i.e., low arterial blood pressure (AP) during surgery is common in patients having non-cardiac surgery under general anaesthesia. It has a multifactorial aetiology, and is associated with major postoperative complications including acute kidney injury, myocardial injury and death. Therefore, IOH may be a modifiable risk factor for postoperative complications. However, there is no uniform definition for IOH. IOH not only occurs during surgery but also after the induction of general anaesthesia before surgical incision. However, the optimal therapeutic approach to IOH remains elusive. There is evidence from one small randomised controlled trial that individualising AP targets may reduce the risk of postoperative organ dysfunction compared with standard care. More research is needed to define individual AP harm thresholds, to develop therapeutic strategies to treat and avoid IOH, and to integrate new technologies for continuous AP monitoring.

Background and Aims: Conventional age-based formulae often fail to predict correct size of endotracheal tube (ETT). In this study, we evaluated usefulness of ultrasound in determining appropriate tube size and derived a formula which enables us to predict correct tube size. Methods: A total of 41 American Society of Anesthesiologists' physical status 1 and 2 children in the age group of 2–6 years, undergoing elective surgery under general anaesthesia with uncuffed ETT were included in the study. Ultrasonography (US) was used to measure the subglottic diameter after induction of anaesthesia. The trachea was intubated with an ETT that allowed an audible leak between 15–30 mmHg. Pearson's correlation was used to assess the correlation between US measured subglottic diameter (US-SD) with diameter of ETT used. Linear regression was used to derive a formula for predicting ETT size. Results: We found that US-SD and patient's age correlated well with actual ETT OD (r: 0.83 and 0.84, respectively). Age-based formula, ETT ID = (Age/3) +3.5 [r: 0.81] had better correlation with actual ETT OD than conventional age-based Cole's formula, i.e., ETT ID = Age/4 + 4 [r: 0.77]. Our results enabled us to derive a formula for selecting uncuffed ETT based on US-SD. Conclusion: Our study concludes that although US-SD correlates with actual tracheal tube used and may be useful in choosing appropriate size ETT, there was no difference in number of correct predictions of ETT size by US measurement, universal formula, and locally derived formula.

Background: Optimal intra-operative fluid therapy in renal transplantation (RT) is essential to ensure adequate graft function while preventing fluid overload related complications. This RCT was to compare the intraoperative goal directed fluid therapy (GDFT) based either on corrected flow time (CFT), measured by trans oesophageal Doppler (TED) or on the stroke volume variation (SVV), by FloTrac in patients undergoing living donor RT. Methods: This prospective, randomised controlled trial (RCT) was done on 60 end stage renal disease (ESRD) patients, American Society of Anaesthesiologists(ASA) grade III–IV, age 18 to 65 years of either sex, scheduled for living donor RT under general anaesthesia. They were randomly divided into two groups: TED group (n = 30) and FloTrac™ group (n = 30) and administered GDFT, based upon CFT (TED) and SVV (FloTrac™). The primary outcome was to compare the total fluid and number of fluid boluses administered intraoperatively, while the secondary outcomes were to compare any postoperative complications due to fluid overload and allograft function, assessed by serial serum creatinine levels up to 90 days postoperatively. Results: The mean total intra-operative fluid [3991.67 ± 856.32 vs. 3543.33 ± 1131.35, P = 0.089] and the amount of fluid administered per kg body weight per hour [13.32 ± 4.67 vs. 11.82 ± 4.76, P = 0.222] were lesser in the FloTrac compared to TED group, though not statistically significant. However, the postoperative incidence of allograft dysfunction, including rejection (P = 0.743) and acute tubular necrosis (ATN) (P = 0.999), and other complications (P = 0.643) were comparable. Conclusions: Both TED and FloTrac devices can be used effectively to guide GDFT in RT, However, lesser total fluid was required in the FloTrac group, which may lead to a lesser number of fluid-related postoperative complications.

Background: Tracheostomy is the surgical creation of an opening into the trachea. Reported complication rates of tracheostomy are varied and depends on the study design, study population, patients’ follow-up and the definition of the different complications. We reviewed the pattern of tracheostomy-related complications and its determinants. Methods: This study was a 10-year retrospective review of patients who had tracheostomy in the study area between January 2008 to December 2017. Case files of the patients were retrieved, reviewed, and information extracted. Results: Of the 149 patients, the male: female ratio was 3.8:1 with age range of 6 months to 86 years. The peak age group was 1−10 years. Foreign body aspiration and head and neck neoplasia were the two most common admitting diagnoses; 56 (37.6%) and 55 (36.8%) respectively. The most common indication was upper airway obstruction (129, 86.6%). Emergency tracheostomy was most commonly done (126, 84.6%) and majority of the tracheostomies were done under general anaesthesia (101, 67.8%). Trainee ENT surgeons performed the most tracheostomies (108, 72.5%). Surgical decanulation was done for 5 (3.4%) of the patients. The complication and mortality rates were 42.3% and 2.6% respectively. The most common period of complication was early postoperative period (46, 73.0%), and the most common complications were tube blockage and tube displacement (26, 41.3% and 11, 17.5%) respectively. The analyzed variables were not statistically significant determinants of tracheostomy-related complications among the patients. Conclusion: Tracheostomy-related complications are common, usually in the early postoperative period and usually involve blockage or displacement of the tube.