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Objective To estimate the cost-effectiveness of craniotomy, compared with decompressive craniectomy (DC) in UK patients undergoing evacuation of acute subdural haematoma (ASDH).Design Economic evaluation undertaken using health resource use and outcome data from the 12-month multicentre, pragmatic, parallel-group, randomised, Randomised Evaluation of Surgery with Craniectomy for Patients Undergoing Evacuation-ASDH trial.Setting UK secondary care.Participants 248 UK patients undergoing surgery for traumatic ASDH were randomised to craniotomy (N=126) or DC (N=122).Interventions Surgical evacuation via craniotomy (bone flap replaced) or DC (bone flap left out with a view to replace later: cranioplasty surgery).Main outcome measures In the base-case analysis, costs were estimated from a National Health Service and Personal Social Services perspective. Outcomes were assessed via the quality-adjusted life-years (QALY) derived from the EuroQoL 5-Dimension 5-Level questionnaire (cost-utility analysis) and the Extended Glasgow Outcome Scale (GOSE) (cost-effectiveness analysis). Multiple imputation and regression analyses were conducted to estimate the mean incremental cost and effect of craniotomy compared with DC. The most cost-effective option was selected, irrespective of the level of statistical significance as is argued by economists.Results In the cost-utility analysis, the mean incremental cost of craniotomy compared with DC was estimated to be −£5520 (95% CI −£18 060 to £7020) with a mean QALY gain of 0.093 (95% CI 0.029 to 0.156). In the cost-effectiveness analysis, the mean incremental cost was estimated to be −£4536 (95% CI −£17 374 to £8301) with an OR of 1.682 (95% CI 0.995 to 2.842) for a favourable outcome on the GOSE.Conclusions In a UK population with traumatic ASDH, craniotomy was estimated to be cost-effective compared with DC: craniotomy was estimated to have a lower mean cost, higher mean QALY gain and higher probability of a more favourable outcome on the GOSE (though not all estimated differences between the two approaches were statistically significant).Ethics Ethical approval for the trial was obtained from the North West—Haydock Research Ethics Committee in the UK on 17 July 2014 (14/NW/1076).Trial registration number ISRCTN87370545.

Background and Aims: Tracheal extubation often causes cardiovascular and airway responses, potentially resulting in hazardous consequences. It remains unknown whether dexmedetomidine or lidocaine is more effective for cough suppression. Hence, we conducted a systematic review and meta-analysis of randomised controlled trials to compare the effectiveness and safety of dexmedetomidine and lidocaine in reducing cough response after tracheal extubation in adult patients. Methods: A thorough search of electronic databases, including PubMed, Embase, Cochrane Library, and Web of Science, was conducted to identify relevant studies (from inception to 31 January 2023). Randomised controlled trials comparing intravenous (IV) dexmedetomidine versus IV lidocaine administration during emergence from anaesthesia to prevent tracheal extubation response in adult patients under general anaesthesia were included. The primary outcome was the incidence of post-extubation cough. Secondary outcomes included emergence time, extubation time, residual sedation, and incidences of bradycardia. Statistical analysis was conducted using RevMan software. The Cochrane risk of bias tool was used to evaluate the potential risk for bias. Results: In total, seven studies with 450 participants were included. There was no statistically significant difference in the incidence of cough between dexmedetomidine and lidocaine groups [Risk Ratio = 0.76; 95% Confidence Interval: 0.46, 1.24]. Emergence and extubation times were not significantly different between the two groups. Meta-analysis revealed a higher incidence of bradycardia and residual sedation in dexmedetomidine compared to the lidocaine group. Conclusion: This meta-analysis found no difference in cough, emergence, and extubation time between dexmedetomidine and lidocaine after tracheal extubation. However, residual sedation and bradycardia were more significant in dexmedetomidine than in lidocaine.

Background Prolonged mechanical ventilation is associated with weaning failure in severe TBI patients. Ultrasound is a noninvasive modality for evaluating diaphragm function. On ultrasonography (USG), diaphragm thickness is observed to decrease over time in mechanically ventilated patients. However, little literature exists on the severity of diaphragmatic dysfunction in traumatic brain injury (TBI) patients. This study aimed to observe the changes occurring in diaphragmatic function in mechanically ventilated TBI patients.

Background: Smooth uneventful extubation and prevention of postoperative complications such as cough and sore throat adds to the quality of perioperative care and patient outcome. This study was designed to compare tube tolerance and hemodynamics during extubation, as well as the incidence of postoperative cough and sore throat, in patients operated under general anesthesia of more than 2-h duration. Materials and Methods: This prospective double-blinded, randomized controlled study included 100 patients posted for elective surgical procedures with expected duration of more than 2 h, under general anesthesia. Patients were divided randomly into two equal groups, namely Group A and Group B. In Group A, endotracheal tube (ETT) cuff was filled with lignocaine with sodium bicarbonate as an adjuvant, while in Group B, dexamethasone was added as an adjuvant to intracuff lignocaine. ETT tolerance at the time of extubation was recorded and compared. Other parameters such as rate pressure product, volume of drug diffused through cuff, and incidence of postoperative cough and sore throat were also compared. Data analysis was done using unpaired t-test and Chi-square test as appropriate, where P < 0.05 was considered statistically significant. Results: Eighty-two percent of patients in Group A while 78% of patients in Group B were categorized as tube tolerant during extubation (P = 0.62). The incidence of postextubation sore throat at 1 h was 30% versus 16% (P = 0.09) while at 24 h was 20% versus 6% (P = 0.03) in Group A and Group B, respectively. The incidence of cough postextubation at 1 h was 6% versus 0 (P = 0.07) while at 24 h was 18% versus 4% (P = 0.02) in Group A and Group B, respectively. The volume of intracuff drug diffused during anesthesia was 0.71 ± 0.27 (mean ± standard deviation [SD]) ml in Group A and 0.5 ± 0.23 (mean ± SD) ml in Group B (P = 0.02). Majority of patients (>85%) in both the groups remained hemodynamic stable during emergence with no statistical difference between the groups. Conclusion: Both bicarbonate and dexamethasone as an adjuvant to 2% intracuff lignocaine offer smooth emergence in terms of tube tolerance and hemodynamic stability during extubation. However, dexamethasone when used as an adjuvant has a better effect on prevention of development of postoperative cough and sore throat.

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.

Background Pediatric traumatic brain injury (TBI) has distinctive pathophysiology and characteristics that differ from adults. These can be attributed to age-related anatomical and physiological differences and distinct patterns of injuries seen in children. Our aim was to identify the patient characteristics, clinical variables during intensive care and intraoperative management associated with poor functional outcome in a cohort of pediatric TBI patients. Methods Retrospective chart review of pediatric TBI patients admitted to neurotrauma intensive care unit (NICU) over a period of 1 year. Results A total of 105 children (< 12 years) with head injury were admitted in the NICU during the study period. The most common mechanism of injury was fall in 78% cases. Fifty-four patients (51.4%) presented with a severe head injury (Glasgow coma scale [GCS] ≤ 8), while 31 (29.5%) and 20 (19.1%) had a mild and moderate head injury. The most common finding was skull fractures (59%), contusions (36.2%), and subdural hematoma (SDH) (30.4%). Forty nine patients (46.7%) required surgical management. The median duration of anesthesia was 205 (interquartile range [IQR] 65, 375) minutes, and median blood loss during the surgery was 16.7 mL/kg body weight with 41% requiring intraoperative blood transfusions. Median duration of ICU and hospital stay was 5 (IQR 1, 47) and 8 (IQR 1, 123) days, respectively. GOS at discharge ≤ 3 representing poor outcome was present in 35 patients (33.3%). Mortality was seen in 15 (14.3%) patients. Multivariate analysis identified postresuscitation GCS ≤ 8 on admission as independent predictor of mortality, and postresuscitation GCS ≤ 8 on admission and NICU stay of > 7 days as independent predictor of poor outcome. Conclusion Despite advances in neurointensive care, mortality and morbidity remains high in pediatric head trauma and is mainly dependent on postresuscitation GCS and NICU stay of more than 7 days. Multidimensional approach is required for its prevention and management.

Background and Aims: Anaesthetic agents can affect the neuroendocrine response to surgical stress. Along with affecting other parameters, this can affect blood glucose levels. This study aimed to compare the effect of sevoflurane and desflurane on hourly intraoperative blood glucose levels in non-diabetic patients undergoing intracranial surgery. Methods: A total of 70 adults (18–65 years) of American Society of Anesthesiologists physical status I and II undergoing elective intracranial surgery for supratentorial and infratentorial lesions were enroled. Patients were randomised to receive either sevoflurane or desflurane as the maintenance anaesthetic agent. The blood glucose level was measured hourly after induction until the completion of surgery. Parametric tests, non-parametric tests, Friedman test, generalised estimating equations, Chi-square test, and Fisher's exact test were used to analyse the data. Results: In the sevoflurane group, the mean (standard deviation) blood glucose (mg/dL) increased from 93.34 (9.33) at the baseline to a maximum of 102.00 (8.61) at the 9 hours timepoint. This change was statistically significant (P < 0.001). In the desflurane group, the mean blood sugar (mg/dL) increased from 89.34 (9.85) at the baseline to a maximum of 92.37 (9.92) at the 4 hours timepoint and then decreased to 88.50 (0.71) at 9 hours timepoint. Conclusion: Desflurane caused an initial rise followed by a decline, whereas a gradual increase in intraoperative blood glucose level was seen with sevoflurane use in non-diabetic adult patients undergoing elective neurosurgery. The intraoperative change in blood sugar was statistically significant but was within the normal clinical range.

Nasal bridge is a common site suffering personal protective equipment-induced skin damages over face among first-line health care workers in this coronavirus disease 2019 pandemic. We hereby report folliculitis as a complication following regular use of N95 respirator and goggles, unreported in literature till now.

Hiccups are usually self-limiting and benign but can be distressing when they become persistent or intractable and produce significant morbidity. In the intubated patients in neurocritical care, persistent hiccups may cause respiratory alkalosis and are also associated with an increased incidence of ventilator-associated pneumonia. Several pharmacological and nonpharmacological strategies have been devised for the treatment of persistent and intractable hiccups. The evidence to support or declare any intervention as harmful is scarce. In this review, we have presented the pathophysiology and workup, and a stepwise management protocol for intractable hiccups.

Carotid artery stenting (CAS) is performed in patients with minor strokes and transient ischemic attacks (TIAs) to prevent further strokes. However, most operators do not intervene in older adults. We had a 92-year patient with recurrent minor strokes with two possible proximate causes – cardioembolism and significant symptomatic left carotid stenosis. This patient continued to have recurrent ischemic events in the left carotid territory despite optimum management of the cardioembolic source with dual antiplatelets and anticoagulation and was successfully treated with left CAS. The role of carotid revascularization in older patients with high-grade symptomatic carotid stenosis and cardiac comorbidities is discussed.

Background and Aims: Posterior vessel wall puncture (PVWP) is a common complication of ultrasound (US) guided central venous cannulation. We evaluated and compared the frequency of PWVP of internal jugular vein using short axis (SA) and long axis (LA) approach of US-guided needle cannulation. As a secondary objective incidence of carotid puncture was assessed. Material and Methods: Prospective, single-blinded, cross over, observational study at Urban Level I Neuroanesthesiology and Critical Care Department. Residents receiving standard education on ultrasound-guided central venous cannulation were asked to place an US-guided catheter using either short axis or long axis approach on a human torso mannequin. During the procedure, the path of the needle was carefully observed by the investigator for any PVWP and carotid puncture without interference with the placement procedure. The confidence level of the resident for the intraluminal placement of the needle tip was measured on a 10-point Likert scale. Results: Forty residents participated in the study. The incidence of PVWP in SA and LA group was 40% and 17.5% respectively and was statistically significant (p = 0.026). There was no incidence of carotid artery puncture in either of the group. The mean confidence of intraluminal placement of needle was significantly higher in the LA group (8.32) as compared to the SA group (5.95). Conclusion: Lower incidence of PVWP was seen in LA as compared to the SA approach during US-guided IJV cannulation in phantom in residents having previous experience of CVC (central venous cannulation) in landmark technique only. Participants were more confident about intraluminal needle placement in the LA group compared to the SA group.

Human errors form a significant portion of preventable mishaps in healthcare. Even the most competent clinicians are not immune to it. Errors in the perioperative period can often have grave consequences, and hence, perioperative clinicians need to be aware of the impact of human errors and how to minimize them. Errors are broadly classified into two kinds: latent and active errors. While active errors need to be addressed at the individual level, latent errors indicate organizational inadequacies. This review describes common errors in perioperative settings, the impact of such errors on healthcare, and preventive strategies to minimize such errors in daily patient care.

Objective: The detailed epidemiological and molecular characterization of an outbreak of Burkholderia cepacia at a neurotrauma intensive care unit of a level 1 trauma centre is described. The stringent infection control interventions taken to successfully curb this outbreak are emphasized. Methods: The clinical and microbiological data for those patients who had more than one blood culture that grew B. cepacia were reviewed. Bacterial identification and antimicrobial susceptibility testing was done using automated Vitek 2 systems. Prospective surveillance, environmental sampling, and multilocus sequence typing (MLST) were performed for extensive source tracking. Intensive infection control measures were taken to further control the hospital spread. Results: Out of a total 48 patients with B. cepacia bacteraemia, 15 (31%) had central line-associated blood stream infections. Two hundred and thirty-one environmental samples were collected and screened, and only two water samples grew B. cepacia with similar phenotypic characteristics. The clinical strains characterized by MLST typing were clonal. However, isolates from the water represented a novel strain type (ST-1289). Intensive terminal cleaning, disinfection of the water supply, and the augmentation of infection control activities were done to curb the outbreak. A subsequent reduction in bacteraemia cases was observed. Conclusion: Early diagnosis and appropriate therapy, along with the rigorous implementation of essential hospital infection control practices is required for successful containment of this pathogen and to curb such an outbreak. Keywords: Burkholderia cepacia, Outbreak, Neurotrauma unit, MLST typing, Novel ST type

Context: Improvement in perioperative care can reduce anesthesia-related morbidity. Noncompliance to protocols and poor working practices can compromise patient safety. Aims: The objective was to survey the working practices of anesthesiologists in India and find out the most commonly overlooked aspects in perioperative period. Setting and Design: Prospective cross-sectional survey involving practicing anesthesiologists in India, conducted over a period of 2 months. Methods: An online questionnaire, including questions pertaining to pre-, intra- and post-operative phases during conduct of anesthesia was mailed to anesthesiologists (members of the Indian Society of Anesthesiologists) over a period of 2 months through the online survey builder SurveyMonkey. The questionnaire was delivered to 13,700 anesthesiologists, of which 2055 responded. Results are expressed as numbers or percentages. Results: Checklist compliance, equipment check, and perioperative record-keeping are the most commonly overlooked aspects by anesthesiologists in perioperative period. The survey also highlights the shortage of postanesthesia care units across the country. Conclusions: Checklist compliance, equipment check, and record-keeping are potential areas for improvement. Professional societies should promote better practices, monitoring standards and should also formulate minimum standards for different setups where anesthesia can be delivered safely.

Administration of general anesthesia requires continuous monitoring of vital parameters of the body including body temperature. However, temperature continues to be one of the least seriously monitored parameters perioperatively. Inadvertent perioperative hypothermia is a relatively common occurrence with both general and regional anesthesia and can have significant adverse impact on patients' outcome. While guidelines for perioperative temperature management have been proposed, there are no specific guidelines regarding the best site or best modality of temperature monitoring and management intraoperatively. Various warming and cooling devices are available which help maintain perioperative normothermia. This article discusses the physiology of thermoregulation, effects of anesthesia on thermoregulation, various temperature monitoring sites and methods, perioperative warming devices, guidelines for perioperative temperature management and inadvertent temperature complications (hypothermia/hyperthermia) and measures to control it in the operating room.

Temperature management in neurocritical care is important and has gained due importance in recent years. Targeted temperature management (TTM) includes deliberate reduction of core body temperature to a range of 32–34°C in comatose survivors of cardiac arrest after return of spontaneous circulation and also therapeutic hypothermia (33–35°C) in normothermic patients or controlled normothermia (cooling patients to 37°C) in hyperthermic patients. This review focuses on the practical aspects of cooling and temperature management in neurocritical care. An electronic search of Google Scholar, MEDLINE (OVID), EMBASE and the Cochrane library was performed. The physiological changes, potential side effects along with significant research and clinical applications in the field of temperature management are main highlights. Currently, the research evidence is available for TTM in adults following cardiac arrest, neonatal hypoxic ischaemic encephalopathy and raised intracranial pressure. Controlled normothermia in neurocritical care population is rapidly gaining popularity. However, data on disease specific therapeutic markers, therapeutic depth and duration and prognostication of this modality are limited. Overall in experienced hands, the technique is safe to execute without the major morbidity and a potential to improve the outcome. Though over the years, clinical applications are unable to consistently demonstrate its benefits, but TTM in neurological insult has become an established and promising concept.

Glanzmann thrombasthenia is a rare inherited coagulation disorder, manifesting itself in early childhood as bleeding episodes. The patients with this disease may present with uncontrollable bleeding following trauma. We report a patient of Glanzmann syndrome with head injury, who presented to us following fall from stairs. Platelet transfusion is the mainstay of treatment in emergency situations. As patients generally have a history of platelet transfusion they may be refractory to the same. Leuko reduced or human leukocyte antigen matched platelets should be used. Recombinant factor VIIa can be used to control bleeding in refractory cases and in patients with antibodies against platelets. Anti-fibrinolytics can also be used as adjuvants. There is need of advanced perioperative coagulation screening spot tests in emergency trauma settings as routine coagulation tests may not be able to pick up the abnormality. Thromboelastography/thromboelastometry can be a great tool for perioperative management of such coagulation disorders.

Accelerated hypertension following therapeutic arterial embolization is a rare phenomenon. A patient of left upper limb chronic lymphedema was posted for shoulder disarticulation under general anaesthesia. Coil embolization of the left subclavian artery was done prior to surgery. Following the intervention, patient’s blood pressure increased by more than 30% of the base line value and was managed with antihypertensives for the next 3 hours to get the blood pressure optimised prior to taking the patient for surgery.

There are multiple causes of perioperative arrhythmias. Some have underlying cardiac disease while others accompany systemic pathology. Use of anaesthetic agents in the intraoperative period is also a known cause of rhythm abnormalities. Preoperative benign arrhythmias may progress to serious ones in intraoperative period. The trigger may be a transient insult such as hypoxemia, cardiac ischaemia, catecholamine excess or electrolyte abnormality. Thus, presence of arrthymia in the preoperative period adds to preoperative work-up and especially in the elective surgery settings, they call for additional opinion and patient evaluation. However, not all arryhthmias are amenable to drug treatment and modalities like pacing, some require just careful watch in the perioperative period. We report a patient with thoracic intramedullary space occupying lesion who presented to us with multiple ventricular ectopics on electrocardiography, which eventually disappeared with tumour removal. The case highlights the association of multiple ectopics with spinal tumour and their management.

Traumatic cervical lesions compressing the spinal cord pose a significant risk of exacerbating the existing neurological condition during tracheal intubation and subsequent positioning. Preexisting ankylosing spondylitis with spinal column involvement renders the spinal column more rigid and introduces difficulty in airway management of the patient with traumatic cervical spinal cord. To improve ease and success, and reduce cervical spine movement, awake fibreoptic intubation (FOI) is considered the gold standard technique for airway management in such cases. Attaining appropriate position for intubation was challenge in this case due to rigid curvature of the ankylosed spinal column. To prevent neurological injury to the spinal cord and preserve spinal cord function, minimizing movement during intubation and attaining appropriate position was of prime concern. Optimal sedation with self-positioning by the patient in a comfortable posture is quite imperative and assures both airway as well as neurological protection in such expected difficult situations. We report the use of dexmedetomidine for self-positioning and awake FOI in a patient with ankylosing spondylitis having traumatic cervical spine who was otherwise neither able to co-operative nor able to give appropriate position for FOI.

Background: There are numerous reports of difficult laryngoscopy and intubation in patients with acromegaly. To date, no study has assessed the application of extended Mallampati score (EMS) for predicting difficult intubation in acromegalics. The primary aim of this study was to compare EMS with modified Mallampati classification (MMP) in predicting difficult laryngoscopy in acromegalic patients. We hypothesized that since EMS has been reported to be more specific and better predictor than MMP, it may be superior to the MMP to predict difficult laryngoscopy in acromegalic patients. Materials and Methods: For this prospective cohort study with matched controls, acromegalic patients scheduled to undergo pituitary surgery over a period of 3 years (January 2008-December 2010) were enrolled. Preoperative airway assessment was performed by experienced anesthesiologists and involved a MMP and the EMS. Under anesthesia, laryngoscopic view was assessed using Cormack-Lehane (CL) grading. MMP and CL grades of I and II were defined "easy" and III and IV as "difficult". EMS grade of I and II were defined "easy" and III as "difficult". Data were used to determine the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MMP and EMS in predicting difficult laryngoscopy. Results: Seventy eight patients participated in the study (39 patients in each group). Both MMP and EMS failed to detect difficult laryngoscopy in seven patients. Only one laryngoscopy was predicted to be difficult by both tests which was in fact, difficult. Conclusion: We found that addition of neck extension did not improve the predictive value of MMP.

Background: Re-intubation of neurosurgical patients after a successful tracheal extubation in the operating room is not uncommon. However, no prospective study has ever addressed this concern. This study was aimed at analyzing various risk factors of re-intubation and its effect on patient outcome. Methods: Patients aged between 18-60 yrs and of ASA physical status I and II undergoing elective craniotomies over a period of two yrs were included. A standard anesthetic technique using propofol, fentanyl, rocuronium, and isoflurane/sevoflurane was followed, in all these patients. ′Re-intubation′ was defined as the necessity of tracheal intubation within 72 hrs of a planned extubation. Data were collected and analyzed employing standard statistical methods. Results: One thousand eight hundred and fifty patients underwent elective craniotomy, of which 920 were included in this study. A total of 45 (4.9%) patients required re-intubation. Mean anesthesia duration and time of re-intubation were 6.3±1.8 and 24.6±21.9 hrs, respectively. The causes of re-intubation were neurological deterioration (55.6%), respiratory distress (22.2%), unmanageable respiratory secretion (13.3%), and seizures (8.9%). The most common post-operative radiological (CT scan) finding was residual tumor and edema (68.9%). Seventy-three percent of the re-intubated patients had satisfactory post-operative cough-reflex. The ICU and hospital stay, and Glasgow outcome scale at discharge were not significantly affected by different causes of re-intubation. Conclusion: Neurological deterioration is the most common cause of re-intubation following elective craniotomies owing to residual tumor and surrounding edema. A satisfactory cough reflex may not prevent subsequent re-intubation in post-craniotomy patients.

The placement of central venous catheter using Seldinger′s technique, remains a commonly performed procedure with its own risks and benefits. Various complications have been reported with the use of guide wire as well as catheter. We report a unique problem during subclavian vein cannulation due to guidewire malposition which led to its kinking and difficult retrieval requiring removal in fluoroscopy suit. The probable mechanism of guide wire entrapment and possible bedside management of similar problems is described.

Aspiration of foreign bodies is common in a pediatric age group but adults can also be at risk. We describe management of two adult trauma victims with aspirated tooth. In the first case, foreign body went missing for sometime by intensive care physician and detected by radiologist while it was obvious in the second case. Both the patients were managed with the help of rigid bronchoscopy. Tooth should be removed as soon as possible or it may result in complete airway obstruction or lung collapse.

Apert syndrome is an autosomal dominant disease characterized by craniosynostosis, midface hypoplasia and syndactyly. In general, patients present in early childhood for craniofacial reconstruction surgery. Anesthetic implications include difficult airway, airway hyper-reactivity; however, possibility of raised intracranial pressure especially when operating for craniosynostosis and associated congenital heart disease should not be ignored. Most of the cases described in literature talk of management of syndactyly. We describe the successful anesthetic management of a patient of Aperts syndrome with craniosynostosis posted for bicornual strip craniotomy and fronto-orbital advancement in a 5-year-old child.

Blockade of the trigeminal nerve and its branches at various locations is a well-established procedure to treat intractable pain syndromes in the distribution of the nerve. Mandibular nerve block is a commonly performed procedure by anesthesiologists, pain physicians, as well as dental practitioners. As it is considered to be a safe procedure, it is usually performed in an outpatient setting with or without monitoring. The complications associated with mandibular nerve block include intravascular injection, hypoesthesia, dysesthesia, sensory loss in mandibular nerve distribution, facial swelling, weakness of the masseter muscle, and injury to the auditory tube leading to severe vertigo. Here, we present an uncommon complication during mandibular nerve block with lignocaine in a patient of trigeminal neuralgia who suffered transient asystole during the procedure. The case highlights the importance of monitoring and emphasizes the need for additional precautions to be taken during pain procedures particularly in high-risk populations such as geriatric patients.

Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency is an X-linked recessive enzymopathy responsible for acute haemolysis following exposure to oxidative stress. Drugs which induce haemolysis in these patients are often used in anaesthesia and perioperative pain management. Neurosurgery and few drugs routinely used during these procedures are known to cause stress situations. Associated infection and certain foodstuffs are also responsible for oxidative stress. Here, we present two patients with G-6-PD deficiency who underwent uneventful neurosurgical procedures. The anaesthetic management in such patients should focus on avoiding the drugs implicated in haemolysis, reducing the surgical stress with adequate analgesia, and monitoring for and treating the haemolysis, should it occur.

Neurogenic pulmonary edema (NPE) is a well-known entity, occurs after acute severe insult to the central nervous system. It has been described in relation to different clinical scenario. However, NPE has rarely been mentioned after endovascular coiling of intracranial aneurysms. Here, we report the clinical course of a patient who developed NPE after aneurysmal rupture during endovascular surgery. There was significant cardiovascular instability possibly from stimulation of hypothalamus adjacent to the site of aneurysm. This case highlights the predisposition of minimally invasive procedures like endovascular coiling to life-threatening complications such as NPE.

Presence of intraoral pathology poses a great challenge during management of pediatric airway. We report management of big intraoral cystic swelling physically occupying the entire oral cavity restricting access to airway. Preintubation aspiration of swelling was done to decrease its size and make room for airway manipulation, followed by laryngoscopy and intubation in lateral position. Airway patency is at risk in postoperative period also, in this case, though the swelling decreased in size postoperatively but presence of significant edema required placement of tongue stitch and modified nasopharyngeal airway. Case report highlights simple maneuvers to manage a difficult case.