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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.

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: 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.

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.

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.

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.