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Introduction: The role of ultrasound in central neuraxial blockade has been underappreciated, partly because of the relative ease of the landmark-guided technique and falsely perceived difficulty in imaging through the narrow acoustic windows. This study was designed to compare conventional landmark technique with preprocedural ultrasonography for identification of the subarachnoid space in patients for elective surgeries under spinal anaesthesia. Materials and Methods: Total 120 patients who were scheduled for elective surgery under spinal anaesthesia were included in this prospective randomised control trial and divided into 2 group, Group L (n = 60) (landmark guided technique) and Group U (n = 60) (ultrasound guided technique). Parameters such as time taken for the identification of the interspace, number of insertion attempts (the primary outcome), number of passes and time taken were recorded in both the groups. Result: The time taken for identification of interspinous space was significantly more in Group U (4.7 ± 2.1 mins) as compared to Group L (1.17 ± 0.52 min) but the number of attempts for needle insertion (1.12 ± 0.41 vs. 1.86 ± 0.91), number of passes in the same interspinous space (3.32 ± 1.44 vs. 6.98 ± 2.51) and the total time for successful lumbar puncture (38.72 ± 12.30 vs. 56.65 ± 11.32 s) were significantly less in Group U as compared to Group L. Conclusion: The ultrasound guided identification of subarachanoid space was time consuming, but resulted in fewer attempts to enter the subarachnoid space when compared to the conventional landmark-based approach. Keywords: Neuraxis, Subarachnoid space, Ultrasonography.

Background and Aims: Identification of subarachnoid space in pregnant patients can pose a great challenge to anaesthesiologists. This study was designed to compare conventional landmark technique with pre-procedural ultrasonography-assisted midline approach for identification of the subarachnoid space in elective caesarean section. Methods: After institute ethics committee approval and written informed consent, 100 parturients scheduled for elective caesarean section under spinal anaesthesia were included in this prospective randomised control trial and divided into Group L (n = 50) (landmark technique) and Group U (n = 50) (ultrasound-guided technique). Parameters such as time taken for the identification of the interspace, distance between skin and dura mater, number of insertion attempts (the primary outcome), number of passes and time taken were recorded in both the groups. Statistical analysis was done using SPSS software 16. Results: Demographic profiles of both groups were comparable. The number of attempts for needle insertion (1.04 ± 0.19 vs. 1.97 ± 0.77), number of passes in the same interspinous space (1.26 ± 0.44 vs. 1.90 ± 0.51) and the total time for successful lumbar puncture (31.90 ± 6.30 vs. 51.80 ± 12.28 s) were significantly less in Group U as compared to Group L, but the time of identification of interspinous space was significantly more in Group U (56.70 ± 13.08 s) as compared to Group L (47.10 ± 10.45 s). Conclusion: Pre-procedural ultrasound is a useful tool for successful lumbar puncture in parturients as it reduces the number of attempts with fewer side effects as compared to conventional landmark technique.

Parapharyngeal tumors are rare head and neck tumors which can present as an intraoral mass and can pose great challenge to anesthesiologists. The primary concern is the difficult airway due to gross anatomical distortion of the upper airway. Securing the airway in an awake state should be the primary goal of anesthesiologists to avoid catastrophic complications. Herewith, we report the successful use of C-MAC ® video laryngoscope with the acute-angle D-BLADE™ in combination with Frova introducer for awake intubation in a patient with parapharyngeal mass after multiple attempts of failed fiber-optic intubation.

Hemodynamic response to laryngoscopy and intubation is usually transient, but it may be more pronounced and unpredictable in certain group of patients. Bradycardia and asystole during laryngoscopy is usually a rare manifestation compared to hypertension and tachycardia. Anesthesiologists should be more vigilant and take special precautions to avoid such life-threatening complications during laryngoscopy. Here, we report recurrent asystole on multiple occasions during laryngoscopy in a patient with obstructive jaundice.

Tuberous sclerosis (TS) or Bourneville disease is a rare autosomal dominant neurocutaneous disorder with an overall prevalence of 1 in 29,000 and a birth incidence of 1 in 11,000.[1] TS usually manifests as a triad of seizures, mental retardation and adenoma sebaceum, but may also involve other organs such as kidney, heart, lung and brain. Renal involvement is characterised by multiple, bilateral angiomyolipomas that are usually benign, but tend to increase in size and may bleed. Such patients may require interventions such as renal artery embolisation or partial nephrectomy under anaesthesia and pose a significant challenge for anaesthesiologists because of variable clinical presentation and multi-organ involvement. A thorough pre-operative evaluation to assess the extent of involvement of other organs and meticulous intraoperative management and post-operative monitoring are crucial for safe management of such patients. We report the successful anaesthetic management of a case of TS with angiomyolipomas for partial nephrectomy under general anaesthesia.

Background: Minimally invasive surgery aims to minimize trauma, cause rapid mobilization, and thus achieve a satisfactory therapeutic result. But the challenging fact with the laparoscopic surgery is its hemodynamic changes because of pneumoperitoneum and the complex visceral pain in the postoperative period. Aim: To find a safe, reliable, and highly effective drug as a premedicant in laparoscopic appendectomies under general anesthesia. Materials and Methods: A total of 110 patients undergoing laparoscopic appendectomies were randomized into two groups: group M (morphine) and group B (buprenorphine) with 55 patients in each group. Group B patients received 0.4 μg of buprenorphine tablet sublingually 1 h before surgery and group M patients received 0.1 mg/kg of intravenous morphine 10 min before anesthesia induction. Intraoperative hemodynamics, postoperative pain score, rescue analgesic requirement, and complications were recorded. Results: Intraoperative vitals that is heart rate and mean arterial pressure were significantly stable in group B compared to group M. Only 11 % patients in group B required dexmedetomidine infusion compared to 37% in group M, to control intraoperative hypertension. Visual analog scale (VAS) values in group B at 2nd (1.30 ± 0.46), 4th (1.31 ± 0.54), and 6th hour (1.33 ± 0.63) were significantly less than group M at 2nd (4.56 ± 0.65), 4th (5.68 ± 0.72), and 6th h (4.45 ± 1.15). Duration of analgesia in postoperative period in group B (260.0 ± 28.52 min) was significantly longer than group M (124.10 ± 20.832 min). Conclusion: Sublingual buprenorphine premedication is an alternative to intravenous injection of morphine with perioperative hemodynamic stability and better postoperative analgesia.

Sir, Flexometallic/reinforced tubes are often used to replace the tracheostomy tubes during laryngectomy procedures. This report identifies the problem that can happen with the insertion of flexometallic tube (Rusch®, Teleflex Medical, Germany) through a low tracheostoma that was solved with the use of flexometallic tube from another manufacturer (UnoFlex™, Unomedical Sdn Bhd, Kedah, Malaysia). A 38-year-old male with carcinoma larynx was scheduled for total laryngectomy. He had already been tracheostomised with 8.0 mm ID Portex® tube. Following induction of anaesthesia, the Portex® tracheostomy tube was replaced with 8.0 mm ID flexometallic tube (Rusch®, Teleflex Medical, Germany) till its black mark was at the tracheostoma and the cuff was inflated. However, soon after this, auscultation of the chest revealed absence of air entry on left side and a drop in saturation to 92% with 100% O2, associated with sudden increase in peak airway pressures to 30 cm H2O leading to suspicion of endobronchial intubation. Therefore, the tracheal tube was gradually withdrawn with simultaneous auscultation for air entry on the left side. However, the tube appeared to remain endobronchial despite pulling the tracheal tube till proximal portion of its cuff was visible at the stomal site. At this juncture, we replaced the existing flexometallic tube (Rusch®, Teleflex Medical, Germany) with another 8.0 mm ID flexometallic tube from another manufacturer (UnoFlex™, Unomedical Sdn Bhd, Kedah, Malaysia) which was inserted until its cuff was well below the stomal site. This resulted in bilateral equal air entry, improvement in SpO2 to 100% and return of airway pressures to 16 cm H2O. Rest of the intraoperative period was uneventful and at the end of the surgery, the flexometallic tube was replaced by 8.0 mm ID Portex® tube. Most patients with carcinoma larynx scheduled for total laryngectomy would have been already tracheostomised or will require a preoperative tracheostomy. Proceeding to total laryngectomy with standard tracheostomy tube has got various problems like flange interfering with surgical site, difficulty in fixation and accidental dislodgement due to excessive drag by ventilator circuits. Whereas flexometallic tubes can be easily angled away from the surgical site without getting kinked and safely secured by suturing or taping it to the chest wall of the patient.[1] Though these tubes are certainly useful, there are various complications associated with these tubes like narrowing of the lumen and complete obstruction.[2,3,4] Flexometallic (Rusch®, Teleflex Medical, Germany) tubes usually contain a barrel shaped large cuff meant for a better seal and their use in patients with low tracheostomy may lead to endobronchial intubation as the distance between the proximal end of the cuff and the tip of the tube is relatively long (8 cm) compared to the other brand (UnoFlex™, Unomedical Sdn Bhd, Kedah, Malaysia) tube, where it is 6 cm [Figure 1]. Thus, changeover to UnoFlex™ tube, (which has smaller cuff) solved the problem of endobronchial intubation in our case. Though different manufacturers produce tubes with different cuff size for added advantage, this may become detrimental at specific situations. Figure 1 (a) Flexometallic (Rusch®) tube 8.0 mm ID. (b) Flexometallic (UnoFlex™) tube 8.0 mm ID. (c) Tracheostomy (Portex®) tube 8.0 mm ID In cases where low tracheostomy is anticipated, this problem can be avoided by the use of laryngectomy tubes. Laryngectomy (Montando®) tubes are reinforced cuffed tubes with J-configuration that have a short distance between cuff and tip and also short bevel to avoid endobronchial intubation.[5]

Background: Unanticipated difficult intubation can be challenging to anesthesiologists, and various bedside tests have been tried to predict difficult intubation. Aims: The aim of this study was to determine the incidence of difficult intubation in the Indian population and also to determine the diagnostic accuracy of bedside tests in predicting difficult intubation. Settings and Design: In this study, 200 patients belonging to age group 18–60 years of American Society of Anesthesiologists I and II, scheduled for surgery under general anesthesia requiring endotracheal intubation were enrolled. Patients with upper airway pathology, neck mass, and cervical spine injury were excluded from the study. Materials and Methods: An attending anesthesiologist conducted preoperative assessment and recorded parameters such as body mass index, modified Mallampati grading, inter-incisor distance, neck circumference, and thyromental distance (NC/TMD). After standard anesthetic induction, laryngoscopy was performed, and intubation difficulty assessed using intubation difficulty scale on the basis of seven variables. Statistical Analysis: The Chi-square test or student t-test was performed when appropriate. The binary multivariate logistic regression (forward-Wald) model was used to determine the independent risk factors. Results: Among the 200 patients, 26 patients had difficult intubation with an incidence of 13%. Among different variables, the Mallampati score and NC/TMD were independently associated with difficult intubation. Receiver operating characteristic curve showed a cut-off point of 3 or 4 for Mallampati score and 5.62 for NC/TMD to predict difficult intubation. Conclusion: The diagnostic accuracy of NC/TM ratio and Mallampatti score were better compared to other bedside tests to predict difficult intubation in Indian population.

Background: Dexamethasone, a long-acting glucocorticoid is used as an additive along with local anesthetics perineurally to prolong the duration of neuraxial blocks. The aim of this prospective, randomized, double-blind study was to evaluate the efficacy of low-dose intravenous (IV) dexamethasone (2 mg) along with bupivacaine for prolongation of supraclavicular block in patients undergoing upper limb surgeries. Materials and Methods: Sixty American Society of Anaesthesiologists 1 and 2 patients, aged between 18 and 60 years were included in this study and randomized into two groups: Group D (dexamethasone group) and Group C (control group). Ultrasound-guided supraclavicular block was performed and patients belonging to Group D received 25 ml of 0.5% bupivacaine and 2 mg (1 ml) dexamethasone intravenously while patients belonging to Group C received 25 ml of 0.5% bupivacaine and 1 ml of normal saline intravenously. Duration of analgesia, motor blockade, and requirement of rescue analgesic were recorded. Results were analyzed using unpaired Student′s t-test and Chi-squared test. P

Sir, We read with great interest the review article on perioperative neonatal and paediatric blood transfusion by Avnish Bharadwaj et al.[1] We congratulate the author for a detailed review on pre-operative evaluation, intraoperative management and complications associated with paediatric and neonatal blood transfusion. We would like to highlight an important step which is routinely missed during neonatal blood transfusion which may lead to adverse complications. Administration of blood components to neonates is generally volume-specific and is usually performed using a calibrated chamber device in the form of a syringe or volumetric buretrol. A standard blood administration set incorporating a filter (170–200 μm) which filters out large clots and aggregates should be used for transfusion in both adults and paediatric patients.[2] But whenever blood is ordered for a neonate in small volumes, it is usually received in a syringe (50 ml) which cannot be transfused using the standard blood set. It is also a common practice to use infusion pumps to transfuse the blood received in syringe aliquots for accurate rate- and volume-controlled delivery, especially during surgery. So, in situations where the blood is received in a syringe and has to be transfused using an infusion pump, it becomes difficult to incorporate a filter in the infusion line. To overcome this difficulty, we created an innovative way where under sterile conditions, the rubber tube at the distal end of another infusion set is removed and used to connect between the tip of the syringe and proximal end of the blood administration set as shown in Figure 1. We adapted this technique in more than 30 neonates without any significant problems, which assures that the blood transfused is filtered. This technique has its own limitations: (i) Increase in cost as two infusion sets are needed for single patient, (ii) strict asepsis should be maintained while connecting the tubings and (iii) increased chance of disconnections. Despite these minor drawbacks, this technique can be safely adapted during neonatal blood transfusion which can avoid adverse complications. Figure 1 Blood administration set modified for syringe aliquots This problem can also be solved by assuring that the blood received in syringe aliquots are already filtered in the blood bank at the time of withdrawing into the syringe. In India, even in tertiary hospitals, it is not a routine practice for the blood banks to filter the blood before withdrawing into the syringe from the main bag. So, it becomes the duty of the anaesthesiologists to confirm whether the blood is filtered or not during withdrawal into the syringe. If this vital step is missed before transfusion, it can lead to adverse life-threatening complications. Blood banks should make it a standard practice to filter the blood before withdrawing into the syringe from the main bag. It should also be made mandatory to label all blood products released as syringe aliquots as “pre-filtered” to avoid any confusion at the time of transfusion. No blood products should be transfused to neonates in pre-filled syringe aliquots without the label “pre-filtered” pasted on it.[3]

Morquio′s syndrome, also known as mucopolysaccharidosis type IV is an autosomal recessive disorder, caused by deficiency of n-acetylgalactosamine-6-sulphate. Anesthetic management of this syndrome is a great challenge, especially in pediatric age group as "cannot ventilate, cannot intubate" scenario can be encountered by anesthesiologist due to the possibility of total airway collapse. Herewith, we are reporting a case of child with Morquio′s syndrome where I-gel assisted fiber-optic intubation was used for safe endotracheal intubation.