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Nonmalignant respiratory diseases are chronic and life-limiting conditions that need holistic palliative care. Such patients not only have a variety of physical symptoms such as dyspnea, pain, cough, depression, and anxiety, but also have a number of psychosocial and spiritual issues, which are not addressed to by us. This leads to a poor quality of life. Hence, these patients require supportive palliative care to relieve their sufferings, but unfortunately such care is not available to them in our country. In this article, we have tried to discuss the barriers to the provision of palliative care to such patients and suggested some measures to overcome them., Competing Interests: There are no conflicts of interest.

Posttracheostomy tracheal stenosis is a rare complication of prolonged tracheal intubation. Treatment modalities that may be used include surgical resection and anastomosis, endoscopic tracheal dilation, laser resection, and tracheal stenting. We describe a novel salvage modality for dilation of a symptomatic tracheal stenosis using a percutaneous tracheostomy dilator wherein rigid bronchoscopic dilation was not feasible and balloon tracheal dilation had failed.

The difficult airway (DA) is a common problem encountered in patients undergoing cardiac surgery. However, the challenge is not only just establishment of airway but also maintaining a definitive airway for the safe conduct of cardiopulmonary bypass from initiation to weaning after surgical correction or palliation, de-airing of cardiac chambers. This review describes the management of the DA in a cardiac theater environment. The primary aims are recognition of DA both anatomical and physiological, necessary preparations for (and management of) difficult intubation and extubation. All patients undergoing cardiac surgery should initially be considered as having potentially DA as many of them have poor physiologic reserve. Making the cardiac surgical theater environment conducive to DA management is as essential as it is to deal with low cardiac output syndrome or acute heart failure. Tube obstruction and/or displacement should be suspected in case of a new onset ventilation problem, especially in the recovery unit. Cardiac anesthesiologists are often challenged with DA while inducing general endotracheal anesthesia. They ought to be familiar with the DA algorithms and possess skill for using the latest airway adjuncts.

Oral morphine remains the drug of choice for the management of severe pain due to cancer as per WHO ladder of analgesia. Providing adequate pain relief in palliative care settings for pain due to cancer is challenging. Options become limited in cases of associated systemic comorbidities such as renal dysfunction, hypoproteinaemia, anaemia. Patients with renal dysfunction and other comorbidities may develop drug overdose due to abnormal pharmacokinetics. Renal dysfunction affects the pharmacokinetics of morphine by altering its absorption, metabolism and clearance. Plasma albumin also influences drug availability, its plasma distribution and thus available free morphine for its clinical effect. Morphine should be used cautiously for the treatment of pain in patients with renal failure, hypoproteinaemia, hyperbilirubinaemia and anaemia. In such patients, alternate opiates like fentanyl, hydromorphone, or oxycodone may be used as these drugs are not significantly excreted by the kidneys., Competing Interests: Conflicts of Interest: None declared., (2016 BMJ Publishing Group Ltd.)

Radiation-induced nausea and vomiting (RINV) is one of the most distressing symptoms that adversely affects quality of life (QOL) as well as the ongoing management plan of cancer patients. Although there are protocols for management of chemotherapy induced nausea and vomiting (CINV) but such guidelines are still lacking for RINV. Various agents like 5-hydroxy tryptophan 3 (5-HT3) antagonist, dexamethasone, metoclopramide and haloperidol are used in clinical practice for RINV but the results are not very encouraging. Because of proposed similarity in the mechanism of nausea and vomiting following chemotherapy and radiotherapy, aprepitant, a substance P neurokinin 1 receptor antagonist can be an optimal agent for RINV on account of its unique pharmacological property. We report a case of metastatic carcinoma breast with bilateral cerebellar metastasis. She presented with complaints of headache and intractable nausea and vomiting. A single fraction whole brain radiotherapy (WBRT) was given for bilateral cerebellum metastasis which further precipitated her symptoms. The prophylactic and therapeutic efficacy of antiemetic used for RINV may be enhanced by adding aprepitant before starting radiotherapy in high risk cases as in ours.

One-lung ventilation is challenging in patients with difficult airway who require lung surgery. The choice of airway technique remains limited in patients with permanent tracheostomy after total laryngectomy. Conventional airway management techniques and available airway equipment have limited the options for securing airway in such patients, and dedicated airway equipment is not available for the management of such patients. Here, using endobronchial blocker through adult silicon hyperflex tracheostomy tube with an adjustable flange, we report a successful airway management for 1-lung ventilation in a patient with total laryngectomy with permanent tracheostomy.

Background: Patient satisfaction with the medical services is an important indicator of quality of healthcare but is seldom given importance in our country. It is difficult to measure patient satisfaction, especially in pre- and perioperative period., Materials and Methods: We conducted this audit by means of a questionnaire designed to assess preanesthetic clinic services in a large government hospital. A total of 200 patients were randomly selected to respond to a multiple item questionnaire., Statistical Analysis: A database was created and analyzed using Microsoft Excel., Results: 95% patients filled the proforma. Most of the patients (60%) were not aware of the purpose of visit to preanesthetic clinic. Majority of them were attended in time by the doctors but most of them (60%) received fitness after 2 to 3 visits. Majority was not explained about the preanesthesia instructions. Most of them were not satisfied by amenities in hospital. Several studies have shown that a thorough preoperative examination can be as effective as an anxiolytic premedication and can increase quality of care. In our study, location of preanesthetic clinic and unable to get fitness in first visit (because of lack of coordination between doctors of various specialties) were the major hindrances., Conclusion: Measures should be taken to improve the functioning of preanesthesia clinic and patient satisfaction.

The goal of preoperative risk assessment is to identify and modify the procedure and patient factors that significantly increase the risk for complications. Preanaesthesia clinics (PACs) have been developed to improve the preoperative experience of the patients by coordinating surgical, anaesthesia, nursing and laboratory care. These clinics can also help in developing practice guidelines, and decreasing the number of consultations, laboratory tests and surgical cancellations. Though these clinics are present in most of our hospitals, a major effort is needed to upgrade these setups so as to maximise the benefits. This review gives a brief account of organisation and functioning of PACs.

Background: The positioning (trendelenburg) and pneumoperitoneum during laparoscopic gynecological surgeries may cause cephalad movement of diaphragm and subsequent endobronchial intubation. PATIENTS #ENTITYSTARTX00026;, Methods: 50 ASA I/II patients posted for laparoscopic ligation were included in the study. Standardized anaesthesia technique was employed in all the patients. The distance of endotracheal tube to carina was measured in supine position, trendelenberg position, 5 min and 25 minutes post pneumoperitoneum and after deflation of pneumo-peritoneum., Results: The mean distance from the tip of the ETT to the carina was 3.41± 1.3 cm, 2.96 ± 1.4, 2.0 ± 1.5 and 1.7 ± 1.6 in supine position, trendelenburg position and 5min and 25 min post pneumoperitoneum. (P<0.01) Following deflation the carina moved back to its position to some extent and was 2.5 ± 1.5 from the tip of endotracheal tube.( P< 0.05), Conclusion: We conclude that pneumoperitoneum and trendelenburg position during laparoscopic surgeries may lead to cephalad migration of carina.

Summary: Total knee arthroplasty (TKA) is generally carried out using a tourniquet and blood loss occurring mainly post operatively is collected in drains. Tranexamic acid is an antifibrinolytic agent which decreases the total blood loss. Patients had unilateral / bilateral cemented TKA using combined spinal and epidural anaesthesia. In a double-blind fashion, they received either placebo (n=25) or tranexamic acid (n=25)10 mg.kg(-1) i.v., just before tourniquet inflation, followed by 1 mg kg(-1) h-1 i.v. till closure of the wound. The postoperative blood loss, transfusion requirement, cost effectiveness and complications were noted. The groups had similar characteristics. The mean volume of drainage fluid was 270 ml and 620 ml for unilateral(U/L) and bilateral(B/L) TKR patients in placebo group. Whereas it was 160ml and 286 ml respectively in unilateral(U/L) and bilateral(B/L) TKR patients who received tranexamic acid. This was considered statistically significant. Control group patients received 26 units of PRBC as compared to 4 units in tranexamic acid groups (p<0.001). This was again statistically significant. None of the patients in any of the groups developed deep vein thrombosis. Tranexamic acid decreased total blood loss by nearly 54% in B/L TKR and 40% in U/L TKR and drastically reduced (> 80%) blood transfusion.

Summary: Hypothermia is a common occurrence under anaesthesia and may prolong the duration of action of neuromuscular blockade. By limiting fall in temperature, an infusion of amino acid enriched solution may speed the recovery from neuromuscular blockade. We studied 60 ASA Grade - I/II patients of aged between 20 to 60 years scheduled for elective surgery under general anaesthesia. The patients were randomly divided into four groups to receive amino acid infusion with vecuronium bromide AV, normal saline with vecuronium bromide(CV), amino acid with atracurium besylate(A-At) and normal saline with atracurium besylate(C-At). Although there was a significantly lesser decrease in the core temperature from the baseline in all the patients receiving amino acid infusion (p<0.05), it significantly reduced the time to 25% recovery from the time of injection of vecuronium only. (60.59 +/- 11.39 in CV vs 51 +/- 14.72 min in AV) (P < 0.05), and not for atracurium.

Summary: Cardiovascular collapse following use of methylmethacrylate for lower limb surgeries has been reported. However there are no reports of cement reaction following shoulder arthroplasty. We report series of four patients exhibiting cement reaction. Two of our patients had cardiovascular collapse following cement insertion during hip arthroplasty. Severe hemodynamic derangement and transient hypoxemia was observed during cemented arthroplasty of shoulder and knee respectively. Peripheral vasodilatory effects of the cement monomer, fat and marrow embolism and activation of the clotting cascade in the lungs, all contribute to cement reaction. Early and aggressive resuscitation with use of vasopressors, establishment of invasive hemodynamic monitoring and surgical modifications are the key to prevention of catastrophic outcome.

Summary: Late cancellation of scheduled operations is a major cause of inefficient use of operating-room time and a waste of resources. We studied elective operating theatre bookings in general surgical discipline. On the day of surgery the intended list was noted and a list of cancellations with the reason was noted by the attending anaesthesiologist. 1590 patients were scheduled for elective surgical procedures in 458 operation rooms. 30.3 % patients were cancelled on the day of surgery. Of these, 59.7% were cancelled due to lack of availability of theatre time, 10.8% were cancelled because of medical reasons and 16.2% did not turned up on the day of surgery. In 5.4% patients, surgery was cancelled by surgeons due to a change in the surgical plan, 3.7% were cancelled because of administrative reasons, and 4.2% patients were postponed because of miscellaneous reasons. We believe that many of the on-the-day surgery cancellations of elective surgery were potentially avoidable. We observed that cancellations due to lack of theatre time were not only a scheduling problem but were mainly caused by surgeons underestimating the timeneeded for the operation. The requirement of the instruments necessary for scheduled surgical list should be discussed a day prior to planned OR list and arranged. The non-availability of the surgeon should be informed in time so that another case is substituted in that slot. All patients who have met PACU discharge criteria must be discharged promptly to prevent delay in shifting out of the operated patient. Day care patients should be counseled adequately to report on time. Computerized scheduling should be utilized to create a realistic elective schedule. Audit should be carried out at regular intervals to find out the effective functioning of the operation theatre.