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Background: Dexmedetomidine is gaining popularity for its sympatholytic, sedative and haemodynamic stabilising properties, without significant respiratory depression. Methods: A prospective randomised double-blind study was conducted on 60 patients belonging to American Society of Anesthesiologists (ASA) Grade I and II undergoing elective abdominal surgeries who were randomised to receive either dexmedetomidine (Group D-P) or fentanyl (Group F-P) 10 Min prior to induction. Induction was done with midazolam along with propofol in 20 mg aliquots until bispectral index (BIS) value drops below 60. Infusion of one of the study drugs was continued along with propofol infusion which was titrated to maintain BIS around 40–60. Vecuronium to provide muscle relaxation and bolus doses of fentanyl were given whenever additional analgesia was needed. Intra-operative propofol, vecuronium and additional fentanyl requirement, time from discontinuation of anaesthetic drugs to extubation, time from the end of surgery to achieve a Ramsay sedation score of 2 and to the first post-operative analgesic request were recorded. Post-operatively, patients were monitored till 24 h for any adverse events. Results: A significant decrement in heart rate was observed in the D-P group in comparison to the fentanyl group. The D-P group was found to have required less propofol for induction, limited additional fentanyl requirement, less time required for extubation and a delay in request for first post-operative analgesia which was statistically significant. Conclusions: Propofol–dexmedetomidine provides better haemodynamic stability with lesser intraoperative propofol and fentanyl requirement, early cognitive recovery and longer postoperative analgesia when compared to propofol–fentanyl.

A 58-year-old female patient with recurrence of carcinoma in the angle of the mouth on the left side was posted for composite resection and Pectoralis major myocutaneous flap reconstruction. The patient had carcinoma left buccal mucosa 1 year back and had undergone left partial mandiblectomy and radiotherapy. On airway examination (MPG) could not be assessed; on mouth opening one-and-half finger was admitted. There was a 4 cm × 4 cm ulceroproliferative growth in the left angle of the mouth extending to lower lip, which was bleeding on touch. After shifting to the operating theatre, venous access was secured with a with a wide-bore cannula. Standard monitoring was connected and preoxygenation was done. Under strict aseptic precaution under local anaesthesia, trachea located with Touhy's needle. Epidural catheter passed through the needle into the larynx and taken out through the oral cavity and Ryle's tube, which the patient already had for feeds, was pulled and taken out of the oral cavity. Catheter tip was tied to it and pulled out through the nostril and passed through murphy's eye of 6.5 mm (ID ETT) and lower end pulled, thereby pulling ETT into the trachea, cuff was inflated and tube fixed at 25 cm. General anaesthesia was administered. Thorough airway assessment, preparat ion and counselling of patient help in reducing airway-related morbidity and mortality.

Background and Aims: Despite advances in minimally invasive surgery, postoperative pain remains a concern after laparoscopic cholecystectomy. This study aims to compare the effect of intraperitoneal instillation of bupivacaine with alpha-2 agonists (dexmedetomidine and clonidine) for postoperative analgesia. Methods: One hundred and eight patients scheduled for elective laparoscopic cholecystectomy were randomised to receive either 20 mL of 0.5% bupivacaine (Group B), 20 mL of 0.5% bupivacaine with dexmedetomidine 1 μg/kg (Group BD) or 20 mL of 0.5% bupivacaine with clonidine 1 μg/kg (Group BC). Study drug made to equal volume (40 mL) was instilled before the removal of trocar at the end of surgery. Standard general endotracheal anaesthesia with intra-abdominal pressure of 12–14 mm Hg during laparoscopy was followed uniformly. The primary objective of our study was the magnitude of pain. One way analysis of variance (ANOVA) for continuous variables and Chi-square test for categorical variables was used. Results: The Numerical Rating Scale (NRS) scores for pain intensity did not show any statistical significance at any of the pre-defined time points. Time to first request for analgesia was shortest in group BC (64.0 ± 60.6 min) when compared to the other groups (B, 78.8 ± 83.4 min; BD, 112.2 ± 93.4 min; P < 0.05). Total amount of rescue fentanyl given in groups BD (16.8 ± 29.0 μg) and BC (15 ± 26.4 μg) was significantly less than B (35.7 ± 40.0 μg); P < 0.05). Conclusion: The addition of alpha-2 agonists to bupivacaine reduces the post-operative opioid consumption, and dexmedetomidine appears to be superior to clonidine in prolonging time to first analgesic request.

Background: A ten-point surgical APGAR score (SAS) has been previously developed and validated that provides surgeons with a simple, objective and direct rating of operative performance and risk. This score has been evaluated in different types of surgeries till date. We validated SAS in both elective and emergency abdominal surgeries separately which was not done previously. Methods: In this prospective, observational and longitudinal study, 105 surgical cases undergoing open abdominal surgeries were studied. The SAS was calculated for all patients, patients were followed up for the occurrence of any major complications or mortality during hospital stay after surgery. All the patients were divided into three groups based on their SAS score (high risk: SAS 0–4, moderate risk: SAS 5–7 and low risk: SAS 8–10) using a threshold that has been previously established. Results: The occurrence of major complications was significantly higher in high-risk SAS group (12%) than in the moderate risk group (5%). In the low-risk SAS group, the occurrence of major complications was low (1%). The mortality rate in high-risk SAS was more than that in low-risk SAS group with statistical significance both in elective and emergency cases. Conclusions: In our study, we found that patients who belong to high-risk SAS group were significantly associated with post-operative major complications and mortality in both elective and emergency surgeries. A patient with low intraoperative SAS should be considered at risk and monitored meticulously. Trial Registration: Clinical Trials Registry-India (CTRI) identifier No. CTRI/2019/02/017567.

Background: Various adjuvants were combined with local anaesthetic agents, either intrathecally or epidurally, to prolong the duration of a denser neuraxial block and achieve adequate intraoperative conditions. Methods: In this prospective randomised double-blind placebo-controlled study, 90 patients were randomly allocated into three groups of 30 each depending upon the intrathecal adjuvant used. Standardised anaesthetic technique and monitoring for subarachnoid block (and epidural catheter placement) with 3 mL of 0.5% hyperbaric bupivacaine was followed. In addition, Group K (n = 30) received 0.3 mg/kg of preservative-free ketamine, Group F (n = 30) received 25 μg (0.5 mL) of fentanyl and Group C (control group, placebo, n = 30) received 0.5 mL normal saline. Time of onset and duration of sensory and motor block and duration of analgesia, haemodynamic parameters, sedation scores intra-operatively and post-operatively and side effects were recorded and analysed. Results: The mean time (sec) to onset of sensory (P = 0.04) and motor (P = 0.02) blockade was prolonged, and the duration (min) of sensory (P = 0.003) and motor (P = 0.009) block and the duration of analgesia (min) (P = 0.022) were shorter in the Group K compared to other two groups. Fentanyl showed shorter onset time, longer duration of sensory and motor block and duration of analgesia in contrast to ketamine and placebo. Conclusions: Fentanyl (25 μg) was superior to 0.3 mg/kg of ketamine and placebo as an intrathecal adjuvant with minimal side effects.

Background and Aims: Skull pin head holder application is intensely painful and is accompanied with abrupt increase in heart rate and arterial blood pressure. We aimed to determine the effects of adding dexmedetomidine to ropivacaine scalp block in attenuating the haemodynamic response to skull pin insertion in neurosurgical procedures. Methods: Sixty patients were randomly allocated to receive scalp block with 25 ml of 0.5% ropivacaine added with either normal saline (control group) or dexmedetomidine (1 μg/kg) after anesthesia induction. A standard uniform general endotracheal anaesthesia protocol was followed in all study subjects. Heart rate and blood pressure measurements were made at baseline, 1, 3, 5, 10, and 15 min following skull pin placement. Student's independent t-test, Chi-square test and repeated measure analysis of variance were used to analyse the obtained data. Results: There was no significant attenuation of heart rate (P = 0.418), systolic (P = 0.542), diastolic (P = 0.793) and mean blood pressure (P = 0.478) with addition of dexmedetomidine to ropivacaine. Conclusions: The addition of dexmedetomidine (1 μg/kg) to 25 ml of 0.5% ropivacaine offers no additional benefit over 25 ml of 0.5% ropivacaine alone scalp block in attenuating the haemodynamic response to skull pin placement in neurosurgical procedures.

Background and Aims: Disparity in spread of spinal anesthesia is a known complication in scoliosis patients. Our primary aim was to compare this disparity based on Cobb Angle and thorocolumbar spine curvature. Secondary aim was to calculate the appropriate lateral angulation of the spinal needle from midline for successful lumbar puncture. Materials and Methods: All poliomyelitis patients with scoliosis posted for lower limb orthopedic contracture release surgeries were enrolled into Group A (Cobb Angle 50°), and on thoracolumbar curve into Group R (Right), Group L (Left). Group A, B, R, and L were studied for bilateral spread of spinal anaesthesia. Lateral angle of the spinal needle from midline was noted with Goniometer in groups A and B. Statistical analysis was done using unpaired t test and Chi-square test. Results: Failures in subarachnoid block (SAB) (unilateral anaesthesia/inadequate/patchy block) was significant in Group B (P = 0.033). Segmental disparity in bilateral spread of spinal anaesthesia was significant in Group R with P value of 0.042. Approximate lateral angle for needle in Group A was (4.1 ± 2.45) and in Group B was (9.14 ± 2.45). Conclusions: The study showed that there was a strong correlation between right-sided thoracolumbar curve and the spread of spinal anesthesia

Background: Following general anaesthesia, post-operative shivering, apart from its physiological and haemodynamic effects, has been described as even worse than surgical pain. Methods: After ethical committee approval and informed consent, ninety patients were subjected to study. They were randomly divided into three groups. Just after intrathecal bupivacaine injection, all patients received prophylactically intravenous drug as normal saline (Group C, n = 30) or ketamine 0.5 mg/kg (Group K, n = 30) or tramadol 2 mg/kg (Group T, no = 30) for shivering. The incidence and degree of shivering and the effectiveness and side effects of ketamine and tramadol in preventing shivering during the post-operative period were recorded. Results: We compared the efficacy of tramadol and ketamine in the prevention of post-anaesthetic shivering in patients undergoing surgery under GA. The incidence of post-anaesthetic shivering was significantly less with tramadol and ketamine as compared to that of the control group (P < 0.01). Tramadol and ketamine were equally effective in controlling the severity of shivering as compared to that of the control group (P = NS). The prevention of shivering was comparable in the tramadol and ketamine groups (P > 0.05). Patients in the ketamine group had statistically significant sedation at 20 and 30 min compared to the tramadol and control groups (P < 0.05). In this study, we can assume that both intravenous tramadol 2 mg/kg and intravenous ketamine 0.5 mg/kg are highly effective and comparable in the prevention of post-anaesthetic shivering and the possible mechanisms is by lowering of shivering threshold.

Background: Laryngoscopy and tracheal intubation (LTI) is associated with undesirable haemodynamic (HD) responses. Both clonidine and dexmedetomidine have been tried to attenuate this HD response. The present study was to assess whether single pre-induction dose of intravenous clonidine (2 μg/Kg) or dexmedetomidine (1 μg/Kg) is more efficient to attenuate the HD response to LTI. Methods: Sixty patients belonging to American Society of Anesthesiologists Grade I and II were randomly divided into two groups: group C (clonidine 2 μg/Kg) and Group D (dexmedetomidine 1 μg/Kg). Study drug was given as an infusion over 10 Min before induction of anaesthesia followed by standardised anaesthetic technique. Heart rate (HR) and blood pressure (BP) were studied at baseline, before study drug infusion (BSD), after study drug infusion, before LTI and at 1, 2, 3, 5 and 10 m in after intubation. Sedation score was analysed BSD, after study drug infusion and at the end of surgery Results: This study revealed suppression of HR and BP at all time points in both the groups without any significant difference in suppression of HR between the groups. The magnitude of fall in BP in the clonidine group is more compared to the dexmedetomidine group before LTI and at 3, 5, and 10 min after tracheal intubation. The patients in the dexmedetomidine group were more sedated than in the clonidine group at the end of the study drug infusion. Conclusions: Both clonidine and dexmedetomidine were effective in attenuating HD response to LTI. Dexmedetomidine appears to be superior to clonidine in maintaining stable HD.

Background: Complications associated with central venous catheter central line central line-associated bloodstream infections (CLABSIs). Methods: We prospective by studied the microbiological profile and antimicrobial susceptibility patterns of isolated bacteria from CLABSIs in respiratory intensive care unit at our a tertiary care teaching hospital in Tirupati, Andhra Pradesh. Results: Colonisers were isolated from 110 of the 288 samples without any growth in blood cultures from among 288 samples that were submitted with a clinical suspicion of sepsis from patients with eligible central line. Among these, Staphylococcus aureus was the predominant coloniser. Seventy-four were blood culture positive, of which 36 showed other sources of infection. In our study, CLABSI rate was 12.9/1000 catheterised days. Among these culture positives, predominant isolate was S. aureus, followed by Staphylococcus hominis, Acinetobacter, Klebsiella and Escherichia coli. All the S. aureus strains were sensitive to linezolid, tetracycline and vancomycin. Among Gram-negative organisms, Acinetobacter baumannii and E. coli strains were 100% sensitive to polymyxin B and tigecycline. In our study, we have observed carbapenem resistance in E. coli and A. baumannii, which is alarming. Methicillin-resistant S. aureus accounted for 71.4% of S. aureus CLABSIs. All A. baumannii (n = 6), Klebsiella (n = 4) and E. coli (n = 4) isolates were extended spectrum beta-lactamase producers. Conclusions: Strict implementation of insertion and maintenance bundle care of the central lines is mandatory to prevent colonisation.

Introduction: Total Intravenous Anaesthesia (TIVA) has been a subject of interest for all anaesthesiologists. TIVA was initially attempted with a single drug but no drug was found to give complete anaesthesia. So, the technique of co-induction using two or more agents to induce anaesthesia has been studied. With the invention of newer induction agents, opioids and amnestic agents having shorter half-life, with advents of infusion pumps and depth of anaesthesia monitors like Bispectral Index (BIS), TIVA is gaining popularity day by day. Aim: To compare the effects of fentanyl or subanaesthetic dose of ketamine given along with propofol in TIVA. Materials and Methods: A randomised double blind study was conducted in patients who underwent elective laparotomy under TIVA. Sixty-two ASA grade I and II patients were randomised to receive either subanaesthetic dose of ketamine or fentanyl along with propofol for induction. Infusion of one of the study drugs was continued during maintenance along with propofol infusion which was titrated to maintain BIS of 40-60. Vecuronium was used to provide muscle relaxation and bolus doses of fentanyl were given whenever additional analgesia was needed. Intraoperative propofol, vecuronium and additional fentanyl requirement, time for tracheal extubation and time for first postoperative analgesic request were recorded. Continuous data was analysed with Student’s t-test and categorical data was analysed with Chi-square test. A p-value less than 0.05 were considered statistically significant. Results: Immediately after induction, haemodynamics were more stable in the ketamine group when compared to the fentanyl group. There was also a significant decrease in propofol requirement (6.501±0.24 Vs 6.672±0.26 mg/kg/hr) and a delay in the request for first postoperative analgesia in ketamine group (57.50±38.20 vs 40.50±22.68 minutes). Conclusion: Pre-incisional bolus of subanaesthetic ketamine followed by an infusion intraoperatively maintains haemodynamic stability, provides analgesia, decreases propofol requirement and delays request for first postoperative analgesia.

Background and Aims: Intraperitoneal local anaesthetic instillation (IPLAI) reduces postoperative pain and analgesic consumption effectively but the timing of instillation remains debatable. This study aims at comparing pre-emptive versus post-surgery IPLA in controlling postoperative pain after elective laparoscopic cholecystectomy. Methods: Ninety patients belonging to American Society of Anesthesiologists physical status I or II were randomly assigned to receive IPLAI of either 30 ml of normal saline (C) or 30 ml of 0.5% bupivacaine at the beginning (PE) or at the end of the surgery (PS) using a double-dummy technique. The primary outcome was the intensity of postoperative pain by visual analogue scale score (VAS) at 30 minute, 1, 2, 4, 6, 24 hours after surgery and time to the first request for analgesia. The secondary outcomes were analgesic request rate in 24 hours; duration of hospital stay and time to return to normal activity. Data were compared using analysis of variance, Kruskal-Wallis or Chi-square test. Results: For all predefined time points, VAS in group PE was significantly lower than that in groups C (P < 0.05). The time to first analgesic request was shortest in group C (238.0 ± 103.2 minutes) compared to intervention group (PE, 409.2 ± 115.5 minutes; PS, 337.5 ± 97.5 minutes;P < 0.001). Time to attain discharge criteria was not statistically different among groups. Conclusion: Pre-emptive intraperitoneal local anaesthetic instillation resulted in better postoperative pain control along with reduced incidence of shoulder pain and early resumption of normal activity in comparison to post surgery IPLAI and control.

Background: Guillain–Barré syndrome (GBS) is an immune-mediated damage to the nerve roots and peripheral nerves which may require intensive care unit management and adequate techniques for airway protection and ventilation. Methods: Sixty four patients with GBS were studied from March 2017 to February 2018 with a detailed history of demographic and clinical data (age, gender, season, and antecedent events), functional disability bed on Hughes score, Medical Research Council (MRC) sum score at the time of admission. Final outcome was dichotomized to good (0–3) or bad (4–6) based on Hughes Disability Scale and was compared with different patient variables to find their association with patient outcome. Results: The mean age of the patients studied was 45.9 ± 15.9 years. There were 37 males. Axonal variety was predominant GBS variant (85%). Twenty-four patients required mechanical ventilation and nine patients underwent tracheostomy. In total, 7 patients expired and 15 patients were discharged from the hospital with severe disability. Twenty patients developed complications during their course of stay in hospital. In total, 12 out of 15 (80%) with low MRC score (0–20) and 22 out of 49 patients with high disability score (Hughes score 4 or 5) at admission had a bad outcome (P = 0.001 and P = 0.001), respectively. Conclusions: We concluded that, in our study, predictors of poor outcome at discharge were low MRC sum score at admission, high GBS disability score at admission, axonal variant GBS, longer duration of mechanical ventilator support, need for tracheostomy, and presence of complications, were associatedwith a poor outcome in patients with GBS.

Background: Multimodal therapy can be used for obtundation of the haemodynamic response to laryngoscopy and tracheal intubation. The current study was undertaken to compare the haemodynamic response to laryngoscopy and tracheal intubation after administration of 0.2 mg/kg morphine or 2 μg/kg fentanyl with 2% end tidal sevoflurane during induction of anaesthesia. Methods: Sixty patients were randomised into two equal groups to receive either 2% end tidal sevoflurane + fentanyl 2 μg/kg (Group SF) or 2% end tidal sevoflurane + morphine 0.2 mg/kg (Group SM). General anaesthesia technique was standardised for both the groups. Haemodynamic parameters heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were recorded for 15 min. Results: The maximum increase in HR compared to baseline was statistically significant in Group SM (16.5%, P = 0.0002) which occurred at one min after tracheal intubation. The maximum increases in SBP, DBP and MAP compared to baseline occurred at one min after tracheal intubation in both the groups, Group SF (7.04%, 6.5% and 7.9% respectively) and Group SM (6.2%, 8.2% and 8.1% respectively) which was not statistically significant. The attenuation of haemodynamic response between the two groups was not statistically significant (for HR P = 0.1428, for SBP P = 0.8558, for DBP P = 0.1958 and for MAP P = 0.5303). Conclusions: With 2% end tidal sevoflurane during induction of anaesthesia, both 0.2 mg/kg morphine and 2 μg/kg fentanyl were equally effective in attenuating haemodynamic response to laryngoscopy and tracheal intubation. However morphine appeared to be less effective in attenuating the chronotropic response resulting in a greater increase in heart rate from baseline.

There are considerable myths which surround not only about the different terminology used for smoking but also about their possible impact during the perioperative period. The health hazards posed by smokeless tobacco(electronic cigar) is lower compared to tobacco cigarette smoke whereas actually the levels of aldehydes aerosol generated from new-generation devices at high power levels (Electronic cigars) could approach or even exceed the levels found in cigarette smoke. Nicotine has analgesic properties and thus many believe that smoking tobacco or inhaling nicotine only (e.g., smokeless tobacco) may have a similar effect on pain perceptions in the perioperative period. Many others have opined and associated smoking as a protective factor against postoperative nausea and vomiting. However smoking whether active or passive is always a general health problem and when such patients come for surgery possess additional challenges to the anaesthesiologist. This review will give a brief account of who is a smoker and different terminology being described in literature to describe smoking who need to quit smoking before surgery and when how smoking adversely affects the physiology of body and based on the available literature formulate an anaesthetic plan in smokers.

Introduction: Two commonly used antiemetics in the perioperative period may attenuate the spinal anaesthesia induced hypotension by attenuating the Bezold-Jarisch Reflex (BJR). Aim: To evaluate and compare the efficacy of intravenous administration of ondansetron and granisetron five minutes prior to spinal anaesthesia on incidence of spinal anaesthesia induced hypotension and bradycardia. Materials and Methods: Ninety patients scheduled for elective infraumbilical non-obstetric surgeries under spinal anaesthesia were enrolled for the study, after obtaining written informed consent. Patients were randomised to receive 4 mg ondansetron (group O), 1 mg granisetron (group G) or normal saline (control group) intravenously, five minutes prior to spinal anaesthesia. Changes in haemodynamics were noted after spinal anaesthesia to identify the number of episodes of hypotension and bradycardia necessitating treatment with ephedrine, atropine or both. The obtained data was analysed with one-way ANOVA or Chi-square test with post-hoc comparison to find out pairwise difference. Statistical significance was considered as p

Background: The present study aim was designed to compare and evaluate the efficacy of adding two different doses of magnesium sulphate to 0.5% hyperbaric levobupivacaine for spinal anaesthesia in terms of block characteristics, haemodynamic and safety profile. Methods: Ninety American Society of Anaesthesiologist (ASA) grade I–II patients undergoing elective infra-umbilical surgeries under spinal anaesthesia were randomly allocated into three groups. Group C (n=30, control group) received 3 mL (15 mg) of 0.5% hyperbaric levobupivacaine; Group M50 (n=30): received 3 mL (15 mg) of 0.5% hyperbaric levobupivacaine + 50 mg of magnesium sulphate. Group M100 (n=30) received 3 mL (15 mg) of 0.5% hyperbaric levobupivacaine + 100 mg of magnesium sulphate. A standard protocol was followed after which a blinded observer assessed the sensory and motor blocks. The onset and duration of sensory (pin-prick) block, onset, intensity and duration of motor block were recorded. Results: All the subarachnoid blocks were adequate. The addition of magnesium sulphate to intrathecal levobupivacaine had not only increased the time to onset of sensory block (p=0.007) but also prolonged the duration of sensory (p

Background: Central venous catheterizations are commonly used in critically ill patients and may cause different complications including infections. Methods: This prospective, randomized observational study was conducted in 60 patients admitted to respiratory intensive care unit (RICU) in a tertiary care hospital to compare the incidence and character of bacterial colonization between internal jugular (IJV) and subclavian (SCV) catheterization after seven days of placing the central venous catheter. Results: The incidence of catheter tip colonization (CTC) was statically higher in IJV compared to SCV (p = 0.030) whereas, there was no significant difference in blood cultures (p = 0.671) between the groups. The incidence of CTC and growth on blood culture increased with increase in number of attempts. Common microorganism colonizing the central venous catheters (CVCs) was non fermenting Gram negative bacteria and Klebsiella spp. Two cases of catheter related blood stream infection (CRBSI) were reported in the SCV group. Microorganisms causing CRBSI were Pseudomonas spp and Staphylococcus aureus. Conclusions: Despite sterile precautions bacterial colonization of central venous catheter tip is seen, more in the IJV group but CRBSI was common in SCV group. Catheter tip culture positivity does not confirm infection. As the number of attempts increase there are more incidences of positive blood culture and CRBSI.

Introduction: Infections are the most important and leading cause of morbidity and mortality among the patients admitted in Intensive Care Units (ICU). The formation of biofilm around the Endotracheal Tubes (ET) by the micro organisms and their subsequent dislodgement following ET suction and repeated incubations contributes to lung colonisation and may lead ultimately to ventilator-associated pneumonia. The study also analysed common micro organisms associated with these infections and their antibiotic sensitivity profile. Aim: To study the time/trends of bacterial colonisation and sensitivity profile in tracheal tubes, in mechanically ventilated patients, in a tertiary care hospital ICU. Materials and Methods: A total of 109 consecutive patients admitted in the intensive care unit who were on mechanical ventilation for more than seven days were chosen. The study period was for one year. The ET suction catheter tip was cultured at 24 hours and at 48 hours post-incubation and ET tube tip culture was done on 7th day of incubation. Sensitivity of bacterial isolates from ET tip and suction tip cultures to commonly used antibiotics was also tested. All data were recorded in a predesigned study proforma and entered in Microsoft Excel (Microsoft Corporation, Redmond). All entries were double checked for any possible errors. Categorical variables were summarised as percentages. Results: A total of 109 subjects were enrolled in the study. Fifteen patients were excluded from the study. Bacterial colonisation was present in 60 patients at 24 hours, in 76 patients at 48 hours, and in 82 patients on 7th day of incubation. Three most common colonising organisms isolated at 24 hours, 48 hours and on the 7th day of incubation were Non-Fermentative Gram Negative Bacilli (NFGNB) including Acinetobacter, Pseudomonas aeruginosa and Klebsiella pneumonia. At 24 hours of incubation, 47.06% of NFGNB including Acinetobacter and 87.5% of Pseudomonas were sensitive to Cephaperazone-Sulbactam and with Imipenem the sensitivity was 35.29% for NFGNB including Acinetobacter and 93.57% for Pseudomonas. Almost similar trends were found in 48 hours post incubation culture and on 7th day culture. Among ventilator-associated pneumonia patients, Klebsiella pneumonia was the most common isolate. Conclusion: Most commonly isolated organisms were NFGNB including Acinetobacter, Pseudomonas aeruginosa and Klebsiella pneumoniae. Most of isolated organisms were sensitive to Cefaperazone-sulbactam and Imipenem antibiotics.

Positioning of a patient with irregular contour of spinal curvature is a common problem faced by anaesthesiologists for surgical procedures. Here we would like to describe how to use routine materials available in the operating room efficiently to accomplish successful endotracheal intubation.

Pulmonary aspiration of gastric contents is one of the most fatal complications not only in the scenario of an operating room but also in critically ill patients, who have an increased risk for silently aspirating oropharyngeal secretions and regurgitated gastric contents. Prevention is the key to avoid this feared event. Strict adherence to guidelines regarding fasting in the preoperative period, avoidance of residual muscle paralysis and early return of protective airway reflexes by carefully choosing appropriate anaesthetic agents are corner stones of safe anaesthetic practice. Routine preoperative pharmacoprophylaxis to reduce gastric acidity and volume is not recommended and tolerance to commonly used histamine 2 receptor antagonists may occur and use of proton-pump inhibitors may be necessary. In the critical care arena small-volume clinically silent aspirations of oropharyngeal secretion are more common and head-of-bed elevation has been identified as the single most important factor which can greatly reduce the risk of aspiration and thereby reduce the incidence of ventilator associated pneumonia. Most of the intensivists favours use a continuous enteral feed and checking of correct placement of feeding tube at regular interval to reduce the frequency of pulmonary aspiration of gastric contents. In this review we summarise the pathophysiologic mechanism and predisposing factors to pulmonary aspiration of gastric contents. We will also present evidence for and rationale behind the practices adopted in critical care area and operation theatre setup to prevent aspiration.

The primary reasons for blood transfusion in cardiac surgery are to correct anaemia and to improve tissue oxygen delivery. However, there is a considerable debate regarding the actual transfusion trigger at which the benefits of transfusion overweight the risk. The association between extreme haemodilution, transfusion and adverse outcome after cardio pulmonary bypass (CPB) is not clear and the current available literature is not sufficient to provide a strong recommendation regarding the safe haematocrit range during CPB. There is no quality evidence to support use of fresh red blood cell except during massive transfusion or exchange transfusion in neonate. Overall concern regarding the safety of allogeneic blood transfusion resulted in the search for autologous blood transfusion and perioperative blood salvage. The aim of this review is to provide cardiac surgery specific clinically useful guidelines pertaining to transfusion triggers, optimal haemodilution during CPB, autologous blood transfusion and role of perioperative blood salvage based on available evidence.

Background and Aim: Central venous catheter (CVC) insertion induces pain and discomfort to a conscious patient despite application of a local anaesthetic (LA) field block and this pain can be greatly lessened by using additional analgesics. The aim of this study was to evaluate the efficacy of dexmedetomidine along with LA field infiltration in controlling pain and discomfort associated with CVC insertion. Methods: A prospective, randomised, double-blind, placebo-controlled trial of 54 patients scheduled for planned CVC insertion was undertaken. Patients were randomly assigned into two groups of 27 each, to receive either dexmedetomidine (1 μg/kg) or 0.9% normal saline, along with LA field infiltration. Pain and discomfort score was measured at 5 time points. Results: The median pain score was worst for placebo group at local anaesthetic injection (6 [4-7]) and at the end of procedure (5 [4-5]), which was significantly attenuated in the dexmedetomidine group (4 [4-5] and 4 [3-5]; P = 0.007 and 0.040 respectively). The lower procedure related discomfort score in the immediate post-procedural period was statistically significant in dexmedetomidine group compared to placebo (4 [4-5] vs. 5 [4-6]; P = 0.008). Conclusions: Pre-procedural bolus dexmedetomidine infusion provides adequate analgesia and patient comfort for CVC insertion along LA field block. However, the tendency for excessive sedation and bradycardia associated with dexmedetomidine render it less desirable for this purpose.

We report a 35-year-old gentleman who presented to us with respiratory distress. He was diagnosed to have a large anterior mediastinal mass and was and posted for debulking of mediastinal mass. Immediately after intubation, airway collapsed and there was difficulty in ventilating the lungs, followed by drop in oxygen saturation. After sternotomy, oxygen saturation and airway pressures improved. In this report we discussed in detail about the successful anaesthetic considerations for patients with large anterior mediastinal tumour including the management of airway obstruction.

Background: Spinal anaesthesia with bupivacaine for lower limb and lower abdominal surgeries is limited by the fixed duration of action and cannot be prolonged except with usage of spinal catheters which increase the chance of infection and occurrence of haemodynamic instability when used in high doses. To minimize the instability in haemodynamics, several neuraxial adjuvants have been used. Methods: We carried out a prospective randomized double-blind study in 60 patients posted for lower abdominal and lower limb surgeries. Patients were divided into two groups of 30 each. Both groups received 3 mL of intrathecal hyperbaric 0.5% bupivacaine. In addition, ketamine group (Gr K) received ketamine 0.1mg/kg body weight intathecal (made to total volume of 0.5 mL); saline group (Gr S) received equal volumes of 0.9% normal saline intrathecally. The onset and duration of sensory and motor blockade and intraoperative haemodynamics were studied. Results: Addition of ketamine in comparison to saline administration produced significantly earlier onset (5.2±1Vs. 3.4±1; p=0.000), prolonged duration of sensory block (129.7±14.9 Vs. 111.3±11; p=0.000) and long duration of postoperative analgesia (150.8±11.7Vs. 127.8±12.8; p=0.000). Conclusion: Addition of ketamine to intrathecal hyperbaric bupivacaine provides better intraoperative spinal block characteristics, stable haemodynamics and longer duration of postoperative analgesia.

Back ground: Laparoscopic surgeries have advantages like shorter stay and rapid return to normal activities because of small incision and less pain. Pain is an unpleasant sensation in the post-operative period. Methods: Fifty patients of American society Anesthesiologists (ASA) grade I and II, scheduled to undergo laparoscopic surgery, were randomized into butorphanol group (Group B) (n=25) and fentanyl group (Group F) (n=25). Four minutes before induction of anesthesia, Group B received inj. butorphanol 40 µg/Kg intravenously while Group F received Inj. fentanyl 2 µg/kg intravenously. All patients received general anaesthesia with controlled ventilation. Heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), end tidal carbon dioxide (ETCO2), and oxygen saturation were monitored at different intervals. Results: The demographic data was comparable in both groups (p

Background: There is limited data to predict the course of sub-arachnoid block in poliomyelitis patients with scoliotic spine. So we intended to study the course of intrathecal anaesthesia in these patients in comparison to patients with normal spine using 0.5% bupivacaine (heavy). Methods: In this prospective observational study, 41 poliomyelitic patients scheduled for lower limb corrective surgeries under spinal anaesthesia were enrolled. Patients were studied in two groups (Scolotic spine, n=20; Normal spine, n=21). All patients were injected 2 ml of 0.5% bupivacaine heavy intrathecally in the sitting position. The extent of block, bilateral spread, regression of sensory block and motor block were recorded. Demographic data were analysed using the unpaired t test or the chi square test as applicable. Block characteristics were analysed using the Mann Whitney U test. Results: There was statistically significant difference in bilateral spread of sensory block in between the groups. However, there was no significant difference in the maximum extent of the sensory block and the time taken for two segment regression of sensory block. There was no significant difference in time taken to reach complete motor block and for complete recovery from motor block to its preoperative value. Conclusions: Bilateral symmetrical spread of local anaesthetics through intrathecal route cannot be predicted accurately in patients with scoliotic spine. Spinal anaesthesia can be safely administered in poliomyelitis patients with scoliosis with less adverse effects.

Background: Treatment of acute post-thoracotomy pain is particularly important not only to keep the patient comfortable but also to minimize pulmonary complications. Aim: This study was designed to test the effect of pre-induction administration of clonidine, given as a single intravenous dose, on post-operative pain scores and fentanyl consumption in patients after thoracic surgery. Setting and Design: Tertiary referral centre. Prospective, randomised, double-blind, placebo-controlled trial. Methods: Sixty patients were randomly allocated to receive clonidine (3 mcg/kg) or saline pre-operatively before induction of anaesthesia. The primary endpoint was pain on coughing (visual analogue scale (VAS) 0-100 mm) 120 min after surgery, time to first analgesic injection in the post-anaesthesia care unit (PACU) and 24-h fentanyl consumption. Statistical Analysis: For between-group comparisons, t-test and U-test were used as appropriate after checking normality of distribution. The incidence of complications between the groups was compared by Fisher′s exact test. Results: The post-operative VAS for the first 120 min and the fentanyl consumption at 24 h was significantly greater in the placebo group compared with the clonidine group (P

Background: The cardiopulmonary bypass (CPB)-associated atelectasis accounted for most of the marked post-CPB increase in shunt and hypoxemia. We hypothesized that pressure-regulated volume-control (PRVC) modes having a distinct theoretical advantage over pressure-controlled ventilation (PCV) by providing the target tidal volume at the minimum available pressure may prove advantageous while ventilating these atelactic lungs. Methods: In this prospective study, 36 post-cardiac surgical patients with a PaO 2 /FiO 2 (arterial oxygen tension/Fractional inspired oxygen) < 300 after arrival to intensive care unit (ICU), (n = 34) were randomized to receive either PRVC or PCV. Air way pressure (Paw ) and arterial blood gases (ABG) were measured at four time points [T1: After induction of anesthesia, T2: after CPB (in the ICU), T3: 1 h after intervention mode, T4: 1 h after T3]. Oxygenation index (OI) = [PaO 2 / {FiO 2 × mean airway pressure (Pmean )}] was calculated for each set of data and used as an indirect estimation for intrapulmonary shunt. Results: There is a steady and significant improvement in OI in both the groups at first hour [PCV, 27.5(3.6) to 43.0(7.5); PRVC, 26.7(2.8) to 47.6(8.2) (P = 0.001)] and second hour [PCV, 53.8(6.4); PRVC, 65.8(7.4) (P = 0.001)] of ventilation. However, the improvement in OI was more marked in PRVC at second hour of ventilation owing to significant low mean air way pressure compared to the PCV group [PCV, 8.6(0.8); PRVC, 7.7(0.5), P = 0.001]. Conclusions: PRVC may be useful in a certain group of patients to reduce intrapulmonary shunt and improve oxygenation after cardiopulmonary bypass-induced perfusion mismatch.

We aimed to show that a single preprocedural dose of either dexmedetomidine or fentanyl reduces procedural pain and discomfort and provides clinically acceptable sedation. In this prospective, double-blind study, sixty patients scheduled for elective surgery and requiring planned central venous catheter insertion were randomized to receive dexmedetomidine (1 μg/kg), fentanyl (1 μg/kg), or 0.9% normal saline intravenously over ten minutes followed by local anesthetic field infiltration before attempting central venous catheterization. The primary outcome measures are assessment and analysis of pain, discomfort, and sedation level before, during, and after the central venous catheter insertion at five time points. The median (IQR) pain score is worst for normal saline group at local anaesthetic injection [6 (4–6.7)] which was significantly attenuated by addition of fentanyl [3 (2–4)] and dexmedetomidine [4 (3–5)] in the immediate postprocedural period (P=0.001). However, the procedure related discomfort was significantly lower in dexmedetomidine group compared to fentanyl group in the first 10 min of procedure after local anaesthetic Injection (P=0.001). Fentanyl is more analgesically efficient for central venous catheter insertion along with local anaesthetic injection. However, dexmedetomidine has the potential to be superior to fentanyl and placebo in terms of providing comfort to the patients during the procedure.

A prone position is not a standard position for anesthesia induction and associated with problems like difficult mask fit, impairment of orotracheal intubation by direct laryngoscopy, and reduction of pulmonary compliance. However anesthetic management of trauma victims presenting with penetrating posterior lumbar spine injury requires airway securement and induction of anesthesia in the prone position to avoid further neurological impairment. We herein present the first reported case of an adult trauma patient presented with an impaled knife protruding out of lower back, who underwent endotracheal intubation with an intubating laryngeal mask airway under general anesthesia in the prone position. Our experience indicates that this technique would be easier and less risky compared to direct laryngoscopy or awake fiber optic intubation and might be considered in an emergency situation.