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We present a case of a 28-year-old pregnant patient in labor with two prior cesarean sections with a history of both successful and failed spinal anesthesia in her first and second pregnancies, respectively. This time, attempts at spinal anesthesia failed twice despite ruling out the common causes such as technical or drug error. Surgery was ultimately performed under general anesthesia uneventfully. While technical factors may contribute substantially to failure of spinal anesthesia, the sequence of events in this case, viz. one successful subarachnoid block followed by two unsuccessful ones three and seven years apart, supported by investigative evidence, indicates a possible acquired resistance to local anesthetics.

Modified radical mastectomy (MRM) is the most common surgical procedure performed for breast carcinoma. It is usually performed under general anesthesia (GA), which becomes challenging in patients with respiratory compromise and multiple comorbidities. Thoracic epidural anesthesia is adequate for simple mastectomies, and when combined with ipsilateral interscalene nerve block, it provides adequate anesthesia for MRM, which involves axillary lymph node (LN) dissection in an outstretched arm that can be a discomfort to the patient. We describe our experience of giving thoracic epidural anesthesia with ipsilateral interscalene brachial plexus block (IBPB) in ten patients posted for MRM. A thoracic epidural was introduced under local anesthesia at T6-T7 intervertebral space and ultrasonography (USG)-guided ipsilateral IBPB was given. A satisfactory anesthetic effect was proved by the absence of tactile sensation over the operative mammary region and axilla within 30 min. This case series demonstrated that combined thoracic epidural anesthesia with ipsilateral IBPB can be used very efficiently in patients posted for MRMs without the need for GA. [ABSTRACT FROM AUTHOR]

Background and Aims: More than 80% of delivered anesthetic gases get wasted at high fresh gas flows as they are vented out unused. Use of minimal flow anesthesia is associated with less waste anesthetic gas emission and environmental pollution. There is no approved or validated technique to initiate minimal flow anesthesia and simultaneously achieve denitrogenation of the breathing circuit. We studied the wash-in characteristics of desflurane, when delivered with 50% nitrous oxide, to reach a target end-tidal concentration at two different gas flow rates. Material and Methods: Patients were allocated randomly to two groups of 25 adults each. In Group A, with the vaporizer dial fixed at 4 vol %, after an initial fresh gas flow of 4 L/min was administered to wash-in of desflurane using the closed-circuit, with 50% N2O in O2, and in group B, 6 L/min was used. Minimal flow anesthesia, with 0.5 L/min, was initiated in both groups on attaining a target end-tidal desflurane concentration of 3.5 vol %. After initiation of desflurane delivery, the inspired/expired gas concentrations were noted every minute for 15 min. Results: In Group A, the target desflurane end-tidal concentration was reached in 499.2 ± 68.6 s±, and in the Group B (P < 0.001), it was reached significantly faster in 314.4 ± 69.89 s. Denitrogenation of the circuit was adequate in both groups. Conclusion: Minimal flow anesthesia can be initiated, without any gas-volume deficit, in about 5 min with an initial fresh gas flow rate of 6 L/min and the vaporizer set at 4 vol%.