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A case of meningocele manqué with its management is presented and the literature of this rarely reported condition is reviewed. A one-year-old child was admitted with a small sac like lesion in the upper dorsal region with a soft swelling in the dorso lumbar region, was also associated with congenital bilateral talipes equinovarus which was being treated by a paediatric orthopedic surgeon. Methods. Craniospinal MRI was suggestive of dorso lumbar lipomyelomeningocele, and corresponding to the dorsal sinus/sac at DV3/DV4 level there was another tethering seen on the MRI due to a band and associated with syrinx of the dorsal cord below that, s/o meningocele manqué. Treatment. This patient underwent in 1st stage, DV2 to DV5 laminoplasty, excision of the sinus, durotomy, dissection of the multiple arachnoid cysts, and cutting of the dorsal band. In second stage will undergo surgery for Lipomyelomeningocele Conclusion: Meningocele Manque is rare, it can present in isolation or associated with other spinal dysraphism. With other spinal dysraphism they can be either at the same or at another location, as was seen in our case. Before operating all cases of spinal dysraphism it is of paramount importance to MRI screen the entire neuraxis and study images thoroughly. In our case along with the dorso lumbar lipomyelomeningocele, there was a Meningocele manqué at DV3/DV4 level. It is essential that the meningocele manqué be addressed first; if not the returning/recoiling cord after de-tethering at the lower level can get tugged/sheared at the tethered meningocele manqué causing deficits.

Introduction: Acute fatty liver of pregnancy remains an elusive and potentially fatal complication of a rare liver disease in late pregnancy. Due to sparse research, diagnostic dilemmas, and multi-organ involvement of the disease, it is imperative to elaborate the evaluation and management principles to confine the outcomes. Case Reports: Here, we aim to discuss in detail the peripartum manifestations and goal-directed management protocols in a case series of four patients managed at a tertiary care setup in India. Conclusion: It was found that all four cases had varied presentations ranging from asymptomatic hypoglycemia to liver failure and multiorgan dysfunction requiring a multidisciplinary perioperative care approach to prevent complications by incorporating supportive care along with latest available point of care diagnostics, interventional care, Extracorporeal Membrane Oxygenation (ECMO) and Continuous renal replacement therapy (CRRT).

PURPOSE: The purpose is to study the anatomical outcome of eyes in aggressive retinopathy of prematurity (AROP), treated with laser photocoagulation alone and to evaluate factors affecting outcomes. METHODS: Records of consecutive babies diagnosed with AROP, undergoing laser photocoagulation treatment in rural tertiary care centers from October 2016 to January 2021 were reviewed retrospectively. Anatomical outcome at 6 months follow-up was grouped as good in eyes with complete regression and poor in those who developed retinal detachment (stage IV a, IV b, and V). Both groups were compared with respect to the period of gestation, birth weight (BW), age at screening, age at treatment, zone of disease, presence of retinal fibrovascular proliferation (FVP), tunica vasculosa lentis, preretinal bleed, need for supplement laser, and associated systemic risk factors. RESULTS: Of the total of 2468 babies screened, 124 (5.02%) were diagnosed with severe retinopathy of prematurity (ROP), of which 54 (43.5%) lasered AROP babies were analyzed. Mean BW and gestation period of the AROP cohort were 1.43 kg and 31.1 weeks, respectively. Eighty-six eyes (79.6%) had good outcomes with laser photocoagulation alone. Posterior location of disease, presence of FVP, neonatal sepsis, shock, and late screening for ROP were found to be factors associated with poor outcomes. CONCLUSION: Adequate and timely treatment with laser photocoagulation in AROP can achieve good treatment outcomes in a significant proportion of babies. Although a combined approach using laser, anti-vascular endothelial growth factor and early vitrectomy is better, laser remains a viable treatment option in AROP, especially with limited resources and high risk of loss to follow-up.

Background: This study was designed to compare the overall success rates and complications of two techniques of internal jugular vein (IJV) catheterization, namely the landmark (LM)-based technique and ultrasound (US)-guided technique in a heterogeneous Indian population at an Armed Forces Tertiary Care Hospital. Methods: Ninety consenting patients were assigned to two groups: LM and US groups. Patients with known coagulation abnormalities, body mass index > 30, infection at the insertion site, known vascular abnormalities, burn contractures, and other dermatologic conditions that precluded an LM technique were excluded. Central venous catheterizations during the code blue scenarios were excluded due to the emergent nature of the procedure. Three operators from the author group with requisite experience in LM and US techniques performed the 90 catheterizations. In LM group, a finder needle with a 2 ml syringe was used to aspirate venous blood from the IJV. A 16G needle was guided in the same direction as the finder needle till venous blood was aspirated, followed by guidewire insertion and cannulation. In the US group, a 6–12 MHz linear US probe was used to identify the IJV in real time and a 16G needle was used to access the IJV under US guidance in the cross-sectional view. Results: The overall success rate was 84.4% in LM group and 100% in US group (P = 0.0059). The first attempt success rate was similar in both groups (71.1% and 86.6%, P = 0.07). The overall complication rates in LM group were 20%, whereas complications in the US group were 2.2% (P = 0.0073). Notably, vascular complications occurred less frequently in US group with fewer arterial punctures and hematomas. Hemothorax and pneumothorax did not occur in any group. The mean cannulation time decreased by 69 s, i.e., from 276 s in the LM group to 207 s in the US group (P < 0.001). Conclusion: US-guided central venous catheter insertion to IJV improves the overall success rate and reduces cannulation time as compared to conventional LM-based technique.

Background & objectives: Emerging zoonotic and vector-borne diseases are posing new challenges to public health authorities. Morbidities and mortalities due to acute encephalitis syndrome (AES) is a serious health problem in paediatric patients. We conducted serological investigations on AES cases from six districts of north eastern Madhya Pradesh (MP), India for Japanese encephalitis (JE). Methods: The paired serum and CSF samples were collected from paediatric patients having signs and symptoms of encephalitis and admitted at a tertiary care hospital during the study period from August 2020 to October 2021. Demographic and clinical information was collected in predesigned formats. Serum and CSF were subjected to JE IgM specific ELISA. Results: Samples from 110 patients were collected during the study period of which 28 (25.4%) were reactive for JE IgM antibodies. JE IgM positivity was marginally higher in male children (26.6%) as compared to female children (22.8%). Out of 28 positive cases, 11 (39.2%) deaths were attributed to JE. Four districts of north eastern Madhya Pradesh showed JE activity. Maximum cases were observed in post-monsoon season. Interpretation & conclusion: Our results show that JEV is an emerging threat in eastern central India and health authorities need to be vigilant. A systematic molecular and serological survey among humans and animals along with xenomonitoring will help in understanding intricacies of JE epidemiology in the region.

Abstract Background Limiting the preoperative fasting period positively impact surgical patient outcome. In tertiary care hospitals, preoperative fasting instructions are mostly implemented by postgraduates. This study was conducted to evaluate the knowledge, attitude, and practice of postgraduate trainees of surgical specialties and anesthesiology regarding preoperative fasting. This observational study was conducted at a tertiary care hospital in May 2020. Consenting 166 postgraduate trainees of anesthesiology and surgical specialties was asked to respond to a questionnaire consisting of nine questions. The primary outcome was the knowledge status of postgraduate trainees regarding preoperative fasting guidelines and secondary outcomes being their attitude and practice of the same. Categorical data were presented as numbers and percentages. Results Out of 166 respondents, 149 (89.8%) and 94 (56.6%) respondents could not correctly describe the practice guidelines published by the American Society of Anaesthesiology pertaining to preoperative fasting in adult and pediatric patients respectively. Of the total respondents, 146 (87.9%) and 108 (65.1%) gave incorrect preoperative fasting instructions to adult and pediatric patients, respectively. The source of information regarding fasting guidelines was seniors amongst 89 (53.6%) respondents. Fifty-one (30.7%) respondents were unaware of the benefits of limiting preoperative fasting. Conclusions There is an imminent need for change in the knowledge, attitude, and practices of residents with regards to preoperative fasting practices. A holistic approach with formal teaching and development of SOP can achieve the change of practice of “NPO after midnight.”

Background: Guillain–Barre Syndrome (GBS) is an autoimmune polyneuropathy involving mainly motor but also sensory and autonomic nerves. It is considered postinfectious and is been linked with many infectious organisms such as human immunodeficiency virus, Zika virus, and others. Since the onset of the pandemic, a few cases of GBS with a temporal association with SARS-CoV-2 infection has been reported in adults and children. The manifestations are similar to the classic clinical phenotype of progressive, ascending, symmetrical flaccid paralysis of the limbs with areflexia/hyporeflexia, and with or without cranial nerve involvement. This series describe three children with post-COVID GBS. Case Description: Three unrelated boys, 14 years, 11 years, and 7 years in age presented with varying combinations of pain, paraesthesias, and ascending weakness involving their limbs for a few days. We suspected GBS based on the clinical phenotype of rapidly progressive symmetrical weakness. The Modified National Institute of Neurological Disorders and Stroke Criteria for establishing the clinical diagnosis of GBS were satisfied. The typical albuminocytological dissociation in cerebrospinal fluid was observed in all. Management: The GBS was presumed to be postinfectious secondary to the COVID-19 virus in each one, based on elevated COVID-19 immunoglobulin G (IgG) and IgM antibody titers, exclusion of other common infectious organisms, and normal magnetic resonance imaging. All these patients were started on intravenous immunoglobulin and methylprednisolone. Two children recovered without any neurological deficits. The third child expired due to respiratory involvement. Conclusion: COVID-19 infection may result in GBS, the clinical profile of which is similar to that seen after other infectious organisms.

Background and Aim: Palm print and prayer signs are manifestations of “limited joint mobility” syndrome caused by long-standing Type I and Type II diabetes mellitus. This study aims at finding out, which of the two signs is more sensitive for the prediction of difficult intubation in type II diabetes mellitus patients. The secondary objective is to correlate the above two signs with the Cormack–Lehane View during direct laryngoscopy and also to determine whether the duration of Type II diabetes mellitus correlates with difficult intubation in isolation. Materials and Methods: A prospective observational study was carried out in a tertiary care hospital. One hundred and fifty patients suffering from Type II diabetes mellitus, undergoing elective general anesthesia with endotracheal intubation, were enrolled in the study. The correlation between Palm print and Prayer sign with Cormack and Lehane grades was studied using the Chi-square test, continuity correction, and Fisher's exact test. The diagnostic efficacy of intubation difficulty for both the signs was assessed by calculating sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratio. Results: The palm print sign was found to be a better indicator of difficult intubation in type II diabetes mellitus patients (P < 0.01). The duration of Type II diabetes mellitus was found to be associated well with difficult intubation (P = 0.007). Conclusion: Palm print sign is the single most important test for predicting difficult intubation in Type II diabetes mellitus patients. Duration of Type II diabetes mellitus itself correlates well with difficult intubation.

Introduction: Blood transfusions (BTs) are often required by neonates for different indications. There is usually a deficiency of available blood because of the non-availability of donors, lack of awareness, irrational demand, poor supply chain management system, etc., especially in developing countries. This study was done to determine the usefulness of umbilical cord blood (UCB) as an alternative to adult blood (AB) in neonates and to compare the change in haematological parameters after transfusion and compare outcomes. Materials and Methods: It was a prospective interventional study of UCB transfusions given to neonates requiring blood. UCB was collected in the labour room, under all aseptic precautions, and pretesting was done in the blood bank. Neonates fulfilling inclusion criteria were included. UCB and AB were given as per availability and consent. Post blood analysis was done after 6 h of transfusion watched for reactions. Outcomes such as death, discharge and duration of hospital stay were analysed. Results: A total of 91 BTs were performed, out of which 34 received UCB and 57 with AB. The mean rise of haemoglobin in UCB transfused patients was 2.01 g/dl. Conclusions: In neonates requiring BT, whole UCB is a good and safe alternative to whole AB.

Background and Aims: Troops deployed at high-altitude area (HAA) suffer from various high-altitude illnesses (HAIs) including high-altitude pulmonary edema (HAPE). There are various criteria to diagnose and assess the severity of HAPE, but point-of-care ultrasound (POCUS) of the lung has also been used in isolation by physicians. The aim is to assess whether POCUS of the lung improves the ability to diagnose the severity of HAPE. Methodology: A retrospective, cross-sectional descriptive study was planned for the patients treated for HAPE (n = 46) at our hospital from January 2019 to March 2020. Prehospital admission data, hospital admission data, and discharge data for the first-time inductees and reinductees were collected from the central hospital admission registry and central database of the medical department and intensive care unit. Results: The incidence of HAPE was 2.2 per 1000. First-time inductees (n = 30) were affected more when compared to reinductees (n = 16) and the maximum were at the third stage of HAA. POCUS of the lung facilitated the diagnosis of the six patients with mild HAPE with no positive radiological features. Conclusions: POCUS of the lung should be routinely used by the medical officers deployed at high altitudes. It will increase the diagnostic rate of HAPE with meticulous grading of the severity, thereby aiding in formulating the case-specific treatment protocol.

Abstract Kafirin, the hydrophobic prolamin storage protein in sorghum grain is enriched when the grain is used for bioethanol production to give dried distillers grain with solubles (DGGS) as a by-product. There is great interest in DDGS kafirin as a new source for biomaterials. There is however a lack of fundamental understanding of how the physicochemical properties of DDGS kafirin having been exposed to the high temperature conditions during ethanol production, compare to kafirin made directly from the grain. An understanding of these properties is required to catalyse the utilisation of DDGS kafirin for biomaterial applications. The aim of this study was to extract kafirin directly from sorghum grain and from DDGS derived from the same grain and, then perform a comparative investigation of the physicochemical properties of these kafirins in terms of: polypeptide profile by sodium-dodecyl sulphate polyacrylamide gel electrophoresis; secondary structure by Fourier transform infra-red spectroscopy and x-ray diffraction, self-assembly behaviour by small-angle x-ray scattering, surface morphology by scanning electron microscopy and surface chemical properties by energy dispersive x-ray spectroscopy. DDGS kafirin was found to have very similar polypeptide profile as grain kafirin but contained altered secondary structure with increased levels of β-sheets. The structure morphology showed surface fractals and surface elemental composition suggesting enhanced reactivity with possibility to endow interfacial wettability. These properties of DDGS kafirin may provide it with unique functionality and thus open up opportunities for it to be used as a novel food grade biomaterial.

The recent advances in telemedicine have offered real and practical opportunities to health-care providers in sharing expertise and resources in health care over distances. In India, telemedicine has revolutionized the health-care system by minimizing the cost, avoiding the long-distance travels and in timely providing specialist care in remote areas. The Indian Army is also reaping the benefits of telemedicine, by providing round-the-clock medical care to the troops deployed in high-altitude areas.

Abstract Ancient Indian iron artefacts have always fascinated researchers due to their excellent corrosion resistance, but the scientific explanation of this feature remains to be elucidated. We have investigated corrosion resistance of iron manufactured according to traditional metallurgical processes by the Indian tribes called ‘Agaria’. Iron samples were recovered from central India (Aamadandh, Korba district, Chhattisgarh). Iron artefacts are investigated using a range of correlative microscopic, spectroscopic, diffraction and tomographic techniques to postulate the hidden mechanisms of superlative corrosion resistance. The importance of manufacturing steps, ingredients involved in Agaria’s iron making process, and post-metal treatment using metal-working operation called hot hammering (forging) is highlighted. This study also hypothesizes the probable protective mechanisms of corrosion resistance of iron. Findings are expected to have a broad impact across multiple disciplines such as archaeology, metallurgy and materials science.

Background and Aims: COVID-19 infection has the potential to spread exponentially during aerosol-generating procedures like intubation. The aim was to find the compliance toward the actual practice as well as the existing knowledge gap and adherence to the guidelines among the medical professionals while attempting intubation in a known or suspected COVID-19 patients. Materials and Methods: A cross-sectional web-based survey format was planned using English questionnaire in an online form (Google® Forms). One hundred and forty valid responses for 27 questions were received. Maximum participation was received from Indian anesthesiologists working in government, semi-government, and private health facilities, performing the intubation routinely. All the valid responses were statistically analyzed by calculating the significant difference in means and proportions, with P < 0.05 being considered statistically significant. Results: Eighty percent of the respondents received training for donning and doffing and regularly wore personal protective equipment for the airway procedure. Scarce simulation training (22.1%), minimum screening before entering into a intubation scene (37.9%), frequent use of bag-mask ventilation (18.2%) or high flow nasal cannula (19.7%) use for preoxygenation, confirmation of the depth of endotracheal tube by auscultation (34.5%), and having no plan B in case of unanticipated difficult airway (27.9%) make the knowledge gap evident. The survey pointed out toward the infrastructural requirement of negative pressure intubation rooms, availability of waveform capnography, and widespread use of videolaryngoscope. Conclusion: This survey gives us an insight into the compliance with existing lacunae and nonuniform practices of the recommended guidelines for the airway management during COVID-19 pandemic with its pragmatic solution.

As anatomical structures get exposed intraoperatively, we present a case series of 18 patients of the surgeon-assisted interfascial plane block with local anesthetic infiltration between pectoralis minor and serratus anterior (SA) and between SA and latissimus dorsi for postoperative analgesia in patients undergoing modified radical mastectomy. Surgeons infiltrated 25 ml of 0.25% bupivacaine with dexmedetomidine (0.5 μg/kg) in the above-mentioned plane after the completion of axillary dissection and the removal of axillary content en bloc with the breast. The median pain score was assessed by numeric rating scale for pain. This score was

Video-assisted thoracoscopic surgery (VATS) is a less invasive approach for thoracoscopic surgery providing better visualization through minimal access. In addition, it offers less postoperative pain, fewer operative complications, and shortened hospital stay. These advantages make VATS ideal for the pediatric age group. Various societies recommend the use of VATS for Stage 2 pulmonary empyema and also in some cases of early Stage 3 where the plane of cleavage exists between the pleura and the exudate. A well-executed one-lung ventilation (OLV) is necessary for a successful VATS; however, performance of OLV and postoperative pain management in children poses a challenging task for an anesthesiologist.

Background: Endoscopic procedures in gastroenterology (GE) imaging suite are conducted primarily under moderate sedation (MS) and general anesthesia (GA). Various factors determine the choice of the technique such as the physical status of the patient, an anticipated difficult procedure, or an unanticipated complication. Aims: The aim was to study various factors affecting the selection of anesthesia techniques in patients undergoing endoscopy. This was a cross-sectional descriptive study in a tertiary care hospital. Methods: All patients who underwent upper gastrointestinal endoscopic procedures (n = 373) from January 2017 to December 2018 were included in the study. Patients were divided into groups on the basis of the anesthesia technique employed as MS – Group I (n = 343) and GA – Group II (n = 30). Data were collected for patient related and procedure related factors such as age, sex, physical status of the patient, complexity of the endoscopic procedures, anesthesia duration, drugs used, complications and recovery profile, which were analyzed for the two groups as per the entries made in the GE suite and central anesthesia registry. Statistical analysis was done using SPSS software Version 22.0 (IBM Corp., Armonk, NY, USA). Categorical variables were tested using Chi-square test and means were compared using t-test. Conclusions: MS was preferred in patients with lesser grades of physical status and in less complex GE procedures as compared to GA.

Introduction: Identifying the Paravertebral Space (PVS) by its anatomical landmarks is associated with high failure rates and complications. With the advent of Ultrasonography (USG), failure rate has decreased leading to an increased interest in performing USG-guided Thoracic Paravertebral Block (TPVB). Aim: To assess the efficacy and safety of ultrasound guided TPVB and its comparison with the landmark-based technique, in patients undergoing elective unilateral breast surgery. Materials and Methods: This cross-sectional study was carried out at Command Hospital, Pune from July 2014 to December 2015, on females between 18-70 years, accepted in American Society of Anaesthesiology (ASA) I-III for unilateral breast surgeries. Patients were divided into two groups with 40 subjects in each group. Group A subjects were treated with anatomical landmark technique and group B subjects with Ultrasound-guided (USG-guided) technique. The p-value 0.05 using Fisher’s-Exact test). Mean (SD) time taken for performing the block in group A was 371.10 (10.37) seconds while it was 613.73 (37.15) seconds in group B (p-value

Background: It is challenging to assess intravascular volume status for clinicians caring for patients in the perioperative period. Previous studies have recommended the inferior vena cava collapsibility index (IVCCI) to assess the volume status of a patient. However, these studies have been carried out in mechanically ventilated patients with consistent tidal volumes. The evidence for this technique in spontaneously breathing patients is far weaker. This study was performed to assess if IVCCI was increased in spontaneously breathing fasting preoperative patients and if this measure decreased with a fluid bolus. Materials and Methods: After ethical approval and registration, we conducted a prospective study to assess the ability of IVCCI in fasting preoperative patients and the change in IVCCI after a fluid bolus. Fifty adult patients scheduled for surgery, who had been fasting for >6 h, had their IVCCI assessed by scanning of the IVC before and after a 500 ml normal saline intravenous fluid bolus. Results: Prior to the fluid bolus, 46 patients (92%) had an IVCCI of >12%, while 41 patients (82%) had a IVCCI of >12% after a fluid bolus. The mean IVCCI before the fluid bolus was 32.2% (standard deviation [SD] 13.4) and it reduced to a mean IVCCI of 26.3% (SD 20) after administration of a 500 ml fluid bolus, indicating fluid responsiveness. The value of P was < 0.001. Conclusion: In this study, IVCCI in spontaneously breathing patients was both a sensitive indicator of fluid depletion and had a high positive predictive value to identify fluid responsiveness.

Background: Various drugs and regional blocks are available for providing suitable postoperative analgesia after lower segment cesarean section (LSCS), however commonly used techniques are conventional wound infiltration with local anesthetic and the current technique of transversus abdominis plane (TAP) block. This study aims to compare the analgesic efficacy of TAP block with that of direct infiltration of local anesthetic into a surgical incision in LSCS patients. Materials and Methods: A total of 80 patients for LSCS under subarachnoid block were allocated in two groups; Group A (TAP block, n = 40). TAP block was done by the Anesthesiologist and Group B (wound site infiltration, n = 40); wound site infiltration was done by the operating Surgeon. Postoperative pain, assessed by the Visual Analog Scale (VAS) levels at 2, 6, 12, and 24th h, the requirement of rescue analgesia and patient satisfaction was analyzed. Results: The VAS scores were lower at the 2nd and 4th h (statistically significant) of the postoperative period but at 6th, 12th, and 24th h, though VAS scores in Group A were lower in comparison to Group B, differences were statistically insignificant. The time to administer the first dose of rescue analgesia (421 ± 118.8 min) was longer in Group A in comparison to Group B (187 ± 148.3 min) with significantly fewer cumulative dose and delayed requirement of rescue analgesia in the first 24 h. Conclusions: Wound site infiltration and TAP block did not significantly differ regarding postoperative pain score in post-LSCS patients except the initial 4 h, but the TAP block showed an advantage with significantly reduced cumulative dose and delayed requirement of rescue analgesia in first 24 h.

Background and Aims: This study was planned to compare intubating conditions with aerosol box, while attempting intubation with either direct laryngoscope (DL) using Macintosh blade or McGrath MAC™, videolaryngoscope (VL). Methodology: Sixty adult patients coming for the emergency surgeries during COVID-19 pandemic were divided equally by consecutive sampling into either Group 1 (DL) or Group 2 (VL). General anesthesia was administered with aerosol box covering the head and trunk of the patient. The laryngoscopy was attempted based on the group allocation with either VL or DL through aerosol box. Following observations were noted, total intubation time, number of attempts, Cormack–Lehane (CL) view, intubation difficulty scale (IDS), use of airway adjuncts, and external laryngeal maneuver. Results: Mean (standard deviation) time taken to intubate was 25.36 (6.22) sec in DL group and 21.9 (5.56) sec in VL group. Median IDS scoring was 1 in DL group and 0 in VL group indicating toward ease of intubation with the videolaryngoscope. Improved glottic view (CL Grade 1) was attained commonly with VL group and higher CL grades (2b) were common with DL group (23.3%). No intubation aids were required in VL group although 30% in DL required bougie for the intubation. External laryngeal maneuver was applied in 40% subjects undergoing DL with no maneuvers needed in VL group. First pass success of intubation was comparable in both the groups. Conclusion: Intubating conditions are favorable with VL when aerosol box is included which requires acquisition of the skills depending on its availability. However, the intubation should be attempted with the technique the clinician has the expertise during this pandemic.

Background: Recovery from neuromuscular blockade is commonly assessed by clinical signs. There exists wide disparity in what is recommended to monitor neuromuscular blockade and routine clinical practice by anesthesiologists. The objective signs of train-of-four (TOF) ratio of >0.9 and double burst stimulation (DBS) ratio of 1.0 indicate adequate neuromuscular function. This study was planned at a tertiary care hospital to evaluate the ongoing practice of assessing neuromuscular recovery employing clinical signs and comparing with simultaneous TOF and DBS values. Design: A cross-sectional analytical study. Methodology: A total of 100 consecutive patients undergoing surgical procedures lasting more than 1-h duration under general anesthesia with intermediate acting muscle relaxant were enrolled and data of 60 patients analyzed. After extubation, an independent observer recorded simultaneous TOF and DBS ratio using acceleromyography as the clinical signs of neuromuscular recovery (eye opening, tongue protrusion, head lift, sustained bite, hand grip strength, and ability to cough) were attained. Statistical Analysis: Statistical analysis was done utilizing SPSS version 20 (SPSS Inc., Chicago IL, USA) software. Continuous variables are expressed as mean (standard deviation) and Pearson's correlation coefficient was applied to study the correlation between the clinical parameters and quantitative measures of neuromuscular recovery. Results: There was a significant association between ability to retain tongue depressor (sustained bite), absent double vision and ability to cough effectively and TOF and DBS ratios (P < 0.05). None of the clinical signs correlated with TOF ratio >0.9 or DBS ratio of 1.0. Conclusion: Clinical signs of recovery fail to reliably predict postoperative residual paralysis compared to objective neuromuscular monitoring.

Pediatric unanticipated difficult airway in cases of subglottic stenosis (SGS) is always a challenge. We present two cases of SGS which were managed according to the pediatric difficult intubation protocols where supraglottic device was used as secondary intubation plan successfully. Airway management in these cases depends on the urgency of the surgery; if the surgery is nonemergent, the case can be postponed and both surgical and nonsurgical modalities of treatment can be offered; however, in wake of emergency surgery, surgical airway is indicated. Strategies of the pediatric airway management have evolved over the years, but the risk and morbidity associated with the adverse airway events loom larger.

Present study investigated the use of fibre reinforced plastic (FRP) sheet roof as alternate roofing material in goat shelters. Twenty lactating goats, 10 each, housed under pen having cemented sheet roof (CR) and FRP sheet roof (PR) were managed uniformly during winter. Analysis of data revealed that microclimate and physiological responses of does were similar and does were equally comfortable. The milk yield was significantly lower up to 30 days, recorded lower trend up to 60 and 90 days of lactation in does housed under PR than does under CR. The overall mean weekly test day milk yield and body weight of does recorded under PR was significantly lower than does under CR. Results indicated that the provision of FRP roof as alternate roofing material in goat shelters in semi-arid areas may not be beneficial in increasing production of lactating goats during winter.

Hyperhomocysteinemia is a rare condition which predisposes to arterial and venous thrombosis. Plasma homocysteine levels are influenced by many genetic factors and environmental factors. Increased levels of homocysteine at high-altitude areas (HAA) can predispose to upper-extremity deep-vein thrombosis (UEDVT). Therefore, awareness by the medical authorities regarding this entity at HAA as a sole cause of UEDVT needs to be established. Prompt reduction in the homocysteine level can be therapeutic as well as prophylactic in preventing the morbidity.

The anesthetic management of a patient with dilated cardiomyopathy (DCM) for noncardiac surgery is challenging due to associated congestive heart failure, malignant dysrhythmias, sudden cardiac arrest, implanted rhythm devices, and thromboembolism. We report successful conduct of a case of DCM on cardiac resynchronization device with Cauda equina syndrome (CES) under general anesthesia in prone position. The anesthetic concerns specific to the pathophysiology of DCM are also discussed.

Postoperative pulmonary complications are uncommon following percutaneous nephrolithotomy (PCNL). However, evidence has shown the occurrence of pneumothorax and pneumomediastinum following PCNL. Such life-threatening complications can prove catastrophic if not diagnosed and intervened immediately. Perioperative point-of-care lung ultrasound can play a pivotal role in immediate diagnosis of the pneumothorax and resultant timely intervention limits the morbidity in the immediate postoperative period.

Temporomandibular joint (TMJ) ankylosis is commonly seen in childhood and its etiology is multifactorial. Common causes include congenital malformations, use of forceps during delivery, local or systemic infections or systemic autoimmune diseases (rheumatoid arthritis, psoriasis, and sickle cell anemia), burns, and trauma. TMJ ankylosis leads to dentofacial deformity, restricted mouth opening, malocclusion, difficulty in mastication, malnutrition, dental caries, poor oral hygiene, impaired speech, and cosmetic disability. Neglected childhood bilateral TMJ patients present in adulthood with micrognathia, retrognathia, and severe symptoms of obstructive sleep apnea (OSA). They have narrow airway passages due to pseudoglossia, subatmospheric intrapharyngeal pressure, and hypotonicity of the oropharyngeal muscles which make the mask ventilation difficult. Highlights of the management of the case include the use of the awake fiber-optic-assisted intubation, a gold standard for difficult airway management, and incorporation of Brainlab Kick navigation station 18070 (USA) aiding in the precise surgical dissection and preventing injuries to great vessels and nerves. Extubation strategy with preextubation dose of hydrocortisone and dexmedetomidine helped in the smooth recovery. Early recovery and rehabilitation were further facilitated with the use of nasal continuous positive airway pressure postextubation which helped in reducing symptoms of OSA and airway obstruction.

Context: Pediatric pain management is always a challenge for the anesthesiologist as surgery and pain inflicted at a young age has a bearing on the response to pain in the future. Aims: The aim of the study was to compare the different regional anesthesia techniques adopted for the postoperative pain relief in children aged between 6 months and 6 years who underwent open pyeloplasty. Settings and Design: It was a retrospective study. Materials and Methods: Children were divided into three groups: caudal group (n = 18), epidural group (n = 23), and transversus abdominis plane (TAP) group (n = 32) based on the regional anesthesia technique used. The primary outcome measured was total duration of postoperative analgesia. The secondary outcomes measured were median Face, Legs, Activity, Cry, Consolability (FLACC) score, intraoperative and postoperative heart rate, and mean arterial pressure along with incidence of any complication. Statistical Analysis Used: One-way ANOVA and Kruskal–Wallis test were applied for comparison between the three groups. Results: Postoperative analgesia duration in minutes was highest in the epidural group (1117.3 ± 112.2), followed by TAP group (1070.0 ± 109.3) and caudal group (261.5 ± 18.2). Median FLACC pain scores achieved at 12 and 24 h were least in the epidural group, followed by the TAP and caudal groups. Conclusions: Epidural analgesia is best suited in terms of the duration as well as the quality of postoperative analgesia is concerned, but surgeon-assisted TAP block looks promising and a feasible option with comparable postoperative analgesia quality and duration.

Context: Intraoperative hypothermia is a leading cause of morbidity in the perioperative period. This retrospective audit study was planned to assess the efficacy of three different active warming devices used in maintaining euthermia in patients who underwent lower segment cesarean section (LSCS). Aims: Audit of the three different fluid warming techniques in maintaining euthermia in patients who underwent cesarean sections. Settings and Design: A retrospective audit. Materials and Methods: In total, 698 patients were included in the study who underwent LSCS and were divided on the basis of the warming technique used into Group 1 (n = 241, blood warming bath), Group 2 (n = 238, cabinet), and Group 3 (n = 219, inline warmer). The preoperative core body temperature was compared in each group with the intraoperative body temperature as well as with core body temperature measured 20 minutes after shifting the patient in the postoperative room as per the entries made in the central anesthesia registry. The incidence of the shivering was also noted from the data for each group separately. Statistical Analysis Used: One-way analysis of variance was applied for comparing the mean (SD) between the three groups and unpaired t-test was used to compare two mean (SD) values.P value

Purpose: To describe the prevalence, characteristics including risk factors, and pattern of severe ROP from eastern Madhya Pradesh region of India. Methods: In this 5-year retrospective study, Baseline characteristics, systemic risk factors, and findings of ROP screening were noted. Factors associated with severe ROP including aggressive posterior ROP (APROP), stage IV and V ROP were analyzed. Statistical analysis was done using SPSS version 20. Results: Of 763 babies screened, 30% were diagnosed to have ROP. Prevalence of severe ROP was 14.2% (109) of which 60 (55.5%) were classic and 30 (27.7%) were APROP. Eighteen (16.6%) were diagnosed as advanced ROP (stage IV and V). Mean gestational age (GA) and birth weight (BW) for severe ROP were 31.05 weeks and 1.34 kg, respectively which were inversely associated with severe ROP. But a significant 10% of severe ROP were seen in late preterm babies, >34 weeks. Low GA and respiratory distress syndrome (RDS) were significant risk factors for APROP. Most important factor for stage IV and V ROP was late presentation for screening. Conclusion: The study found a high prevalence of severe ROP including APROP. Almost 7% severe ROP cases were outside screening guidelines of NNF. Late presentation for screening is the most important factor associated with ROP related blindness.

Obesity is an important problem with increasing incidence in affluent society. Managing obese patients in prone positions under general anesthesia requires optimization and adequate preparation for a successful outcome. Despite all optimizing measures are taken preoperatively, complications such as kinking of armored endotracheal tubes may take place in these patients in prone position leading to problems during mechanical ventilation. Armored tubes are being widely used in anesthesia practice in surgeries involving procedures during which kinking are anticipated. There have been reports of armored tube kinking both intraorally and extraorally in the prone position. Hence, prompt anticipation of tube kinking is desirable, especially in obese patients (increased neck circumference and submental fat) positioned prone. Herewith, we report two cases of unusual complication of armored tube kinking in prone position in obese patients.

Spinal anesthesia (SA) is utilized as an effective means of anesthesia and has an impressive safety record but it is not devoid of complications, and sometimes, the complications are as fatal as cardiac arrest. Although many factors are involved in etiology of cardiac arrest under SA, the vagal responses to the decreased preload are the most common culprits. We report two cases of cardiac arrest under SA; which happened despite our patient being adequately preloaded utilizing the ultrasonography-guided targeted volume therapy. The patients were successfully resuscitated with no neurological deficit.

In this report, we present a case of Purtscher-like retinopathy in a 12-year-old male child with nephrotic syndrome. He was a known case of steroid-dependent nephrotic syndrome, frequent relapser with spontaneous bacterial peritonitis, who presented with complaints of difficulty in vision in both eyes. The fundus examination showed multiple cotton-wool spots and Purtscher fleckens centered around the optic nerve head with superficial retinal hemorrhages in both eyes. Fluorescein angiography confirmed the diagnosis of Purtscher-like retinopathy.

Background: The cardiopulmonary resuscitation (CPR) in prone position has been dealt with in 2010 American Heart Association (AHA) guidelines but have not been reviewed in 2015 guidelines. The guidelines for patients presenting with cardiac arrest under general anesthesia in lateral decubitus position and regarding resuscitation in confined spaces like airplanes are also not available in AHA guidelines. This article is an attempt to highlight the techniques adopted for resuscitation in these unusual situations. Aims: This study aims to find out the methodology and efficacy in nonconventional CPR approaches such as CPR in prone, CPR in lateral position, and CPR in confined spaces. Methods: We conducted a literature search using MeSH search strings such as CPR + Prone position, CPR + lateral Position, and CPR + confined spaces. Results: No randomized controlled trials are available. The literature search gives a handful of case reports, some simulation- and manikin-based studies but none can qualify for class I evidence. The successful outcome of CPR performed in prone position has shown compressions delivered on the thoracic spine with the same rate and force as they were delivered during supine position. A hard surface is required under the patient to provide uniform force and sternal counter pressure. Two rescuer technique for providing successful chest compression in lateral position has been documented in the few case reports published. Over the head CPR and straddle (STR), CPR has been utilized for CPR in confined spaces. Ventilation in operating rooms was taken care by an advanced airway in situ. Conclusion: A large number of studies of high quality are required to be conducted to determine the efficacy of CPR in such positions.

Context: An analytical pilot study was conducted prospectively to ascertain the efficacy of a new method of throat packing “Flange Slide Pack Technique” (FSPT) in patients undergoing nasal, faciomaxillary, and oral surgeries. Aim: To compare the conventional technique of throat packing guided by direct laryngoscopy with FSPT where the Macintosh laryngoscope blade is used as aid for throat packing. Settings and Design: A comparative observational pilot study was conducted at a tertiary care hospital. Subjects and Methods: Subjects were randomly allocated into two groups based on the technique for throat packing by computer-generated random numbers as Group A (conventional technique) and Group B (FSPT). Primary outcomes measured were total time duration taken for packing the throat with a standardized length of ribbon gauze and changes in heart rate and change in Mean Arterial Pressure (MAP) from baseline. Secondary outcomes measured were incidence of postoperative sore throat (POST) at 6 h postoperatively and ease of insertion of the throat packs. Statistical Analysis: Parametric data were analyzed using “unpaired t-test.” Comparison of proportions and data were analyzed using Chi-square test. SPSS Version 17 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Results: The time taken to pack the throat was shorter in Group B; percentage increase of MAP from baseline was higher in Group A. Ease of insertion of throat pack was more in Group B. POST results were insignificant. Conclusions: FSPT can prove to be an alternative technique to the conventional method of packing the throat by minimizing duration of laryngoscopy and thereby limiting the stress response.