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Adults with congenital heart disease are increasing due to improvement in infant heart surgery and availability of better cardiac care. Pregnancy in these patients requires multidisciplinary team approach due to circulatory changes. We describe an anesthetic management of the parturient undergoing cesarean section having severe pulmonary restenosis.

Introduction: Laparoscopy is increasingly being performed for urologic surgeries either through transperitoneal or retroperitoneal approach. While physiological changes during transperitoneal surgeries have been extensively studied, very few studies have explored the effect of retroperitoneal laparoscopy. Aim: To compare physiological changes that occurred when urologic laparoscopic surgeries were carried out through either transperitoneal or retroperitoneal approach in lateral positions. Primary outcome was respiratory changes and haemodynamic changes were considered secondary outcome. Materials and Methods: This single centre prospective non randomised human study was conducted in 46 healthy individuals undergoing elective urologic laparoscopic surgeries at Dr. H.L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India, from January 2017 to July 2017 and patients were divided into two groups according to the surgical approach used: 1) Transperitoneal (Trans) group; and 2) Retroperitoneal (Retro) group. Compliance, Peak Inspiratory Pressure (PIP), Minute Ventilation (MV), Heart Rate (HR) and Mean Arterial Pressure (MAP) were monitored at defined time interval. Arterial blood gases were also measured to compare Partial Pressure of Arterial Oxygen/Fraction of Inspired Oxygen (PaO2 /FiO2 ) ratio. Chi-square and t-test were used for statistical comparison between the two groups. A p-value

One of the causes of failed epidurals is catheter misplacement. Though various techniques of epidural space identification have been developed, none of them is 100% successful. Here, we present a case of lumbar epidural catheter misplacement in a patient scheduled to undergo right sided open nephrectomy. Catheter was found in the surgical field coming out of psoas major muscle.

Study Objective: To assess outcome from anaesthesia during laparoscopic bilateral simultaneous nephrectomy. Design: Retrospective study. Measurements: Preoperative Hb%, serum potassium, coagulation profile electrocardiography (ECG) changes, 2D Echography, x-ray chest, haemodynamic changes, end-tidal carbon dioxide (EtCO 2 ), fluid management and postoperative analgesia. Results: The mean age was 24.75 ± 14.35 years. The mean duration of surgery was 120 ± 80 minutes. The Hb%, serum creatinine and serum potassium were 9.4 ± 1.04%, 6.79 ± 4.91 meq/L and 3.61 ± 0.51 meq/L, respectively. Pulse rate mean blood pressure and EtCO 2 were recorded after creation of pneumoperitoneum and at 15, 30, 45 and after exsufflation of pneumoperitoneum. After pneumoperitoneum, there was increase in pulse rate, systolic blood pressure, diastolic blood pressure and EtCO 2 . After 30 minutes and throughout the surgery, these variables remained stable. Four patients required nitroglycerine infusion for intraoperative hypertention. Only one patient required packed cell volume (PCV) transfusion and total intravenous fluid was 1 ± 0.5 L. At the time of exsufflation, there was decrease in pulse rate, systolic and diastolic blood pressure and EtCO 2 . Conclusion: Because of advancement in anaesthetic agents and muscle relaxant, there is safe outcome from anaesthesia during laparoscopic bilateral simultaneous nephrectomy.

Background: A specially designed wire-reinforced endotracheal tube - the Fastrach silicone tube (FTST) designed to facilitate endotracheal intubation through intubating laryngeal mask airway (ILMA) are expensive and not readily available. Hence, it is worth considering alternative such as polyvinyl chloride tracheal tube (PVCT), which is disposable, cheap and easily available. The aim of the present study was to compare the clinical performance of FTST with conventional PVCT for tracheal intubation through ILMA. Methods: After informed consent, 60 ASA I-II adults with normal airway undergoing elective surgery were randomly allocated to undergo blind tracheal intubation through ILMA with a FTST or conventional PVCT. Overall success rate, ease of insertion, number of attempts for successful intubation, critical incidence during intubation and post-operative sore throat were compared. Results: The overall success rate with FTST was 96.63% and 93.33% with PVCT; in addition, the first-attempt success rate was 86.25% with FTST compared to 82.14% with PVCT. The time taken for intubation was 18.6 ± 6.8 s. in FTST group and 22.42 ± 8.5 s. in PVCT group. Incidence of sore throat was 21.42% in PVCT group compared with 6.89% in FTST group. Conclusion: Blind tracheal intubation through an ILMA with the conventional PVCT instead of FTST is a feasible alternative in patients with normal airways.

Background : Percutaneous nephrolithotomy is a routine endourologic procedure in patients with renal stones. Although it is less painful than open surgery, good postoperative analgesia is required to alleviate pain around nephrostomy tube. Materials and Methods : Sixty ASA grade I patients, 18 to 60 years of age, of either sex were randomized to receive 20 ml of 0.25% bupivacaine (group S) or 20 ml of normal saline (group C) through 23-gauge spinal needle along the nephrostomy tube under fluroscopic guidance at the end of the surgery. Postoperative pain score was assessed by visual and dynamic visual analog scores. When the scores were ≥4, rescue analgesia was given in the form of tramadol 1 mg/kg i.v. upto maximum 400 mg in 24 hours. Time to first demand analgesia and total dose of tramadol in first 24 hours was noted. Results : Pain scores at rest and during coughing as well as rescue analgesic requirements for first 24 hours were significantly less in the bupivacaine group than those of the control group (P < 0.05). The first request for demand analgesia was around 9 hours in group S, while in group C it was around 2.6 hours (P < 0.05). Total requirement of tramadol in group S was 119.3 mg and in C group it was 276.8 mg (P < 0.05). Conclusion : Peritubal infiltration of 0.25% bupivacaine is efficient in alleviating postoperative pain after PCNL.

Sir, Central venous catheterization (CVC) is a routine procedure in intensive care unit as well as in surgical patients requiring monitoring of hemodynamic variables, for medications and parentral nutrition, hemodialysis etc. The incidence of complications ranges from 5% to 29%[1] such as arterial puncture, hemothorax, pneumothorax, nerve injury, air embolism or dysrthythmias. Guidewire embolism during CVC is a rare iatrogenic complication.[2] The Seldinger technique is commonly used to cannulate the vessels.[3] We report a case of lost guidewire following internal jugular catheter placement and its successful management. A 64-year-old male, weighing 67 kg, 176 cm height had c/o hematuria since last 15 days. Patient was suffering from chronic obstructive pulmonary disease, diabetes and hypertension. Ultrasound showed bladder mass lesion, enlarged prostate, and hepatomegaly. His serum creatinine was 5.07 mg/dl, total cholesterol-18,170/cmm, serum glutamic-pyruvic transaminase-122.0 and serum glutamic oxaloacetic transaminase-118.0. In view of acute renal failure and septicemia, CVC for fluid management and drug administration was advised. During a busy night shift, a 2nd year resident was assigned to perform the procedure. The left internal jugular vein was cannulated using double lumen (Polymed Novocent Duo, 160 mm) polyurethane catheter by central approach after local infiltration, under ultrasound guidance. A J-tipped guidewire (0.035 mm, 50 cm) was introduced through the needle followed by dilatation of the tract with a dilator (8.5 Fr, 4 inches) and insertion of the catheter on the guidewire. During this procedure, the guidewire was inadvertently pushed further ahead into the vein. This went unnoticed by the resident, who tried to aspirate blood from both the lumen to confirm proper positioning of the catheter. Due to inability to aspirate free flow of blood from one of the lumen, the resident flushed saline through that lumen, which could have resulted in embolization of the guidewire. After completion of the procedure, he realized that the guidewire was missing and informed the seniors. An urgent chest X-ray [Figure 1] and X-ray kidneys, ureters, and bladder [Figure 2] were done in which guidewire was clearly visible. It was removed by gooseneck snare device through femoral percuteneous approach under local anesthesia and fluoroscopic guidance without any complication. Figure 1 Chest X-ray showing guidewire Figure 2 X-ray kidneys, ureters, and bladder showing embolized guidewire For the management of guidewire embolism, if the guidewire has embolized systemically, chest X-ray and if required X-ray abdomen will determine the position of the guidewire. The percutaneous method of extraction has fewer complications for which interventional radiology techniques such as dormia basket, gooseneck snare, endovascular forceps are preferable.[4] Cheddie and Sing[5] describe a similar approach for guidewire extraction using a goose snare device. Our take home massage is that, the complications of CVC should be kept in mind during cannulation. The guidewire should not be inserted too far as average distance from all access site is 18 cm. One should hold the guidewire tip firmly while introducing the catheter and should check the guidewire outside before flushing the percutaneous catheter. Without free flow of blood during aspiration, one should not flush the catheter. Gooseneck snare technique is safe for removal of embolized guidewire.

Idiopathic thrombocytopenic purpura (ITP) with HELLP represents a rare complication that requires combined care of obstetrician, anesthesiologist, hematologist, and neonatologist. At 37-week gestation a 35-year-old parturient (G2A1P0) a known case of chronic ITP presented with severe pregnancy induced hypertension (PIH), thrombocytopenia, and elevated liver enzymes. We describe successful anesthetic management of this patient who was taken for emergency caesarean section.

Background Appropriate anesthesia for pediatric renal transplantation requires stable intraoperative hemodynamics, optimal perfusion of the newly transplanted kidney and good analgesia during recovery. The aim of this study was to assess the preliminary application, success and safety of combined epidural and general anesthesia in pediatric renal transplantation in a small cohort. Methods We retrospectively reviewed the anesthesia records of 46 consecutive pediatric patients who received renal transplantation under combined epidural and general anesthesia from January 2003–2007. Results The mean patient age and weight were 13.2 ± 2.4 years and 25.7 ± 5.46 kg, respectively. The infused crystalloids, 20% albumin and red blood cell concentrates were 120 ± 2 mL/kg to achieve a CVP of 13 to 15 mm Hg. Brisk diuresis was observed in all patients. Epidural tramadol (2 mg/kg) provided good postoperative analgesia in 89% patients. 15% patients developed radiological evidence of pulmonary edema, only one required mechanical ventilation for hypoxemia. Minor adverse effects were nausea and vomiting (17.5%) and convulsions (8.5%). No perioperative mortality or major morbidity was recorded. Conclusion Epidural anesthesia is a useful adjunct to general anesthesia due to stable intraoperative haemodynamics and good postoperative analgesia.

Epidural route is preferable for postoperative pain relief in thoraco-abdominal and lower limb surgeries. We aimed to compare epidural butorphanol versus morphine for postoperative analgesia up to 24 hours in open nephrectomy surgery.80 ASA physical status I and II adult patients were selected for this randomized double blind prospective study. A standard balanced general anesthesia technique was applied for all patients. Epidural catheter was placed in lower thoracic inter-vertebral space before the start of surgery. Injection butorphanol 0.04 mg/kg in group B (n = 40) or morphine 0.06 mg/kg in group M (n = 40) was given in a double blind manner after completion of surgery and before extubation through the epidural catheter. Patients were observed for pain relief by Visual Analogue Scale (VAS) for the next 24 hours. Dose was repeated when VAS was4. The onset and peak effect of pain relief, duration of analgesia of 1st dose, frequency of drug administration and side effects if any were observed.The average onset of analgesia was 26.5 +/- 7.61 minutes with butorphanol and 62.5 +/- 13.4 minutes with morphine group which was statistically significant (p0.05). The mean peak effect of pain relief following 1st dose was 173 +/- 51.25 minutes with butorphanol and 251 +/- 52.32 minutes with morphine group. The duration of pain relief after 1st dose was statistically significant and was 339.13 +/- 79.57 minutes in group B and 709.75 +/- 72.12 minutes in group M which was gradually increased on repeated dosing in group B while it was almost same in Group M. Number of doses required in 24 hours was significantly higher (p0.05) in butorphanol group than morphine group. Somnolence was the main side effect in group B while pruritus was the main side effect with group M.Epidural butorphanol appears to provide safer and faster postoperative analgesia without much untoward effects but its analgesic action is short so more repeated doses are required than morphine via epidural catheter up to 24 hours.

Percutaneous nephrolithotomy (PCNL) is a common endourologic procedure with less morbidity than open surgery. However, pain around the nephrostomy tube requires good post operative analgesia. So we hypothesize that infiltration of local anesthetic from the renal capsule to the skin around the nephrostomy tract would relieve the pain in the initial postoperative period.60 adult patients of either sex with ASA physical status I to III and undergoing percutaneous nephrolithotomy were randomized for a prospective double-blind controlled study. Patients were divided into control group (n = 30) and ropivacaine group (n = 30). Balanced general anesthesia was given. After completion of surgical procedure, 23 gauge spinal needle was inserted at 6 and 12 o'clock position under ultrasonic guidance up to therenal capsule along the nephrostomy tube. 10 ml of 0.25% ropivacaine or normal saline solution was infiltrated in each tract while withdrawing the needle from renal capsule to the skin. Post-operative pain was assessed using visual analogue scale (VAS) and dynamic visual analogue scale (D-VAS) during deep breathing and coughing on a scale of 0-10 during the initial postoperative 24 hours. Rescue analgesia was given in the form of injection tramadol 1.0 mg/kg intravenously when VAS4 and maximum up to 400mg in 24 hours. Time to first rescue analgesic, number of doses of tramadol and total amount of tramadol required in the initial postoperative 24 hours were noted. Patients were observed for any side effect and treated accordingly.VAS at rest (VAS) as well as during deep breathing and coughing (DVAS) were significantly lower in ropivacaine group during first 24 hours. Mean time to 1st rescue analgesic in ropivacaine group was longer (10.7 +/- 2.64 hours) as compared to control group (2.05 +/- 1.44 hours) (P = 0.0001). Mean number of doses of tramadol in 24 hours in group-R were less (2.25 +/- 0.51) than group-C (4.4 +/- 0.68) (P = 0.0001). The mean total amount of tramadol in 24 hours in group-R was significantly lower than group-C. Side effects like nausea and vomiting and sedation were minimum and non-significant in both groups.Local anesthetic infiltration of 0.25% ropivacaine along the nephrostomy tract is efficient in alleviating post-operative pain after percutaneous nephrolithotomy surgery. The number of doses and total consumption of rescue analgesic were also decreased in the initial postoperative 24 hours.

A 24-year-old female at 34-week gestation, presented with malaise, nausea, vomiting, jaundice, and absent foetal movements. A clinical diagnosis of acute fatty liver of pregnancy was made. Although early caesarean section was performed, postoperative course was complicated by acute respiratory distress syndrome (ARDS) sepsis, and continuing coagulopathy. Supportive management in an intensive care unit resulted in successful outcome.

Background: Laparoscopic donor nephrectomy is a routine practice since 1995. Until now, the recipient has always undergone open surgery for transplantation. In our institute, laparoscopic kidney transplantation (LKT) started in 2010. To facilitate this surgery, the patient must be in steep Trendelenburg position for a long duration. Hence, we decided to study the effect of CO2 pnuemoperitoneum and Trendelenburg position in chronic renal failure (CRF) patients undergoing LKT. Methods: A total of 20 adult CRF patients having mean age of 31.7±10.36 years and body mass index 19.65±3.41 kg/m 2 without significant coronary artery disease were selected for the procedure. Cardiovascular parameters heart rate (HR), mean arterial pressure (MAP), Central venous pressure (CVP) and respiratory parameters (ETCO 2 , peak airway pressure) were noted at the time of induction, after induction, 15 min after creation of pnuemoperitoneum, 30 min after Trendelenburg position, 15 min after decompression of pnuemoperitonuem and after extubation. Arterial blood gas analysis was carried out after induction, 15 min after creation of pnuemoperitoneum, 30 min after Trendelenburg position and 15 min after clamp release. Total duration of surgery, anastomosis time, time for the establishment of urine output and total urine output were noted. Serum creatinine on the 1 st and 7 th post-operative day were recorded. Results: Significant increase in HR was observed after creation of CO 2 pneumoperitoneum and just before extubation. Significant increase in the MAP and CVP was noted after creation of pneumoperitoneum and after giving Trendelenburg position. No significant rise in the ETCO 2 and PaCO 2 was observed. Significant increase in the base deficit was observed after the clamp release, but none of the patients required correction. Conclusion: LKT performed in steep Trendelenburg position with CO 2 pneumoperitoneum significantly influenced cardiovascular and respiratory homeostasis; however, measured parameters remained within clinically acceptable range without affecting early function of the transplanted kidney.

Background: Epidural analgesia with opioid provides good control of postoperative pain in cesarean section, thereby improving the mother's ability to mobilize and interact with her newborn infant. Aim: The aim of this study is to evaluate and compare the analgesic actions and side effects of epidural analgesia with sufentanil, morphine or combination of the two after cesarean section. Materials and Methods: 60 women undergoing elective cesarean section were allocated into three groups of 20 each in a randomized blinded fashion. Epidural analgesia was administered with sufentanil 50 mcg in Group S; morphine 4 mg in Group M; and, a combination of sufentanil 25 mcg and morphine 2 mg was used in Group SM. Analgesic efficacy in terms of onset of action and duration of analgesia was assessed by using the Visual Analog Scale (0 to 10 cm) for 24 hours. Number of opioid doses needed in 24 hours was noted. Side effects like respiratory depression /excessive sedation, pruritus and nausea were recorded. Results: Onset of action were at 7.6 ± 1.5 minutes in group S, 67.6 ± 1.5 minutes in group M and 12.2 ± 2.6 minutes in group SM. Duration of analgesia was longer in group M 17.5 ± 1.9 hours and SM 13.8 ± 1.6 hours than in group S 5.2 ± 1.2 hours. More doses of analgesia were required in group S compared to group M and SM. Side effects were comparable in the three groups. Conclusion: Epidural administration of a combination of sufentanil and morphine offered the advantage of faster onset of action and longer duration of analgesia as compared to the two drugs administered alone.

Central venous catheters are routinely placed in patients undergoing major surgeries where expected volume and hemodynamic disturbances are likely consequences. The incorrect positioning may give false central venous pressure (CVP) readings leading to incorrect volume replacement and other serious complications. 50 American Society of Anaesthesiologists grade II-IV patients aged 18-60 years were selected for right-sided internal jugular vein (IJV) catheterization using Seldinger's technique. In group A, central venous catheterization was done under electrocardiography (ECG) guidance. In group B, the catheter was inserted blindly using Peres' formula of "height (in cm)/10". The position of the tip of central venous catheter was confirmed radiologically by postoperative chest X-ray. 92% of patients in group A had radiologically correct positioning of catheter tip i.e. above the carina, while in group B 48% patients had over-insertion of the catheter in to the right atrium. Intra-atrial ECG technique to judge correct tip positioning is simple and economical. It can determine the exact position intraoperatively and can justify a delayed postoperative chest X-ray to confirm CVC line tip placement.

Background: As an anesthetic adjuvant dexmedetomidine has been shown to provide good perioperative hemodynamic stability with minimum alveolar concentration sparing effect on inhalational anesthetic agents during laparoscopic surgeries performed under general anesthesia. Aim: The study was planned to investigate the effects of dexmedetomidine on attenuation of hemodynamic changes and requirements of intra-operative analgesic and inhalational anesthetic during laparoscopic surgeries and its postoperative side effects. Materials and Methods: A total of 70 patients scheduled for elective laparoscopic surgeries were randomized to receive bolus infusion of dexmedetomidine (group D) or saline (group S) 1 mcg/kg/h, followed by continuous infusion of the same, at the rate of 0.5 mcg/kg/h. Anesthesia was maintained with nitrous oxide in oxygen, muscle relaxant and isoflurane. Supplementation with end-tidal isoflurane was considered when heart rate (HR) and mean arterial blood pressure (BP) exceeded 20% of the baseline value. Hemodynamics, end-tidal isoflurane concentration and adverse events were recorded. Results: Intra-operative mean HR and mean BP in group D were lower than group S (P < 0.05) throughout the laparoscopy surgery. Requirement of intra-operative fentanyl, end-tidal isoflurane and postoperative tramadol were significantly more in group S compared to group D (P < 0.05) Statistically significant nausea and vomiting were noted in group S. Undue sedation and other adverse effects are comparable in both the groups. Conclusion: Dexmedetomidine as an adjuvant in general anesthesia for laparoscopic surgeries provided a stable hemodynamic profile in the perioperative period and effectively blunted pressor response to intubation and extubation, leading to minimal requirements for additional analgesics and potent inhalational agents. There were less adverse events.

Background and Aims: Minimal consumption of local anesthetic and opioid for epidural labor analgesia has been advocated for safe obstetric outcome and superior maternal satisfaction. The primary objective of this study was to evaluate and compare the analgesic efficacy of mode of administration of epidural 0.1% ropivacaine with 0.0002% fentanyl via continuous infusion or intermittent boluses during labor. Material and Methods: Sixty term primi or second gravida healthy parturients in labor requesting epidural analgesia were recruited in this study. Lumbar epidural catheter was inserted, and analgesia initiated with 0.2% ropivacaine. Patients were randomized to receive ropivacaine 0.1% with fentanyl 0.0002% via either continuous infusion (Group A) or intermittent boluses (Group B) on an hourly basis. If the parturient complained of pain and visual analog scale (VAS) score was >3, an additional bolus of the study drug was given. VAS score, motor blockade, maternal hemodynamics and fetal heart sounds were frequently monitored . Side effects, mode of delivery and neonatal outcome were noted. Results: To achieve similar VAS, the mean total dose of ropivacaine was 18.78 ± 3.88 mg in Group A and 16.86 ± 4.3 mg in Group B, the difference being statistically significant (P = 0.04). Seventeen out of 30 patients in Group A that is, 56.6% and nine patients in Group B that is, 30% required additional top-ups, and this was significantly higher (P = 0.037). Side effects, mode of delivery and neonatal outcome were comparable in both groups. Conclusion: Intermittent bolus administration provides a more efficacious route of drug delivery when compared to continuous infusion by significantly decreasing the total amount of local anesthetic plus opioid without adversely affecting patient safety or maternal satisfaction.

Hypertrophic cardiomyopathy (HCM) is a most common genetic cardiovascular disorder, characterized by asymmetric hypertrophy of the interventricular septum that leads to intermittent obstruction of the left ventricular outflow tract (LVOT). Clinical presentation ranges from absence of symptoms to sudden death in the young and disability at any age. Although patients are asymptomatic in basal conditions, but anesthesia and surgical stress can lead to exacerbation of the LVOT obstruction and may complicate the perioperative course. Therefore, complete understanding of the pathophysiology and anesthetic implications is needed for the successful perioperative outcome. We describe the successful management of a case of HCM with atrial flutter posted for percutaneous nephrolithotomy.

Carbon dioxide (CO2) embolism is a rare but potentially fatal complication of laparoscopic surgery. We report a case of presumed CO2 embolism in a 35-year-old female during laparoscopic ureteric reconstructive surgery. After 2 h of operating time, a sudden decrease in end-tidal carbon dioxide and deterioration of hemodynamic status followed by cardiac arrest with pulseless electrical activity suggested gas embolism. Immediate cardiopulmonary resuscitation and inotropic support resulted in successful outcome. Thus, early recognition of the complication and prompt treatment can avoid catastrophy.

Objective : To compare effectiveness of inhalation sevoflurane and intravenous (IV) propofol anaesthesia with the laryngeal mask airway (LMA) in children undergoing surgeries below umbilicus. Method : Sixty premedicated children 3-12 years old with the American Society of Anaesthesiologists physical status of I to II were enrolled and received either induction with sevoflurane 7% by face mask and maintained with a 50% oxygen and 50% nitrous oxide mixture followed by 1.7% sevoflurane or induction with 3 mg/kg propofol IV followed by infusion of 170µg/kg/min with LMA. Demographic data, induction time, number of attempts, LMA insertion, removal and recovery times, haemodynamic parameters, complications, Aldrete score and child’s behaviour score were recorded. Results: Demographic data and induction time were similar for the 2 treatment groups. LMA insertion was successful at the first attempt in 93% with sevoflurane and 83% with propofol. LMA insertion, removal and recovery times were significantly longer in the propofol group (1.56±0.22, 5.89±1.23, 12.3±3.09 minutes respectively) than in the sevoflurane group (1.26±0.36, 2.76±0.51, 5.16±1.6 minutes respectively) (P Conclusions: Sevoflurane provided shorter LMA insertion, removal and recovery times than IV propofol in children undergoing minor surgeries below umbilicus with comparable perioperative complications. Agitation was significantly more with sevoflurane. Sri Lanka Journal of Child Health , 2014; 43 (2): 77-83 (Key words: Sevoflurane; laryngeal mask airway; propofol; paediatric) DOI: http://dx.doi.org/10.4038/sljch.v43i2.7004

Background and Aim: Percutaneous nephrolithotomy (PCNL) is a common for managing renal calculi. Pain in the initial post operatie period is relieved by infiltration of local anaesthetic around the nephrostomy tract.We aimed to compare the analgesic efficacy of bupivacaine and ropivacaine. Methods: A total of 100 adult patients undergoing elective PCNL- under balanced general anaesthesia were randomly divided into bupivacaine group (Group B) and ropivacaine group (Group R). After completion of procedure, 23G spinal needle was inserted at 6 and 12 O′clock position under ultrasonic guidance up to renal capsule along the nephrostomy tube. A volume of 10 ml of either 0.25% bupivacaine or 0.25% ropivacaine solution was infiltrated in each tract while withdrawing the needle. Post-operative pain was assessed using visual analogue scale (VAS) and dynamic visual analogue scale (D-VAS) for initial 24 h. Intravenous tramadol was given as rescue analgesia when VAS >4. Time to first rescue analgesic, number of doses and total amount of tramadol required in initial 24 h and side-effects were noted. Results: Visual analogue scale and D-VAS at 6 h and 8 h in Group B was significantly higher than Group R. Mean time to first rescue analgesia in Group R was significantly longer than Group B. Mean number of doses of tramadol and total consumption of tramadol in 24 h was less in Group R, though not statistically significant. Conclusion: Peritubal infiltration of 0.25% ropivacaine infiltration along the nephrostomy tract is more effective than 0.25% bupivacaine in alleviating initial post-operative pain after PCNL.

Aim The aim of the study was to identify the prevalence of internal jugular vein (IJV) thrombosis and usefulness of preoperative color Doppler study in chronic renal failure patients undergoing live related renal transplant surgery. Materials and methods Two hundred and fifty adult patients of either sex having history of prolonged IJV cannulation were enrolled in this study. They were advised to undergo Doppler neck vessels study. Normal IJV was used to measure central venous pressure during renal transplantation surgery. Results Results are shown as mean±SD. Two hundred and fifty adult patients were included in the study, aged 36 ± 12 years. All patients were cannulated with Mahorkar 16 Fr double-lumen catheter. Duration of catheterization was 52.38 ± 18.91 days. Of the 250 patients, 50 were female patients. The cause of removal was infection, blockage, or maturation of arteriovenous fistula. All patients were clinically asymptomatic. Color Doppler study showed chronic thrombosis either complete/partial in 93 (37.2%) patients. Five (2%) patients had bilateral thrombosis, 80 (86%) patients had partial thrombosis, and 13 (14%) patients had complete thrombosis. The incidence and prevalence were 0.62 and 37.2%, respectively. Right IJV was the common site for insertion [right: 70 (75.2%) and left: 23 (24.7%)]. Conclusion To prevent inadvertent catheter placement and embolism, all patients having history of prolonged IJV cannulation should undergo preoperative color Doppler study.

Adequate intravascular volume maintenance is essential to ensure early graft function during renal transplantation. Various recommendations on optimum fluid therapy are based, at best, on sparse evidence, and that too only from observational studies. This prospective randomized controlled study was done to evaluate the effect of 20% human albumin on the early graft function in living donor renal transplantation. Eighty patients undergoing renal transplantation were randomly assigned to one of the intraoperative fluid regimens, 0.9% normal saline with 20% human albumin (albumin group) or 0.9% normal saline alone (saline group), after confirming the exclusion criteria. Intravenous fluid infusion was given to keep central venous pressure (CVP) between 12 to 15 mm Hg. The statistical package of social sciences, SPSS version 12, was used for statistical analysis. The intraoperative fluid volume infused [albumin group - 3381 ± 1021.2 vs. saline group - 3487 ± 978.5 (mL)] to maintain target CVP was comparable between the two groups (P value >0.05). Statistically, no significant difference was found between the two groups in terms of post transplant serum creatinine [day one; 2.76 ± 1.0 vs. 2.58 ± 0.94, day three; 1.48 ± 0.53 vs. 1.43 ± 0.71, day seven; 1.42 ± 0.6 vs. 1.42 ± 0.53 (mg/dL)] and urine output [day one; 13122.5 ± 5767.8 vs. 13909.4 ± 5324.7, day three; 9233.9 ± 3267.4 vs. 9250 ± 4794.2, day seven; 7517.6 ± 3043.6 vs. 6921.4 ± 3170 (mL)] (P value >0.05). Postoperative change in body weight [1.89 ± 3.82 vs. 2.48 ± 3.89 (kg)], tissue edema (10% vs. 7.5%), and pulmonary edema (2.5% vs. 5%) did not differ significantly (P >0.05). Twenty percent human albumin given intraoperatively, as a volume expander, does not improve early graft function in living donor renal transplantation. It should be used selectively rather than as a routine protocol.

In a developing country such as India, deceased donor renal transplantation (DDRTx) accounts for only about 1% of all renal transplants (RTx). Our institute initiated an intercity DDRTx in the year 2006, which significantly increased the number of RTx. We retrieved 74 kidneys from 37 deceased donors from various cities of Gujarat from January 2006 to December 2009. We transplanted the allografts in 66 recipients and a retrospective analysis of the donor profile and management and recipient outcome was performed. The mean age of the donors was 43.3 ± 18.8 years. The causes of death included road traffic accident in 51.35% of the donors and cerebrovascular stroke in 48.65% of the donors; 83.78% of the donors required ionotropes for hemodynamic stability in addition to vigorous intravenous fluid replacement. The average urine output of the donors was 350 ± 150 mL. The organs were perfused and stored in HTK solution. The mean cold ischemia time (CIT) was 9.12 ± 5.25 h. The mean anastomosis time in the recipient was 30.8 ± 8.7 min. 57.6% of the recipients established urine output on the operating table and 42.4% developed delayed graft function. At the end of 1 month after transplantation, the mean serum creatinine was comparable to the Ahmadabad city DDRTx, although the CIT was significantly longer in the intercity patients. Intercity organ harvesting is a viable option to increase the donor pool. Distance may not be an impediment, and good recipient outcome is possible in spite of prolonged CIT in case of proper harvesting and preservation.