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Background and Aims: Supraglottic airway devices (SGAs) are used to rescue difficult and failed mask ventilation (DMV). We aimed to use the SGA as first-line device, prior to obtaining a definitive airway and to find any predictors of difficulty for the same, in the morbidly obese patients. Material and Methods: Obese surgical patients [body mass index (BMI) >35 kg/m2] were investigated. Difficulties with bag mask ventilation (MV) was graded using the following scale: MV-1, one anesthesiologist unassisted could achieve MV and maintain SpO2 >90%; MV-2, one additional anesthesiologist was needed to facilitate MV to achieve SpO2> 90%; MV-3, two additional anesthesiologists were needed for this purpose; and MV-3P, when a supraglottic device was required to ventilate and maintain SpO2more than 90%. Parameters studied were age, gender, neck circumference (NC), BMI, STOPBANG score, and safe apnea time (SAT). Results: Logistic regression was performed for predictors of MV-3P; receiver operating characteristic curve was used to locate the best cut-off. Analysis of 834 morbidly obese patients revealed an incidence of MV 1/2/3/3-P as 16%/38%/27%/19%, respectively. DMV was associated with BMI ≥50 kg/m2, NC ≥49.5 cm, and STOPBANG ≥6; P < 0.001. The mean SAT for a population with mean BMI 48 ± 8 kg/m2 was 256 ± 66 s. The SAT showed inverse relation to BMI and NC. As per our results, the NC was the single most important predictor of MV-3P, with sensitivity 0.62 and specificity 0.85 at best cut-off 49.5 cm; P < 0.001. Conclusion: NC ≥49.5 cm is strongly associated with low SAT and need for SGA to achieve MV. SGA may provide safety for initial management following induction of anesthesia in this patient population.

Abdominal wall hernia is a very common surgical problem. In the last two decades laparoscopic/endoscopic approach has become the preferred surgical option for management of the same. Laparoscopic techniques have become popular due to the major advantages they offer. These include minimal incision size, minimal postoperative discomfort, earlier discharge readiness, lesser postoperative pain and lesser incidence of postoperative wound infections. These factors further contribute to lesser hospital stay and minimal perioperative morbidity.

We discuss the anesthetic outcome in morbidly obese patients under the enhanced recovery after surgery (ERAS) protocol. Our evidence-based clinical pathways focused on prehabilitation and included interventions like aggressive preoperative optimization of medical comorbidities, familiarizing with perioperative protocols, thromboprophylaxis, opioid free multimodal analgesia, and early ambulation. We did a retrospective analysis of prospectively collected data of 823 patients who underwent laparoscopic bariatric surgery. Our goal was to assess the effects of BMI on the recovery and anesthetic outcome parameters, under the categories of severely obese (SeO: BMI 60 kg/m2). Time to ambulate (TA) was the primary variable. Requirement for non-invasive ventilation (NIV) was the only significant predictor of TA and discharge readiness (DR); the DR was further affected by functional capacity and presence of chest pain. Our analysis indicated that each unit increase in BMI (kg/m2) contributes to increase in ambulation time by 1.24 min (95 % CI: 0.648 to 1.832 min; P

We report airway management of a morbidly obese with possible difficult mask ventilation and previous cervical fixation, posted for bariatric surgery under general anesthesia. We achieved insertion of the supra glottic device (SGD ) under conscious sedation. Endotracheal intubation was further facilitated using Aintree intubation catheter (AIC) and flexible endoscope assisted intubation via the SGD. Consent from the patient and the IEC approval was obtained prior topublication. We reviewed evidence-based anaesthetic concerns and described our airway management. Our aim was to maintaining continuous oxygenation and achieve a secure airway with minimal neck move-ment. This further guides anesthesia practitioners caring for the obese patients withanticipated difficulty in mask ventilation and additionalrisks and need for continuous oxygenation. Keywords: Obese, bariatric, difficult airway, mask ventilation, BMI, neck circumference, Aintree, Cervical instability

Introduction: Transversus abdominis plane (TAP) block is now a well-established technique in post-operative analgesia for lower abdominal surgeries. We evaluated the effect of ultrasound-guided TAP block on recovery parameters in patients undergoing endoscopic repair of abdominal wall hernia. Methods: Thirty adults were randomised to receive either ropivacaine with dexmedetomidine (TR) or saline (TP) in TAP block, before emergence from anaesthesia. The patients were assessed for pain relief, sedation, time to ambulate (TA), discharge readiness (DR), postoperative opioid requirement and any adverse events. Results: The median visual analogue scale pain score of the study group (TR) and the control group (TP) showed a significant difference at all time points. TA was 5.3 ± 0.5 (TR) versus 7.4 ± 0.8 (TP), P < 0.001 and DR was 7.5 ± 0.9 (TR) versus 8.9 ± 0.6 (TP), P < 0.001 in hours. No adverse events were observed in any group. Conclusion: This study demonstrates that TAP block is a feasible option for pain relief following endoscopic repair of abdominal wall hernias. It produces markedly improved pain scores and promotes early ambulation leading to greater patient satisfaction and earlier discharge.

Background and Aims: We aimed to redefine the preoperative factors that may challenge the airway and safe apnea time (SAT) in the obese. Material and Methods: We analyzed 834 patients with body mass index (BMI) >35 kg/m2 for their difficult airway score (DASc). DASc is a consolidation of measures of difficult airway like mask ventilation, difficult intubation, change of device, and number of personnel required. DASc varied from “0” no difficulty to “12” serious difficulty and DASc ≥6 was considered difficult. Preoperative parameters – neck circumference (NC), BMI, STOPBANG score, Mallampati score, obstructive sleep apnea grade, and waist circumference– were assessed. Results: Receiver operating characteristic curve was used to identify risk factors for obese patients at DASc ≥6. The Youden index (for the best threshold, with highest sensitivity and specificity) was BMI 45 kg/m2 and NC 44.5 cm. Their absence had an 81% negative predictive value to include a difficult airway, while their presence had a positive predictive value of 55%. This further has sensitivity of 66% and specificity of 73%. The mean SAT (256 ± 6 s) was inversely related to DASc (P < 0.001). Conclusion: This study demonstrates that BMI and NC have a strong association with difficult airway in obese patients and are inversely related to SAT. Amongst these NC is the single most important predictor of difficult airway in obese and should be used as a screening tool.

Summary Background and objectives Syringomyelia is a rare neurological condition characterized by the presence of an expansive cystic cavity in the spinal cord, resulting in several neurologic manifestations. The objective of the present report was to address the safety of general anesthesia in this group of patients. Case report This is a 28-year old primipara with lumbar syringomyelia scheduled for lower segment cesarean section (LSC). Surgery was performed under general anesthesia without complications. General anesthesia was chosen for this patient to avoid manipulation of the subarachnoid space during neuraxial anesthesia, which could cause changes in intracranial pressure or worsening neurological symptoms. We used rocuronium considering that it avoids rising in cerebrospinal fluid pressure and hyperkalemia that can be seen with succinylcholine. Conclusions General anesthesia can be safely used in patients with syringomyelia. Care should be taken to prevent increase in intracranial pressure and neuromuscular blockade should be monitored.

Laparoscopic adrenalectomy is gaining popularity because of its well-documented benefits. The aim of our study was to see if a decreased intraoperative intraabdominal pressure during laparoscopic adrenalectomy would affect the hemodynamic variables and the serum levels of catecholamines. We randomly divided 9 patients into 2 groups, maintaining either an intraabdominal pressure of 15 mm Hg (group A) or 8-10 mm Hg (group B). Norepinephrine and epinephrine blood levels were measured preoperatively, during endotracheal intubation, carboperitoneum, surgical manipulation of tumor just before the ligation of the adrenal vein, and tracheal extubation; the hemodynamic variables were recorded. The introduction of carboperitoneum resulted in an increase in heart rate and mean arterial blood pressure (MAP), although it was statistically insignificant. The norepinephrine levels showed a statistically significant increase in group A as compared with group B (P = 0.0002). Surgical manipulation of the tumor resulted in a significant increase in MAP and norepinephrine levels in group A (P = 0.007 and P = 0.0001, respectively). The epinephrine levels did not change as much because the tumor was probably predominantly norepinephrine-secreting. Norepinephrine levels continued to be high even during tracheal extubation in group A patients (P = 0.027). We conclude that a low intraabdominal pressure of 8-10 mm Hg causes less catecholamine release and fewer hemodynamic fluctuations.

JUSTIFICATIVA E OBJETIVOS: Siringomielia é uma condição neurológica incomum caracterizada pela presença de uma cavidade cística expansiva na medula espinhal, resultando em várias manifestações neurológicas. O objetivo deste relato de caso é destacar a segurança da anestesia geral nesse grupo de pacientes. RELATO DO CASO: Primigesta de 28 anos, com diagnóstico de siringomielia lombar, foi programada para cirurgia de cesareana (CC). A cirurgia foi realizada sob anestesia geral, sem complicações. A anestesia geral foi escolhida no caso dessa paciente para evitar qualquer manipulação do espaço subaracnoideo no bloqueio do neuroeixo central, o que poderia levar a alterações da pressão intracraniana ou agravamento de sintomas neurológicos. Foi utilizado rocurônio, considerando que evita aumento de pressão no líquido cefalorraquidiano e hipercalemia, que podem ser vistos com succinilcolina. CONCLUSÕES: A anestesia geral pode ser usada com segurança em pacientes portadores de siringomielia. Devem-se tomar precauções para evitar aumento da pressão intracraniana e o bloqueio neuromuscular deve ser monitorado. BACKGROUND AND OBJECTIVE: Syringomyelia is a rare neurological condition characterized by the presence of an expansive cystic cavity in the spinal cord, resulting in several neurologic manifestations. The objective of the present report was to address the safety of general anesthesia in this group of patients. CASE REPORT: This is a 28-year old primipara with lumbar syringomyelia scheduled for lower segment cesarean section (LSC). Surgery was performed under general anesthesia without complications. General anesthesia was chosen for this patient to avoid manipulation of the subarachnoid space during neuraxial anesthesia, which could cause changes in intracranial pressure or worsening neurological symptoms. We used rocuronium considering that it avoids rising in cerebrospinal fluid pressure and hyperkalemia that can be seen with succinylcholine. CONCLUSIONS: General anesthesia can be safely used in patients with syringomyelia. Care should be taken to prevent increase in intracranial pressure and neuromuscular blockade should be monitored. JUSTIFICATIVA Y OBJETIVOS: La Siringomielia es una condición neurológica poco frecuente y caracterizada por la presencia de una cavidad cística expansiva en la médula espinal, resultando en varias manifestaciones neurológicas. El objetivo de este artículo es destacar la seguridad de la anestesia general en ese grupo de pacientes. RELATO DEL CASO: Primípara de 28 años, con diagnóstico de siringomielia lumbar, que fue programada para la cirugía de cesárea (CC). La cirugía fue realizada bajo anestesia general, sin complicaciones. La anestesia general fue elegida, en el caso de esa paciente, para evitar cualquier manipulación del espacio subaracnoide durante el bloqueo del neuro eje central, lo que podría conllevar a alteraciones de la presión intracraneana o al empeoramiento de los síntomas neurológicos. Se usó el rocuronio, al considerar que evita el aumento de la presión en el líquido cefalorraquídeo y la hipercalemia, que puede ser vista con la succinilcolina. CONCLUSIONES: La anestesia general puede ser usada con seguridad en pacientes portadores de siringomielia. Debemos tomar precauciones para evitar el aumento de la presión intracraneana y el bloqueo neuromuscular debe ser monitorizado.

Morbidly obese patients are at risk of hypoxemia at the time of induction of anesthesia. The aim of this study was to assess the possible increase in the safe apnea time with the use of ProSeal laryngeal mask airway (PLMA) as a conduit prior to laryngoscope-guided intubation in morbidly obese patients undergoing surgery under general anesthesia. Hundred patients with BMI greater than 35 kg/m2, undergoing surgery under general anesthesia, were randomly divided to receive either PLMA or facemask with oropharyngeal airway (FM) as the airway device. Following preoxygenation with 100 % oxygen with continuous positive airway pressure of 10 cm H2O, in ramp position for 5 min the patients were made apneic. From start of apnea to the time to reach SpO2 to 92 % was recorded as safe apnea time. Ventilation was initiated and time to reach SpO2 of 100 % was recorded as recovery time. The mean safe apnea time was 205 (96–320) s in FM vs. 337 (176–456) s in PLMA (P = 0.0000). The mean recovery period was 49 (36–68) s in FM vs. 42(30–56) s in PLMA groups (P = 0.0000). Arterial blood gas analysis showed significant difference in pO2 between the two groups. The use of ProSeal laryngeal mask airway prior to laryngoscope-guided intubation is beneficial in increasing safe apnea period and achieving faster recovery from hypoxemia in morbidly obese patients.

The efficacy of ultrasound-guided transversus abdominis plane (USG-TAP) block as a part of multimodal analgesia was evaluated in morbidly obese patients undergoing laparoscopic bariatric surgery.We studied 100 patients with body mass index35 kg/m2. They were randomly allocated to study (USG-TAP) and control groups. Pain scores at rest and on movement at various time points up to 24 postoperative hours were compared. Other parameters evaluated were patients requiring Tramazac hydrochloride (TMZ) as rescue analgesic, sedation score, time to ambulate, any adverse events, and patient satisfaction.The median visual analogue scale pain score of the study (USG-TAP) group was consistently lower at 1, 3, 6, 12, and 24 h at rest and on movement, in the postoperative period. Number of patients requiring TMZ required in the first, third, and sixth hour was significantly lower in the USG-TAP group. The prolonged sedative effect of the TMZ affected the time to ambulate. Patients in the control group remained more sedated. Four patients in the control group required BIPAP support postoperatively; no adverse event was observed. Time to ambulate was 6.3 ± 1.8 h in USG-TAP and 8 ± 1.8 h in control groups; P0.001. Patient satisfaction scores were significantly higher in the USG-TAP group; P0.001.Our study demonstrates that the USG-TAP as part of multimodal analgesic technique in morbidly obese patients undergoing laparoscopic gastric bypass reduces opioid requirement, improves pain score, decreases sedation, promotes early ambulation, and has greater patient satisfaction.

Liposuction is one of the most popular treatment modalities in aesthetic surgery with certain unique anaesthetic considerations. Liposuction is often performed as an office procedure. There are four main types of liposuction techniques based on the volume of infiltration or wetting solution injected, viz dry, wet, superwet, and tumescent technique. The tumescent technique is one of the most common liposuction techniques in which large volumes of dilute local anaesthetic (wetting solution) are injected into the fat to facilitate anaesthesia and decrease blood loss. The amount of lignocaine injected may be very large, approximately 35-55 mg/kg, raising concerns regarding local anaesthetic toxicity. Liposuction can be of two types according to the volume of solution aspirated: High volume (>4,000 ml aspirated) or low volume (

A common drawback of propofol is pain on injection and lignocaine is commonly mixed with propofol to reduce the incidence and severity of this pain. In this study we sought to draw a comparison between the effectiveness of propofol medium chain and long chain triglyceride (MCT/LCT) alone, propofol medium chain and long chain triglyceride (MCT/LCT) premixed with lignocaine, and propofol long chain triglyceride (LCT) premixed with lignocaine, in preventing propofol pain on injection. 300 patients were randomly divided into three equal groups. Group A received propofol-MCT/LCT premixed with normal saline, Group B received propofol-MCT/LCT premixed with 20 mg lignocaine and Group C received propofol-LCT premixed with 20 mg lignocaine. The incidence of pain in Group A was 63% compared to 15% in Group B (X2 = 48.242, p0.001), whereas in Group C the incidence of pain was 24% compared to 63% in Group A (X2 = 30.247, p0.001). There was no significant difference in incidence of pain between Groups B and C (X2 = 2.5, p = 0.11). To conclude, propofol MCT/LCT alone provides no advantage to reduce pain on injection in comparison to propofol MCT/LCT premixed with lignocaine and propofol LCT premixed with lignocaine. Also, there is no significant difference in pain on injection between propofol LCT and propofol MCT/LCT as soon as lignocaine is added.