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Ultrasound has now become an eye of anaesthesiologist and has encouraged for its pervasive use. Its considerable use in the perioperative period for various invasive purposes has added an extra caution to prevent unforeseen complications over blind blocks. The ultrasound-guided thoracic paravertebral block provides excellent perioperative analgesia following thoracic surgery. It can be given as a single shot or a continuous infusion technique placing a catheter. Here the local anesthetic agent is deposited in the paravertebral space from where the spinal nerve emerges which are devoid of coverings and are sensitive to local anesthetics. Even a single-shot block provides analgesia of 4-6 dermatomal levels. The use of local anesthetics using ultrasound not only adds safety measures to minimize procedural complications but also reduces the perioperative requirement of opioids. It also helps in the reduction of postoperative pulmonary complications and early extubation following thoracic surgery. We report a case series where single-shot ultrasound-guided unilateral paravertebral blocks were used as an analgesic technique for the repair of tracheoesophageal fistula in neonates. After delivering anesthesia and confirming the correct placement of the endotracheal tube the neonate was kept on the left lateral position to undergo right thoracotomy and repair of fistula. Scanning at T4 level with a linear probe was done to identify the transverse process, pleura, costotransverse ligament, intercostal muscle, and the paravertebral space where the local anesthetic agent was deposited under aseptic precautions. Tenting of pleura was the endpoint for the completion of the block. The extensive use of various regional anesthetic technique has significantly improved the postoperative outcome of the patients along with adequate perioperative pain management.

Background: Cooled Radiofrequency ablation is a newer technique for management of chronic knee pain in osteoarthritis. The aim of the study is to evaluate the clinical outcomes in patients with chronic osteoarthritis in terms of pain scores for first six months of cooled radiofrequency ablation using ultrasound guidance. Methods: A cross-sectional study with retrospective review of database was evaluated to analyze the change in the Numerical Rating Scale from baseline scores at 1 day, 1 month and 6 months after the Cooled Radiofrequency ablation of genicular nerves around knee in patients with chronic knee osteoarthritis. Results: Median age was 71 years [ 61-73 years (IQR: 25-75)] with more female preponderance. Numerical Rating Scale (Mean ± S.D.) was significantly less at 1 day (1.87 ± 1.22), 1 month (3.03 ± 0.99) and 6 months (3.37 ± 1.098) from baseline values (6.77 ± 1.00). No soreness and numbness were noted.Conclusions: Cooled Radiofrequency using Ultrasound guidance for management of knee pain in chronic osteoarthritis is promising and reduces Numerical Rating Score significantly from baseline at 1 month and 6 months respectively.Keywords: Cooled radiofrequency ablation; genicular nerve; numeric rating scale

With the use of ultrasound, peripheral nerve blocks can be more precise and deposition of local anesthetics under direct vision reduces drug volume and minimizes untoward toxicity. Its extensive use in peri-operative period add a safety measures to reduce procedural complications. Pain in children's are often under recognized and under treated which can lead to emotional, psychological trauma for rest of their life. Peripheral nerve blocks have the advantage of greater overall safety and efficacy for lower abdominal surgeries. An abdominal truncal block technique known as Quadratus Lumborum block has emerged recently with a goal of anesthetizing the thoracolumbar nerves for somatic as well as visceral analgesia of both lower and upper abdomen. A sound knowledge of sensory supply to the genitourinary system is important for the success of regional anesthesia. We report a case of four years old child who was diagnosed as left sided pelvic ureteric junction obstruction and was planned for pyeloplasty where continuous quadratus lumborum block was used as a mode of post operative analgesia which showed a promising result. Antibiotic resistance and lack of newer effective antibiotic against multidrug resistant bacteria like Acinetobacter baumannii is a common problem in intensive care unit. Trimethoprim -Sulfamethoxazole may help in combating this problem.

The clinical presentation, biochemical characteristics, and outcomes of patients infected with SARS-CoV-2 can vary in different populations. The purpose of the study is to assess the clinical presentation and identify predictors of mortality among patients with severe acute respiratory distress syndrome admitted to different critical care units in Nepal.An observational study was conducted among the confirmed SARS-CoV-2 patients admitted to different critical care units in seven provinces of Nepal. Retrospective data was collected for the period of three months (April 14, 2021 to July 15, 2021) in relation to the peak of the second wave of COVID-19 pandemic in Nepal. Clinical, biochemical and mortality data were collected from the admitted patients of different critical care units. Univariate logistic regression analysis was done among the selected variables at 5% significance. Final predictor variables were identified after multiple regression analysis.Out of total of 646 patients admitted to critical care units of different provinces of Nepal, there was a male predominance 420 (65%). A total of 232(35.91 %) patients were non-survivors with the majority of mortality occurring in patients50 years of age. Cough (72.3 %), shortness of breath (70.9%) and fever (56 %) were the most common presenting clinical features. Increasing age, presence of comorbidity, critical COVID-19 cases, respiratory rate, temperature, serum urea and alanine aminotransferase were identified as predictors of mortality after multiple regression analysis.Approximately 36 % of the confirmed SARS-CoV-2 patient admitted to critical care units did not survive. There was a male preponderance with most casualties occurring in patients more than 50 years of age. Cough, shortness of breath and fever were the most common presenting features. After multiple regression analysis of the identified clinical and biochemical factors, age, presence of comorbidity, respiratory rate, temperature, severity grade as per the World Health Organization classification, serum urea and alanine aminotransferase were identified as the predictors of mortality.

Conversion of fetal circulation to adult-type occurs immediately after birth but neonates with problems in the development of pulmonary vasculature are prone to revert back to fetal circulation. This phenomenon is known as flip-flop circulation which may be induced perioperatively and as such anesthesiologist are central to its management. We report a case of term neonate planned for repair of duodenal atresia that despite having no respiratory symptom preoperatively developed severe hypoxemia under anesthesia that was even unresponsive to 100% oxygen. The intraoperative hemodynamics of the neonate was managed along with supportive care successfully. A postoperative echocardiogram confirmed the evidence of persistent pulmonary hypertension of the newborn.Keywords: Duodenal atresia; flip flop circulation; neonates; persistent pulmonary hypertension of newborn

Background: Ultrasound guided peripheral nerve blocks have become increasingly popular in the lower limb orthopaedic and gaining more acceptances in total hip replacement surger­ies too. The main objective of this study was to compare peripheral nerve block and spinal anesthesia for total hip replacement surgeries. Methods: In this retrospective study, total patients that underwent total hip replacement in our institution during specific time period were included for the study. They were divided into spinal and peripheral nerve block groups, and data were collected for the analysis. USG guided lumbar plexus, sacral plexus, superior gluteal nerve block was done and conventional landmark technique was done for spinal group. Mean arterial blood pressure, total fluid con­sumption, total fentanyl consumption, pain scores and incidence of nausea was compared. Results: We included 43 patients for the study in which 23 patients were included in nerve block group, and 20 patients in the spinal group. In compared to spinal group, nerve block group had more stable mean arterial blood pressure (P

Acute appendicitis is commonly encountered surgical emergency worldwide. Although, it is commonly found in young and middle aged groups, the incidence of the diseases in geriatric age group is very rare and possesses a great challenge to safe technique of anesthesia due to co-existing comorbid conditions and medications used. Geriatric population are more susceptible to complications of appendicitis. This is a case report of 82 years old male patient, presented with appendicular perforation with localized abscess formation in a septic state with multiple comorbid condition. Routinely performed Spinal and general anaesthesia adds further challenge in management of this patient during and after surgery. Therefore, we performed the case in regional nerve block; paravertebral, ilioinguinal- iliohypogastric (ILIH) and coeliac plexus block and sedation.

Entrapment abdominal neuropathy is not a common diagnosis in our context. Chronic Abdominal wall pain is often mistaken for gastritis, gynecological issue, thoracic spinal radiculopathy, rectus sheath hematoma, abdominal muscle injury or psychiatric disorder. Anterior cutaneous nerve entrapment syndrome is one of the frequent causes of abdominal wall pain occurring due to trapped thoracic intercostal nerves between abdominal muscles. History and bedside Carnett's sign can elicit the diagnosis. Injection of the local anesthetics with steroids in the junction between the rectus sheath and abdominal muscle under ultrasound guidance can provide sustained pain relief. We should consider Anterior cutaneous nerve entrapment syndrome as a differential diagnosis while evaluating the abdominal wall pain. Keywords: ACENE; carnett's test; chronic abdominal pain; entrapment neuropathy; hydrodissection.

The practice of continuous spinal anaesthesia is not common. Though underutilised, it offers significant advantage when compared to the single-shot technique nonetheless. Time and again, it has proven its worth in patients with advanced cardiac illness, spinal deformities, and obesity. We here successfully employed this neuraxial anaesthetic technique in a sixty-two-year-old male patient with skeletal dysplasia, who presented for surgical fixation of intertrochanteric fracture of the femur. With short stature, anticipated difficult airway, and poor pulmonary status complicating the anaesthetic plan, we opted for continuous spinal anaesthesia. The procedure was carried out uneventfully with 8 mg of hyperbaric bupivacaine used in titration to anaesthetic needs. Patients with skeletal dysplasia present with wide array of clinical conditions that pose a formidable challenge to anaesthesiologists. Continuous spinal anaesthesia can be safely practiced in such patients as it provides a titratable form of neuraxial blockade with reduced dose of local anaesthesia. This, in turn, ensures a predictable block and, thus, hemodynamic stability.

Background: Ultrasound guided abdominal nerve blocks are increasingly being used for anaesthesia and analgesia for surgeries like appendectomy, hernia repair in our centre. The aim of the study was to compare abdominal nerve blocks and subarachnoid block for appendectomy. Method: Retrospective data of patients that underwent appendectomy either under subarachnoid block (Group-S) or abdominal nerve blocks (Group-A) for three months were collected from hospital records. The groups were compared for conversion to general anaesthesia as a primary end point of study and also for the time taken for the procedure, the first requirement of opioids, total opioid consumption and length of hospital stay. Result: Out of 116 patients studied, 75 surgeries were performed under subarachnoid block and 41 under abdominal plane blocks. Two patients in Group-S and 1 patient in Group-A were converted to general anaesthesia due to inadequate blockade. The time taken to perform the block was around four minutes in Group-S and 12 minutes in Group-A. The mean pethidine consumption in 24 hours was 62.33 +- 16.63 mg and 23.17 +- 15.19 mg in Group-S and Group-A respectively. The time to the first dose of pethidine in Group-S groups was 224.66 +- 43.56 minutes and 813.17 +- 361.80 minutes in Group-A. The mean duration of hospital stay in Group-S was 5.14 +- 0.72 days and Group-A was 2.24 +- 0.58 days. Conclusion: Appendectomy can be safely performed under subarachnoid block as well as the abdominal nerve blocks. The abdominal nerve block technique is found to be advantageous in terms of better postoperative analgesia, less opioid consumption and early hospital discharge.

Anesthetic management of pathological fracture due to multiple myeloma with systemic manifestation poses a perioperative challenge especially in low-resource setups like Nepal. Regional anesthesia using ultrasound-guided block can improve the accuracy, reduce complications, and improve overall perioperative management of pathological fractures due to malignancy with systemic spread in resource-deprived setups. We present a case of a 53-year-old lady with pathological fracture of left humerus shaft, a diagnosed case of multiple myeloma with compression fracture of multiple lumbar spine with chest wall metastasis with resolving acute kidney injury with chest infections. Ultrasound-guided interscalene brachial plexus block with sedation was done for open reduction internal fixation of humerus shaft fracture taking in consideration the overall high perioperative risk of patient. Intraoperative hemodynamic was uneventful, with no neurological sequelae and good recovery status perioperatively. Ultrasound-guided interscalene brachial plexus block if done cautiously can be a very useful alternative technique for better perioperative outcome in patients with malignancy with systemic spread in areas where expertise is scarce and resource is limited.

Ultrasound guided nerve blocks are gaining popularity these days due to its higher accuracy and reduced incidence of complications. Ultrasound guided unilateral paravertebral block in combination with unilateral coeliac plexus block and unilateral Rectus sheath block in patients with multiple co-morbidities provides adequate anesthesia for surgery and it also reduces incidences of mortality, morbidity and hospital stay in comparison to General anesthesia and spinal / epidural anesthesia. Paravertebral block , Coeliac plexus block and Rectus sheath blocks can be performed with higher success rate with the use of ultrasound. BJHS 2018;3(2)6:508-510.

Iatrogenic pneumothorax is life threatening complication that an anesthesiologist may encounter in operating room while performing various procedure such as central venous catheterization brachial plexus block paravertebral block or during surgery like pyelolithotomy, laparoscopic cholecystectomy, percutaneous nephrolithotomy. Ultrasound can be the diagnostic tool for prompt diagnosis and managementof these situations. As there is overwhelm use of ultrasound in emergency department and ICU setting, by understanding few ultrasonic terms like lines, modes, signs and points of lung scan it can be easily utilized in operation room. Likewise, lung ultrasounds in emergency (BLUE) and fluid administration by lung ultrasound (FALL) are recently being recommending to be used in emergency and ICU. We report two cases where lung scan was beneficial for management of pneumothorax in our operation theater.Birat Journal of Health Sciences 2016 1(1): 75-77

Background: Induction of anesthesia with propofol is known to produce systemic hypotension. Co-induction adds a small dose of other anesthetics to reduce the dose of induction agent to decrease hemodynamic disturbances. The aim of the study was to compare hemodynamic changes associated with Midazolam and ketamine as a coinduction agent with Propofol and to compare induction dose of Propofol following the co-induction.Methods: Fifty adult patients undergoing elective surgery to be performed under general anesthesia were randomized to receive 0.3 mg/kg of Ketamine or 0.03 mg/ kg of Midazolam intravenously as co-induction agent. A minute after administration of co-induction agent, anesthesia was induced with Propofol 40 mg bolus then 10 mg every 10 seconds until the loss of verbal response. The hemodynamic response at 0, 1, 2, 5 minutes respectively and the induction dose of Propofol were noted.Results: The mean arterial pressure heart rates were significantly lower at 1, 2 and 5 minutes in midazolam group. However, mean arterial pressure and heart were within the physiological range in both the groups. Propofol dose requirement for induction between the two groups was similar (p>0.05) but co-induction significantly decreased the induction dose of Propofol as compared to standard recommended dose for induction.Conclusion: Our study showed that hemodynamic variables were maintained within the physiological range with midazolam and ketamine co-induction. However, lesser degree of decrease in mean arterial pressure was seen with ketamine but the heart rate was higher. A similar reduction of induction dose of propofol was achieved with both the drugs.Journal of Society of Anesthesiologists of Nepal 2015; 2(2): 62-66

Diagnosis and surgery pertaining cancer are increasing day by day in the developing world. Delay in diagnosis, poor socioeconomic status, and poor medical facilities are the challenge in treating these patients. Decreasing or preventing postoperative morbidity is of paramount importance in these cases. Ultrasound guided abdominal plane blocks like transversus abdominis plane block, rectus sheath block and coeliac plexus in combination with ketofol and/or dexmedetomidine sedation may be the alternative to general anaesthesia with an endotracheal tube or neuraxial block. These techniques, successfully used in our patients undergoing cancer surgeries, have a potential to decrease intensive care length of stay, decrease requirement of mechanical ventilation, early ambulation, and discharge.

Ultrasound-guided transversus abdominis plane block is an extremely attractive technique ensuring adequate perioperative analgesia. The use of ultrasound has enhanced the accuracy of local anaesthetic deposition in the plane between internal oblique and transversus abdominis, thereby blocking the spinal nerves more effectively and hence enhancing the efficacy of analgesia. Pregnancy is associated with higher frequency of arrhythmias in Wolff-Parkinson-White syndrome and poor perioperative pain management may contribute to life threatening arrhythmias. We report a case of Wolff-Parkinson-White syndrome posted for elective caesarean section, managed successfully under regional anesthesia with transverses abdominis plane block. The block and catheter were deposited under ultrasound guidance with continuous infusion of 0.2% of ropivacaine was used for postoperative pain relief. Dexmetedomidine was also used as intravenous adjunct at titrated dose of 0.4-0.6 mics/kg/min to attenuate maternal hormonal and hemodynamics during surgery.