Search

Our knowledge about thyroid function during pregnancy has made rapid strides in the recent past. However, there are not much published reports in anesthesia literature regarding these newer developments. Even though an anesthesiologist is not the primary care physician, he/she may occasionally encounter pregnant patients with thyroid dysfunction in routine practice of anesthesia. This article aims to update anesthesiologists about recent developments in understanding of thyroid physiology during pregnancy, effects of thyroid dysfunction on mother and fetus, interpretation of thyroid function tests as well as treatment and anesthetic considerations.

Topical morphine along with intrasite gel has been proven to be a simple and effective method to relieve pain. However, morphine is still not freely available in developing countries due to drug restrictions and stringent laws governing it. Loperamide has been reported to relieve pain caused by stomatitis effectively when given topically. Loperamide, being an mu receptor agonist with no systemic absorption, can serve a dual purpose here. Also loperamide being freely available as an over-the-counter drug can be a surrogate drug for topical application.The primary aim was to compare the efficacy of loperamide and morphine in treating pain when applied topically along with intrasite gel.Adult patients with healthy wounds with pain on Numeric Rating Scale (NRS-11) greater than 5 with no systemic comorbid illness were divided randomly into 2 groups - group morphine or group loperamide - for 24 hours followed by a 1-day washout and crossover in the other group for 24 hours. Pain was assessed once every day.Medical college and hospital.The parameters assessed included: (1) characteristics of the ulcer; (2) pain was assessed by NRS-11 at 12-hour intervals for a period of 72 hours; and (3) patient satisfaction. Statistical analysis used repeated measures analysis of variance to measure change in mean NRS-11 within each group. Analysis of covariance was used to compare the mean change in NRS-11 in the 2 groups.Morphine and loperamide were equivocal in pain relief after 12 and 24 hours (P = 0.400 and P = 0.753); however, the patient satisfaction scores were better in the morphine group.The earlier studies performed used injectable forms of morphine, for the sake of comparison, we used powdered morphine and powdered Loperamide diluted with saline. Confounding variables include ulcer size and aetiology, which can be a source of bias. The ulcer size was not standardized due to the paucity of sample to study. Equianalgesic doses of loperamide and morphine could not be found even after an extensive literature search. The loperamide dose used in our case was equal to the dose used orally since the same dose appears effective across a range of oral opioid analgesics. The morphine dose was standardized as 10 mg based on a mixture previously used to treat pain due to epidermolysis bullosa.Topical loperamide can be an efficacious and novel intervention to treat painful ulcers while avoiding systemic effects.

Objective Minor surgical procedures under general anaesthesia require a patent airway without the use of muscle relaxant. Supraglottic airway devices have been widely used for airway management. A study was undertaken to compare first-time insertion success rate, insertion time, sealing pressure and complications between the Baska® mask and I-gel. Methods After approval from the institutional ethical committee, a randomised single-blinded study was conducted on 50 American Society of Anesthesiologists' physical status I and II female patients aged 18-40 years who underwent minor surgical procedures under general anaesthesia. Patients were randomly categorized into two groups of 25 each; group Baska® mask and group I-gel, and the first-time success rate, mean insertion time and sealing pressure were measured. The results were analysed using unpaired t-test, Mann-Whitney U test, Chi-square test and ANOVA. A p value

Background and Aims: Bupivacaine is the most frequently used local anaesthetic for spinal anaesthesia, however, use of levobupivacaine in clinical practice has advanced recently. This study aimed to compare the anaesthetic potency and haemodynamic effects of intrathecal bupivacaine with buprenorphine versus levobupivacaine with buprenorphine in infraumbilical surgeries. Methods: This prospective randomised double blind study was conducted in seventy patients aged 18–65 years, American Society of Anesthesiologists grade I-II, scheduled for lower abdominal and lower limb surgery under spinal anaesthesia. The patients either received 0.5% isobaric racemic bupivacaine 3 ml with 2 μg/kg of buprenorphine (Group B) or 0.5% isobaric levobupivacaine 3 ml with 2 μg/kg of buprenorphine (Group L). The time for onset of sensory block between the two groups was the priomary end-point. Other measurements included haemodynamic variables, sensory and motor blockade characteristics, postoperative analgesia, and complications in the first 24 h. Results: There was no significant difference in the onset of sensory block between the two groups. Sensory and motor blockade characteristics were similar between the two groups. However, there was significant fall in the heart rate at 5 min in Group B compared to Group L. There was statistically significant fall in systolic blood pressure in group B compared to Group L from 5 min up to 60 min and fall in diastolic blood pressure from 10 min to 45 min. Conclusion: Our study showed that onset of sensory block is similar between isobaric levobupivacaine with buprenorphine 37 38 and isobaric bupivacaine with buprenorphine.

Background and Aims: Cesarean sections are performed mostly under spinal anesthesia. Shivering is one of the distressing complications. The aim of the study was to compare the efficacy of intravenous (i.v) magnesium sulfate and tramadol with placebo (normal saline) on postspinal shivering in elective cesarean section when used as prophylaxis. Methods: One hundred and thirty-five pregnant women between 18 and 35 years age, belonging to the American Society of Anesthesiologists' physical Status II, undergoing elective cesarean section under spinal anesthesia were enrolled into the study. Patients belonging to Group C (control group, n = 45) received isotonic saline 100 mL i.v, Group T (tramadol group, n = 45) received tramadol 0.5 mg/kg in 100 mL isotonic saline i.v, whereas those in Group M (magnesium sulfate group, n = 45) received magnesium sulfate 30 mg/kg in 100 mL isotonic saline i.v after administering spinal anesthesia. Incidence and grades of shivering were noted. Data were analyzed using one-way ANOVA test and Chi-square test. Results: The incidence of shivering in Group C, Group T, and Group M were 67.5%, 43.9%, and 39%, respectively. The incidence of shivering in Group M and Group T was significantly low when compared to Group C (P = 0.008; P = 0.026), whereas there was no statistically significant difference between Groups T and M (P = 0.654). Conclusion: Magnesium sulfate and tramadol significantly reduce the incidence of shivering compared to placebo when used as prophylaxis in pregnant women undergoing cesarean section under spinal anesthesia. Magnesium sulfate reduces the severity of the shivering.

Anticoagulants remain the primary strategy for the prevention and treatment of thrombosis. Unfractionated heparin, low molecular weight heparin (LMWH), fondaparinux, and warfarin have been studied and employed extensively with direct thrombin inhibitors typically reserved for patients with complications or those requiring interventions. Novel oral anticoagulants have emerged from clinical development and are expected to replace older agents with their ease to use and more favorable pharmacodynamic profiles. Increasingly, anesthesiologists are being requested to anesthetize patients who are on some form of anticoagulants and hence it is important to have sound understanding of pharmacology, dosing, monitoring, and toxicity of anticoagulants. We searched the online databases including PubMed Central, Cochrane, and Google Scholar using anticoagulants, perioperative management, anesthetic considerations, and LMWH as keywords for the articles published between 1994 and 2015 while writing this review. In this article, we will review the different classes of anticoagulants and how to manage them in the perioperative settings.

OBJECTIVE: Minor surgical procedures under general anaesthesia require a patent airway without the use of muscle relaxant. Supraglottic airway devices have been widely used for airway management. A study was undertaken to compare first-time insertion success rate, insertion time, sealing pressure and complications between the Baska(®) mask and I-gel. METHODS: After approval from the institutional ethical committee, a randomised single-blinded study was conducted on 50 American Society of Anesthesiologists’ physical status I and II female patients aged 18–40 years who underwent minor surgical procedures under general anaesthesia. Patients were randomly categorized into two groups of 25 each; group Baska(®) mask and group I-gel, and the first-time success rate, mean insertion time and sealing pressure were measured. The results were analysed using unpaired t-test, Mann-Whitney U test, Chi-square test and ANOVA. A p value

Management of homicidal cut-throat injuries requires a multi-disciplinary approach. The role of an anesthesiologist in instituting an airway using an endotracheal intubation or tracheostomy before wound exploration and repair of transected tissues, is challenging, as, such injuries are most of the time associated with distortion of the normal anatomy of the airway. We hereby report a case of 60-year-old lady diagnosed as homicidal cut-throat injury with vocal cords exposed externally and injury of thyroid cartilage and pharyngeal muscles. Patients with cut-throat injury may present with airway compromise, aspiration, and acute blood loss with hypoxemia because of injury to the airway and major vessels. Securing an airway becomes the first priority in patients with cut-throat injuries. It could be done by an endotracheal intubation, cricothyroidotomy, or by an emergency tracheostomy. For the effective management of patients with a cut-throat injury, there is a need for a multidisciplinary approach by a team consisting of an otorhinolaryngologist, anesthesiologist, and a psychiatrist.

Introduction: Spinal anesthesia with bupivacaine is associated with hypotension and inadequate postoperative analgesia. The addition of clonidine as an adjuvant to intrathecal bupivacaine is beneficial in reducing the dose of the local anesthetic and also provides prolonged postoperative analgesia. Methodology: One hundred and five American Society of Anesthesiologists physical status Classes 1 and 2 parturient women undergoing elective cesarean section were randomly divided into three groups. Patients in Group C (control) received 2 ml of 0.5% of heavy bupivacaine (10 mg) with 0.5 ml of 0.9% saline to a total volume of 2.5 ml, those in Group H (high dose of bupivacaine) received 2 ml of 0.5% of heavy bupivacaine (10 mg) with 1 μg/kg of clonidine and 0.9% saline to make a total volume of 2.5 ml, and those in Group L (low dose of bupivacaine) received 1.5 ml of 0.5% of heavy bupivacaine (7.5 mg) with 1 μg/kg clonidine and 0.9% saline to make a total volume of 2.5 ml. Patients were observed for onset and duration of sensory and motor block and for postoperative analgesia. Results: Patients who received clonidine as adjuvant had effective prolonged postoperative analgesia (Group H – 480 ± 40 min, Group L – 480 ± 34 min) as compared to control group (180 ± 19 min). Conclusion: The dose of intrathecal bupivacaine 0.5% was effectively reduced to 7.5 mg by adding 1 μg/kg of clonidine as adjuvant in patients undergoing elective cesarean section.

Steroids are perhaps one of the most widely used group of drugs in present day anaesthetic practice, sometimes with indication and sometimes without indications. Because of their diverse effects on various systems of the body, there has been renewed interest in the use of steroids in modern day anaesthetic practice. This paper focuses on the synthesis and functions of steroids and risks associated with their supplementation. This paper also highlights the recent trends, relevance, and consensus issues on the use of steroids as adjunct pharmacological agents in relation to anaesthetic practice and intensive care, along with emphasis on important clinical aspects of perioperative usefulness and supplementation.

Heterotaxy syndromes refer to disorders of lateralisation whereby the arrangement of abdominal and thoracic viscera differ from normal and are mirror-images of normal.[1] They are classified into two main subgroups, right-sided isomerism with asplenia, and left-sided isomerism with polysplenia. The patients of right-sided isomerism with asplenia have more severe congenital heart diseases and lateralisation defects when compared with left-sided isomerism.[2] We present a primigravida with single ventricle heterotaxy syndrome for emergency caesarean section managed under graded lumbar epidural anaesthesia.

Background and aims: Laryngeal mask airway (LMA) insertion requires anesthesia and suppression of airway reflexes. In search of an optimal drug, we compared dexmedetomidine and fentanyl, in combination with propofol for insertion of LMA. Material and Methods: This study was a prospective double blind randomized study. Eighty patients of ASA class 1&2 were randomly divided into two groups of 40 each. Group D received dexmedetomidine 1 mcg/kg and group F received fentanyl 1 mcg/kg intravenously (IV) over 2 minutes. For induction, propofol 2mg/kg was given IV and 90 seconds later LMA was inserted. We observed apnea time, heart rate, respiratory rate, non invasive blood pressure and oxygen saturation before induction, 30 seconds after induction, 1, 3, 5, 10 and 15 minutes after insertion of LMA. Patient's response to LMA insertion like coughing, gagging or any movement were noted and scored. Statistical analysis of data was done using student t test for parametric data, Chi-square test for non parametric data and SPSS 15.0 for windows software. Results: 37 (92.5%) patients of group D and 35 (87.5%) patients of group F had LMA insertion score of 2. Adverse events to insertion of LMA and hemodynamic variables were comparable in both the groups. Number of patients developing apnoea was larger and apnoea times were longer in group F compared to group D. When compared to group F, group D showed an increased respiratory rate. Conclusion: Dexmedetomidine can be a comparable alternative to fentanyl as an adjuvant to propofol for providing optimum insertion conditions for LMA and preservation of respiration.

Background: The spread of local anaesthetics during spinal anaesthesia is affected by various factors and can be unpredictable especially in parturients undergoing caesarean section. Factors like abdominal girth, symphysis fundal height etc have to studied to know their impact on level of sensory blockade. We hypothesized a study to find any correlation between weight of the baby and the level of sensory blockade. Methods: 46 parturients posted for elective caesarean section belonging to American Society of Anaesthesiologists (ASA) physical status 1 and 2 were included in the study. Maternal height and weight were noted down before entering operation theatre. All patients were instituted subarachnoid block with 2 cc of 0.5% of hyperbaric bupivacaine in sitting position. Level of sensory blockade was assessed with pin prick along midline of the patient every min till 5th minute and 5 minutes till 15th minute. The birth weight of baby was recorded soon after delivery. Results: The weight of the baby and height of the mother were correlated with the sensory blockade of T4. The number of babies weighing more than 3.5 kgs were 3 in our study out of which 2 babies were associated with maximum sensory blockade at 15th minute. It amounts to 66.7% when compared with 14.7% in babies weighing 2.5 to 3.5 kgs which is suggestive of significance ('P' value of 0.093). Conclusion: There is no statistically significant correlation between weight of the baby and the level of sensory blockade.

Cerebral palsy (CP) refers to a spectrum of nonprogressive neurological disorders with disturbances in posture and movement, resulting from perinatal intrauterine insult to developing infant brain. Many conditions associated with CP require surgery. Such cases pose important gastrointestinal, respiratory, and other perioperative considerations. Anesthetic management in these cases is delicate. Intraoperative complications including hypovolemia, hypothermia, muscle spasms, seizures, and delayed recovery might complicate the anesthetic management. A thorough preanesthetic evaluation allows for a better intra- and post-operative care. Postoperative analgesia is important, particularly in orthopedic surgeries one for pain relief. This review highlights the clinical manifestations in CP and anesthetic considerations in such child presenting for various surgeries.

Background: Caesarean section is one of the most frequently performed surgeries in obstetrics. Optimal pain relief of the mother is possible with multimodal methods. Wound infiltration is one of the simplest and safe methods. The aim of the study was to compare the analgesic efficacy of wound infiltration of bupivacaine, with tramadol and bupivacaine mixture for postoperative pain. Materials and Methods: After obtaining Institutional Ethical Committee approval, 60 pregnant women of age group 18–35 years, undergoing elective caesarean section under spinal anaesthesia were included in the study. The patients were randomized into two groups of 30 each. Patients belonging to group B received bupivacaine 0.25% 0.7 mg/kg (diluted to 20 mL with normal saline), while those belonging to group T received tramadol 2 mg/kg mixed in bupivacaine 0.25% 0.7 mg/kg (diluted to 20 mL with normal saline). The time for first request of analgesia, numerical rating scale score, and cumulative consumption of diclofenac and tramadol in 24 h were compared. Results: The time for first request of analgesia in group T was 386.17 ± 233.84 min compared to group B which was 192.50 ± 134.77 (P < 0.0002). The total diclofenac consumption in the first 24 h was significantly reduced in group T when compared to group B (P < 0.0068). Conclusions: Subcutaneous wound infiltration with tramadol and bupivacaine prolongs the pain-free period and analgesic consumption after caesarean section, while it also enhances the patient satisfaction.

Background: Epidural administrations of α2 agonists are being used as adjuvants as they lead to anxiolysis, sedation, analgesia, and hypnosis. Aim: This study aims to evaluate the analgesic effects of epidural α2 agonists-dexmedetomidine and clonidine in conjunction with intrathecal levobupivacaine in combined spinal epidural anesthesia (CSEA). Methods: A prospective, randomized controlled study was done to assess and compare the efficacy and clinical profile of two α2 adrenergic agonists, clonidine, and dexmedetomidine administered epidurally in combination with intrathecal levobupivacaine in CSEA. The study was conducted for 1 year. Sixty adult patients physical status Class I and II undergoing below umbilical surgeries under CSEA were included in the study after a valid consent. Patients were randomly assigned into two groups, to receive either epidural dexmedetomidine (1.5 μg/kg) or clonidine (2 μg/kg) in 10 ml normal saline along with 0.5% isobaric levobupivacaine 15 mg (3 ml). Block characteristics, ability to provide sedation, duration, and quality of analgesia and side effects were studied and compared between the groups. Results: The characteristics of intraoperative block were comparable among two groups. As compared to clonidine, dexmedetomidine provided a better sedation and prolonged analgesia, evidenced by the distribution of visual analog scale scores and requirement rescue analgesic among two groups. The side effect profile of the two drugs was comparable. Conclusion: Dexmedetomidine at 1.5 μg/kg epidurally with intrathecal levobupivacaine is a better adjuvant compared to clonidine at 2 μg/kg epidurally in CSEA because of better sedation, prolonged analgesia, and safe side-effect profile.

Ebstein's anomaly is an uncommon congenital heart defect with an extremely variable natural history due to a wide spectrum of pathological features. We report on the anesthetic management of a 24-year-old primigravida woman with Ebstein's anomaly with recurrent supraventricular tachycardia for emergency cesarean section.

Endotracheal intubation has been performed during the administration of Propofol anaesthesia without neuromuscular blockade. In the study, we have assessed tracheal intubating conditions and haemodynamic responses in children aged 4 to12 years by using combination of either Fentanyl and Propofol; or Propofol and a neuromuscular blocker, suxamethonium. Intubating conditions were assessed on a 1-4 scale based on ease of laryngoscopy, position of vocal cords, degree of coughing and jaw relaxation. Tracheal intubation was successful in 95% of patients receiving Fentanyl-Propofol and 100% of patients receiving Propofol-suxamethonium. Fentanyl-Propofol provided better haemodynamic stability than Propofol-suxamethonium. We conclude that Propofol-Fentanyl combination could be a useful alternative technique for tracheal intubation when neuromuscular blocking drugs are contraindicated or need to be avoided.

Postoperative nausea and vomiting (PONV) is one of the complex and significant problems in anesthesia practice, with growing trend toward ambulatory and day care surgeries. This review focuses on pathophysiology, pharmacological prophylaxis, and rescue therapy for PONV. We searched the Medline and PubMed database for articles published in English from 1991 to 2014 while writing this review using “postoperative nausea and vomiting, PONV, nausea-vomiting, PONV prophylaxis, and rescue” as keywords. PONV is influenced by multiple factors which are related to the patient, surgery, and pre-, intra-, and post-operative anesthesia factors. The risk of PONV can be assessed using a scoring system such as Apfel simplified scoring system which is based on four independent risk predictors. PONV prophylaxis is administered to patients with medium and high risks based on this scoring system. Newer drugs such as neurokinin-1 receptor antagonist (aprepitant) are used along with serotonin (5-hydroxytryptamine subtype 3) receptor antagonist, corticosteroids, anticholinergics, antihistaminics, and butyrophenones for PONV prophylaxis. Combination of drugs from different classes with different mechanism of action are administered for optimized efficacy in adults with moderate risk for PONV. Multimodal approach with combination of pharmacological and nonpharmacological prophylaxis along with interventions that reduce baseline risk is employed in patients with high PONV risk.

Background and Objectives: Laryngoscopy and intubation elicits huge spectrum of stress response which is hazardous in high-risk patients. Many drugs and techniques have been used to attenuate the stress response. Lornoxicam 16 mg is a potent nonsteroidal anti-inflammatory drug agent with analgesic potency equivalent to morphine 10 mg, fentanyl 100 μg and tramadol 100 mg. Lornoxicam has been found to attenuate stress response in some studies. We compared the lornoxicam with fentanyl in attenuating stress response. Materials and Methods: A double blind randomized controlled study was conducted on 60 adult patients of American Society of Anesthesiologist physical status 1 and 2. Group L (n = 30) receives injection lornoxicam 16 mg intravenous 30 min before induction, Group F (n = 30) receives injection fentanyl 2 μg/kg during induction. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR) were recorded baseline (BL), before induction, every minute up to 5 min and at 10 min after intubation. Results: After intubation, there is a gradual decrease in SBP and DBP in both groups. The MAP was also comparable between the two groups except at 5 min and 10 min during which MAP recovered toward BL in Group L where as it remained low in Group F which was statistically significant (P < 0.05). Both the drugs have successfully attenuated the HR response. Conclusion: Lornoxicam successfully attenuated the hemodynamic response to laryngoscopy and endotracheal intubation and is equally efficacious as fentanyl.

Asthma is a chronic disorder of airway characterized by hypersensitiveness to a variety of triggers. With a potential to cause an anaesthetic disaster during perioperative period, acute episode of asthma can lead to life threatening complications. It is important for an anaesthesiologist to make a positive difference in the outcome of the asthmatic patient by stepwise approach pre, peri and post operatively. This review takes the anaesthetists perspective to discuss the approach to asthma, safe practices and special considerations to be followed in asthmatics. This article focuses on the pathophysiology, pharmacotherapy and perioperative management in acute bronchial asthma.

Leprosy is a granulomatous disease affecting the skin and nerves caused by mycobacterium leprae. It continues to be a significant public health problem and remains a stigmatizing disease. The disease causes skin lesions and neuropathy. Complications secondary to neuropathy can result in deformity and disability. Here, we share our experience in successful management of a lepromatous leprosy patient posted for correction of deformity. Perioperative Management of a Patient with LeprosyA Case Report

Post dural puncture headache (PDPH) is a common complication of interventional neuraxial procedures. It carries a considerable morbidity with symptoms lasting for several days, sometimes severe enough to immobilise the patient. If left untreated it can result in serious complication which may be fatal. It is therefore important that the doctors should aware of the methods available for reducing the incidence of PDPH. This article reviews the scientific literature involved in the management of PDPH including the epidural blood patch.

Venous thromboembolism has a high incidence in hospitalised patients. These patients may present for surgery. Type of anaesthesia may be considered, general or regional, based on the therapeutic or prophylactic anticoagulant treatment they are receiving and the type and urgency of surgery. Best informed decision regarding the type of anaesthesia can only be made if the anaesthesiologist is abreast with the latest developments in the management of venous thromboembolism.

Huge goiters can lead to tracheal compression and, hence, difficulty in endotracheal intubation. This along with retro-sternal extension makes it an anticipated difficult airway scenario. In this report, we present a case of huge goiter (papillary carcinoma) compromising the airway, which presented with difficult airway for total thyroidectomy. CT scan of neck revealed retro-sternal extension with the pretracheal plane fixed to the trachea. Trachea was completely pushed to the right. We successfully performed an awake direct laryngoscopy and successful intubation by locally anesthetizing the airway. Plan B was ready with fiberoptic bronchoscopy and rigid bronchoscopy. Patient was successfully extubated in the intensive care unit (ICU).

Delayed awakening from anaesthesia remains one of the biggest challenges that involve anaesthesiologists. Most commonly, delayed awakening is due to drugs effects persistence. 1 The time taken to emerge to fully consciousness is affected by patient factors, anaesthetic factors, duration of surgery and painful stimulation. Non pharmacological causes may have serious sequel; thus recognising these organic conditions is important. 2 Unexpected delayed emergence after the use of general anaesthesia has a plethora of causes. 3 The most common cause for delayed awakening following anaesthesia is medications and anaesthetic agents used in the perioperative period. There may be an over dose of medications. Emergence from anaesthesia depends on the tissue uptake of the drug, average concentration used and the duration of exposure. Certain underlying metabolic disorders such as hypoglycaemia, severe hyperglycaemia, electrolyte imbalance especially hyponatremia, hypoxia, hypercapnia, central cholinergic syndrome, chronic hypertension, liver disease, hypoalbuminemia, uraemia and severe hypothyroidism may also be responsible for delayed recovery after anaesthesia. Preoperative medications such as opioids and sedatives and hypothermia can further interfere with postoperative recovery. Intraoperative cerebral hypoxia, haemorrhage, embolism or thrombosis also can manifest as delayed awakening from anaesthesia. The ultimate goal of treatment is to find the cause and treat the cause, but primary management is to maintain airway, breathing and circulation.

The concept of multimodal analgesia was introduced more than a decade ago as a technique to improve analgesia and reduce the incidence of opioid related adverse events. Multimodal analgesia is achieved by combining different analgesics that act by different mechanisms and at different sites in the nervous system resulting in additive or synergistic analgesia with lowered adverse effects of sole administration of individual analgesics. The analgesic benefits of controlling post-operative pain are generally maximised when a multimodal strategy to facilitate the patients convalescence is implemented. Principles of multimodal strategy include control of post-operative pain to allow early mobilisation, early enteral nutrition, education and attenuation of the perioperative stress response through the use of regional anaesthetic techniques and a combination of analgesic agents(i.e multimodal analgesia). The adaptation of multimodal ( or balanced) analgesic techniques as the standard approach for prevention of pain in the ambulatory setting is one of the keys to improving the recovery process after day care surgery. An aggressive multimodal perioperative analgesic regimen that provides effective pain relief has minimal side effects, is intrinsically safe and can be managed by the patient and their family members away from a hospital or surgical center. The approach that combines the consideration of peripheral and central treatment of pain possibly in combination with pre-emptive analgesia, may contribute eventually to a post-operative course without pain and one that provides for very early mobilisation and restoration of function with subsequent reduction in post-operative morbidity and hospital stay.

Awareness while under general anaesthesia can be experienced by patients as horrific events that leave lasting mental trauma behind. For some patients it leaves no sequelae but for others can lead to post traumatic stress disorder consisting of complex psychopathological phenomena such as anxiety, insomnia, nightmares, irritability, and depression possibly leading to suicidality. The aim of this review is to evaluate awareness during general anaesthesia in term of its incidence, risk, and possible prevention and management. In case of intraoperative awareness our aim is to gather information from patient and verify the patients statement. The patient should be assured that his or her claims are taken seriously and possible explanation should be provided. Psychological support to be given.

Ludwig's angina and deep neck infections are potentially lethal entities because of their tendency to cause oedema, distortion, and obstruction of the airway and may arise as a consequence of airway management mishaps. In the early stages of the disease, patients may be managed with observation and intravenous antibiotics. Advanced infections, however, require the airway to be secured in addition to immediate surgical drainage. This is complicated by pain, trismus, airway oedema, and tongue displacement creating a compromised airway. Awake fibreoptic intubation under topical anaesthesia may be the ideal method to secure the airway in advanced cases of Ludwig's angina. Here we discuss the successful anaesthetic management with fibreoptic nasal intubation of a 20-year-old female with Ludwig's angina scheduled for emergency drainage with a brief review of airway management options

The pandemic of AIDS (Acquired immune deficiency syndrome) is virtually creating a panic among healthcare workers. Out of 40 million HIV infections 5.2 million are in India 1 . Because the advances in treatment of HIV infection increase the patient's survival, anaesthesiologists may care for these patients during their practice. HIV infection is a spectrum of disease varying from asymptomatic to multiple organ involvement. Safe anaesthetic management in HIV-infected patients includes understanding basic knowledge of HIV infection, organ involvement, pharmacology and adverse reactions of antiretroviral agents. There are no specific anaesthetic agents and techniques for HIV-infected patients. General anaesthesia should not be withheld on the grounds of HIV infection alone. Regional anaesthesia is safe but one must consider local infection, bleeding problems and neuropathies. Infection control to prevent transmission of infections to and from HIV-infected patients must be strictly conducted.

The anaesthetic management of patients with severe post-burn contracture presents many difficult problems ranging from scarce venous access to a difficult airway. Airway management is a challenge to anaesthesiologist owing to contractures and deformity resulting in nonalignment of oral, pharyngeal and laryngeal planes for intubations. Severe post burn neck contracture results in difficult intubation, which can be life threatening and can result in multiple serious complications and sequels. We present the successful anaesthetic management of a patient with severely limited neck extension, fixed flexion deformity and microstomia by awake nasal fibreoptic intubation.

Ebstein′s anamoly is a rare congenital heart defect comprising less than 1% of patients with congenital heart disease. Among the congenital heart lesions, Ebstein′s anamoly is one of the most diverse in presentation, severity and management. Even though pregnancy in women with Ebstein′s anamoly is usually well-tolerated, they are at increased risk of developing ventricular and supraventricular tachycardias, congestive cardiac failure, sudden collapse and even death. Here, we report a case of the pregnant woman with mild pre-eclampsia, known case of Ebstein′s anamoly posted for emergency caesarean section.