Over the last few years the role of ultrasound has steadily increased and has now an established role in anesthesia and critical care. The various applications of this technology in this field include ultrasound-guided insertion of central lines (internal jugular, subclavian, axillary, femoral) and peripheral venous catheters, arterial line insertion, regional blocks etc. The simple reason of using this technology is "You believe what you see". In this text we will mainly focus on central line, peripheral venous placement and arterial blood flow patterns under ultrasound guidance.In our institution at KFMC, internal jugular vein cannulation is preferred to cannulation of the subclavian vein because of the higher incidence of pneumothorax and subclavian artery puncture associated with the later. The incidence of carotid artery puncture is higher in children younger than five years than in older children during this procedure. The use of ultrasonography has been shown to increase the success rate and decrease the incidence of complications associated with IJV cannulation in adults. We will go through a stepwise approach in identifying and confirming the required blood vessels for ultrasound-guided cannulation using B-mode (2D), color flow doppler and Pulse Wave Doppler

Background: Critical incidents occur inadvertently where ever humans work. Reporting these incidents and near misses is important in learning and prevention of future mishaps. The aim of our study was to identify the incidence, outcome and potential risk factors leading to critical incidents during anaesthesia in a tertiary care teaching hospital and attempt to suggest preventive strategies that will improve patient care. Materials and Methods: A retrospective audit of all anaesthesia charts for documented critical incidents over a 12 month period was carried out. Age and ASA classification of patient, urgency of surgery, timing of the incident, body system involved and the grade of the anaesthetists were noted. The data collected was analysed using the SPSS software. Results: Fourteen incidents were documented in 54 patients, giving a frequency of 0.071. More females suffered critical incidents. Patients in the 4 ^th and 5 ^th decades of life were noted to be more susceptible. Airway and cardiovascular incidents were the commonest. Anaesthetists with less than 6 years experience were involved in more mishaps. Conclusion: We conclude that airway mishaps and cardiovascular instability were the commonest incidents especially in the hands of junior anaesthetists.

Background: This study was undertaken to evaluate the analgesic effect of the combination of epidural Clonidine with Bupivacaine versus epidural Bupivacaine alone in patients undergone knee replacement surgery. Materials and Methods: A randomized double-blind design was used, and 60 adult patients (40-60 years) of ASA grade I and II scheduled for post-operative pain relief in total knee replacement surgeries by epidural Clonidine were studied. Patients received either an epidural Clonidine (1μg/kg) with Bupivacaine (1.5mg/kg) group CL (n=30) or Bupivacaine alone group CT (n=30) for Knee replacement surgeries. The pain score, blood pressure, heart rate, respiratory rate were measured at fixed times during the first 24 h after operation. Onset and duration of sensory and motor blockade, duration of analgesia, and analgesic requirement were compared. Results: The onset of sensory anesthesia was faster (493.8±31.66 in sec.) and the duration was significantly longer in Clonidine group (334.2 min). Requirement of supplementary analgesia (Inj. diclofenac) was markedly decreased in Clonidine group as evident from the findings that in control group 18 patients required 3 supplemental analgesic doses in first 24 hours as compared to only 3 patients in Clonidine group. Epidural Clonidine produced a significant decrease (P less than 0.05) in heart rate and blood pressure, whereas the respiratory rate was not affected. We also observed for side effects in both the groups. Incidence of significant hypotension was higher, 8 patients (26%) in Clonidine group compared to 2 patient (6%) in control group. Incidence of dryness of mouth was higher, 12 patients (48%) in Clonidine group compared to 5 (18%) in control group. Conclusion: The addition of Clonidine to Bupivacaine epiduraly prolongs motor and sensory block and analgesia, without an increased incidence of side effects.

Background: Acute postoperative pain can cause detrimental effects on multiple organ systems, leading to chronic pain syndromes. Objective: To compare thoracic epidural block (TEB) and paravertebral block (PVB) for relief of postoperative pain in adult patients undergoing thoracotomy. Materials and Methods: In this randomized, single-blinded, prospective study, 60 adult patients of both sexes, belonging to ASA physical status I and II, were scheduled for elective thoracotomy under general anesthesia. They were randomly divided into two groups, A and B of 30 each, who were comparable in terms of demographic parameters and body weight. Group A received TEB and Group B received PVB. All the patients underwent thoracotomy under general anesthesia using a uniform standard anesthetic technique. Thirty minutes before the anticipated end of skin suture, blocks were activated in both the groups with 7.5 ml for TEB and 15 ml for thoracic PVB of 0.25% bupivacaine, along with 1 ml of fentanyl for postoperative analgesia. Results: Patients receiving PVB for postoperative analgesia experienced better analgesia than those receiving TEB from the immediate postoperative period that lasted longer. Intragroup comparison showed that in the cases receiving TEB, there was a significant statistical difference in preoperative and postoperative values with regard to the mean systolic blood pressure (SBP), mean arterial pressure and mean pulse rate. However, in patients receiving PVB, significant difference in preoperative and postoperative values was seen in mean SBP only. Conclusions: We observed longer duration of analgesia with PVB compared to TEB.

Background: The Smile Train is an international charity with an aim to restore satisfactory facial appearance and speech for poor children with cleft abnormalities who would not otherwise be helped. A total of 241 children of cleft lip and palate anomaly, scheduled for surgery under general anesthesia, were studied. Cleft abnormality requires early surgery. Ideally cleft lip in infants should be repaired within the first 6 months of age; and cleft palate, before development of speech, i.e., at the age of 2 years. But in our study, only 27% of children underwent corrective surgery by ideal age of 2 years, which may be due to ignorance, poverty or unawareness about the fact that cleft anomaly can be corrected by surgery. Context: Smile Train provides care for poor children with clefts in developing countries. The guidelines were designed to promote safe general anesthesia for cheiloplasty and palatoplasty. Aims: Smile Train promotes free surgery for cleft abnormalities to restore satisfactory facial appearance and speech. Settings and Design: This was a randomized prospective cohort observational study. Materials and Methods: A total of 241 consenting patients of American Society of Anesthesiologt (ASA) I and II aged 6 months to 20 years of either sex, scheduled for elective cheiloplasty and palatoplasty, were studied. Children suffering from anemia, fever, upper respiratory tract infections or any associated congenital anomalies were excluded. Approved guidelines of the Smile Train Medical Advisory Board were observed for general anesthesia and surgery. Statistical Analysis: The Student t test was used. Results: The infants were anemic and undernourished, and two thirds of the children were male. Only 27% of the children presented for surgery by the ideal age of 2 years. Conclusions: Pediatric anesthesia carries a high risk due to congenital anomaly and shared airway, venous access and resuscitation; however, cleft abnormality requires surgery at an early age to make the smiles of affected children more socially acceptable.

Objectives: To set up and validate a patient satisfaction questionnaire based on Iowa Satisfaction in Anesthesia Scale (ISAS) for evaluating the degree of patient satisfaction in anesthesia. Materials and Methods: We established and validated a survey questionnaire of 13 questions measuring the following dimensions adequacy of patient information; participation in decision making, nurse patient relation, accessibility of communication with the anesthesiologist, patient fear and anxiety and the post anesthesia care management. The process passed through three steps: instrument validation, survey conduction and data analysis. Cronbach's alpha was used to measure the reliability and standard psychometric techniques were used to measure instrument validity. Results: Our modified instrument shows good reliability which is obvious with a Cronbach's alpha value of 0.72 and all the perspectives of validity (face, content and construct). Also, 173 (21.54%) patients achieved an overall satisfaction score of less than 85% female patients are were less satisfied than male patients. Educated patients were less satisfied, and those belonging to ASA group I and II were significantly less satisfied. Dimensions pinpointed are related to information and decision making, adverse events in recovery room, fear and anxiety contributed to patient dissatisfaction. Conclusion: The instrument used for the evaluation of patient satisfaction in anesthesia is a valid tool for the Arabic speaking patients. There is room for improvement in the anesthesia care, mainly in the dimension of information, decision making and postoperative anesthesia care.

Objective: To compare spinal anesthesia with the gold standard general anesthesia for elective laparoscopic cholecystectomy in healthy patients. Materials and Methods: Controlled, prospective, randomized trial of 60 patients with symptomatic gallstone disease and American Society of Anesthesiologists status I or II were operated for laparoscopic cholecystectomy under spinal (n=30) or general (n=30) anesthesia between the academic years March 2009 and July 2010. Results: All the procedures were completed by the allocated method of anesthesia, as there were no conversions from spinal to general anesthesia. Pain was significantly less at 4 hours (P<0.0001), 8 hours (P<0.0001), 12 hours (P<0.0001), and 24 hours (P=0.0001) after the procedure for the spinal anesthesia group, compared with those who received general anesthesia. There was no difference between the two groups regarding complications, hospital stay, recovery, or degree of satisfaction at follow-up. Conclusions: Spinal anesthesia is adequate and safe for laparoscopic cholecystectomy in otherwise healthy patients and offers better postoperative pain control than general anesthesia without limiting the recovery.

Objective: Benefit of amiodarone in restoring sinus rhythm (SR) after cardiac surgery was concluded in previous studies that used different protocols for giving amiodarone. The purpose of this study was to assess the use of single parenteral intraoperative loading dose of amiodarone without maintenance as prophylaxis against atrial fibrillation (AF) after valvular heart surgery. Materials and Methods: This was a prospective, randomized, double-blind controlled study on 94 patients listed for valvular heart surgery. The patients received either amiodarone, 3 mg/kg diluted in 100 ml of normal saline and started prior to making skin incision and administrated through venous line over a period of 30 minutes, or the same volume of normal saline infused in a similar fashion. The incidence of AF during the first 5 days after surgery was the main outcome measured. Results: There was significant difference in favor of the amiodarone group regarding restoration of sinus rhythm after aortic cross-clamp removal, number of patients requiring cardioversion, incidence of AF and the time elapsed before incidence of it postoperatively (P values=0.02, 0.04, 0.02, 0.02, respectively). There was no difference in hospital mortality, major postoperative morbidity, intensive care unit (ICU) stay or hospital stay. Conclusions: Amiodarone prophylaxis in a single intraoperative dose was significantly effective in prevention of new-onset postoperative AF after valvular heart surgery. This amiodarone dose is well tolerated and not associated with postoperative complications.

Background: The optimal method for intra- and post-operative analgesia for adult tonsillectomy is uncertain. Tramadol hydrochloride is an analgesic with mixed mu and nonopioid activities, having less/no respiratory depression. Aim: The aim of our study was to compare the analgesic efficacy and nausea/vomiting produced by tramadol via intravenous and rectal administration during the first 24 h after anesthesia for adult tonsillectomy. Materials and Methods: The study design was prospective, randomized, single blind and hospital based. Forty adult patients of ASA grade 1 and 2 posted for tonsillectomy were randomized to receive either intravenous tramadol (1 mg/kg) (n=20) Group A or rectal tramadol (1.5-2 mg/kg), maximum 100 mg (n=20), Group B immediately after the induction of anesthesia. Pain measurement was performed using visual analogue scale. Rescue analgesia was given when the VAS was ≥3 in the postoperative period up to 24 h. Complaint of nausea/vomiting was recorded during the same period. Results: Duration of analgesia was prolonged and requirement of rescue analgesics was less with the suppository group. Nausea and vomiting were lower with the suppository group. Conclusion: The rectal route of tramadol is a better alternative to the intravenous route in comparison with the duration of analgesia and nausea/vomiting for adult tonsillectomy.

Foreign bodies of the respiratory tract are frequently encountered emergencies in children. A male child of 4 years was brought to our hospital by anxious parents with a history of loss of speech. No information could be gathered from the frightened child and his parents regarding the incidence to elucidate the cause of loss of speech. On examination, the breathing was normal and vital signs did not reveal any abnormality. Roentgenogram of the neck showed a foreign body of metallic density located at the glottis region. The child was immediately taken up for emergency bronchoscopic removal of the foreign body under general anesthesia. A laryngoscopic view revealed this as a piece of safety razor blade lying between the cords and hanging into the subglottis of the larynx. Immediately, this foreign body was successfully removed with the Magill's Forceps by the anesthesiologist. Lack of anesthesia and surgical complications encouraged us to present this case on the basis of our experience.

This report describes an interesting case of pin-ended earring, a foreign body, in a child, which could not be manipulated by rigid esophagoscope. The surgeon was able to extract it, on the suggestion of the anesthesiologist, by Magill forceps. Examination of the site of impaction of FB showed a small tear attributed to penetration of pin end of the earring. The pediatric surgeon, on post-procedure consultation, advised to follow-up the patient in pediatric intensive care unit with antibiotic prophylaxis. Chest radiograph on the following days showed opacity in the upper right chest region, which was cleared on the fourth post-operative day. This paper describes the anesthetic and operative procedural manipulations that led to safe outcome.

We report the first case of retromolar trigonum tissue injury in an 80-year-old female, caused by the Rigid GlideScope^® Stylet. This complication was discovered during oral surgery.

Cardiac diseases in the pregnancy pose a multitude of challenges to the obstetricians as well as anesthesiologists. Cardiac pregnant patients presenting for emergency cesarean section do not give time for cardiac optimization and stabilization if they come to the hospital for the first time without any antenatal check-up. The situation can get worse if there is no history related to the decompensated cardiac tissue with asymptomatic gestation and also if the relatives hide all the facts from the doctor about any past cardiac history. We report a case of term pregnancy for emergency cesarean section with asymptomatic dilated cardiomyopathy, which developed severe ventricular arrhythmias and cardiac arrest during the surgical procedure. She was resuscitated successfully on the operation table and was shifted to Intensive Care Unit for further management. The diagnosis of dilated cardiomyopathy was made only after carrying out echocardiography in the postoperative period. The history of previous cardiac complaints was not revealed purposefully by the relatives to avoid the expenses which they would have incurred on investigations and treatment of cardiac ailment.