Anaphylactic shock is medical emergency characterized by circulatory collapse resulted from severe acute allergic reactions, namely anaphylaxis and anaphylactoid reaction. Anaphylaxis is an acute, systemic, IgE-mediated, and immediate hypersensitivity reaction caused by the release of mediators by mast cells and basophils after exposure to antigens. The pathophysiology involves activated mast cells and basophils releasing preformed, granule-associated mediators, and newly formed lipid mediators, as well as generating cytokines and chemokines. These cause vasodilatation, increased capillary permeability, and smooth muscle contraction, and attract new cells to the area. Positive feedback mechanisms amplify the reaction, although conversely reactions can self-limit. Anaphylaxis is a clinical diagnosis with a combinations of symptoms and signs that include weakness, dizziness, flushing, angioedema, urticaria of the skin, congestion, and sneezing. More severe symptoms include bronchial constriction, hypotension, vascular collapse associated with angioedema and urticaria, gastrointestinal distress, cardiovascular arrhythmias, and arrest. Prompt administration of epinephrine is critical for the success in the treatment of acute anaphylaxis.

The incidence of anaphylaxis during anesthesia has been reported to range from 1 in 4000 to 1 in 25,000. Anaphylaxis during anesthesia can present as cardiovascular collapse, airway obstruction, and/or skin manifestation. It can be difficult to differentiate between immune and nonimmune mast cell-mediated reactions and pharmacologic effects from the variety of medications administered during general anesthesia. In addition, cutaneous manifestations of anaphylaxis are less likely to be apparent when anaphylaxis occurs in this setting. The evaluation of IgE-mediated reactions to medications used during anesthesia can include skin testing to a variety of anesthetic agents. Specifically, thiopental allergy has been documented by skin tests. Neuromuscular blocking agents such as succinylcholine can cause nonimmunologic histamine release, but there have also been reports of IgE-mediated reactions in some patients. Reactions to opioid analgesics are usually caused by direct mast cell mediator release rather than IgE-dependent mechanisms. Antibiotics that are administered perioperatively can cause immunologic or nonimmunologic reactions. Protamine can cause severe systemic reactions through IgE-mediated or nonimmunologic mechanisms. Blood transfusions can elicit a variety of systemic reactions, some of which might be IgE-mediated or mediated through other immunologic mechanisms. The management of anaphylactic reactions that occur during general anesthesia is similar to the management of anaphylaxis in other situations.

Simulation in anesthesia is a field that has revolutionized the teaching outlook. The uncommon grave situations are no more unseen. The ability of these devices to test and give a taste of nerves to an anesthetist is actually preparing him for a safe future management when the need be. The role of simulation in testing a new device for its likely success in clinical world can be foreseen. Mastering a difficult skill no longer subjects a patient to danger. These advanced methods not only see how anesthetist responds to environment, but also how the OT environment reacts to him. The review highlights how technology will help us become technically sound clinicians for tomorrow.

Objective: To evaluate the efficacy of lidocaine patch applied around wound in laparoscopic colorectal surgery in reduction of postoperative pain and illus compared to intravenous lidocaine infusion and placebo. Background: Postoperative illus and pain after colorectal surgery is a challenging problem associated with increased morbidity and cost. Inflammatory response to surgery plays crucial rule in inducing postoperative illus. Systemic local anesthetics proved to have anti-inflammatory properties that may be beneficial in preventing ileus added to its analgesic actions. The lidocaine patch evaluated in many types of pain with promising results. We try to evaluate the patch in perioperative field as a more simple and safe technique than the intravenous route. Materials and Methods: Prospective, randomized, controlled study was conducted, comparing three groups. Group 1 (placebo) received saline infusion, group 2 received i.v. lidocaine infusion after induction of anesthesia, 2 mg/min if body weight >70 kg or 1 mg/min if body weight <70 kg, group 3 received lidocaine patch 5%, three patches each one divided into two equal parts and applied around the three wounds just before induction. Data collected were, pain scores (VAS), morphine consumption, return of bowel function, pro-inflammatory cytokines plasma levels and plasma lidocaine level. Results: Pain intensity (VAS) scores at rest and during coughing were significantly lower during the first 72 h postoperative in i.v. lidocaine group and patch group compared to the placebo group. Mean morphine consumption were significantly lower in the i.v. lidocaine group and patch group compared to placebo group. Return of the bowel function was significantly earlier in i.v. lidocaine group in comparison to the other groups. Proinflammatory cytokines (IL6, IL8, and C3a) were significantly lower in i.v. lidocaine group compared to the other two groups. Conclusion: The lidocaine patch was equal to i.v. lidocaine infusion in decreasing pain scores and morphine consumption but not in acceleration of bowel function return.

Aims: To evaluate and compare the analgesic efficacy and adverse effects of tramadol and meperidine in labor. Subjects and Methods: One hundred sixty-three of the 213 parturients at term in active labor were randomly assigned to one of three groups to receive intramuscularly either tramadol 50 mg (N = 54), tramadol 100 mg (N = 55) or meperidine 75 mg (N = 54). Single person who was not aware of the given drug (NS) assessed analgesic effect using visual analogue scale (VAS). Maternal side effects, effect on labor, and perinatal outcome were also studied. Statistical Analysis: Effect of the drugs used on maternal and fetal wellbeing was compared within study groups in reference to the control group. The quantitative analysis was done using unpaired t-test and for qualitative analysis chi-square test was applied. Results: Proportion of cases with satisfactory to good pain relief (VAS difference >5) after 2 h of administration was 35.2 (19 of 54), 61.8 (34 of 55) and 70.3% (38 of 54) in tramadol 50 mg, tramadol 100 mg and meperidine 75 mg groups, respectively. Nausea and/or vomiting (11% vs. 7%), drowsiness (20.4% vs. 5.5%) and fatigue (16.7% vs. 6%) were significantly high in meperidine than in tramadol groups (P<0.05). Proportion of cases with nonreassuring fetal heart rate and neonates with <7 Apgar were high in the meperidine group. Meconium stained liquor was seen equally in tramadol 100 mg and meperidine groups, and was lower in tramadol 50 mg group. All the intervention groups had relatively shorter observed active phase of labor than controls. Conclusions: Tramadol 100 mg is an equally effective labor analgesic as meperidine with less maternal and perinatal side effects.

Introduction: Daily interruption of sedation could minimize the problem of sedatives accumulation. Nevertheless, whatever is the sedation strategy; sedation, particularly deep levels, has been associated with high frequency of patient-ventilator asynchrony. Extending these findings, one would expect that no sedation protocol could reduce the frequency of patient-ventilator asynchrony. Aim: To assess the effect of no sedation protocol compared with daily interruption of sedation on patient-ventilator asynchrony in surgical intensive care patients. Materials and Methods: The study included 230 patients who expected to require mechanical ventilation for more than 48 h. They were randomized to receive either continuous sedation (1 mg/mL midazolam) to achieve a Ramsay score of 3-4 with daily interruption until awake (group D; n = 115), or no sedation (group N; n = 115). Both groups received bolus doses of morphine (2.5-5 mg) as needed to achieve a score of ≤2 on behavioral pain scale. Results: No sedation was associated with significantly lower ineffective triggering and asynchrony index but significantly higher double triggering. Patient's effort during triggering was significantly higher during no sedation. The respiratory rate increased and the PaCO ₂ decreased significantly in no sedation group. Conclusion: No sedation protocol reduces the asynchrony index and preserves the patient's effort during triggering.

Background: Endotracheal intubation is important to carry out various surgical procedures. The estimation of endotracheal tube size is governed by narrowest diameter of the upper airway. The objective of the study was to assess the narrowest tracheal diameter by ultrasound for selection of the appropriate size endotracheal tube. Materials and Methods: After the approval of institution ethical committee and written informed consent, 112 patients aged 3 to 18 years of both genders with normal airways, scheduled for surgery under general anesthesia and intubation, were enrolled for this prospective clinical observational study. Preanesthetic ultrasonography of the subglottic region was performed by experienced ultrasonologist with a high-resolution linear array transducer in sniffing position for every patient and the subglottic tracheal diameter was estimated to select the appropriate-size endotracheal tube. The endotracheal tube, calculated on the basis of physical indices and by ultrasound, was statistically correlated with the appropriate size endotracheal tube used clinically for intubation. Results: The ultrasound guided selection criterion has estimated the appropriate-sized endotracheal tube better than physical indices (age or height)-based formulas. The estimated endotracheal tube size by ultrasound was significantly correlated with the clinically used endotracheal tube. Conclusion: Ultrasonography may be used for the assessment of the subglottic diameter of trachea in children to estimate the appropriate size endotracheal tube for intubation.

Context: There is paucity of data regarding the role of submental intubation (SI) in the airway management of patients with craniomaxillofacial trauma from India. Aims: To study the characteristics of patients presenting with craniomaxillofacial injuries requiring submental intubation, the duration of SI procedure and complications of this technique. Settings and Design: Tertiary level, teaching institute, retrospective, observational study. Materials and Methods: Forty patients requiring submental intubation between June, 2007 and December, 2009. The primary outcome measure was the time required for submental intubation defined as starting from the completion of the orotracheal intubation to the fixation of the submental tube. The secondary outcome measures included characteristics of patients with craniomaxillofacial injuries, intraoperative and postoperative complications of the SI technique. Statistical Analysis Used: Data are presented as mean± standard deviation and frequency and percentages, where relevant. Results: Most of the patients were young (average age = 35.15 ± 12.02 years), males (75%) and sustained craniomaxillofacial injuries due to road traffic accidents (85%). The 40 patients included in this audit had 56 injuries recorded at the time of admission including, orthopedic injuries in 65% and head injuries in 55% of patients. The mean time required for completion of SI was 8.90 min. The complications observed included, intraoperative tube migration, development of extra oral fistula, and sialocele, in one patient each. Conclusions: Submental intubation is a simple, safe, quick, and relatively harmless alternative to tracheostomy for securing the airway in selected patients with craniofacial trauma. Familiarity with the submental intubation technique will help the anesthesiologist to avoid tracheostomy in selected patients with craniofacial trauma who do not require long-term mechanical ventilation.

Background: Laparoscopic cholecystectomy became the standard surgery for gallstone disease because of causing less postoperative pain, respiratory compromise and early ambulation. Objective : This study was designed to compare spinal anesthesia, (segmental thoracic or conventional lumbar) vs the gold standard general anesthesia as three anesthetic techniques for healthy patients scheduled for elective laparoscopic cholecystectomy, evaluating intraoperative parameters, postoperative recovery and analgesia, complications as well as patient and surgeon satisfaction. Materials and Methods: A total of 90 patients undergoing elective laparoscopic cholecystectomy, between January 2010 and May 2011, were randomized into three equal groups to undergo laparoscopic cholecystectomy with low-pressure CO ₂ pneumoperitoneum under segmental thoracic (TSA group) or conventional lumbar (LSA group) spinal anesthesia or general anesthesia (GA group). To achieve a T ₃ sensory level we used (hyperbaric bupivacaine 15 mg, and fentanyl 25 mg at L2/L3) for LSAgroup, and (hyperbaric bupivacaine 7.5 mg, and fentanyl 25 mg at T10/T11) for TSAgroup. Propofol, fentanyl, atracurium, sevoflurane, and tracheal intubation were used for GA group. Intraoperative parameters, postoperative recovery and analgesia, complications as well as patient and surgeon satisfaction were compared between the three groups. Results: All procedures were completed laparoscopically by the allocated method of anesthesia with no anesthetic conversions. The time for the blockade to reach T ₃ level, intraoperative hypotensive and bradycardic events and vasopressor use were significantly lower in (TSA group) than in (LSA group). Postoperative pain scores as assessed throughout any time, postoperative right shoulder pain and hospital stay was lower for both (TSA group) and (LSA group) compared with (GA group). The higher degree of patients satisfaction scores were recorded in patients under segmental TSA. Conclusion: The present study not only confirmed that both segmental TSA and conventional lumber spinal anesthesia (LSA) are safe and good alternatives to general anesthesia (GA) in healthy patients undergoing laparoscopic cholecystectomy but also showed better postoperative pain control of both spinal techniques when compared with general anesthesia. Segmental TSA provides better hemodynamic stability, lesser vasopressor use and early ambulation and discharge with higher degree of patient satisfaction making it excellent for day case surgery compared with conventional lumbar spinal anesthesia.

Background: Morbidly obese patients are at increased risk of difficult mask ventilation and intubation as well as increased risk of hypoxemia during tracheal intubation. Recently, new video-assisted intubation devices have been developed . The GlideScope^® videolaryngoscope and LMA CTrach^™ (CT) allows continuous video-endoscopy of the tracheal intubation procedure. Objective: this study is to determine whether the GlideScope^® videolaryngoscope (GVL) and the LMA CTrach^™ (CT) provide the best airway management, measured primarily in intubation difficulty scale (IDS) scores, time and numbers of intubation attempts, and improvement in the intubation success rate of morbidly obese patients when compared with the direct Macintosh laryngoscope (DL) . Materials and Methods: After Ethics' Committee approval, 90 morbidly obese patients (BMI > 35 kg/m ² ) scheduled for general, gynecological, and bariatric surgery were included in this prospective study. Patients were randomly assigned in three groups: tracheal intubation using direct laryngoscopy (DL), GlideScope^® videolaryngoscope (GVL) or the LMA CTrach^™ (CT). Characteristics and consequences of airway management were evaluated. The primary outcome was the intubation difficulty scale score (IDS), Secondary outcomes were theintubation time, overall success rate, number of attempts, Cormack-Lehane grade, subjective difficulty of intubation, desaturation and upper airway morbidity. Results: Difficulty in facemask ventilation was similar in the three groups. IDS scores were significantly lower with GVL and CT than with DL. The mean TTI was 14 s faster in patients intubated with the GVL (86 s, IQR: 68-115) compared with DL (100 s, IQR; 80-150), and was 34 s faster when compared with CT (120 s, IQR; 95-180). The success rate of tracheal intubation was lower with the DL (80%) compared with the GVL (100%) or the CT (100%). Six cases of failed intubation occurred in group DL, four patients from the six patients were intubated successfully with GVL, and two patients were intubated with the CT. Both the GVL and the CTimproved the Cormack and Lehane view obtained at laryngoscopy, compared with the DL. Significantly high percent of patients in DL (43%) and CT (27%) required optimization maneuvers (external laryngeal pressure) compared with GVL (0%). In the CT group, 30% of the patients required laryngeal mask manipulation (for view optimization) compared with (0%) in GVL and CT groups. Conclusion: The GlideScope^® videolaryngoscope and the LMA CTrach^™ reduced the difficulty, improved laryngoscopic views and overall success rate of tracheal Intubationto a similar extent compared with the Macintosh laryngoscope in morbidly obese patients. The GVL improved intubation time for tracheal intubation compared with the CT and DL but no patient became hypoxic with CT because of prolonged intubation time.

Context: The newest variation of the i-gel supraglottic airway is a pediatric version. Aims: This study was designed to investigate the usefulness of the size 2 i-gel compared with the classic laryngeal mask airway (cLMA) of the same size in anesthetized, paralyzed children. Settings and Design: A prospective, randomized, single-blinded study was conducted in tertiary care teaching hospital. Subject and Methods: Sixty ASA grade I-II patients undergoing lower abdominal, inguinal, and orthopedic surgery were included in this prospective study. The patients were randomly assigned to i-gel and cLMA groups (30 patients in each group). Size 2 supraglottic airway was inserted according to the assigned group. We assessed ease of insertion, hemodynamic data, oropharyngeal sealing pressure, and postoperative complications. Statistical Analysis Used: Parametric data were analyzed with the unpaired t-test and non-parametric data were analyzed with the Chi-square test. Unless otherwise stated, data are presented as mean (SD). Significance was taken as P < 0.05. Results: There were no differences in the demographic and hemodynamic data among the two groups. The airway leak pressure of the i-gel group (26.1 ± 2.4 cm H ₂ O) was significantly higher than that of the cLMA group (22.64 ± 2.2 cm H ₂ O). The success rates for first attempt of insertion were similar among the two devices. There were no differences in the incidence of postoperative airway morbidity among the two groups. Conclusions: Hemodynamic parameters, ease of insertion, and postoperative complications were comparable between the i-gel and cLMA groups, but airway sealing pressure was significantly higher in i-gel group.

Background: Axillary brachial plexus block for below elbow orthopedic surgery provides a safe and low-cost technique with the advantage of prolonged postoperative analgesia. Clonidine, with selective partial agonist activity on α₂ adrenergic receptors, has significantly demonstrated its role in this regard as an adjuvant to local anesthetics. The current study compares the locally administered clonidine with systemically administered control group in terms of onset and duration of sensory block, motor block, and analgesia; hemodynamic variability; sedation; and other side effect profile. Materials and Methods: Seventy patients (ASA I or II) scheduled for below elbow orthopedic surgeries were randomly allocated in equal numbers to receive either 30 ml of 0.5% plain bupivacaine with 150 μg (1 ml) of inj. clonidine locally in the axillary sheath and 1 ml of normal saline (NS) subcutaneously (Group L) or 30 ml of 0.5% plain bupivacaine with 1 ml of NS locally and 150 μg (1 ml) of inj. clonidine subcutaneously (Group S). Standard monitoring of vital parameters was done. Duration of sensory and motor block, analgesia, hemodynamic changes, and any adverse effects were observed and recorded for different duration up to 24 h. Results: Duration of sensory block (625 ± 35 min), motor block (690 ± 38 min), and analgesia (930 ± 45 min) was significantly longer in Group L than in Group S [sensory block (480 ± 30 min), motor block (535 ± 25 min), and analgesia (720 ± 30 min)] (P < 0.05). Significant alteration of heart rate, systolic blood pressure and diastolic blood pressure, and mean arterial pressure in Group S was observed compared to Group L (P < 0.05). Side effects like nausea and vomiting were comparable, but highly significant sedation score (χ΂ = 47.75 and 49.51 at 120 and 240 min, respectively; P < 0.01) was observed between the two groups. Conclusion: Compared to systemic administration, local clonidine as an adjuvant in axillary block resulted in significant prolongation of duration of sensory and motor blockade, and analgesia without any hemodynamic alteration, probably by locally mediated mechanism of action.

Background: Epidural volume extension (EVE) is claimed to increase the block height and decrease the dose requirement for intrathecal drug. However, almost all studies have been done in obstetric population and none actually compares the effect of additional drugs added to epidural volume. Materials and Methods: Seventy-five (ASA I and II) patients scheduled for lower abdominal surgery were randomly divided into three groups. All groups received intrathecal 10 mg bupivacaine; two groups received additional 10 ml of normal saline epidurally with 25 mg tramadol or 25 mg of fentanyl. Groups were than compared for maximal block height, rate of sensory block regression to T10, and motor block regression to Bromage scale of 0. Time to first analgesia and adverse effects were also compared among the three groups. Results: Groups with EVE had statistically significant higher block height, with a significant faster regression that the control group. However, both fentanyl and tramadol groups were inseparable in respect to motor or sensory block regression. Fentanyl group had maximal time to first analgesia, followed by tramadol and control groups. Hemodynamic alterations were also more common in EVE groups. Conclusion: EVE can increase the block height significantly, but it seems to be limited only to the physical property of additional volume in epidural space and fentanyl or tramadol do not seem to differ in their ability to alter block properties.

In this historical report, a new light is shed on details of the development of anesthesiology and medical service in Kingdom Saudi Arabia 1956-2011. What Dr. Al-khawashki has done between the period of 1956-1980 was commendable. He has found himself and few anesthetists from Egypt and Pakistan in the front of huge task. The shortage of anesthetists worldwide and the increasing surgical specialties in Saudi Arabia, imposed a huge dilemma on the service. In order to face this problem, there was only one way to cover the continuous expanding surgical services by establishing technical institutes to produce anesthesia technicians able to work under supervision of consultants. This was known as the technician's era. It continued for a long period, but the changes were introduced from 1980 onwards by me. This was the era of the development of an up-to-date anesthesia service from 1980-2011. the first, developing the-state-of- the-art anesthesia services in the university hospitals. Second, the Saudi Anaesthetic Association was established under the auspices of the King Saud University. Third, this period culminated by starting the residency training programmes in the country and the Arab world. Moreover the Saudi specialty of anaesthesia and intensive care graduated over 60 specialists and has 98 residents up till now in the programme. Finally three subspecialties fellowships in critical care, cardiac, and pediatric anesthesia were established. The total number of Saudi anaesthetists jumped from one or two anaesthetists in the seventies to almost 300 in 2011. The numbers of consultants or senior registrar are over 160 and the rest are residents in the training program nationally and internationally.

Dr. Mohaimen Alkurdi narrates his father the anesthesia technician of the last century as he worked and taught anesthesia in Riyadh.

Congenital lobar emphysema (CLE) is a rare congenital anomaly of lung causing over aeration of one or more lobes of a histologically normal lung. It presents in infancy with respiratory distress due to compression atelectasis and often associated with mediastinal shift and hypotension. CLE poses a challenge in diagnosis and positive pressure ventilation due to air trapping. We report a case of 8-week-old infant with CLE posted for right lobectomy. Strategies to prevent misdiagnosis, over aeration and use of IPPV have been reviewed.

The patients with complicated congenital heart diseases are reaching adulthood with advances in corrective surgeries and medical management. Impact of anesthetic agents on complex cardiac and extra cardiac anomalies and presence of previous palliative procedures can be a challenge for the anesthesiologist perioperatively, while these patients present for cardiac/noncardiac surgeries. We report the perioperative management of a patient with ventricular septal defect, dextrocardia, pulmonary hypertension, and situs inversus who underwent a successful hernioplasty and hydrocelectomy with a combined spinal epidural anesthesia. This discussion relates to the anesthetic management in such conditions with a special reference to Kartagener's syndrome.

Air embolism is an uncommon but potentially catastrophic event that occurs when air enters the vasculature. Because of a scared and friable colorectal mucosa, patients with anastomotic stricture are at an increased risk of complications associated with sigmoidoscopy such as bowel perforation and bleeding. This is a report of fatal air embolism confirmed on an immediate postmortem chest radiograph in a patient with a high colorectal anastomotic stricture undergoing sigmoidoscopy under spinal anesthesia is reported. The literature on air embolism in patients undergoing sigmoidoscopy/colonoscopy is reviewed.

Pulmonary edema is a rare complication of pre-eclampsia. We report a case of severe pre-eclampsia with abruptio placentae with intra-uterine fetal demise, complicated by pulmonary edema, managed under general anesthesia for caesarean section.

We report the anesthetic management in a 4-year-old child with maxillofacial injuries for emergency reduction of mandibular fracture. The problem of leakage of anesthetic gases through the externally communicating wound was successfully overcome by the use of an adult-sized face mask for inhalational induction of anesthesia in this case.

It is difficult to predict the neurological outcome in survivor of cardio respiratory arrest. We report a case of 32 year old survivor of respiratory arrest who developed myoclonic jerks following overdose of sedation during spinal anesthesia. We initially thought these to be myoclonic status epilepticus (MSE). Accurate distinction between MSE and Lance-Adams syndrome (LAS) is very important as both have very different prognosis. LAS is a common occurrence in cardiac arrest survivors where the cause is respiratory arrest. Less than 150 cases have been reported in the medical literature till date. Making an early diagnosis and properly managing LAS is positively related to improving the patient's functional outcome. The aim of this manuscript is to spread awareness and knowledge of LAS among ICU doctors. The diagnosis of LAS and the controversies and difficulties that surround its diagnosis and treatment and other aspects of prognostication in cardiac arrest are reviewed.

Job's syndrome also known as hyper-IgE syndrome is a rare disorder associated with immunodeficiency. It includes recurrent abscesses of staphylococcal origin affecting skin and musculoskeletal system, recurring pneumonia and pneumatoceles, eosinophilia, craniofacial, and bone growth changes. This case report describes the disease and anesthetic management. Ten-year-old male child weighing 18 kg was diagnosed recently as Job's syndrome and was posted for abscess drainage over chest, back, upper, and lower limb. He had associated severe mental retardation. The choice of anesthetic technique was based on multiple surgical sites and associated mental retardation. Due to associated mental retardation child was sedated under our vigilance with syrup midazolam 9 mg orally and EMLA cream applied with occlusive dressing 30 min prior to shifting to OT. Upon arrival to the OT, pulse oximetry, noninvasive blood pressure, Electrocardiogram, temperature probe, cardioscope were attached. Inhalation induction done with sevoflurane and IV line secured with 22G cannula. Glycopyrolate 0.1 mg + fentanyl 30 mcg + Propofol 30 mg given intravenously. General anesthesia was maintained with bag and mask ventilation with oxygen + nitrous oxide + sevoflurane with spontaneous ventilation. Postoperative period was uneventful. This case is presented in view of rarity of its occurrence and frequency of repeated surgical intervention and anesthesia. Associated mental retardation in this case could be an isolated incident or could be an occurrence related to underlying disease process itself.

Ultrasound-guided transversus abdominis plane (TAP) block is an extremely attractive alternative to the technically difficult epidural in obese patients. It provides adequate perioperative analgesia and reduces the opioid requirement. 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. We present a case of 65-year-old male patient weighing 96 kg who underwent umbilical hernia repair and had adequate perioperative pain relief after the ultrasound-guided TAP block. Epidural analgesia planned for him was abandoned after we faced technical difficulty in securing the epidural, but the TAP block administered under ultrasound guidance ensured adequate pain relief perioperatively.

Tracheal compression due to any cause can lead to difficulty in either ventilating or intubating the patient. Most often, it is due to a large thyroid swelling. Often the anesthetist is completely guided by the radiological findings to plan the airway management, giving much less importance to the patient's clinical picture. We report two cases of large multinodular goiter that caused tracheal compression without any symptoms of breathing difficulty in the patients. In both the cases we were able to pass larger size endotracheal tubes beyond the site of compression without any resistance. The external diameter of the endotracheal tubes were much larger than the diameter at the narrowest part of the airway measured by computerized tomography. We conclude that along with the extent of tracheal compression, its cause and site is of paramount importance in anesthetic planning and management of airway. A thorough history on the severity of patient symptoms due to the swelling is also important.

We present a unique case series restricting ourselves only to the high-risk case of different specialities who underwent successful surgery in our Institute by using epidural volume extension's technique using 1 mL of 0.5% ropivacaine and 25 μg of fentanyl.

Byssinosis is an occupational disease occurring commonly in cotton mill workers; it usually presents with features of chronic obstructive pulmonary disease (COPD). The management of patients with COPD presents a significant challenges to the anesthetist. Regional anesthesia is preferred in most of these patients to avoid perioperative and postoperative complications related to general anesthesia. We report a known case of Byssinosis who underwent nephrectomy under segmental spinal anesthesia at the low thoracic level.

Incidence of acute kidney injury (AKI) in adult trauma patients is 18% with 70% requiring renal replacement therapy. It is a challenge to treat AKI with coagulopathy since there are no defined transfusion triggers for these patients. We report a case wherein a polytrauma patient developed AKI for which he/she was dialysed and subsequently had an intracerebral bleed. There is a need to develop guidelines to transfusion triggers in AKI patients keeping vigilance on fluid overload, hyperkalemia and uraemia-induced platelet dysfunction.

General anesthesia and neuraxial blockade have their own advantages and disadvantages over each other when used for hip surgery. Single shot lumbar plexus block can be the choice of the anesthetic technique for postrenal transplant, immunocompromised, postspinal surgery patient to undergo dynamic hip screw surgery.

Tetralogy of Fallot is the most common cyanotic congenital heart disease. We report the anesthetic management of a patient with uncorrected Fallot's tetralogy for Cesarean section.

Anesthesia for a patient with pheochromocytoma is challenging; irrespective of whether it is a diagnosed case for planned surgery or an occult case, it can be a nightmare. The patient may be given anesthesia for removal of the primary tumor or for surgery other than for the removal of the primary tumor. Hemodynamic derangements like hypertension and arrhythmia can be catastrophic. Monitored anesthesia care, though used for many cases, is unusual for a patient with diagnosed pheochromocytoma, with vertebral metastasis leading to paraplegia and atrial myxoma. In the case described below, the patient was operated for closed reduction, internal fixation with interlock nail femur, for pathological fracture. Surgery was done under monitored anesthesia care as there was no need for regional, spinal, or general anesthesia because of coexisting paraplegia. Surgery was uneventful and the postoperative period was smooth. This case is presented for its uniqueness of multiple diseases and uneventful recovery without any complications of anesthesia. The nightmare of pheochromocytoma eased without any morbidity for the patient, but this may not always be the case.