Context: Laryngoscopy and intubation cause an intense reflex increase in heart rate, blood pressure, due to an increased sympathoadrenal pressor response. Lignoocaine has shown blunting of pressor response to intubation. Dexmedetomidine has sympatholytic effects. Aims: To the best of our knowledge there is no study comparing the efficacy of lignocaine with two different doses of dexmedetomidine for attenuating the pressor response. With this idea, we planned to conduct the present study. Materials and Methods: After approval by the Hospital Ethics committee, 90 consenting adults aged 18-65 years of age of either sex of non-hypertensive ASA Grade I or II were randomly allocated into three groups. Group D1- IV Dexmedetomidine 0.5μg/kg over 10 minutes Group D2- IV Dexmedetomidine 1μg/kg over 10 minutes Group X- IV Lignocaine 1.5mg/kg in 10 ml normal saline Statistical Analysis Used: ANOVA and Student's t test used for analysis. Results: Dexmedetomidine 1μg/kg was more effective than 0.5μg/kg and lignocaine 1.5mg/kg in attenuating the pressor response. Conclusions: We conclude that dexmedetomidine 1μg/kg adequately attenuates the hemodynamic response to laryngoscopy and endotracheal intubation when compared with dexmedetomidine 0.5μg/kg and lignocaine 1.5mg/kg.

Background: The aim of the study was to compare postoperative pain relief in patients undergoing an elective thoracotomy with thoracic epidural analgesia using single shot magnesium and clonidine as adjuvants to bupivacaine. Methods: In a randomized prospective study, 60 patients of American Society of Anesthesiologists physical status I-III of either sex, between 20 and 60 years undergoing elective unilateral thoracotomy, were allocated to three equal groups of 20 patients. Each patient received thoracic epidural analgesia using bupivacaine alone (Group A) or with magnesium (Group B) or clonidine (Group C) at the end of surgery during skin closure. Postoperatively, pain was measured using a visual analog scale (VAS). Rescue analgesia (50 mg tramadol intravenous) was given at a VAS score of ≥4. Duration of analgesia and total dose of rescue analgesic during 24 h was calculated. Postoperative sedation and other side effects if any were recorded. Results: All the groups were homogeneous with respect to their demographics. The 24 h cumulative mean VAS score in Groups A, B, and C was 3.12 ± 0.97, 2.86 ± 0.43, and 1.83 ± 0.59, respectively. The duration of analgesia was prolonged in Group C (165 ± 49.15 min), followed by Group B (138 ± 24.6 min), and Group A (118.5 ± 52.8 min). The duration of analgesia was significantly prolonged in the clonidine group as compared to the control group (P = 0.001). The number of rescue analgesia doses were more in Group A (3.3 ± 1.65) followed by Group B (2.35 ± 0.98) and Group C (1.75 ± 0.71). The sedation scores were significantly higher in Group C. However, shivering was seen in Group A (40%) and Group C (20%) and absent in Group B (P = 0.003). Conclusion: Thoracic epidural analgesia using bupivacaine with clonidine is an efficient therapeutic modality for postthoracotomy pain. Magnesium as an adjuvant provided quality postoperative analgesia decreasing the need for postoperative rescue analgesia and incidence of postoperative shivering without causing sedation.

Background: There were several studies using either low dose Bupivacaine as unilateral selective spinal anesthesia (SSA) or low dose lidocaine SSA for ambulatory knee arthroscopy. There were many concerns about high failure rate, complications, and different times to home readiness discharges. Aim of the Study: The study aimed to: (1) Compare the clinical efficacy and side effects of two different techniques of SSA in subarachnoid block for ambulatory knee arthroscopy (2) evaluate the possibility of a shorter stay in post-anesthesia care unit (PACU) or eligibility for fast tracking anesthesia (bypassing PACU) after SSA and numbers of patient bypassed PACU (3) compare the time to ambulate and time to home readiness. Patients and Methods: Prospective, randomized and open study was conducted, including 50 outpatients undergoing knee arthroscopy. Patients allocated into two groups: Bupivacaine group (group B); was injected with 3 mg bupivacaine and 10 ug fentanyl intrathecally in lateral decubitus position and remained for 20 min then supine position. Lidocaine group (group L) was injected with 20 mg lidocaine, plus 25 ug fentanyl intrathecally and immediately keeps in the supine position after injection. The quality and durations of motor and sensory block were compared between groups. Sensory block assessed by pin brick method and motor block assessed by Bromage scale. Time spent in PACU, the time to ambulate, and times to home-readiness were compared. Number of patients bypassed PACU was recorded. Side effects as pain, nausea, vomiting, postdural puncture headache, transient neurological symptoms, retention of urine and pruritus were evaluated and compared after SSA. Results: Bupivacaine group provided unilateral spinal anesthesia with significantly longer duration of both motor and sensory blocks than bilateral spinal of lidocaine group P < 0.001 and P < 0.01 respectively. The upper dermatomal height of sensory block reached was T9 and T8 in groups B and L respectively. Group B showed more intense motor block than group L. There was no significant difference between both groups as regards postoperative side effects P > 0.05. Group L patients did not stay in PACU, and all patients bypassed it P < 0.001. Bupivacaine group patients showed significantly longer time to ambulate and time to home-readiness than lidocaine group P < 0.001 and P < 0.01 respectively. Conclusion: Both techniques of SSA were clinically efficient as subarachnoid block, and they had less postoperative side effects. Lidocaine spinal was more eligible for fast-tracking anesthesia than bupivacaine spinal with shorter time to ambulate and home-readiness time.

Background: Many adjuvants are used to increase the efficacy of epidural local anesthetics for postoperative analgesia. Aims: The aim was to compare the efficacy of epidural morphine (0.1 mg/kg) and clonidine (2 μg/kg) with bupivacaine (0.125%) for postoperative analgesia in abdominal surgeries. Settings and Design: Double-blind retrospective randomized study. Methodology: All the patients (n = 60) varying from age group belonging to American Society of Anesthesiologists I-II were randomly allocated to receive epidural analgesia Group A - Morphine (0.1 mg/kg). + Bupivacaine (0.125%) (n = 30), Group B - Clonidine (2 μ/kg) + Bupivacaine (0.125%) (n = 30). We monitored vitals and requirement of inhalational gases intra-operatively, pain by visual analogue score (VAS) and vitals postoperatively. We used rescue analgesics (injection diclofenac 1 mg/kg intravenous) when VAS score > 5. Postoperatively, various parameters were monitored for first 2 h at intervals of 30 min and at 4, 8, 12, 16, and 24 hourly intervals after giving 1 ^st dose. Statistical Analysis Used: Continuous data are analyzed by Student's t-test (paired 't'- test for intragroup variations and unpaired 't'- test for intergroup variations). Chi-square test was used for categorical data. A P ≤ 0.05 was considered to be statistically significant. Results: Mean duration of analgesia was 8.35 ± 0.42 h in Group A (morphine) and 7.45 ± 0.44 h in Group B (clonidine). This difference was statistically significant (P < 0.001), indicating a prolongation of analgesia in group morphine. There was no need of rescue analgesia in any subjects. Group A patients were hemodynamically stable and required less inhalation agents intra-operatively compared to group B patients. Conclusions: Epidural morphine plus bupivacaine has a longer duration of analgesia and greater hemodynamic stability as compared to epidural clonidine plus bupivacaine for postoperative analgesia in abdominal surgeries.

Background: Postoperative pain is a common complaint and despite the availability of various drugs, is still not managed well. Analgesic effects of glucocorticoids are still to be substantially established. Hence, we designed randomized, double-blind, placebo-controlled trial to compare the effect of two different doses of dexamethasone on postoperative pain in patients undergoing infra-umbilical surgeries under spinal anesthesia. Methods: Ninety American Society of Anesthesiologists Grade I and II patients were randomized to receive injection dexamethasone 8 mg (Group DI), dexamethasone 16 mg (Group DII) or placebo (Group C) prior to performance of intrathecal block. Outcome studied was postoperative pain on the rest and motion and nausea and vomiting. Result: There was no difference in Visual Analog Scale (VAS) scores during rest in all the three groups. However, VAS scores on motion showed a significant decrease in Group DII at 24 and 36 h when compared to Group C (95% confidence interval [CI] of mean at 24 h for Group C = 5.6093-7.1049 and Group DII = 4.8709-5.9567, P = 0.04; 95% CI of mean at 36 h for Group C = 4.5868-5.8418 and Group DII = 3.5388-4.7378, P = 0.01). There was no significant difference in the incidence of postoperative nausea and vomiting or additional analgesic requirements. Conclusion: Dexamethasone 16 mg reduces postoperative pain on motion at 24 and 36 h. It has no effect on postoperative pain at rest or on nausea and vomiting.

Background: Nonsteroidal anti-inflammatory drugs used for postoperative analgesia have considerable adverse effects, with paracetamol having a different mechanism of action, superior side effect profile and availability in intravenous (IV) form, this study was conducted to compare intra-peritoneal bupivacaine with IV paracetamol for postoperative analgesia following laparoscopic cholecystectomy. Aim: The aim was to compare the efficacy of intra-peritoneal administration of bupivacaine 0.5% and IV acetaminophen for postoperative analgesia in patients undergoing laparoscopic cholecystectomy. Settings and Design: Randomized, prospective trial. Materials and Methods: A total of 60 patients of American Society of Anesthesiologists physical Status I and II scheduled for laparoscopic cholecystectomy were enrolled for this study. Group I received 2 mg/kg of 0.5% bupivacaine as local intra-peritoneal application and Group II patients received IV 1 g paracetamol 6 ^th hourly. Postoperatively, the patients were assessed for pain utilizing Visual Analog Scale (VAS), Visual Rating Prince Henry Scale (VRS), shoulder pain. The total number of patients requiring rescue analgesia and any side-effects were noted. Statistical Analysis: Data analysis was performed using Students unpaired t-test. SPSS version 11.5 was used. Results: The VAS was significantly higher in Group I compared with Group II at 8 ^th , 12 ^th and 24 ^th postoperative hour. At 1 ^st and 4 ^th postoperative hours, VAS was comparable between the two groups. Although the VRS was higher in Group I compared with Group II at 12 ^th and 24 ^th postoperative hour; the difference was statistically significant only at 24 ^th postoperative hour. None of the patients in either of the groups had shoulder pain up to 8 h postoperative. The total number of patients requiring analgesics was higher in Group II than Group I at 1 ^st postoperative hour. Conclusion: Although local anesthetic infiltration and intra-peritoneal administration of 0.5% bupivacaine decreases the severity of incisional, visceral and shoulder pain in the early postoperative period, IV paracetamol provides sustained pain relief for 24 postoperative hours after elective laparoscopic cholecystectomy.

Background: Maxillofacial trauma is an apt example of a difficult airway. The anesthesiologist faces challenges in their management at every step from airway access to maintenance of anesthesia and extubation and postoperative care. Methods: A retrospective study was done of 288 patients undergoing surgery for maxillofacial trauma over a period of five years. Demographic data, detailed airway assessment and the method of airway access were noted. Trauma scores, mechanism of injury, duration of hospital stay, requirement of ventilator support were also recorded. Complications encountered during perioperative anaesthetic management were noted. Results: 259 (89.93%) of the patients were male and 188 (62.85%) were in the 21-40 year range. 97.57% of the cases were operated electively. 206 (71.53%) patients were injured in motor vehicular accidents. 175 (60.76%) had other associated injuries. Mean Glasgow coma scale score (GCS), injury severity score (ISS) and revised trauma score (RTS) were 14.18, 14.8 and 12, respectively. Surgery was performed almost nine days following injury. The mean duration of hospitalization was 16 days. ICU admission was required in 22 patients with mean duration of ICU stay being two days. Majority of patients had difficult airway. 240 (83.33%) patients were intubated in the operating room and fibreoptic guided intubation was done in 159 (55.21%) patients. Submental intubation was done in 45 (14.93%) cases. Conclusions: Maxillofacial injuries present a complex challenge to the anaesthesiologist. The fibreoptic bronchoscope is the main weapon available in our arsenal. The submental technique scores over the time-honored tracheostomy. Communication between the anaesthesiologist and the surgeon must be given paramount importance.

Background: Various sedative and analgesic techniques have been used during shock wave lithotripsy (SWL). Aim: This study aimed at evaluating the efficacy of ultrasound-guided unilateral transversus abdominis plane (TAP) block as an analgesic technique alternative during ureteric SWL. Settings and Design: Prospective randomized comparative study . Materials and Methods: Fifty patients scheduled for ureteric SWL were randomly allocated into two equal groups: Group (F) received 1.5 mcg/kg fentanyl intravenous and group (T) received unilateral TAP block with injection of 25 ml of bupivacaine 0.25% (62.5 mg). Statistical Analysis: Statistical analysis was performed using SPSS program version 19 and EP16 program. Results: The visual analog scale was significantly less in group (T) than in group (F) both intra-operatively (at 10, 20, 30, and 40 min) and postoperatively (at 10 min intervals in the postanesthesia care unit [PACU]) (P < 0.001). Rescue analgesia with pethidine during the procedure and in the PACU was less (P < 0.001) in the group (T) than group (F) with a median of 20 mg versus 55 mg, respectively. The higher sedation scores observed in group (F) at 15, 25, and 35 min during the procedure, and at 20 min during the PACU time were statistically highly significant (P < 0.001), but only significant at 10 min (P = 0.03) and 30 min (P = 0.007) during the PACU time. There was also highly significant decrease (P < 0.001) in the time of PACU stay in group (T) (38.2 ± 6.6 min) compared with group (F) (89.2 ± 13.39 min). We recorded 6 patients in group (F) (24%) who have developed respiratory depression (respiratory rate < 10 breaths/min) compared to 0% in group (T) (P = 0.022). In addition, in group (F) nausea was noted in 8 patients (32%) and vomiting in 6 patients (24%), which was statistically significant when compared to group (T) (0%) (P = 0.01 and 0.022, respectively). Conclusion: Ultrasound-guided unilateral TAP block is an effective alternative analgesic technique during ureteric SWL.

Background: To date, racemic bupivacaine is the most popular local anesthetic for spinal anesthesia in parturients undergoing elective cesarean delivery. With the introduction of levobupivacaine as pure S (-) enantiomer of bupivacaine which offers advantages of lower cardiotoxicity and neurotoxicity and shorter motor block duration, its use has widely increased in India. However, very few studies have been conducted about its efficacy in obstetric anesthesia. Thus, this study was undertaken to compare the sensorial, motor block levels, and side-effects of equal doses of hyperbaric bupivacaine and levobupivacaine with intrathecal fentanyl addition in elective cesarean cases. Materials and Methods: After approval of College Ethical Committee, 30 parturient with American Society of Anesthesiologists I-II undergoing elective cesarean section were enrolled for study with their informed consent. They were randomly divided equally to either Group BF receiving 10 mg (2 ml) hyperbaric bupivacaine and 25 mcg (0.5 ml) fentanyl, or Group LF receiving 10 mg (2 ml) isobaric levobupivacaine and 25 mcg (0.5 ml) fentanyl. Sensory and motor block characteristics of the groups were assessed with pinprick, cold swab, and Bromage scale; observed hemodynamic changes and side-effects were recorded. Effects on the neonate were observed by APGAR score at 1 and 5 min and umbilical cord blood gas analysis. Results: Hemodynamic parameters like mean arterial pressure of Group BF were found to be lower. Group BF exhibited maximum motor block level whereas in Group LF, max sensorial block level and postoperative visual analog scale scores were higher. Umbilical blood gas pCO ₂ was slightly higher, and pO ₂ was marginally lower in Group BF. Onset of motor block time, time to max motor block, time to T10 sensorial block, reversal of two dermatome, the first analgesic need were similar in both groups. Conclusion: Intrathecal isobaric levobupivacaine-fentanyl combination is a good alternative to hyperbaric bupivacaine-fentanyl combination in cesarean surgery as it is less effective in motor block, it maintains hemodynamic stability at higher sensorial block levels.

Background: Intrathecal neostigmine and magnesium sulfate (MgSO ₄ ) produce substantial antinociception, potentiate analgesia of bupivacaine without neurotoxicity. Aims: The aim was to investigate the effect of neostigmine and MgSO ₄ on characteristics of spinal anesthesia (SA), hemodynamic stability and postoperative analgesia when added to 0.5% hyperbaric bupivacaine for SA. Subjects and Methods: In this prospective, randomized, double-blind study 75 American Society of Anesthesiologist status I and II adult females posted for major gynecological surgery were assigned to one of the three groups (n = 25). Group N received Neostigmine 25 μg, Group M received MgSO ₄ 50 mg, Group C received 0.5 ml saline as an adjuvant to 17.5 mg hyperbaric bupivacaine. Onset, duration of block, heart rate, mean arterial pressure, postoperative analgesia, analgesic requirement, and adverse effects were recorded. Data expressed as mean (standard deviation) or number (%). P <0.05 were statistically significant. Results: The three groups were comparable in characteristics of SA. The mean duration of analgesia was significantly longer in Group N (5.1 h) followed by Group M (4.2 h) and Group C (3.8 h) (P = 0.0134). Analgesic requirement was significantly less in Group N followed by Group M and Group C (P = 0.00232). The pain score was significantly less in Group M (P < 0.05). The incidence of hypotension and vasopressor requirement was lowest (48%) in Group N than in Group M (64%) and Group C 84% (P = 0.0276). The incidence of bradycardia and atropine requirement was the lowest in Group M (P = 0.0354). Sedation was observed in 56% patients in Group M compared to 20% in Group N and 8% in Group C (P = 0.0004). Conclusion: Intrathecal Neostigmine and MgSo ₄ does not affect characteristics of SA. Postoperative analgesia of neostigmine was better than MgSO ₄ . Neostigmine provides some protection against hypotension of SA whereas MgSO ₄ protects against bradycardia.

Background: Flupirtine is a centrally-acting, nonopioid analgesic that interacts with N-methyl-D-aspartate receptors. Aim: The present study was designed to compare analgesic efficacy and adverse effects of orally administered flupirtine and diclofenac sodium for postoperative pain relief. Settings and Design: In a prospective, randomized double-blind study, 100 patients of American Society of Anesthesiologist grade I and II in the age group of 18-65 years of either sex undergoing elective abdominal surgeries were included after taking informed consent. Materials and Methods: The present study started after 12 h of surgery and patients were randomly divided into two groups of 50 each. For postoperative analgesia, group A received flupirtine 100 mg orally and group B received diclofenac sodium 50 mg orally and study drugs were repeated every 6 hourly for 5 days postoperatively. Vital parameters and visual analogue scale (VAS) scores for pain were recorded at 0, 1, 2, 4, 6, 8, 12, 16 and 24 h, and adverse effects were noted for 48 h of the study period. Statistical Analysis: Data were compiled and analyzed statistically using Chi-square test and two-tailed Student's t-test. Results: Visual analogue scores decreased more rapidly in diclofenac group during 1 ^st h, hence there was rapid onset of analgesia in this group as compared to flupirtine group but later on VAS was comparable in both groups at all measured intervals (P > 0.05). Patients in diclofenac group experienced significantly more heartburn (P = 0.00), impaired taste sensation (P < 0.001) and dizziness (P = 0.004) as compared to flupirtine group. Conclusion: Oral flupirtine and diclofenac sodium were equally effective for postoperative analgesia. There was faster onset of analgesia with diclofenac sodium, but flupirtine was better tolerated by the patients because of its minimal adverse effects.

Introduction: Local anesthesia has a paramount role in any branches of medical sciences specially dentistry. Soft tissue irritations and lips biting are adverse side-effects in some cases. This study tried out to represent a new pharmaceutical solution in returning sensations faster. Materials and Methods: Five New Zealand laboratory rabbits were anesthetized with 1 cc Ketamine and Xilosine intramuscularly in thigh site. Electrodes were attached to the palms and wrists. Then, 0.2 cc lidocain 2% was injected in forearm origin in order to block median proximal nerve in both forelegs. The nerves conduction study (NCS) was recorded before and after lidocain injection, plus 30 min and once again 1 h after calcium gloconate 10%, dextrose 50%, citric acid solution injection. The recorded data were analyzed using Wilcoxon test and using SPSS software (version 11.5) at significant level of 0.05. Results: The NCS of left and right forearms was 1.4 ± 1.35 mV and 0.48 ± 0.45 mV. According to the statistical test, there was no significant difference between two groups (P > 0.05). Conclusion: Calcium gloconate 10%, dextrose 50%, citric acid solution did not reverse the effect of anesthetic drugs. Possible reasons were pressure to the nerves, which were caused by drug volume, and low sample size.

Background: Epidural infusion of 0.2% ropivacaine is recommended by the manufacturers for labor analgesia. Aims: The aim of this study is to evaluate the analgesic efficacy, degree of motor blockade, obstetric outcome in the form of incidence of normal vaginal, assisted vaginal and lower segment cesarean section. Settings and Design: Pilot study. Materials and Methods: In this pilot study, 30 nulliparous parturients in active labor had epidural analgesia established using 0.2% ropivacaine with 25 mcg fentanyl for initiation when cervical dilatation was 3-4 cm and then analgesia was maintained with 0.2% ropivacaine at 10 ml/h till the delivery of baby. Statistical Analysis: It was done by Wilcoxon sign rank test and paired t-test as applicable. Results: There was a significant difference (P < 0.05) between prebolus, postbolus and postinfusion with respect to visual analog score. There was a significant difference (P > 0.05) between prebolus, postbolus, and postinfusion with respect to Bromage motor score, (Wilcoxon sign rank test). Six out of 30 paturients complained of tingling and heaviness in lower limbs after continuous infusion of 2-2.5 h. Conclusion: We conclude that 0.2% ropivacaine (8 ml) with fentanyl 25 mcg is good for initiation of ambulatory labor analgesia. But for maintenance of labor analgesia lower concentration of ropivacaine may be preferred.

Background: Rocuronium (R) bromide and vecuronium (V) are monoquaternary aminosteroid compounds. The aim of this study was to evaluate the onset time, conditions of intubation and duration of action of equipotent doses (3ED ₉₅ ) of R and V. Materials and Methods: The study was carried out in 60 adult American Society of Anesthesiologists physical status 1-2 patients of age 20-60 years. The patients were divided into two groups of 30 each and received either 0.9 mg/kg of R (Group R) or 0.168 mg/kg of V (Group V) to facilitate endotracheal intubation. Neuromuscular blockade was assessed at corrugator supercilii and adductor pollicis muscles to evaluate onset time and duration of neuromuscular block, respectively. Results: The mean onset time was significantly rapid in Group R as compared to Group V ( P -0.011). Overall intubating conditions were excellent in 100% of patients in Group R as compared to 70% in Group V. The mean duration of action did not show a significant variation between the groups. Conclusion: At equipotent doses, R provides clinically acceptable intubation conditions much earlier than V without significant variation in clinical duration of action.

Huntington's chorea (HC) is a rare hereditary disorder of the nervous system. It is inherited as an autosomal dominant disorder and is characterized by progressive chorea, dementia, and psychiatric disturbances. There are only a few case reports regarding the anesthetic management of a patient with HC and the best anesthetic technique is yet to be established for those patients which are at higher risk of perioperative complications. We report the anesthetic management of a 64-year-old patient with HC admitted for cataract surgery.

The main anesthetic concern with oral submucous fibrosis is progressive restriction of mouth opening due to fibrosis producing difficult airway. Securing airway by nasotracheal intubation and tracheostomy are associated with potential complications. Flexible fiberoscope is not available in all the institutes. Submental intubation using intubating laryngeal mask airway is an acceptable alternative technique in such situations. It also provides an unobstructed surgical field.

Ankylosing spondylitis is characterized by progressive ossification of the spinal column with resultant stiffness. Ankylosing spondylitis can present significant challenges to the anaesthetist as a consequence of the potential difficult airway and performing neuraxial blockade. We describe a case of intubation with lighted stylet, and use of the continuous lumbosacral plexus for THA and postoperative analgesia with an elastomeric pump.Key words: Airways difficult anticipated, anesthesia, ankoylosing spondylitis, arthroplasty, conduction, continuous lumbosacral plexus, hip, infusion pumps, intubation awake, replacement

Internal jugular catheterization is associated with arterial puncture in 6.3-9.4% of cases and subclavian artery (SCA) injuries are probably under-reported. Several complications like hemothorax, delayed presentation of hemomediastinum due to SCA injury have been reported. We report a case of critical upper limb ischemia due to SCA thrombosis developing a few hours after a difficult right internal jugular vein cannulation without any evidence of initial arterial injury with the finder or introducer needle and which was successfully treated by surgical thrombectomy. Arterial trauma should be kept in mind during subsequent manipulations and at all stages, particularly if a technical difficulty arises during the procedure. Although the ultrasound (US) was not used in this case, US should be used not just to identify the vein, but also to verify guide-wire and catheter insertion. High index of suspicion is necessary for detection of postprocedure thrombosis of SCA. Close monitoring for neurologic and vascular sequelae after the procedure is suggested in all difficult catheter insertions, even without a direct arterial puncture.

Betel quid is used by 10-20% of world of population. Oral submucus fibrosis (OSF) is a chronic premalignant disease common in South Asian countries where betel quid is chewed. It is characterized by juxtaepithelial fibrosis of oral cavity and limited mouth opening, which can cause difficult intubation. A recent study in Taiwan has revealed long-term betel nut chewing is not predictor of difficult intubation. We describe two cases of OSF and critically analyze this study and its implications for clinical practice. OSF is now seen in Saudi Arabia and western countries with use of commercial betel quid substitutes. Although betel quid without tobacco is used in Taiwan, available evidence suggests rapid and early development of OSF where commercial chewing products like Pan Masala are used in India. Effects of betel quid may vary depending on the composition of quid and chewing habits. Studies where personal habits are involved must be analyzed carefully for external validity. Even though, Taiwan study is controlled, its validity outside Taiwan is highly questionable. Since OSF can cause unanticipated difficult intubation, thus during preanesthetic assessment, history of betel quid chewing, more importantly use of commercial chewing products is more likely to give clues to severity of OSF and possible difficult intubation. Further controlled trails in populations where commercial chewing products are used is necessary to detect association of chewing habits and difficult intubation.

Here we present a case of high spinal blockade in a patient belonging to ASA Grade I which lead to need for endotracheal intubation. A 35 year old healthy male, weighing 59 kg, of height 165 cms presented with a post traumatic raw area over the left lower limb. A reverse sural graft along with skin grafting (from the thigh) was planned. In OR, the patient was placed in sitting position and the extradural space was identified by 'loss of resistance to air' technique at the L2-L3 intervertebral space. The catheter could not be threaded into the extradural space, hence 5ml of 0.9% saline was injected. However, still the catheter could not be negotiated. Further attempts to identify the extradural space at the L1-L2 and L3-L4 interspace levels were made. During these attempts a total of 18 ml of 0.9% saline was injected into the extradural space. Within 2 minutes blood pressure fell to 90/60 mmHg. Injection mephenteramine (3 mg) was given intravenously and a slight head up tilt was applied. After 2 more minutes the patient started complaining of tingling in his hands and difficulty in breathing. Oxygen 100% was administered via a face mask attached to the anesthesia circle system. In view of onset of respiratory failure, general anesthesia was induced. Thiopentone (200 mg) and Suxamethonium (75 mg) were given intravenously, the patient's trachea was intubated and his lungs ventilated with 40% oxygen, 60% nitrous oxide and 0.2-0.4% Isoflurane, without additional neuromuscular blockade. The arterial saturation promptly returned to 97% and, immediately after intubation, the heart rate was found to be 103 beats/min and the arterial BP 162/102 mmHg. At the end of surgery, spontaneous ventilation returned and the patient was allowed to breathe 100% oxygen via the tracheal tube until he awoke, when his trachea was extubated.

The anesthetic management of a patient with severe left ventricular (LV) dysfunction undergoing noncardiac surgery poses a challenge to the anesthesiologist as LV dysfunction is commonly complicated by progressive congestive heart failure and malignant arrhythmias. When the cause for LV dysfunction is postvalve replacement, additional complications such as intraoperative thrombosis, bleeding, and infective endocarditis need to be addressed perioperatively. In such situations, the anesthesiologist must have the knowledge hemodynamics, diagnostic evaluations, and treatment modalities, more so regarding various drugs used during anesthesia. We report a case of postmitral valve replaced patient with severe LV dysfunction posted for surgery of fracture of the femur and facial fractures managed successfully during anesthesia.

Although mephentermine (Termin) and ephedrine are commonly used drugs for the treatment of hypotension during anesthesia but their abuse have markedly increased, especially in the young population due to its stimulant properties. Here, we report a case of 23-year-old man with a history of chronic mephentermine abuse, posted for Achilles tendon repair under spinal anesthesia. During intraoperative period, spinal induced hypotension showed unusual resistance to ephedrine boluses and was managed by using directly acting vasoconstrictor, that is, phenylephrine.

Hyperhomocysteinemia is a genetic disorder of metabolism and transport of amino acid, commonly present as a pro-coagulant state. Evan's syndrome is an autoimmune disorder with pancytopenia, a diagnosis of exclusion. The present report highlights the anesthetic management of a rare case, where both these clinical entities coexist. A 26-year-old male, a known case of hyperhomocyteinemia on medication for 4 years, came with a history of severe headache, blurring of vision and bleeding gums. Computerized tomography brain report showed subdural hematoma (SDH) of 16 mm with 9 mm right midline shift and on investigation had thrombocytopenia (5000 cells/cumm). Patient was diagnosed to have Evan's syndrome. Because he was refractory to the medical management, taken up for emergency splenectomy, followed by burr hole evacuation of SDH. Successful anesthetic management of the case is presented in this report.

Thoracic epidural analgesia is one of the most effective and time-tested modalities of providing postthoracotomy pain relief. It improves postoperative pulmonary outcome. Nevertheless, being a blind procedure several complications have been associated with the technique. Pleural puncture is one rare complication that might occur following thoracic epidural catheterization. We have discussed a patient who underwent a right thoracotomy for excision of emphysematous bulla of lung under general anesthesia with thoracic epidural. The epidural catheter was misplaced in the pleural cavity and was detected intraoperatively after thoracotomy. The catheter was left in situ and was successfully utilized to provide postoperative analgesia via the interpleural route.

Pycodysostosis is a genetic autosomal rare disease with an incidence of 1:1.7 million births; the pathophysiology of the disease is related to mutation of cathepsin K gene. Sleep apnea, respiratory difficulties because of chest and oral abnormalities may cause a challenge to the anesthetist during intubation and/or mechanical ventilation. In this case report we will discuss a case of pycodysostosis with a difficult airway.

Limb-girdle muscular dystrophy (LGMD) is an autosomal recessive disorder in which the pelvic or shoulder girdle musculature is predominantly or primarily involved. We report the management of a 27-year-old primigravida with LGMD associated with obesity posted for elective cesarean section. She was successfully managed with epidural anesthesia assisted with noninvasive positive pressure ventilation. She had an uncomplicated intra- and post-operative course.

A 45-year-old male patient with an irregularly irregular rhythm and fast ventricular rate was posted for an emergency laparotomy for hollow viscus perforation. His history was not suggestive of any systemic disorders. An echocardiography revealed left ventricular dysfunction with an ejection fraction of 47% without any valvular or chamber abnormality. Thyromegaly noticed during placement of central venous catheter was suspected to be the etiology for his cardiovascular status and was successfully managed. Thyroid crisis in an undiagnosed case of hyperthyroidism poses a diagnostic and therapeutic challenge. Timely and aggressive management is essential to correct the homeostatic decompensation characteristic of thyroid storm.