Context: Celphos poisoning is one the most common and lethal poisonings with no antidote available till now. Aims: To evaluate the effectiveness of new treatment regimens and interventions in reduction of mortality from the fatal effects of celphos poisoning. Settings and Design: A profile of 33 patients, who got admitted in Intensive Care Unit (ICU) of our institute with alleged intake of celphos pellets, was studied. Materials and Methods: In all the 33 patients with alleged celphos poisoning, extensive gastric lavage was done with a mixture of coconut oil and sodium bicarbonate solution. Strict monitoring, both invasive and non-invasive, was done and symptomatic/supportive treatment was carried out on a patient to patient basis. Statistical Analysis: At the end of the study, all the data were compiled systematically and statistical analysis was carried out using the non-parametric tests and value of P<0.05 was considered significant. Results: Majority of the patients out of the total 33 were young with mean age of 21.86±4.92 and had good educational level. Most of the patients presented clinically with cardiovascular signs and symptoms (58%), followed by respiratory distress (15%) and little higher incidence of multi-organ symptomatology (18%). The mean stay of the patients in ICU was 5.84±1.86 days and the survival rate was 42%. Conclusions: With the treatment regimen we have formulated, we were able to save 42% of our patients and recommend the use of this regimen by all the intensivists and physicians.

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Dexmedetomidine is a new generation highly selective α 2-adrenergic receptor (α 2-AR) agonist that is associated with sedative and analgesic sparing effects, reduced delirium and agitation, perioperative sympatholysis, cardiovascular stabilizing effects, and preservation of respiratory function. The aim of this review is to present the most recent topics regarding the advantages in using dexmedetomidine in clinical anesthesia and intensive care, while discussing the controversial issues of its harmful effects.

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Background: Inferior alveolar nerve block (IANB) is a technique of dental anesthesia, used to produce anesthesia of the mandibular teeth, gingivae of the mandible and lower lip. The conventional IANB is the most commonly used the nerve block technique for achieving local anesthesia for mandibular surgical procedures. In certain cases, however, this nerve block fails, even when performed by the most experienced clinician. Therefore, it would be advantageous to find an alternative simple technique. Aim and Objective: The objective of this study is to find an alternative inferior alveolar nerve block that has a higher success rate than other routine techniques. To this purpose, a simple painless inferior alveolar nerve block was designed to anesthetize the inferior alveolar nerve. Materials and Methods: This study was conducted in Oral surgery department of Vinayaka Mission's dental college Salem from May 2009 to May 2011. Five hundred patients between the age of 20 years and 65 years who required extraction of teeth in mandible were included in the study. Out of 500 patients 270 were males and 230 were females. The effectiveness of the IANB was evaluated by using a sharp dental explorer in the regions innervated by the inferior alveolar, lingual, and buccal nerves after 3, 5, and 7 min, respectively. Conclusion: This study concludes that inferior alveolar nerve block is an appropriate alternative nerve block to anesthetize inferior alveolar nerve due to its several advantages.

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The inferior alveolar nerve block is the most common injection technique used in dentistry and many modifications of the conventional nerve block have been recently described in the literature. Selecting the best technique by the dentist or surgeon depends on many factors including the success rate and complications related to the selected technique. Dentists should be aware of the available current modifications of the inferior alveolar nerve block techniques in order to effectively choose between these modifications. Some operators may encounter difficulty in identifying the anatomical landmarks which are useful in applying the inferior alveolar nerve block and rely instead on assumptions as to where the needle should be positioned. Such assumptions can lead to failure and the failure rate of inferior alveolar nerve block has been reported to be 20-25% which is considered very high. In this basic review, the anatomical details of the inferior alveolar nerve will be given together with a description of its both conventional and modified blocking techniques; in addition, an overview of the complications which may result from the application of this important technique will be mentioned.

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Pain control is an important part of dentistry, particularly in the management of children. Behavior guidance, and dose and technique of administration of the local anesthetic are important considerations in the successful treatment of a pediatric patient. The purpose of the present review is to discuss the relevant data on topics involved, and on the current methods available in the administration of local anesthesia used for pediatric dental patients.

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Background: The posterior superior alveolar nerve (PSAN) block is a dental nerve block used for profound anesthesia of the maxillary molars. Although it is being written in texts as a commonly used technique, but in dentistry it is rarely followed due to its nonreliable landmarks, variation in depth of insertion and frequent complications. The aim and objective are to find a technically simple method of the PSAN block without any complications. Study and Design: This study was based on the experience gained from 200 patients of 125 males and 75 female in age group of 20 to 65 years in University of Vinayaka and department of oral and maxillofacial surgery of VMS Dental College and hospital, Salem, Tamil Nadu. Results: In 200 patients' positive anesthesia obtained within a period of 5 to 10 min. No visual complications reported in this study. There was no pain during and after extraction. Conclusion: This study shows this PSA nerve block using curved needle would avoid all complications reported in the literature. Therefore, the technique described in this study is an ideal option to anesthetize PSA nerve.

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Delayed awakening from anesthesia remains one of the biggest challenges that involve an anesthesiologist. With the general use of fast-acting anesthetic agents, patients usually awaken quickly in the postoperative period. The time to emerge from anesthesia is affected by patient factors, anesthetic factors, duration of surgery, and painful stimulation. The principal factors responsible for delayed awakening following anesthesia are anesthetic agents and medications used in the perioperative period. Nonpharmacological causes may have a serious sequel, hence recognizing these organic conditions is important. Certain underlying metabolic disorders such as hypoglycemia, severe hyperglycemia, and electrolyte imbalance, especially hypernatremia, hypoxia, hypercapnia, central anticholinergic syndrome, chronic hypertension, liver disease, hypoalbuminemia, uremia, and severe hypothyroidism may also be responsible for delayed recovery following anesthesia. Unexpected delayed emergence after general anesthesia may also be due to intraoperative cerebral hypoxia, hemorrhage, embolism, or thrombosis. Accurate diagnosis of the underlying cause is the key for the institution of appropriate therapy, but primary management is to maintain airway, breathing, and circulation. This comprehensive review discusses the risk factors, causes, evaluation and management of delayed recovery based on our clinical experience, and literature search on the internet, supported by the standard textbooks of anesthesiology.

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This is a review of Ibn al Quff's account of surgical pain relief in his surgical book Al Omdah, in which he mentioned the word anesthetic (Al moukhadder) and the involvement of physician (al tabbaaee) to give mixture of drugs to prevent pain in a surgical condition to relieve the patient from pain or to make surgical management possible. Hich indicated one rare occasion to such description in Arabic medical texts. Methods of administration of these drugs were inhalation, ingestion and by rectal suppositories. The drugs used in anesthetic sponges include all the drugs that are recorded in the modern literature of anesthesia. They are as follows: opium, mandrake, Hyocymus albus, belladonna, Cannabis sativus, Cannabis indica, wild lettuce. The anesthetic sponge, mentioned in many references as an inhalation method, may be of symbolic value to surgery.

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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.

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Ketamine was introduced commercially in 1970 with the manufacturer's description as a "rapidly acting, nonbarbiturate general anesthetic" and a suggestion that it would be useful for short procedures. With the help of its old unique pharmacological properties and newly found beneficial clinical properties, ketamine has survived the strong winds of time, and it currently has a wide variety of clinical applications. It's newly found neuroprotective, antiinflammatory and antitumor effects, and the finding of the usefulness of low dose ketamine regimens have helped to widen the clinical application profile of ketamine. The present article attempts to review the current useful applications of ketamine in anesthesia, pain and critical care. It is based on scientific evidence gathered from textbooks, journals, and electronic databases.

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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.

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Newer developments and advancements in anesthesiology, surgical, and medical fields have widened the functional scope of anesthesiologist thus increasing his professional responsibilities and obligations. While at workplace, anesthesiologist is exposed to a wide array of potential hazards that can be detrimental to his overall health. Numerous risks and safety concerns have been mentioned in the literature, but the magnitude of challenges in anesthesiology practice are far greater than those cited and anticipated. Many times these challenging situations are unavoidable and the attending anesthesiologist has to deal with them on an individual basis. These hazards not only affect the general health but can be extremely threatening in various other ways that can increase the potential risks of morbidity and mortality. This article is an attempt to bring a general awareness among anesthesia fraternity about the various health hazards associated with anesthesia practice. Also, a genuine attempt has been made to enumerate the various preventive methods and precautions that should be adopted to make practice of anesthesiology safe and smooth.

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Beta thalassemia is the most common cause of hemolytic anemia in India. Hereby we are reporting four cases of beta thalassemia major aged between 5 and 10 years posted for splenectomy over a period of 2 months. These patients were on repeated blood transfusions since the day of diagnosis, and two patients had a history of cardiac failure. In addition to emphasizing the anesthetic challenges, the purpose of reporting such cases is to raise the awareness of the disease and prevention of the same by aggressive screening and prenatal diagnosis.

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Context: Spinal block is the first choice for lower abdominal surgeries. Bupivacaine is the most common local anesthetic used but has a shorter duration of action. Many adjuvants have been used to improve the quality of analgesia till postoperative period. In this study, we used α₂-agonists. Aims: The aim of this study is to compare the effects of intrathecal dexmedetomidine and clonidine as adjuvants to hyperbaric bupivacaine with respect to onset and duration of sensory and motor blockade duration of analgesia and incidence of side effects. Settings and Design: This was a prospective randomized double-blind study. Subjects and Methods: One hundred and fifty patients of physical status American Society of Anesthesiologists Classes I and II were randomly divided into Groups B, C, and D each administered with bupivacaine with normal saline, clonidine, and dexmedetomidine, respectively. Statistical Analysis Used: Data were entered into Microsoft excel data sheet. Analysis software used in this study was SPSS 22 version IBM. Categorical data were represented in the form of frequencies and proportions. Chi-square test was the test of significance. Continuous data were represented as mean and standard deviation. Independent t-test was used for mean difference between two groups. P < 0.05 was statistically significant. Results: Mean sensory onset in Group B was 2.8 ± 0.7 min, in Group C was 1.4 ± 0.5 min, and in Group D was 1.2 ± 0.4 min. Mean sensory regression by two segments in Group B was 78.5 ± 9.9 min, in Group C was 136.7 ± 10.7 min, and in Group D was 136.4 ± 11.7 min. Conclusions: α₂-agonists with hyperbaric bupivacaine intrathecally have a faster onset of both motor and sensory block. It also prolongs the duration of analgesia.

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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

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Eclampsia is one of the most common emergencies encountered by anesthesiologists which involve a safe journey of two lives. The definition, etiology, pathophysiology, treatment guidelines along with a special reference to management of labour pain and caesarean section are discussed. Eclampsia is commonly faced challenging case in our day to day anaesthesia practice,but less is discussed in our anaesthesia text books. Lot of controversies with regard to fluid management and monitoring still remain unanswered

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One of the most exiting recent technological advances in the field of anesthesia to track the region of interest is the introduction of anatomical evaluation by ultrasound imaging. Widespread use of this modality depends on its proven clinical efficacy, cost effectiveness, and practicality as it allows anesthesiologist to evaluate complex and varied anatomy prior to needle insertion. Sound used in medicine is not significantly transmitted by air or bone but through fluids which make up the larger part of soft tissues in the body. Ultrasound has been shown to offer excellent guidance for difficult venous access, epidural space identification in cases of difficult anatomy, delineating nerve plexuses for chronic nerve blocks, for regional anesthesia, and in transesophageal echocardiography for cardiac imaging with blood flows or in an otherwise high-risk patient where interventional procedure is required. It has special application to assess the narrowest diameter of the subglottic upper airway. A systemic literature search was performed in PubMed and the Cochrane library. The search strategy was set up using either single text word or combinations. We also included the studies where in these techniques were compared with conventional methods . Despite the initial excitement of this technique, ultrasound visualization is still indirect and images are subject to individual interpretation. It is gradually becoming routine in daily practice at our institution due to its reliability and safety. Though ultrasound is much safer, exposure in terms of intensity and time should be limited as far as possible, as high-energy ultrasound can cause heating and damage to tissues. In this review, we discuss established and future areas of ultrasound imaging and emphasize the use of B-mode ultrasound to improve the efficacy of interventional techniques. We have also illustrated potential uses with reference to cross-sectional B-mode images which visually represent a slice of tissues and are the easiest images for interpretation by clinicians.

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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.

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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.

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Classic hemophilia or hemophilia A is a congenital bleeding diathesis in which the affected individual may present with spontaneous hemorrhage or persistent bleeding even after minor trauma. Knowledge about the disease process, multidisciplinary team approach, and timely management can lead to favorable outcome in these patients. We report management of a child with hemophilia A for suturing of lacerated upper lip mucosa following trauma. A review of literature with recommendations for perioperative management, especially in the setting of emergency surgery, is also provided.

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This review article is going to elaborate on the description, components, and advantages of mini-cardiopulmonary bypass (mini-CPB), with special reference to the anesthetic management and fast track anesthesia with mini-CPB. There are several clinical advantages of mini-CPB like, reduced inflammatory reaction to the pump, reduced need for allogenic blood transfusion and lower incidence of postoperative neurological complications. There are certainly important points that have to be considered by anesthesiologists to avoid sever perturbation in the cardiac output and blood pressure during mini-CPB. Fast-track anesthesia provides advantages regarding fast postoperative recovery from anesthesia, and reduction of postoperative ventilation time. Mini bypass offers a sound alternative to conventional CPB, and has definite advantages. It has its limitations, but even with that it has a definite place in the current practice of cardiac surgery.

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This case report describes the first case in intraoperative magnetic resonance imaging operating theater (iMRI OT) (BrainSuite;) of awake craniotomy for frontal lobe glioma excision in a 24-year-old man undergoing eloquent cortex language mapping intraoperatively. As he was very motivated to take pictures of him while being operated upon, the authors adapted conscious sedation technique with variable depth according to Ramsey's scale, in order to revert to awake state to perform the intended neurosurgical procedure. The patient tolerated the situation satisfactorily and was cooperative till the finish, without any event. We elicit in this report the special environment of iMRI OT for lengthy operation in pinned fixed patient having craniotomy.

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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.

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Global warming refers to an average increase in the earth's temperature, which in turn causes changes in climate. A warmer earth may lead to changes in rainfall patterns, a rise in sea level, and a wide range of impacts on plants, wildlife, and humans. Greenhouse gases make the earth warmer by trapping energy inside the atmosphere. Greenhouse gases are any gas that absorbs infrared radiation in the atmosphere and include: water vapor, carbon dioxide (CO ₂ ), methane (CH ₄ ), nitrous oxide (N ₂ O), halogenated fluorocarbons (HCFCs), ozone (O ₃ ), perfluorinated carbons (PFCs), and hydrofluorocarbons (HFCs). Hazardous chemicals enter the air we breathe as a result of dozens of activities carried out during a typical day at a healthcare facility like processing lab samples, burning fossil fuels etc. We sometimes forget that anesthetic agents are also greenhouse gases (GHGs). Anesthetic agents used today are volatile halogenated ethers and the common carrier gas nitrous oxide known to be aggressive GHGs. With less than 5% of the total delivered halogenated anesthetic being metabolized by the patient, the vast majority of the anesthetic is routinely vented to the atmosphere through the operating room scavenging system. The global warming potential (GWP) of a halogenated anesthetic is up to 2,000 times greater than CO ₂ . Global warming potentials are used to compare the strength of different GHGs to trap heat in the atmosphere relative to that of CO ₂ . Here we discuss about the GWP of anesthetic gases, preventive measures to decrease the global warming effects of anesthetic gases and Xenon, a newer anesthetic gas for the future of anesthesia.

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Neuraxial blockade such as spinal anaesthesia can cause severe hypotension due to pharmacological sympathectomy resulting in potential deleterious consequences for the patient. Prevention of this spinal anaesthesia induced hypotension is of utmost importance especially in pregnant population as the life of mother as well as fetus is at risk. Several techniques and methodologies have been adopted for the prevention of this neuraxial hypotension with varying degree of success. The administration of intravenous fluids to optimize the blood volume during sympathectomy has been the most popular and widely used as the first line of therapy among these techniques. The intravenous fluids can be used both before and during the administration of spinal anaesthesia, the techniques appropriately named as pre-loading and co-loading respectively. Numerous research studies and available literary evidence suggests that both of these techniques can be equally effective in prevention of hypotension. The use of colloids has been observed to be more effective for pre-loading due to their longer half-life in the intravascular compartment. However, it has also been suggested that no technique is efficient in preventing the hypotension alone and has to be coupled with judicious use of vasopressors.

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