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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Background: Goal of premedication in pediatric anesthesia are relieving pre and postoperative anxiety, good parental separation, and smooth induction of anesthesia. Anxiety can produce aggressive reactions, increased distress, increased postoperative pain and postoperative agitation. The benzodiazepine, midazolam, is the most frequently used premedication in pediatric anesthesia. Midazolam has a number of beneficial effects when used as premedication in children: Sedation, fast onset, and limited duration of action. Though midazolam has a number of beneficial effects, it is far from an ideal premedicant having untoward side effects such as paradoxical reaction, respiratory depression, cognitive impairment, amnesia, and restlessness. Dexmedetomidine is a newer α-2-agonist, which can be used as premedicant. Aims: To compare the level of sedation, parental separation, mask acceptance, postoperative recovery of intranasal premedication with dexmedetomidine and dexmedetomidine-ketamine combination in pediatric patients. Settings and Design: Prospective randomized double-blind study. Subjects and Methods: After written informed consent from the patient's parents or legal guardian, 54 children of American Society of Anesthesiologists physical status I or II, aged between 1 and 6 years, scheduled to undergo elective minor surgery were enrolled. In group D patient received 1 μ g/kg dexmedetomidine intranasally and in group DK received 1 μ g/kg dexmedetomidine and 2 mg/kg ketamine intranasally. Patients were assessed every 10 min for the level of sedation, parenteral separation, heart rate, and oxygen saturation by an independent observer. Mask acceptance and postoperative agitation were noted using an appropriate scale. Statistical Analysis Used: Pearson Chi-square analysis to determine differences between two groups with respect to separation anxiety and acceptance of the anesthesia mask. Percentages used to represent frequencies. The level of significance was set at P< 0.05. Results: Acceptable parenteral separation was achieved in 90% of patients 30 min after premedication. Sedation was acceptable in 80% of patients at induction. Good mask acceptance was seen in 60% of patients. The incidence of emergence agitation (EA) was 2%. None of the above parameters was statistically significant between the two groups. Conclusions: Dexmedetomidine, as premedicant in children provides acceptable parenteral separation. However, mask acceptance in operation room is poor. Combination of dexmedetomidine and ketamine does not increase the success of premedication. Use of dexmedetomidine is associated with decreased EA.

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Background: Reduction in central sensitization by gabapentinoids that include gabapentin and pregabalin may reduce acute postoperative pain. Aims: The aim of this study is to evaluate postoperative analgesic benefit and efficacy in patients administered with oral gabapentin or pregabalin as premedication for laparoscopic cholecystectomy under general anesthesia. Settings and Design: Randomized, prospective, and comparative study. Materials and Methods: In this study, recruited patients were randomly allocated in three groups. Groups A, B, and C received 2 capsules of B complex, 3 capsules of 300 mg gabapentin each, and 2 capsules of 75 mg pregabalin, respectively, each in 30 patients of each group, 1 h before induction of anesthesia. Postoperative efficacy among these three groups was compared with respect to increase in duration of analgesia, reduction in postoperative pain scores, total postoperative requirements of analgesics and side effects. Statistical Analysis: Mean and standard deviation were calculated. Test of analysis between two groups was done by t-test and among three groups by analysis of variance, and then P value was calculated. Results: Pregabalin and gabapentin group had lower visual analog scale (VAS) score (P < 0.05), prolonged timing of first rescue analgesic (4.67 ± 14.79 vs. 158 ± 13.10 vs. 343.16 ± 9.69) min, and less opioid consumption (169.87 ± 20.32 vs. 116.13 ± 14.08 vs. 64.67 ± 16.69) mg compared to placebo group. Between the gabapentinoids, pregabalin group had lower VAS score, prolonged timing of first rescue analgesic, and less opioids consumption than the gabapentin group. Conclusion: It is concluded in this study that pregabalin group had lower VAS score, prolonged timing of first rescue analgesic, and less opioids consumption than the gabapentin group. Both gabapentinoids had better postoperative analgesic profile than placebo.

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Background: Intrathecal morphine provides effective postoperative analgesia, but their use is associated with numerous side effects, including pruritus, nausea, vomiting, urinary retention, and respiratory depression. Pruritus is the most common side effect with a reported incidence of 58–85%. Objectives: This prospective, randomized, and double-blinded study was performed for women scheduled for cesarean delivery using spinal anesthesia to compare nalbuphine and ondansetron in the prevention of intrathecal morphine-induced pruritus. Patients and Methods: Ninety women after spinal anesthesia with hyperbaric bupivacaine and intrathecal morphine patients randomly divided into three groups. Women in placebo group (P group) received 4 ml of normal saline intravenous (IV) injection, nalbuphine group (N group) received 4 ml of a 4 mg nalbuphine IV injection, and ondansetron 4 group (O group) received 4 ml of a 4 mg ondansetron IV injection, immediately after delivery of the baby. Studied women observed in postanesthesia care unit for 4 h. The primary outcome measures success of the treatment, defined as a pruritus score 1 (no pruritus) or 2 (mild pruritus - no treatment required) at 20 min after treatment. Results: Although, three was no significant difference between the three studied groups regarding; score 1 pruritus, while, score 2 pruritus (mild pruritus - no treatment requested) was significantly high in N and O groups compared to placebo group. Pruritus score 1 (no pruritus) plus pruritus score 2 were significantly high in N and O groups compared to placebo group (20 cases, 20 cases, 5 cases; respectively, P = 0.008). In addition; score 3 pruritus (moderate - treatment requested) was significantly less in N and O groups compared to placebo group. Conclusion: Nalbuphine and ondansetron were found to be more effective than placebo for prevention of intrathecal morphine-induced pruritus in women undergoing cesarean delivery and nalbuphine is preferred than ondansetron because it is not excreted in the breast milk.

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Aim: The study aimed at evaluating the clinical efficacy of articaine over lidocaine in the surgical removal of impacted mandibular third molars. Objective: The objectives were to compare the onset of anesthesia, pain during injection, during the procedure and after the procedure, compare the duration of anesthesia, and need for re-anesthesia. Materials and Methods: A prospective study was conducted on 70 subjects planned for surgical removal of mandibular third molars. Subjects were randomly administered one of two local anesthetics. The anesthetic agent used was unknown for the patient and the observer who performed the measurements. Results: The differences in latency with 4% articaine (56.57 ± 9.8 s) and with 2% lignocaine (88.26 ± 12.87 s), pain during procedure for articaine 1.31 ± 0.87 and for lignocaine 2.60 ± 1.06, pain after procedure was 0.89 ± 0.58 for articaine and 1.31 ± 1.05 for lignocaine, and mean duration of anesthetic effect for articaine was 231 ± 57.15 min and 174.80 ± 37.02 min for lignocaine, which was statistically significant. For re-anesthesia, 6 out of 35 patients needed re-anesthesia at the frequency of 8.57% for articaine and 13 out of 35 patients needed re-anesthesia at a frequency of 18.57% for lignocaine. Conclusion: The results proved that articaine had a significant faster onset of action and longer duration of action when compared to lignocaine. Hence, the pain experienced by the patients during and after the surgical procedure was significantly less. The study was concluded that articaine is a safe alternative to lignocaine, which is potent and effective in minor surgical procedures such as removal of mandibular third molars.

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Difficult airway, a scenario with potentially life threatening outcome, is routinely encountered by an anesthesiologist leaving him with the dilemma of whether to use regional anesthesia (RA) or general anesthesia. Our study aims to look into this problem. The literature search was performed in the Google, PubMed, and Medscape using key words “regional anesthesia, difficult airway, pregnancy, ventilation, intubation, epidural anesthesia, nerve blocks.” More than 38 free full articles and books published from the year 1987 to 2014 were retrieved and studied. At first sight, RA may appear to offer an ideal solution as it helps to avoid the problem of difficult airway. However, the possibility of a total spinal block, failed or incomplete RA, local anesthetic toxicity or unforeseen surgical complication may make it imperative that the airway is secured. The correct decision can only be made by the anesthetist when all the relevant clinical information is taken into account. It is also important to ensure that before considering RA in a patient of difficult airway, an anesthesiologist must have a preformulated strategy for intubation.

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Traditional acupuncture has been introduced more than 2500 years ago which provides an alternative and complementary option during clinical practices. Its main mechanism is based on stimulating the nerves by altering the processes and perception of pain transmitters. It facilitates releasing natural pain relievers such as endorphins and serotonin. Its success for various dental procedures has been proved earlier. However, its effects on controlling the gag reflex seem to be overlooked. The gag reflex is recognized as a protective reaction for stopping the entrance of any foreign bodies into the oropharynx. Pronounced gag reflexes can have negative impacts on the quality of dental procedures. Many techniques have been suggested for managing this reflex and acupuncturing is one of those which seems to be overlooked recently. The aim of this paper is reviewing the published high-quality researches about the efficacy of this technique for eliminating the gag reflex during dental procedures.

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Aims of Study: To evaluate the efficacy, hemodynamic changes, and patient comfort during awake fiberoptic intubation done under combined regional blocks. Materials and Methods: In the present observational study, 50 patients of American Society of Anesthesiologists ( ASA) Grade I–II, Mallampati Grade I–IV were given nerve blocks - bilateral glossopharyngeal nerve block, bilateral superior laryngeal nerve block, and recurrent laryngeal nerve block before awake fiberoptic intubation using 2% lidocaine. Results: Procedure was associated with minimal increases in hemodynamic parameters during the procedure and until 3 min after it. Most of the intubations were being carried out within 3 min. Patient comfort was satisfactory with 90% of patients having favorable grades. Discussion: The most common cause of mortality and serious morbidity due to anesthesia is from airway problems. One-third of all anesthetic deaths are due to failure to intubate and ventilate. Awake flexible fiberoptic intubation under local anesthesia is now an accepted technique for managing such situations. In awake patient's anatomy, muscle tone, airway protection, and ventilation are preserved, but it is essential to sufficiently anesthetize the upper airway before the performance of awake fiberoptic bronchoscope-guided intubation to ensure patient comfort and cooperation for which in our study we used the nerve block technique. Conclusion: A properly performed technique of awake fiberoptic intubation done under combined regional nerve blocks provides good intubating conditions, patient comfort and safety and results in minimal hemodynamic changes.

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The management of cancer pain still poses a major challenge for clinicians. Tramadol is a centrally acting synthetic opioid analgesic. Its well-known side effects include nausea, vomiting, and dizziness; seizures are a rare side effect. Some reports have found that tramadol triggers seizure activity at high doses, whereas a few preclinical studies have found that this seizure activity is not dose-related. We herein present a case involving a patient with laryngeal cancer who developed seizures while on low-dose oral tramadol.

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Background: Pregabalin and gabapentin are the gamma-aminobutyric acid analogs used as a part of multimodal analgesic regimen. Aim: To compare the postoperative analgesic benefits of gabapentin or pregabalin as a premedication for lower limb orthopedic surgery under combined spinal-epidural techniques. Settings and Design: Randomized double-blind study. Materials and Methods: A total of 90 patients were divided into three groups: G, P, C who received gabapentin 1200 mg, pregabalin 300 mg, and placebo, respectively 1.5 h before surgery. All patients received combined spinal-epidural block with 3 ml of 0.5% intrathecal bupivacaine. Assessment of pain was made with visual analog scale (VAS). Postoperative analgesia was provided with epidural top-ups with 2.5 ml of 0.5% bupivacaine and fentanyl 25 μg when VAS >3. Rescue analgesia in the form of injection diclofenac (75 mg) intramuscularly was given if VAS >3 even after epidural top-up. A total number of epidural top-ups, rescue analgesia, pain-free interval postspinal anesthesia, and sedation score were noted. Statistical Analysis: This was done using SPSS version 17. Mean and standard deviation were calculated using Chi-square test and analysis of variance. Results: The total postoperative analgesic time was 7.23 h in Group G, 14.80 h in Group P, and 4.17 h in Group C. A total number of epidural top-ups were 2.43 in Group G, 0.77 in Group P, and 4.43 in Group C. Conclusion: Pregabalin 300 mg and gabapentin 1200 mg significantly reduce the need of postoperative rescue analgesia, epidural top-ups, and increase the duration of postspinal anesthesia without altering hemodynamics with sedation as a major side effect.

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Context: Postoperative pain management is becoming an integral part of anesthesia care. Various techniques of pediatric pain relief have been designed among which the most commonly practiced is caudal epidural block. Several adjuvants have been used to prolong the duration of caudal analgesia such as clonidine, neostigmine, ketamine, opioids, and ephedrine. We have designed the study using dexmedetomidine as an adjuvant to assess analgesic efficacy, duration of postoperative analgesia, hemodynamic stability, postoperative sedation, and any adverse effects in children. Aims: The aim is to study the effects of dexmedetomidine as an adjuvant to bupivacaine in caudal analgesia in pediatric patients posted for infraumbilical surgeries. Settings and Design: This is a randomized, double-blind study in which effect of dexmedetomidine is studied when added to bupivacaine in the caudal epidural block. The observations are made intraoperatively for hemodynamic stability and postoperatively for the duration of analgesia. Subjects and Methods: This study was conducted in 100 children of American Society of Anesthesiologists physical status I and II, aged 2–10 years, undergoing elective infraumbilical surgeries. They were divided into two groups as follows: Group A: (0.25%) bupivacaine 1 ml/kg + normal saline (NS) 1 ml. Group B: (0.25%) bupivacaine 1 ml/kg + 1 μg/kg dexmedetomidine in 1 ml NS. As this study was double-blind, patients were randomly assigned to receive either (bupivacaine + saline) or (bupivacaine + dexmedetomidine) in each group. The patients were observed for hemodynamic stability, respiratory depression, and postoperative pain using face, legs, activity, cry, consolability (FLACC) pain scale for 24 h postoperatively. Statistical Analysis Used: Unpaired Student's t-test. Results: The mean duration of effective analgesia in Group A patients was 4.33 ± 0.98 h versus 9.88 ± 0.90 h in Group B patients. Likewise, the difference in mean FLACC score of both the groups was also statistically significant, 7.21 ± 0.76 and 6.49 ± 1.72 in Group A and Group B, respectively. Conclusion: Dexmedetomidine as adjuvant to Bupivacaine increases duration of caudal analgesia and improves hemodynamic stability without an increase in adverse effects in children undergoing infraumbilical surgeries.

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Background and Objective: Femoral fractures are extremely painful and pain invariably worsens on any movement. Anesthesia for fracture femur surgery is usually provided by spinal block. This study was undertaken to compare the analgesic effects of femoral nerve block (FNB) using nerve stimulator with 0.2% ropivacaine (15 ml) and intravenous (I.V.) fentanyl before patient positioning for fracture femur surgery under spinal anesthesia. Materials and Methods: A prospective, randomized, double-blind, comparative study was conducted on 60 American Society of Anesthesiologists I and II patients (18–60 years) scheduled for femur surgery under combined spinal epidural anesthesia. Patients in Group I (n = 30), were administered FNB using nerve stimulator with 0.2% ropivacaine (15 ml) and in Group II patients (n = 30), I.V. fentanyl 0.5 μg/kg was given as preemptive analgesia. Parameters observed included time to spinal anesthesia, intra-operative and postoperative visual analog scale (VAS) for any pain and postoperative epidural top-ups dosages. Results: Demographic profile was comparable in both the groups. VAS at 2 min in Group I was 5.63 and in Group II it was 8.00. Satisfaction score was better in Group I as compared to Group II patients. Time to administer subarachnoid block was 17.80 min in patients of Group I as compared to 25.03 min in Group II patients. Postoperatively, VAS scores were lower in Group I than Group II patients. The frequency of epidural top-ups was higher in Group II than in Group I patients. Conclusions: FNB is comparatively better in comparison to I.V. fentanyl when used as preemptive and postoperative analgesic in patients being operated for fracture femur.

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Background and Introduction: Spinal block, a known technique to obtain anaesthesia for infraumblical surgeries. Now physician have advantage of using adjuvant to prolong the effect of intrathecal block, which can be given either intravenously or intrathecally, dexmedetomidine is one of them. We studied effect of intravenous dexmedetomidine for prolongation of duration of intrathecal block of 0.5% bupivacaine block. Objective: To evaluate the effect of intravenous dexmedetomidine on sensory regression, hemodynamic profile, level of sedation and postoperative analgesia. Methodology: 60 patients of ASA grade I and II posted for elective infraumblical surgeries were included in the study and randomly allocated into two groups. Group D recieved intrathecal 0.5% bupivacaine heavy, followed by infusion of intravenous dexmedetomidine 0.5mic/kg over 10 min, patients in group C received intrathecal 0.5% bupivacaine heavy 3ml followed by infusion of same volume of normal saline as placebo. Results: Two segment regression of sensory block was achieved at 139.0 ± 13.797 in group D whereas in group C it was only 96.67 ± 7.649min, the total duration of analgesia achieved in both study groups was 234.67 ± 7.649min and 164.17 ± 6.170min respectively in group D and group C. The time at which first analgesic was given to the patients when VAS >3 achieved that is in group D at 234.67 ± 7.649min and in group C at 164.17 ± 6.170min. Inj diclofenac sodium 75mg intramuscular was used as rescue analgesic.

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Background: Spinal anesthesia for cesarean section is not a 100% successful technique. At times, despite straightforward insertion and drug administration, intrathecal anesthesia for cesarean section fails to obtain any sensory or motor block. Very few studies and literature are available regarding repeat administration of spinal anesthesia and its drug dosage, especially after first spinal failure in cesarean section lower segment cesarean section (LSCS) due to fear of the excessive spread of drug. The aim of our study is to compare the outcome between two different doses of 0.5% hyperbaric bupivacaine repeated intrathecally after failed spinal. Materials and Methods: After taking informed consent and Ethical Committee approval this prospective, randomized single-blinded study was conducted in 100 parturients of American Society of Anesthesiologists I-II who were posted for elective LSCS and had Bromage score 0 and no sensory block even at L₄dermatome after 10 min of first spinal anesthesia; were included in the study. Group A (n = 50) patients received 2.4 ml and Group B (n = 50) patients received 2 ml of 0.5% hyperbaric bupivacaine respectively for administering repeat spinal anesthesia. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), oxygen saturation, respiratory rate and electrocardiogram were monitored both intra- and post-operatively and complications were recorded. Results: Incidence of high spinal, bradycardia, hypotension, respiratory complications, and nausea vomiting are significantly higher in Group A compared to Group B (P < 0.05). SBP, DBP, and HR were significantly low in Group A patients compared to Group B in the first 10 min (P < 0.05). Conclusion: Spinal anesthesia can be safely repeated in the cesarean section with 10 mg of 0.5% hyperbaric bupivacaine provided after first spinal anesthesia, the level of sensory block is below L₄and motor power in Bromage scale is 0.

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Background: Mandibular nerve block reverses the trismus caused by pain and muscle spasm, thereby allowing for selection of a safer intubation technique. Aims: As ultrasonographic imaging has added newer dimensions to clinical anesthesia practice, we utilized this tool in performing mandibular nerve block and evaluated its efficacy in segregating trismus patients on etiological basis, to predict safer anesthetic induction. Settings and Design: Prospective, randomized controlled, outcome assessor blinded trial. Materials and Methods: Sixty-eight patients with unilateral mandibular fracture, acute pain, and trismus were randomized to receive mandibular nerve block by Vazirani-Akinosi approach (Group V) or the ultrasound-guided (USG) technique (Group U) before the general anesthetic induction for corrective surgery. Visual Analog Scale (VAS) score and inter-incisor distance was measured at intervals. Primary outcome measure was blocked failure (continued pain [VAS > 30] after the block procedure). Statistical Analysis Used: Mann–Whitney U-test and Wilcoxon signed rank test. Results: There was a significant decrease in pain score following the block procedure, except for six patients (block failure) in Group V. Inter-incisor distance increased to near-maximal levels after the nerve blockade, except for nine patients in Group V (including all block failures) and four in Group U having continued limited mouth opening. General anesthetic induction increased the inter-incisor gap in block failures (Group V) only. Conclusion: USG mandibular block appears to relieve reversible trismus more reliably, thereby allowing for a precise decision on a safer intubation technique.

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Background: Lignocaine + adrenaline; a local anesthetic agent; frequently used for perilesional infiltration, maintains the stable hemodynamics and decreases the postoperative pain after maxillofacial surgery. α₂agonists have peripheral analgesic effects. This prospective study was to evaluate the effectiveness of perilesional dexmedetomidine administered preincisionally in addition to conventional lignocaine adrenaline combinations for reconstructive maxillofacial surgery in an ambulatory care setting. Materials and Methods: 76, American Society of Anesthesiologists I-II patients scheduled for unilateral traumatic maxillofacial surgeries were randomly allocated into group DL (n = 38) receiving 15 cc of 2% lignocaine + adrenaline (1:200,000) mixed with 1 μg/kg dexmedetomidine and group PL receiving 15 cc of 2% lignocaine + adrenaline with normal saline (placebo) via local wound infiltration 5 min prior to skin incision. Perioperative hemodynamics, time to first analgesic use, total analgesic need, bleeding, and side effects were recorded for each patient. Results: Dosage of supplemental propofol; total perioperative, postoperative, and postanesthesia care unit (PACU) fentanyl consumption was significantly lower (P = 0.0001, P= 0.0001, P= 0.0001, P= 0.004, respectively) in dexmedetomine treated group than placebo. Rescue analgesic requirement was significantly earlier in group PL than group DL. Group DL patients suffered from significantly less (P = 0.02) bleeding and surgeon's satisfaction score was also high in this group. Discharge from PACU was significantly earlier in group DL. Intraoperative hemodynamic parameters were significantly lower in group DL (P < 0.05) without any appreciable side effects. Conclusion: Thus, prior dexmedetomidine local infiltration at the site of maxillofacial trauma has significantly reduced bleeding from wound site; perioperative fentanyl, propofol consumption, and subsequently ensured earlier discharge from PACU, better surgeon's satisfaction score with better hemodynamic control and lesser side effects.

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Introduction: Endotracheal tube (ETT) has been associated with various pharyngolaryngeal morbidities (PLMs) following general anesthesia (GA). Laryngeal mask airway (LMA), currently the most commonly used supraglottic airway device, has several advantageous over the ETT but has been associated with varying results of PLM. The aim of our study was to compare the PLM between them and to know whether LMA is a better alternative. Materials and Methods: One hundred and seventy American Society of Anesthesiologists Grades 1 and 2 women scheduled for elective mastectomy were included in the study, 85 each in either group, E Group (intubated with ETT) and L Group (using LMA) on a random basis. All patients received GA with controlled ventilation using a muscle relaxant. PLMs such as hoarseness, pain on phonation, sore throat, and difficulty in swallowing were documented by an interview done postoperatively. Peroperative parameters such as intubation attempts, trauma during airway device insertion, and intraoperative incidents were also analyzed. A sample size of 85 patients in each group was calculated in order to achieve a study power of 0.8 and alpha level was taken as 0.05. Data were analyzed using SPSS version 16 using Chi-square test, Mann–Whitney U-test and Fisher's exact test were used as nonparametric tests. A two-tailed P< 0.05 was considered significant. Results: Patients in E Group had statistically significant increased incidence of a sore throat and voice complaints whereas L Group showed a statistically significant increase of swallowing problems. There was also a significant correlation between traumatic insertion and sore throat, pain on swallowing in the L Group, which could be due to direct trauma. Conclusions: ETT was associated with an increased incidence of voice problems and sore throat whereas LMA had an increased incidence of dysphagia and odynophagia. Use of LMA changes the pharyngolaryngeal profile to a more acceptable one.

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Context: While giving low-flow anesthesia, it is a routine practice to give fixed duration of initial high-flow. This study was conducted to show the use of equilibration point as changeover point from initial high-flow to low-flow. Aims: It was to compare the use of equilibration point, hemodynamics, end-tidal agent concentration, recovery time, and recovery score between isoflurane and sevoflurane. Settings and Design: It was a prospective randomized study conducted on 100 patients who were admitted for elective surgery expected to be < 2 h duration. Materials and Methods: Patients were randomly assigned to one of the two groups of 50 each. Group I received isoflurane and Group S sevoflurane as an inhalational agent. Statistical Analysis: The observations obtained in both the groups were recorded and compared. Analysis was done using unpaired t-test and Chi-square test. Results: Hemodynamic parameters were comparable in both the groups. The mean equilibration times obtained for sevoflurane and isoflurane were 8.22 ± 1.060 min and 17.24 ± 10.2 min, respectively. The drift in end-tidal agent concentration over time was less in sevoflurane group. Mean recovery time was 7.92 ± 1.56 min in the sevoflurane group and 12.89 ± 3.45 min in the isoflurane group (P = 0.001). There was no significant difference between intraoperative and postoperative complications. Conclusion: Use of equilibration time of the volatile anesthetic agent as a changeover point, from high-flow to low-flow, can help us to use circle system with low-flow anesthesia in a more efficient way, especially with newer anesthetics such as sevoflurane.

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Background: Multiple trials have been tried to prevent hypotension during spinal anesthesia. However, the drug choice and mode of administration is still a matter of debate. Objectives: To compare the outcome of spinal injection of hyperbaric bupivacaine and fentanyl separately to standard injection of mixed fentanyl with hyperbaric bupivacaine. Settings and Design: A randomized, controlled clinical trial. Patients and Methods: One hundred twenty-four parturient scheduled for elective cesarean section were randomly allocated into two groups, each 62 parturient: Group M received spinal anesthesia using 10 mg bupivacaine 0.5% premixed with 25 μg fentanyl in the same syringe and Group S received 25 μg fentanyl in one syringe and 10 mg bupivacaine 0.5% without barbotage in a second syringe. Results: Patients with intraoperative pain that was controllable without the need for a shift to general anesthesia was significantly lower in Group S (3.2%) than in Group M (16.1%). The frequency of hypotension was significantly lower in Group S compared to Group M (P < 0.05). Time till the onset of sensory block was nonsignificantly shorter with nonsignificantly higher mean level of maximal sensory block in Group S compared to Group M (P > 0.05). There was no significant difference in the time till occurrence of hypotension, duration of hypotension, mean dose of ephedrine used for the treatment of hypotension and frequency of patients developed itching between the groups (P > 0.05). Conclusion: Separate intrathecal injection of fentanyl and hyperbaric bupivacaine provided a significant improvement in the quality of sensory block and significant reduction of the frequency of hypotension compared to injection of mixed medications.

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Background: Postoperative shivering (PAS) is a common problem following general and spinal anesthesia and may lead to multiple complications. This placebo-controlled, randomized study was performed to evaluate the efficacy of Ondansetron and butorphanol premedication reduces shivering after general and spinal anaesthesia. Aims: The aim of this study to highlight the efficacy of Butorphenol and ondosteron in controlling postoperative shivering. Materials and Methods: This clinical trial included 180 patients scheduled for elective general surgery, E.N.T., Ophthamological operations, randomly divided to six groups. Three groups in which General Anaesthesia was used i.e. Group 1-ondansetron 8 mg intravenously(IV).Group 2 butorphanol 2 mg IV and Group 3 – saline 4 ml IV. And three groups where spinal Anaesthesia was used i.e. Group 4-Ondosteron 8 mg IV, Group 5 butorphanol 2 mg IV and Group 6 – saline 4 ml IV 3-5 minutes before anaesthesia. Patients were observed in terms of vital signs, side effects and shivering. Settings and Design: The type of the study was double blind randomized trial. Statistical Analysis Used: Statistical Package for Social Sciences version 13.0 statistical analysis software. Results: Postoperative shivering was observed in 15.5%, 22.2% and 60% in general anaesthesia groups I II and III respectively. The reduction of core and dermal temperature during the anaesthesia and recovery, changes in systolic and diastolic blood pressure and heart rate were similar in all three groups (i.e. Group I ,II,III). In spinal anaesthesia groups, PAS occurred 10%, 13.3% and 43.3% in group IV, V, VI respectively. The reduction of core temperature is similar in all three groups of spinal anaesthesia. But heart rate and mean arterial pressure increase were significant in control saline group in post operative recovery time. No complication seen in any of the six groups. Conclusion: This study suggested that use of Butorphanol and Ondansteron both are effective in reducing the incidence of PAS after general and spinal anaesthesia.

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Context: Perioperative analgesia in paediatric herniotomies demand safe, effective and less invasive strategies. Local infiltration with Bupivacaine, rectal Diclofenac and caudal Bupivacaine are widely used for pain relief. Aims: To compare the analgesic effects of caudal epidural using 1 mlkg^-1 of 0.25% Bupivacaine against a combination of local infiltration 0.25% Bupivacaine 0.5 mlkg^-1 with Diclofenac suppository 2 mgkg^-1 in the management of post-operative pain following paediatric inguinal herniotomy. Settings and Design: This is an observational study from a tertiary care teaching hospital. Methods and Material: A total of 60 children for elective unilateral inguinal herniotomy were assigned to two groups of 30 each. Patients who received caudal block with 1 mlkg^-1 of 0.25% Bupivacaine were allocated to Group A and who received Diclofenac suppository 2 mgkg^-1 and infiltration with 0.25% Bupivacaine 0.5 mlkg^-1 were allocated to Group B. Post operative Pain was assessed using Hannallah's modified objective pain scale. At score ≥3 rescue analgesic oral Paracetamol 15 mgkg^-1 was given. Pain was assessed at 0,15,30,45,60 minutes and half hourly thereafter until 8 hours following surgery or until patient requires rescue analgesic whichever happens first. Statistical Analysis Used: Employed SPSS software. Data was analysed using sample t test and P-value was calculated. Results: The demographic profile was comparable between two groups. The mean analgesic duration in group A and group B was 228.5 and 331.0 minutes respectively and is found to be statistically significant (P < 0.05). Conclusions: Diclofenac suppository with local infiltration is a less invasive and effective alternative to caudal Bupivacaine for analgesia in paediatric herniotomy.

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Background: Traditional awake extubation leads to respiratory complications and hemodynamic response which are detrimental in neurosurgery, ENT surgery and patients with comorbidities. Aims: The primary objective was to compare the respiratory complications and hemodynamic stress response between traditional awake extubation of a endotracheal tube (ETT) and that following exchange extubation of ETT by using a laryngeal mask airway (LMA). Settings and Design: This prospective randomized study was conducted in a Tertiary Care Centre in 60 American Society of Anesthesiologists I and II patients coming for general surgery. Materials and Methods: Patients were randomized by permuted blocks into traditional awake extubation group and exchange extubation group. At the end of surgery in traditional group, awake extubation of ETT was done. In exchange group, 0.3 mg/kg propofol was administered, and the ETT was exchanged for a LMA. Awake extubation of LMA was then performed. Respiratory complications such as bucking, coughing, desaturation and the need for airway maneuvers and hemodynamic response were noted in both groups. Analysis Tools: Chi-square test, independent sample t- and paired t-tests were used as applicable. Results: Incidence of respiratory complication was 93.3% in traditional extubation while it was only 36.7% in exchange extubation group (P < 0.001). Hemodynamic response measured immediately at extubation in terms of heart rate, systolic blood pressure (BP), diastolic BP, mean arterial pressure, and rate pressure product were all significantly lesser in exchange group when compared to traditional extubation. Conclusion: Exchange extubation with LMA decreases respiratory complications and hemodynamic stress response when compared to traditional awake extubation.

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Background: The objective of this study was to study and compare the effects of intravenous dexmedetomidine and fentanyl on intraoperative hemodynamics, opioid consumption, and recovery characteristics in hypertensive patients. Methods: Fifty-seven hypertensive patients undergoing major surgery were randomized into two groups, Group D (dexmedetomidine, n = 29) and Group F (fentanyl, n = 28). The patients received 1 μg/kg of either dexmedetomidine or fentanyl, followed by 0.5 μg/kg/h infusion of the same drug, followed by a standard induction protocol. Heart rate (HR), mean arterial pressures (MAPs), end-tidal isoflurane concentration, and use of additional fentanyl and vasopressors were recorded throughout. Results: Both dexmedetomidine and fentanyl caused significant fall in HR and MAP after induction and dexmedetomidine significantly reduced the induction dose of thiopentone (P = 0.026). After laryngoscopy and intubation, patients in Group D experienced a fall in HR and a small rise in MAP (P = 0.094) while those in Group F showed significant rise in HR (P = 0.01) and MAP (P = 0.004). The requirement of isoflurane and fentanyl boluses was significantly less in Group D. The duration of postoperative analgesia was longer in Group D (P = 0.015) with significantly lower postoperative nausea and vomiting (PONV) (P < 0.001). Conclusion: Infusion of dexmedetomidine in hypertensive patients controlled the sympathetic stress response better than fentanyl and provided stable intraoperative hemodynamics. It reduced the dose of thiopentone, requirement of isoflurane and fentanyl boluses. The postoperative analgesia was prolonged, and incidence of PONV was less in patients who received dexmedetomidine.

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Background: Peroral endoscopic myotomy (POEM) is a novel method of treating achalasia of the esophagus. Very little data are available to guide the anesthesia providers caring for these patients. The anesthetic challenges are primarily related to the risk of pulmonary aspiration. There is also a potential risk of pneumomediastinum, pneumoperitoneum, subcutaneous, or submucosal emphysema, as a result of carbon dioxide tracking into the soft tissues surrounding the esophagus and lower esophageal sphincter. Methods: In this retrospective study, electronic charts of 24 patients who underwent POEM over 18 months were reviewed. Demographic data, fasting status, relevant aspiration risks, anesthetic technique, and postoperative care measures were extracted. Results: Fasting times for both solids and liquids were variable. None of the patients underwent preprocedural esophageal emptying. Standard induction and intubation were performed in 16, rapid sequence induction (RSI) with cricoid pressure in seven, and modified rapid sequence without application of cricoid pressure in one of the patients. One of the patients aspirated at induction, and the procedure was aborted. However, the procedure was performed successfully after a few weeks, this time a RSI with cricoid pressure was chosen. Conclusion: As there are no guidelines for the perioperative management of patients presenting for POEM presently, certain recommendations can be made. Preprocedural esophageal emptying should be considered in patients considered as high-risk, although cultural factors might preclude such an approach. Induction and intubation in a semi-reclining position might be useful. Although debatable, use of RSI with cricoid pressure should be strongly considered.

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Context: The continued success of regional anesthetic techniques can be credited due to improved local anesthetic drugs, with lower toxicities and longer duration of action, but still many efforts are being done to increase the duration of the block and postoperative analgesia. Therefore, use of adjuvant drugs for anesthesia is intended to prolong analgesia and preventing deleterious clinical effects of local anesthetics. Aims: The present study is designed to evaluate effects of intrathecal hyperbaric bupivacaine versus hyperbaric bupivacaine with low dose clonidine on the onset and level of sensory and motor block, the intensity of motor blockade, and time of analgesia required in the postoperative period. Settings and Design: Study area were our operation theater and postanesthesia care unit of Department of Anesthesiology, this was a prospective, randomized, placebo-controlled, and double-blind study for a period of 1 year comprising of 60 patients. Materials and Methods: Patients were randomly allocated into two groups: Group 1 (S) (n = 30): Patients received intrathecal hyperbaric bupivacaine 12.5 mg with normal saline 0.5 ml and Group 2 (C) (n = 30): Patients received intrathecal hyperbaric bupivacaine 12.5 mg with 1 μg/kg clonidine (approximated to 0.5 ml with normal saline). Statistical Analysis: Two groups were compared by Student's t-test, Chi-square test; ANOVA and significance of mean difference bet were done by Newman–Keuls test. Results and Conclusion: Duration of analgesia was prolonged in Group C (363.07 ± 166.30 min) patients compared to Group S patients (226.95 ± 119 min) and they also required less top up analgesic in the postoperative period.

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Background: The main stay of treatment in organophophosphorous [OP] poisoning is with atropine, oximes and supportive therapy. Despite the therapy, no improvement in mortality and morbidity. Fresh frozen plasma [FFP] a source of serum cholinesterase act as bio-scavenger to neutralise organophosphate toxins to improve the patients out come. Methods: The prospective study was conducted in 80 patients with acute OP poisoning. Patients with moderate to severe grade of OP poisoning with serum cholinesterase level <1000 IU/L were included in the study. Study group received atropine and oximes along with FFP given as 4 units first day, 3units on 2^nd day, 2 units on 3^rd day. Control group was given atropine and oximes only. Serum cholinesterase enzymes level, consumption of atropine per day, number of days on ventilator, length of ICU stay, and need for tracheostomy were assessed. Results: There was a significant increase in the serum cholinesterase levels after FFP infusion in the study group in comparison to the control group. Mean duration of Intensive Care Unit [ICU] stay was 8.35±4.3 in the study group and 12.45±4.13 in the control group. 06 patients in the control group succumbed whereas there were no fatalities in the study group. Conclusion: Daily reducing dose of FFP therapy for 3 consecutive days has beneficial effect in acute OP poisoning by increasing serum cholinesterase enzymes in blood with reduction in total dose of atropine consumption per day. It also reduces the ICU stay with zero mortality in OP poisoning.

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Background: Better adjuvants for epidural analgesia are still evolving. Dexmedetomidine that is alpha-2 agonist can be used as an adjuvant in epidural analgesia and anesthesia. Aims: The aim of this study was to compare the effect of dexmedetomidine versus clonidine in combination with ropivacaine in epidural anesthesia on intraoperative and postoperative analgesia, to find out the better adjuvant for regional anesthesia. Settings and Design: Randomized control trial. Materials and Methods: Sixty adult patients (18–60 years) with American Society of Anesthesiologists (ASA) 1/ASA 2 grade and undergoing lower abdominal and lower limbs surgeries were included and randomized into three groups of 20 patients each. Group 1 - received ropivacaine with normal saline. Group 2 - received ropivacaine with dexmedetomidine. Group 3 - received ropivacaine with clonidine. Statistical Analysis: Mean and Standard deviation were calculated. All the data were analyzed using analysis of variance and Chi-square test. The value of P< 0.05 was considered significant. Results: All the three groups were comparable with respect to age, sex, and ASA grade. There was statistically significant mean time to reach T10 sensory block level (15.8, 5.7, 9.6 min in Groups 1, 2, and 3, respectively). The maximum duration of analgesia was statistically higher in Group 2 patients (383.7 vs. 365.3 and 280.5 min in Group 3 and Group 1, respectively). The mean time to reach motor block was significantly shorter in Group 2. Side effects were comparable in all groups with statistically insignificant fall in mean arterial pressure and hypotension was noted with Group 2. Conclusion: We concluded that the patients receiving the addition of dexmedetomidine to ropivacaine in epidural anesthesia had a faster onset and longer duration of sensory and motor blockade. Dexmedetomidine in comparison to clonidine had acceptable sedation and hemodynamic stability and minimal dose requirement make very effective adjuvant in epidural anesthesia with comparable side effects.

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Background: Lumbar plexus block, combined with a sciatic nerve block, is an effective locoregional anesthetic technique for analgesia and anesthesia of the lower extremity. The aim of this study was to compare the clinical results outcome of the adductor canal block versus the psoas compartment block combined with sciatic nerve block using real time ultrasound guidance in patients undergoing elective laparoscopic knee surgeries. Patients and Methods: Ninety patients who were undergoing elective laparoscopic knee surgeries were randomly allocated to receive a sciatic nerve block in addition to lumbar plexus block using either an adductor canal block (ACB) or a posterior psoas compartment approach (PCB) using 25 ml of bupivacine 0.5% with adrenaline 1:400,000 injection over 2-3 minutes while observing the distribution of the local anesthetic in real time. Successful nerve block was defined as a complete loss of pinprick sensation in the region that is supplied by the three nerves along with adequate motor block, 30 minutes after injection. The degree of motor block was evaluated 30 minutes after the block procedure. The results of the present study showed that the real time ultrasound guidance of PCB is more effective than ACB approach. Although the sensory blockade of the femoral nerve achieved equally by both techniques, the LFC and OBT nerves were faster and more effectively blocked with PCB technique. Also PCB group showed significant complete sensory block without need for general anesthesia, significant decrease in the post-operative VAS and significant increase time of first analgesic requirement as compared to the ACB group. Result and Conclusion: The present study demonstrates that blockade of lumber plexus by psoas compartment block is more effective in complete sensory block without general anesthesia supplementation in addition to decrease post-operative analgesic requirement than adductor canal block.

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Background: Esmolol has an established role in attenuation of hemodynamic response to laryngoscopy and endotracheal intubation. We studied the effect of dexmedetomidine compared to that of esmolol in this study. Aim: To study the role of dexmedetomidine in attenuation of hemodynamic response to laryngoscopy and oral endotracheal intubation compared to that of esmolol hydrochloride in patients posted for elective surgery under general anesthesia. Study Design: Prospective randomized study double-dummy blinding method. Materials and Methods: A total of 60 American Society of Anesthesiologists I patients, aged 18–60 years randomly divided into two groups; Group A patients received dexmedetomidine 1 mcg/kg diluted in 50 ml with normal saline and infused over 10 min before induction and also 20 ml of normal saline intravenous (IV) 2 min before endotracheal intubation. Group B patients received 50 ml IV infusion of normal saline over 10 min before induction and IV bolus of esmolol 0.5 mg/kg diluted in 20 ml with normal saline given 2 min before intubation. Standard induction technique followed. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded just before induction and after intubation at 1 min, 3 min, and 5 min after intubation. Statistical Analysis: Independent samples t-test and repeated measures of analysis of variance. Results: Dexmedetomidine group showed statistically significant reduction in all the study parameters at all study time intervals following intubation. While esmolol group showed significant attenuation of HR, SBP, and MAP following intubation but failed to produce significant reduction in DBP. Conclusion: Dexmedetomidine is more effective in attenuating the hemodynamic response to oral endotracheal intubation compared to that of esmolol hydrochloride.

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Context: Traditionally, pain in children is a topic that has received only minimal attention. However, in the recent times, considerable progress has been made in the field of neonatal and pediatric pharmacology. The concept of preemptive analgesia is important in combating postoperative pain in children. In this study, we sought to compare the effectiveness of preemptive analgesia provided by paracetamol alone and by its combination with diclofenac when administered per rectum. Aims: To compare the efficacy of preoperative rectal paracetamol with paracetamol - diclofenac combination for postoperative analgesia in pediatric surgeries under general anesthesia. Settings and Design: Prospective randomized double-blind study. Subjects and Methods: Sixty children scheduled for various surgeries under general anesthesia were randomly allocated into two Groups A and B, with 30 in each. Children in Group A received paracetamol suppository 20 mg/kg and those in Group B received paracetamol 20 mg/kg + diclofenac 2 mg/kg as suppository immediately after tracheal intubation. All the children were assessed for 24 h from the time of extubation. The pain was measured using numerical rating scale in children above 7 years and face-legs-activity-cry-consolability scale in children below 7 years. The time interval between extubation and the administration of the first dose of rescue analgesic was taken as the duration of postoperative analgesia. Statistical Analysis Used: Descriptive and inferential statistical methods were used to analyze the data. Results: The duration of postoperative analgesia was significantly longer in paracetamol + diclofenac group (21.13 ± 2.68 h) as compared to paracetamol alone group (10.18 ± 2.39 h). Conclusions: The combination of paracetamol and diclofenac administered per rectum preoperatively is more effective than paracetamol alone in providing postoperative analgesia in children.

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Background: Head injury presents a major worldwide social, economic, and health problem. Hyperglycemia is a significant indicator of the severity of injury and predictor of outcome, which can easily be prevented. There has been a long-standing controversy regarding the use of inhalational or intravenous (i.v.) anesthetic agents for surgery of head injury cases and impact of these agents on blood sugar level. Aims and Objectives: The aim of this study is to find out anesthetic drugs and technique having minimal or no effect on the blood sugar, and Glasgow Coma Scale (GCS) of patients with a head injury by comparing two types of anesthetic techniques in surgery of head injury patients. Materials and Methods: This was a prospective, randomized, and comparative study, conducted on 60 adult head injury patients. The patients were divided into two groups of 30 each. Group I patients received induction with sevoflurane and then had O₂ + air + sevoflurane for maintenance with controlled ventilation. Group II patients received induction with i.v. propofol and then had O₂ + air + propofol for maintenance with controlled ventilation. Injection fentanyl was used in both the groups at the time of induction and in intermittent boluses in maintenance. In observation, blood sugar level and mean arterial pressure were assessed at different time periods perioperatively in both groups while GCS was analyzed pre- and post-operatively. Statistical Analysis: Statistical analysis was performed by Microsoft Excel 2010 using t-test for comparison between the two groups and Z-test for comparison of proportions. Results and Conclusion: Blood sugar level was found significantly higher in patients of sevoflurane group at 30 min after induction, at the end of surgery, and 1 h after the end of anesthesia than propofol group patients. This increase of blood sugar level did not have any significant alteration in the GCS profile of the patients in sevoflurane group as compared to propofol group patients. Nausea and vomiting were found more in sevoflurane group while hypotension and bradycardia were found more with propofol group.

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Background: Dexmedetomidine, an α2 agonist, when used as an adjuvant in general anesthesia attenuates stress response to various noxious stimuli, maintains perioperative hemodynamic stability and provides sedation without adversely affecting recovery in postoperative period. Materials and Methods: Sixty patients were randomly divided into two groups of 30 each. In Group A, dexmedetomidine was given intravenously as loading dose of 1 μg/kg over 10 min, and normal saline was given in Group B patients. After induction with propofol, in Group A, dexmedetomidine was given as infusion at a dose of 0.2–0.8 μg/kg/h. Sevoflurane was used as inhalation agent in both groups. Perioperative monitoring parameters were recorded. Postoperative sedation and recovery were assessed. Statistical Analysis Used: Demographic data were analyzed using Pearson's Chi-square test. Changes in the heart rate (HR), systolic blood pressure (BP) and diastolic BP were analyzed using unpaired t-test and Mann–Whitney rank sum test was used to calculate “P” value wherever (Shapiro–Wilk)/normality test gave ambiguous results. Results: Dexmedetomidine significantly attenuates stress response at intubation with lesser increase in HR (86.00 ± 5.16 vs. 102.97 ± 7.07/min.), mean BP (95.78 ± 5.35 vs. 110.18 ± 5.35) as compared to the control group (P < 0.05). After pneumoperitoneum, HR was 85.07 ± 6.23 versus 107.10 ± 4.98, mean BP was 98.98 ± 10.16 versus 118.54 ± 6.27 (P < 0.05). Thus maintains intraoperative hemodynamic stability. Postoperatively, the test group showed no statistically significant difference in the extubation time (7.00 ± 0.58 vs. 6.74 ± 0.73) and response to oral commands (8.78 ± 0.72 vs. 8.66 ± 0.73) (P > 0.05). Conclusion: Dexmedetomidine attenuates various stress responses during surgery and maintains the hemodynamic stability when used as an adjuvant in general anesthesia and dexmedetomidine does not delay recovery.

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Background: Thermoregulation is markedly affected in patients undergoing surgical procedures under anesthesia. Monitoring of temperature is very important during such conditions. Skin temperature is one of the easy and noninvasive ways of temperature monitoring. Common skin temperature monitoring sites are unreliable and did not correlate to the core temperature measurement. Aim: To compare and study the correlation of skin temperature over carotid artery in the neck to that of simultaneously measured nasopharyngeal temperature in adult patients undergoing surgical procedures under general anesthesia. Settings and Design: Prospective double-blinded study in a Tertiary Care Center. Materials and Methods: Ninety-seven consecutive American Society of Anesthesiologists I–II patients of age 18–40 years posted for elective surgical procedures under general anesthesia were included. Two temperature sites are monitored: The skin temperature over the carotid artery in the neck with a skin temperature probe T (skin-carotid) and the nasopharyngeal temperature T (naso) with another nasopharyngeal probe. The temperature readings are taken at 0, 15, 30, 45, and 60 min after induction of general anesthesia. Statistical Analysis: Paired t-test, Pearson correlation and Bland–Altman analysis for the rate of agreement. Results: The skin over the carotid artery in the neck showed statistically significant lower values than simultaneously measured nasopharyngeal temperature. This comparison is done with paired t-test at P< 0.05 significance. Bland–Altman plots showed good agreement between the two sites of temperature measurement. Conclusion: This study has shown that the skin temperature over the carotid artery in the neck was strongly correlated to the nasopharyngeal temperature in adult patients undergoing surgical procedures under general anesthesia.

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Background: GlideScope (GS) is a video laryngoscope that allows a real-time view of the glottis and endotracheal intubation. It provides a better view of the larynx without the need for alignment of the airway axes. Aim: This prospective randomized comparative study is designed to compare the intubation time, hemodynamic response, and complications associated with intubation using a GS or Macintosh laryngoscope (ML) in adult subjects undergoing elective surgical procedures. Materials and Methods: Sixty American Society of Anesthesiologists physical status 1–2 patients were included in this prospective randomized comparative study. Patients were randomized to be intubated using either a GS or an ML. The primary outcome measure was the intubation time. The secondary outcome measures were the hemodynamic response to intubation and the incidence of mucosal injury. Statistical Analysis: Mean and standard deviation were calculated for different parameters under the study. The observed results were analyzed using Student's t-test for quantitative data and Z-test of proportions.P<0.05 was considered statistically significant. Results: Intubation time was longer in GS group (45.7033 ± 11.649 s) as compared to ML (27.773 ± 5.122 s) P< 0.0001 with 95% confidence interval (95% CI) −13.2794 to −22.5806. GS provided better Cormack and Lehane laryngoscopic view (P = 0.0016 for grade 1 view) with 95% CI −0.1389 to −0.5951. GS group exhibited more laryngoscopic response than ML group with more increase in blood pressure and heart rate, but the difference was not statistically significant. More cases of mucosal trauma were documented in GS group. Conclusion: Use of GS to facilitate intubation led to better glottic view but took a longer time to achieve endotracheal intubation. GS was associated with more hemodynamic response to intubation and mucosal injury in comparison with an ML.

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Background: We conducted an audit of various communication practices during perioperative care among anesthesiology resident (R), faculties (F), and private practitioners (PP) in South India. We also documented the level of psycho-social support given to the patient and patient relatives and communication with the surgical colleagues during perioperative care. Methodology: A 15-point questionnaire based on communication practices was distributed in three major anesthesiology conferences requesting anesthesiologists to answer and drop the forms in the drop box provided. Resident and consultant level anesthesiologists of various Medical Schools in South India and private practitioners were involved in the study. The answers were analyzed to find out the various communication practices in perioperative care. Results: The freelancing private practitioners (PP) were more communicative to patient and relatives especially in complicated cases (Q1 - 45.6%, Q2 - 97.8%, Q4 - 94.4%, Q8 - 98.9%, respectively) in comparison with institutionalized practitioners. The choice of anesthesia and discussion related to the advantages of one mode of anesthesia over other was the most neglected part of communication (R - 14.2%, F - 17.6%, and PP - 5.6%). The PP's (95.6%) are more concerned about intraoperative communication (R - 27.6%, F - 39.2%). The discussion of postoperative pain management plan with the surgeon is not given priority in the communication by postgraduates (7.9%) and teaching faculties (8.8%). Conclusion: There is an urgent need to introspect and change the communication practices. We strongly recommend that communications skills should be introduced in anesthesiology resident curriculum.

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Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic syndrome of headache, visual changes, altered mental status and seizures with radiologic findings of posterior cerebral white matter edema. It is seen in hypertensive encephalopathy, renal failure, and autoimmune disorders or in patients on immunosuppressants. We report a case of 24-year-old primigravida who presented at term with sudden onset hypertension, neurological deficits, and an episode of the visual blackout. Magnetic resonance imaging showed features suggestive of PRES. She was posted for emergency lower segment cesarean section. General anesthesia was administered and blood pressure managed with antihypertensives. Postoperatively, she developed acute respiratory depression after prophylactic administration of injection magnesium sulfate. This case highlights that good clinical acumen along with early neuroimaging helps in prompt diagnosis, treatment and prevention of long-term neurological sequelae in PRES and the anesthetic implications of administering magnesium sulfate in the immediate post neuromuscular block reversal phase.

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Difficult airway is one of the most challenging situations invariably encountered in modern anesthesia practice and requires a high level of skill. This case report highlights the use of video laryngoscopy as an assist device for lateral position intubation in a patient with a large lumbar mass who was unable to lie supine. This case emphasis the significance of careful approach to planning and preparation in the management of airway in such a case.

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Context: Airtraq^™ (Prodol Meditec, Vizcaya, Spain) is a recently developed laryngoscope, which facilitates easy visualization of glottis through a matrix of sequentially arranged lenses and mirrors. In this observatory study, we sought to compare the ease of tracheal intubation with Airtraq^™ and Macintosh laryngoscope when performed by 2^nd year postgraduate residents of Anesthesiology in NRI Medical College, Mangalagiri. Aims: To compare the ease of tracheal intubation by Airtraq^™ laryngoscope with that by Macintosh laryngoscope among the 2^nd year postgraduate residents of anesthesiology in terms of time taken for intubation and the rise of rate-pressure product (RPP) with intubation. Settings and Design: Prospective randomized observational study. Subjects and Methods: Eighty adult and healthy patients with an easy airway, scheduled for general anesthesia were allocated into two groups A, and M. Patients in Group A were intubated with Airtraq^™ laryngoscope and those in Group M were intubated with Macintosh laryngoscope by the 2^nd year postgraduate residents of anesthesiology. The time taken for intubation, the RPPs at baseline, after induction of general anesthesia, postintubation, at 3 and 5 min after intubation, the rise of RPP to intubation and the occurrence of a sore throat were compared between the two groups. Statistical Analysis Used: Descriptive and inferential statistical methods were used to analyze the data. Results: The mean time for intubation in Macintosh group was 28.18 s and was 40.98 s in Airtraq group. The mean rise of RPP to intubation was 4644.83 in Airtraq group and 2829.27 in Macintosh group. The incidence of a sore throat was equal in both the groups. Conclusions: The time for intubation and the sympathetic response to airway instrumentation were more with Airtraq^™ laryngoscope than with Macintosh laryngoscope.

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