Fast-track surgery is a multimodal approach to patient care using a combination of several evidence-based peri-operative interventions to expedite recovery after surgery. It is an extension of the critical pathway that integrates modalities in surgery, anesthesia, and nutrition, enforces early mobilization and feeding, and emphasizes reduction of the surgical stress response. It entails a great partnership between a surgeon and an anesthesiologist with several other specialists to form a multi-disciplinary team, which may then engage in patient care. The practice of fast-track surgery has yielded excellent results and there has been a significant reduction in hospital stay without a rise in complications or re-admissions. The effective implementation begins with the formulation of a protocol, carrying out each intervention and gathering outcome data. The care of a patient is divided into three phases: Before, during, and after surgery. Each stage needs active participation of few or all the members of the multi-disciplinary team. Other than surgical technique, anesthetic drugs, and techniques form the cornerstone in the ability of the surgeon to carry out a fast-track surgery safely. It is also the role of this team to keep abreast with the latest development in fast-track methodology and make appropriate changes to policy. In the Indian healthcare system, there is a huge benefit that may be achieved by the successful implementation of a fast-track surgery program at an institutional level. The lack of awareness regarding this concept, fear and apprehension regarding its implementation are the main barriers that need to be overcome.

The advent of newer developments in anesthesia techniques and current clinical scenario has necessitated assurance of quality anesthesia services delivery. Numerous factors including availability of newer drugs, availability of newer advanced monitoring gadgets, increased awareness among the patient population, implementation of newer medico-legal laws and professional competitiveness has mandated a quality control and assurance in anesthesia. These domains of quality control are adapted from public health and are being incorporated into daily anesthesia practice in a gradual and phased manner. Quality control and assurance can be assessed and measured with certain quality indicators, which are also helpful in determining the perioperative outcome in anesthesia and surgical practice. Patient's perception about various anesthetic procedures, drug effects and recovery state are the prime underlying basis for assessing the quality assurance and control. At the same time, a positive impact of feedback mechanism cannot be under-emphasized while aiming for improvement in delivery of quality anesthesia services. The current review is aimed at highlighting the important aspects associated with quality assurance and quality control in anesthesia practice.

Postprocedural chest radiograph is done to illustrate the position of endotracheal tubes (ETTs), nasogastric and drainage tubes, indwelling catheters, and intravascular lines or any other lifesaving devices to confirm their position. These devices are intended to save life, but may be life-threatening if in the wrong place. The incidence of malposition and complications ranges from 3% to 14%, respectively. The portable chest radiograph is of tremendous value, inexpensive and can be obtained quickly at the patient's bedside in any location of the hospital. A systemic literature search was performed in PubMed and the Cochranre library by setting up the search using either single text word or combinations. Those studies were also included where the chest radiograph was compared with other imaging modalities. Its clinical efficacy, cost-effectiveness and practicality allow anesthesiologist to evaluate the post-procedural position and complications of ETT, indwelling catheters, and multi lumen intravascular lines. Knowledge of the radiological features of commonly used devices is of utmost importance.

Background: Idiopathic scoliosis is a common spinal deformity in teenagers, which is managed mainly by orthomorphia. However, due to great trauma, long operative duration and large blood loss, a great amount of blood transfusion is needed during the surgery. Allogeneic blood transfusion should be reduced in order to release blood insufficient, decline blood transfusion expense, as well as avoid transfusion diseases. Objective: The objective of the following study is to investigate the value of controlled hypotension combined with autotransfusion in idiopathic scoliosis orthomorphia and in order to reduce surgical bleeding and reduction in blood transfusion. Subjects and Methods: Intra-operative controlled hypotension was performed during posterior orthomorphia surgery on all the 46 cases of idiopathic scoliosis, 17 cases in which were served as the control group, who underwent allogeneic blood transfusion without autotransfusion, whereas the other 29 cases were served as the experimental group, who underwent autotransfusion that including reinfusion of pre-operative deposited autologous blood and intra-operative salvaged autologous blood. The blood loss volume and transfusion status in two groups were observed. Results and Conclusion: Blood loss volume in the control group was 400-1000 (835.3 ± 167.5) mL and that in the experimental group was 350-1400 (812.1 ± 152.7) mL, there was no marked difference between the two groups (P > 0.05). The volume of allogeneic blood transfusion in the control group was 500-1800 (855.9 ± 321.1) mL, which was greater than that in the experimental group ((0-1300 (337.9 ± 258.3) mL) (P < 0.01). The results suggested that controlled hypotension reduces intraoperative bleeding and post-operative autotransfusion minimizes the need of allogeneic blood transfusion.

Context: The favorable kinetic properties of sevoflurane could be advantageous in obese patients undergoing bariatric surgery, improving recovery from general anesthesia (GA). Aims: To compare the recovery criteria following anesthesia with sevoflurane and isoflurane in morbidly obese patients undergoing laparoscopic gastric sleeve resection. Settings and Design: This was a prospective randomized controlled study conducted in 50 patients undergoing laparoscopic sleeve gastrectomy. Materials and Methods: Following awake fiberoptic intubation, GA was induced and maintained with sevoflurane in Group A and isoflurane in Group B. 2% sevoflurane and 1.2% isoflurane were used and concentration varied to maintain a mean arterial pressure (MAP) of >75 mm of Hg, maximum concentration being 3% for sevoflurane and 2% for isoflurane. Inhalational agent was terminated at time of skin suturing and patients were extubated when completely awake. Recovery criteria followed were eye opening on call, voluntary head raising on command for 5 s and orientation assessed by answering name and location. Statistical Analysis Used: Student's t-test was used to test statistical significance of difference in mean values between the groups, analysis of covariance was used to test diastolic blood pressure (DBP) changes and Chi-square test to assess association between categorical variables. Results: There was no significant variability in heart rate, systolic blood pressure, DBP and MAP between 2 groups up to 210 min. Group A patients had significantly faster eye opening compared to Group B (4.4 ± 1.6 vs. 9.2 ± 2.18 min), were significantly faster in obeying commands (6.08 ± 1.6 vs. 10.08 ± 2.02 min), had a significantly shorter extubation time (7.08 ± 1.6 vs. 11.16 ± 2.18 min) and significantly faster orientation in time as compared to Group B (9.24 ± 1.7 vs. 12.32 ± 2.42 min). Conclusion: Sevoflurane has a better recovery profile based on eye opening, obeying commands, time for extubation and orientation, than isoflurane in morbidly obese patients undergoing laparoscopic sleeve gastrectomy.

Background: The prevalence of hip fracture is increasing with the continued aging of the population. The aim of this study was to compare the results after implementing the project accelerated post-operative recovery after surgery femur in patients aged over 60 years. Methods: Patients were observed during two distinct periods: Before implantation and after the implementation of the project Acerto. Patients underwent spinal anesthesia with post-operative analgesia by lumbar plexus block. Data evaluation was carried out in four stages of the study in both groups: Before arrival to the operating room during surgery, post-anesthesia care unit and on the ward in the morning of day 1 post-operatively. Results: The project implementation significantly reduces the length of stay, the number of suspension of surgery, duration of fasting, the incidence of hunger and thirst and the reintroduction of oral feeding. Oral feeding 2-4 h before surgery with dextrinomaltose not attended with nausea and vomiting. All patients were able to discharge on day 1 post-operatively. Conclusions : The use of clinical measures of accelerating patient recovery decreased length of stay, the number of suspensions of surgery, the time of fasting, the time of oral food reintroduction, high earlier and faster return to family life, working as humanization of treatment to the elderly.

Background: Neuraxial blocks result in sympathetic block, sensory analgesia and motor block. Continuous epidural anesthesia through a catheter offers several options for perioperative analgesia. Local anesthetic boluses or infusions can provide profound analgesia. Although the role of low-dose ketamine (<2 mg/kg intramuscular, <1 mg/kg intravenous [IV] or ≤ 20 μg/kg/min by IV infusion) in the treatment of post-operative pain is controversial, perioperative administration of a small dose of ketamine may be valuable to a multimodal analgesic regimen. A local anesthetic can be used for wound infiltration intra-operative to minimized the surgical pain. Patients and Methods: A prospective randomized study was performed in which 40 patients scheduled for elective open cholecystectomy under general anesthesia admitted to the Medical Research Institute were included and further subdivided into two groups, group A, received thoracic epidural catheter at T7-8, activation was done 20 min before induction of anesthesia with plain bupivacaine at a concentration of 0.25% at a volume of 1 ml/segment aiming to block sensory supply from T4-L2, then received continuous thoracic epidural infusion intra and postoperatively with plain bupivacaine at a concentration of 0.125% at a rate of 5 ml/h for 24 h, group B received 0.3 mg/kg bolus of ketamine at the time of induction then 0.1 mg/kg/h ketamine IV infusion during surgery followed by wound infiltration with 15 ml of plain bupivacaine 0.5% at the time of skin closure. Results: Bupivacaine thoracic epidural analgesia had better control on heart rate and mean arterial blood pressure than ketamine infusion plus wound infiltration with local anesthetic in patients undergoing open cholecystectomy. Conclusion: Thoracic epidural analgesia had better control on hemodynamic changes intra-and postoperatively than ketamine infusion with local wound infiltration in open cholecystectomy.

Background: Difficult tracheal intubation contributes to significant morbidity and mortality during induction of anesthesia. There are divided opinions regarding ease of intubation in obese patients. Moreover, the definition of difficult intubation is not uniform; hence we have use the Intubation Difficulty Scale (IDS) to find the incidence of difficult intubation in obese patients. Aims: The primary aim of the following study is to find out the incidence of difficult intubation in obese and lean patients using IDS and secondary aim is to assess the performance of bedside screening tests to predict difficult intubation, mask ventilation and laryngoscopy in obese and lean patients. Materials and Methods: A prospective, observational cohort study of 200 patients requiring general anesthesia were categorized into 100 each based on body mass index (BMI) into lean (BMI <25 kg/m ² ) and obese (BMI ≥25 kg/m ² ) groups. IDS score ≥5 was termed as difficult intubation. Pre-operative airway assessment included Mallampati score, mouth opening, neck circumference (NC), upper lip bite test, thyromental distance, sternomental distance (SMD) and head neck mobility. Patients having difficulty in mask ventilation and laryngoscopy was recorded. Results: Over all in 200 patients the incidence of difficult intubation was 9%. Obese patients were slightly more difficult to intubate than lean (11% vs. 7%, P = 0.049). Age >40 years, NC >35 cm, SMD <12.5 cm and restricted head neck mobility were factors which were associated with IDS ≥5. Multivariate analysis revealed SMD <12.5 cm to predict difficult intubation in obese patients. Obese patients were difficult to mask ventilate (6% vs. 1%, P = 0.043). There was no difference regarding grading of laryngoscopy between the two groups. Conclusion: Obese patients are difficult to mask ventilate and intubate. During intubation of obese patients who is more than 40 years age and SMD <12.5 cm, it is preferable to have a second skilled anesthesiologist.

Background: Intravenous dexmedetomidine is used as adjuvant during general anesthesia due to its sedative and analgesic effects. The present study was aimed to evaluate the effects of intravenous dexmedetomidine on sensory and motor block characteristics, hemodynamic parameters and sedation during subarachnoid block. Materials and Methods: In this double-blind randomized placebo control study, 60 patients of American Society of Anesthesiologist I and II were randomized into two groups by computer generated table. Patients of Group D administered intravenous dexmedetomidine 0.5 μg/kg and patients of Group C received similar volume of normal saline, administered after 20 min of subarachnoid block with 0.5% hyperbaric bupivacaine. The cephalic level of sensory block, total duration of sensory analgesia and motor block were recorded. Sedation scores using Ramsey Sedation Score (RSS) and hemodynamic changes were also assessed. Results: Demographic profile, duration of surgery and cephalic level of sensory block were comparable. The time for two segments regression was 142.35 ± 30.7 min in Group D, longer than Group C (98.54 ± 23.2 min). Duration of sensory blockade was 259.7 ± 46.8 min in the Group D versus 216.4 ± 31.4 min in Group C (P < 0.001). The mean duration of motor blockade showed no statistically significant difference between groups. There was clinically significant decrease in heart rate and blood pressure in patients of Group D. The RSS was higher (arousable sedation) in patients of Group D. No respiratory depression was observed. Conclusion: Intravenous dexmedetomidine in dosage of 0.5 μg/kg, administered after 20 min of subarachnoid block prolonged the duration of sensory and motor blockade with arousable sedation.

Background: For optimum magnetic resonance imaging (MRI) image quality and to ensure precise diagnosis, patients have to remain motionless. We studied the effects of intranasal dexmedetomidine and ketamine with intravenous midazolam for pre-procedural and procedural sedation in school aged children. Patients and Methods: Children were randomly allocated to one of two groups: (Group D) received intranasal dexmedetomidine 3 μg kg^–1 and (Group K) received intranasal ketamine 7 mg kg^–1 . Sedation levels 10, 20 and 30 min after drug instillation were evaluated using a Modified Ramsay sedation scale. A 4-point score was used to evaluate patients when they were separated from their parents and their response to intravenous cannulation. Results: The two groups were comparable in terms of the child's anxiety at presentation (P = 0.245). We observed that Group K achieved faster sedation at 10 min point with P < 0.05. A comparable sedation score at 20 and 30 min were noted. The two groups were comparable regarding to the child's acceptance of nasal administration (P = 0.65). The sedation failure rate was insignificantly differ between groups (13.7% vs. 20.6% for Group D and K respectively). Heart rate and systolic blood pressure showed a significant difference between the two groups starting from the point of 20 min. Conclusion: Intranasal dexmedetomidine 3 μg kg^–1 or ketamine 7 mg kg^–1 can be used safely and effectively to induce a state of moderate conscious sedation and to facilitate parents' separation and IV cannulation. Addition of midazolam in a dose not sufficient alone to produce the target sedation achieved our goal of deep level of sedation suitable for MRI procedure.

Background: Preemptive analgesia is known modality to control the peri-operative pain. The present study was aimed to evaluate the effects of oral clonidine on subarachnoid block characteristics, hemodynamic changes, sedation and respiratory efficiency in patients undergoing laparoscopic gynecological procedures. Patients and Methods: A total of 64 adult consenting females of American Society of Anesthesiologist physical status I and II were randomized double blindly into two groups of 32 patients each. Patients in the clonidine group received oral clonidine (100 μg) and patients of the control group received placebo capsule, 90 min before subarachnoid block with 0.5% hyperbaric bupivacaine (3.5 ml). The onset of sensory and motor block, maximum cephalic sensory level and regression times of sensory and motor blockade were assessed. Intra-operative hemodynamic changes, respiratory efficiency, shoulder pain and sedation score were recorded. The other side-effects, if any were noted and managed. Results: The onset of sensory blockade was earlier in patients of clonidine group with prolonged duration of analgesia (216.4 ± 23.3 min vs. 165.8 ± 37.2 min, P < 0.05), but no significant difference was observed on motor blockade between groups. The hemodynamic parameters and respiratory efficiency were maintained within physiological limits in patients of clonidine group and no patient experienced shoulder pain. The Ramsey sedation score was 2.96 ± 0.75. In the control group, 17 patients experienced shoulder pain, which was effectively managed with small doses of ketamine and 15 patients required midazolam for anxiety. Conclusion: Premedication with oral clonidine (100 μg) has enhanced the onset and prolonged the duration of spinal analgesia, provided sedation with no respiratory depression. The hemodynamic parameters remained stabilized during the pneumoperitoneum.

Aim: The present study aimed to compare the efficacy of injectable diclofenac intramuscularly (IM), injection paracetamol intravenously (IV), or a combination of both to provide post-operative analgesia in patients undergoing lower abdominal gynecological surgeries. Materials and Methods: A total of 90 female patients (American Society of Anesthesiologists I and II), aged 20-50 years, scheduled for elective total abdominal hysterectomy with or without bilateral salpingo-oophorectomy were randomized to receive 75 mg diclofenac IM 8 hourly (Group D) or 1 g paracetamol IV 8 hourly (Group P) or a combination of both 8 hourly (Group PD) for 24 h post-operative period from the start of surgery. The primary outcome measured was the requirement of rescue analgesic (tramadol), the secondary outcomes measured included visual analog score (VAS) for pain, time until first rescue analgesic administration, patient satisfaction score and any side effects. Results: The requirement of rescue analgesic was significantly lower in Groups D and PD compared to Group P. Mean (standard deviation) tramadol requirement during 24 h was 56.67 (62.60) mg, 20.00 (40.68) mg and 20.00 (40.68) mg in the Groups P, D and PD respectively. Less number of patients in Groups D and PD (20% in both the groups) required rescue analgesic compared to Group P (50%). The VAS showed a significant decrease in Groups D and PD compared to Group P between 4 and 12 h post-operatively. However, Group PD showed no significant difference when compared to Group D alone. Conclusion: Injection diclofenac IM is more effective than paracetamol IV in terms of rescue analgesic requirement, but the combination of diclofenac IM and paracetamol IV provides no added advantage over diclofenac IM alone.

Background: Postoperative nausea and vomiting is commonly associated with adverse consequences and hamper the postoperative recovery in spite of the availability of many antiemetic drugs and regimens for its prevention. The study was aimed to compare the prophylactic effects of intravenously administered palonosetron, ondansetron, and granisetron on prevention of postoperative nausea and vomiting after general anesthesia. Materials and Methods: This prospective, double-blind study, comprised 120 adult consented patients of ASA grade I and II of either gender, was carried out after approval of Institutional Ethical Committee. Patients were randomized into three equal groups of 40 patients each in double-blind manner. Group P received inj. palonosetron (0.075 mg), group O received inj. ondansetron (4 mg), and group G received inj. granisetron (2 mg) intravenously five minutes before induction of anesthesia. The need for rescue antiemetic, episode of postoperative nausea and vomiting, and side effects were observed for 12 hours in the post-anesthesia care unit. At the end of study, results were compiled and statistical analysis was done by using ANOVA, Chi-square test, and Kruskal Wallis Test. Value of P < 0.05 was considered significant. Results: The incidence of nausea and vomiting was maximal during the first four hours postoperatively. The complete control of postoperative nausea and vomiting for first 12 hours was achieved in 30% patients of ondansetron group, 55% patients of granisetron group, and 90% patients of palonosetron group. Safety profile was more with palonosetron. Conclusion: Palonosetron was comparatively highly effective to prevent the PONV after anesthesia due to its prolonged duration of action than ondansetron and granisetron.

Background: Mixing of various adjuvants has been tried with local anesthetics in an attempt to prolong anesthesia from peripheral nerve blocks but have met with inconclusive success. More recent studies indicate that 8 mg dexamethasone added to perineural local anesthetic injections augment the duration of peripheral nerve block analgesia. Aims: Evaluating the hypothesis that adding dexamethasone to ropivacaine significantly prolongs the duration of analgesia in supraclavicular brachial plexus block compared with ropivacaine alone. Patients and Methods: It was a randomized, prospective, and double-blind clinical trial. Eighty patients of ASA I and II of either sex, aged 16-60 years, undergoing elective upper limb surgeries were equally divided into two groups and given supraclavicular nerve block. Group R patients (n = 40) received 30 ml of 0.5% ropivacaine with distilled water (2 ml)-control group whereas Group D patients (n = 40) received 30 ml of 0.5% ropivacaine with 8 mg dexamethasone (2 ml)-study group. The primary outcome was measured as duration of analgesia that was defined as the interval between the onset of sensory block and the first request for analgesia by the patient. The secondary outcome included maximum visual analogue scale (VAS), total analgesia consumption, surgeon satisfaction, and side effects. Results: Group R patients required first rescue analgesia earlier (557 ± 58.99 min) than those of Group D patients (1179.4 ± 108.60 min), which was found statistically significant in Group D (P < 0.000). The total dose of rescue analgesia was higher in Group R as compared to Group D, which was statistically significant (P < 0.00). Conclusion: Addition of dexamethasone (8 mg) to ropivacaine in supraclavicular brachial plexus approach significantly and safely prolongs motor blockade and postoperative analgesia (sensory) that lasted much longer than that produced by local anesthetic alone.

Background: Hypothermia is a frequent observation in elderly males undergoing transurethral resection of prostate (TURP) under spinal anesthesia. The use of irrigating fluids at room temperature results in a decrease body temperature. Warmed irrigating solutions have shown to reduce heat loss and the resultant shivering. Such investigation was not much tried in low resource settings. Aim: To compare the resultant change in core temperature and hemodynamic changes among patients undergoing TURP surgery under spinal anesthesia using warm and room temperature irrigation fluids. Settings and Design: Randomized prospective study at a tertiary care center. Methods: This study was conducted on 40 male patients aged 50-85 years undergoing TURP under spinal anesthesia. Of which, 20 patients received irrigation fluid at room temperature 21°C and 20 patients received irrigation fluid at 37°C after random allocation. Core temperatures and hemodynamic parameters were assessed in all patients at preoperative, intra-operative, and postoperative periods. Intra-operative shivering was also noted in both groups. Statistical Analysis: Unpaired and Paired Student's t-test. Results: For patients who underwent irrigation with fluid at room temperature Core temperature drop from 36.97°C in preoperative to 34.54°C in postoperative period with an effective difference of 2.38°C. Among patients who received warmed irrigation fluid at 37°C had core temperature drop from 36.97°C to 36.17°C and the effect of fall was 0.8°C. This difference was statistically significant (P < 0.001). Shivering of Grades 1 and 2 was observed in nine patients, of Group 1 while only three patients had Grades 1 and 2 shivering in Group 2. The hemodynamic parameters were similar in the two groups and did not reach significant difference. Conclusion: Use of warm irrigation fluid during TURP reduces the risk of perioperative hypothermia and shivering.

Background: Anesthetists used lower doses of fentanyl, successfully with hemodynamic control by titrating volatile anesthetic agents or vasodilators for fast-tracking in cardiac surgery. Hypothesis: Lower total doses of anesthetics and fentanyl could be required with hemodynamic control by use of supraglottic devices than endotracheal tube (ETT) and helps in fast-tracking. Design: A prospective randomized observational clinical trial study. Aims: The authors compared the utility of I-gel airway with a conventional ETT during the induction and maintenance of anesthesia with sevoflurane and fentanyl in adults undergoing cardiac surgery. Patients and Methods: A total of 49 adult patients underwent cardiac surgery were randomized into two groups according to the airway management: I-gel group (n = 23) and ETT group (n = 26). Doses of fentanyl and hemodynamic parameters (heart rate [HR], mean arterial pressure [MAP] central venous pressure [CVP], pulmonary artery pressure [PAP], and pulmonary capillary wedge pressure [PCWP]) were recorded preoperative, 5 min following tracheal intubation or I-gel airway insertion, after skin incision, after stenotomy, and after weaning off bypass. Results: None of the patients in the I-gel group required additional doses of fentanyl during the I-gel insertion, compared with 74% of the patients during laryngoscopy and endotracheal insertion in the ETT group, for an average total dose of 22.6 ± 0.6 μg/kg. The MAP and HR did not significantly differ from the baseline values at any point of measurement in either group. Furthermore, CVP, PAP, and PCWP measured during the procedure were significantly lower in I-gel group than ETT group. Extubation required more amount of time in ETT than I- gel group. Conclusion: The I-gel airway is well-tolerated by adult patients undergoing cardiac surgery, and requires lower total doses of anesthetics than endotracheal intubation with hemodynamic control and helps in fast-tracking.

Aim: A double-blinded randomized controlled study to compare discharge time and patient satisfaction between two groups of patients submitted to open surgeries for abdominal malignancies using segmental thoracic spinal or general anesthesia. Background: Open surgeries for abdominal malignancy are usually done under general anesthesia, but many patients with major medical problems sometimes can't tolerate such anesthesia. Regional anesthesia namely segmental thoracic spinal anesthesia may be beneficial in such patients. Materials and Methods: A total of 60 patients classified according to American Society of Anesthesiology (ASA) as class II or III undergoing surgeries for abdominal malignancy, like colonic or gastric carcinoma, divided into two groups, 30 patients each. Group G, received general anesthesia, Group S received a segmental (T9-T10 injection) thoracic spinal anesthesia with intrathecal injection of 2 ml of hyperbaric bupivacaine 0.5% (10 mg) and 20 ug fentanyl citrate. Intraoperative monitoring, postoperative pain, complications, recovery time, and patient satisfaction at follow-up were compared between the two groups. Results: Spinal anesthesia was performed easily in all 30 patients, although two patients complained of paraesthesiae, which responded to slight needle withdrawal. No patient required conversion to general anesthesia, six patients required midazolam for anxiety and six patients required phenylephrine and atropine for hypotension and bradycardia, recovery was uneventful and without sequelae. The two groups were comparable with respect to gender, age, weight, height, body mass index, ASA classification, preoperative oxygen saturation and preoperative respiratory rate and operative time. Conclusion: This preliminary study has shown that segmental thoracic spinal anesthesia can be used successfully and effectively for open surgeries for abdominal malignancies by experienced anesthetists. It showed shorter postanesthesia care unit stay, better postoperative pain relief and patient satisfaction than general anesthesia.

Multiple casualties and the complex set of injuries in survivors of a terrorist bomb blast poses a real challenge to health care providers. We are presenting three such cases, first case suffered a fracture of both bone lower limb bilaterally along with head injury (foreign bodies were impacted in the scalp and brain parenchyma). Following primary resuscitation, patient shifted to operation theatre after a quick computerized tomography scan and external fixator applied in general anesthesia using the rapid sequence induction. No active neurosurgical intervention was done. As this patient had acute post-traumatic stress response, he was subjected to low pressure hyperbaric oxygen therapy (pressure of 1.5 ATA for 60 min a day for 10 days) and group counseling. He had good recovery except one lost a limb because of extensive neurovascular damage due to blast. Second case had much more extensive damage involving multiple organ systems. He had blast lung, big cerebrovascular hemorrhage along with gut perforation. Despite best possible surgical and intensive care interventions, patent developed multiple organ failure and unfortunately we lost our patient. Third case was of a right sided globe rupture resulted from blast induced flying foreign bodies. After primary survey and initial resuscitation evisceration done for the damaged eye and patient later on discharged with necessary instruction (including warning signs) for follow-up.

Eisenmenger's physiology has significant anesthetic implications. The symptamology, in the early course of disease can be subtle at times and missed on regular PAC. Pulse oximetry, in our patient detected differential saturations. The possibility of underlying congenital cardiac illness was assumed, rescheduling of case was debated and finally the abnormal cardiac lesions were identified in ECHO in immediate postoperative period.

Lumbar laminectomies are usually performed under general anesthesia in the prone position. We report a case of lumbar laminectomy done under segmental continuous epidural anesthesia, so that direct visual intra-operative monitoring of the motor and sensory component of the lower extremities was possible.

It is known that, unilateral thoracic paravertebral block (TPVB) applications performed with general anesthesia provide satisfactory conditions for open cholecystectomy increase the quality of post-operative analgesia and patient comfort and decrease the frequency of post-operative nausea and vomiting. In this case report, the TPVB was presented which was performed for two patients with high risk of anesthesia who have been planned to undergo open cholecystectomy.

A well-secured endotracheal tube (ETT) is essential for safe anesthesia. The ETT has to be fixed with the adhesive plasters or with tie along with adhesive plasters appropriately. It is specially required in patients having beard, in intensive care unit (ICU) patients or in oral surgeries. If re-adjustment of the ETT is necessary, we should be cautious while removal of the plasters and tie, as there may be damage to the cuff inflation system. This can be a rare cause of ETT cuff leak, thus making maintenance of adequate ventilation difficult and requiring re-intubation. In a difficult airway scenario, it can be extremely challenging to re-intubate again. We report an incidence where the ETT cuff tubing was severed while attempting to re-adjust and re-fix the ETT and the patient required re-intubation. Retrospectively, we thought of and describe a safe, reliable and novel technique to prevent cuff deflation of the severed inflation tube. The technique can also be used to monitor cuff pressure in such scenarios.

Tetany a syndrome of sharp flexion of the wrist and ankle joints (carpopedal spasm), muscle twitching, cramps and convulsions, sometimes with an attack of stridor, is due to hyperexcitability of nerves and muscles caused by decreased extracellular ionized calcium. Hyperventilation secondary to anxiety can result in tetany. We report a case of hyperventilation induced tetany 2 h following spinal anesthesia for inguinal hernia repair.

Foreign body (FB) aspiration into the respiratory tract is a common incident, especially in the pediatric age group and can, sometimes, pose a real challenge to the anesthesiologists as far as the airway management is concerned. Here, we report a case of FB bronchus in a 3 year 2 months old boy, presenting to the emergency in a cyanosed and comatosed condition with severe respiratory distress. In spite of the unavailability of a pediatric fiberoptic bronchoscope in our hand, the gradual declining condition of the baby made us to take the challenge. The FB was successfully removed through a tracheotome using a nasal endoscope.

Regional anesthesia is preferred world-wide for its distinct advantages. The benefits of regional anesthesia in patients with comorbid conditions are well-established. The administration of regional anesthesia can sometimes pose a challenge to the anesthesiologist due to the structural abnormalities of the spine. The most common difficulty encountered for spinal anesthesia in our hospital (Nalgonda District) is skeletal fluorosis. Apart from the midline approach, paramedian, and Taylor's approaches are advocated for difficult scenarios. This article reports two orthopedic cases, conducted under a novel spinal anesthesia technique, i.e., transforaminal sacral approach under C-arm guidance with a successful outcome. The sacral foraminal subarachnoid block is a method to access the subarachnoid space through the upper posterior sacral foramina.

Positioning has always been a special and important concern for any regional anesthetic technique. The standard positions recommended for epidural anesthesia include lateral decubitus, sitting and prone. We report a special situation where we employed the standing position for placing epidural catheter. A 40-year-old man presented with severe ischemic pain of right lower limb due to near total thrombosis of right common iliac artery. He was scheduled for peripheral angiogram and referred to us for pain management as his pain was not permitting him to sit or lie down. Epidural analgesia was planned for managing the pain in the catheterization laboratory and for any other possible management intervention later. As the patient was not tolerating any position other than standing because of severe pain, we placed the lumbar epidural catheter in the standing position and quickly activated the analgesia in the supine position. Patient had good pain relief immediately and an infusion was commenced. Safety and comfort are the major issues to be addressed, while positioning for any procedure. Standing position was chosen for this particular case as it was the only comfortable position for the patient and the safety was not compromised.

Carotid body tumor (CBT) is a rare tumor, which arises at bifurcation of carotid artery from chemoreceptor cells. These cells sense the partial pressure of oxygen and carbon dioxide from the blood. Hence, carotid body plays an important role in the control of ventilation during hypoxia, hypercapnia, and acidosis. The tumor arising from these cells is benign and has tendency to turn out malignant. This tumor is found in persons who live at high altitudes. Removal of tumor poses several anesthetic challenges and perioperative morbidity or mortality. We report successful anesthetic management of CBT excision.