This illustrated detailed article will describe history of over forty years struggle, of hardship and discrimination to the specialty. I have with my colleagues faced obstacles and disappointments during the development of modern anaesthesia services with its subspecialties in Saudi Arabia. I have all support and encouragement from the top authorities of the university. I have managed to establish a top class anaesthesia department, Saudi Anaesthetic Association and the King Saud Fellowship in anaesthesia and intensive care within one decade. The next decade was assigned for expansion to create the Arab Board of anaesthesia and Intensive Care followed by the Saudi Specialty of anaesthesia and intensive care and its fellowship in different Subspecialties. I always wonder within myself, have I and my colleagues achieved our goal and did we do well.

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

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

Background: The purpose of this study was to evaluate the effect of two different volume of crystalloid given intraoperatively on postoperative nausea and vomiting (PONV). Materials and Methods: Eighty adult patients of either sex belonging to ASA I and II class undergoing elective surgeries under general anesthesia for 1-2 h were studied in this prospective, randomized double blinded study. First group (group L) (n=40) received normal saline 4 mL/kg and second group (group H) (n=40) received 10 mL/kg of normal saline. This was in excess of the fasting requirement of the patients. No propofol or antiemetic drugs were given. PONV was evaluated by verbal descriptive score (VDS) [0 = none, 1 = mild, 2 = moderate, 3 = severe, and 4 = unbearable]. Ondansetron (4 mg i.v.) was given if VDS score was 3 or more. Results: The median immediate PONV score was 2 and 1 in group L and H, respectively. The median 2 h PONV score in group L was 3 and in group H was 1. The median 6 h PONV score in group L was 3 and in group H was 1. The 24 h median postoperative PONV score was 1 and 0 in group L and H, respectively. In all these period of time the differences were statistically significant. The incidence of vomiting was more in group L [72.5% (29/40)] than in group H [30% (12/40)]. This was statistically significant (P=0.0003). Conclusion: From the current study it was concluded that patients who received larger volume of crystalloid intraoperatively have lesser incidence of PONV.

Background: Obstetric anesthesia presents a challenge to the anesthesiologist. The effective pain management allows the partu­rient adequate degree of comfort and promotes physical reco­very and a sense of well being. Materials and Methods: This randomized controlled study was designed to assess the analgesic efficacy and side effects of 1.20 mg single-dose epidural morphine (Group 1) versus intermittent 12 hourly epidural morphine (0.5 mg) with bupivacaine (Group2) for postoperative analgesia in lower segment caesarean section cases. Results: Each group consisted of 36 patients. Demographic characteristics of two groups were comparable and differences among them were not statistically significant. Mean duration of analgesia was significantly longer in group one patients (16.5±2.5h) in comparison to group two patients (11.5±1.5h). Mean highest visual analog scales (VAS scale) was significantly lower (3.2±0.9) in group one patients in comparison of group two (6.7±0.8) patients. Only 43% patient in group one required supplementary perenteral analgesic (Paracetamole/Diclofenac) and 71% required epidural morphine/bupivacaine in group two. Mean number of supplementary perenteral analgesic required in group one was 0.7 and it was 1.8 in group two. There was no significant difference in nausea, vomiting, itching, and pruritis in two groups of patients. Conclusion: Our study showed that the use of single dose epidural morphine is associated with lower pain scores at rest and movement when compared to intermittent epidural morphine with bupivacaine in postcaesarean section analgesia.

Background: Ultrasound-guided sciatic nerve block, in combination with femoral nerve and lateral femoral cutaneous nerve blocks, is frequently used to induce anesthesia for lower limb surgery. The anterior approach to the sciatic nerve is performed in the supine position and repositioning of the patient between injections is avoidable. We compared the relative utility and efficiency of anterior versus transgluteal sciatic nerve blocks in conjunction with femoral nerve and lateral femoral cutaneous nerve blockade. Materials and Methods: Twenty-four patients were enrolled in this prospective double-blind randomized study and were randomly divided into two equal groups: Anterior (Group A) and transgluteal (Group T). We evaluated the following parameters: ultrasound view quality, procedural duration, onset time to block, quality of anesthesia during surgery and postoperative analgesia, required administration of supplemental sedation or narcotics during surgery, amount of pethidine administered within 24 hours post surgery, and overall patient satisfaction. Results: There were no significant differences between patient groups with regard to the demographic data, onset time to block, quality of ultrasound view, use of narcotics to augment the anesthesia during surgery, and patient satisfaction. Although procedural completion time for the sciatic injection alone was shorter in Group T, the total completion time of all blocks together was significantly less in Group A. Conclusion: Ultrasound-guided anterior blockade of the sciatic nerve has advantages over the transgluteal approach - it provides efficient anesthesia and results in excellent patient satisfaction.

The aim of this study was to determine the incidence of early postoperative hypoxia after general anesthesia and to evaluate the need of oxygen supplementation. A total of 150 patients aged between 18-60 years belonging to ASA I or II were studied. Patients were alternately allocated to two groups of 75 each. Group-I (n=75) patients received 2 L of oxygen via nasopharyngeal catheter during transfer from operation theatre to recovery room and in the recovery room for a period of 4 h. Group-II (n=75) patients did not receive oxygen either during transfer or in the recovery room. Twenty percent in Group-II developed hypoxaemia during transfer from operation theatre to recovery room out of which 24% developed mild (SaO ₂ 86-90%), 2.66% moderate (SaO ₂ 85-81%), and 1.33% extreme (SaO ₂ <76%) hypoxaemia. None of the patients in Group - I, who received oxygen supplementation, developed hypoxaemia in the early postoperative period.

Background: Subarachnoid anesthesia is used as the sole anesthetic technique for below umbilical surgeries, but patients with deformed spine represent technical difficulty for its establishment. This study was aimed to find out whether training of Taylor's approach to residents on normal spine is beneficial for establishing subarachnoid block in patients with deformed spine. Materials and Methods: The total of 174 patients of ASA I-III with normal and deformed spine of both genders scheduled for below umbilical surgeries under the subarachnoid block and met the inclusion criteria, were enrolled for this two-phased clinical teaching study. All participating residents have performed more than 100 subarachnoid block with the median and paramedian approach. Residents were randomized into two equal groups. During the first phase program, Group I was taught Taylor's approach by hands on method for the subarachnoid block while Group II kept on observation for the technique. During the second phase of program, Group II was also taught Taylor's approach for establishing the subarachnoid block. Block success was defined according to clinical efficacy. Results: The results of teaching of Taylor's approach were encouraging. Initially, the residents faced difficulty for establishing the subarachnoid block in deformed spine but after learning by observation and practical hands on, both groups had successfully performed the subarachnoid block by Taylor's approach in one or more attempts in patient with deformed spine with the acceptable failure rate of 15%. Conclusion: Taylor's approach for establishing subarachnoid block in deformed spine should be taught to residents on normal spine.

Background: Postoperative pain has a significant impact on patient's recovery and optimal nonopioid analgesia would reduce postoperative pain and pain-related complications. This study was aimed to evaluate the analgesic efficacy and safety of intravenous paracetamol versus parecoxib for postoperative analgesia after surgery. Materials and Methods: Sixty-eight adult consented patients belonging to ASA I and II, scheduled for surgery, were randomly allocated in two treatment groups receiving either infusion of paracetamol (1 gm) or parecoxib (40 mg). The surgical and anesthetic techniques were standardized. Postoperative pain was assessed using visual analog score (VAS) at rest, during coughing and movement. The primary variables were the differences between the mean values of postoperative pain scores, time of first dose of rescue analgesic (tramadol) required, and patient satisfaction throughout the first 12 postoperatively. Results: There was no significant difference among groups to first request for tramadol. The VAS score was significantly less in parecoxib group at rest compared to paracetamol group (P<0.05), but the same did not differ for pain score while coughing and movement. Patients in the parecoxib group were more satisfied regarding the postoperative pain management at 12 h postoperatively. The incidence of adverse side effects was infrequent in both the groups. Conclusion: Postoperative nonopioid intravenous analgesia with paracetamol and parecoxib is comparable in the early postoperative period with no adverse effects.

Aims and Objectives: This study aims to compare relative efficacy of three different doses of intrathecal bupivacaine in combined spinal epidural anaesthesia (CSEA) for caesarean delivery. Materials and Methods: In a double blinded manner, 204 cases were randomized into three groups: I, II, and III to receive a dose of 4, 5.5, and 7 mg of hyperbaric bupivacaine with a fixed dose of 25 μg fentanyl intrathecally, and Dextran 40 w/v 10 mL given for epidural volume extension (EVE), in CSEA. Our primary outcome was the number of effective doses. The block characteristics and side effects were also monitored. Results: Out of 198 patients completing the study, 53, 63, and 65 in group I, II and III had effective doses. Mean P _i (probability of an effective dose) in group I, II, and III, was 0.81, 0.95, and 0.97, respectively. The P _b (superiority of one group over the other) of group II and III was higher than group I. The maximal sensory block height in group II and III (T ₂ ) was higher than group I (T ₃ ), with a shorter time required to achieve the same. Group I and II exhibited lesser motor blockade, lesser hypotension with early recovery as compared to group III. No significant adverse effects were observed between the groups. Conclusion : The intermediate dose of bupivacaine (5.5 mg) provided safe and effective anaesthesia for caesarean delivery with an additional advantage of lesser episodes of hypotension and partial motor blockade in CSEA.

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

Background and Objectives: The objective of this study is to evaluate the intraoral high tuberocity maxillary nerve block technique in zygoma and arch fracture reduction and fixation. Study and Design: This study was carried out at Arvind Multi-Specialty Hospital, Namakkal, Tamil Nadu on seven male patients with zygomatic bone and arch fracture. Materials and Methods: Intraoral high tuberocity maxillary nerve block administered in seven patients for management of isolated zygomatic bone and arch fracture. Lidocaine 2% measuring 4 mL with 1:80000 adrenaline anesthetic solutions was used to anesthetize maxillary nerve through a 3.2 cm length and 24G, needle. The following parameters were evaluated namely onset of anesthesia, nerve block duration, outcome of treatment and Patient's comfort. Results: The blocks were effective and patients were comfortable without pain during initial stage of surgery, but in latter stages two patients had mild to moderate pain. Duration of block varied from 60 to 90 min while onset varied from 3 to 10 min. There were vascular punctures in three patients, however, without hematoma. Conclusions: The maxillary nerve block is a good alternative option in selective cases of zygomatic bone fracture reduction.

Context: Though rocuronium has a rapid onset of neuromuscular blockade like succinylcholine without the latter's adverse effects, its use is limited due to its prolonged action. Aim: Aim was to evaluate whether reducing the intubating dose of rocuronium shortens its duration of action, yet provides clinically acceptable intubating conditions. Settings and Design: tt was a prospective, randomized, and double blind trial. Materials and Methods: 100 American Society of Anaesthesiologists Physical Status (ASAPS) I or II patients aged between 18-65 years scheduled for elective surgery were randomly allotted one of the four rocuronium groups (rocuronium dose of 0.3 mg/kg intubated at 60 s or at 90 s, rocuronium 0.6 mg/kg intubated at 60 s or at 90 s) orsuccinylcholine group (succinylcholine 1.0 mg/kg intubated at 60 s) and intubating conditions were assessed with: Ease of laryngoscopy, vocal cord position, and reaction to insertion of tracheal tube and cuff inflation. Statistical Analysis: Statistical tests used were analysis of variance (ANOVA), Chi-Square test, Repeated measures of ANOVA and Mann-Whitney U test. Results: Rocuronium in dosage of 0.3 mg/kg gaveclinically acceptable intubating conditions in 35% and 60% subjects at 60 s or 90 s, respectively, whereas in dosage of 0.6 mg/kg, intubating conditions were acceptable in 80% and 100% subjects intubated at 60 s and 90 s. Conclusion: Rocuronium in dose of 0.3 mg/kg does not give clinically acceptable intubating conditions at 60 or 90 s but has shorter duration of action. Rocuronium in dose of 0.6 mg/kg gives clinically acceptable intubating conditions at 60 or 90 s, comparable to succinylcholine 1 mg/kg.

Background: The radical surgical procedures are associated with perioperative blood loss. This study was aimed to evaluate the clinical efficacy and safety of tranexamic acid in reducing perioperative blood loss in patients undergoing radical surgery. Materials and Methods: Sixty ASA class I and II adult consented female patients, scheduled for elective radical surgery and met the inclusion criterion, were blindly randomized into two groups to receive either intravenous 1 g tranexamic acid 20 min before skin incision or an equivalent volume of normal saline as placebo (P). All patient's total blood loss was measured and recorded perioperatively at the 12 ^th h postoperatively. The preoperative and postoperative hemoglobin, hematocrit values, serum creatinine, activated thromboplastin time, prothombin time, thrombocyte count, fibrinogen, D-dimer, and symptoms of pulmonary embolism were comparatively evaluated. Results: The tranexamic acid significantly reduced the quantity of total blood loss, 576 ± 53 mL in study group as compared to 823 ± 74 mL in the control group (P<0.01). Postoperatively hematocrit values were higher in the tranexamic acid group. The coagulation profile did not differ between the groups, but D-dimer concentrations were increased in the control group. No complications or adverse effects were reported in the either group. Conclusion: The prophylactic administration of tranexamic acid has effectively reduced theblood loss and transfusion needs during radical surgery without any adverse effects or complication of thrombosis.

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

Children with arthrogryposis multiplex congenita often require multiple orthopedic corrective procedures. We present a case of a child with arthrogryposis multiplex congenita posted for contracture release of both lower limbs that were successfully managed with total intravenous anesthesia and caudal epidural analgesia with Bupernorphine as an additive.

Preterm neonates present unique challenges to the anesthesiologist due to their immature physiology and anatomy. Many preterm neonates are critically ill and can develop necrotizing enterocolitis, respiratory distress syndrome, intra ventricular hemorrhage, and heart failure or retinopathy of prematurity. Anesthesiologists play a vital role in the management of preterm neonates requiring surgical interventions, by integrating their knowledge of the developmental physiology and pharmacology. The successful conduct of anesthesia in premature neonates requires an understanding of the basic principles of neonatal care.

Ebstein's anomaly is a rare congenital heart disease characterized by downward displacement of the tricuspid valve, atrialization of right ventricle, enlarged right atrium with tricuspid regurgitation, or stenosis. It is often associated with atrial septal defect (ASD) or patent foramen ovale with right to left shunt. It has a varied clinical presentation and can manifest as cyanosis, ventricular, or supraventricular arrhythmias and recurrent episodes of congestive heart failure. We describe the anesthetic management of a female patient with Ebstein's anomaly who had right frontal lobe abscess due to paradoxical embolism for decompressive craniotomy.

Perioperative myocardial infarction (PMI) during video-assisted thoracoscopy (VAT) surgery is rarely reported in the literature. ST-segment-elevated myocardial infarction (STEMI) is rare in the perioperative period. We report a case of STEMI, following VAT surgery, complicated by acute coronary syndrome. A 53-year male, admitted with recurrent left-sided pneumothorax, an intercostal chest drain was inserted and planned for VAT and lung resection. The intra-operative period was stable, minimal lung resection, and excision of bullae was done. Just before extubation, patient had acute myocardial infarction and cardiogenic shock. An immediate percutaneous coronary intervention (PCI) angiogram showed 90% blockage of the right coronary artery with thrombus. Export thrombectomy and balloon angioplasty was done. Weaned off from inotropes and ventilator. He was transferred to ward from there by day 12, discharged home on double antiplatelet therapy. The PMI can occur earlier than it is commonly thought, and in our patient, it was STEMI, which is rare and occurred during VAT Surgery. In our patient early detection and earlier PCI may have resulted in better outcome.

Peripartum cardiomyopathy (PPCM) is defined as onset of acute heart failure without demonstrable cause in last trimester of pregnancy or within the first 6 months after delivery. We report a case of PPCM with left ventricular ejection fraction less than 25% who had reported to us at 38 weeks of gestation for emergency caesarean section managed with graded epidural anaesthesia. PPCM is a form of dilated cadiomyopathy with left ventricular systolic dysfunction that results in signs and symptoms of heart failure.

Patent foramen ovale (PFO) is defined as a valve-like opening at the level of foramen ovale or between septum primum and secundum without evidence of the anatomical defect. Paradoxical embolism (PDE) is an embolus passing through a defect PFO leading to end-organ dysfunction. PDE in septic shock is not yet reported in the literature. A 49-year male presented to the emergency department with shortness of breath since one day and pain in the left side of the chest. Chest x0 -ray revealed middle-left lobe pneumonia with pleural effusion; he was started on Co-amoxiclav, and admitted to the ward. After 6 h, his chest pain suddenly significantly increased difficulty in breathing and his oxygen saturation dropped. X-ray of the chest showed left pneumothorax, chest drain was inserted and he was intubated. He became hemodynamically unstable with maximum ventilatory support and noradrenalin. On day 4, he was found to have new pansystolic murmur in the tricuspid area. An echocardiogram revealed global hypokinesia, two mobile thrombi in the right atrial cavity, and PFO. It was noticed that his right toe had blackish discoloration. An angiogram showed occlusion of the right superficial femoral artery and immediately an embolectomy. On day 11, he was transferred to the ward. PDE needs a high index of suspicion in septic shock patients with ARDS. PDE requires PEEP adjustment, early anticoagulation, and thromboprophylaxis.

This case report details the development of an acute heart dysfunction during gastroscopy under sedation in a patient with normal coronary arteries. The early diagnosis by echocardiography and aggressive management allowed us to prevent a serious and fatal outcome. We spot on the diagnosis of allergic cardiogenic shock based on our clinical and laboratory finding.

Brugada syndrome is a myocardial transmembrane conduction of sodium abnormality and a common cause of sudden cardiac death. It is characterized by a distinctive electrocardiograph pattern with right bundle branch block and ST segment elevation in precordial leads V ₁ -V ₃ . Many factors during general anesthetic management could precipitate malignant dysrhythmia. We report the anesthetic management of a patient with Brugada syndrome for emergency appendectomy uneventfully.

The most common cause of difficult intubation in pediatrics is due to congenital anomalies of airway. We report a case of neonate with congenital epulis (CE) who presented with a difficult airway. A 7-day old neonate weighted 3.2 kg with a large mass occupying the oral cavity that was diagnosed as congenital epulis was scheduled for excision biopsy. The mass was large, mobile, and moving in and out with no clear pedicle. An intravenous line was inserted and secured. The airway was then assessed while the patient was awake and an assistant displaced the mass and a laryngoscope was placed to visualize the larynx easily. After preoxygenation, inhalation induction of anesthesia was accomplished using sevoflurane in oxygen. Endotracheal intubation was performed with conventional laryngoscopy. The baby made uneventful recovery after the surgical procedure. In conclusion, epulis presents a real challenge to anesthesiologists. It can be excised either under local or general anesthesia, depending on the size of its pedicle. If done under general anesthesia, assessment of the airway is mandatory for better airway management and safe endotracheal intubation.