Sugammadex (ORG 25969) is a unique neuromuscular reversal drug; a novel cyclodextrin, the first in a new class of selective relaxant binding agents, which reverse neuromuscular blockade (NMB) with the aminosteroid non-depolarizing muscle relaxants rocuronium and vecuronium. Sugammadex can reverse moderate or deep NMB. The clinical use of sugammadex promises to eliminate many of the shortcomings in current anesthetic practice with regard to antagonism of rocuronium and other aminosteroid muscle relaxants.

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Aim: The authors examined the analgesic effect of wound infiltration with bupivacaine or lower dose bupivacaine and magnesium versus normal saline for postoperative analgesia after cesarean section. Materials and Methods: A total of 120 patients, American Society of Anesthesiologists (ASA) I-II were prepared for elective cesarean section. At the end of the surgery, the wound was continuously infiltrated at a rate of 5 ml/h for 24 h post-operatively by one of the following solutions: 0.25% bupivacaine, a mixture of 0.125% bupivacaine and 5% magnesium sulphate or normal saline (0.9%). Total opioid consumption, Visual Analogue Scale (VAS) at rest and movement, incidence of opioid side-effects and signs of wound inflammation were assessed during the period of the study (24 h post-operatively). Three months later, residual pain, surgical wound infection, need for extra-antibiotic therapy and wound healing impairment were assessed. Results: Post-operative pain scores at rest were statistically significant higher in the control group than those in the both wound infiltration groups from 4 ^th h and onwards (P0 < 0.0001). Meanwhile, post-operative pain was higher in bupivacaine group versus magnesium group (P < 0.0001, P < 0.0001, 0.0012, respectively). There was statistically significant increase in VAS during movement in the control group versus others at 2, 4, 12, 24 h post-operatively ( P < 0.0001). However, patients received magnesium plus bupivacaine wound infiltration showed a significant decrease in post-operative pain scores than whom received bupivacaine from 4 ^th h and onward (P < 0.0001, 0.0054, 0.0001, respectively). Morphine consumption was significantly reduced in the magnesium group, ( P < 0.0001). Incidence of residual pain was comparable in the three groups. The incidence of sedation and urine retention were noted to be significantly higher in the control group in comparison to other groups, ( P <0.0001). The incidence of post-operative nausea and vomiting was reduced in patients received magnesium plus bupivacaine block versus others ( P < 0.0001). Conclusion: Continuous wound infiltration with a mixture of bupivacaine and magnesium sulphate after cesarean section showed an effective analgesia and reduced post-operative Patient Controlled Analgesia (PCA) requirements as compared to continuous wound infiltration with local anesthetic only or placebo with fewer incidences of opioid adverse effects.

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Arterial blood gas (ABG) analysis is the gold standard method for assessment of oxygenation and acid base analysis, yielding valuable information about a variety of disease process. This study is aimed to determine the extent of correlation between arterial and peripheral venous samples for blood gases and acid base status in critically ill and emergency department patients and to evaluate if venous sample may be a better alternative for initial assessment and resuscitation. The prospective study was conducted on 45 patients of either sex in the age group of 15-80 years of intensive care unit and emergency ward. Relevant history, presenting complaints, vital signs, and indication for testing were recorded. Arterial and peripheral venous samples were drawn simultaneously in a pre-heparinized syringe and analyzed immediately for blood gases and acid base status. Mean difference and Pearson's product moment correlation coefficient was used to compare the result. After statistical evaluation, the present study shows minimal mean difference and good correlation (r > 0.9) between arterial and peripheral venous sample for blood gases and acid base status. Correlation in PO ₂ measurement was poor (r < 0.3). Thus, venous blood may be a useful alternative to arterial blood during blood gas analysis obviating the need for arterial puncture in difficult clinical situation especially trauma patients, for initial emergency department assessment and early stages of resuscitation.

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Introduction: With the advent of ultrasound (US) guidance, this technique saw resurgence in the late 1990s. As US guidance provides real-time view of the block needle, the brachial plexus, and its spatial relationship to the surrounding vital structures; it not only increased the success rates, but also brought down the complication rates. Most of the studies show use of US guidance for performing brachial plexus block, results in near 100% success with or without complications. This study has been designed to examine the technique and usefulness of state-of-the-art US technology-guided supraclavicular brachial plexus block and compare it with routine nerve stimulator (NS)-guided technique. Aim: To note block execution time, time of onset of sensory and motor block, quality of block and success rates. Settings and Design: Randomized controlled trial. Materials and Methods: A total of 60 patients were enrolled in this prospective randomized study and were randomly divided into two groups: US (Group US) and NS (Group NS). Both groups received 1:1 mixture of 0.5% bupivacaine and 2% lignocaine with 1:200000 adrenaline. The amount of local anaesthetic injected calculated according to the body weight and not crossing the toxic dosage (Inj. bupivacaine 2 mg/kg, Inj. lignocaine with adrenaline 7 mg/kg). The parameters compared between the two groups are block execution time, time of onset of sensory and motor block, quality of sensory and motor block, success rates are noted. The failed blocks are supplemented with general anesthesia. Statistical Analysis: The data were analyzed using the SPSS (version 19) software. The parametric data were analyzed with student "t" test and the nonparametric data were analyzed with Chi-square test A P < 0.05 was considered significant. Results: There was no significant difference between patient groups with regard to demographic data, the time of onset of sensory and motor block. Comparing the two groups, we found that the difference in the block execution time and success rates is not statistically significant. A failure rate of 10% in US and 20% in NS group observed and is statistically insignificant (P = 0.278). No complication observed in either group. Conclusions: US and NS group guidance for performing supraclavicular brachial plexus blocks ensures a high success rate and a decreased incidence of complications that are associated with the blind technique. However, our study did not prove the superiority of one technique over the other. The US-guided technique seemed to have an edge over the NS-guided technique. A larger study may be required to analyze the advantages of using US in performing supraclavicular brachial plexus blocks, which could help justify the cost of purchase of the US machine.

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Context: Establishing a near perfect surgical field during functional endoscopic sinus surgery (FESS) is essential and even a minor bleeding can severely compromise an already restricted view. So, if controlled hypotension can be provided without compromising the safety of patient by a relatively effortless method, surgical field can be improved greatly. Aims: The aim of this study was to compare the hemodynamic changes and surgical conditions during FESS following oral premedication with clonidine and metoprolol. Settings and Design: A total of 40 patients undergoing FESS were included in this prospective, randomized controlled study. Subjects and Methods: Patients were divided into two equal groups. Group A patients were premedicated with oral clonidine 300 mcg and Group B with oral metoprolol 50 mg, 2 h before surgery. All patients received fentanyl 2 mcg/kg and induced with propofol 2 mg/kg. Intubation was done following vecuronium 1 mg/kg. Anesthesia was maintained with 66% N ₂ O, 33% O ₂ and 1% isoflurane. The heart rate (HR) and blood pressure (BP) were measured before induction and thereafter every 15 min up to 2 h. The surgeons were asked to estimate the quality of the operative field using a pre-defined category scale with scores 1-5. Statistical Analysis: Difference within the groups was analyzed using analysis of variance and post-hoc test was used to test the difference between individual groups. Chi-square test was used to find out the association between categorical variables. Results: Comparison of category scale revealed a lower score in Group A up to 60 min. Group B patients showed a statistically lower HR from pre-induction up to 90 min while systolic BP (SBP), diastolic BP (DBP) and mean arterial pressure did not show a significant difference. Conclusions: Oral premedication with 300 mcg of clonidine produced a better operative field than oral metoprolol 50 mg during FESS.

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Background: Unrelieved post-operative pain may result in the physical suffering as well as multiple physiological and the psychological consequences, which may adversely affect the peri-operative outcome and contribute to increase the length of stay in hospital. Objectives: We designed this study to evaluate the effect of IV Paracetamol and Dexmedetomidine as multimodal analgesic technique on post-operative analgesia and to reduce the consumption of the systemic opioid and its adverse effects in cases of laparoscopic cholecystectomy. Materials and Methods: Eighty consenting, American society of Anesthesiologist-physical status-I (ASA-PS-I), female patients, aged 19-60 year was randomly assigned to one of the following two groups: Group P (n = 40) received IV 1 g Paracetamol infusion over 10 min pre-operatively and 6 hourly thereafter and Group D (n = 40) received IV Dexmedetomidine 1 ΅g/kg bolus over 10 min pre-operatively and 0.2-0.4 ΅g/kg/h thereafter for 24 h. Peri-operative hemodynamic variables, post-operative pain scores, and the need for rescue analgesics were recorded and compared. Results: Profiles of intra-operative hemodynamic changes were similar in both groups in respect to heart rate (HR), diastolic blood pressure, mean arterial pressure except in the systolic blood pressure where Dexmedetomidine significantly reduced it in compare to Paracetamol (P = 0.014). Post-operatively 4 ^th h and 24 ^th h changes in mean HR between two groups was a statistically significant (P < 0.05). Visual analog scale scores were significantly lower in the Group P compared with Group D at 8 ^th , 16 ^th , and 24 ^th h (P < 0.001). Sedation score were statistically higher in the Group D compared with the Group P at post-operative 4 ^th , 8 ^th , 16 ^th , and 24 ^th h (P < 0.006). Conclusion: Adjunctive use of both Paracetamol and Dexmedetomidine infusion reduced opioid use. However, Paracetamol peri-operatively provides adequate analgesia with the less sedation whereas Dexmedetomidine provides analgesia and co-operative sedation.

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Context: Anaesthesia during cleft lip and palate surgery carries a high risk and difficult airway management in children. Aim: to study the perioperative anesthetic complications in poor children with cleft abnormalities. Settings and Design: Retrospective analysis. Materials and Methods: This retrospective audit was conducted on 2917 patients of smile train project under going general anesthesia for cleft lip and palate from January 2007 to December 2010. Demographic, pre-anesthetic status, anesthetic management and anesthesia complications were recorded. Chi-square test was used to assess the relation between patient factors and occurrence of complications. Results: Of the 3044, we were able to procure complete data of 2917 patients. Most of children presented with anemia 251 (35%), 202 (29%) had eosinophilia while 184 (26%) had upper respiratory tract infection. The incidence of perioperative complications was 8.19% of which 33.7% critical incidents occurred during the induction time. The most common complication was laryngospasm 77 (40.9%) followed by difficult intubation 64 (30.9%). There was no mortality. Conclusion: Since these procedures do not characterize an emergency, most of the perioperative complications can be prevented by following the routine installed by the institute and smile train protocols.

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Background: Thoracic spinal anesthesia has been used for laparoscopic cholecystectomy and abdominal surgeries, but not in breast surgery. The present study compared this technique with general anesthesia in breast cancer surgeries. Materials and Methods: Forty patients were enrolled in this comparative study with inclusion criteria of ASA physical status I-III, primary breast cancer without known extension beyond the breast and axillary nodes, scheduled for unilateral mastectomy with axillary dissection. They were randomly divided into two groups. The thoracic spinal group (S) (n = 20) underwent segmental thoracic spinal anesthesia with bupivacaine and fentanyl at T5-T6 interspace, while the other group (n = 20) underwent general anesthesia (G). Intraoperative hemodynamic parameters, intraoperative complications, postoperative discharge time from post-anesthesia care unit (PACU), postoperative pain and analgesic consumption, postoperative adverse effects, and patient satisfaction with the anesthetic techniques were recorded. Results: Intraoperative hypertension (20%) was more frequent in group (G), while hypotension and bradycardia (15%) were more frequent in the segmental thoracic spinal (S) group. Postoperative nausea (30%) and vomiting (40%) during PACU stay were more frequent in the (G) group. Postoperative discharge time from PACU was shorter in the (S) group (124 ± 38 min) than in the (G) group (212 ± 46 min). The quality of postoperative analgesia and analgesic consumption was better in the (S) group. Patient satisfaction was similar in both groups. Conclusions: Segmental thoracic spinal anesthesia has some advantages when compared with general anesthesia and can be considered as a sole anesthetic in breast cancer surgery with axillary lymph node clearance.

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Background: Although fluid bolus is considered as a conventional prophylactic measure to prevent spinal-induced hypotension; vasopressors are nevertheless required. Low dose spinal anesthetics could markedly reduce such episodes of hypotension, by minimizing sympathetic blockade. Aims: We chose to compare the relative efficacy of colloid preload versus coload under low dose spinal anesthesia, for elective cesarean delivery. Settings and Design: A prospective, randomized, double-blinded study. Materials and Methods: In total, 42 parturients were randomized to receive a preload (Group P) of hydroxyl ethyl starch (10 ml/kg) over 20 min before initiation of low dose spinal anesthesia (hyperbaric bupivacaine 5.5 mg with fentanyl 25 μg) or coload (Group C) of an identical fluid over 5 min, starting at the time of identification of cerebrospinal fluid. Our primary outcome included hemodynamic parameters and the incidence of hypotension. The neonatal outcome and side-effects were also monitored. Statistical Analysis: Mann-Whitney U test and Fisher's exact/Chi-square test, whichever appropriate. A P < 0.05 was considered to be significant. Results: The incidence of hypotension was lower in Group P (10%) when compared with Group C (25%), though insignificant statistically. The hemodynamic parameters were better in Group P, though intergroup statistical differences were not observed. The time to the first episode of hypotension was longer in the Group P (17 min) as compared with Group C (14 min). No notable side-effects or adverse neonatal outcome was noted. Conclusion: Colloid preload has a clinical advantage over the coload strategy, in reducing hypotensive episodes under low dose spinal anesthesia. Preload is better under large hemodynamic fluctuations while coload is preferable for emergency scenarios.

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Background: A prospective randomized clinical study was conducted to study the efficacy and safety of ropivacaine with bupivacaine intrathecally for lower abdominal and lower limb surgeries. Material and Methods: 70 patients aged between 18 to 65 years were randomized into two groups, n = 35 in each group. Group A received 3 ml of (0.5%) isobaric bupivacaine (15 mg) and Group B 3 ml of (0.75%) isobaric ropivacaine (22.5 mg). Spinal anesthesia procedure was standardized. Haemodynamic parameters, onset and duration of sensory and motor blockade, level achieved, regression and side effects were compared between the two groups. Results: Onset and regression of sensory blockade in ropivacaine group was faster with a P < 0.001 which was statistically significant. Onset of motor blockade was rapid in both the groups but duration of motor blockade was significantly shorter in ropivacaine group. Excellent analgesia, with no side effects and stable haemodynamics was noted in ropivacaine group. Conclusion: Hence ropivacaine was safe and equally effective as bupivacaine for lower abdominal and lower limb surgeries with early motor recovery, providing early ambulation.

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Difficulties arising during tracheostomy tube insertion can be rapidly fatal if the airway is not adequately controlled. We report a case of difficult tracheostomy in a gentleman with severe subcutaneous emphysema following a previously failed tracheostomy attempt. Tracheostomy tube insertion through the pre-existing stoma failed repeatedly due to rapidly increasing distance of trachea from the skin and unexpected false passages; however, the trachea was eventually cannulated using a regular endotracheal tube.

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Context: This study evaluated the effectiveness of paravertebral block as an alternative anesthetic technique for extracorporeal shock wave lithotripsy (ESWL) procedure. A total of 50 patients with renal stones, aged 20-60 years, were randomly allocated into two groups; 25 patients in group P; received unilateral paravertebral block from T8 through L1 with injection of 5 mL 0.5% bupivacaine and 25 patients in group L; received local infiltration by bupivacaine 0.25% (2 mg/kg) into the 30 cm ² area after localizing the stones site, 10 min before the session. A total of 10 mm visual analogue scale (VAS) was used to evaluate pain every 10 min during the session. At the end of the procedure, total doses of rescue analgesia, the number of shockwaves, their power, and the total duration of shockwave treatment were recorded. After completion of the procedure, the patient was assessed for pain and nausea in the postanesthesia care unit (PACU) using the VAS. Patient's satisfaction and time needed to discharge patients to home also were recorded. Time to do the anesthetic technique was significantly higher (P < 0.001) in group-P than group-L, it was 12.7 ± 2.3 min versus 6.9 ± 1.9 min, respectively; intraoperative rescue analgesia by fentanyl was lesser (P < 0.001) in group-P than group-L, 26.7 ± 6.32 mcg versus 78.6 ± 5.41 mcg, respectively, also time interval between ends of the procedure till discharge to home was significantly higher (P < 0.001) in group-P than group-L, it was 99 ± 17 min versus 133 ± 31 min, respectively. VAS was not significant difference between both groups either intraoperative or postoperative in first hour. Patient's satisfaction was significantly higher (P < 0.05) in group-P than group-L, it was 8.8 ± 1.1 versus 6.1 ± 0.6, respectively. Adverse events were lesser, but not significant in group-P than in group-L. Two patients (8%) in group-L and one patient (4%) in the group-P experienced episodes of postoperative nausea and vomiting (PONV). Paravertebral block is an effective alternative anesthesia for outpatient lithotripsy; multiple level paravertebral blocks provide an optimal anesthetic condition, with acceptable adverse events for ESWL. And, providing proper analgesia during the procedure and in first hour after finishing of the procedure, early discharge to home and providing better patient's satisfactions. Aims: This study evaluated the effectiveness of paravertebral block as an alternative anesthetic technique for ESWL procedure. Settings and Design: Prospective open label study. Subject and Methods: A total of 50 patients with renal stones, aged 20-60 years, were randomly allocated into two groups; 25 patients in group P; received unilateral paravertebral block from T8 through L1 with injection of 5mL 0.5% bupivacaine and 25 patients in group L; received local infiltration by bupivacaine 0.25% (2 mg/kg) into the 30 cm ² area after localizing the stones site, 10 min before the session. A total of 10 mm VAS was used to evaluate pain every 10 min during the session. At the end of the procedure, total doses of rescue analgesia, the number of shockwaves, their power, and the total duration of shockwave treatment were recorded. After completion of the procedure, the patient was assessed for pain and nausea in the PACU using the VAS. Patient's satisfaction and time needed to discharge patients to home also were recorded. Statistical Analysis: The findings of the two groups were statistically compared using SPSS version 12 (SPSS Inc., Chicago, IL). Data were expressed as mean ± standard deviation, number, and percentage. Nominal nonparametric data were analyzed using Chi-square test. Parametric data were compared using unpaired t-test. Ordinal nonparametric data were analyzed using Mann-Whitney U-test. Results: Time to do the anesthetic technique was significantly higher (P < 0.001) in group-P than group-L, it was 12.7 ± 2.3 min versus 6.9 ± 1.9 min, respectively; intraoperative rescue analgesia by fentanyl was lesser (P < 0.001) in group-P than group-L, 26.7 ± 6.32 mcg versus 78.6 ± 5.41 mcg, respectively, also time interval between ends of the procedure till discharge to home was significantly higher (P < 0.001) in group-P than group-L, it was 99 ± 17 min versus 133 ± 31 min, respectively. VAS was not significant difference between both groups either intraoperative or postoperative in first hour. Patient's satisfaction was significantly higher (P < 0.05) in group-P than group-L, it was 8.8 ± 1.1 versus 6.1 ± 0.6, respectively. Adverse events were lesser, but not significant in group-P than in group-L. Two patients (8%) in group-L and one patient (4%) in the group-P experienced episodes of PONV. Conclusions: Paravertebral block is an effective alternative anesthesia for outpatient lithotripsy; multiple level paravertebral blocks provide an optimal anesthetic condition, with acceptable adverse events for ESWL. And providing proper analgesia during the procedure and in first hour after finishing of the procedure, early discharge to home and providing better patient's satisfactions.

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Neuromonitoring aims to detect harmful physiologic events, early enough to guide the treatment instituted. Evidences encourage us to implement multimodal monitoring, as no single monitor is capable of providing a complete picture of dynamic cerebral state. This review highlights the role of intracranial pressure monitoring, cerebral oxygenation (jugular venous oximetry, brain tissue oxygenation, near infrared oximetry, cerebral microdialysis) and cerebral blood flow monitoring (direct and indirect methods) in the management of neurologically injured patients. In this context, the recent developments of these monitors along with the relevant clinical implications have been discussed. Nevertheless, the diverse range of data obtained from these monitors needs to be integrated and simplified for the clinician. Hence, the future research should focus on identification of a most useful monitor for integration into multimodal system.

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We report a case of unexplained transient ventricular fibrillation in a child with ventricular septal defect (VSD) scheduled for VSD closure. The bispectral index (BIS) values dropped within 15s of transient cardiac arrest and it showed recovery within 15 s of restoration of circulation. Monitoring BIS during surgery, especially cardiac surgeries may help identify periods of cerebral ischemia early.

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

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Patients who are diagnosed having acromegaly develop a lot of cardiovascular Complications such as hypertension, arrhythmias, systolic and diastolic dysfunction, valvular dysfunction and heart failure. Dilated cardiomyopathy (DCM) with systolic and diastolic dysfunction is relatively rare but is associated with an increased mortality. We report a case of acromegaly diagnosed at 52 years of age in a known diabetic, non-hypertensive male who had DCM with severe left ventricular dysfunction, global hypokinesia, moderate mitral regurgitation, and grade II diastolic dysfunction who was treated with diuretics, digitalis, and vasodilators. He was diagnosed with a growth hormone secreting pituitary macroadenoma and underwent endoscopic excision of the pituitary tumor under general anesthesia.

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Aims and Objectives: Laparoscopic surgery is the choice for gynaecological surgery these days, but pneumoperitoneum (PNO) and trendelenburg position increase the intraocular pressure (IOP) leading to decrease in perfusion of retina and at times the significant risk of ischemic retinopathy. Our present aim is to find out the suitable combination of induction and maintenance agent for combating the increase in IOP by PNO, lithotomy and trendelenburg position, and to study the changes in IOP at different time points and positions in gynaecological laparoscopic procedures. Patients and methods: After taking permission from the Ethical Committee 120 female patients of ASA grade 1 and II were divided arbitrarily in four groups each comprising 30 patients. In group A and B induction was done with propofol 2.5 mg/kg given IV and in group C and D induction was done with thiopentone 5 mg/kg given IV. Atracurium 0.5 mg/kg IV was used as neuromuscular blocking agent (NMBA).Laryngeal mask airway (LMA) was inserted in all the cases and patients were ventilated with Bain's circuit. Maintenance of anesthesia was done with total intra venous anesthesia (TIVA) with propofol and100% oxygen in group A and C. In group B and D maintenance was done with 1% isoflurane with oxygen (O ₂ ) and nitrous oxide (N ₂ O) in the ratio of 40:60. Changes in IOP, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean blood pressure (MBP) were measured. Baseline readings were taken initially and then 2 min after premedication, 1 min after LMA insertion, 1 min after PNO with lithotomy position, 5 min after 20° head down tilt and PNO in situ and 2 min after exsufflation of PNO with supine horizontal position. Results and Conclusion: To mitigate increase in IOP during gynaecological laparoscopic surgeries, propofol, and propofol TIVA (Group A) proved to be the best option. Propofol and isoflurane (Group B) thiopentone and propofol TIVA (Group C) were not as effective as group A. However, induction with thiopentone and maintenance with isoflurane (Group D) were not effective at all.

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Background: Narcotic drugs have been used to attenuate laryngoscopy and intubation induced circulatory responses, but are not always available due to tough narcotics laws. Nalbuphine a synthetic opioid, free from restrictions has been in use for post-operative pain relief. Hence, we decided to compare nalbuphine and pentazocine for attenuation of hemodynamic effects during larygoscopy and endotracheal intubation in a randomized, double-blind clinical study. Materials and Methods: A total of 60 patients (ASA I and II) of either sex, between 18 years and 50 years were given either nalbuphine 0.2 mg/kg (group N, n = 30) or pentazocine 0.5 mg/kg (group P, n = 30) 5 min before induction of general anesthesia. After, induction with thiopentone and endotracheal intubation with succinylcholine balanced anesthesia was maintained with O ₂ :N ₂ O, 0.2% halothane and non-depolarizing relaxants for surgical duration. Changes in heart rate (HR), systolic blood pressure (SBP), diastolic pressure, mean arterial pressure, and rate pressure product calculated by HR × SBP were recorded at various time intervals. Results: A non-significant fall (P > 0.05) up to 3 min and thereafter a significant rise (P < 0.05) in all the parameters were observed throughout the remaining study period with nalbuphine, whereas a continuous and significant (P < 0.05) rise in these parameters were observed with pentazocine. Maximum rise in both the group was observed immediately after larygoscopy and intubation and these started to return toward the basal values at the end of the study period, but remained above the initial values. (pentazocine > nalbuphine P = <0.01). Conclusion : Nalbuphine effectively reduces the tachycardia, hypertension, and cardiac workload associated with laryngoscopy and endotracheal intubation.

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The presence of co-morbidities during pregnancy can pose numerous challenges to the attending anesthesiologists during operative deliveries or during the provision of labor analgesia services. The presence of cardiac diseases, endocrinological disorders, respiratory diseases, renal pathologies, hepatic dysfunction, anemia, neurological and musculoskeletal disorders, connective tissue diseases and many others not only influence the obstetric outcome, but can significantly impact the anesthetic technique. The choice of anesthesia during the pregnancy depends upon the type of surgery, the period of gestation, the site of surgery, general condition of patient and so on. Whatever, the anesthetic technique is chosen the methodology should be based on evidentially supported literature and the clinical judgment of the attending anesthesiologist. The list of co-morbid diseases is unending. However, the present review describes the common co-morbidities encountered during pregnancy and their anesthetic management during operative deliveries.

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Surgical repair of complex maxillofacial trauma presents a challenge to the surgeon and anaesthetist. Submental intubation is an alternative where oral and nasal intubation cannot be used. We present a case where tracheostomy was avoided in a patient with multiple maxillofacial fractures by opting for sub-mental endotracheal intubation technique. Time required for intubation, accidental extubation, postoperative complications, and the healing of intraoral and submental scars were evaluated. The technique avoids the complications associated with tracheostomy.

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Objective: Sevoflurane and propofol are considered to be the agents of choice in surgeries of short duration due to their better recovery profile and few post-operative complications. This study was designed to compare the early recovery profile of sevoflurane and propofol anesthesia in patients undergoing open cholecystectomy. Materials and Methods: A total of 60 patients of either sex with American Society of Anesthesiologists grade 1 and 2 scheduled for elective cholecystectomy were prospectively randomized into two groups. Group S (30 patients) were maintained with sevoflurane anesthesia (1-2%), while in Group P (30 patients) were maintained with propofol infusion (75-125 μg/kg/min) in both the groups the anesthetic concentration/dose was so adjusted to keep hemodynamic parameter (mean arterial pressure and heart rate) within 15% of their respective baselines values. Results: It was observed that there was no significant difference (P > 0.05) between there early recovery profile that includes spontaneous eye opening (7.5 ± 1.6 min for sevoflurane group and 6.9 ± 1.7 min for propofol group), following simple verbal command (9.2 ± 2.2 min for sevoflurane group and 8.9 ± 1.9 min for propofol group) and extubation time (10.7 ± 2.3 min for sevoflurane group and 10.3 ± 2.0 min for propofol group) but there was a significant difference (P < 0.05) in incidence of post-operative nausea and vomiting (PONV) in both groups. Conclusion: Propofol is as good as sevoflurane for maintenance of anesthesia in surgeries like open cholecystectomy with an added advantage of lower incidence of PONV owing to its intrinsic antiemetic properties.

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The most common arrhythmia seen during pregnancy is paroxysmal supraventricular tachycardia and Wolff-Parkinson-White syndrome accounts for majority of this in such population. The presence of pre-disposing factors may facilitate the onset of tachyarrhythmias in previously asymptomatic parturients with the WPW syndrome such as increased hemodynamic, hormonal, autonomic, and emotional changes. Therefore, meticulous monitoring is essential perioperatively. Epidural anesthesia providing added advantage of hemodynamic stability and post-operative analgesia is preferred in such pregnant patients undergoing emergency cesarean section.

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A 65-year-old patient with renal amyloidosis presented for Trans Urethral Resection of Prostate (TURP). There were no symptoms pertaining to the cardiorespiratory system. Preoperative investigations showed only secondary cardiomyopathy. Intraoperatively the patient developed atrial fibrillation with hypotension which was successfully managed by cardioversion.

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Anesthesia for non-cardiac surgeries in patients with ischemic cardiomyopathy with other co-morbidities is a challenging situation for anesthetists. The choice of anesthesia and anesthetic agents should be judicious and balanced to maintain optimum cardiac output and to avoid myocardial depression for a successful postoperative outcome. Here, we describe the anesthetic management for emergency exploratory laparotomy in a patient who was suffering from ischemic cardiomyopathy along with chronic obstructive pulmonary disease and was presented to the emergency operation theater for gastrointestinal tract perforation.

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Context: Accurate patient weight is an important factor in the emergency and operating room departments. Aims: The aim of this study is to determine the accuracy of estimation of total body weight by legs and head weight measuring and comparison method in the anesthetized patients. Settings and Design: Education of hospitals, Mazandaran University of Medical Sciences, prospective, observational study. Subjects and Methods: This is prospective observational study. Nursing staff were asked to estimated weight that knows about a similar person weight on the operating room and matched together, then told his/her guests. They were measured total body weight before anesthesia and then patient head and legs weight after anesthesia. The main outcome was mean weight of these methods and percent accuracy in weight estimation for each group recorded. Statistical Analysis: Descriptive statistically used. Results: Overall, 57.3% (243/425) of operating personnel estimations were equal with actual weight. 35.4% (150/425) of the estimations were less 10 kg than the actual weight and only 7.3 (31/425) of the estimations were above 5 kg of actual weight. The accuracy of overall estimations by operating personnel and its comparison to the accuracy of legs weight, head, and sum weight by a similar method is demonstrated. Conclusions: Despite having no formula in the critical intensive care and anesthesia region for estimation anesthetized, for comatose patient weight. We can use this formula, but where possible, should be based on measured weight for drug dose calculation and this is not possible, combination of these formulas is suitable.

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Background: Patient's awareness can be reduced during ultrasound guided nerve block for inguinal herniorraphy with propofol sedation. The study was aimed to evaluate the clinical efficacy of direct visualization of anatomy of inguinal region by ultrasound and benefits of bispectral index (BIS) monitoring. Materials and Methods: After approval, 40 adult male consented patients of ASA grade I-III of 18-58 years with body mass index <25 were randomized into two groups of 20 patients each. A high frequency (8-13 MHz) linear transducer was used to perform the ilioinguinal and iliohypogastric nerves (ILHN and ILIN) block between the internal oblique and transversus abdominis muscles with 20 mL of 0.75% ropivacaine. The propofol infusion rate for sedation in patients of group I (non-BIS) was managed clinically and in patients of group II (BIS) was managed with BIS index of 65-75. Any surgical or anesthetic complications were recorded. The two groups were compared by evaluating the propofol consumption during surgery. Results: Ultrasonographic visualization of the ILHN and ILIN was possible in all patients and inguinal herniorraphy was performed uneventfully. The mean dose of propofol required for sedation was 5.45 mg/kg/h in patients of group I (non-BIS) while 4.92 mg/kg/h in patients of group II (BIS). The mean propofol consumption was not statistically significant ( P = 0.12). All patients were hemodynamically stable and there was no respiratory depression during propofol sedation. Conclusion: Ultrasonography has facilitated the clinically effective nerve block for inguinal herniorraphy and BIS monitoring has ensured amnesia and faster emergence.

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