Hyperreactive airway disease occurs due to acute viral or bacterial infections in children, and due to chronic bronchitis, Asthma or Emphysema in adults. Smoking and exposure to allergens may worsen the disease. Anaesthesia in these patients is associated with higher incidence of perioperative bronchospasm, postoperative laryngospam, breath holding, and hypoxia due to maldistribution of Ventilation and Perfusion. Smoking and exposure to allergens may worsen the outcome. Severe bronchospasm is a life threatening emergency. Selective β2 agonists form the main drug of choice for bronchospasm. Corticosteroids should be given early to reduce inflammation and mucosal oedema. For anaesthesia, Propofol, Vecuronium or Rocuronium, Halothane or Sevoflurane and Fentanyl are drugs of choice. Histamine releasing drugs like morphine and atracurium should be avoided. If ventilator support is required, Non invasive Pressure Support ventilation should be used first. However, Intubation and mechanical ventilation may become necessary, which however, may be associated with difficult weaning.

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Background: In unstable cervical spine, optimal intubation positioning of the patient may be unsafe. Awake intubation is indicated, which is rendered more comfortable by light sedation. Aims and Objectives: This study compared intravenous dexmedetomidine versus propofol-based sedation for awake fiberoptic intubation along with airway blocks. Materials and Methods: 100 ASA I and II patients with cervical PIVD are recruited for this study. Vital parameters such as heart rate, systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), and SPO2 were monitored at regular intervals. Patient sedation score, endoscopy score, intubation score, post-intubation conditions, and discomfort score were also recorded. Results: There was no statistically significant difference between the two groups with respect to SBP, DBP, mean blood pressure (MBP), heart rate (HR), and SPO2. Conclusions: Dexmedetomidine appeared to offer better patient tolerance, better preservation of a patent airway, and spontaneous ventilation.

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Huge goiters can lead to tracheal compression and, hence, difficulty in endotracheal intubation. This along with retro-sternal extension makes it an anticipated difficult airway scenario. In this report, we present a case of huge goiter (papillary carcinoma) compromising the airway, which presented with difficult airway for total thyroidectomy. CT scan of neck revealed retro-sternal extension with the pretracheal plane fixed to the trachea. Trachea was completely pushed to the right. We successfully performed an awake direct laryngoscopy and successful intubation by locally anesthetizing the airway. Plan B was ready with fiberoptic bronchoscopy and rigid bronchoscopy. Patient was successfully extubated in the intensive care unit (ICU).

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Patients undergoing noncardiac surgery may develop cardiac complications. Perioperative myocardial infarction (PMI) may be an important predictor of short- and long-term morbidity and mortality associated with noncardiac surgery. The etiology of PMI can be multifactorial; hence, it is indicated that one single intervention will not successfully improve cardiac outcome following noncardiac surgery and multifactorial stepwise approach. Perioperative management of ischemic heart disease (IHD) patients undergoing noncardiac surgery requires careful teamwork and communication between the patient, primary care physician, anesthesiologist, and surgeon.

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Background: Laryngoscopy and intubation are intensely stimulating procedures and can induce marked sympathetic responses. We hypothesized that by minimizing the oropharyngeal stimulus with Bonfils rigid fiberscope intubation, the hemodynamic responses to endotracheal intubation will be lesser. Therefore, we compared Bonfils intubation with conventional direct laryngoscopic intubation in adult patients with normal airway. Materials and Methods: Sixty adult patients of either sex, belonging to American Society of Anesthesiologists grade 1 or 2, were randomized into Bonfils group and laryngoscopy group, and studied over a 2-year period. Anesthet ic technique was standardized in both the groups. Hemodynamic variables were recorded at pre-induction, induction, post-induction at laryngoscopy and intubation, thereafter for every minute for 10 min, and half hourly till the end of surgery for both the groups. Intubation time, intubation attempts, and postoperative complications like hoarse voice and sore throat were compared between the two groups. Results: There was no statistically significant difference between the two groups with respect to systolic blood pressure, mean blood pressure, and heart rate changes throughout the study period. There was a statistically significant difference in the diastolic blood pressure (DBP) values between the groups (P < 0.05) for the first 10 min following intubation. The time required for intubation was significantly longer in the Bonfils group (36 ± 6 s) compared to the laryngoscopy group (28 ± 6 s) (P = 0.000). The incidence of postoperative sore throat (P = 0.009) and hoarseness of voice (P = 0.045) was significantly lesser in the Bonfils group compared to the laryngoscopy group. Conclusion: There was no clinically significant difference in the hemodynamic changes following intubation using either Bonfils fiberscope or conventional laryngoscope. Bonfils intubation required longer time, but was associated with lesser incidence of sore throat and hoarseness of voice when compared to laryngoscopic intubation.

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Ventricular bigeminy is a type of dysrhythmia which can complicate any pregnancy and labor. These dysrhythmias occur most commonly as sporadic occurrences in view of anxiety and can be treated by reassurance. Nevertheless, in certain cases where if they occur in an increased frequency even after adequate reassurance and primary supportive care can lead to dangerous morbidities and mortalities. We present the management of a case of 21-year-old female patient presenting with ventricular bigeminy posted for elective lower segment cesarean section in our institution. General anesthesia was considered the anesthetic modality of choice and injections loxicard and metaprolol IV were used introperatively to tackle the occurrence of ventricular ectopics. In conclusion, thorough history, clinical examination, and judicious use of antiarrhythmic agents recommended during pregnancy can prevent an asymptomatic ventricular ectopy transforming into a fatal arrhythmia in managing a case of ventricular bigeminy.

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Today elderly patients with complex health-related issues undergoing successfully a day care ophthalmic procedure are a common scenario. How can these high risk patients safely undergo an eye surgery and be back at home on the same day? This is possible, only when a well-planned, scientifically drawn protocol is in place at an institution. This plan of action takes into consideration every possible detail about the patient and also his or her special requirements if not demands. The anesthesiologist commands these well-set actions and guides the other health care staff to streamline the day care program, thereby sparing the busy ophthalmologist to attend to his clinical and surgical workload.

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Background and Aims: Postoperative nausea and vomiting (PONV) still present an important problem in anesthesia. In order to identify surgical patients who may benefit from prophylactic antiemetic medication, it is of interest to evaluate the risk factors for PONV using a simple scoring system. The simplified Apfel score includes four factors: female gender, nonsmoking status, postoperative use of opioids, and previous history of PONV or motion sickness. Each of these risk factors is supposed to elevate the incidence of PONV by about 20%. The aim of this study was to validate Apfel's clinical risk assessment score for identification of patients with high risk for PONV in our hospital. Materials and Methods: In a prospective study, 150 patients posted for various elective surgeries under general anesthesia with endotracheal intubation were analyzed and grouped into five groups, based on the Apfel risk scoring system. Each risk was given a score of 1, the total score being 4. PONV was monitored for 24 h and classified as grades 0, 1, and 2. Grades 1 and 2 were considered as PONV. The results obtained were analyzed for total incidence of PONV in each group of Apfel's scores and they were compared with the predicted incidence of PONV as per the documented Apfel's risk assessment. Collected data were analyzed by the Chi-square test, and the scoring system was assessed for sensitivity and specificity. Results: Of the 150 patients assessed, a total of 42% had PONV. Patients grouped under Apfel Score I had PONV incidence of 25.5%, the group with Score II had an incidence of 37.8%, the group with Score III had 64.6%, and the group with Score IV had 83.3%. This incidence of PONV corresponded to the predicted approximate values of 20% for Apfel Score I, 40% for Apfel II, 60% for Apfel III, and 80% for Apfel IV. Conclusions: The Apfel scoring system is simple and useful for identifying patients with high risk for PONV.

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Background: Stress response to laryngoscopy and intubation causes autonomic or endocrine disturbance such as hypertension, tachycardia, and arrhythmias that may be potentially dangerous in cardiovascular disease patients. These changes are maximum at 1 min after intubation and last for 5-10 min. Labetalol is a selective α1- and nonselective β1- and β2-adrenergic antagonist. It lowers blood pressure (BP) by decreasing systemic vascular resistance by α1-blockade and reflex tachycardia attenuated by simultaneous β-blockade. Fentanyl is a potent synthetic opioid agonist with rapid onset and short duration of action. It blocks afferent nerve impulses resulting from stimulation of the pharynx and larynx during intubation. This is a prospective, randomized, control trial carried out to compare the effect of labetalol and fentanyl on sympathomimetic response to laryngoscopy and intubation in vascular surgeries. Materials and Methods: Eighty four patients [American Society of Anesthesiologists (ASA) grade I and II] scheduled for vascular surgeries were divided into three groups (28 each). Group A received fentanyl 2 μg/kg intravenous (IV), Group B received labetalol 0.25 mg/kg IV, and Group C received 10 mL saline IV. The groups were compared for heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and rate pressure product (RPP). Results: The groups were comparable as per their demographic data and preoperative vitals. All the vitals decreased significantly (P < 0.05) in Group A and Group B from just before intubation (5 min after the study drug) to 15 min after intubation compared to the control group. Labetalol decreased SBP, DBP, and MAP significantly at 1 min and 3 min after intubation and RPP at 1 min and 15 min after intubation. In HR, the difference was not significant (P > 0.05). The incidence of hypertension and tachycardia was higher in Group C. No hypotension, bradycardia, and abnormal electrocardiogram (ECG) were recorded in any group. Conclusion: In lower doses, labetalol is a better agent than fentanyl in attenuating the sympathomimetic response to laryngoscopy and intubation but the difference is not significant. However, both effectively blunt the pressure response.

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Thrombocytopenia is a common manifestation in pregnancy. It is mostly dilutional when no pathological causation is evident. There are no clear-cut guidelines to determine the platelet count at which anesthesiologists can safely administer regional anesthesia in obstetric patients. A safe approach in an asymptomatic mother is outlined here.

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Context: Intravenous (IV) tramadol has been in use for the treatment of postanesthetic shivering. Aims: To assess the efficacy of addition of tramadol to bupivacaine in subarachnoid block to reduce the incidence of shivering. Settings and Design: The study was conducted as a single-blind study in a 350-bedded teaching hospital. Materials and Methods: One hundred parturients undergoing cesarean section were randomly divided into two groups of 50 each. Group T received 0.2 mL (10 mg) of tramadol with 2 mL of 0.5% bupivacaine. The presence of shivering was noted intraoperatively and postoperatively. Statistical Analysis Used: Student's t-test (two-tailed, independent) was applied for continuous variables and Chi-square/Fisher's exact test was applied for categorical variables between the two groups. Results: Shivering was noted in 66% of the patients in Group NS as against the 16% noted in Group T with a majority of the cases (88%) noted in the intraoperative period. The mean duration to the two-segment regression was 135 ± 26 min in Group T versus 104 ± 22 min in Group NS and duration to 1-grade motor block regression was 128 ± 21 min in Group T versus 103 ± 18 min in Group NS. The analgesic effect of the block lasted for a mean duration of 232 min in Group T and 176 min in Group NS while nausea and vomiting were increased in group T versus NS. Conclusions: Tramadol (10 mg), along with bupivacaine given intrathecally plays a significant role in reducing the incidence of anesthesia-induced shivering in parturients while prolonging both the sensory and motor components of the subarachnoid block.

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When we study the anatomy of the larynx, a pattern is seen emerging. The number 3, its multiples and, fractions of 3 like 1/3 and 2/3 come throughout the description. The larynx is made up of three structures, namely, cartilages, muscles, membranes and ligaments. The cartilages are nine in number. The muscles are divided into nine groups. The membranes and ligaments are also grouped into nine. Inside the larynx there are three levels. There are three folds outside the larynx and three pairs of folds inside it. The nerve supply comprises three nerves. There are three pairs of joints in the larynx.

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Context: We have evaluated the effect of ramelteon, clonidine, and a placebo on perioperative sedation, anxiety, cognition, and postoperative analgesia in cases of laparoscopic cholecystectomies. Aims: To study the comparative efficacy of ramelteon and clonidine on sedation and in reducing anxiety perioperatively. Settings and Design: Prospective, randomized, double-blinded, placebo-controlled trial. Materials and Methods: Ninety patients undergoing laparoscopic cholecystectomies were randomized into the following three groups; the control group (placebo), the clonidine group, and the ramelteon group. The sedation, anxiety, orientation scores, psychomotor functions, the hemodynamic parameters, and the recall and total analgesic consumption postoperatively for 24 h were assessed. Statistical Analysis Used: Statistical analysis was done with Student's t-test for the quantitative data and Chi-square test for the categorical data. Results: The anxiety scores were significantly lower in both the clonidine group and the ramelteon group in comparison to the placebo group. Higher level of sedation was noted in the clonidine and ramelteon groups compared to the placebo group. Patient satisfaction score was significantly higher in the clonidine group. Analgesic consumption was noted to be significantly less in the clonidine group. Statistically significant reduction in the mean arterial pressure (MAP) and heart rate were observed in the clonidine group. Conclusions: We observed that oral premedication of ramelteon and clonidine resulted in a significant level of sedation and reduction of anxiety score with no significant impairment of the psychomotor functions compared to the placebo. The clonidine group, in addition, showed significant analgesic sparing effect in the first 24 h and reduction in the MAP and heart rate pre- and postoperatively.

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Reported is a case series of high risk geriatric patients with multiple co-morbidities presenting for lower limb orthopaedic surgeries. Combined psoas compartment and sciatic nerve block proved useful as an alternative anaesthetic technique to central neuraxial blockade and general anaesthesia. We recommend the use of these peripheral nerve blocks as the sole anaesthetic option for lower limb surgeries in the emerging phase of easy accessibility of peripheral nerve stimulator and ultrasound in the operation theatres.

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Pethidine is used by anesthesiologists to provide pain relief during the perioperative period, labor, and trauma, but it is not frequently used nowadays because of the availability of more potent shorter-acting opioids. But even today it is commonly used by many to alleviate shivering in surgical patients. Because of these actions on the autonomic nervous system, pethidine may produce changes in the heart rate in combination with other medications or interventions. We encountered ill-sustained complete heart block in a patient who received 25 mg pethidine intravenously to alleviate shivering. No other treatment except 0.2 mg glycopyrrolate was required as the patient had hemodynamic stability.

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Background: Laparoscopic surgeries have become one of the most common procedures performed on an outpatient basis and for sicker patients, rendering anesthesia for laparoscopy technically difficult and challenging. This study is done to evaluate the efficacy of intrathecal fentanyl in maintaining the hemodynamics in patients undergoing laparoscopic hysterectomies under general anesthesia (GA). Materials and Methods: Sixty patients classified as American Society of Anesthesiologists (ASA) physical status I and II, 30-50 years of age, and posted for elective laparoscopic hysterectomies under GA were selected. Patients were randomly divided into two groups of 30 each. Group 1 received intrathecal fentanyl 25 μgm diluted to 3 mL with normal saline (NS) before GA and Group 2 received intravenous (IV) fentanyl 2 μgm/kg before GA. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), peripheral capillary oxygen saturation (SpO ₂ ), and electrocardiogram (ECG) were recorded before induction, after intubation, at 15 min, at 30 min, and every 30 min thereafter till the end of the surgery. Statistical Analysis: The results obtained in the study are presented as mean ± standard deviation (SD) in tabulated form and statistical analysis was done with SPSS software version 17 using Student's t-test. Results: In this present study, we found that HR, SBP, DBP, and MAP in both the groups were not significant after intubation for up to 15 min. Once pneumoperitoneum was achieved HR, SBP, DBP, and MAP were found to be significantly higher in Group 2 compared to that of Group 1 (P < 0.001). The time for first rescue medication was significantly shorter in Group 2 compared to that of Group 1. There were no side effects observed in any of the groups. Conclusion: From this study, we conclude that intrathecal fentanyl 25 μgm is very effective in controlling the intraoperative hemodynamics during laparoscopic hysterectomies under GA. We also observed better postoperative analgesia, with prolonged time for rescue analgesia.

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Context: Epidural anesthesia is one of the many advances that has gained rapid acceptance due to an evidence-based reduction in morbidity and overall patient satisfaction. Settings and Design: We present an audit of 1,143 patients who were administered epidural anesthesia solely, with successful outcomes between January 2009 and August 2014 at Sagar Hospitals, Banashankari, Bengaluru employing conventional techniques with a unique drug combination. Materials and Methods: A retrospective followed by prospective data collection of all patients given sole epidural at our hospital was taken and analyzed. The number of conversions to GA due to ineffective anaesthetic block was tabulated and charted for assessment. Laboratory analysis of the drug combination was performed in order to understand the pharmacology better. Results and Conclusion: The audit revealed that our technique of sole epidural using the unique drug combination is definitely effective with minimal rates of conversion to GA and negligible complication rates.

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A 52-year-old man, a known case of hepatic cirrhosis and portal hypertension, presented with a bleeding lacerated wound of his pharyngeal wall and tongue with prolapse of the tonsil. He underwent emergency surgical repair of the laceration. We discuss the airway management and other anesthetic implications of this case.

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The success of endoscopic surgery in otolaryngology largely depends on the surgical field, where the presence of significant bleeding is a critical factor. Bleeding obscures surgical planes and the recognition of anatomical landmarks becomes quite difficult. Various manoeuvers and drugs have been used for optimization of the surgical field. Conventionally, beta blockers and sodium nitroprusside have been used to control the intraoperative blood pressure. Newer agents such as remifentanil and adrenergic alpha-2 agonists such as clonidine and dexmedetomidine are also being tried. We report two cases of endoscopic sinus surgery (ESS) where dexmedetomidine infusion as adjunct to propofol infusion and inhalational anesthesia with sevoflurane [minimum alveolar concentration (MAC) 0.5-0.8] were utilized for providing an optimal surgical field.

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We present a perioperative case of spontaneous pneumothorax in a 50-year-old female patient. The case report describes the presentation and outlines the management. The patient presented with difficulty in breathing, desaturation, and restlessness immediately after extubation. Decreased chest movements, hyperresonant percussion note, and absent air entry on auscultation on one side of her chest was noted. The patient was hemodynamically stable. Then, 100% O ₂ with closed circuit was continued while a portable X-ray of her chest was taken to confirm the diagnosis of pneumothorax. Intercostal drainage was done on the affected side immediately and the symptoms were relieved. The case report discusses a very rare perioperative complication and highlights the importance of clinical diagnosis and swiftness of intervention.

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Context: Succinylcholine cannot be used for rapid sequence induction or intubation (RSI) in several situations due to associated side effects. Rocuronium bromide has faster onset time among nondepolarizing muscle relaxants and can offer a safe alternative for RSI when the priming principle is used. Aims: This study was designed to compare the effects of rocuronium with different priming intervals on the time of intubation and intubating conditions. Setting and Design: This randomized, prospective double-blind study was conducted in patients for abdominal and peripheral limb surgeries under general anesthesia at a tertiary care hospital. Materials and Methods: Ninety patients of American Society of Anesthesiologists (ASA) physical status I and II, aged 20-50 years, of both sexes were divided into three groups of 30 each. Group A patients received a priming dose of 0.06 mg/kg of rocuronium followed by 0.54 mg/kg rocuronium 3 min later. Group B received 0.06 mg/kg followed by 0.54 mg/kg rocuronium 2 min later, and Group C received saline followed by 0.6 mg/kg rocuronium 3 min later. Time of intubation was assessed using train-of-four (TOF) stimuli, and intubating conditions were compared by the Cooper scoring system. Statistical Analysis: Analysis of variance (ANOVA) test was used to compare the time of intubation and intubating conditions among the groups. Results: The onset time of intubation was 57.4 ± 16.3 s in Group A, 104.8 ± 11.5 s in Group B, and 123.9 ± 13 s in group C. Intubating conditions were clinically acceptable in all three groups. Conclusion: The 3-min priming interval of rocuronium provides excellent intubating conditions in less than 60 s and can be used in RSI.

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Isolated dysphagia is a rare form of presentation of myasthenia gravis (MG), resulting in discoordinated peristalsis. Accidental aspiration of barium sulfate may occur during radiological examinations of the upper gastrointestinal system using contrast media in conditions affecting the anatomical and functional integrity of the oropharynx and the esophagus. Though inert, barium may result in severe pulmonary inflammatory reaction and acute respiratory distress syndrome (ARDS). Thus, it is important to identify patients at risk of aspiration. Timely consideration of MG during evaluation of dysphagia is crucial to prevent complications and improve the quality of life. Whenever neuromuscular weakness is suspected, videofluroscopic technique for barium swallow needs to be advocated. We, hereby, report an unusual case of MG who presented with dysphagia only and developed fatal barium aspiration pneumonitis.

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Context: Endotracheal intubation constitutes a period of extreme hemodynamic stress. The search for an ideal agent to attenuate this pressor response still continues. Clonidine, α₂ adrenergic agonist, slows down the heart rate and leads to a dose-dependent decrease in systolic and diastolic blood pressure. It has 100% bioavailability following oral administration. Aims: To evaluate the efficacy of oral clonidine in attenuating the hemodynamic responses to laryngoscopy and endotracheal intubation and to study associated side effects. Setting and Design: This was a prospective, randomized controlled, double-blind study. Materials and Methods: Fifty patients of either sex, aged 20-60 years, ASA grade I/II undergoing elective surgeries under general anesthesia were included. Group A received Clonidine 3 mcg/kg orally 90 min before induction and group B received 5 ml distilled water. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure, and rate pressure product were noted at baseline, preinduction, postinduction, intubation and thereafter, 1, 3 and 5 min following intubation. Statistical Methods: Student's t-test was used to find the significance of study parameters on a continuous scale. A Chi-square and the Fisher exact test has been used to find the homogeneity of samples on categorical scale. Results: There was a statistically significant difference in heart rate, systolic, diastolic, mean arterial pressure and rate pressure product between two groups during laryngoscopy and the difference in parameters persisted for 5 minutes. Clonidine group had more stable hemodynamic parameters throughout. Conclusion: Oral clonidine premedication in the dose of 3 mcg/kg can effectively attenuate the hemodynamic stress response to laryngoscopy and intubation with minimal side effects.

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