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A letter to the editor is presented in response to the article "Anesthetic management of a patient with Montgomery t-tube in situ for direct laryngoscopy" published in the previous issue.

Competing Interests: There are no conflicts of interest.

Background and Aims: An exaggerated hemodynamic response to endotracheal intubation is observed in hypertensive patients, and its attenuation proves challenging. The role of oral ivabradine, a unique heart rate-lowering drug with a favorable hemodynamic profile, is not yet studied. The aim of this study was to evaluate the effect of oral ivabradine on the attenuation of hemodynamic response to endotracheal intubation in hypertensive surgical patients assessed by rate pressure product (RPP), which is a very reliable indicator of myocardial oxygen demand., Material and Methods: Sixty medically controlled hypertensive surgical patients, aged 30-65 years, receiving general anesthesia were divided into two equal groups: Group I received a tablet of ivabradine 5 mg and group C received a placebo tablet 1 hour before induction. Heart rate (HR) and systolic, diastolic, and mean arterial blood pressure (SBP, DBP, and MAP) were recorded at baseline, preoperative, immediately after intubation, 1 min, 3 min, 5 min, and 10 min following intubation. RPP was calculated at the above time intervals. Data were analyzed using the unpaired t -test and the Chi-square test as required, with P < 0.05 considered significant., Results: The maximum value of RPP after intubation was significantly less in group I (11065.64 ± 606.56) as compared to group C (16774.64 ± 1242.87), P = 0.000. All hemodynamic variables, RPP, HR, SBP, DBP, and MAP, remained significantly less in group I than group C at all time intervals ( P = 0.000). These parameters never increased above baseline after intubation in the ivabradine group, indicating effective attenuation of the intubation response., Conclusion: Premedication with oral ivabradine 5 mg is very effective in attenuating the hemodynamic response to intubation in hypertensive patients., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Journal of Anaesthesiology Clinical Pharmacology.)

Background and Aims: Bloodless surgical field during functional endoscopic sinus surgery (FESS) is an essential part, and research continues to find simple and effective regime for it. This study was aimed to compare the efficacy of oral clonidine versus oral metoprolol as premedicants regarding surgical field condition and controlled hypotension in patients undergoing FESS., Material and Methods: Sixty-eight patients of American Society of Anesthesiologists (ASA) physical status (PS) I and II aged 18-60 years, of both genders, scheduled for FESS under general anesthesia were randomly allocated in two groups. Group C ( n = 34) received oral clonidine 300 μg and group M ( n = 34) received oral metoprolol 50 mg, 2 h before surgery. Controlled hypotension (mean arterial pressure [MAP] 65-75 mmHg) was achieved by titrating sevoflurane (1%-3%). Primary outcome measured was surgical field visualization by Average Category Scale (ACS 0-5), and the secondary outcomes measured were hemodynamic parameters, sevoflurane requirement, recovery, and side effects. Categorical, continuous, and ordinal data were compared using Chi-square test, t -test, and Mann-Whitney test, respectively. P < 0.05 was considered as statistically significant., Results: ACS was significantly less in group C compared to group M up to 60 min, ( P < 0.05). Mean systolic blood pressure (SBP), diastolic blood pressure (DBP), and MAP were significantly less in group C compared to group M at all time intervals ( P < 0.05) Intraoperative sevoflurane requirement (vol %) was significantly less in group C (1.21 ± 0.42) compared to group M (1.68 ± 0.53) ( P = 0.000)., Conclusions: Premedication with oral clonidine was found to be superior to oral metoprolol as it provided significantly better surgical field condition during FESS with much efficient controlled hypotension and anesthetic-sparing effect. Standardized Study Reporting Requirements: CONSORT: http://www.consort-statement.org/., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Journal of Anaesthesiology Clinical Pharmacology.)

Background and Aims: Using a humidifier in intubated patients is now a standard of care as the humidifying effect of the upper airway is lost. We conducted this study to compare the efficacy of a heated humidifier (HH) with the more commonly used conventional mist nebulizer on overnight intubated and spontaneously breathing post-operative patients., Material and Methods: This prospective, randomized control trial included 60 post-operative overnight intubated and spontaneously breathing patients, of which 30 patients were allocated to the HH group and 30 to the mist nebulizer group. The reduction of endotracheal tube (ETT) patency was measured quantitatively by the difference between the pre-intubation and immediate post-extubation ETT volume and compared between the two groups. Also, the characteristics of secretion, the temperature of inspired gas at the Y-piece, and the frequency of refilling the humidifier chamber were recorded and compared., Results: The reduction of ETT volume was significantly more in the mist nebulizer group compared to the HH group ( P -value 0.00026). The mean temperature of the inspired gas (°C) was higher in the HH group ( P -value < 0.0001). More patients in the mist nebulizer group had thicker ( P -value 0.057) and drier secretions ( P -value 0.005) compared to the HH group. None of the patients in the HH group required refilling of the humidifier chamber while the mean frequency of the refilling was 3.5 times per patient in the mist nebulizer group., Conclusion: HH may be preferred over mist nebulizer as the latter requires more frequent refilling which may not be practically possible in a busy recovery room rendering the patient at the risk of inhaling dry gas and consequent thick and dry secretions with decreased ETT patency., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Anaesthesiology Clinical Pharmacology.)

Background and Aims: Dexmedetomidine is a highly selective α-2 adrenoreceptor agonist and has been found to be an effective premedication agent when administered via the intranasal route. We aimed to compare the efficacy of dexmedetomidine premedication administered via intranasal route and through nebulization in pediatric patients., Material and Methods: This non-inferiority randomized controlled trial was conducted after getting approval from institutes ethics committee and informed written parental consent. Sixty-four children aged 2-8 years scheduled for elective surgery under general anesthesia were enrolled and were divided into two groups. Group I (Intranasal, n = 33) received 2 mcg/kg dexmedetomidine via intranasal route and group N (Nebulized, n = 31) received 2 mcg/kg dexmedetomidine through nebulization. The primary outcome was number of patients with satisfactory sedation 30 minutes after premedication at separation from parent. The secondary outcome included ease of medication acceptance, anxiety at parental separation, acceptance of anesthesia mask, perioperative hemodynamics, emergence agitation during recovery and adverse effects. Data collected was analyzed using Chi-square test, Student "t" test and Mann-Whitney U test with the help of SPSS 22. A one tailed P value < 0.025 was considered significant., Results: Demographic profile was comparable between groups. On arrival in OR 27 (81.8%) patients in group I and 21 (67.7%) patients in group N had satisfactory sedation score ( P = 0.19). The median (IQR) sedation score was comparable between group I and group N ( P = 0.057). Patients in Group I showed significantly better medication and mask acceptance scores ( P < 0.0001, P = 0.001 respectively), parental separation anxiety score ( P < 0.0001) and emergence agitation score ( P = 0.001). There were no significant differences in hemodynamic parameters and adverse effects between the groups., Conclusion: Although nebulized dexmedetomidine is non-inferior to intranasal dexmedetomidine in providing desired level of sedation but intranasal administration had better acceptance of medication and anesthesia mask with lesser anxiety at parental separation and postoperative emergence agitation., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Anaesthesiology Clinical Pharmacology.)

Background and Aims: Operation theater (OT) complex is an important area for a hospital as it needs expensive infrastructure, disposable, and reusable resources and a multidisciplinary highly qualified and efficient team, the metrics of which are key in generating revenue, and improved productivity. The efficient utilization of OT ensures maximum output in view of the investment of highly qualified doctors, equipment, and outcomes. Our study aimed to evaluate the utilization of OT functioning stepwise, reasons for delays, case cancellations, and areas of improvement if any., Material and Methods: This prospective observational study was planned in three phases; in phase 1 audit of OT functioning was carried out for 1 month and based on data analysis recommendations were given for improvement. In phase 2, the recommendations would be implemented over 3 months and in phase 3 re-audit will be carried out for 1 month. Data analysis was done on IBM SPSS version 26 software. Descriptive statistics measures were calculated by the mean and standard deviation., Results: The total available resource time was 52920 min and the total time utilized was 37740 min. Overall, raw utilization was 71.31%. OT was started late 63.50% times. Case cancellation occurred on 8.99% occasions., Conclusion: We conclude that utilization of operating room time can be maximized by proper planning and realistic scheduling of elective lists, communication among team members, and resource management. Audit of OT utilization is an important tool to identify problem areas and formulate protocols accordingly., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Anaesthesiology Clinical Pharmacology.)

Background and Aims: Various adjuvants have been added to local anesthetics in single shot blocks so as to prolong the duration of postoperative analgesia. The present study was conceived to evaluate the effect of dexmedetomidine as an adjuvant to ropivacaine for institution of supraclavicular brachial plexus block., Material and Methods: Ninety adult patients (ASA physical status I, II) scheduled for elective upper limb surgeries under ultrasound-guided subclavian perivascular brachial plexus block were allocated randomly into two groups; the study was designed in double-blind fashion. All patients received 20 ml 0.75% ropivacaine, in addition, patients in group A ( n = 43) received 2 ml 0.9% normal saline and those in group B ( n = 44) received dexmedetomidine (1 μg/kg body weight); total volume was made up to 22 ml with sterile 0.9% saline in both groups. The onset and duration of sensory and motor blocks, time to first request of analgesia, total dose of postoperative analgesic administration, and level of sedation were also studied in both the groups. All the data were analyzed by using unpaired t -test. P < 0.05 was considered significant., Results: Sensory and motor block durations (613.34 ± 165.404 min and 572.7 ± 145.709 min) were longer in group B than those in group A (543.7 ± 112.089 min and 503.26 ± 123.628 min; P < 0.01). Duration of analgesia was shorter in group A (593.19 ± 114.44 min) compared to group B (704.8 ± 178.414 min; P < 0.001)., Conclusion: Addition of dexmedetomidine to 0.75% ropivacaine in supraclavicular brachial plexus block significantly prolongs the duration of analgesia., Competing Interests: There are no conflicts of interest.

Competing Interests: There are no conflicts of interest.

Background and Aims: Efficacy of epidural analgesia depends on placement of the epidural catheter at the appropriate level. Manual palpation using surface landmarks to identify the desired intervertebral level may not be a reliable method. Ultrasonography (USG) is an alternative technique but requires training and may increase procedure time. The objective of this study was to compare the accuracy of ultrasound (US) imaging with manual palpation for locating the intervertebral level., Material and Methods: We included postoperative adult patients without an epidural catheter who were scheduled to have a chest radiograph in the recovery room. A radio-opaque marker was placed at random at an intervertebral space along the thoracic or lumbar spine of the patient (in the field of the chest radiograph). The level of intervertebral space corresponding to the radio-opaque marker was determined by palpation technique by one anesthetist. Two other anesthetists (A and B) blinded to the result of manual palpation, independently used USG to determine the level of intervertebral space. A consultant radiologist assessed the radiographs to determine the correct position of the marker, which was judged to be the accurate space., Results: We recruited a total of 71 patients, of which 64 patients were included in the final analysis. Accurate identification by manual method was 31/64 (48%), by US A was 27/64 (42%) and by US B was 22/64 (34%). The difference in accuracy between manual palpation and US imaging was not statistically significant ( P = 0.71)., Conclusion: US imaging may not be superior to manual palpation for identifying intervertebral level., Competing Interests: There are no conflicts of interest.

Background and Aims: Hypotensive anesthesia technique is used to reduce intraoperative bleeding and to improve the visibility of the operative field. The aim was to evaluate the efficacy of desflurane with and without labetalol for producing hypotensive anesthesia., Material and Methods: Sixty adult patients undergoing elective middle ear surgery were administered general anesthesia and randomly divided into two groups - Group D and Group L. The target mean arterial pressure (MAP) was 55-65 mmHg during hypotensive period. Group D patients received an increasing concentration of desflurane alone. Group L patients received 3% desflurane plus labetalol (loading dose 0.3 mg/kg intravenously, followed by 10 mg increments every 10 min). Student's t -test and paired t -test were used to compare the hemodynamic parameters. Visibility of the operative field, anesthetic and rescue drug requirement, partial pressure of oxygen in arterial blood, time taken for induction and reversal of hypotension and recovery characteristics were noted., Results: Target MAP was achieved in both the groups. Group D was associated with a higher mean heart rate compared with Group L (77.3 ± 11.0/min vs. 70.5 ± 2.5/min, respectively; P < 0.001) during the hypotensive period, along with a higher requirement for desflurane ( P = 0.000) and metoprolol ( P = 0.01). Time taken to achieve target MAP was lesser in Group L compared with Group D (33.7 ± 7.1 vs. 39.8 ± 6.2 min, respectively; P = 0.000). Time taken to return to baseline MAP was faster in Group D ( P = 0.03). Emergence time was longer with desflurane alone ( P = 0.000) resulting in greater sedation ( P = 0.000) in the immediate postoperative period., Conclusion: Although desflurane is effective for inducing deliberate hypotension in middle ear microsurgery, the combination of desflurane with labetalol is associated with decreased requirement of desflurane, absence of reflex tachycardia, faster induction of hypotension, faster recovery from anesthesia, and less postoperative sedation., Competing Interests: There are no conflicts of interest.

Background and Aims: The incidence of intra-operative awareness with explicit recall in the Western world has been reported to be between 0.1% and 0.2% in the general surgical population and up to 1-2% of patients at high risk for this complication. Awareness in the Indian population has never been studied; we therefore wanted to detect the incidence of awareness in patients who were at high risk of experiencing awareness during surgery in our population., Material and Methods: We conducted a prospective single-center observational study at a 600-bedded tertiary cancer care referral hospital. We recruited adult patients posted for major cancer surgery who were considered to be at high risk for awareness. These patients were interviewed at three time-points using the structured modified Brice interview questionnaire. The primary outcome studied was the incidence of definite intra-operative awareness., Results: A total of 934 patients were included in the final analysis of which none reported awareness. Using the rule of three (Hanley and Lippman-Hand) we conclude that the upper 95% confidence interval for the incidence of awareness in this population is <1 in 300 (0.33%)., Conclusion: Awareness under anesthesia is a distressing complication with a potential for long-term psychological consequences, and every effort should be undertaken to prevent it. It is reassuring though that our data in Indian cancer patients at high risk for intra-operative awareness suggests that it is an uncommon occurrence., Competing Interests: Conflicts of Interest: None declared.

Background: We undertook this study to ascertain if a small dose of clonidine (30 μg) when added to a bupivacaine-fentanyl mixture improves spinal analgesia, without producing side effects, as compared to a bupivacaine-fentanyl or a bupivacaine-clonidine mixture., Materials and Methods: In this prospective, randomized, double-blind study, 75 (American Society of Anesthesiologists) ASA grade I-II patients, aged between 45 and 65 years, who were scheduled for vaginal hysterectomy with pelvic floor repair or non-descent vaginal hysterectomy under spinal anesthesia were recruited. The patients received hyperbaric bupivacaine (2.3 ml) with fentanyl 15 μg (Group BF) or clonidine 30 μg (Group BC) or both fentanyl (15 μg) and clonidine (30 μg) (Group BCF). The total amount of intrathecal mixture was constant (2.8 ml) in all the groups. Duration of sensory, motor block and effective analgesia, hemodynamic profile, postoperative pain score and analgesic requirements were recorded., Results: The duration of effective analgesia, mean time till two-segment regression, and duration of sensory and motor block were significantly longer in group BCF as compared to group BC (P ~ 0.002), and in group BC as compared to group BF (P ~ 0.01). The incidence of intraoperative pain and requirement of postoperative analgesics in the first 24 hours was significantly more in group BF as compared to the other groups (P ~ 0.01). There was no difference in the hemodynamic profile between the groups., Conclusion: Low-dose clonidine (30 μg) when added to a bupivacaine-fentanyl mixture increased the duration of effective analgesia and the duration of sensory and motor block in gynecological surgery. The incidence of intraoperative pain and requirement of postoperative analgesics was significantly less when clonidine was added to intrathecal bupivacaine with or without fentanyl.