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Background and Aims: General anaesthesia (GA) is the preferred modality for breast surgeries; however, neuraxial anaesthesia can be performed in cases where GA poses a significant risk. We hypothesise that neuraxial blockade is a safe and effective alternative to GA in short-duration breast surgeries. Methods: This randomised study included 30 patients of the American Society of Anesthesiologists physical status I and II, who were scheduled for elective breast surgeries of a duration of less than 90 min. Group I received thoracic spinal anaesthesia, while in Group II, standardised GA was administered. The primary outcome was the time to the first rescue analgesic, and the secondary outcomes were time to recovery, patient satisfaction and the cost incurred. Results: The demographic characteristics of both groups were comparable (P > 0.05). The time to first rescue analgesic in Group I was more than in Group II (P = 0.001). Patient satisfaction score was superior in Group I compared to Group II (P = 0.002). The average cost was lower in Group I compared to Group II (P = 0.002). Recovery was quicker in Group I than in Group II (P = 0.001). There were no significant haemodynamic disturbances or major complications in either group. Conclusion: Thoracic spinal anaesthesia is an excellent alternative to GA in terms of analgesic efficacy, patient satisfaction, recovery and cost-effectiveness for short-duration breast surgeries.

Background and Aims: A quality improvement project (‘Safe Anaesthesia for ALL-SEAL’) was implemented to reduce preventable medication errors and drug wastage in the operating theatre (OT) of a tertiary hospital. The primary objective of this quality improvement project was to prevent the incidence of medication errors, and the secondary objective was to reduce the wastage of unused drugs. Methods: A pre-intervention questionnaire and an audit survey were performed, and multidirectional interventions were designed post-survey. A post-intervention survey was conducted to evaluate effectiveness. The incidence of medication errors, including near misses, was assessed for root causes. Unused drugs drawn or diluted in syringes were recorded daily in each OT. The weekly drug orders and mid-week reordering frequency were also monitored. The data were reported as simple means and percentages. Results: Ninety-eight anaesthesia care providers participated in the survey (72.4% doctors and 27.6% anaesthetic nurses). Pre-intervention, 76.1% of respondents had experienced medication errors during their practice. Common errors included misidentification of ampoules or vials (65.2%), miscalculation of dosages (65.2%), improper syringe labelling (56.5%), accidental drug omission (54.3%) and wrong prescriptions (39.1%). The main sources of errors were fatigue/overwork (80.4%) and a hectic OT environment (71.7%). Post-intervention, no incidents of medication errors were reported. In addition, there was a significant reduction in drug wastage. Conclusions: The SEAL project positively prevented medication errors and reduced drug wastage, which should be further validated in other clinical settings.

Background and Aims: Preoperative parental anxiety can have a profound impact on their children undergoing surgery. The present study was done to analyse the correlation between preoperative parental anxiety and their child’s anxiety in paediatric patients undergoing elective surgery. Methods: Paediatric patients aged 2–12 years, scheduled for elective surgeries under general anaesthesia, were included in the study. The child’s behaviour and anxiety were assessed in the preoperative area using the modified Yale Preoperative Anxiety Scale (m-YPAS). The parent filled out the demographic questionnaire and the Spielberger State–Trait Anxiety Inventory (STAI) form in the preoperative area on the day of surgery. Statistical analysis was conducted using Statistical Package for the Social Sciences (SPSS) statistics software version 23.0 (IBM Corp, Armonk, NY, USA). Results: A total of 150 children undergoing elective surgery were analysed. Our results showed a strong positive correlation between a child’s m-YPAS and his/her parents’ anxiety on the day of the surgery (STAI-state) (r = 0.545, P < 0.001). However, the correlation between a child’s m-YPAS and his/her parents’ anxiety levels (STAI-trait) was not found to be significant (r = 0.109, P = 0.188). A positive correlation was observed between a parent’s STAI-state and STAI-trait (r = 0.366, P < 0.001). Factors like area of residence, type of surgery and previous hospitalisation had an influence on the anxiety levels of the child. The birth order of the child, previous hospitalisation and gender of the parent also influenced parental anxiety. Conclusion: Parental anxiety has a significant impact on the child’s anxiety during the preoperative period.

Background and Aims: Surgeons often request a Valsalva manoeuvre (VM) at the end of surgery (head–neck surgery, craniotomy) to check haemostasis and to unmask covert venous bleeders. We aimed to compare an anaesthesia machine-generated objective technique for delivering VM under pressure-control (PC) mode with the traditional subjective technique of delivering VM in manual mode. Methods: This randomised controlled study included 60 adult patients randomised to manual (Group M) and controlled ventilation (Group C) groups. Our primary outcome measure was internal jugular vein (IJV) diameter at pre-determined time points (T0 = baseline, T1 = VM initiation, T2 = 20 s after VM initiation, T3 = immediately after VM release, and T4 = 1 min, T5 = 2 min and T6 = 5 min post-VM release). Secondary outcome measures included mean arterial pressure (MAP), heart rate, time to desired plateau airway pressure, number of patients with bleeders unmasked and surgeon satisfaction. Independent/paired sample t-tests were applied. Results are expressed as mean (standard deviation), mean difference (95% confidence interval), dotted box–whisker plots and trendlines. P

Background and Aims: The infraclavicular brachial plexus block (ICB) provides analgesia and anaesthesia of the upper limb. It is given using the classical or the more recently described costoclavicular (CC) approach at the level of cords. This systematic review aimed to assess which approach is better for the ICB in terms of onset, performance, and safety. Methods: This PROSPERO (vide registration number CRD42022361636) registered meta-analysis included randomised trials of patients undergoing upper limb surgery in ultrasound-guided ICB from MEDLINE, EMBASE, SCOPUS, and IRCTP from inception to March 2023. The quality of evidence was assessed using GradePro software. The primary outcomes were sensory and motor block onset time and the number of patients having complete block at 30 minutes. Secondary outcomes included block performance time (BPT), number of attempts, duration of the block, and any incidence of complications. Results: Five trials with 374 adult patients (classic = 185, CC = 189) were included. No significant difference was found in the sensory (Mean difference (MD): 1.44 minutes [95% confidence interval (CI): 3.06, 5.95]; I2 = 95%; very low level of evidence (LOE); P = 0.53) and motor block onset times (MD: 0.83 minutes [95% CI: 0.96, 2.62]; I2 = 84%; very low LOE P = 0.36) and BPT (MD: 5.06 seconds [95% CI: 38.50, 48.63]; I2 = 98%; very low LOE; P = 0.82) in classic and CC approach of ICB. Trial sequential analysis revealed our sample size to be 0.65% of the required sample size to achieve 80% power, deeming our study underpowered. Conclusion: Costoclavicular approach was not superior or inferior to the classical technique for infraclavicular brachial plexus block. However, the quality of evidence is low and further studies are needed to corroborate the findings.

Background: Local anaesthesia is most commonly used for cataract surgery in adult patients. Different combinations of local anesthetic agents and adjuvants have been used to provide adequate anaesthesia and analgesia. This study assessed the effect of adding 25 µg fentanyl to lidocaine with adrenaline mixture on the onset and duration of anaesthesia in adult patients undergoing cataract surgery under peribulbar anaesthesia. Methods: This was a double blind, randomized controlled study. Adult patients aged 40 years and above with American Society of Anesthesiologists Physical Status Classes 1 and 2 undergoing cataract surgery under peribulbar block (PB) were studied. Sixty-six patients were randomized into two equal groups. Group A had 25 µg fentanyl (0.5 mL) added to 6 mL of 2% lidocaine with adrenaline while Group B had sterile water 0.5 mL added to 6 mL of 2% lidocaine with adrenaline for PB. Onset and duration of lid akinesia, globe akinesia, globe anaesthesia, Numerical Rating Scale (NRS) pain score, time to analgesia request as well as patient and surgeon satisfaction were assessed. Results: The differences in the onset of lid akinesia, globe akinesia, and globe anaesthesia between the two groups were statistically significant (P ≤ 0.001, respectively). The mean duration of globe akinesia and globe anaesthesia was longer in Group A as compared to Group B (P = 0.008 and P = 0.009, respectively). Statistically significant differences in median NRS scores were found at the 4th, 5th, and 6th h (P = 0.001, respectively). The mean duration to analgesia request was 238.1 ± 65.5 min in Group A compared to 207.2 ± 49.1 min in Group B (P = 0.034). Conclusion: The addition of 25 µg fentanyl to 2% lidocaine plus adrenaline mixture improved the quality of peribulbar anaesthesia and is recommended in Nigerian adults scheduled for cataract surgery under peribulbar anaesthesia to improve their surgical experience.

Background and Aims: Acute kidney injury (AKI) is a significant postoperative complication. Multiple perioperative factors are implicated in the causation of AKI in the postoperative period in patients with oesophageal cancer. The study aimed to find out the incidence, causes and effects of AKI following oesophagectomy surgery. Methods: A prospective observational study was conducted in consecutive adult patients undergoing elective oesophagectomy at a tertiary cancer care hospital. Patients with preoperative chronic renal insufficiency (serum creatinine >1.5 mg/dl), AKI in the past and a history of renal replacement therapy were excluded. Serum creatinine values were measured on postoperative days 1, 3, 5, the day of discharge or day 15 and on the day of first follow-up or day 28, following oesophagectomy surgery. The incidence of AKI was measured using the ‘Kidney Disease Improving Global Outcome’ (KDIGO) criteria. Results: The incidence of AKI was 14.7% [95% confidence interval (CI) 9.9%, 20.7%] (i.e., 27/183) in patients who underwent elective oesophagectomy. AKI was associated with prolonged hospital stay [median- 13 days (interquartile range {IQR} 11–21.5) versus 9 days (IQR 8–12), P < 0.001] and increased in-hospital mortality (14.8% versus 1.3%, P 0.004, odds ratio = 13.2, 95% CI 2.3, 77.3). After multivariate analysis, age, anastomotic leak and use of vasopressors in the postoperative period were independent predictors of AKI. Conclusion: The incidence of AKI was 14.7% after elective oesophagectomy. AKI was associated with prolonged hospital stay and in-hospital mortality. Higher age, anastomotic leak and use of vasopressors in the postoperative period were independent predictors of AKI.

Background and Aims: Tracheal extubation often causes cardiovascular and airway responses, potentially resulting in hazardous consequences. It remains unknown whether dexmedetomidine or lidocaine is more effective for cough suppression. Hence, we conducted a systematic review and meta-analysis of randomised controlled trials to compare the effectiveness and safety of dexmedetomidine and lidocaine in reducing cough response after tracheal extubation in adult patients. Methods: A thorough search of electronic databases, including PubMed, Embase, Cochrane Library, and Web of Science, was conducted to identify relevant studies (from inception to 31 January 2023). Randomised controlled trials comparing intravenous (IV) dexmedetomidine versus IV lidocaine administration during emergence from anaesthesia to prevent tracheal extubation response in adult patients under general anaesthesia were included. The primary outcome was the incidence of post-extubation cough. Secondary outcomes included emergence time, extubation time, residual sedation, and incidences of bradycardia. Statistical analysis was conducted using RevMan software. The Cochrane risk of bias tool was used to evaluate the potential risk for bias. Results: In total, seven studies with 450 participants were included. There was no statistically significant difference in the incidence of cough between dexmedetomidine and lidocaine groups [Risk Ratio = 0.76; 95% Confidence Interval: 0.46, 1.24]. Emergence and extubation times were not significantly different between the two groups. Meta-analysis revealed a higher incidence of bradycardia and residual sedation in dexmedetomidine compared to the lidocaine group. Conclusion: This meta-analysis found no difference in cough, emergence, and extubation time between dexmedetomidine and lidocaine after tracheal extubation. However, residual sedation and bradycardia were more significant in dexmedetomidine than in lidocaine.

Background and Aims: During endoscopic sinus surgery, anaesthetic conditions significantly impact the intraoperative surgical field and bleeding during emergence. While the endotracheal tube (ETT) has been traditionally used in sinus surgery, a reinforced laryngeal mask airway (RLMA) that produces less upper airway stimulation may result in smoother emergence. Methods: A randomised controlled trial of 72 patients undergoing elective sinus surgery was conducted, with the allocation of airway technique to either ETT with a throat pack or RLMA. The primary outcome measure was emergence time, measured by time to opening eyes on commands at the cessation of anaesthesia, and the secondary outcomes were time to removal of airway device, remifentanil use, procedure times, mean arterial pressure (MAP) and the RLMA grade of blood contamination. The continuous variables were analysed using Student's t-tests and discrete variables, count tables were analysed using Fisher's exact tests. Results: There was no significant difference in the emergence time between the ETT and RLMA groups (P = 0.83). Remifentanil use was significantly higher in the ETT group than in the RLMA group (P = 0.022). The ETT group showed a significantly increased total anaesthetic time (P = 0.01). MAP was not significant during preinduction, maintenance or post-RMLA removal. The highest grade of contamination was grade 2 in RLMA. RLMA had lower rates of postoperative adverse events. Conclusions: RLMA comparable to ETT in terms of emergence time. The RMLA group had lower remifentanil use, anaesthesia duration and fewer postoperative adverse events such as cough and throat pain.

Background and Aims: Postextubation airway complications are more common in paediatric patients than in adults. Intravenous lignocaine effectively prevents extubation response; however, data on using intracuff lignocaine in microcuff endotracheal tubes is scarce. The primary aim of this study was to compare the incidence of postextubation cough between intracuff lignocaine and intracuff air in the paediatric population during tracheal extubation. Methods: This randomised controlled study was conducted in 120 paediatric patients aged 1 month to 12 years who were scheduled to undergo surgeries under general anaesthesia. They were randomised to Group C (intracuff air) and Group L (intracuff 2% lignocaine). After administering general anaesthesia, the airway was secured with an age-appropriate microcuff endotracheal tube. According to groups, the cuff was inflated with air or lignocaine to achieve a cuff pressure of 10 cm H2O. Incidences of cough, desaturation, laryngospasm, apnoea and haemodynamic changes were recorded after tracheal extubation. Categorical variables were compared using the Chi-square or Fisher's exact test, and continuous variables were compared using the Student's t-test or Mann–Whitney U test. Intergroup differences between the variables were analysed by a two-way repeated measure analysis of variance. Results: The incidence of postextubation cough was significantly higher in Group C [17 (28.3%) (confidence interval {CI} = 17.4–41.4)] when compared to Group L [8 (13.3%) (CI = 5.9–24.6)], with P = 0.043. One patient in Group C had laryngospasm compared to none in Group L. In Group C, there was also a significant increase in heart rate at all time points (1–5 min after extubation) from the baseline, and this increase was also significantly higher when compared to Group L (P < 0.05). Conclusion: The incidence of postextubation cough was significantly lower with intracuff lignocaine compared to that with intracuff air in paediatric patients.

Background and Aims: Short-term hypotension after general anaesthesia can negatively impact surgical outcomes. This study compared the predictive potential of the pleth variability index (PVI), pulse pressure variability (PPV), and perfusion index (PI) for anaesthesia-induced hypotension. This study's primary objective was to evaluate the predictive potential of PI, PVI, and PPV for hypotension. Methods: This observational study included 140 adult patients undergoing major abdominal surgery under general anaesthesia. Mean arterial pressure, heart rate, PVI, PPV, and PI were collected at 1-min intervals up to 20 min post anaesthesia induction. Hypotension was assessed at 5-min and 15-min intervals. Receiver operating characteristic (ROC) curves were plotted to determine the diagnostic performance and best cut-off for continuous variables in predicting a dichotomous outcome. Statistical significance was kept at P < 0.05. Results: Hypotension prevalence within 5 and 15 min of anaesthesia induction was 36.4% and 45%, respectively. A PI cut-off of 11.5, while PPV's AUROC was 0.742 (P = 0.001) at cut-off >12.5. At 15 min, PVI's AUROC was 0.615 (95% confidence interval 0.521–0.708, P = 0.020), with 54.9% positive predictive value and 65.2% negative predictive value. Conclusion: PVI, PPV, and PI predicted hypotension within 5 min after general anaesthesia induction. PVI had comparatively higher accuracy, sensitivity, specificity, and positive predictive value than PI and PPV when predicting hypotension at 15 min.

Background and Aims: There is paucity of studies on preoperative risk assessment tools in patients undergoing emergency surgery. The present study evaluated the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II, American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator and American Society of Anesthesiologists (ASA) physical status (PS) classification system in patients undergoing emergency exploratory laparotomy. Methods: This retrospective study included 60 adult patients who underwent emergency exploratory laparotomy for perforation peritonitis. The clinical details, ASA PS classification, laboratory investigations and postoperative course of patients were retrieved from their medical records. Based on these details, APACHE II and ACS-NSQIP were calculated for the patients. The study's primary outcome was the accuracy of the preoperative APACHE II, ACS-NSQIP risk calculator and ASA PS class in predicting the postoperative 30-day mortality of patients. Results: The area under the curve (AUC) of APACHE II, ACS-NSQIP score, and ASA PS classification for mortality 30 days after surgery was 0.737, 0.694 and 0.601, respectively. The P value for the Hosmer–Lemeshow (H–L) test of scoring systems was 0.05, 0.25 and 0.05, respectively. AUC for postoperative complications was 0.799 for APACHE II, 0.683 for ACS-NSQIP and 0.601 for ASA PS classification. H–L test of these scoring systems for complications after surgery revealed P values of 0.62, 0.36 and 0.53, respectively. Conclusion: Compared to the ACS-NSQIP and ASA PS classification system, the APACHE II score has a better discriminative ability for postoperative complications and mortality in adult patients undergoing emergency exploratory laparotomy.

Artificial intelligence (AI) is making giant strides in the medical domain, and the field of anaesthesia is not untouched. Enhancement in technology, especially AI, in many fields, including medicine, has proven to be far superior, safer and less erratic than human decision-making. The intersection of anaesthesia and AI holds the potential for augmenting constructive advances in anaesthesia care. AI can improve anaesthesiologists' efficiency, reduce costs and improve patient outcomes. Anaesthesiologists are well placed to harness the advantages of AI in various areas like perioperative monitoring, anaesthesia care, drug delivery, post-anaesthesia care unit, pain management and intensive care unit. Perioperative monitoring of the depth of anaesthesia, clinical decision support systems and closed-loop anaesthesia delivery aid in efficient and safer anaesthesia delivery. The effect of various AI interventions in clinical practice will need further research and validation, as well as the ethical implications of privacy and data handling. This paper aims to provide an overview of AI in perioperative monitoring in anaesthesia.

Simulation-based education is now recognised to be a valuable tool to impart both technical and non-technical skills to healthcare professionals of all levels. Simulation is an well accepted educational tool for cultivating teamwork skills among residents globally. Simulation-based education encompasses diverse modalities, ranging from task trainers and simulated patients to sophisticated high-fidelity patient simulators. Notably, anaesthesiologists globally were early advocates of integrating simulation into education, particularly to instruct anaesthesia residents about the intricacies of perioperative crisis resource management and collaborative interdisciplinary teamwork. Given the inherent high-risk nature of anaesthesia, where effective teamwork is pivotal to averting adverse patient outcomes, and also to improve overall outcome of the patient, simulation training becomes imperative. This narrative review delves into the contemporary landscape of simulation training in perioperative anaesthesia management, examining the pedagogical approaches, simulators, techniques and technologies employed to facilitate this training.

Surgery for excision of juvenile nasopharyngeal angiofibroma (JNA) carries the possibility of massive life-threatening haemorrhage. Anaesthetic management aims to maintain haemodynamic stability and reduce blood loss. This case series describes the application of the bundled approach as a multimodal blood loss prevention bundle (MBLPB). Twenty patients underwent 23 surgeries with MBLPB. The blood loss and the number of units of blood transfused were recorded. The surgeon satisfaction score was assessed. The median [interquartile range (IQR)] estimated blood loss was 1300 (650–2350) ml. Patients with tumours in stages I and II had a median (IQR) blood loss of 550 (270–750) ml compared to patients with higher grades of tumours (stages III, IV) with a median (IQR) blood loss of 2100 (1300–2500) ml. Median (IQR) units of packed red cells transfused was 1 (0–3). The surgeon's satisfaction score was high when MBLPB was applied for JNA. However, it does not appear to reduce blood loss markedly.

Caffeine has a multitude of uses in anaesthesia, and numerous studies have evaluated its efficacy and usefulness in various aspects of anaesthesia and medical practice. Its various applications in anaesthesia include its role in awakening from anaesthesia, managing post-dural puncture headache, managing post-sedation paradoxical hyper-activity in children, post-operative bowel paralysis, and apnoea in paediatric populations, that is, apnoea in infancy, paediatric obstructive apnoea, and post-anaesthetic apnoea in pre-mature infants. Though the effects of caffeine on bronchial smooth muscle, neurological, and cardio-vascular systems are well known, the relatively little-known effects on the endocrine and gastro-intestinal (GI) system have been recently taking primacy for eliciting its therapeutic benefits. The literature shows encouraging evidence in favour of caffeine, but unambiguous evidence of caffeine benefits for patients is lacking and needs further investigation. In this narrative review of literature, we summarise the available literature to provide insights into the pharmacokinetics, pharmacodynamics, clinical application of caffeine in modern anaesthetic practice, and evidence available in this field to date. An awareness of the various physiological effects, adverse effects, reported applications, and their evidence will widen the horizon for anaesthesiologists to increase its rational use and advance research in this field. Well-designed randomised controlled trials regarding the various outcomes related to caffeine use in anaesthesia should be planned to generate sound evidence and formulate recommendations to guide clinicians.

Background: Perioperative anxiety may adversely influence anaesthetic induction and patient's recovery. Pharmacological interventions include the use of narcotics, sedatives and anxiolytics. However, such drug interventions are typically accompanied by adverse reactions. Perioperative anxiety experienced by patients can be significantly diminished through the provision of comprehensive information regarding the anaesthesia procedure, surgical procedure and perioperative events during the pre-anaesthetic assessment conducted in an outpatient consultation clinic. Aims: This prospective study was conducted to assess the impact of providing comprehensive information on alleviating patient anxiety throughout the perioperative period. Materials and Methods: This prospective observational study was conducted on 60 patients to assess patient's perioperative anxiety for anaesthesia and surgery. All study participants were asked to mark their pre-operative anxiety on the Visual Analogue Scale-Anxiety (VAS-A) and asked to fill the questionnaire of Amsterdam Pre-operative Anxiety and Information Scale (APAIS). Results: During the pre-information evaluation, patient's mean VAS-A score was 4.73 ± 2.75 which decreased to 3.65 ± 2.53 in post-information evaluation (P = 0.027). The overall APAIS score during pre-information and post-information evaluation was 17.4 ± 8.06 and 13.18 ± 7.06 (P = 0.002). The mean APAIS score for anaesthesia and surgery during the pre-information evaluation was 2.67 ± 1.46 and 3.13 ± 1.54, respectively, which decreased to 2.04 ± 1.18 and 2.35 ± 1.30, respectively, in post-information evaluation. This difference in APAIS score evaluation during pre-information and post-information evaluation for anaesthesia (P = 0.0105) and surgery (P = 0.003) was statistically significant. Conclusion: Perioperative anxiety experienced by patients can be effectively mitigated by providing comprehensive information pertaining to anaesthesia procedures, surgical procedures and perioperative events during the pre-anaesthetic assessment conducted within an outpatient consultation clinic.

Background and Aims: Femoral nerve block is a widely used analgesia technique for positioning before spinal anaesthesia for proximal femur fracture surgeries. Pericapsular nerve group (PENG) block is a newer technique with motor-sparing characteristics. We compared the analgesic efficacy of these blocks for patient positioning for spinal anaesthesia. Methods: In this study, 60 patients were randomised to either the PENG group (n = 30) or the femoral group (n = 30). After performing the block, the pain was assessed every 10 min using a visual analogue scale (VAS) score for 30 min. The primary objective was the median [interquartile range (IQR)] reduction in pain (dynamic VAS with 15-degree passive limb elevation) at 30 min. Secondary objectives were ease of spinal position score (EOSP), angle obtained during positioning, duration of postoperative analgesia and quadriceps weakness. Results: The demographics were comparable in both groups. After 30 min, the median (IQR) VAS was 6 (5–7) in the PENG group and 5 (5–6) in the femoral group (P = 0.004). Secondary outcomes such as EOSP score and angle obtained by patients were comparable. In the postoperative period, patients had significantly lower pain in the PENG group compared to the femoral group. The duration of analgesia was prolonged with PENG block. Quadriceps weakness was significantly low with PENG block (P < 0.001). Conclusion: PENG block provides better analgesia than a femoral block before spinal anaesthesia for proximal femur fracture surgery. The postoperative duration of analgesia was also longer.

Background and Aims: Post-anaesthesia shivering is distressing and is observed after spinal and general anaesthesia. Nalbuphine, a partial mu-opioid receptor antagonist with kappa-opioid receptor agonist properties, has been successfully used to manage post-anaesthesia shivering. Methods: After registering the review with the International Prospective Register of Systematic Reviews (PROSPERO), we searched PubMed/Medline, Scopus, Ovid, Cochrane Library and clinicaltrials.gov with keywords for randomised controlled trials. The risk of bias-2 (RoB-2) scale was used to assess the quality of evidence. We also used Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines to evaluate the strength of evidence and trial sequential analysis to validate the conclusions. Results: Of the 240 articles, 10 were considered eligible for review (700 patients, 350- nalbuphine, 350- control or placebo). When compared to placebo, the success rate of nalbuphine controlling shivering was significantly better (risk ratio [RR]: 2.37, 95% confidence interval [CI]:1.91, 2.94; P = 0.04, I2 = 94%), but comparable to the control group drugs (opioids, dexmedetomidine, ondansetron, pethidine). Compared to placebo, shivering recurrence was significantly less with nalbuphine than with placebo (RR: 0.47, 95% CI: 0.26, 0.83; P = 0.01, I2 = 61%), but comparable with the control group. The incidence of postoperative nausea/vomiting (PONV) was significantly less with nalbuphine when compared to the control group (RR: 0.67, 95% CI: 0.47, 0.95; P = 0.02, I2 = 37%), but PONV in the nalbuphine group was comparable to placebo (RR: 1.20, 95% CI: 0.68, 2.12; P = 0.54, I2 = 0%). Other outcomes, like the grade of shivering and hypotension, were comparable between the nalbuphine and control groups. Conclusion: Nalbuphine successfully controls post-anaesthesia shivering and reduces the recurrence of shivering.

Background and Aims: The traditional sitting position (TSP) and crossed leg sitting position (CLSP) are positions used for neuraxial anaesthesia. This study compared the interspinous space (ISS) distance using ultrasound assessment of the spine in these positions in parturients in term gestation. Methods: This prospective, observational study involved ultrasonographic spine assessment in 100 parturients in term gestation with them in either TSP or CLSP. The median sagittal view measured the crescent-shaped hyperechoic reflections of the spinous processes and ISSs in L3–L4, L4–L5 and L5–S1 levels. The paramedian sagittal oblique view showed interlaminar spaces (ILSs). Paired t-test and Chi-square test were used for continuous and categorical variables, respectively. Results: The ISS distance (cm) increased in CLSP compared to TSP at levels L3–L4 (1.44 [0.34] [1.34–1.54] versus 1.22 [0.30] [1.12–1.32], P = 0.04), L4–L5 (1.34 [0.39] [1.20–1.48] versus 1.14 [0.30] [0.96–1.32], P = 0.01) and L5–S1 (1.28 [0.33] [1.17–1.39] versus 1.18 [0.23] [1.11–1.26], P = 0.02). The ILS distance (cm) increased in CLSP compared to TSP at interspaces L3–L4 (1.27 [0.34] [1.18–1.36] versus 1.12 [0.20] [1.08–1.16], P = 0.001), L4–L5 (1.26 [0.33] [1.17–1.35] versus 1.19 [0.32] [1.12–1.26], P = 0.01) and L5–S1 (1.28 [0.33] [1.18–1.38] versus 1.16 [0.27] [1.09–1.23], P = 0.001). Conclusion: Crossed leg sitting position for neuraxial anaesthesia in term pregnancy results in more widening of both interspinous and interlaminar spaces compared to traditional sitting position.

Background and Aims: Paracetamol (PCM) has an anti-shivering effect and may also exacerbate intraoperative hypothermia. This study compares the incidence of shivering as the primary outcome and the incidence of perioperative hypothermia (

Background and Aims: Laparoscopic surgeries result in increased intra abdominal pressure and cephalad displacement of the diaphragm. The Trendelenburg position can augment these respiratory changes. The primary objective of this study was to compare diaphragmatic excursions before and after a major laparoscopic pelvic surgery under general anaesthesia in the Trendelenburg position using ultrasonography (USG). Methods: This prospective observational study included 90 patients of either gender, aged 20–60 years, with American Society of Anesthesiologists physical status I/II. M-mode USG was used to assess diaphragm inspiratory amplitude (DIA) before induction of anaesthesia and 10 minutes after tracheal extubation. Factors such as age, gender, body mass index, positive end-expiratory pressure (PEEP), pain, peak airway pressures, duration of pneumoperitoneum, duration and degree of Trendelenburg position and duration of anaesthesia were recorded. Pearson's correlation and multiple linear regression were used to analyse the factors affecting change in DIA (ΔDIA). Results: The mean difference (95% confidence interval (CI)) of measured DIA was 0.70 (0.598–0.809), P < 0.001. ΔDIA had a weak positive significant correlation with age, anaesthesia duration, pneumoperitoneum, and visual analogue scale (VAS) score 10 minutes after extubation. Multiple linear regression analysis showed 14.86% of the variance in DIA. Age (β = 0.008, P = 0.049), duration of anaesthesia (β = 0.002, P = 0.02) and VAS score 10 minutes after extubation (β = 0.128, P = 0.001) were significant independent predictors. Conclusion: DIA decreased significantly after pelvic laparoscopic surgeries performed in the Trendelenburg position. Age, duration of anaesthesia and pain after the procedure were significant independent predictors.

Background and Aims: Magnesium sulphate and zinc sulphate have been reported to attenuate postoperative sore throat (POST). The study aims to compare the effect of preoperative magnesium sulphate and zinc sulphate gargle on the incidence and severity of POST following endotracheal intubation within 24 h. Methods: After ethics committee approval, 132 patients were randomly allocated to three groups (M, Z and D). Fifteen minutes before laryngoscopy and tracheal intubation, patients assigned to groups M and Z received a solution for gargle containing magnesium sulphate 20 mg/kg and zinc sulphate containing 40 mg of elemental zinc dissolved in 20 ml of 5% dextrose solution, respectively. Group D received 20 ml of 5% dextrose solution. Incidence and severity of POST (4-point score: Grade 0- no sore throat, Grade 1- mild sore throat, Grade 2- moderate sore throat, Grade 3- severe sore throat) was assessed for 24 h after extubation. Statistica, Version 8.0 (StatSoft, Inc., Tulsa, Oklahoma, USA) was used for analysing the data. Results: The lowest incidence of POST in group M was 13.6% (95% confidence interval [CI] 3.5–23.7) compared to 0% in group Z, whereas the highest incidence recorded in group M was 25% (95% CI 12.2–37.7) in contrast to 13.6% (95% CI 3.5–23.7) in group Z during the first 24 h after operation. It was observed that the incidence of mild POST (POST score 1) was significantly lower (P < 0.05) in group Z compared to group M in the first 4 h postoperatively. Conclusion: Zinc sulphate gargle before laryngoscopy and tracheal intubation is more effective for reducing the incidence of POST than magnesium sulphate gargle.

Background and Aims: In the present study, we hypothesised that the laryngeal mask airway (LMA) Protector would provide higher oropharyngeal leak pressure (OLP) than LMA ProSeal. Thus, we planned this study to compare the clinical performance of LMA Protector and LMA ProSeal in terms of OLP as a primary objective and insertion characteristics as secondary objectives. Methods: Ninety patients of either gender, aged 18–70 years, were randomised into groups PS (LMA ProSeal) and P (LMA Protector). Following anaesthetic induction, the device was inserted as per group allocation. OLP of both devices was taken as a primary objective. Secondary objectives such as insertion time, ease of insertion, number of attempts required, fibre-optic view grading, amount of air (mL) required to get a cuff pressure (CP) of 60 cm H2O, and CP adjustment required and complications, if any, were also noted. Data were analysed using coGuide statistics software, Version 1 (BDSS Corp. Bangalore, Karnataka, India). Results: The median (interquartile range) OLP was significantly higher with LMA protector than with LMA ProSeal [33.00 (27.0, 36.0) versus [29.50 (26.0, 32.0) (P = 0.009)]. First-attempt success rate was 95.4% (42/44) in group PS and 93% (40/43) in group P. Insertion time, ease of insertion, and fibre-optic view grading were not different between the groups. Gastric tube placement failed in one patient in group PS and in three patients in group P (P = 0.606). The median amount of air (mL) required to get a CP of 60 cm H2O was 26.5 (20, 28) in group PS and 12 (8,13) in group P (95% confidence interval [CI] =10.808–14.575) (P < 0.001). At all time points, CP was significantly higher, and more CP adjustments were needed in group PS than in group P (P < 0.001). Incidence of blood staining and post-operative sore throat at 1 and 24 h were not different between the groups. Conclusion: LMA Protector provided a significantly higher OLP and less requirement of CP adjustments but comparable first-attempt success rate, mean insertion time, fibre-optic view, and gastric tube insertion as compared to LMA ProSeal.

Background and Aims: Etomidate is a popular induction agent, but its use is associated with myoclonus in 50%–80% of non-premedicated patients. This study aims to compare dexmedetomidine and butorphanol for their relative efficacy in preventing etomidate-induced myoclonus. Methods: This randomised study was conducted after obtaining institutional ethical committee clearance and written informed consent from sixty American Society of Anesthesiologists (ASA) I or II consenting patients between 18 and 60 years of age of either sex who had been scheduled for elective surgeries under general anaesthesia. Patients were randomly allocated to dexmedetomidine 0.5 μg/kg (Group D) or butorphanol 0.015 mg/kg (Group B). Both the drugs were given as an infusion over a period of 10 min before induction of anaesthesia. The primary outcome was the incidence of myoclonic movements after etomidate, and the secondary outcomes were the severity of myoclonus, changes in the haemodynamic parameters and incidence of airway complications. Normally distributed variables were compared using Student's t-test, and non-normally distributed variables were compared using Mann–Whitney U test. Qualitative data were analysed using Chi-square/Fisher's exact test. A P-value

Target-controlled infusion pumps and depth of anaesthesia monitors have made total intravenous anaesthesia (TIVA) easy, safe, and precise. The merits of TIVA were highlighted during the coronavirus disease 2019 (COVID-19) pandemic, confirming its potential further in the post-COVID clinical practice as well. Ciprofol and remimazolam are newer drugs that are being tried with a hope to upgrade the practice of TIVA. While research on safe and effective drugs continues, TIVA is being practised with a combination of drugs and adjuncts to overcome the disadvantages of each and to provide complete and balanced anaesthesia with additional benefits in recovery and pain relief postoperatively. Modulation of TIVA for the special population groups is still under process. Advancement in digital technology with mobile apps has increased the scope of TIVA in day-to-day use. The formulation and update of guidelines can establish a safe and efficient practice of TIVA.

Recent trend shows that minimally invasive surgery is in great demand. Robot-assisted procedures have become more popular, as they overcome several drawbacks of traditional laparoscopic techniques. Robotic surgery, however, might necessitate changes in how patients are positioned and how staff and equipment are organised generally, which might go against the traditional approach to anaesthesia care. The novel effects of this technology have the potential to produce paradigm-shifting therapeutic improvements. To provide better anaesthetic treatment and advance patient safety, anaesthesiologists should be aware of these developments by understanding the fundamental components of robotic surgical systems.

Despite an increase in knowledge on the biology of cancer and newer therapeutic modalities, the incidence and mortality of cancer continue to rise. Interventions to enhance perioperative outcomes in cancer is a growing research area that targets early recovery and initiation of cancer-specific treatment. Increasing mortality in non-communicable diseases such as cancer mandates an integrated palliative care for these patients to achieve the best possible quality of life. The aim of this review is to discuss in brief the advancements in onco-anaesthesia and palliative medicine that have helped improve oncological outcomes and the quality of life of patients.

Organ transplantation has undergone remarkable revolution in the last two decades and offers a scope for survival amongst patients with end-stage organ failure. Along with availability of advanced surgical equipment and haemodynamic monitors, minimally invasive surgical techniques have emerged as options for surgery both amongst the donors and recipients. Newer trends in haemodynamic monitoring and expertise in ultrasound guided fascial plane blocks have changed the management in both donors and recipients. The availability of factor concentrates and point-of-care tests for coagulation have allowed optimal and restrictive fluid management of patients. Newer immunosuppressive agents are useful in minimising rejection following transplantation. Concepts on enhanced recovery after surgery have allowed early extubation, feeding and shorter hospital stay. This review gives an overview of the recent progress in anaesthesia for organ transplantation.

Transvaginal oocyte retrieval (TVOR), done for the purpose of assisted reproduction can instigate enormous pain and therefore requires adequate analgesia with the least adverse effects. As the procedure involves retrieving oocytes for in vitro fertilisation, the effect of the anaesthetic drugs on the oocyte quality should also be considered. This review focuses on the various modes of anaesthesia and the anaesthetic drugs which can be administered safely to provide effective analgesia in normal and in special conditions such as women with pre-existing comorbidities. Medline, Embase, PubMed and Cochrane electronic databases were searched according to modified Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines. According to this review, conscious sedation appears to be the most preferred mode of anaesthesia in women undergoing TVOR owing to fewer adverse effects, faster recovery, better patient and specialist comfort and the least effect on oocyte quality and embryo development. Combining it with paracervical block resulted in lesser consumption of the anaesthetic drug, which may have a beneficial effect on the oocyte quality.

Background and Aims: Aerosol protection equipment aim at protecting the anaesthesiologist, from aerosol-borne infections, namely, severe acute respiratory syndrome corona virus-2. Methods: We improvised the first-generation intubation box (IB) by increasing its dimensions, including heat and moisture exchanger with filter, suction catheter, and attaching arm sleeves to make a modified intubation box (MIB). The impact of IB, MIB and transparent sheets (TS) on the patient outcomes during airway management was evaluated. Results: A significant difference in median (interquartile range in minutes) was observed in time to intubate between IB (4 [4–5]); TS (0.5 [0.3–0.5]) and MIB (0.3 [0.3–1.5]): P = 0.004); and airway devices; McCoy (0.5 [0.3–2]), CMac (0.5 [0.3–1.5]): P = 0.004. First-pass success was 100% with the TS, whereas more than three attempts were required with IB 66.7% and 5.2% with MIB. Video laryngoscope was associated with less airway-related adverse events (ARAEs). The need for mask ventilation (and hence possible aerosolisation) was maximum with IB. All the ARAEs resolved uneventfully. No breach of personal protective equipment was observed; none of the health-care professionals involved in patient care developed any symptoms suggestive of COVID-19. Conclusion: Video laryngoscope is favourable for managing airway in COVID-19 times. In view of the ongoing pandemic and added protection that it offers, it is worthwhile to include the MIB in the armamentarium for managing the airway of patients with COVID-19.

Background and Aims: Acute pain management in drug addicts is a critical yet understudied topic. Drug addicts have a decreased pain threshold, impairing anaesthetic pain control. This study aimed to evaluate the postoperative quality of recovery in addicts and non-addicts after receiving erector spinae plane block (ESPB) with general anaesthesia. Methods: Sixty males, aged 18-60 years, with an American Society of Anesthesiologists physical status I/II, scheduled for elective lumbar decompression surgery, were divided into two equal groups. Group A included 30 addicts and group N included 30 non-addicts. Both groups received bilateral ultrasound-guided ESPB with 20 mL bupivacaine (0.25%) before induction of general anaesthesia. The primary outcome was comparison of the 24-hour postoperative quality of recovery (QoR-15) score. The secondary outcomes were time to first analgesic requirement, postoperative pain scores, morphine consumption, and adverse events. Results: The QoR-15 score was higher in group N (median = 128.5, interquartile range = 107-136) than in group A (118 [99-130]), indicating a better recovery in group N. The visual analogue scale pain score was lower in group N than in group A, especially in the first 12 hours postoperatively. Time to first analgesic request was significantly longer in group N than in group A (mean ± standard deviation: 8.67 ± 2.74 and 5.53 ± 1.64 hours, respectively, P =0.001), Morphine consumption was significantly higher in group A than in group N (9.62 ± 3.2 and 7.08 ± 2.57 mg, respectively, P =0.041). Conclusion: Drug addicts experienced decreased analgesic efficacy of ESPB compared to non-addicts, with comparable postoperative QoR-15 score following lumbar decompression surgery.

Background and Aims: Retrograde transillumination technique has been found helpful for performing direct and video laryngoscopy by better identification of glottis. The usefulness of this technique during flexible videoscopy by novices has not been evaluated. So, we aimed to compare the retrograde transillumination and conventional technique of flexible videoscopy by novices. The primary outcomes were the time required to visualise the glottis from the point of insertion of the scope into the nostril (T1) and the time needed to see tracheal rings after glottis visualisation (T2). The secondary outcomes were incidence of desaturation with peripheral oxygen saturation (SpO2)

Administration of anaesthesia in post-COVID mucormycosis patients is a real challenge due to complications such as dyselectrolytemia, renal failure, multi-organ failure, and sepsis. The aim of this study was to evaluate the challenges and perioperative complications of administration of anaesthesia in terms of morbidity and mortality in patients undergoing surgical resection of post-COVID rhino-orbito-cerebral mucormycosis (ROCM). The present study was a case series, which was carried out on 30 post-COVID, biopsy-proven mucormycosis patients enrolled for ROCM resection under general anaesthesia, and all data were collected retrospectively for this series. The post-COVID mucormycosis patients had diabetes mellitus as the most common comorbidity (96.6%), and difficult airway was a common feature (60%) among them. Anaesthetic management of post-COVID mucormycosis patients is a real challenge due to associated comorbidities.

Background and Aims: Supraglottic airway (SGA) devices are a boon to paediatric airway management. The clinical performances of the BlockBuster® laryngeal mask airway (LMA) and Ambu® AuraGain™ in preschool children were compared in this study. Methods: After ethical approval and trial registration, this randomised controlled study was conducted on 50 children, aged 1–4 years, randomised into two groups. Appropriate sized Ambu® AuraGain™ (group A) and LMA BlockBuster® (group B) were placed as per the manufacturer's recommendation under general anaesthesia. Appropriate size of the endotracheal tube was then chosen and inserted through the device. Primary objective of the study was to compare the oropharyngeal seal pressure (OSP), and secondary objectives were the first attempt intubation success rate, overall intubation success rate, SGA insertion time, intubation time, haemodynamic changes and postoperative pharyngolaryngeal complications. The Chi-square test was used to analyse the categorical variables, while the intragroup comparison of mean changes in outcomes was evaluated by the unpaired t-test. The level of significance was set at P < 0.05. Results: Demographic parameters were uniformly distributed in both the groups. The mean OSP in group A was 26.6 ± 0.95 cm H2O and in group B was 29.08 ± 0.75 cm H2O. Both the devices were successfully inserted in all the patients. The success rate of blind endotracheal intubation through the device in first attempt was 4% in group A and 80% in group B. Postoperative pharyngolaryngeal complications were relatively less in group B. Conclusion: LMA BlockBuster® provides higher OSP and provides a higher success rate of blind endotracheal intubation in paediatric patients.

Background and Aims: Supraglottic devices are preformed or flexible, and the insertion characteristics of the two types may be different. This study aims to compare the insertion characteristics of Ambu AuraGain (AAG), preformed) and LMA ProSeal (PLMA), flexible, requires an introducer tool for placement. Methods: Forty American Society of Anesthesiologists (ASA) physical status I/II patients of either sex between 18 and 60 years with no anticipated airway difficulty were randomly allocated to either group AAG or PLMA (n = 20 each). Pregnant females, known case of chronic respiratory disorders and gastroesophageal reflux were excluded. After induction of anaesthesia and muscle relaxation, appropriately sized AAG or PLMA was inserted. Time for successful insertion (primary outcome), ease of device insertion and gastric drain insertion, first attempt success rate (secondary outcomes) were recorded. Statistical analysis was done using SPSS version 20.0. Quantitative parameters were compared using Student's t-test, and qualitative parameters were compared using Chi-square test. A P value of

Background and Aims: Recovery from surgery and anaesthesia is usually observed through conventional indicators. The Quality of Recovery (QoR-15) score was specially designed to measure psychometric and functional recovery from the patient's perspective. This study aimed to evaluate QoR-15 following the administration of intravenous (IV) lignocaine or IV fentanyl in patients undergoing septoplasty surgery. Methods: This randomised, controlled trial was conducted on 64 patients of American Society of Anesthesiologists (ASA) physical status I and II, of either sex, of ages between 18 and 60 years, and who were scheduled for septoplasty. The primary end point was to compare the quality of recovery following the administration of IV lignocaine(group L) and IV fentanyl (group F) using the QoR-15 score in patients undergoing septoplasty. Secondary end points were to compare postoperative analgesia, recovery characteristics, and adverse effects in both groups. Statistical analysis was done using the Shapiro–Wilk test, paired t test/ Wilcoxon signed-rank test, and unpaired t test/Mann–Whitney U test. A P-value 9 and gastrointestinal recovery was shorter in group L compared to group F. Conclusion: Both IV lignocaine and IV fentanyl improved postoperative QoR-15 score; however, lignocaine had a higher postoperative QoR-15 score than fentanyl, in addition to showing early discharge readiness, better analgesia, and better recovery profile in patients following septoplasty surgery.

Introduction: Despite the benefits of analgesic suppositories, there remains controversy around their administration. The perceptions of the parents and caregivers regarding this are unknown in our population. We investigated the perceptions of parents/caregivers towards the use of analgesic suppositories in elective paediatric surgery. We also explored whether parents/caregivers perceived a need for additional consent for the administration of suppositories. Materials and Methods: This was a prospective cross-sectional study conducted at Charlotte Maxeke Johannesburg Academic Hospital, South Africa. The primary outcome was to describe perceptions of parents/caregivers towards analgesic suppositories. Questionnaire-guided interviews were conducted with parents/caregivers of children presenting for elective paediatric surgery. Results: Three hundred and one parents/caregivers were enrolled in the study. Two hundred and sixty-two (87%) were female and 174 (13%) were male. Two hundred and seventy-six (92%) were parents and 24 (9%) were caregivers. There was a high level of acceptability of suppository use in 243 (81%) parents/caregivers. Majority (235, 78%) felt that they should be asked for permission before their child was given a suppository, and more than half (134, 57%) expressed that it should be in a written consent format. The parents/caregivers did not believe that suppositories would cause pain (unadjusted odds ratio [uOR]: 2.49; 95% confidence interval [CI]: 1.29–4.79; P = 0.006) but were unsure whether they would relieve post-operative pain (uOR: 0.25; 95% CI: 0.11–0.57; P = 0.001). Those who had previously used a suppository themselves were significantly more likely to accept the use of suppositories in children (uOR: 4.34; 95% CI: 1.56–12.07; P = 0.005). Conclusion: There was a high level of acceptability of the use of analgesic suppositories. Our population showed a unique preference for written consent over verbal consent. There was a strong positive association between previous use of suppositories by parents/caregivers and acceptance for use in children.

Brain tumors and intracranial bleeding are rare cases in pregnancy. Anesthesia management for a C-section with comorbidity remains challenging. We presented a 33-year-old woman (34–36 weeks pregnant) with the complaint of weakness in her right extremities, blurred vision, and ptosis of her left eye from a month before hospitalization. The brain computed tomography (CT) revealed a mass at the left parasellar region with a bleeding component and cerebral edema accompanied by subfalcine herniation. We conducted general anesthesia for cesarean delivery in a patient with a brain-protective technique. Brain CT revealed a decrease in the mass size and neither intracranial bleeding nor cerebral edema. In conclusion, general anesthesia management provided a good outcome in a parturient with a brain tumor and intracranial bleeding that underwent C-section. The mechanism of clinical improvement and tumor regression is unclear and requires further research, but it is believed that it is related to pregnancy hormones.

Background and Aims: The speed of inhalational induction depends on a variety of factors, of which priming the breathing circuit with volatile anaesthetics plays a vital role. This study compared ventilator-assisted priming (VAP) and a passive priming technique using different fresh gas flows (FGFs) in neonatal, paediatric, and adult anaesthetic circuits. Methods: In both techniques, FGF with 100% oxygen and 8% sevoflurane vaporiser concentration were set at 2 Lmin-1, 4 Lmin-1, and 8 Lmin-1, representing three groups FGF-2, FGF-4, and FGF-8, respectively. The time taken to achieve 6% sevoflurane concentration at the patient end of the circuit was measured. In addition to this, we explored various combinations of tidal volumes and respiratory rates in the VAP technique and recorded the priming time with each combination. The amount of sevoflurane consumed for priming in both techniques was also calculated. Results: VAP was three times faster than passive priming in all the FGF groups in the three circuits. In the VAP technique, the shortest priming times were similar for FGF-4 and FGF-8 (P > 0.05) but were significantly higher for FGF-2 (P = 0.001) in the three circuits. Sevoflurane consumption did not differ in FGF-2 and FGF-4 groups, whereas it doubled in the FGF-8 group using the VAP technique in all three circuits. Conclusion: The VAP technique provides a quick and effective method for priming to achieve a high anaesthetic concentration within the breathing circuit for inhalational induction.

Background and Aims: Airtraq has been found to be useful in improving the view of the glottis. However, directing the tube tip into the glottis can be challenging during nasotracheal intubation. This problem gets resolved if the bougie is placed first. The present study was conducted for the evaluation of nasotracheal intubation using a nasal Airtraq laryngoscope with and without a bougie. Methods: Fifty patients of either gender, aged between 18 and 60 years, who belonged to the American Society of Anesthesiologists physical status (PS) I or II, requiring nasotracheal intubation were included. In group I (number (n) = 25), nasotracheal intubation was performed with a bougie, and in group II (n = 25), it was performed without a bougie. The primary objective was a comparison of the time taken to achieve successful nasotracheal intubation. Secondary objectives were ease of intubation and additional manoeuvres required for intubation. Results: The mean (± standard deviation) for time for intubation in group I was 59.24 ± 9.98 s and that in group II was 41.00 ± 4.23 s (P = 0.001). Two patients (8%) in group I and ten patients (40%) in group II required additional manoeuvres for intubation (P = 0.008). Twenty-three patients (92%) in group I and 15 patients (60%) in group II had easy intubation (P = 0.030). In group I, no patient had trauma, whereas, in group II, four patients (16%) had trauma (P = 0.030) during intubation. Conclusion: The time taken for nasotracheal intubation using an Airtraq laryngoscope was more with the use of a bougie as compared to the non-bougie technique. However, bougie-guided intubation was easier with less requirement of additional manoeuvres. In addition, trauma was also significantly less with the bougie technique.

Background and Aims: Despite the importance of statistics being well established for medical research, it remains a neglected area of understanding and learning. The present survey aimed to examine the use of various statistical methods in a two-year sample (2019–2020) of representative Indian anaesthesia journals and compare it with an international top-ranked journal. Methods: The literature survey included analysis of 748 original articles from 'Indian Journal of Anaesthesia' (179), 'Journal of Anaesthesiology Clinical Pharmacology' (125) and 'Anesthesia & Analgesia' (444) published over the period. Original research articles were identified from the table of contents of each issue. Articles were assessed for statistical methods, categorised as being descriptive, elementary, multivariable, advanced multivariate or diagnostic/classification. Results: Compared to Anesthesia & Analgesia, the Indian journals (considered together) had a significantly greater use of mean (standard deviation) (91.2% versus 70%) and percentages (79.5% versus 67.6%) (P = 0.000 each); and lesser for Wilcoxon (5.4% versus 14.6%) and Pearson/Spearman (5.1% versus 13.5%) correlation tests (P = 0.000 each), multivariable tests including various regression methods (P < 0.001), classification/diagnostic tests [Receiver operating characteristic (ROC) curve analysis, P = 0.022; sensitivity/specificity, P = 0.000; precision, P = 0.006; and relative risk/risk ratio, P = 0.010] and a virtual absence of complex multivariate tests. Conclusion: The findings show limited use of advanced complex statistical methods in Indian anaesthesia journals, usually being restricted to descriptive or elementary. There was a strong bias towards using randomised controlled designs. The findings suggest an urgent and focussed need on training in research methodology, including statistical methods, during postgraduation and continued medical training.

Background and Aims: A definitive cutoff of inferior venacava (IVC) diameter in expiration (dIVCmax) and inferior vena cava collapsibility index (IVCCI) for predicting general anaesthesia associated hypotension (GAAH) is not yet determined. Primary objective of this study was to determine the correlation of dIVCmax and IVCCI, with GAAH. Other objectives were to determine the correlation of these IVC parameters with preoperative fasting duration, temperature and humidity. The correlation of dIVCmax with patient demography was also studied. Methods: A total of 110 adult patients undergoing elective surgery under general anaesthesia were included in the study. IVC ultrasonography was done in the preoperative room, 20 to 30 minutes before shifting the patient to the operating room. Hypotension at (hypo@) 2 minutes and 10 minutes after administering vecuronium was recorded. Results: Hundred and seven patients were analysed. A significant positive correlation was present between patient height and dIVCmax (ρ = 0.25, P = 0.009). Area under receiver operating characteristics curve was 0.595 (95% confidence interval (CI) 0.485–0.705) and 0.568 (95% CI 0.458–0.679) for dIVCmax and IVCCI for predicting hypo@2 min, with a diagnostic accuracy of 54% and 53%, respectively. dIVCmax ≤1.14 cm had a sensitivity of 31% and specificity of 87% in predicting GAAH. IVCCI ≥63.3% could predict GAAH with 31% sensitivity and 84% specificity. No significant correlation was found between preoperative IVC parameters and preoperative fasting or environmental factors. Conclusion: Both dIVCmax and IVCCI have poor diagnostic accuracy, with good specificity and low sensitivity in predicting GAAH. A steady formula for calculating baseline IVC diameter adjusted for patient demography is needed.

Background: Male circumcision is the most common surgical procedure worldwide and is often carried out for religious, cultural, medical and public health reasons. It is commonly performed during the neonatal period. Many studies have now shown that pain is a common intra- and post-operative complication. To ensure proper analgesia during the procedure, many surgeons opt for the use of pacifiers as an adjunct to anaesthesia during neonatal circumcision. The aim of this study is to compare nutritive pacifiers (NPs) versus non-NPs (NNPs) as adjuncts to local anaesthesia in male neonatal circumcision using the Plastibell technique. Methods: A prospective randomised controlled study was carried out between October 2019 and March 2020. A total of 100 neonates were circumcised using the Plastibell technique and randomised into NP (Group A, n = 33), NNP (Group B, n = 33) and controls (Group C, n = 34), respectively. The differences in pain scores using the Neonatal Infant Pain Scale, total crying time and heart rate during circumcision were recorded and assessed. Results: The age of participants ranged from 5 to 28 days and the weight ranged from 2.5 to 5.0 kg. The overall mean age, birth weight and current weight of the participants were 15.5 ± 6.1 days, 3.4 ± 0.4 kg and 3.5 ± 0.6 kg, respectively. The control group had the highest average pain score of 5.5 (4.5–5.8) compared to the intervention groups with median pain score (NP: 3.3 [1.3–4.3] and (NNP: 4.3 [3.1–5.1], respectively). NPs had significantly lower pain scores (P = 0.023) and reduced total crying time (P = 0.019) at all stages of the circumcision compared to those given NNPs and controls. Conclusion: This study showed that NPs were superior to NNPs in providing additional pain control during male neonatal circumcision.

Background: Infant mortality due to congenital malformations has an incident rate of 8 cases per 1000 live births. Due to Africa's inadequate health-care systems, congenital cardiac disease (CCD) remains a paediatric health-care issue. CCD patients undergo an open-heart operation (OHO) at the Komfo Anokye Teaching Hospital (KATH) in Kumasi. Aim: This study aimed to compare trends of cardiac anaesthesia protocols before and after 2014 and to assess the efficiency and quality of surgical care provided to children with CCD following the implementation of new cardiac anaesthesia protocols in 2014. Materials and Methods: Groups A and B were represented by the years before and after 2014. This was a retrospective study involving 118 patients who underwent OHO under general anaesthesia from 2007 to 2016 after obtaining Institutional ethical approval. Results: In Groups A and B, the mean length of hospitalization in days and cardiac care unit stay in days were (6.87 ± 3.51 and 4.20 ± 3.66) (P = 0.046) and (3.14 ± 2.37 and 1.96 ± 2.85) (P = 0.382), respectively. In Group B, ultrafast track extubations increased from 7.25% to 39.71% (P = 0.021), while patients mean mechanically ventilation time decreased by 82.34 ± 11.70–23.48 ± 7.94 h (P = 0.018). In the first 48 h, the chest tube's postoperative drainage reduced by 133 ± 28.46–95 ± 20.38 ml (P = 0.018) and haemorrhage leading to re-exploration decreased 11.77%–1.50% (P = 0.019). After 2014, postoperative haemorrhage, the chest tube's drainage, and re-exploration were statistically significantly reduced by tranexamic acid. Conclusions: This ten-year program primarily focused on selecting simple cases and simplifying anaesthesia protocols after 2014. Given the success of our OHO program at KATH Kumasi, there is a need for a paradigm shift to sustain OHO programs in other parts of Africa.

Epidural volume extension involves injection of normal saline into the epidural space soon after an intrathecal injection, with the aim of augmenting the sensory block height. It has significant dose-sparing effect, providing adequate level of anaesthesia and analgesia with minimal haemodynamic disturbances. We present this case series that shows the successful use of this technique in high risk cardiac patients coming for elective lower segment caesarean section.

Introduction: Kyphoscoliosis with pregnancy is a rare but serious disorder which often requires caesarean delivery. Both general and regional anaesthesia have been used in these cases but data regarding outcomes with spinal anaesthesia (SA) are limited. Methods: We conducted a retrospective study to identify patients with kyphoscoliosis undergoing caesarean delivery at a tertiary care hospital in India. Those parturients who received SA were compared with those receiving general anaesthesia (GA group) with respect to cardiorespiratory parameters, maternal outcomes and neonatal outcomes. Results: The GA group had significantly worse cardiorespiratory parameters including pulmonary function tests, right atrial pressures and cardiac ejection fraction as compared to SA group. All the GA group patients required mechanical ventilation while no patients in the SA group needed mechanical ventilation. Intraoperative hypotension was more common in the SA group. Neonatal outcomes were worse in the GA group with lower Apgar scores at 1 and 5 min and more nursery admissions than the SA group. No maternal or neonatal deaths occurred in either group. Conclusion: Kyphoscoliotic parturients scheduled for CD can be successfully managed with SA with good maternal and neonatal outcomes. GA may be reserved for severe kyphoscoliotic parturients with cardiorespiratory complications. The safety of SA in severe kyphoscoliosis requires further studies.

The association of Parkinson's disease and pregnancy is very rare. We present a case of juvenile Parkinson's disease patient who underwent emergency caesarean section. The anaesthetic considerations and management are discussed.

Emergency Medicine (EM) is a fast upcoming medical speciality wherein patients presenting with emergent life-saving medical and surgical problems are managed. Emergency physicians are first-line providers of emergency care. They diagnose important clinical conditions even before completing patient assessment, order investigations, interventions, resuscitation and treatment for life-threatening acute conditions. There are several interesting sub-specialisations of EM like trauma care, disaster medicine, toxicology, ultrasonography, critical care medicine, hyperbaric medicine, etc. In some countries, the speciality of EM is a popular choice among medical students; whereas in some other countries, the speciality is now evolving. In India, the speciality is growing fast; Nonetheless, the National Medical Commission has made the existence of the department of EM compulsory in all medical colleges in India from the session of 2022-23. Anaesthesiologists suit the speciality of EM because they have quick decision making skills and swift reflexes as well as diverse knowledge and skills in the fields of critical care, resuscitation and pain management. This article written by anaesthesiologists working in the field of EM, attempts to guide the postgraduate students wanting to take up a career in EM.

Paediatric anaesthesia is an upcoming speciality which is gaining wide interest and can be a career choice for the new trainees. The need to develop paediatric anaesthesia as a speciality was realised with the progress in the field of paediatric surgery. The profile of the 'patient' encountered by a paediatric anaesthesiologist spans from an extremely premature neonate on the fringes of survival, to a full-grown adolescent equivalent to an adult. Perioperative morbidity and mortality are 2-3 times higher in infants and neonates compared to adults particularly in middle and low-income countries. The anatomical, physiological, pharmacological variations and presence of congenital cardiac, pulmonary and metabolic diseases in young children make perioperative management challenging. Special expertise and training are required for anaesthetic management of these preverbal children. In India, 3-years DM and 1-year Fellowship courses in paediatric anaesthesia are now available for specialisation. An ideal paediatric anaesthesia training centre should have substantial paediatric and neonatal patient load with exclusive intensive care facility. Paediatric anaesthesiologists, having knowledge of several facets of paediatrics and anaesthesia are capable of coordinating with health care professionals performing procedures outside the operating room. Paediatric anaesthesia, as a career thus offers a great opportunity to enhance quality and safety of anaesthesia in this high-risk surgical population. Persistent coordinated team efforts improve patient outcomes, reduce stress at work and increase job satisfaction.