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Background: Rational laboratory use is defined as effective and correct laboratory use by providing the most appropriate test selection with the right clinical approach in line with the evidence-based data and considering the cost and patient safety. The present study was thus conducted for the prevalence and features associated with rational use of investigations in a tertiary hospital. Aims and Objectives: The objectives of the study were to estimate prevalence of rational use of investigations and its associated confounding factors; to explain the educational approach underlying the study; and to explain how to teach rational approach of investigations so that we reduce the use of unnecessary and inappropriate tests which are not likely to have any ill effects on the patient. Materials and Methods: A cross-sectional study including 100 patients was selected by random sampling from medicine and orthopedic wards and OPD. Results: In our study,we observed 29 different types of clinical and laboratory investigations out of 2155 investigations ordered by physicians before any intervention. These investigations done in 100 patients, among those 39.16% were contributed to the management of patients and 60.83% were not considered to have contributed toward management of patients. Conclusion: Several external and internal factors can promote irrational use of investigation at different stages. Hence, understanding these factors and implementing appropriate measures are key steps to change behavior of prescriber and nursing staff. We must have logic-based flow chart or algorithm in all investigations for diagnosis as a part of good laboratory or good clinical practices.

Venous air embolism (VAE), though, clinically benign in majority of cases, the significant ones can lead to life-threatening cardiopulmonary and neurological consequences. Though studies mention the success rate of only 6 to 16% in aspirating air from the central venous catheter (CVC) during VAE, the technique is very specific for diagnosing VAE and has high therapeutic significance. We report a case in which delayed aspiration of air emboli from the CVC in suspected massive VAE during decompressive craniectomy resulted in rapid resolution of hemodynamic instability. If not inserted previously, CVC may be considered in a hemodynamically unstable patient with suspected VAE.

Study Design This was a double-blind randomized study. Purpose The primary purpose was to compare the effects of propofol and ketofol on amplitudes and latencies of transcranial motor evoked potentials (TcMEPs) during thoracolumbar spine surgery. In addition, intraoperative hemodynamics and muscle power were compared. Overview of Literature Propofol is commonly used during intraoperative TcMEP monitoring. However, propofol inhibits TcMEP amplitudes and causes hypotension in a dose-dependent fashion. Methods Amplitude and latency of TcMEPs were recorded bilaterally from the abductor pollicis brevis (APB) and abductor hallucis (AH) muscles in 38 adult American Society of Anesthesiologists I and II patients undergoing thoracolumbar spine surgery. Baseline recordings of TcMEPs in both groups were recorded under propofol infusion. Group X patients then received propofol and fentanyl (1 mcg/kg/hr), and group Y patients received ketofol and fentanyl (1 mcg/kg/hr). Bispectral index was maintained at 40–60 in both groups. Amplitude and latency were recorded at 30 minutes intervals for 2 hours. Results Propofol caused no significant changes in amplitude and latency in any muscle. In contrast, amplitude increased significantly at all time points in the bilateral APB muscles and 60, 90, and 120 minutes in the left AH muscle without changes in latency in response to ketofol. When the two groups were compared, ketofol induced significantly higher amplitudes at 60, 90, and 120 minutes in the (left) APB, at all time points in the (right) APB, and at 120 minutes in both AH muscles, compared with propofol. Blood pressures were lower and fluid and vasopressor requirements were higher in group X. Muscle power was similar between the two groups. Conclusions Ketofol facilitates TcMEP amplitudes without affecting latency. Use of ketofol resulted in a better and more stable hemodynamic profile than did use of propofol.

Trigeminal neuralgia (TN) is a chronic facial pain condition that affects one or more divisions of the trigeminal nerve (5th cranial nerve). It can be idiopathic, primary, or secondary. The cornerstone of the therapy has been antiepileptic medications, peripheral nerve blocks with various neurolytic agents, and surgical procedures. With the advent of newer technologies, minimally invasive neurolytic techniques like low-level laser therapy and ozone injection have revolutionized the management of TN. Novel drugs like vixotrigine and eslicarbazepine have been promising in reducing the frequency and severity of attacks. Inhaled carbon dioxide too has shown promising results in initial trials. Neuromodulation has given robust data in controlling neuralgic pain especially refractory to medical management. Pulsed radiofrequency has been used with increasing success and the side effects like dysesthesia and paresthesia are less. Cryotherapy, neural prolotherapy, and fiber knife techniques have helped us believe that TN can be controlled and cured. The need of the hour is to develop and explore newer modalities for trigeminal neuralgia treatment with minimum side effects. In this narrative review, we have tried to shed light into the newer modalities of treatment of TN along with new clinical classification for better disease recognition and management.

Anaesthesiology is an ever-changing science and amongst its sub-specialities, the field of neuroanaesthesia is making rapid strides. The fragility of the brain and spinal cord and the multitude of complexities involved in neurosurgery and interventional neuroradiological procedures demand dedicated training in neuroanaesthesia. With rapid advancement in other neuroscience specialties, neuroanaesthesia too has made outstanding progress, owing to establishment of structured training, publication of high-quality scientific research, and invention of novel medications and monitoring modalities. The opportunities for training in India and abroad and resources to broaden knowledge in neuroanaesthesia have increased over the last two decades. A career in neuroanaesthesia offers a great future for budding anaesthesiologists.

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions and is usually treated by simple burr-hole drainage. Prognosis is usually good unless complications occur. Use of infant feeding tube (IFT) for irrigation of hematoma in case of CSDH with septum is a common practice. However, it poses a significant risk. We present two cases of intraparenchymal hemorrhage as a complication of CSDH evacuation in which IFT was used for irrigation.

Multimodal neuromonitoring (NM) is the concept of integrating various tools and data to understand brain physiology and guide therapeutic interventions to prevent secondary brain injury. There exists a range of invasive/noninvasive and global/regional monitors of cerebral hemodynamics, oxygenation, metabolism, and electrophysiology that can be used to guide treatment decisions after neurological insult. No single monitoring modality is ideal for all patients. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism allows individualized patient care. The ability to analyze these advanced data for real-time clinical care, however, remains intuitive and primitive. Advanced informatics is promising and may provide us a supportive tool to interpret physiological events and guide pathophysiological-based therapeutic decisions. Available literature is not robust regarding multimodality NM and favorable patient outcome. This narrative review is undertaken to know the status and recent advancement of multimodal NM in neurocritical care.

Patients with severe traumatic brain injury often presents with extracranial injuries, which may contribute to fatal outcome. Anesthetic management of such polytrauma patients is extremely challenging that includes prioritizing the organ system to be dealt first, reducing on-going injury, and preventing secondary injuries. Neuroprotective and neurorescue measures should be instituted simultaneously during extracranial surgeries. Selection of anesthetic drugs that minimally interferes with cerebral dynamics, maintenance of hemodynamics and cerebral perfusion pressure, optimal utilization of multimodal monitoring techniques, and aggressive rehabilitation approach are the key factors for improving overall patient outcome.

Background Intracranial pressure (ICP) monitoring is an essential component in management of traumatic brain-injured (TBI) patients. While invasive techniques are associated with many complications, noninvasive nature of ultrasonographic measurement of optic nerve sheath diameter (ONSD) is now becoming popular. Carbon dioxide (CO2) alters the ICP by changing the size of cerebral vasculature. We aimed to assess the effect of (hypercarbia and hypocarbia) different levels of end-tidal carbon dioxide (EtCO2) on ONSD. Methods Thirty adult patients aged between 18 and 65 years, undergoing brachial plexus injury surgery under general anesthesia, were enrolled. Following standard anesthetic protocol, ONSD was measured at different time points of EtCO2. ONSD was measured at EtCO2 of 40 and then 30 mm Hg to assess change in ONSD due to hypocarbia (Thypocarbia). Similarly, ONSD was measured at EtCO2 of 50 mm Hg to assess change in ONSD due to hypercarbia (Thypercarbia). The mean of three ONSD values at each time point was taken as the final value. The generalized estimating equation (GEE) was used to analyze correlation between different levels of EtCO2 and ONSD. Results The calculated 95% confidence interval (CI) for the difference of two measures (Thypocarbia, EtCO2 40 and 30 mm Hg) on ONSD was −0.056 to −0.036, and the calculated CI for the difference of other two measures (Thypercarbia, EtCO2 40 and 50 mm Hg) on ONSD was 0.044 to 0.077, and thus were observed to be significant. Conclusions ONSD changes significantly in response to different EtCO2 levels in healthy non-neurosurgical patients under general anesthesia.

Pallidotomy is a surgical procedure done widely for Parkinson's disease and various dystonias refractory to medical treatment. The technique involves radiofrequency (RF) thermal coagulation of globus pallidus internus, either unilaterally or bilaterally. The technique has been shown to produce good success. However, the involvement of nearby vital structures can result in new post-operative complications. We encountered a case of delayed emergence from anaesthesia associated with bilateral mydriasis and visual field defects in a patient after bilateral RF thermal lesioning.

Severe brain swelling during routine neurosurgery can herald serious consequences. Failure to control brain swelling despite adequate measures warns of a surgical cause and should be dealt efficiently. We report a case of an adult female who developed intraoperative acute subdural haematoma (SDH) and consequent intractable brain swelling during surgery of supratentorial arteriovenous malformation (AVM). Such a manifestation of contralateral acute SDH during supratentorial AVM surgery has not been reported earlier.

Gilbert's syndrome, a hereditary disorder characterized by mild unconjugated hyperbilirubinemia, poses multiple anesthetic challenges during major surgery. Despite an indolent course, it can manifest with severe jaundice in the postoperative period. Anesthetic strategies should be based on thorough preoperative planning, minimizing fasting period, maintaining hepatic blood flow, avoiding hepatotoxic drugs, and reducing surgical duration, blood loss, and blood transfusion. We report the successful management of a case of Gilbert's syndrome for lumbar spine surgery along with a review of literature.

Background: Spinal instrumentation and fusion surgery presents the anaesthesiologist with multiple issues like intraoperative blood loss, hemodynamic changes, prolonged surgery etc, but the most probing aspect is analgesia. While both ketamine and dexmedetomidine as adjuvants have shown to decrease intraoperative anaesthetics and post operative analgesic consumption but there are no comparative studies. The primary aim of this study was comparison of post-operative analgesic requirements for 1st 24 hours after surgery when either of the drugs was used as adjuvants. Methods: Adult patients aged 18-60 years, of either sex, and ASA status I or II scheduled for elective lumbar spine instrumentation (of 2 or more spinal levels) surgery were enrolled for the study. Patients were randomised into one of the 3 treatment regimens ketamine/group K (0.5mg/kg bolus followed by 250 mcg/kg/h infusion), dexmedetomidine/ group D (0.5mcg/kg bolus followed by 0.5 mcg/kg/h infusion) or the placebo/ group S (saline/placebo). The study drugs were started after turning the patient prone. Data were recorded for intraoperative hemodynamics, anesthetic consumption (inhalational agent and opioids), emergence through RAS scale (Riker sedation agitation scale), PCA (patient controlled analgesia)-fentanyl use and VAS (visual analog scale) score in the 1st 24 hours after surgery. Appropriate statistical analysis was done. Results: A total of 42 patients (14 in each group) were enrolled. The total PCA fentanyl consumed in first 24 hours of surgery was maximum with the group-S (1366.6±382.6 mcg) in compared with group- D (1035.4±391.8 mcg) and group- K (1164.9±503.6 mcg) (P=0.13). The post extubation RAS score was lower in group-K (3.7±0.6) when compared with group-D (4±0.4) and group-S (4.5±0.9) (P=.009). Total intraoperative sevoflurane and fentanyl consumption showed no difference (P=0.19 and P=0.28). VAS score at rest was higher at baseline with group-S (P=0.009). The ICU stay was comparable (group-D: 1.4±0.5 d, group-K: 1.5±0.5 d, group-S: 1.9±0.5 d) among the groups. Hospital stay was also comparable (P=0.09). Conclusion: In patients undergoing lumbar instrumentation surgery, opioid consumption, VAS scores, PCA pump bad demands, inhalational agent consumption, hospital stay were comparable when either ketamine or dexmedetomidine was used as intraoperative anesthetic adjuvants.

Background: Spinal instrumentation and fusion surgery presents the anaesthesiologist with multiple issues like intraoperative blood loss, hemodynamic changes, prolonged surgery etc, but the most probing aspect is analgesia. While both ketamine and dexmedetomidine as adjuvants have shown to decrease intraoperative anaesthetics and post operative analgesic consumption but there are no comparative studies. The primary aim of this study was comparison of post-operative analgesic requirements for 1st 24 hours after surgery when either of the drugs was used as adjuvants. Methods: Adult patients aged 18-60 years, of either sex, and ASA status I or II scheduled for elective lumbar spine instrumentation (of 2 or more spinal levels) surgery were enrolled for the study. Patients were randomised into one of the 3 treatment regimens ketamine/group K (0.5mg/kg bolus followed by 250 mcg/kg/h infusion), dexmedetomidine/group D (0.5mcg/kg bolus followed by 0.5 mcg/kg/h infusion) or the placebo/ group S (saline/placebo). The study drugs were started after turning the patient prone. Data were recorded for intraoperative hemodynamics, anesthetic consumption (inhalational agent and opioids), emergence through RAS scale (Riker sedation agitation scale), PCA (patient controlled analgesia)-fentanyl use and VAS (visual analog scale) score in the 1st 24 hours after surgery. Appropriate statistical analysis was done. Results: A total of 42 patients (14 in each group) were enrolled. The total PCA fentanyl consumed in first 24 hours of surgery was maximum with the group-S (1366.6±382.6 mcg) in compared with group- D (1035.4±391.8 mcg) and group- K (1164.9±503.6 mcg) (P=0.13). The post extubation RAS score was lower in group-K (3.7±0.6) when compared with group-D (4±0.4) and group-S (4.5±0.9) (P=.009). Total intraoperative sevoflurane and fentanyl consumption showed no difference (P=0.19 and P=0.28). VAS score at rest was higher at baseline with group-S (P=0.009). The ICU stay was comparable (group-D: 1.4±0.5 d, group-K: 1.5±0.5 d, group-S: 1.9±0.5 d) among the groups. Hospital stay was also comparable (P=0.09). Conclusion: In patients undergoing lumbar instrumentation surgery, opioid consumption, VAS scores, PCA pump bad demands, inhalational agent consumption, hospital stay were comparable when either ketamine or dexmedetomidine was used as intraoperative anesthetic adjuvants.

Central pontine myelinolysis (CPM) is a demyelinating disease of the pons which is also associated with the demyelination of extrapontine areas of the central nervous system. Although the aetiology and pathogenesis are unclear, CPM is usually associated with hyponatremia or its rapid correction. Malnutrition and chronic alcoholism are also the common underlying conditions. Herein, we report a rare presentation of ODS, secondary to hyperosmolar hyperglycaemic state. We observed a 37-year-old female with diabetes type 1 and hypertension who presented with ataxia, dysarthria and pseudobulbar effect which evolved over a duration of few weeks at home with no evidence of hyponatremia or its rapid correction and no history of alcohol abuse or malnutrition.

Hyperglycaemia following surgical and anaesthetic stress is a well-established entity which might have undesirable clinical consequences in known diabetics. We encountered a rare event where an undiagnosed diabetic patient developed ketoacidosis in the immediate post-operative period which was her initial presenting symptom of deranged glucoregulation. Presumably, the stress induced by surgery and anaesthesia lead to the genesis of this event. We discuss the management of this case. In addition, we highlight the importance of glycosylated haemoglobin as a subject of future research in identifying such "at risk" patients and for stratifying the risk of hyperglycaemic complications in perioperative settings.