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Abstract Background There is a high incidence of pulmonary atelectasis during paediatric laparoscopic surgeries. The authors hypothesised that utilising a recruitment manoeuvre or using continuous positive airway pressure may prevent atelectasis compared to conventional ventilation. Objective The primary objective was to compare the degree of lung atelectasis diagnosed by lung ultrasound (LUS) using three different ventilation techniques in children undergoing laparoscopic surgeries. Design Randomised, prospective three-arm trial. Setting Single institute, tertiary care, teaching hospital. Patients Children of ASA PS 1 and 2 up to the age of 10 years undergoing laparoscopic surgery with pneumoperitoneum lasting for more than 30 min. Intervention Random allocation to one of the three study groups: CG group: Inspiratory pressure adjusted to achieve a TV of 5–8 ml/kg, PEEP of 5 cm H2O, respiratory rate adjusted to maintain end-tidal carbon dioxide (ETCO2) between 30-40 mm Hg with manual ventilation and no PEEP at induction. RM group: A recruitment manoeuvre of providing a constant pressure of 30 cm H2O for ten seconds following intubation was applied. A PEEP of 10 cm H2O was maintained intraoperatively. CPAP group: Intraoperative maintenance with PEEP 10 cm H2O with CPAP of 10 cm H2O at induction using mechanical ventilation was done. Outcome measures Lung atelectasis score at closure assessed by LUS. Results Post induction, LUS was comparable in all three groups. At the time of closure, the LUS for the RM group (8.6 ± 4.9) and the CPAP group (8.8 ± 6.8) were significantly lower (p

Background and aims: Dexamethasone as adjunct to local anesthetic solution improves the quality of brachial plexus block (BPB). However, evidence for its efficacy at low doses (< 4 mg) is lacking. This study was designed to evaluate the duration of analgesia attained with low dose dexamethasone as adjuvant to local anesthetic for creation of arteriovenous fistula (AVF) under BPB. Methods: Sixty-six patients scheduled for AVF creation were randomly allocated to receive either saline (control) or 2 mg dexamethasone, together with 0.5% ropivacaine and 0.2% lignocaine. The primary outcome was duration of analgesia, defined as time from performing the block to the first analgesic request. The secondary outcomes were time from injection to complete sensory block, time from injection to complete motor block, duration of motor block, postoperative analgesic consumption, and fistula patency at three months. Results: All the blocks were effective. In the group that received dexamethasone, the time to first analgesic request was significantly delayed (432 ± 43.8 minutes vs. 386.4 ± 40.2 minutes; p < 0.01). The onset of sensory and motor blockade occurred faster in dexamethasone group and overall analgesic consumption was also reduced. However, dexamethasone addition did not prolong the duration of motor block. There was no statistically significant difference in the patency of fistulas between the two groups at three months. (p = 0.34). Conclusion: Addition of low-dose perineural dexamethasone to local anesthetic solution significantly prolonged the duration of analgesia. Further trials are warranted to compare the adverse effects between dexamethasone doses of 4 mg and lower.

Abstract Background Acquired tracheoesophageal fistula (TEF) is a rare presentation in pediatric lymphoma patients. Most heal spontaneously following chemotherapy/radiotherapy without requiring surgery. Case presentation A 10-year-old child is presented with persistent tracheoesophageal fistula after completion of chemotherapy for Hodgkin’s lymphoma. The mid-tracheal location of the fistula had significant implications in terms of airway management. Securing the airway with a microcuff tube helped meet the goals of achieving adequate ventilation while preventing airway contamination and permitting the repair without any complication. Conclusions The index case posed surgical and anesthetic challenges due to the size and location of the fistula. However, timely surgical intervention improved the quality of life of the child as well as that of the parents.

Introduction: General anesthesia causes pulmonary atelectasis within few minutes of induction. This can have significant impact on postoperative outcome of cancer patients undergoing prolonged reconstructive surgeries. Objective: The purpose of this study was to evaluate the impact of sonographically detected perioperative atelectasis on the need for postoperative oxygen supplementation, bronchodilator therapy and assisted chest physiotherapy in patients undergoing free flap surgeries for head and neck carcinoma. Methods: Twenty eight head and neck cancer patients underwent bilateral pulmonary ultrasonographic assessments before and after lung surgery. Lung ultrasound scores, serum lactate, and PaO2/FiO2 ratio were measured both at the beginning and at end of the surgery. Patients were scanned in the supine position and the number of single and confluent B lines was noted. These values were correlated with the need for oxygen therapy, requirement of bronchodilators and total weaning time to predict the postoperative outcome. Other factors affecting weaning were also studied. Results: Among twenty eight patients, seven had mean lung ultrasound score of ≥10.5 which correlated with prolonged weaning time (144.56 ± 33.5 min vs. 66.7 ± 15.7 min; p = 0.005). The change in lung ultrasound score significantly correlated with change in PaO2/FiO2 ratio (r = −0.56, p = 0.03). Elevated total leukocyte count >8200 μL and serum lactate >2.1 mmoL/L also predicted prolonged postoperative mechanical ventilation. Conclusion: This preliminary study detected significant levels of perioperative atelectasis using point of care lung ultrasonography in head and neck cancer patients undergoing long duration surgical reconstructions. Higher lung ultrasound scores highlighted the need for frequent bronchodilator nebulizations as well as assisted chest physiotherapy and were associated with delayed weaning. We propose more frequent point of care lung ultrasonographic evaluations and use of recruitment maneuvers to reduce the impact of perioperative pulmonary atelectasis.

Background: Thoracic paravertebral block (TPVB) has emerged as an effective and feasible mode of providing analgesia in laparoscopic cholecystectomy. Though a variety of local anaesthetic combinations are used for providing TPVB, literature is sparse on use of dexmedetomidine in TPVB. We aimed to compare levobupivacaine and levobupivacaine-dexmedetomidine combination in ultrasound guided TPVB in patients undergoing laparoscopic cholecystectomy. Methodology: 70 ASA I/II patients, aged 18–60 years, scheduled to undergo laparoscopic cholecystectomy under general anaesthesia were enrolled and divided into two groups. Before anaesthesia induction, group A patients received unilateral right sided ultrasound guided TPVB with 15 ml 0.25% levobupivacaine plus 2 ml normal saline while group B patients received unilateral right sided ultrasound guided TPVB with 15 ml 0.25% levobupivacaine plus 2 ml solution containing dexmedetomidine 1 μg.kg-1. Patients were monitored for pain using Numeric Rating Scale (NRS) at rest, on movement, coughing and comfort scores post surgery. Total analgesic consumption in first 48 hour postoperative period, time to first request analgesic and pain scores were recorded. Results: Total amount of rescue analgesia (injection tramadol plus injection tramadol intravenous equivalent dose) consumed during 48 hours postoperatively in group A was 146.55 mg while in group B was 111.30 mg (p = 0.026). Mean time for demanding rescue analgesia was 273 minutes in group A while in group B was 340 minutes (p = 0.00). Conclusion: TPVB using dexmedetomidine 1 μg.kg-1 added to levobupivacaine 0.25% in patients undergoing laparoscopic cholecystectomy significantly reduced total analgesic consumption in first 48 hours and provided longer duration of analgesia postoperatively compared to levobupivacaine 0.25% alone.

In the past, management of pain in neonates was regarded as unnecessary, with the belief that neonates have an immature nervous system and do not perceive pain. Later studies confirmed that neonates certainly do feel pain, though they lack the inhibitory mechanisms that modulate excruciating stimuli, unlike in older children. Repeated painful encounters experienced in the newborn period are associated with poor cognitive and motor development by 1 year of age. Pain in preverbal infants and children is also poorly recognized and often undertreated. Neonates and preverbal children cannot verbally communicate their pain and discomfort but express them through specific behavioral, physiological, and biochemical responses. Several pain measurement tools have been developed for young children as surrogate measures of pain. To achieve optimum postoperative or procedural pain relief, easily understandable tools and a multimodal treatment module should be tailor-made for each health-care facility that cares for neonates and young infants. The aim of this advisory is to outline key concepts of pain assessment in neonates and preverbal children and suggest a rational approach to its management by all anesthesiologists, pediatricians, nursing staff, and other medical personnel caring for these children. The Indian Association of Paediatric Anaesthesia (IAPA) convened an online meeting in April 2020 to formulate the advisory on pain management in neonates and preverbal children under the chairmanship of Dr. Elsa Varghese, President IAPA, and members of the guideline committee. After several such meetings and revisions using feedback from IAPA members, the final guidelines were released in October 2020 on the IAPA website. Recommendations: Pain relief should generally be accomplished with a combination of nonpharmacologic approaches and pharmacologic techniques in a stepwise tiered manner by escalating type and dose of analgesia with anticipated increases in procedural pain. Nonpharmacological distraction measures may be sufficient for minor needle procedures like vaccination and venipuncture and may be offered as a first step and to complement other pain management remedies. An interdisciplinary approach involving pharmacologic, cognitive-behavioral, psychologic, and physical treatments should be employed whenever feasible.

Background and Aims: In the cleft lip and palate, the laryngoscope blade often tends to lodge inside midline clefts, causing reduced manoeuvrability and tissue trauma. The paraglossal technique avoids the midline and offers better Cormack Lehane (CL) grades. We aimed to assess the first-pass intubation rate in performing the left paraglossal laryngoscopy with a curved-blade videolaryngoscope (VLS) versus direct laryngoscope (DLS) in children with cleft palate and evaluate the time taken for successful endotracheal intubation (TTI) and Intubation Difficulty Score (IDS) with both devices. Methods: This randomised controlled trial included 60 patients with cleft palate, between 3 months and 6 years. Patients were randomised into group V (VLS) (n = 30) and group D (DLS) (n = 30). Left paraglossal laryngoscopy was done with VLS or DLS, and the first-pass intubation, TTI, CL grade and IDS were recorded. Results: First-pass intubation (primary outcome) was successful in all cases in group V and in 29 (96%) cases in group D (P = 0.923). Amongst the secondary outcomes, the IDS of the majority in both groups was 1–4 (slight difficulty) (P = 0.98) and the mean TTI In group D was 34.6 s (SD = 19.0) (95% CI: 27.5–41.7) versus 39.8 s (SD = 5.2) (95% CI: 37.8–41.7) in group V (P = 0.151). Conclusions: There was no significant difference in the use of a VLS over a DLS in performing the left paraglossal laryngoscopy in terms of first-pass intubation rate, CL Grade, IDS and TTI. Further studies with different VLS may be done to improve the ease of this technique.

Introduction. The study aims to test whether flexible silicone tubes (FST) improve performance and provide similar intubation success through I-Gel as compared to ILMA. Our trial is registered in CTRI and the registration number is “CTRI/2016/06/006997.” Methods. One hundred and twenty ASA status I-II patients scheduled for elective surgical procedures needing tracheal intubation were randomised to endotracheal intubation using FST through either I-Gel or ILMA. In the ILMA group (n=60), intubation was attempted through ILMA using FST and, in the I-Gel group (n=60), FST was inserted through I-Gel airway. Results. Successful intubation was achieved in 36.67% (95% CI 24.48%–48.86%) on first attempt through I-Gel (n=22/60) compared to 68.33% (95% CI 56.56%–80.1%) in ILMA (n=41/60) (p=0.001). The overall intubation success rate was also lower with I-Gel group [58.3% (95% CI 45.82%–70.78%); n=35] compared to ILMA [90% (95% CI 82.41%–97.59%); n=54] (p