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Background: Percutaneous nephrolithotomy (PCNL) is the most common surgical procedure for the removal of renal stone of size >2 cm. It has evolved over the years both in terms of surgical technique and plan of anesthesia. The procedure is performed most commonly in the prone position. This position provides edge in offering greater anatomical feasibility due to the posterior retroperitoneal position of kidneys. Supine position bestows several perks over prone in terms of better access to patient’s airway, lower cardiopulmonary complications, better patient comfort, repositioning issues addressal along with convenient access to the patient by anesthesiologist in case of untoward medical emergency. Aims and Objectives: The primary aim to compare the safety and efficacy of prone versus supine PCNL. The objective Visual Analog Scale Score, patient satisfaction rate, stone-free rate, procedure time (calculated from placement of ureteric catheter to skin closure), overall complication rate. Materials and Methods: This prospective randomized study of 80 patients was conducted at our institute from December 2022 to June 2023. Institutional Ethical Committee clearance was sought and the inclusion criteria were all adult patients aged between 16 and 65 years with single renal, upper ureteric calculus of size 10–25 mm with ASA physical status 1 and 2 having normal renal function and a sterile urine culture. Results: All the patients completed the study and there were no dropouts. Male/female ratio, age, and stone size were comparable in both the groups. The mean time taken in supine PCNL was 48.3 min and in prone PCNL was 68.7 min, which was significant. Conclusion: Supine PCNL is a safe and efficacious procedure for renal stone disease in the selected group of patients with results comparable to prone PCNL, having additional advantages like less time-consuming, better upper calyceal access through lower calyx, less radiation exposure to surgeon’s hand, overcoming positional difficulties of prone position, simultaneous accessibility for performing flexible ureteroscopy and more convenient airway access to anesthesiologist and better pain scores.

Costoclavicular block has garnered the attention of regional anesthesia enthusiasts because the cords are snuggly packed and consistently arranged in a particular pattern around the first part of the axillary artery. The single injection technique has been widely used conventionally, but the effect is unpredictable. The effect is unpredictable because of the septum that compartmentalizes cords in upper and lower compartments. We propose a triple injection technique targeting the individual cords separately. Onset time of sensory block from 16 min to 7 min. The average time for a complete motor block was 9.6 min. The chances of the median nerve sparing, as has been reported in some cases in previous studies, are almost nil by this technique–the corner pocket injection that involves the medial root of the median nerve and the lateral cord that is specifically blocked separately, covering the lateral root of the median nerve. The costoclavicular block has already carved a niche as an excellent choice for surgeries of the upper limb involving the elbow or below the elbow. The use of the triple injection technique makes the block effect more predictable and reliable.

Temporomandibular joint (TMJ) ankylosis is defined as bony or fibrous adhesion of the anatomic joint components accompanied by a limitation in opening the mouth. Airway management is a grueling task and has confronted anesthesiologists ever since. The challenge is even more exaggerated when it is a pediatric patient. We present a case series of five pediatric patients with TMJ ankylosis with age 7 years or less, who were posted for its corrective surgery. Although all patients belonged to the pediatric age group, the challenges faced and techniques employed to overcome them were different partly because of different age groups and partly the nature of the airway, with tailoring of each technique accordingly. Pediatric airway management is no less than waging a war as all necessary skills and expertise are put to the test. It combines fortuity with skills. We have to be prepared for the worst in any unforeseen scenario.

Open nephrectomy is a common surgery usually performed for malignant and non-malignant renal pathologies. The external oblique intercostal block (EOIB) blocks the anterior and lateral cutaneous nerves from T6 to T10 and provides somatic analgesia. We present a case series of the use of EOIB in patients undergoing open nephrectomy by subcostal incision. Ten patients were given EOIB, which included patients undergoing simple nephrectomy for non-functioning kidneys and radical nephrectomy for renal mass. The patients had satisfactory numerical rating scale scores, mostly

Burn injuries are complex and challenging, requiring a multidisciplinary approach. We have done more than 15 cases of severely distorted airways in patients with burns (photos attached); although the basic case management remains the same, there are a plethora of other concerns that make these patients unique. The most unique and severe 11 cases we have discussed assiduously. Out of all the concerns, airway management remains the most challenging one. Timely intervention and keen vigilance are required to prevent a disaster later on.

Goldenhar syndrome, also called oculoauriculovertebral dysplasia, is characterized by craniofacial, central nervous system, cardiac, renal, and vertebral anomalies. It occurs due to the faulty unilateral development of vertebral arches. Patients presenting for surgery are usually in the pediatric age group. General anesthesia is the preferred mode of anesthesia considering the type of surgery, age of the patient, and vertebral anomaly in this patient group. The first and foremost consideration while anesthetizing these patients is the anticipated difficult airway. Frequently encountered airway abnormalities in these patients are micrognathia, retrognathia, mandibular dysplasia, craniovertebral anomalies leading to limited neck flexion and cervical spine instability, decreased thyromental distance, fascial asymmetry, cleft lip and palate, high arched palate, dental abnormalities, and temporomandibular joint abnormalities. Difficult airways often come disguised as syndromes, and thorough pre-operative evaluation along with preparation for the worst scenarios is a must. We have a myriad of alternative airway management equipment at our disposal. Adequate knowledge is a must for their best use.

Despite the presence of numerous options for breast analgesia, our women continue to suffer the consequences of acute post-operative pain that progresses to chronic pain in up to 55% of the post-mastectomy patients a rapid surge in the use of interfacial blocks for analgesia of chest and abdominal procedures. The importance and efficacy of these blocks are because of the continuity of the interfacial planes across varied anatomical tissues. We report a series of cases of modified radical mastectomy (MRM) in five female patients with the American Society of Anesthesiology Grade II/III in whom rhomboid intercostal subserratus was used for post-operative analgesia proved to be a boon. Two were post-radiation with metastasis to axillary lymph nodes. The other three had invasive ductal carcinoma and were on chemotherapy. Rhomboid intercostal subserratus plain block is a novel block and provides pain management for patients of MRM. The analgesic efficacy may not be superior but the non-inferiority to an epidural is certainly an added advantage with safe efficacious profile fulfilling the enhanced recovery after surgery protocols following minimally invasive surgical techniques.

Atrial septal defect (ASD) accounts for 35% of all congenital heart diseases in adults. Patients usually present in their twenties or thirties owing to gradually progressive right ventricular remodeling because of left to right shunt, right-sided heart failure, and pulmonary hypertension. In this case report, we present the management of young female patient with ASD posted for D5 spine decompression and fixation. Patients with congenital heart disease for spine surgery present with unique set of challenges for anesthesiologists. Well-prepared anesthesia plan is essential to prevent increase in shunt fraction, shunt reversal, hypoxia, hypercapnia, acidosis, and hypothermia along with careful addressal of positioning issues to ensure smooth recovery of patient.

Sir, We did a case series in five patients undergoing modified radical mastectomy who were given RISS for post-operative analgesia. We noticed that the intraoperative fentanyl consumption as well as the post-operative analgesic consumption was significantly less. The overall quality of life and satisfaction score for routine daily activities like wearing clothes was better in our patients. The importance and efficacy of these blocks are because of the continuity of the interfacial planes across varied anatomical tissues. These planes have various cutaneous as well as sympathetic branches and hence drug given spreads to cover a large dermatomal area. RISS has been proposed to cover lateral cutaneous branches of T2 to T11 that extend medially to cover dorsal rami deep to the errector spinae muscle plane (ESP). The site of injectate is at T5-T6. The dermatomal coverage is 4 cm lateral to the midline anteriorly, posteriorly 4 cm medial to the posterior axillary line, cranially up to serrated posterior superior caudally up to serratus posterior inferior. The advantages of RISS block are that the injection is far from the surgical site and hence the drug does not interfere with the surgical field or cautery if given preoperatively. After induction technically, it is more feasible than serratus plane block or pectoral blocks. Logistically prior catheterization is possible that does not interfere with the sterility of the surgical field. Despite the above advantages, the axillary coverage is inconsistent as it does not cover the intercostobrachial nerve (LCB of second ICN T2). The midline, thoracodorsal nerve, and long thoracic nerve are not covered. Complete analgesia is not provided for latissimus dorsi flap, segmental resection surgeries, lymph node dissections, or radical mastectomies. Dr. Tulgar, first-ever reported of the use of RIB in a patient of MRM and highlighted the superiority of peri-peri-paravertebral blocks apart from previously used ESP and paravertebral blocks for a similar condition. Altiparimak conducted an RCT on 30 MRM patients with axillary lymph node dissection. The patients had enhanced recovery and quality of life scores (QoR-40), especially in terms of pain and emotional status. RISS has proved its non-inferiority as compared to ESP, paravertebral, PEC, and SAP which are closer to neuroaxis, at non-compressible sites and difficult to execute in obese patients. Thus RISS is excellent as a part of MMA for post-operative pain management in MRM patients, who remain comfortable for up to 14 h and have an NRS score

Methaemoglobinemia is a rarely encountered haematological condition that can be congenital or acquired. Methaemoglobin is an abnormal type of haemoglobin that is oxidised and incapable of delivering oxygen to tissues. This can lead to cyanosis, hypoxia, acidosis, arrhythmias, and more, depending on the methaemoglobin concentration, and can be fatal. A thorough understanding of the disease process is essential to develop a suitable anaesthesia plan and prevent complications. Ensuring adequate tissue oxygenation, assessing oxygenation using appropriate monitoring tools, and avoiding trigger agents are the cornerstones of anaesthetic management. A co-oximeter is the gold standard for monitoring, as it detects and quantifies methaemoglobin levels. Methylene blue acts as an antidote, functioning as an oxidising agent that converts itself to leukomethylene blue, which reduces methaemoglobin back to haemoglobin. In the present case of a 60-year-old male, the authors present the anaesthetic management and challenges in a diagnosed case of congenital methaemoglobinemia undergoing laparoscopic inguinal hernia repair surgery. Methylene blue was administered prophylactically preoperatively. An arterial line was established before anaesthesia induction for close haemodynamic monitoring and quick blood gas and oxyhaemoglobin sampling, as a co-oximeter was not available. Adequate oxygenation during induction and emergence was ensured to prevent hypoxia, given the lower amount of normal haemoglobin in these patients. All potential trigger agents, such as nitrous oxide, local anaesthetics, nitrates, and metoclopramide, were avoided. The patient had an uneventful intraoperative and postoperative course and was discharged after one day.

Sir, Securing the phrenic nerve when achieving effective anesthesia block for the upper limb has been a topic intriguing regional anesthesia enthusiasts ever since. Interscalene brachial plexus block is known to involve the phrenic nerve in 100% of the cases and costoclavicular block which has gained momentum since 2015 is declared to involve the phrenic nerve in 0% of the cases. Besides this the compact, reliable topography of the cords in the triangular costoclavicular space along with an expedited sensorimotor block with local anesthesia deposited in the center of the three cords makes costoclavicular block an attractive option for elbow and below elbow surgeries. According to the studies, the success rate of the blockade is 92.5% with single injection in the center of the cords. Another study by Sebastian, where apart from classical single injection, another injection was given after redirecting the needle, between the medial cord and subclavian artery (labeling it a corner pocket technique) for costoclavicular block. They concluded that the block’s onset time and total anesthesia-related time were significantly shortened with the double injection technique compared with single injection. The basis of this was explanation laid by Dr. Monzo and Hadzic where they proposed in a series of 40 patients a linear septum arising from the lateral part of axillary artery separating the lateral code from the posterior and the medial code, thus compartmentalizing the costoclavicular space. They reported a success rate of 97.5% in their study on 40 patients.4 Hence,double injection is used to overcome the septum “issue.” Pornpatra is defined a high definition ultrasonographic presence of paraneural sheath and facial compartments surrounding the brachial plexus cords at the lateral infraclavicular fossa and the costoclavicular space. We propose that a triple injection with 3rd injection in the vicinity of the lateral cord just before withdrawing the needle apart from the other two injections significantly shortens the onset time of sensory block from 16 min to 9 min. The various sites for injection are shown in the figure below, but the exact point of injection of the second and third is more prominent after giving the first injection. The chances of the median nerve sparing as has been reported in some cases in previous studies are almost nil by this technique - the corner pocket injection that involves the medial root of the median nerve and the lateral cord that is specifically blocked separately covering the lateral root of the median nerve. CONCLUSION We did a case series in 15 cases and although the sample size is small and this is definitely not a randomized control trial, to make such a bold statement, we would like to decipher a positive future of the costoclavicular block with triple injection technique with an RCT already underway.

Background and Aims: Transcatheter device closure of congenital heart defects (CHD) has recently gained popularity. As limited literature exists regarding the ideal anesthetic technique for these procedures, we studied the perioperative anesthetic management and its effects on hemodynamics and complication rate in patients undergoing device closure. Methods: In this prospective observational study, all patients of 1 month to 50 years of age with acyanotic congenital heart diseases undergoing device closure were included. The anesthesia technique, i.e., general anesthesia with endotracheal tube (GETA)/supraglottic airway device (SGD) or conscious sedation with face mask (S-FM), and intravenous induction agent used was noted. Intraoperatively vital parameters, use of transesophageal echocardiography (TEE), and perioperative complications if any, were noted. Descriptive statistical analysis was done using a statistical package for the social sciences (SPSS) version 15. Results: GETA was used in the atrial septal defect (ASD) (62.8%), patent ductus arteriosus (PDA) (66.7%), ventricular septal defect (VSD) (65%) patients, SGD in ASD (6.3%), PDA (16.7%), and VSD (13.3%) patients. S-FM in ASD (31.3%), PDA (16.7%) and VSD (21.7%) patients. Etomidate was used as an induction agent in 30.61% of the patients and propofol in 69.39% of the patients. The mean arterial pressure (MAP) in the etomidate and propofol groups was statistically insignificant while decreased heart rate was noted in both groups. Complications like SGD dislodgement, supraventricular tachycardia, and device dislodgements were seen. Conclusion: In PDA device closure patients, GETA should be preferred. Patients for VSD device closure should receive general anesthesia as complications are common. In ASD device closure, patients without TEE use can be done under general anesthesia with SGD.