Purpose: The main objective of this survey is to describe the current practice of thoracic anesthesia in the Middle Eastern (ME) region. Methods: A prospective online survey. An invitation to participate was e-mailed to all members of the ME thoracic-anaesthesia group. A total of 58 members participated in the survey from 19 institutions in the Middle East. Questions concerned ventilation strategies during one-lung ventilation (OLV), anesthesia regimen, mode of postoperative analgesia, use of lung isolation techniques, and use of i.v. fluids. Results: Volume-controlled ventilation was favored over pressure-controlled ventilation (62% vs 38% of respondents, P<0.05); 43% report the routine use of positive end-expiratory pressure. One hundred percent of respondents report using double-lumen tube (DLT) as a first choice airway to establish OLV. Nearly a third of respondents, 31.1%, report never using bronchial blocker (BB) in their thoracic anesthesia practice. Failure to pass a DLT and difficult airway are the most commonly cited indications for BB use. Regarding postoperative analgesia, the majority 61.8% favor thoracic epidural analgesia over other techniques (P<0.05). Conclusions: Our survey provides a contemporary snapshot of the ME thoracic anesthetic practice.

Background: Addition of clonidine to ropivacaine (0.2%) can potentially enhance analgesia without producing prolonged motor blockade. The aim of the present study was to compare the post-operative pain relieving quality of ropivacaine 0.2% and clonidine mixture to that of plain ropivacaine 0.2% following caudal administration in children. Methods: In a prospective, double-blinded, randomized controlled trial, 30 ASA 1 pediatric patients undergoing infraumbilical surgery were randomly allocated to receive a caudal injection of either plain ropivacaine 0.2% (1 ml/kg) (group A) or a mixture of ropivacaine 0.2% (1 ml/kg) with clonidine 2 μg/kg (group B). Objective pain score and need for supplemental analgesics were compared during the 1 ^st 24 hours postoperatively. Residual post-operative sedation and motor blockade were also assessed. Results: Significantly prolonged duration of post-operative analgesia was observed in group B (P<0.0001). Heart rate and blood pressure were not different in 2 groups. Neither motor blockade nor post-operative sedation varied significantly between the groups. Conclusion: The combination of clonidine (2 μg/kg) and ropivacaine 0.2% was associated with an improved quality of post-operative analgesia compared to plain 0.2% ropivacaine. The improved analgesic quality of the clonidine-ropivacaine mixture was achieved without causing any significant degree of post-operative sedation or prolongation of motor blockade.

Objectives : This study was designed to compare the intrathecal morphine and paravertebral block with bupivacaine given before induction of anesthesia for intra-operative and post-thoracotomy pain relief for 48 hours using patient controlled paravertebral analgesia in post-operative period. Methods : After taken an approval from the ethics committee of the University, 40 patients were randomly assigned to receive either preservative-free intrathecal morphine 0.3 mg in 3 ml normal saline together with paravertebral block (group I) or paravertebral block alone using bupivacaine (group II) before an induction of anesthesia. No continuous infusion of bupivacaine was started in both groups. Primary outcomes were Visual Analogue Score (VAS) at rest and on coughing. Hemodynamic and respiratory effects, bupivacaine consumption, patient's satisfaction, and side effects like nausea, vomiting, urinary retention, and itching were considered as secondary outcomes. All patients in both groups received paracetamol 1 gram (gm) IV every 6 hourly for the 1 ^st 24 hr. Amount of rescue analgesic (pethidine 0.5 mg/kg IV) in both groups and total bupivacaine cumulative doses in 48 hrs were calculated. Results : VAS at rest and on coughing did not differ significantly between the 2 groups at 0, 1, 6, 12, 18, 24, and 48 hours (P=>0.1). At 24 hours, VAS increased in both the groups, but the increase in VAS was comparable in both groups. There were insignificant incidences of nausea, purities, and urinary retention in intrathecal group compared with paravertebral group. The other side effects and patient satisfaction did not show any statistical significant difference between 2 groups. Conclusion : Intrathecal morphine 0.3 mg is safe and effective way to improves pain control for thoracic surgery and was comparable to paravertebral patient control analgesia (PPCA) with bupivacaine for the 1 ^st 48 hours post-thoracotomy.

Background: Ketorolac is widely used for postoperative analgesia in patients who undergo cesarean delivery. In countries where the use of opioids is considerably restricted, alternatives to narcotics are required. Aim: We hypothesize that the addition of complex B synergize the analgesic effect of ketorolac in postoperative cesarean patients, thus requiring a smaller dose of the anti-inflammatory agent, and therefore decreasing the potential side effects of ketorolac. Methods: A randomized clinical trial with 100 patients undergoing a primary elective cesarean delivery enrolled in the study. Pain was assessed in the recovery room and then they were randomized to receive ketorolac 30 mg intramuscular (i.m.) or 15 mg of ketorolac plus complex B vitamin (CBV). The pain score with an analog scale was assessed 1, 2, 6, 12, 18, and 24 h after the baseline. The student's t test was performed to compare the demographic differences between the 2 means. Results: 100 patients were included in the study, showing no statistical differences in the demographics. The patient's pain score at 1, 2, 6, 12, 18 and 24 hours showed no statistical differences between the control group (ketorolac 30mg) compared to the group of ketorolac 15mg and complex B vitamins. No changes in the coagulation studies were found in both groups. Conclusion: The present study demonstrates that ketorolac 30 mg and ketorolac 15 mg plus complex B vitamins can provide acceptable analgesia in many patients with severe pain.

Background: Effect on hemodynamic changes and experience of robot-assisted laparoscopic radical prostatectomy (RALRP) in steep Trendelenburg position (45°) with high-pressure CO ₂ pneumoperitoneum is very limited. Therefore, we planned this prospective clinical trial to study the effect of steep Tredelenburg position with high-pressure CO ₂ pneumoperitoneum on hemodynamic parameters in a patient undergoing RALRP using FloTrac/Vigileo™1.10. Methods: After ethical approval and informed consent, 15 patients scheduled for RALRP were included in the study. In the operation room, after attaching standard monitors, the radial artery was cannulated. Anesthesia was induced with fentanyl (2 μg/kg) and thiopentone (4-7 mg/kg), and tracheal intubation was facilitated by vecuronium bromide (0.1 mg/kg). The patient's right internal jugular vein was cannulated and the Pre Sep™ central venous oximetry catheter was connected to it. Anesthesia was maintained with isoflurane in oxygen and nitrous oxide and intermittent boluses of vecuronium. Intermittent positive-pressure ventilation was provided to maintain normocapnea. After CO ₂ pneumoperitoneum, position of the patient was gradually changed to 45° Trendelenburg over 5 min. The robot was then docked and the robot-assisted surgery started. Intraoperative monitoring included central venous pressure (CVP), stroke volume (SV), stroke volume variation (SVV), cardiac output (CO), cardiac index (CI) and central venous oxygen saturation (ScvO ₂ ). Results: After induction of anesthesia, heart rate (HR), SV, CO and CI were decreased significantly from the baseline value (P>0.05). SV, CO and CI further decreased significantly after creating pneumoperitoneum (P>0.05). At the 45° Trendelenburg position, HR, SV, CO and CI were significantly decreased compared with baseline. Thereafter, CO and CI were persistently low throughout the 45° Trendelenburg position (P=0.001). HR at 20 min and 1 h, SV and mean arterial blood pressure after 2 h decreased significantly from the baseline value (P>0.05) during the 45° Trendelenburg position. CVP increased significantly after creating pneumoperitoneum and at the 45° Trendelenburg position (after 5 and 20 min) compared with the baseline postinduction value (P>0.05). All these parameters returned to baseline after deflation of CO ₂ pneumoperitoneum in the supine position. There were no significant changes in SVV and ScvO ₂ throughout the study period. Conclusions: The steep Trendelenburg position and CO ₂ pneumoperitoneum, during RALRP, leads to significant decrease in stroke volume and cardiac output.

Background : Fiberoptic intubation is the gold standard technique for difficult airway management in patients of temporomandibular joint. This study was aimed to evaluate the clinical efficacy and safety of dexmedetomidine as premedication with propofol infusion for fiberoptic intubation. Methods: Consent was obtained from 46 adult patients of temporomandibular joint ankylosis, scheduled for gap arthroplasty. They were enrolled for thisdouble-blind, randomized, prospective clinical trial with two treatment groups - Group D and Group P, of 23 patients each. Group D patients had received premedication of dexmedetomidine 1 μg/kg infused over 10 min followed by sedative propofol infusion and the control Group P patients were given only propofol infusion to achieve sedation. Condition achieved at endoscopy, intubating conditions, hemodynamic changes and postoperative events were evaluated as primary outcome. Results : The fiberoptic intubation was successful with satisfactory endoscopic and intubating condition in all patients. Dexmedetomidine premedication has provided satisfactory conditions for fiberoptic intubation and attenuated the hemodynamic response of fiberoptic intubation than the propofol group. Conclusion : Fiberoptic intubation was found to be easier with dexmedetomidine premedication along with sedative infusion of propofol with complete amnesia of the procedure, hemodynamic stability and preservation of patent airway.

Context: The newest variation of the i-gel supraglottic airway is a pediatric version. Aims: This study was designed to investigate the usefulness of the size 2 i-gel compared with the ProSeal laryngeal mask airway (PLMA) and classic laryngeal mask airway (cLMA) of the same size in anesthetized, paralyzed children. Settings and design: A prospective, randomized, single-blinded study was conducted in a tertiary care teaching hospital. Methods: Ninety ASA grade I-II patients undergoing lower abdominal, inguinal and orthopedic surgery were included in this prospective study. The patients were randomly assigned to the i-gel, PLMA and cLMA groups (30 patients in each group). Size 2 supraglottic airway was inserted according to the assigned group. We assessed ease of insertion, hemodynamic data, oropharyngeal sealing pressure and postoperative complications. Results: There were no differences in the demographic and hemodynamic data among the three groups. The airway leak pressure of the i-gel group (27.1±2.6 cmH ₂ O) was significantly higher than that of the PLMA group (22.73±1.2 cmH ₂ O) and the cLMA group (23.63±2.3 cmH ₂ O). The success rates for first attempt of insertion were similar among the three devices. There were no differences in the incidence of postoperative airway trauma, sore throat or hoarse cry in the three groups. Conclusions: Hemodynamic parameters, ease of insertion and postoperative complications were comparable among the i-gel, PLMA and cLMA groups, but airway sealing pressure was significantly higher in the i-gel group.

Purpose: Different adjuvants have been used to improve the quality and increase the duration of local anesthetics during various nerve block techniques. The current study was aimed to evaluate the effect of adding dexamethasone to bupivacaine on the quality and duration of transversus abdominis plane (TAP) block. Methods: Sixty adult patients undergoing elective open abdominal hysterectomy were randomly allocated to receive TAP block using 20 mL of bupivacaine hydrochloride 0.25% + 2 mL saline 0.9% (control group, n=30) or 20 mL of bupivacaine hydrochloride 0.25% + 2 mL dexamethasone "8 mg" (dexamethasone group, n=30). The primary outcome was postoperative pain, as evaluated by visual analog scale (VAS) for pain scoring at 1, 2, 4, 12, 24 and 48 h postoperatively, whereas the secondary outcomes were time to first analgesia (TFA), morphine consumption and the occurrence of nausea, vomiting or somnolence. Results: The pain VAS score was significantly lower at the postoperative 2 h (4.9 vs. 28.1, P=0.01), 4 h (12.2 vs. 31.1, P=0.01) and 12 h (15.7 vs. 25.4, P=0.02). Furthermore, TFA was significantly longer in the dexamethasone group (459.8 vs. 325.4 min, P=0.002), with lesser morphine requirements in the postoperative 48 h (4.9 vs. 21.2 mg, P=0.003) and lower incidence of nausea and vomiting (6 vs. 14, P=0.03). No complications attributed to the block were recorded. Conclusion: Addition of dexamethasone to bupivacaine in TAP block prolonged the duration of the block and decreased the incidence of nausea and vomiting.

Purpose: To retrospectively review anesthesia and intensive care management of 145 consented volunteers subjected to right lobe or left hepatectomy between 2003 and 2011. Methods: After local ethics committee approval, anesthetic and intensive care charts, blood transfusion requirements, laboratory data, complications and outcome of donors were analyzed. Results: One hundred and forty-three volunteers successfully tolerated the surgery with no blood transfusion requirements, but with a morbidity rate of (50.1%). The most frequent complication was infection (21.1%) (intraabdominal collections), followed by biliary leak (18.2%). Two donors had major complications: one had portal vein thrombosis (PVT) treated with vascular stent. This patient recovered fully. The other donor had serious intraoperative bleeding and developed postoperative PVT and liver and renal failure. He died after 12 days despite intensive treatment. He was later reported among a series of fatalities from other centers worldwide. Epidural analgesia was delivered safely (n=90) with no epidural hematoma despite significantly elevated prothrombin time (PT) and international normalization ratio (INR) postoperatively, reaching the maximum on Day 1 (16.9±2.5 s and 1.4±0.2, P<0.05 when compared with baseline). Hypophosphatemia and hypomagnesemia were frequently encountered. Total Mg and phosphorus blood levels declined significantly to 1.05±0.18 mg/dL on Day 1 and 2.3±0.83 mg/dL on Day 3 postoperatively. Conclusions: Coagulation and electrolytes need to be monitored perioperatively and replaced adequately. PT and INR monitoring postoperatively is still necessary for best timing of epidural catheter removal. Live donor hepatectomy could be performed without blood transfusion. Bile leak and associated infection of abdominal collections requires further effort to better identify biliary leaks and modify the surgical closure of the bile ducts. Donor hepatectomy is definitely not a complication-free procedure; reported complication risks should be available to the volunteers during consenting.

Background: Prediction of outcome after cardiac surgery is difficult despite a number of models using pre-, intra- and post-operative factors. Ideally, risk factors operating in all three phases of the patients' stay in the hospital should be incorporated into any outcome prediction model. The aim of the present study was to identify the perioperative risk factors associated with morbidity, mortality and length of stay in the recovery room (LOSR) and length of stay in the hospital (LOSH). Methods: Eighty-eight adults of either sex, patients undergoing elective open cardiac surgery were studied prospectively. The ability of a number of pre-, intra- and post-operative factors to predict outcome in the form of mortality, immediate morbidity (LOSR) and intermediate morbidity (LOSH) was assessed. Results: Factors associated with higher mortality were preoperative prothrombin index (PTI), American Society of Anesthesiology-Physical Status (ASA-PS) grade, Cardiac Anaesthesia Risk Evaluation (CARE) score and New York Heart Association (NYHA) class, intraoperative duration of cardiopulmonary bypass (DCPB), number of inotropes used while coming off cardiopulmonary bypass and postoperatively, Acute Physiology and Chronic Health Evaluation (APACHE) II excluding the Glassgow Comma Scale (GCS) component and the number of inotropes used. Immediate morbidity was associated with preoperative PTI, inotrope usage intra- and post-operatively and the APACHE score. Intermediate morbidity was associated with DCPB and intra- and post-operative inotrope usage. Individual surgeon influenced the LOSR and the LOSH. Conclusion: APACHE score, a general purpose severity of illness score, was relatively ineffective in the postoperative period because of sedation, neuromuscular blockade and elective ventilation used in a number of these patients. The preoperative and intraoperative factors like CARE, ASA-PS grade, NYHA, DCPB and number of inotropes used influencing morbidity and mortality are consistent with the literature, despite the small size of our sample.

Context: The cervical spine has to be stabilized in patients with suspected cervical spine injury during laryngoscopy and intubation by manual in-line axial stabilization. This has the propensity to increase the difficulty of intubation. An attempt has been made to compare TruView EVO2 and McCoy with cervical spine immobilization, which will aid the clinician in choosing an appropriate device for securing the airway with an endotracheal tube (ETT) in the clinical scenario of trauma. Aims: To compare the effectiveness of TruView EVO2 and McCoy laryngoscopes when performing tracheal intubation in patients with neck immobilization using manual in-line axial cervical spine stabilization. Settings and design: K. M. C. Hospital, Mangalore, This was a randomized control clinical trial. Methods: Sixty adult patients of either sex of ASA physical status 1 and 2 who were scheduled to undergo general anesthesia with endotracheal intubation were studied. Comparison of intubation difficulty score (IDS), hemodynamic response, Cormack and Lehane grade, duration of the tracheal intubation and rate of successful placement of the ETT in the trachea between TruView EVO2 and McCoy laryngoscopes was performed. Results: The results demonstrated that TruView has a statistically significant less IDS of 0.33 compared with an IDS of 1.2 for McCoy. TruView also had a better Cormack and Lehane glottic view (CL 1 of 77% versus 40%) and less hemodynamic response. Conclusions: The TruView blade is a useful option for tracheal intubation in patients with suspected cervical spine injury.

Background: Intrathecal magnesium has been found to prolong the duration of analgesia in various surgical procedures like lower limb surgeries and as adjuncts to general anesthesia for pain management. The present study was designed to examine whether addition of intrathecal magnesium sulfate would enhance the analgesic efficacy of intrathecal bupivacaine and fentanyl in patients undergoing total abdominal hysterectomy. Methods: After taking informed consent, 60 patients were randomised into two groups with 30 patients. Group "S" received 2.5 mL (12.5 mg) of hyperbaric bupivacaine + 0.5 mL (25 mcg) of fentanyl + 0.5 mL of normal saline and Group "M" received 2.5 mL (12.5 mg) of hyperbaric bupivacaine + 0.5 mL (25 mcg) of fentanyl + 0.5 mL (100 mg) of magnesium sulfate. Onset of sensory, motor block and duration of analgesia was noted. Results: Demographic profile and duration of surgery were comparable (P>0.5). Time of onset of sensory and motor blockade was delayed in Group M compared with Group S, and this was statistically significant. A statistically significant longer duration of analgesia was observed in Group M compared with the control Group S. However, the recovery of motor blockade was found to be statistically insignificant in both the groups. The hemodynamic parameters were comparable in the perioperative period (P>0.05). The incidence of side-effects in both the groups were also comparable (P>0.05). Conclusion: The addition of 100 mg intrathecal magnesium led to prolonged duration of analgesia significantly without increasing the incidence of side-effects. Also, there was a significant delay in the onset of both sensory and motor blockade.

Background: Unintentional bronchial intubation may result in serious complications such as lung collapse or pneumothorax. These complications amount to sentinel events should be reported, and a hospital sentinel event policy should be implemented, including corrective actions to prevent recurrence. Methods: A 12-month prospective observational study in a multidisciplinary adult intensive care unit (ICU) to estimate the frequency of inadvertent bronchial intubation and its major sequels in intubated patients admitted to the unit. Complications will be reported as sentinel events attracting investigation by root cause analysis method, action plan, and follow-up. Results: There were 36 (12.9%) cases of inadvertent bronchial intubations in 279 orally-intubated patients admitted to the ICU during the study period (1.5.2010 - 30.4.2011), 2 (0.7%) of them already developed total left lung collapse. The hospital sentinel event policy was activated followed by action plan, which included raising the awareness of the problem, presentations, and regular checking on the position of the tube following tracheal intubation at different location in the hospital. Conclusion: Early detection and correction of endobronchial intubation will prevent complications developing. Applying sentinel event policy on complications of inadvertent bronchial intubation will encourage finding permanent solution to an old and preventable problem. Anesthetic and resuscitative regulatory bodies should incorporate methods of checking on correct position of tracheal tubes in their training programs. Knowing that the tube may advance into a bronchus, they should insist on regular checking of the tube in a manner similar to monitoring patient's vital signs.

Background: The present study sought to determine whether premedication with oral β-blocker before hypotensive anesthesia with sodium nitroprusside could improve the quality of surgical field, decrease the blood loss, and decrease the need for homologous blood transfusion and duration of surgery. Methods: Eighty patients scheduled for spinal fixation surgery were included in a prospective, randomized, double-blinded study. Patients were classified into two groups: Group I received oral atenolol 50 mg twice one day before surgery; and Group II received placebo tablets identical in appearance to atenolol tablets for the same period and interval. All patients in both the groups received intraoperative sodium nitroprusside (SNP) as a hypotensive agent. Hemodynamic variables, amount of sodium nitroprusside used, quality of surgical field, and the amount of homologous blood transfusion and blood loss were compared between groups. Results: Heart rate and amount of SNP used were significantly less (P<0.0001) in the atenolol group, but no significant difference was found in intraoperative mean arterial blood pressure (MABP) between the two groups. The time of surgeries was significantly shorter in Group I than in Group II (185±15.21 vs 225±12.61 min), P<0.0001. The quality of surgical field was better in Group I than in Group II in all times of measurements, P<0.0001. The amount of blood loss and the amount of packed red blood cells transfused were significantly less in Group I than in Group II, P<0.0001. No clinically significant complications were observed in either group. Conclusion: Premedication with oral atenolol 50 mg twice/day for one day before hypotensive anesthesia with SNP during spinal surgeries seems to be clinically safe and effective to reduce heart rate, amount of SNP used, amount of blood loss, and amount of blood transfused with better quality of surgical field.

Background: Despite several recent innovations in phacoemulsification surgery, importance of pupil diameter in this surgery is becoming more evident. Purpose : To compare the effect of opioid agonist (fentanyl) versus opioid agonist-antagonist (buprenorphine) on pupil diameter in cataract surgery and to choose the best opioid in high-risk phacoemulsification surgery. Methods: In this randomized double-blinded clinical trial, 60 patients who were candidates for elective phacoemulsification surgery were randomly divided into two equal groups: experimental (buprenorphine, 0.3 μg/kg) and control (fentanyl, 1 μg/kg). Pupil diameter was measured preinjection and at several times postinjection. Blood pressure was recorded at several intervals, as well as shivering, nausea and vomiting, and recovery time. Results: Mean (SD) recovery time was significantly less in the control group (19.46±5.43) than in the experimental group (33.23±10.75) (P<0.0001). The constriction effect (ie, pupillary diameter in mm) was significantly lower in the experimental group (0.53±0.45) than in the control group (1.06±0.52) (P=0.0001). The percentages of constriction effect in experimentaland control groups were 7.68% and 15.07%, respectively. The eye was two times more constricted in the control group in comparison with the experimental group after induction of anesthesia. Conclusion: Buprenorphine is a better solution to decrease pupil constriction in comparison with fentanylinhigh-risk phacoemulsification surgery.

Objective: Magnesium has been used as an adjuvant by various routes, including intravenous, intrathecal, and epidural in different dosage regimens. The effect of single bolus dose of magnesium as an adjuvant to fentanyl for postoperative analgesia has not been studied. This prospective randomized controlled trial was done to evaluate the efficacy of single bolus administration of magnesium epidurally as an adjuvant to epidural fentanyl for postoperative analgesia in patients undergoing total hip replacement under combined spinal epidural anesthesia. Methods : Sixty patients received combined spinal-epidural anesthesia with 2 mL of 0.5% hyperbaric bupivacaine intrathecally. After the surgery, patients were randomized into Group F [epidural fentanyl (1 μg/kg) in 10 mL saline] and Group FM [epidural magnesium (75 mg) along with fentanyl (1 μg/kg) in 10 mL saline]. Supplementary analgesia was provided by 50 mg intravenous tramadol if Verbal Rating Score (VRS) >4. Patient's first analgesic requirement and duration of analgesia were recorded. Results : The duration of analgesia was significantly longer for Group FM, 340±28.8 min, compared with Group F, 164±17.1 min (P=0.001). The frequency of rescue analgesics required in 24-h postoperative period in Group FM (2.3±0.5) was significantly less than that in Group F (4.3±0.5) (P=0.001). VRS was significantly lower in Group FM up to 4 h in the postoperative period (P=0.001). Bromage scale was statistically insignificant at all points of time. Conclusions : The administration of magnesium (75 mg) as an adjuvant to epidural fentanyl (1 μg/ kg) for postoperative analgesia results in significantly lower VRS with prolonged duration of analgesia as compared with epidural fentanyl (1 μg/kg) alone. Concomitant administration of magnesium also reduces the requirement of breakthrough analgesics with no increased incidence of side effects.

Acute epiglottitis is a life-threatening disorder with serious implications to the anesthesiologist because of the potential for laryngospasm and irrevocable loss of the airway. Acute epiglottitis can occur at any age. Early diagnosis with careful and rapid intervention of this serious condition is necessary in order to avoid life-threatening complications.

Spasticity is motor alteration characterized by muscle hypertonia and hyperreflexia. It is an important complication of spinal cord injury, traumatic brain injury, cerebral palsy, and multiple sclerosis. If uncorrected, fibrosis and eventually bony deformity lock the joint into a fixed contracture. Chemical neurolysis using various agents is one of the therapeutic possibilities to alleviate spasticity. We are, hereby, reporting 3 patients in whom 65% alcohol was used as neurolytic agent for the treatment of hip adductor spasticity, and the effect lasted for a variable period.

Topical phenylephrine solutions are widely used in eye procedures to promote pupil dilation without cycloplegia. We report a case of intraoperative severe hypertension and acute pulmonary edema occurring in a child during retinal surgery after possible systemic absorption of topical phenylephrine eyedrops. Our objective is to discuss the proper treatment and preventive strategies for such a complication. A 4-year-old, male patient, 18.4 kg in weight, physical status ASA I was admitted for right retinal detachment surgery. Anesthesia was induced with sevoflurane in oxygen, followed by glycopyrrolate (5.0 μg/kg), propofol 25 mg, fentanyl 50 μg and cisatracurium 0.15 mg/kg given intravenously. Anesthesia was maintained with sevoflurane 2-2.5% in a mixture of nitrous oxide and oxygen (60%:40%). After incision, two drops of 10% aqueous phenylephrine were administered topically by the surgeon to the right eye for further pupil dilation. Few minutes later, the noninvasive blood pressure rose to 220/120 mmHg and the heart rate increased to 140 beats/min. Oxygen saturation (SpO ₂) dropped from 99% (with an inspired oxygen concentration (FiO ₂) of 0.4) to 82%. Auscultation revealed crepitations throughout the chest and a blood-stained frothy fluid was aspirated from the trachea with possible development of acute pulmonary edema. Hydralazine (5 mg) and furosemide (10 mg) were administered intravenously. Seven minutes later, the blood pressure returned to normal and the SpO ₂ increased to 92% on FiO ₂ of 1.0, with decreased intratracheal secretions. After approximately 20 minutes, the SpO ₂ had improved to 99%, with a FiO ₂ of 1.0 and the blood pressure was 109/63 mmHg and heart rate was 121 beats/min. The FiO ₂ gradually reduced back to 0.4 over 30 min with no further desaturation. The patient was discharged from the post anesthesia care unit 5 h after surgery with adequate spontaneous breathing, SpO ₂ 99% on room air, normal blood pressure and pulmonary auscultation. Anesthesiologists and ophthalmologists should be aware of the possible cardiovascular side-effects of topical phenylephrine, and it should be used cautiously with appropriate intraoperative monitoring of hemodynamic variables. Moreover, preventive strategies to minimize systemic absorption of the drug should be taken.

Anaesthetic management of patients with hepatic dysfunction can be quite challenging, as many anaesthetic agents are metabolized by liver. Heart disease on anti coagulation can pose additional challenge. Here we report a case of Gilbert's syndrome with rheumatic heart disease on anti coagulation posted for elective hernia repair.

We report two cases of successful urgent intubation using a Seldinger technique for airway management through an anesthesia facemask, while maintaining ventilation in patients with difficult airways and grossly distorted airway anatomy. In both cases, conventional airway management techniques were predicted to be difficult or impossible, and a high likelihood for a surgical airway was present. This technique was chosen as it allows tracheal tube placement through the nares during spontaneous ventilation with the airway stented open and oxygen delivery with either continuous positive airway pressure and/or pressure support ventilation. This unhurried technique may allow intubation when other techniques are unsuitable, while maintaining control of the airway.

Acute swelling of the parotid gland after general anesthesia (commonly known as anesthesia mumps or acute postoperative sialadenitis) is a rare but declared complication of anesthesia. The etiology is not clear, but some possible causes such as obstruction of glandular excretory ducts caused by patient position and increase in the viscosity of the saliva because of acute dehydratation and/or medications like atropin have been proposed. We report a swelling in the left preauricular and postauricular region extending to the angle of the mandibule in a 35-year-old patient after left lateral decubitus position for laparoscopic nephrectomy.

Aplastic anemia is a rare heterogeneous disorder of hematopoietic stem cells causing pancytopenia and marrow hypoplasia with the depletion of all types of blood cells. This results in anemia, neutropenia and thrombocytopenia, which pose a challenge to both surgical and anesthetic management of such cases. We report a child with aplastic anemia who sustained traumatic ulcer on the arm and underwent split-thickness skin grafting under general anesthesia. There are only two case reports on anesthetic considerations in aplastic anemia patients in the literature. The anesthetic management is challenging because of the rarity of the disease, associated pancytopenia and immunosuppression.

Regional anesthesia is one of the most satisfying expertise in anesthesia. Nerve stimulation guided peripheral nerve blocks greatly enhance the success rate of block. Often the nerve stimulation needle becomes a limiting factor due to cost and unavailablity. We have proposed a simple innovation to create a nerve stimulation needle at the point of care that would overcome the limitation associated with commercially available needle for nerve stimulation .This innovation may prove instrumental in training of anesthesia residents at no extracost to the patient.