Context: Postoperative pain management remains a cornerstone in patient's management to ensure a better quality of life. Preemptive analgesia is reported to inhibit the persistence of postoperative pain. Aims: The aim of this study is to assess the analgesic effectiveness of preincisional infiltration of ketamine following elective abdominal hysterectomy as compared to levobupivacaine. Settings and Design: This was a prospective, randomized, double-blind study. Subjects and Methods: This study included 48 patients undergoing abdominal hysterectomy under general anesthesia. They were randomized into two equal groups; Group K received subcutaneous infiltration of 20 ml containing ketamine 2 mg/kg and Group L received subcutaneous infiltration of 20 ml of levobupivacaine 0.25% along the Pfannenstiel incision 5 min before incision. Postoperative pain was assessed using visual analog scale (VAS) at rest and on coughing with evaluation of additional opioid analgesic requirements. Statistical Analysis Used: Numerical variables were presented as mean and standard deviation or median and range as appropriate. The intergroup differences were compared using the independent-sample Student's t-test or Mann–Whitney test for numerical variables. Results: VAS score decreased significantly in Group L from 10 to 24 h and in Group K from 8 to 24 h as compared to the immediate postoperative reading. VAS score in ketamine group was significantly lower than that in the levobupivacaine group 8, 10, and 24 h postoperatively. Ketamine group showed delayed request of additional opioid analgesia (P < 0.001) with significantly less opioid consumption (P < 0.001) as compared to levobupivacaine. The total dose of meperidine consumed during the 24 postoperative h was significantly smaller in ketamine group (P < 0.001). Conclusion: Surgical site infiltration of ketamine is a promising preemptive analgesic method in the lower abdominal surgery with minimal sedation and adverse effects.

Background: Several morphometric airway measurements have been used to predict difficult laryngoscopy (DL). This study evaluated sternomental distance (SMD) and sternomental displacement (SMDD, difference between SMD measured in neutral and extended head position), as predictors of DL and difficult intubation (DI). Materials and Methods: We studied 610 adult patients scheduled to receive general anesthesia with tracheal intubation. SMD, SMDD, physical, and airway characteristics were measured. DL (Cormack-Lehane grade 3/4) and DI (assessed by Intubation Difficulty Scale) were evaluated. The optimal cut-off points for SMD and SMDD were identified by using receiver operating characteristic (ROC) analysis. Multivariate logistic regression was used to predict DL and ROC curve was used to assess accuracy on developed regression model. Results: The incidence of DL and DI was 15.4% and 8.3%, respectively. The cut-off values for SMD and SMDD were ≤14.75 cm (sensitivity 66%, specificity 60%) and ≤5.25 cm (sensitivity 70%, specificity 53%), respectively, for predicting DL. The area under the curve (AUC) with 95% confidence interval (CI) for SMD was 0.66 (0.60–0.72) and that for SMDD was 0.687 (0.63–0.74). Multivariate analysis with logistic regression identified inter-incisor distance, neck movement <80°, SMD, SMDD, short neck and history of snoring as predictors and the predictive model so obtained exhibited a higher diagnostic accuracy (AUC: 0.82; 95% CI 0.77–0.86). SMDD, but not SMD, correlated with DI. Conclusions: Both SMD and SMDD provide a rapid, simple, objective test that may help identifying patients at risk of DL. Their predictive value improves considerably when combined with the other predictors identified by logistic regression.

Background: Robotic radical prostatectomy (RRP) is associated with various anesthetic challenges due to pneumoperitoneum and deep Trendelenburg position. Tenting of the abdominal wall done in RRP surgery causes decrease in peak airway pressure leading to better ventilation. Herein, we aimed to describe the effects of tenting of the abdominal wall on peak airway pressure in RRP surgery performed in deep Trendelenburg position. Methods: One hundred patients admitted for RRP in Kokilaben Dhirubhai Ambani Hospital of American Society of Anesthesiologists 1 and 2 physical status were included in the study. After undergoing preanesthesia work-up, patients received general anesthesia. Peak airway pressures were recorded after induction of general anesthesia, after insufflation of CO₂, after giving Trendelenburg position, and after tenting of the abdominal wall with robotic arms. Results: Mean peak airway pressure recording after induction in supine position was 19.5 ± 2.3 cm of H₂O, after insufflation of CO₂in supine position was 26.3 ± 2.6 cm of H₂O, after giving steep head low was 34.1 ± 3.4 cm of H₂O, and after tenting of the abdominal wall with robotic arms was 29.5 ± 2.5 cm of H₂O. P value is highly statistically significant (P = 0.001). Conclusion: Tenting of the abdominal wall during RRP is beneficial as it decreases peak airway pressure and helps in better ventilation and thus reduces the ill effects of raised peak airway pressure and intra-abdominal pressures.

Background: Nasogastric tube (NGT) insertion may pose a special problem in patients under general anesthesia with first attempt failure rates up to 50%. To increase insertion success rate and decreases related complications, several techniques have been developed. In this study, digital assistance technique is compared to the classic insertion technique in neck flexion. Materials and Methods: In this prospective randomized study, 160 patients were randomly allocated into two groups; control group (Group C, n = 80) where NGT tube will be inserted with the neck in flexion position and digital facilitation group (Group D, n = 80). Results: Overall success rate and first attempt success were statistically higher in Group D compared to Group C (94% vs. 81%, P= 0.02, 80% vs. 62%, P= 0.01 respectively) with significantly lower insertion time in Group D (13 ± 5 s. vs. 10 ± 3 s., P= 0.00). Conclusions: Digital assistance of NGT insertion in the anesthetized or unconscious patient is an effective, fast, and safe method that can be either used as a routine technique or as a rescue in case of failed other methods.

Background and Objectives: Only a few different approaches are currently utilized for saphenous nerve block. Our study aimed to compare two different ultrasound (US)-guided saphenous nerve blocks and designed this study to test the hypothesis that the medial infracondylar approach has more success rate than the subsartorial approach applied in saphenous nerve blockage. Methods: The study included 76 patients (18–65 years old) with the American Society of Anesthesiologists physical status of I–III, who were scheduled for below-knee surgery by the orthopedics clinic. The patients who underwent US-guided saphenous nerve blockade were randomly divided into two groups: Group S (subsartorial approach) and Group M (medial infracondylar approach). For all patients who had a block procedure, the pinprick test was performed using a blunt needle on the saphenous nerve dermatome. Success rate, time of block performance (TBP), onset time of block (OTB), and duration of sensory blockade (DSB) were recorded using a patient follow-up form. Results: The US-guided saphenous nerve block success rate was similar (88% vs. 91%) or both techniques. The DSB values were 415.2 ± 65.3 min (95% confidence interval [CI]: 286.3–539.8) for Group S and 369.7 ± 52.2 min (95% CI: 265.6–467.8) for Group M (P = 0.04), and no significant differences in the TBP and OTB were observed between the groups. Conclusion: Both of the different anatomical approaches have equally high success rates. Although the DSB was found to be significantly longer in the subsartorial approach, this is clinically unimportant, and the medial infracondylar approach is still a viable alternative technique during saphenous nerve blockage.

Context: Dexmedetomidine is being increasingly used in nerve blocks. However, there are only a few dose determination studies. Aims: To compare two doses of dexmedetomidine, in femoral nerve block, for postoperative analgesia after total knee arthroplasty (TKA). Settings and Design: A prospective, randomized, controlled trial was conducted in the Department of Anesthesia at AIIMS, a Tertiary Care Hospital. Materials and Methods: Sixty American Society of Anesthesiologists I–II patients undergoing TKA under subarachnoid block were randomized to three Groups A, B, and C. Control Group A received 20 ml (0.25%) of bupivacaine in femoral nerve block. Groups B and C received 1 and 2 μg/kg dexmedetomidine along with bupivacaine for the block, respectively. Outcomes measured were analgesic efficacy measured in terms of visual analog scale (VAS) score at rest and passive motion, duration of postoperative analgesia, and postoperative morphine consumption. Adverse effects of dexmedetomidine were also studied. Statistical Analysis Used: All qualitative data were analyzed using Chi-square test and VAS scores using Kruskal–Wallis test. Comparison of patient-controlled analgesia (PCA) morphine consumption and time to first use of PCA were done using ANOVA followed by Least Significant Difference test. A P < 0.05 was considered statistically significant. Results: The VAS score at rest was significantly lower in Group C compared to Groups A and B (P < 0.05). There was no difference in VAS score at motion between Groups B and C. The mean duration of analgesia was significantly longer in Group C (6.66 h) compared to Groups A (4.55 h) and B (5.70 h). Postoperative mean morphine consumption was significantly lower in Group C (22.85 mg) compared to Group A (32.15 mg) but was comparable to Group B (27.05 mg). There was no significant difference in adverse effects between the groups. Conclusion: The use of dexmedetomidine at 2 μg/kg dose in femoral nerve block is superior to 1 μg/kg for providing analgesia after TKA, although its role in facilitating early ambulation needs further evaluation.

Purpose: The current study aimed to systematically evaluate the sonoanatomy of floor of the mouth and upper airway using protocol-based ultrasonography (USG); and to assess the feasibility of imaging the valleculae and pyriform fossae. Materials and Methods: An institutional prospective observational study was planned on fifty volunteers of all ages and both sexes, attending outpatient department for nonairway-related diseases. Protocol for ultrasonographic systemic evaluation was designed before starting the trial. All the patients were positioned supine with neck extended (sniffing position), seven steps of ultrasonographic protocol were followed and visualization of structures denoted in each step was documented. Furthermore, time taken to complete each scan was noted. Results: The USG was completed, and checklist successfully followed in all cases. Floor of mouth structures was easy to evaluate and visualized with ease in all the cases. Epiglottis was visualized in 100% cases in transverse plane. Valleculae and pyriform fossae were identified in 82% and 90% of the cases, respectively, and they appeared either as paired air-filled round structures or air-lined linear structures. Complete visualization of vocal cords was seen in 78% females and 63% males. The average time taken to complete the protocol-based study was 10.4 ± 1.4 min. Conclusions: Application of protocol-based USG for upper airway can allow the examination of structures from tongue to thyroid cartilage in a thorough, convenient, and timely manner. The air filled/lined structures such as valleculae, pyriform fossae, and vocal cords can be visualized in majority of the cases.

Background and Aim: The increasing cases of the cervical epidural but the practitioners in need for a new method to decrease the safety of the injection and to improve the learning curve of the trainee. Furthermore, it should replace the potentially hazards, conventional one, which is the fluoroscope. Acoustic signals were tested for this purpose. Methods: Thirty-two patients were assigned to have a cervical epidural for pain management using both acoustic signals and fluoroscopy simultaneously. Results: The incidence of success was 100% with no complications. Likewise, the decrease in fluoroscopy shots number was 70%. Conclusions: Acoustic signals are a simple, effective method of cervical epidural insertion. It reduces the usage of fluoroscopy and can be used as a learning tool.

Background and Aim: The aim of this prospective randomized trial is to compare the quality of reversal of rocuronium with either sugammadex (SUG) versus 2.5 mg or 5 mg neostigmine (NEO). Patients and Methods: A total of 110 patients with body mass index >40 underwent elective gastric sleeve surgery were enrolled in this study. Exclusion criteria included patients with co-existing muscular and cardiovascular diseases. Patients were randomly allocated to one of the following groups: group A (SUG), Group B (NEO 2.5 mg), and Group C (NEO 5 mg). General anesthesia was induced in the three groups using propofol 2.0 mg/kg of corrected body weight (CBW) and fentanyl 3 mcg/kg of CBW. Anesthesia was maintained with O₂/air/desflurane 1 minimum alveolar concentration. Remifentanil infusion started at 0.05–0.2 mcg/kg/min. Tracheal intubation was facilitated with rocuronium 1.2 mg/kg of CBW guided with PNS. When the train of four (TOF) reached zero, intubation was performed using a GlideScope. At the end of surgery, TOF ratio and posttetanic counts were recorded. SUG 2 mg/kg of CBW (Group A), NEO 2.5 mg (Group B), and NEO 5 mg (Group C) were administered according to the random envelope. The time to achieve 90% of TOF was recorded in seconds using a timer. ANOVA for repeated measurements was used for statistical analyses. P<0.05 was considered statistically significant. Results: There was a positive correlation (P < 0.05) between the duration of surgery and the time to reach 90% of TOF in all the three groups. The time to reach 90% TOF was significantly shorter with Group A versus Groups B and C (P < 0.05). Conclusion: Although SUG proved to be faster than NEO 5 mg in attaining TOF >90%, the recovery pattern of both was similar.

Context: Tracheal intubation is frequently facilitated with sevoflurane induction without the use of muscle relaxants in children. Aim: The aim of this study was to compare the effects of two different doses of propofol preceded by a fixed dose of fentanyl during sevoflurane induction on quality of tracheal intubation in children. Settings and Design: This was a prospective randomized study. Subjects and Methods: Ninety American Society of Anesthesiologists I-II children aged 2–6 years were randomly assigned to one of two equal groups to receive 2 μg/kg of fentanyl with 2 mg/kg of propofol (Group I) or 2 μg/kg of fentanyl with 3 mg/kg of propofol (Group II) during sevoflurane induction. The intubating conditions and hemodynamic responses were evaluated. The time from sevoflurane induction to loss of consciousness, to intravenous line insertion, and to intubation was measured. The occurrence of any adverse effect was recorded. Statistical Analysis Used: Results were analyzed using Student's t-test, paired t-test, and Chi-square test. P< 0.05 was considered statistically significant. Results: The incidence of excellent intubating conditions was achieved more significantly in Group II (41/45 patients, 91%) than that in Group I (31/45 patients, 69%) (P = 0.008) (95% confidence interval [CI] =0.39–0.8). Whereas, there were no significant differences between the two groups in terms of the overall acceptable intubating conditions in Group I (40/45 patients, 89%) and Group II (43/45 patients, 96%) (P = 0.81) (95% CI = 0.71–1.31). No patient developed any adverse effect. Conclusion: The administration of 3 mg/kg propofol preceded by 2 μg/kg fentanyl provided a higher proportion of excellent intubating conditions compared with 2 mg/kg propofol preceded by 2 μg/kg fentanyl during sevoflurane induction in children without muscle relaxants.

Minimal access procedures have revolutionized the field of surgery and opened newer challenges for the anesthesiologists. Pectus carinatum or pigeon chest is an uncommon chest wall deformity characterized by a protruding breast bone (sternum) and ribs caused by an overgrowth of the costal cartilages. It can cause a multitude of problems, including severe pain from an intercostal neuropathy, respiratory dysfunction, and psychologic issues from the cosmetic disfigurement. Pulmonary function indices, namely, forced expiratory volume over 1 s, forced vital capacity, vital capacity, and total lung capacity are markedly compromised in pectus excavatum. Earlier, open surgical correction in the form of the Ravitch procedure was followed. Currently, in the era of minimally invasive surgery, Nuss technique (pectus bar procedure) is a promising step in chest wall reconstructive surgery for pectus excavatum. Reverse Nuss is a corrective, minimally invasive surgery for pectus carinatum chest deformity. A tailor-made anesthetic technique for this new procedure has been described here based on the authors' personal experience and thorough review of literature based on Medline, Embase, and Scopus databases search.

Thoracic surgical procedures can be either thoracotomy or thoracoscopy. In thoracotomy, the incision could be either muscle-cutting or muscle-sparing incision. The posterolateral thoracotomy incision is used for most general thoracic surgical procedures. This incision, which involves division of the latissimus dorsi and serratus anterior muscles, affords excellent exposure of the thoracic cavity. However, it is associated with significant morbidity, including impaired pulmonary function, postoperative chest pain, and restricted arm and shoulder movement. Various muscle-sparing incisions have been proposed to decrease the morbidity. Postthoracotomy pain originates from pleural and muscular damage, costovertebral joint disruption, and intercostal nerve damage during surgery. Inadequate pain relief after surgery affects the quality of patient's recovery and exposes the patients to postoperative morbidities. There is a tendency nowadays among thoracic surgeons and anesthesiologists toward the area of enhanced recovery after thoracic surgery which requires careful titration of the anesthetic drugs in awake patients undergoing thoracoscopic procedures. There is a common feeling among thoracic anesthesiologists that potthoracoscopy procedures produce less pain intensity versus thoracotomy which is partially true. However, effective management of acute pain following either thoracotomy/thoracoscopy is needed and may prevent these complications and reduce the likelihood of developing chronic pain. In this report, we are going to review the newly introduced postthoracotomy/thoracoscopy pain relief modalities with special reference to the new tendency of awake thoracic surgical procedures and its impact on enhanced recovery after surgery.

Bronchial injuries are infrequently seen following blunt chest trauma and mostly have subtle clinical presentation. Its diagnosis is challenging and may be delayed resulting in myriad complications such as secondary infection, bronchiectasis, atelectasis, collapse, and fibrosis. We discuss the anesthetic management of a case of complete right principle bronchus transection with distal lung collapse, posted for surgical repair and highlight the unique intraoperative ventilation maneuver to identify the functional lung segment. This unique yet less recognized ventilation maneuver of the collapsed lung segment was performed just before bronchoplasty. The aforesaid maneuver may act as a pointer for further surgical course and a useful diagnostic and therapeutic modality in ensuring the eventual outcome in this subset of patients.

Hypoxic hepatitis (HH) is characterized by marked and transient elevations in liver enzyme levels in the absence of other potential causes of liver injury. Although rare, it can occur in the presence of hemodynamic instability and hypoxemia in patients with cor pulmonale. We report two cases of perioperative HH in patients with severe pulmonary disease and cor pulmonale. The first case is of a patient with cor pulmonale who underwent hemiarthroplasty for a femur fracture. Transient hypotension developed during spinal anesthesia and severe hypoxemia were observed in the postoperative period. After surgery, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels suddenly increased to 3740 and 817 U/L, respectively. The second case is of a patient with congestive heart failure and cor pulmonale whose blood pressure and oxygen saturation decreased during induction of general anesthesia and after surgery, and AST, ALT, and lactic dehydrogenase levels increased to 1291, 1292, and 2710 U/L, respectively. The liver enzyme levels normalized within 7–14 days in both cases. We speculate the diagnosis of these cases as HH.

Bronchogenic cyst, a benign congenital cystic lesion of the lung, is a rare cause of respiratory distress in children comprising 7.5% of all mediastinal masses. A thorough preoperative evaluation is crucial to plan for definitive intra- and post-operative management. All patients should be thoroughly evaluated for the presence of compression, deviation or distortion of airways and great veins. The easiest means of providing one lung ventilation in pediatrics is to intubate the main stem bronchus of the nonoperated lung. Other options available for pediatric one lung ventilation are single lumen endobronchial tubes, micro cuff tubes, Marraro bilumen tubes, and bronchial blockers. We hereby present a case report of a 2-month-old infant posted for excision of bronchogenic cyst along with a review of literature.

High-dose radiation brachytherapy is a treatment for inoperable cervical and endometrial carcinoma. A general anesthetic is often utilized for patient comfort, facilitating patient transport to imaging resources, and allowing rapid discharge home after the procedure. Patient comorbidities, however, must be considered for every anesthetic performed. We describe a successful surgical epidural anesthetic for a patient with challenging comorbidities, including cardiac, pulmonary, and hematologic body systems.