INTRODUCTION: Managing the airway presents a significant challenge in anesthesia, particularly in obese patients, and is a leading cause of morbidity and mortality associated with anesthesia. Although increased tongue thickness in the obese is generally assumed to be associated with a difficult intubation. So that aim of this study was to evaluate ultrasound guided measurement of tongue thickness in predicting difficult tracheal intubation in obese patients. MATERIALS AND METHODS: Study included 45 patients aged 18 to 65 of any gender. These patients, classified as American Society of Anesthesiologists Grade I and II, had a Body mass index exceeding 30 kg/m2. Tongue thickness was evaluated using ultrasound, measuring the distance from the tongue surface to the submental skin, while also documenting the modified Mallampatti score (MMP). Number of attempts for intubation, time taken for intubation and use of any alternate device or technique were noted. RESULTS: The tongue thickness cutoff for predicting difficult intubation was determined to be 6.5 cm. The Receiver operating characteristic (ROC) curve analysis revealed an AUC (Area under the ROC Curve) of 0.920 (Standard Error: 0.230, 95% Confidence interval: 0.850-0.950) for a cutoff value exceeding 6.5 cm, indicating excellent predictive capability. Tongue thickness demonstrated a combined diagnostic accuracy of 95.5%, with sensitivity and specificity of 75% and 97.5% respectively. MMP grade was compared with tongue thickness, a positive correlation was seen with co-efficient of 0.45. There was a statistically significance (p value <0.001). CONCLUSIONS: This study concludes that ultrasound guided measurement of tongue thickness > 6.5 cm can reliably predict difficult tracheal intubation in obese patients.

Introduction: Supraglottic airway devices have become extremely popular for minor therapeutic and surgical procedures. Their insertion requires an adequate depth of anesthesia with suppression of pharyngeal reflexes. Propofol is the most commonly used agent, but has hemodynamic side-effects. Etomidate, although hemodynamically stable, does not suppress pharyngeal reflexes adequately. Moreover, the use of clinical signs to assess the depth of anesthesia has questionable accuracy. Using bispectral index (BIS) monitoring, the hypnotic component of the anesthetic can be measured, with values of 40e60 implying adequate depth of anesthesia.Methods: This randomized controlled trial included 80 ASA I patients, divided into two groups of 40 patients. Each group received either propofol or etomidate infusion, with BIS monitoring. At BIS 50, infusions were stopped and SGA was inserted. Changes in hemodynamic parameters, time for SGA insertion, number of attempts, and SGA insertion scores were recorded.Results: When BIS reached 50, a statistically significant fall in mean arterial pressure was observed in the propofol group. Time for SGA insertion was less in the propofol group (30.7 & PLUSMN; 8.0 s), with successful SGA insertion observed in 92.5% of patients on the first attempt, compared with 47.9 & PLUSMN; 9.1 s and 32.3% in the etomidate group.Conclusion: In comparison with etomidate, the use of propofol is associated with better conditions for SGA insertion but has the side-effect of hypotension, even with BIS-guided titration of dose for main-taining an adequate depth of anesthesia.& COPY; 2023 Published by Elsevier Ltd.

Background and Aims: Obstetric airway guidelines recommend preoxygenation before the induction of general anesthesia to achieve an end tidal oxygen concentration of ≥90%. Recently, high flow nasal oxygenation (HFNO) has been evaluated as a technique for delivering a high concentration of oxygen using high flow rates to patients. We evaluated the use of HFNO as a technique for preoxygenation in full-term pregnant women. Methods: A cross-sectional observational study was conducted on 100 term pregnant women. They underwent preoxygenation using HFNO for 4 minutes (30 L/min for 30 secs followed by 50 L/min for 210 secs) and end tidal oxygen concentration (ETO2) was measured at the end of preoxygenation. The primary outcome was the percentage of women who achieved an expired oxygen concentration of ≥90% for the first expired breath. The secondary outcome was the acceptability and comfort of HFNO as compared to facemask preoxygenation using a 4-point Likert scale. Results: The percentage of women who achieved expired oxygen concentration of ≥90% after 4 minutes of HFNO preoxygenation was 32% [95% confidence interval (CI):22.7-41.3%] with the mean end tidal oxygen (SD) being 86.67 (3.4). 71% [mean (SD): 2.94 (0.92)] found nasal cannula and 56% [mean (SD): 2.67 (1.21)] found facemask comfortable and acceptable for preoxygenation (P value, 0.05). Conclusion: Although HFNO is a comfortable technique, when used for preoxygenation for 4 minutes, it did not achieve an acceptable level of preoxygenation (ETO2 ≥90% in 95% of individuals). Therefore, it is an inadequate technique for preoxygenation in term pregnant women.

Dear Editor, The vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to expand across the globe. Concurrently, a large number of dermatological adverse effects related to vaccination are vigorously reported. A study conducted by Rerknimitr et al encompassing over 35 000 vaccine receiving healthcare workers stated the incidence of cutaneous adverse effects to be <1%. India launched its vaccination drive on 16 January 2021 and has vaccinated over 320 million individuals (23.4% of the total population) by July 2021. Amongst various vaccine-related adverse effects, leprosy reactions have sparse mention in the literature limited to mere case reports and case series. We report a series of four cases of Hansen’s disease with leprosy reactions spanning across the entire spectrum after being administered the vaccine from a leprosy care centre in India. Of the four cases included in the series, three were borderline tuberculoid (BT) leprosy while one was of borderline lepromatous (BL) pole of the Ridley–Jopling classification. Of the three BT leprosy cases, two were released from treatment (RFT) after completing 6 months and one year of MDT, respectively. Two kinds of vaccines were administered, covishield (Recombinant ChAdOx1-S) vaccine manufactured by the serum institute of

Peripartum cardiomyopathy (PPCM) is a potentially life-threatening disease. However, timely intervention and early detection can save lives. It presents in peripartum period as left ventricular dysfunction and heart failure. Although the disease is relatively rare, its incidence is rising. Previous research states vascular dysfunction, triggered by late-gestational maternal hormones such as abnormal prolactin and many other causes may lead to the development of PPCM. We have reviewed here the known epidemiology, pathophysiology, clinical presentation, management, and anesthesia concerns of PPCM.

Sir, A 46-year-old American Society of Anesthesiologists grade I female presented with pseudomyxoma peritonei (PMP) planned for cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). PMP is an uncommon slow-growing tumor arising in appendix and ovaries (80%)[1] with diffuse intra-abdominal mucinous implants on peritoneum and omentum. CRS with HIPEC has emerged as an effective treatment for patients with various gastrointestinal cancers, peritoneal mesothelioma, and ovarian cancers compared with intravenous chemotherapy alone. Inside operation theater 16 G intravenous cannulas secured in upper limb and thoracic epidural was inserted at T7–T8 space. After preoxygenation rapid sequence induction done with propofol and rocuronium. The maintenance of anesthesia was carried on using oxygen, nitrous oxide (40:60), and isoflurane. Intraoperative monitoring consisted of electrocardiography, pulse oximetry, capnography, temperature, invasive blood pressure, central venous pressure, hourly urine output, and arterial blood gas at regular intervals. Deep vein thrombosis pump was applied. To avoid intraoperative hypothermia forced-air warming blanket used and warm fluids were administered. To treat macroscopic disease, complete surgical resection is done during the CRS phase Midline incision extended from xiphisternum to pubic symphysis [Figure 1]. Resection included omentectomy, left hemicolectomy, hysterectomy, bilateral salpingo-oophorectomy, cholecystectomy, and excision of diaphragmatic peritoneum. Total blood loss during this phase was 800 ml. Crystalloids (10 ml/kg/h) were used as maintenance and replacement fluids. CRS phase lasted for 9 h.Figure 1: Surgical Exposure- Balfour RetractorBefore starting the HIPEC phase forced air heating blanket was stopped, and warm fluids were replaced with cold fluids. For microscopic disease, specific intraperitoneal chemotherapy is administered using 30 mg Mitomycin C dissolved in 3 L of saline which was heated to 41°C–42°C. The solution was then poured in abdomen using open technique. A sterile temperature probe was placed in abdomen to monitor the intra-abdominal temperature continuously and abdomen was covered with plastic cover to prevent any heat loss [Figure 2]. The intra-abdominal temperature was maintained by intermittently in vitro heating the drug solution. The HIPEC phase lasted for 90 min during which urine output monitored every 15 min and arterial blood gas monitoring was done every 20 min. Throughout the HIPEC phase, cold crystalloids (15 ml/kg/h) were infused to maintain normothermia. The maximum core body temperature recorded during the HIPEC phase was 38.4°C, which dropped down to 37.0°C. At the conclusion of HIPEC core, body temperature came down to 37.0°C. Intraperitoneal chemotherapy has the advantage that it acts immediately and can be given in high concentration as compared to intravenous route.[2] Hyperthermia is directly cytotoxic to cancer cells, causing increased drug penetration and is synergistic with some chemotherapy agents.[3]Figure 2: Hyperthermic PhaseTotal duration of the procedure was 13 h. The patient was shifted to ICU for elective ventilation and extubated next day. CRS with HIPEC is a long and complex procedure with significant blood and fluid loss during debulking. Hemodynamic, hematological, and metabolic alterations before and during the HIPEC phase, and even in the early postoperative period may result in significant morbidity and mortality.[4] Hence, the maintenance of normovolemia, normothermia, coagulation status, and pain management are the main goal CRS with HIPEC has now become standard treatment for patients having peritoneal surface malignancies. But as of now, very few centers are performing this procedure because of shortcomings of equipment availability, complexity, and expertise. The available literature shows the use of closed technique only but in our institute roller pumps are not available, and we adopted open technique with limited resources. The outcome was rewarding as patient walked of hospital cancer free on 13th postoperative day. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgment We would like to acknowledge Dr. Neerja Banerjee, Senior Consultant, Department of Anaesthesia, Dr. RML Hospital, PGIMER.

Patients with a congenital single ventricular chamber, survives only because the systemic and pulmonary venous blood mixes. However such an arrangement has two major disadvantages of arterial desaturation and chronic volume overload to the single ventricle. In 1971, Francis Fontan from France, reported a new approach to the operative treatment of these malformations, separating the systemic and pulmonary circulations. The advancement of surgical techniques and medical management have resulted in greater than 90% survival rate of about 10 years after Fontan palliation. As a result, patients with Fontan physiology are increasingly presenting in the adult perioperative setting for various noncardiac surgeries. Understanding the Fontan physiology is essential for the successful anaesthetic management of these patients. We report a case of 22 year female with fontan physiology posted for elective laparoscopic cholecystectomy.

A 64 years, ASA 1 male patient with median arcuate ligament syndrome was posted for laparoscopic release of coeliac artery compression. The median arcuate ligament is a fibrous arch that unites the diaphragmatic crura on either side of the aortic hiatus. The ligament usually passes superior to the origin of the celiac artery near the first lumbar vertebra. . Infrequently, when this union occurs anterior to celiac axis it may cause hemodynamically significant stenosis compressing the vessel and nerves leading to median arcute ligament (MALS).The surgery of median arcuate ligament release for coeliac artery decompression involved working in the proximity of major vessels. Anticipation of major blood loss should be kept in mind that may be may be further compounded by the disease process in the vessels which make repair of vessels more difficult.Iatrogenic aortic injury happened in our case which was succesfully managed. Timely involvement of cardiovascular surgeons is important therefore the case has to be discussed with them prior proceeding for surgery. Hypothermia, hemorrhagic shock, coagulopathy, hypoxia, acidosis,pre-renal failure can be prevented with thorough preparation and timely intervention.

Acute intermittent porphyria (AIP) presents with diverse group of symptoms making its early diagnosis difficult. Delaying diagnosis and treatment of AIP can be fatal or can cause long term or permanent neurological damage. We present here a case report of AIP where the diagnosis was missed. The diversity of symptoms and details concerning the treatment options for AIP are discussed.

Aims to compare the efficacy of Proseal laryngeal mask airway(PLMA) and endotracheal tube (ETT) in patients undergoing laparoscopic surgeries under general anaesthesia. This prospective randomised study was conducted on 60 adult patients, 30 each in two groups, of ASA I-II who were posted for laparoscopic procedures under general anaesthesia. After preoxygenation, anaesthesia was induced with propofol, fentanyl and vecuronium. PLMA or ETT was inserted and cuff inflated. Nasogastric tube (NGT) was passed in all patients. Anaesthesia was maintained with N(2) O, O(2), halothane and vecuronium. Ventilation was set at 8 ml/kg and respiratory rate of 12/min. The attempts and time taken for insertion of devices, haemodynamic changes, oxygenation, ventilation and intraoperative and postoperative laryngopharyngeal morbidity (LPM) were noted. There was no failed insertion of devices. Time taken for successful passage of NGT was 9.77 s (6-16 s) and 11.5 s (8-17 s) for groups P and E, respectively. There were no statistically significant differences in oxygen saturation (SpO(2)) or end-tidal carbon dioxide (EtCO(2)) between the two groups before or during peritoneal insufflation. Median (range) airway pressure at which oropharyngeal leak occurred during the leak test with PLMA was 35 (24-40) cm of H(2)O. There was no case of inadequate ventilation, regurgitation, or aspiration recorded. No significant difference in laryngopharyngeal morbidity was noted. A properly positionedPLMA proved to be a suitable and safe alternative to ETT for airway management in elective fasted, adult patients undergoing laparoscopic surgeries. It provided equally effective pulmonary ventilation despite high airway pressures without gastric distention, regurgitation, and aspiration.

Background and objectives: Adequate patient sedation is necessary for diagnostic and therapeutic upper gastrointestinal endoscopic procedures. Propofol is being increasingly used due to its potential advantages of rapid action and clear headed recovery. The aim of this prospective, randomized study was to compare propofol and midazolam for conscious sedation during upper gastrointestinal tract endoscopy with respect to quality of sedation, safety and recovery profile along with the satisfaction of endoscopist in carrying out the procedure on an outpatient setting . Methods: Eighty-one consecutive patients of (ASA) status I-III undergoing upper GI endoscopy were randomly assigned to

AIMS:To evaluate the antiemetic efficacy of ondansetron, metoclopramide or small dose of propofol following ear, nose and throat (ENT) surgery.MATERIALS AND METHODS:A prospective randomized study involving 60 patients, both children and adults undergoing elective ENT surgery under standard general anesthesia. At the completion of surgery the patients received either 0.1 mg/kg of ondansetron or 0.2 mg/kg of metoclopramide or 0.5 mg/kg of propofol intravenously. The patients were observed for 24 hrs after operation for any occurrence of nausea and vomiting.RESULTS:The incidence of postoperative nausea and vomiting (PONV) during first 24 hrs was recorded in 20%, 70%, 50% of patients who had received ondansetron, metoclopr-amide or propofol respectively (p < 0.05). Fewer patients given ondansetron needed rescue antiemetic. The incidence of PONV was higher following middle year surgery.CONCLUSION:It was concluded that ondansetron was most effective in preventing occurrence of PONV while metoclopramide was least effective. Propofol was effective only in 50% of patients, thus not recommended for routine use.

Conservative management of subdural haematoma with antioedema measures in second gravida with idiopathic thrombocytopenic purpura (ITP) resulted in resolution of haematoma. We present a case of second gravida with ITP who developed subdural haematoma following normal vaginal delivery. She was put on mechanical ventilation and managed conservatively with platelet transfusion, Mannitol 1g/kg, Dexamethasone 1mg/kg and Glycerol 10ml TDS. She regained consciousness and was extubated after 48 hrs. Repeat CT after 10 days showed no mass effect with resolving haematoma which resolved completely after 15 days. Trial of conservative management is safe in pregnant patient with ITP who develops subdural haematoma.

Subsequent investigation revealed that on the previous day gas hoses of the same OR were disconnected for maintenance. Subsequently, only the O2 hose was connected by the maintenance staff and the N2O hose remained disconnected from the terminal unit overnight. It was possible that the water vapour entering from the atmosphere could have condensed under pressure on reconnection in the morning. A routine morning check of the machine did not reveal any problem due to the small quantity of water, which took some time to reach up to the flowmeter. A similar incident had been reported earlier, where a central air pipeline was found contaminated by water condensation, as it was kept open to atmosphere during maintenance.[1] We feel that purging of hoses must be done with central pipeline dry gases before connecting the yoke adapter to the machine for prevention of this problem. In addition to patient safety concerns, any water in the gas supply would also lead to malfunction of vaporisers and a major break down in the modern anaesthesia machines with electronic components.

Purpose of review To evaluate the efficacy of a single preoperative dose of 600 mg of gabapentin for reducing postoperative pain and tramadol consumption after minilap open cholecystectomy. Method A total of 120 adult patients of either sex were randomly assigned to receive 600 mg of gabapentin or a matched placebo orally 2 h before operation in a double-blind manner. All the patients received gabapentin using the same technique. Postoperative analgesia was provided with intravenous patient-controlled analgesia with tramadol using a 50-mg initial bolus dose, 20-mg incremental dose, 15-min lockout interval and 4-h limit of 240 mg. Patients were assessed at 0, 2, 4, 8, 12, 24 and 48 h after operation for verbal analogue pain scores at rest and at movement. Consumption of tramadol on first and second postoperative days and any adverse effects were also recorded. Results Verbal analogue pain scores were significantly lower on first postoperative day at all times of observation both at rest and at movement in gabapentin group than in placebo group (P < 0.01). Tramadol consumption was also reduced by 33% in gabapentin group. But pain scores and tramadol consumption were similar in two groups on second postoperative day. Sedation was common but the incidence of postoperative nausea and vomiting was significantly lower in gabapentin group. Conclusion Preoperative administration of 600 mg of gabapentin resulted in significant reduction in postoperative verbal analogue pain scores at rest and at movement as well as tramadol consumption compared with placebo on first postoperative day. Lower incidence of nausea and vomiting was an additional advantage. Sedation was the commonest side effect.

Objectives: A study to compare the efficacy between fentanyl and sufentanil combined with low concentration (0.0625%) of bupivacaine for epidural labor analgesia in laboring women Materials and Methods: Fifty full term parturients received an initial bolus dose of a 10 ml solution containing 0.125% bupivacaine. The patients were randomly divided into two: group F received 0.0625% bupivacaine with 2.5 mcg/ml fentanyl and group S received 0.0625% bupivacaine with 0.25 mcg/ml sufentanil. Verbal analogue pain scores, need of supplementary/rescue boluses dose of bupivacaine consumed, mode of delivery, maternal satisfaction, and neonatal Apgar scores were recorded. No significant difference was observed between both groups. Results: Both the groups provided equivalent labor analgesia and maternal satisfaction. The chances of cesarean delivery were also not increased in any group. No difference in the cephalad extent of sensory analgesia, motor block or neonatal Apgar score were observed. Although mean pain scores throughout the labor and delivery were similar in both groups, more patients in fentanyl group required supplementary boluses though not statistically significant. Conclusion: We conclude that both 0.0625% bupivacaine-fentanyl (2.5 μg/ml) and 0.0625% bupivacaine-sufentanil (0.25 μg/ml) were equally effective by continuous epidural infusion in providing labor analgesia with hemodynamic stability achieving equivalent maternal satisfaction without serious maternal or fetal side effects. We found that sufentanil was 10 times more potent than fentanyl as an analgesic for continuous epidural labor analgesia.

Summary This preliminary study on I-gel™ (Intersurgical Ltd, Wokingham, U K) was conducted on 50 consecutive patients of ASA physical status I-III, to determine the ease of insertion, time to achieve effective airway, oropharyngeal seal pressure and airway stability on head and neck movement. After premedication with midazolam and fentanyl, induction was done with propofol and I-gel was inserted according to manufacturer's instruction. An effective airway was confirmed by bilateral chest movement, square wave on capnograph and SpO2>95%. The success rate at first attempt was 90% with a median insertion time of 11 sec (range 8-45sec). Five patients (10%) needed second attempt while none needed 3rd attempt. The manipulation needed to achieve effective airway were increasing the depth of insertion of I-gel in 4 (8%) cases, jaw thrust or chin lift in 2(4%) cases. Oropharyngeal seal pressure was 20 cm of H2O (16-40 cm of H2O). Gastric tube placement was done in 50% of the cases; it was easy and successful in all the cases. No significant adverse event was noted in any of the patient in perioperative period. Our initial experience showed that I-gel is a simple, easy to use supraglottic airway device with a high success rate at first time insertion.