Objectives: Traditionally, caudal epidurals are performed by a landmark-guided approach using the loss of resistance technique. Improvisations to increase the success rate can be attained by implementing modalities, namely neurostimulation and ultrasound, but there is a paucity of literature comparing these 3 approaches. Here, we compare the 3 techniques in terms of the success rate. Materials and Methods: The primary outcome of this study was to compare the success rate of the 3 techniques, and the secondary outcome was the blood or cerebrospinal fluid aspiration during the procedure. It was a prospective, randomized, open-label parallel-group study. Three hundred children aged 1 to 5 years scheduled for circumcision, hypospadias repair, and minor lower extremity surgeries were enrolled after taking written informed consent from the parents. Results: Demographic profiles were comparable in terms of age, weight, sex distribution, and types of surgeries. Success rates in landmark-guided, neurostimulation-guided, and ultrasound-guided were 97%, 97%, and 98%, respectively which was comparable (P=0.879). There was no significant difference in the incidence of blood or cerebrospinal fluid aspiration. Discussion: We found a similar success rate of the caudal epidural block by using landmark-guided, nerve stimulation–guided, or ultrasound-guided techniques in children aged 1 to 5 years with normal anatomy.

A 3-year-old boy presented with episodes of uneasiness and transient loss of consciousness. Atrial tachyarrhythmias with rapid ventricular rate was diagnosed and initially unsuccessfully treated with oral antiarrhythmic drugs. Subsequent Holter monitoring revealed ventricular arrhythmias. Despite pharmacologic treatment, he needed numerous cardioversions. Surgical sympathectomy was planned. Initially, sympathectomy was achieved using a continuous high thoracic epidural block and was performed to ascertain the efficacy of the thoracic sympathectomy. This successfully reduced the ventricular arrhythmias and the need for antiarrhythmic agents. The epidural infusion was also used for pain relief following the subsequent surgical sympathectomy.

Background Caudal epidural analgesia is the most common regional anesthetic performed in infants. Dural puncture, the most common serious complication, is inversely proportional to age. Measuring the distance from the sacrococcygeal membrane to the dural sac may prevent dural puncture. This study measures the sacrococcygeal membrane to dural sac distance using ultrasound imaging to determine feasibility of imaging and obtaining measurements. Methods Sacral ultrasound imaging of 40 preterm neonates was obtained in left lateral decubitus, a typical position for caudal blockade. No punctures were made. The sacrococcygeal membrane and termination of the dural sac were visualized, and the distance measured. The spinal levels of the conus medullaris and dural sac termination were recorded. Results 20 males and 20 females former preterm neonates with an average weight (SD; range) of 1740 (290; 860-2350) g and average age (SD; range) of 35.0 (1.35; 32.2-39) weeks gestational age at the time of imaging. The average sacrococcygeal membrane to distal dural sac distance (SD; range) was 17.4 (3.1; 10.6-26.3) mm. Overall, the weights correlated positively with the distance but the coefficient of variation was large at 23%. The conus medularis terminated below the L3 level and dural sac below the S3 level in 20% and 10% of subjects respectively with hip flexion. Conclusion Ultrasound can be used to measure the sacrococcygeal membrane to dura distance in preterm neonates prior to needle insertion when performing caudal block and demonstrates large variability. Ultrasound imaging may identify patients at risk for dural puncture. When ultrasound is not available, needle insertion less than 3 mm/kg beyond the puncture of the sacrococcygeal membrane should prevent dural contact in 99.9% of neonates.

Video-assisted thoracoscopic surgery (VATS) is a frequently performed procedure in children which requires an efficient technique for lung isolation. Unavailability of appropriate size double-lumen tubes (DLT) for children and fiber optic scopes inspired us to create our own technique for lung isolation. This retrospective case series aims to describe our technique of C arm-aided endotracheal tube (ETT) placement for one-lung ventilation in these patients. 15 patients, aged 3 months to 10 years posted for VATS were recruited. Standard monitoring, general anesthesia and Lung isolation done as per the described protocol. Mean, standard deviation, and 95% Confidence interval was used. The mean age and weight was 43.93 months was 16.4 kg respectively. All right bronchus intubations were achieved in the first attempt. Of the 8 left bronchus intubations, 4 needed more than one attempt with a stylet inserted with a gentle J-shaped curve. Mild desaturation, seen in 2 patients during surgery was corrected with neck extension and increasing the FiO2. None of the cases required withdrawal of the tube into the trachea. One-lung anesthesia was achieved successfully in all the cases using C Arm with routine ETT.

The interscalene block (ISB) is seldom performed in neonates. We suggest that with congruous indications, favourable risk-benefit ratio and fitting expertise, any regional block that can be performed in grown-up children can be performed in neonates and premature babies as they are more sensitive to the depressant effects of anaesthetic drugs.[1] With this premise, the dense analgesia offered by regional anaesthesia (RA) without affecting the physiological milieu is beneficial. This letter aims to highlight the utility of ultrasound-guided interscalene brachial plexus block in a premature neonate thus avoiding opioids, muscle relaxants and airway instrumentation. Secondly, with sepsis being a relative contraindication for RA, it can still be judiciously implemented provided the risk-benefit ratio is favourable. We report a case of a 25-day-old baby boy, weighing 2.1 kg with the gestational age of 36 weeks and posted for left septic shoulder debridement.

The benefits of regional anaesthesia and the accompanying concerns of general anaesthesia in newborns make the former a safe and valuable addition. Multiple regional anaesthesia techniques, ranging from the central neuraxial blocks, truncal blocks, and peripheral nerve blocks are available. Empowering us to make the case to case decision to choose the most beneficial and safe block for the neonate. The applications of regional anaesthesia, over the period, have encompassed perioperative analgesia and therapeutic uses. With the addition of ultrasonography, neonatal regional anaesthesia has reached a fine amount of objectivity and accuracy. A trend of utilising regional blocks as the sole anaesthetic as against an adjuvant to general anaesthesia is setting in. In this review, we take a look at recent developments in this field in a generalised manner followed by dwelling into most of the commonly used blocks in daily practice. However, a detailed description of each block is beyond the scope of this review.

Background and Aims: The fascia iliaca compartment block (FICB) is commonly administered in children for anterolateral thigh surgery. The actual spread of the local anaesthetic (LA) beneath the fascial layers in children is not known. We hypothesised that in children there could be a possibility of the LA to reach lumbar plexus with the dose we used. Methods: This study included 25 children, aged 1-15 years for lower limb surgeries after standardised general anesthesia, the FICB was done with ultrasonography. Radio-opaque dye was tagged to LA and the fluoroscopic study was performed. The catheter was placed under ultrasonography. The primary objective was to investigate the fluoroscopic demonstration of the extent of LA spread by our technique and drug volume which is not known in children. The secondary objectives were to evaluate the intraoperative and postoperative analgesic efficacy, complications if any, of the continuous FICB catheters placed by our method. Results: In all patients, the visualisation of ilium and iliacus muscle, the fascia iliaca and needle tip was possible. The fluoroscopic imaging showed that the LA did not spread till the lumbar plexus in 20 patients. In 5 patients, delineated the psoas muscle and reached the L4 vertebral level. The analgesia was adequate. In the postoperative period, 92% had sufficient pain relief. Mild soakage was an issue with catheters. Conclusion: Although single shot fascia iliaca compartment block has limited spread of local anaesthetic in children, it is efficacious. Continuous fascia iliaca compartment block is feasible and effective in this age group.

Background and objectives The most widely used emergency medical services (EMS) model in India is the ‘108’ emergency service which primarily functions as an emergency response system to attend patients in need of critical care, trauma and accident victims. This is an observational cross-sectional study which was conducted using a questionnaire that asks the participants about their awareness and opinion of the current EMS system. The results of this study will enable us to ascertain the level of awareness of EMS among the population and address any misconceptions if they exist. Materials and methods All participants had to complete a 24-item self-administered questionnaire consisting of eight socio-demographic questions and 16 questions based on the EMS system. Questions regarding the development of the ‘112’ unified emergency service were also included. The convenient sampling method was used for data collection. The distribution of responses was examined using frequencies and percentages. Further analysis was done using the Chi-square test to compare responses between various subgroups based on the age, gender, profession, and level of education. Results A total of 1220 people from the state of Maharashtra responded to the survey and the maximum responses were from Mumbai. Majority of the respondents (59.2%) were from the age group of 15 to 30 years and, most of our responders had received education at the graduate level or above (78.2%). Only 17.5% of the respondents said that they will try to check for responsiveness if they saw a person lying unconscious by the side of the road with the scene being free of any danger. Interestingly, 78.9% of the healthcare professionals who participated in this survey would not check for responsiveness. Only 76.2% of the respondents knew that '108' is the number to dial in case of a medical emergency and about a quarter of them was not aware of it. It may seem that a good number of people are aware of the number. However, with the high number of fatalities occurring every day due to lack of medical facilities and a high current annual death toll on the roads, 100% of the population should know the emergency number. Only 20.2% of the respondents had called the EMS and asked for an ambulance. 68.5% of the respondents would immediately move out of the way and 27.5% of them would move out of their way if the ambulance’s lights and sirens were on. About two-thirds of the respondents were unaware of the development of a unified emergency number (112). However, a large majority (82.9%) were in favor of having a unified emergency number instead of a different number for each emergency. Only 43.8% of the respondents were of the opinion that the current EMS coverage was inadequate. 24.9% of the participants rated the current EMS as good, whereas 53.5% rated the EMS average and 16.9% rated it poor. Conclusions An effort should be made to make 100% of the population aware of this service. The first step for increasing awareness would be starting various advertisement campaigns. The next step would be to implement the unified emergency number (112) to address all kinds of distress calls such as police, fire, and ambulance. A very small proportion of the population is trained in first-aid or basic trauma life support. Awareness campaigns and training sessions for the general public should be conducted for the same. It is also necessary to spread awareness and help the populace know about the Good Samaritan law.

Introduction: Post-operative analgesia in patients undergoing lower abdominal surgery is very essential for immediate postoperative pain relief which can be provided by oral or parenteral medication, epidural analgesia, local blocks etc. The combined spinal–epidural technique (CSE) has become increasingly popular in recent years. The study was designed to evaluate the efficacy of epidural butorphanol and tramadol for postoperative pain relief. After the surgical procedure and regression of spinal analgesia, the epidural catheter can be used to provide postoperative pain relief. Materials and Methods: After permission from hospital ethics committee, study was conducted on 60 patients undergoing lower abdominal surgeries. Combined spinal epidural anaesthesia was planned in all these 60 patients using two segment technique.18 G epidural catheter was placed in L2-L3 space and spinal anaesthesia was given at L3-L4 space using 26 G Quincke’s needle and 0.5% bupivacaine 3ml.Sensory, motor block and hemodynamic parameters were monitored intraoperatively. Postoperatively along with hemodynamic parameters visual analogue score (VAS) was observed and at VAS > 4, study drug (either butorphanol 1mg or tramadol 50mg) was given through epidural catheter. Onset of analgesia, quality of analgesia, duration of analgesia, cardio-respiratory parameters and any side effects were monitored and documented. Statistical Analysis: Data analysis was done using the SPSS (Statistical Package for the Social Science) Version 17 for window. Discussion: Mean onset of analgesia in Butorphanol group (10.03 ± 1.85 min) was significantly faster than Tramadol group (12.17 ± 2.19 min) [Z = 4.07, p Conclusion: Epidural butorphanol provides a rapid, excellent but shorter duration of analgesia when compared to epidural tramadol. Keywords: Butorphanol, Tramadol, Postoperative analgesia, Epidural analgesia.

Introduction: Brachial plexus block is a reliable regional anaesthetic technique and a suitable alternative to general anaesthesia for upper limb surgery. We used dexamethasone 8 mg along with 0.5% ropivacaine for supraclavicular brachial plexus block. Aims: We aimed at assessing the effect of dexamethasone as an adjuvant with ropivacaine in supraclavicular brachial plexus block. Methods and materials: Sixty ASA grade I and II patients, 18-60 years old, scheduled for upper limb surgeries under supraclavicular brachial plexus block, were included in this prospective study. The patients were randomly assigned to two groups, Group RS which received ropivacaine 0.5% 28 ml + 2ml normal saline and Group RD which received ropivacaine 0.5% 28 ml+ 2 ml dexamethasone (8 mg). Onset and recovery time of sensory and motor block, duration of analgesia and quality of block were studied in both groups. Results: The two groups were comparable in demographic data. Group RD showed early onset of sensory and motor block (P<0.05). Duration of sensory and motor block was also prolonged in group RD. (P<0.05) Conclusion: Addition of dexamethasone 8mg to 0.5% ropivacaine for supraclavicular brachial plexus block provides faster onset and prolonged duration of sensory and motor blockade.