Airway management in patients with faciomaxillary injuries is challenging due to disruption of components of upper airway. The anesthesiologist has to share the airway with the surgeons. Oral and nasal routes for intubation are often not feasible. Most patients have associated nasal fractures, which precludes use of nasal route of intubation. Intermittent intraoperative dental occlusion is needed to check alignment of the fracture fragments, which contraindicates the use of orotracheal intubation. Tracheostomy in such situations is conventional and time-tested; however, it has life-threatening complications, it needs special postoperative care, lengthens hospital stay, and adds to expenses. Retromolar intubation may be an option, But the retromolar space may not be adequate in all adult patients. Submental intubation provides intraoperative airway control, avoids use of oral and nasal route, with minimal complications. Submental intubation allows intraoperative dental occlusion and is an acceptable option, especially when long-term postoperative ventilation is not planned. This technique has minimal complications and has better patients' and surgeons' acceptability. There have been several modifications of this technique with an expectation of an improved outcome. The limitations are longer time for preparation, inability to maintain long-term postoperative ventilation and unfamiliarity of the technique itself. The technique is an acceptable alternative to tracheostomy for the good per-operative airway access.

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Colorectal surgery carries significant morbidity and mortality, which is associated with an enormous use of healthcare resources. Patients with pre-existing morbidities, and those undergoing emergency colorectal surgery due to complications such as perforation, obstruction, or ischemia / infarction are at an increased risk for adverse outcomes. Fluid therapy in emergency colorectal surgical patients can be challenging as hypovolemic and septic shock may coexist. Abdominal sepsis is a serious complication and may be diagnosed during pre-, intra-, or postoperative periods. Early suspicion and recognition of medical and / or surgical complications are essential. The critical care management of complicated colorectal surgical patients require collaborative and multidisciplinary efforts.

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Diagnosing and managing critically ill patients with renal dysfunction is a part of the daily routine of an intensivist. Acute kidney insufficiency substantially contributes to the morbidity and mortality of critically ill patients. Renal replacement therapy (RRT) not only does play a significant role in the treatment of patients with renal failure, acute as well as chronic, but also has spread its domains to the treatment of many other disease conditions such as myaesthenia gravis, septic shock and acute on chronic liver failure. This article briefly outlines the role of renal replacement therapy in ICU.

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Dystonic movements after general anesthesia are very rare. The differential diagnosis includes adverse drug reaction, local anesthetic reaction, emergence delirium, hysterical response, and shivering. We present a case of a 10-year-old, otherwise healthy girl undergoing outpatient foot surgery. Involuntary jerking movements of her arms and torso every time she would drift off to sleep started about 2.5 hours after emergence from general anesthesia. The patient was easily arousable and absolutely unaware of the movements. These movements lasted for several days before they resolved completely. We believe to present the first case of sleep-related rhythmic movement disorder after general anesthesia, considering the nature of the movements in our patient.

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Background: Propofol emulsion in medium and long-chain triglycerides (MCT/LCT) has been reported to cause less injection pain than other propofol solutions in adult studies. The aim of this study was to compare the injection pain of two different propofol emulsions using two different pain scales on the pediatric population. Materials and Methods: 100 children scheduled for general anesthesia were divided into two groups. Patients were randomly assigned to receive propofol LCT or propofol MCT/LCT. Assessment and evaluation of the Ontario Children's Hospital Pain Scale (mCHEOPS) and the Wong-Baker Faces Scale (WBFS) were performed at the start of the injection until the patients lose consciousness. Results: There were no significant differences between groups in terms of demographic data. According to the mCHEOPS scale, the pain incidence of propofol LCT was 5%, whereas for propofol MCT/LCT it was 15% (P < 0.05). According to the WBFS Pain Scale, the pain incidence of propofol LCT was 17%, whereas for propofol MCT/LCT it was 21% (P > 0.05). Conclusions: Propofol MCT/LCT does not decrease injection pain; contrary to the general assumption, it causes more pain than propofol LCT in children.

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Background: Dexmedetomidine is a highly selective α₂ agonist with properties of sedation, analgesia and anxiolysis, making it an ideal anesthetic adjuvant. Using an anesthetic adjuvant that decreases requirement of anesthetics and analgesics may predispose the patient to awareness. We monitored the depth of anesthesia (DOA) using entropy to avoid unwanted awareness under anesthesia. Materials and Methods: 30 patients, American Society of Anesthesiologists grade I and II, aged between 18 to 50 years of either gender undergoing laparoscopic surgeries under general anesthesia were studied. Loading dose infusion of dexmedetomidine was started 1 mcg/kg for 15 minutes and patients were premedicated. Routine induction with propofol and fentanyl was carried out, and maintenance infusion of dexmedetomidine 0.2 mcg/kg/hr was given. Patients were monitored with standard monitoring, and in addition, the DOA was monitored with entropy. Results: A 62.5% reduction (0.75 mg/kg) in the induction dose of propofol was observed, with a 30% less end-tidal concentration of isoflurane requirement for maintenance of anesthesia, while maintaining the adequate DOA. Conclusion: Dexmedetomidine is an effective anesthetic adjuvant that can be safely used in laparoscopy without the fear of awareness under anesthesia.

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Background: Pain experienced following laparoscopic cholecystectomy is largely contributed by the anterior abdominal wall incisions. This study investigated whether subcostal transversus abdominis (STA) block was superior to traditional port-site infiltration of local anesthetic in reducing postoperative pain, opioid consumption, and time for recovery. Materials and Methods: Forty-three patients presenting for day case laparoscopic cholecystectomy were randomly allocated to receive either an ultrasound-guided STA block (n = 21) or port-site infiltration of local anesthetic (n = 22). Visual analog pain scores were measured at 1 and 4 h postoperatively to assess pain severity, and opioid requirement was measured in recovery and up to 8 h postoperatively. The time to discharge from recovery was recorded. Results: STA block resulted in a significant reduction in serial visual pain analog score values and significantly reduced the fentanyl requirement in recovery by >35% compared to the group that received local port-site infiltration (median 0.9 vs. 1.5 ΅cg/kg). Furthermore, STA block was associated with nearly a 50% reduction in overall 8-h equivalent morphine consumption (median 10 mg vs. 19 mg). In addition, STA block significantly reduced median time to discharge from recovery from 110 to 65 min. Conclusion: The results suggest that STA block provides superior postoperative analgesia and reduces opioid requirement following laparoscopic cholecystectomy. It may also improve theater efficiency by reducing time to discharge from the recovery unit.

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Objectives: To compare propofol and thiopental as anesthetic agents for electroconvulsive therapy (ECT) with respect to seizure duration, stimulus charge, and clinical effects. Materials and Methods: Randomized, blinded study of 28 patients of depression treated with bilateral ECT. In group P (n = 14), sedation was achieved with propofol 1.5 mg/kg, whereas in group T (n = 14), it was achieved with thiopentone 3 mg/ kg IV. Succinylcholine 0.4 mg/kg intravenous was given in all patients as for neuromuscular blockade. Results: The mean seizure duration of the patients in the thiopental group was 83 ± 34.43 seconds vs. 94.45 ± 21.37 seconds in the propofol group (P < 0.01). The energy delivered per treatment was 10.88 ± 4.78 J in the thiopental group vs. 12.20 ± 4.53 J in the propofol group (P < 0.05). Number of ECTs required were significantly higher in propofol group (9.71 ± 2.87) as compared to thiopental group (5.86 ± 0.36) P < 0.0001. No significant difference in duration of hospitalization was seen in both groups. The mean score on Mini-Mental State Examination (MMSE) was 29.14 in the thiopental group vs. 29.57 in the propofol group (P > 0.05). The mean score on Beck Depression Inventory (BDI) was 7.14 in the thiopental group vs. 3.29 in the propofol group (P < 0.05). Conclusions: Propofol significantly increases number of ECT required to treat although the patients received higher electrical charge and had longer seizure duration. BDI scores suggest this resulted in better outcome. Results, however, might be confounded by the differences in pharmacological treatment in the groups.

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We present a child posted for magnetic resonance imaging of brain under general anesthesia with the rare combination of mucopolysachharidosis type VI and congenital adrenal hyperplasia. The presence of both these disorders has important anesthetic implications. The pathophysiology of this rare combination of disease is reviewed with emphasis on the anesthesia management.

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Background: Supraglottic airway devices play an important role in ophthalmic surgery. The flexible laryngeal mask airway (LMA ^TM ) is generally the preferred airway device. However, there are no studies comparing it with the Cobra perilaryngeal airway (CobraPLA ^TM ) in pediatric ophthalmic procedures. Aims: To analyze the intraoperative device stability and ability to maintain normocarbia of CobraPLA ^TM and compare it to that with flexible LMA ^TM . Materials and Methods: Ninety children of American Society for Anesthesiologists physical status 1 and 2, aged 3-15 years scheduled for elective ophthalmic surgeries were randomly assigned to either the CobraPLA ^TM or the flexible LMA ^TM group. After placement of each airway device, oropharyngeal leak pressure (OLP) was noted. Adequate seal of the devices was confirmed at an inspired pressure of 15 cm H ₂ O and pressure-controlled ventilation was initiated. Device displacement was diagnosed if there was a change in capnograph waveform, audible or palpable gas leak, change in expired tidal volume to <8 ml/kg, end-tidal carbon-dioxide persistently >6 kPa, or need to increase inspired pressure to >18 cm H ₂ O to maintain normocarbia. Results: Demographic data, duration, and type of surgery in both the groups were similar. A higher incidence of intraoperative device displacement was noted with the CobraPLA ^TM in comparison to flexible LMA ^TM (P < 0.001). Incidence of displacement was higher in strabismus surgery (7/12). Insertion characteristics and ventilation parameters were comparable. The OLP was significantly higher in CobraPLA ^TM group (28 ± 6.8 cm H ₂ O) compared to the flexible LMA ^TM group (19.9 ± 4.5 cm H ₂ O) (P < 0.001). Higher surgeon dissatisfaction (65.9%) was seen in the CobraPLA ^TM group. Conclusion: The high incidence of device displacement and surgeon dissatisfaction make CobraPLA ^TM a less favorable option than flexible LMA ^TM in ophthalmic surgery.

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Endotracheal tube block due to various mechanical causes such as mucous, blood clot, denture, and ampoules have been reported. A patient of achalasia cardia with chronic passive aspiration pneumonitis developed mucoid mass in the respiratory passage which dislodged during the surgical procedure. The episode occurred almost an hour after induction of anesthesia and the dislodged mucoid mass blocked the lumen of endotracheal tube, leading to hypoxia and impending cardiac arrest. However, the patient was salvaged by replacing the tube.

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Bilateral cleft lip and palate may occasionally be associated with complex congenital cyanotic heart disease. An infant with common atrium and single ventricle with infundibular pulmonary stenosis (Blalock-Taussig shunt done recently) presented for lip repair surgery. Balanced general anesthesia was administered using sevoflurane along with a regional nerve block to maintain optimal pulmonary and systemic vascular resistance.

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Background: It is well documented that pressure-controlled ventilation (PCV) improves oxygenation and ventilation compared to volume-controlled ventilation and reduces peak airway pressure in gynecological laparoscopy. PCV with moderately inversed inspiratory-expiratory (I: E) ratio can successfully recruit collapsed alveoli and has been proved to be beneficial in intensive care. We tested the hypothesis that altering the I: E ratio to 1.5:1 in PCV improves ventilation during gynecological laparoscopy using laryngeal mask airway (LMA). Objective: To study pressure-controlled inverse ratio ventilation (PCIRV) with I: E ratio 1.5:1 as against PCV with I: E ratio 1:2 in gynecological laparoscopy with LMA using noninvasive parameters. Materials and Methods: Intraoperative hemodynamics and side-stream spirometry recordings were noted in 20 consecutive patients undergoing major gynecological laparoscopy with LMA. Flexible LMA or LMA supreme were used depending on normal body mass index (BMI) or high BMI, respectively. Results: Reversing the I: E ratio to 1.5:1 increased the tidal volume, mean airway pressures, and dynamic lung compliance significantly, all indicating better oxygenation at comparable peak airway pressures as against PCV with I: E ratio 1:2. There was no change in the end-tidal carbon dioxide. There was no auto-positive end expiratory pressure (PEEP) or change in the hemodynamics. Conclusion: Reversal of I: E ratio with PCV can be beneficially used with LMA in laparoscopy.

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Neurological events similar to transient ischemic attack in a peripartum woman are uncommon. Cerebral complications of preeclampsia, thrombo-embolic phenomena, or high spinal can mimic such situations. Spinal anesthesia with local anesthetic and opioid is an established anesthetic technique for cesarean section. Although intrathecal opioids are safe for both the mother and fetus; some unusual complications such as dysphagia alone or associated with facial numbness, aphasia, have been reported. We report a case of transient aphonia and tingling sensation over the face without any dysphagia after intrathecal administration of bupivacaine and fentanyl for cesarean section.

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Objective: To assess the influence of proseal laryngeal mask airway (PLMA) insertion on intraocular pressure (IOP). Aim: We compared the effects of PLMA insertion and laryngoscopic intubation on IOP and hemodynamic response in pediatric patients. Background: Previous studies have shown that there is no hemodynamic response to PLMA insertion similar to classic LMA insertion, but there is no published report about the influence of PLMA insertion on IOP. Conventional laryngoscopic tracheal intubation evokes a rise in IOP and cardiovascular response and has been traditionally used to secure the airway in pediatric patients undergoing ophthalmic surgery. Materials and Methods: 59 patients, less than 14 years of age, scheduled for elective ophthalmic surgery were randomly divided into two groups, group P, in which the patient's airway was secured with PLMA (using introducer tool technique), and group T, in which the airway was secured with laryngoscopy-guided endotracheal intubation. Heart rate, blood pressure, and IOP were measured just before insertion of the airway device and subsequently three times at intervals of 1 min after insertion of the airway device. Results: In group T, there was a significant rise in IOP as well as hemodynamic parameters recorded. In group P, there was no significant rise in hemodynamic parameters, but a significant rise in IOP was found though the rise was less than in group T. Conclusion: We conclude that the PLMA use is associated with lesser cardiovascular response and rise in IOP as compared to tracheal intubation.

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Background: Age related limited physiological reserves and associated co-morbidities in elderly patients require careful titration of inhalational anesthetic agents to minimize their side effects. The use of Bispectral index (BIS) monitoring may be helpful in this regard. The objectives of this study were to evaluate the effect of BIS monitoring on Isoflurane consumption during maintenance and recovery profile at the end of anesthesia. This Quasi experimental study was conducted for a 1 year period at the main operating units of a tertiary care hospital. Materials and Methods: Total 60 patients of age 60 years and above were enrolled in either standard practice (SP) or (BIS) group. In the SP group, the anesthesia depth was maintained as a routine clinical practice, while in BIS group it was maintained by monitoring the BIS score between 45 and 55. Standard anesthesia care was provided to all of the patients. Data including demographics, isoflurane consumption, hemodynamic variables and recovery profiles were recorded in both groups. Results: The mean isoflurane consumption was lower (P = 0.001) in the BIS group. The time to eye opening, extubation and ready to shift was shorter (P = 0.0001) in BIS group. The patients in BIS group had higher Post anesthesia recovery score ( P = 0.0001) than the SP group. Conclusion: The use of BIS in an elderly Asian population resulted in 40% reduction of isoflurane usage. The patients having BIS monitoring awoke earlier and had better recovery profiles at the end of anesthesia.

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Management of the difficult airway in an infant is a challenge for the anesthesiologist. A 10-month-old infant presented to an otolaryngologist with nasopharyngeal mass since birth, which had increased rapidly in size in the last 1 month and was hanging through the cleft palate into the oropharynx. The infant was scheduled for excision of the nasopharyngeal mass through a maxillary approach and the tongue mass through an oral approach under general anesthesia. This case report describes endotracheal intubation performed successfully under sedation and local anesthesia in an infant with a nasal mass protruding through the cleft palate into the oropharynx.

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Context: ProSeal Laryngeal Mask Airway (PLMA) is extensively being used in pediatric anesthesia. Aims: To evaluate the efficacy of PLMA as compared to Classic Laryngeal Mask Airway (CLMA) for airway maintenance in pediatric patients. Settings and Design: A prospective, randomized, Single-blinded study was conducted in a tertiary care teaching hospital. Materials and Methods: Sixty ASA I and II children were included. Patients were randomized to either size 2 PLMA or size 2 CLMA groups. Parameters noted were time for insertion, number of attempts, airway sealing pressure, blood pressures (systolic, diastolic, and mean), pulse rate, end-tidal carbon dioxide (EtCO ₂ ), peripheral oxygen saturation (SpO ₂ ), and postoperative change in abdominal circumference, and airway trauma. Statistical analysis used: Parametric data were analyzed with the unpaired t-test and non-parametric data were analyzed with the chi-square (c² ) test. Unless otherwise stated, data are presented as mean (SD). Significance was taken as P < 0.05. Results: There was no statistical difference between the two groups for the success rates at the first attempt of insertion, airway sealing pressure, hemodynamic responses, SpO _2, EtCO ₂ and postoperative changes in abdominal circumference. Patients in the PLMA group had longer time of insertion and higher incidence of airway trauma. Conclusions: The PLMA and the CLMA were comparable for hemodynamic and ventilatory parameters and change in abdominal circumference; however, the time taken for insertion and airway trauma was more with PLMA.

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Midazolam can induce acute dystonia in childhood. We report the development of acute dystonia in a 6-year-old girl after receiving midazolam as a sedative. Dystonic contractions persisted despite flumazenil and biperiden lactate injections and the patient was treated with diazepam. Acute dystonia was rapidly abolished after the administration of diazepam intravenously. Diazepam may be an effective treatment option in patients who are unresponsive to flumazenil.

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Background: Individual parturients experience pain differently, and it is unknown how these differences affect their requirements for labor analgesics. Materials and Methods: Cuff algometry of the upper limb was used to determine the pain thresholds and temporal summation of pain scores in nulliparous women about to undergo induction of labor. Analgesia was provided, upon request, with a patient controlled epidural analgesia infusion of bupivacaine and fentanyl. Nurse-administered epidural boluses of bupivacaine or lidocaine were given for breakthrough pain. Partial Spearman correlations were used to correlate the cuff algometry measurements with the amount of analgesic medication required by the patient. Results: There was no significant correlation between any of the algometry measurements and the number of patient or nurse administered bupivacaine boluses. There was a correlation of 0.7 (P = 0.001) between the temporal summation scores and the hourly number of nurse-administered epidural lidocaine boluses; however, this was based on only 3 patients who required lidocaine boluses. Conclusions: The use of pre-labor cuff algometry of the upper limb does not correlate with the patient epidural analgesic requirements and subsequent analgesia administration.

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Lighted stylets may be used for assisting in oral intubation in both adult as well as pediatric age groups. We report the anesthetic management of an 11- month-old infant with fractured mandible where the airway was secured with tracheal lightwand-guided nasal intubation after the failure of repeated attempts of conventional laryngoscopy.

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Airway management of adult patients with acute supraglottitis is challenging. The sign and symptoms of the disease may show marked variation in terms of severity and progression. Thorough evaluation is required before selecting any particular approach. We report the case of an adult patient with acute supraglottitis, in whom active airway intervention was planned. The clinical predictors were not suggestive of any airway compromise in our patient. However, the disease was found to have an unanticipated rapidly progressive course leading to the significant edema of the oropharynx and the surrounding structures as evidenced by the laryngoscope and computerized tomography scan findings.

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