Anxiety is an emotional state characterized by apprehension and fear resulting from the anticipation of a threatening event. The incidence of preoperative anxiety ranges from 11% to 80% in adult patients and also varies among different surgical groups. Preoperative anxiety may lead to various problems and a wide range of physiological and psychological responses. A variety of objective and subjective methods are available for measuring preoperative anxiety. Every patient scheduled for surgery should be assessed for the presence of anxiety in their routine preoperative anesthesia assessment, and counseling should be done by anesthesiologist in patients with a high level of anxiety. Surgery information reduces anxiety in the preoperative period.

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Aim and Objective of the Study: This prospective study was undertaken at Christian Medical College and Hospital Vellore, India. In this study we evaluated the sensitivity and specificity of airway examination tests including: modified Mallampati test (MMT) Thyromental Distance (TMD), ULBT (Upper Lip Bite Test). BMI (Body Mass Index) was also included as one of the predictors. The tests were evaluated individually and in combination. Methods: Total of 354 patients was recruited. Preoperative airway assessments of patients by Mallampati test, Thyromental Distance measurement, ULBT were done. The BMI was also calculated. The tests were done by the investigator and Laryngoscopic grading done by another experienced Anaesthetist according to modified Cormack and Lehane classification. The sensitivity, specificity, positive predictive and negative predictive values were analyzed for the individual tests and in combination. Statistical analysis was performed using SPSS version 11.0. Results: The modified Mallampati had the highest sensitivity of 70% which was statistically significant with a P = 0.001. Conclusion: From this study we conclude that the modified Mallampati test was a better predictor of difficult intubation than the upper lip bite test and Thyromental Distance.

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Background: The benefit of postoperative analgesia in regional block is short lived due to limited duration of action of local anesthetics. Various adjuvants have been tried to enhance the duration of analgesia. The aim of this study was to evaluate the analgesic efficacy and safety of nalbuphine as an adjuvant to 0.5% ropivacaine for ultrasound-guided supraclavicular brachial plexus block. Methods: A prospective, randomized, double-blind study was conducted on 100 patients of American Society of Anesthesiologists physical status I/II aged 18–70 years scheduled for upper limb surgeries under USG supraclavicular brachial plexus block. The patients were randomly allocated into two groups of 50 each to receive either 20 ml of 0.5% ropivacaine with 1 ml of normal saline (Group A) or 20 ml of 0.5% ropivacaine with 1 ml (10 mg) of nalbuphine (Group B). The onset and duration of sensory and motor block, duration of analgesia, and side effects were noted. Results: There was no significant difference in mean onset of sensory and motor blocks between the two groups; but in Group B, there was significantly longer duration of sensory block (401.20 ± 19.963 vs. 387.60 ± 29.731 min, P = 0.009), longer duration of motor block (333.20 ± 20.941 vs. 323.00 ± 26.283 min, P = 0.03), and prolonged duration of analgesia (502.60 ± 22.751 vs. 441.20 ± 30.815 min, P < 0.0001) as compared to Group A. No significant side effects were observed in any of the two groups (P > 0.05). Conclusion: Nalbuphine (10 mg) used as an adjuvant to 0.5% ropivacaine for supraclavicular brachial plexus block prolonged the duration of both sensory and motor blockade along with the duration of postoperative analgesia without any increase in side effects.

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Background: Intubation of trachea with conventional laryngoscopy requires alignment of the oropharyngeal–laryngeal axis in a straight line. This causes significant movement of the cervical spine, which in case of any previous injury to the spinal cord, may be further damaged due to impingement of the cord between the broken vertebrae. King Vision^® video laryngoscope due to its particular J shape and a channel to carry the tube, causes less movement of the spine and hence provides better and safer intubation conditions in patients who have cervical injury. Methods: The study was conducted in a tertiary-level orthopedic and spine center. It was a single-blind randomized control study. After obtaining permission from Hospital Ethics Committee and patient's consent, 60 patients of cervical spine injury of American Society of Anesthesiologists I-III, and normal airway anatomy, were assessed for ease and safety of intubation by – (a) King Vision^® video laryngoscope and (b) Macintosh laryngoscope. The primary criteria were Intubation Difficulty Scale (IDS), while the secondary criteria were duration of intubation, heart rate, and mean arterial pressure. Results: Results were analyzed by Chi-square, Mann–Whitney, and Student t-test using SPSS software. P value was 0.05. The mean IDS in King Vision^® video laryngoscope group was significantly less than Macintosh group. However, there was no statistical difference in duration of intubation and hemodynamic parameters. Conclusions: Intubation in cervical spine injury patients with neck immobilization is easier with King Vision^® video laryngoscope, but duration of intubation, complication rate, and hemodynamic parameters remain the same as compared with Macintosh laryngoscope.

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Background: Caudal block is a popular regional anesthesia technique in pediatrics for anesthesia and perioperative analgesia. Conventional landmark-based technique is a simple technique with good success rate but associated with complications such as dural puncture and venous injection. Ultrasound-guided caudal block is known to improve the success rate and reduce the complications noted with the landmark technique. We aimed to compare the success rates of caudal block in landmark- and ultrasound-guided techniques. Methods: One hundred and twenty-four children under 10 years admitted for infraumbilical surgeries were randomly allocated to Group L and Group U caudal block was administered based on landmarks in Group L and by using ultrasound in Group U. In both the groups, observations noted were success of caudal block, visibility and palpability of sacral cornu; identification of hiatus; first attempt success; number of attempts; block performance time; and complications. In Group U, ultrasound visualization of sacral hiatus, needle, and distension of sacral canal with injection was also noted. Results: Success rates were 81.8% and 92.1% in Group L and Group U, respectively (P = 0.045). Complications noted in Group L were blood tap (23.8%), subcutaneous swelling (15.2%), dural puncture (1.5%), and rectal perforation (1.5%). In Group U, only blood tap (3%) was the complication noted. Block performance was faster in Group L than Group U. There was no significant difference in the first attempt success rate and number of attempts. Conclusion: Ultrasound-guided caudal block improves the success rate, reduces complications, and ensures safety.

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Background: The current bedside predictors of the difficult airway are not perfect. A new test, the acromio-axillo-suprasternal notch index (AASI), has been found to be superior to conventional predictors. In this study, we have compared the accuracy of AASI with upper lip bite test (ULBT) and modified Mallampati (MMP) test to predict difficult laryngoscopy and the time taken to complete each test. Methods: Institutional ethical committee clearance was obtained, and written informed consent was taken from 150 patients posted for elective surgery under general anesthesia with endotracheal intubation. Preoperative airway examination was carried out with AASI, ULBT, and MMP score. AASI ≥0.49, ULBT Class III, and MMP score III/IV were considered as predictive of difficult visualization of larynx (DVL). After the induction of anesthesia, the laryngeal view was recorded according to Cormack–Lehane (CL) grade. Sensitivity, specificity, predictive values, and accuracy were calculated for all the three tests. Results: DVL (CL Grades 3/4) was observed in 18 (12%) patients. AASI was found to have higher specificity (93.2%), positive predictive value (PPV) (55%), and accuracy (89.3%) when compared to MMP and ULBT. MMP was found to have the highest sensitivity (77.8%), and ULBT was found to have least sensitivity (50%). Time taken for AASI was higher (13.01 ± 1.03 s) when compared to ULBT (7.49 ± 1.95 s) and MMP (3.97 ± 0.49 s). Conclusion: We conclude that the MMP is the most sensitive and fastest test to predict DVL when compared to AASI and ULBT. AASI is a better predictor for DVL as it has higher specificity, PPV, accuracy, and odds ratio when compared to standard tests such as MMP and ULBT.

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Background and Aim: Physiology of the human body changes with aging making physicians more inclined toward the use of routine preoperative investigations in the elderly to detect hidden abnormalities. The present study was aimed to assess the prevalence of abnormal test results and their impact on anesthetic management among patients aged 60 years or more. Methods: This observational study was conducted during December 2016 to April 2017. Data were collected by prospectively screening the files of the patients attending preanesthetic evaluation clinic (PAEC). Demographic parameters, physical status, surgery grade, normal and different abnormal test results, and their impacts were noted. Data were expressed in absolute numbers, percentage scale, and number needed to investigate (NNI). Central tendencies and dispersions were calculated using INSTAT software. Results: Data from file of 181 patients (mean + standard deviation age 66.69 + 5.89 years; 82 [45.30%] female) were collected. The median American Society of Anesthesiologists physical status was II and 59.67% underwent National Institute of Clinical and Health Excellence Grade 1 surgery. Entire patient attended PAEC with routine investigations done; 125 (69.06%) had at least one abnormality. Out of total 1275 tests done, 241 (18.90%) results were abnormal. Only 27 (11.20%) abnormality had an impact; 21 (77.78%) did not alter preoperative/anesthetic management but led to further testing, unnecessary consultation, and mean 3.84 days delay. The NNI for detecting one significant impact was 255. Conclusion: Majority of the patients aged 60 years or more were having at least one abnormal test results in routine preoperative tests but had minimal impacts in perioperative anesthetic management. It caused unnecessary further testing, consultation, and delay. Age per se should not be a criterion for ordering routine preoperative testing. The clinical trial registration number was CTRI/2018/01/011235.

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Background: Different central venous devices are required in cancer patients for long duration, especially in hematological malignancies. In this new era of highly developed long-term central venous devices such as port and peripherally inserted central catheter line, incidence of catheter-related bloodstream infection (CRBSI) is low. However, immunocompromised cancer patients may acquire catheter-related opportunistic infections frequently including Burkholderia cepacia. B.cepacia can cause various bloodstream infections, pneumonias, and wound infections etc. Methodology and Result: We analyzed an outbreak of 14 cases of B. cepacia infection in patients with long-term central venous lines at a tertiary oncology care center. Febrile neutropenia was the only clinical presentation at the time of detection of infection in almost all patients, and the catheter had to be removed in 10 patients owing to partial response to susceptible antibiotic therapy. The source of infection that led to the outbreak could not be identified. Nevertheless, all possible measures to prevent cross-contamination including training of the staff to maintain hand hygiene and aseptic precautions were taken. Although resecuring central venous access is difficult in these patients due to bleeding diathesis, timely decision to remove the catheter based on standard guidelines can prevent complications. To the best of our knowledge, this is the first outbreak of B. cepacia-positive CRBSI reported in this specific subgroup of patients in North India. Conclusion: The opportunistic infection (B. cepacia) of central venous devices during chemotherapy being resistant to commonly used antibiotics could be an important factor in increasing morbidity and mortality in cancer patients.

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Background: Management of preoperative anxiety in surgical patients is usually required for better perioperative hemodynamics and patient management. Various pharmacological and nonpharmacological entities have been used for the management of anxiety. The aim of this study was to analyze the effect of oral melatonin on patient anxiety scores and dose requirement of propofol using bispectral index (BIS)-guided induction of general anesthesia. Materials and Methods: Sixty patients of American Society of Anesthesiologists physical Status I and II between 18 and 45 years of age scheduled to undergo elective surgery of more than 30 min participated in this study. Patients were divided into control and melatonin groups, comprising 30 patients each. Group M patients received two melatonin tablets (3 mg each) and Group C patients received two placebo tablets 120 min before induction. Anxiety scores using visual analog scale-anxiety at baseline and 120 min, mean dose requirement of propofol, time to attain BIS value of 55 in seconds, and hemodynamic parameters were studied in-between the groups. Results: There were significant differences between two groups in anxiety scores 120 min after drug dosage (P = 0.0013) with Group M patients with reduced levels of anxiety, and mean requirement of propofol in Group C (104.67 ± 16.34 mg) was found to be statistically significantly higher than Group M (70.67 ± 16.39 mg), P < 0.001. Hemodynamic parameters in terms of heart rate and mean arterial blood pressures were better for Group M in comparison to Group C. Conclusion: 6 mg of melatonin 120 min before elective surgery can allay anxiety in patients along with reduced dose requirement for propofol for BIS-guided induction of general anesthesia without any adverse effects.

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Volume capnography is the graph of expired carbon dioxide concentration against the expired volume. It often requires special and bulky equipment to be recorded. It can be used to estimate the dead space with fair amount of precision. Various formulae and equations have been described to estimate the dead space. While the Bohr formula is likely the most accurate for measurement of dead space, the Enghoff's equation is likely the most popular and convenient to use. Volume capnography has found uses in both the operating room (OR) and the Intensive Care Unit setting. It can be used to identify the optimal level of positive end-expiratory pressure in patients suffering from the acute respiratory distress syndrome as well as to identify its effect on the ventilation. In the OR, it can be invaluable to monitor ventilation and alveolar recruitment in the obese population. It is also a useful diagnostic adjunct in medical emergencies like pulmonary embolism. In the pediatric population, it finds uses in the monitoring of infants suffering from bronchiolitis. In spite of its multiple and diverse uses, it remains an underutilized technology; the main reasons for this being lack of experience of the providers with volume capnography and the expensive and bulky equipment that is often required. However, volume capnography has a great deal of potential and with further advances in technology, is likely to gain popularity.

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Among the hematopoietic stem cells disorders, polycythemia vera (PV) constitutes a rare entity. The excess production of erythrocytes with thrombocytosis and leukocytosis in patients lead to both thrombotic and hemorrhagic complications. These complications may cause significant perioperative morbidity and mortality. Anesthetic challenges in a patient of PV and brief review of literature are described in this report.

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Congenital lobar emphysema (CLE) is a rare cause of sudden respiratory distress in infants. It poses a diagnostic and therapeutic dilemma. Hyperinflation and progressive air trapping causes expansion of the affected lobe leading to compression of other lung tissue, mediastinal shifting, and impaired venous return. We report a case of a 5 weeks old male infant with CLE. The left upper lobectomy was performed under general anesthesia with intercostal nerve block and pressure control ventilation. The anesthetic challenges and various management options are discussed here.

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Aims: In recent years, the number of surgical procedures performed in high-risk patients has increased, and the need for postoperative intensive care has also increased. In this study, it is aimed to identify the risk factors that can be used to estimate the need for intensive care stay of more than 1 day for patients with brain tumor resection. Methods: In this study, an open-accessible dataset was used, which included preoperative, perioperative, and intensive care follow-up data of 400 patients who were admitted to intensive care unit (ICU) after craniotomy due to brain tumor. The patients were divided into two groups according to the length of stay in the ICU. Patients who had less than a day stay were included in the short-term intensive care need (SICN) group and those staying more than 1 day were included in the long-term intensive care need (LICN). The effect of patients' data on ICU length of stay in ICU was investigated by logistic regression analysis. Results: Thirty-nine (9.75%) patients and 361 (90.25%) patients were assigned to the LICN group and SICN group, respectively. In the multivariate binary logistic regression model, the increase in total intravenous anesthesia (TIVA) and patient-controlled analgesia (PCA) applications decreases the patients' LICN likelihood while being intubated at ICU admission, need of mechanical ventilation (MV), postoperative hematoma formation, and increased duration of anesthesia increase the patients' LICN likelihood. Conclusions: The results of our study showed that the likelihood of patients' stay in ICU for more than 1 day could be estimated by such parameters as anesthesia duration, TIVA application, use of PCA device, being intubated at ICU admission, MV requirement, and postoperative hematoma formation.

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Introduction: Difficult airway management (intubation and/or ventilation) results in significant morbidity and mortality. In the present study, we evaluated various clinical parameters of airway assessment and their ability to predict difficult laryngoscopy and intubation in patients with diabetes mellitus (DM) compared to nondiabetic individuals. Methods: In this prospective comparative study, we enrolled an equal number of 110 patients in DM group and non-DM group. Patients were examined for body mass index (BMI), Modified Mallampati class (MMC), mouth opening, neck extension (NE), mobility of mandible by upper lip bite test, thyromental distance (TMD), collar size, palm print sign, and prayer sign. Primary outcome measure was Cormack and Lehane's grading on direct laryngoscopy. The comparison of quantitative and qualitative variables between the groups was done using unpaired Student's “t”-test and Chi-square test, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value of each test were done. Results: In DM patients, sensitivity was highest for MMC followed by prayer sign, whereas specificity was highest for palm print, followed by TMD, BMI, prayer sign, and other predictors. In non-DM individuals, sensitivity was highest for MMC whereas specificity was highest for prayer sign, followed by TMD, palm print and NE, and other predictors. Conclusions: In DM patients, sensitivity and specificity was highest for MMC and palm print, respectively. In non-DM individuals, sensitivity was highest for MMC whereas specificity was highest for prayer sign. A combination of tests may predict difficult laryngoscopy.

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Introduction: Subcostal transversus abdominis plane (TAP) block involves nerves of anterior abdominal wall. In the present study, the primary objective was to find out whether subcostal TAP block reduces the requirement of rescue analgesics following laparoscopic cholecystectomy. Materials and Methods: Fifty patients scheduled for laparoscopic cholecystectomy under general anesthesia were randomly divided into two groups. Twenty-five patients in Group B received subcostal TAP block with 0.25% bupivacaine 20 mL on each side and 25 patients in Group A received 0.9% normal saline 20 mL on each side after completion of surgery. Each patient's pain was assessed using visual analog scale (VAS) score at 0, 2, 4, 8, 16, and 24 h. The primary outcome measure was to compare the requirement of rescue analgesia, whereas secondary outcome measure was to compare satisfaction grades between the two groups. Comparison of quantitative and qualitative variables between groups was done using unpaired student's t-test and Chi-square test, respectively, using Statistical Package for the Social Sciences. Results: Percentage of patients who required paracetamol (P < 0.002) and nalbuphine (P < 0.001) as rescue analgesic was significantly less in Group B as compared to Group A. In all, 92% of Group B and 4% of Group A patients had a satisfactory overall quality of postoperative analgesia which was statistically significant (P < 0.002). Conclusion: Subcostal TAP block is an effective method of providing postoperative analgesia in patients undergoing laparoscopic cholecystectomy.

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Thoracosopic repair of tracheoesophageal fistula and esophageal atresia (TREAT) is an advanced endoscopic procedure which requires a skilled approach in minimally invasive surgeries. TREAT is considered as a superior technique in achieving cosmesis and avoiding complications when compared to open thoracotomy. It requires a team of surgeons, anesthesiologists, and assistants and neonatal intensivists to look after the neonate in the perioperative period. Recent meta-analysis has shown no significant difference in outcome and functional evaluation in open thoracotomy and thoracoscopic approach to TEF repair. Anesthesiologists should be well versed with knowledge and ability to anticipate challenges in managing neonates under thoracoscopic TEF repair which plays an important role in the management and survival of these kids. We searched PubMed and Google Scholar databases with the following keywords anesthetic management, tracheoesophageal repair, surgical repair, non-intubated video-assisted thoracoscopic surgery, video-assisted thoracoscopic surgery, video-assisted thoracoscopic surgery, pediatric one-lung ventilation, and pediatric regional anesthesia. The last search was made on July 31, 2018.

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