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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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We report a case focusing on achieving an optimum cardiac output (CO) in a patient with heart failure with severely reduced ejection fraction using EV1000 monitor to obtain various dynamic parameters such as stroke volume (SV), SV variation (SVV), systemic vascular resistance (SVR), and CO. We optimized preload by SVV-guided intraoperative goal-directed fluid transfusion and modulated SVR using multipronged anesthetic techniques to decrease afterload and increase forward flow to improve CO in a patient undergoing radical cholecystectomy with wedge liver resection.

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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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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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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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Pulmonary hypertension is defined as persistent rise in mean pulmonary artery pressure of 25 mmHg or more with pulmonary occlusion pressure <15 mmHg. Most of the symptoms encountered in pulmonary hypertension overlap with that of normal pregnancy such as shortness of breath, weakness, fatigue, chest pain, syncope, and abdominal discomfort. Pulmonary hypertension in pregnant patients carries high mortality rates between 30% and 56% and is also the important cause of increased perioperative morbidity and mortality. Basic principles of management include maintaining right ventricular function and reducing pulmonary vascular resistance. Preoperative risk assessment and successful management of patients with pulmonary hypertension undergoing surgery are crucial and important and involve an understanding of the pathophysiology of the disease, analysis of preoperative and operative risk factors, thorough multidisciplinary planning, meticulous intraoperative management, and early recognition and treatment of postoperative complications. We searched PubMed and Google Scholar databases with the following key words: pulmonary hypertension, anesthesia concerns, and parturient female for literature search.

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Drug-induced dysrhythmias are frequently encountered with several drugs that are routinely used in the practice of medicine. However, it is difficult to predict in which group of patients the rhythm disturbances can happen. The clinician should try to identify the cause of the new onset rhythm disturbance (electrolyte imbalance, ongoing cardiac insult, hypoxia, hemodynamic disturbance, cerebrovascular event, etc.). Once a drug is suspected, it should be documented on medical case record and everyone involved in the patients care should be informed.

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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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Anesthetic management of patients having immune thrombocytopenic purpura (ITP) remains a challenge for the anesthesiologist. Surgeries such as knee arthroplasty are associated with significant bleeding. Neuraxial anesthesia is often preferred for knee arthroplasty. However, in patients with bleeding diathesis such as ITP, neuraxial anesthetic management remains controversial as there are no specific guidelines, and there is a risk of spinal hematoma. There are numerous case reports of safe regional anesthesia administered in parturients suffering from thrombocytopenia, but no explanation has been given. A new emerging concept of "rebalanced hemostasis" is now being used to explain the discrepancies observed in the laboratory reports versus the actual bleeding. In our case report, we have reviewed the literature and described the anesthetic management of a patient having chronic ITP and chronic obstructive pulmonary disease undergoing knee arthroplasty under neuraxial technique.

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Renal disorders in pregnancy can be both difficult to diagnose and manage. They are associated with poor maternal and/or fetal outcomes. In pregnancy, proteinuria is common and can range from mild urinary protein elevations to nephrotic levels. The diagnosis of nephrotic syndrome (NS) can be challenging, especially in pregnancy as it can be confused with preeclampsia. NS has an incidence of 0.012%–0.025% in pregnant women. It is diagnosed by the presence of more than 3 g/day of proteins in urine, serum albumin <30 g/dL, generalized edema, hypercholesterolemia, and lipiduria. Proteinuria with hypertension is characterized by the presence of hematuria, red cell casts, raised serum creatinine, and features suggestive of systemic disease. Other causes of proteinuria include preeclampsia, diabetes mellitus (Type 1 and Type 2), Immunoglobulin A nephropathy (Ig A glomerulonephritis), focal and segmental glomerulosclerosis, and lupus nephritis. The maternal risks of NS include acute kidney insult, chronic renal failure, gestational hypertension, preeclampsia, and complications due to hypoalbuminemia. Fetal considerations in NS include fetal growth retardation, prematurity, stillbirth, fetal anasarca, and polyhydramnios. Preconception counseling and immunosuppressive drug therapy can improve overall fetomaternal outcome. We hereby present a unique case of successful anesthetic management of NS in a parturient along with concurrent hypothyroidism and hypertension, for elective cesarean section.

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Context: During endotracheal intubation, as we aim for smooth induction, smooth extubation is also mandatory. During extubation, coughing, sore throat, hoarseness, and laryngospasm are not desired and have to be prevented. Aims: The aim of the study is to study the effects of inflating the endotracheal tube (ETT) cuff with alkalinized lignocaine (Group L) or dexamethasone (Group D) or saline (Group S) on the emergence phenomena of endotracheal extubation. Settings and Design: Tertiary hospital, randomized double-blinded prospective study. Subjects and Methods: A total of 90 patients undergoing surgery under general anesthesia were randomly allotted into three groups, 30 in each group. After endotracheal intubation, the tube cuff was inflated with alkalinized lignocaine (Group L) or dexamethasone (Group D) or saline (Group S) as per the randomization sequence. At emergence and 1 h after surgery for hemodynamic indices and incidence of postextubation, sore throat, cough, hoarseness, and laryngospasm were assessed. Results: With respect to cough and sore throat, Group L and Group D were significantly better than Group S but the hoarseness was the worst in Group D. Conclusions: Inflating the ETT cuff with alkalinized lignocaine or dexamethasone helped in preventing sore throat and cough to a better extent than saline, the hoarseness, however, being the worst in dexamethasone group.

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Autistic spectrum disorder (ASD) is a developmental disability of the central nervous system with rapid worsening. A subset of patients also has mitochondrial dysfunction leading to increased sensitivity to various anesthetic agents. Rarely, gene mutation in these patients results in homocysteinemia which causes higher incidences of thromboembolism, hypoglycemia, and seizures. Anesthetic management of ASD with homocysteinemia and refractory seizures has not been previously reported.

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Background: Postdural puncture headache (PDPH) is an iatrogenic complication associated with spinal anesthesia. Median and paramedian are two common techniques used for spinal anesthesia. Female pregnant patients are important risk factors for PDPH. The present study was conducted to compare the incidence of PDPH in female pregnant patients undergoing cesarean section using median versus paramedian approach. Materials and Methods: A total of 200 obstetric patients, having physical status I or II, undergoing cesarean section were included in the study. Patients were randomly allocated into two groups. Group I (n = 100) – Median approach and Group II (n = 100) – Paramedian approach. Results: Single attempt was successful in 75 patients (75%) in group I and 80 patients (80%) in group II. Two attempts were used in 20 patients (20%) in group I and 19 patients (19%) in group II. PDPH was not observed in any patient with one or two attempts including both groups. Six patients presented with PDPH out of total 200 patients. In group I, five patients (5%) developed PDPH out of 100 patients while in group II, only one patient (1%) developed PDPH out of 100 patients; however, the difference was not significant statistically. Conclusion: There is no difference regarding the incidence of PDPH in obstetric patients between median and paramedian approach.

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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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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: Local anesthetics with various adjuvants are used to increase the duration of postoperative analgesia in supraclavicular brachial plexus block. Perineural injection of steroid is known to influence postoperative analgesia. Materials and Methods: A total of fifty patients of the American Society of Anaesthesiologist Grade I–II undergoing various upper limb surgeries under supraclavicular brachial plexus block were randomly divided into two groups. In Group C, patients received 32 ml of mixture of 1.5% lignocaine–adrenaline 10 ml, 0.5% bupivacaine 20 ml and normal saline 2 ml, whereas in Group D, patients received the same amount of local anesthetics with dexamethasone 2 ml (8 mg). Sensory and motor block were recorded at the regular intervals. Postoperative analgesia was assessed using visual analog scale (VAS) score. Statistical analysis was performed using Student's unpaired t-test. Results: The mean onset time of sensory and motor block was 3.24 ± 1.09 min and 6.2 ± 1.44 min in Group D and 4.24 ± 1.42 min and 7.52 ± 1.50 min in Group C, respectively. There was markedly prolonged duration of analgesia in Group D (12–16 h) compared to Group C (4–5 h). The mean VAS score was 4.16 ± 1.39 at the end of 6 h in Group C, whereas it was 0 (zero) in Group D at the same time. The difference was statistically significant (P < 0.05). Conclusion: Addition of dexamethasone as an adjuvant to local anesthetics in brachial plexus block provides in significantly early-onset and markedly prolonged duration of analgesia without hemodynamic disturbances.

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Background and Aims: Shivering is one of the causes of discomfort in patients undergoing surgeries under spinal anesthesia. A variety of drugs and physical methods are used to control shivering. Among pharmacological interventions ondansetron, a 5-hydroxytryptamine3 antagonist has been found effective in controlling shivering. The aim of this study is to evaluate the effect of prophylactic administration of ondansetron for prevention of shivering during spinal anesthesia. Methods: A prospective, randomized, and double-blind study was conducted on 70 patients, from either gender, aged 20–60 years, of the American Society of Anesthesiologists Grade I or II, scheduled for various surgeries under spinal anesthesia. The patients were randomly divided into two groups of 35 each to receive either saline (Group S) or ondansetron 8 mg, (Group O) as slow intravenous infusion before spinal anesthesia. The primary outcome of the study was intraoperative incidence of shivering. Secondary outcomes, such as hemodynamic parameters and adverse reactions, were recorded. Results: A total of 16 patients in Group S (45.7%) and 4 (11.3%) patients in Group O experienced shivering (P = 0.014). A total of 14 patients in Group S (40%) and five patients in Group O (14.3%) had nausea (P = 0.155). A total of 11 patients in Group S (31%) and three patients in Group O (8%) had hypotension (P = 0.168). No patients in either group experienced bradycardia. Conclusion: Prophylactic administration of ondansetron significantly reduced shivering in patients undergoing spinal anesthesia without significant side effects.

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Takayasu's arteritis (TA) is found commonly in young women presenting for cesarean section. A 24-year-old woman with a history of cerebrovascular disease and known case of Type I TA was managed successfully without perioperative complications under general anesthesia.

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Pregnant patient with heart disease is a unique challenge to the obstetrician and anesthesiologist, and requires a thorough understanding of the impact of pregnancy on the haemodynamic response in view of existing cardiac lesion. Among the congenital heart diseases causing right to left shunt, Tetralogy of Fallot (TOF) is commonest congenital heart disease. Symptoms of TOF may get worsened during pregnancy and if neglected, it causes significant morbidity and mortality to the patient as well as to fetus. Uncorrecrected TOF parturient posted for LSCS poses an unique challenge to the anesthesiologist. We present 2 case reports of patients of TOF with BT shunt who underwent caesarean section under general anaesthesia. Both the patients had post partum hemorrhage (PPH) which was treated successfully without further complications

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Objective: The goal of this study was to assess the reliability of different tension and saturation-based oxygen indices with traditional oxygenation index (OI) in the assessment of disease severity and its progress in adult patients with acute respiratory distress syndrome (ARDS) when compared to the standard arterial oxygen tension (PaO₂)/inspired fraction of oxygen (FiO₂) (PF) ratio included in the Berlin definition of ARDS; the primary objective was assessed by the correlation of different OIs to the standard PF index. Design: This was a prospective, observational study. Setting: This study was carried out in Intensive Care Unit (ICU) in a university hospital. Patients and Methods: Sixty adult patients with different grades of ARDS severity according to Berlin definition were enrolled in this study. Measurements: The following indices were measured: (1) PF, (2) OI = FiO₂ × mean airway pressure [MAP] × 100/PaO₂ , (3) oxygen saturation index (OSI) = FiO₂ × MAP × 100/oxygen saturation by pulse oximeter. The primary outcome measurement was the correlation of different OIs to the standard PF index. The secondary outcome measurements were sensitivity and specificity of each index. Results: There were a strong significant negative correlation between OI and OSI with the PF (r = −0.9 and −0.91, respectively) and a significant positive correlation between OI and OSI (r = 0.93). Total mortality rate was 36% (22 patients). The PF, OI, and OSI were sensitive and specific (sensitivity: 0.63, 0.77, and 0.81, respectively, and specificity: 0.76, 0.86, and 0.78, respectively). Conclusion: OSI can be used as a noninvasive index for the assessment of ARDS severity in adults as it correlates significantly with PF ratio and OI with high sensitivity and specificity to predict ICU mortality.

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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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