The COVID-19 is an ongoing global crisis. To deal with it efficiently, health-care system has to gear up to the increasing burden by judicious use of workforce and resources. In the perioperative setting, adequate preventive measures are of prime importance to prevent infection spread among health-care workers. The knowledge regarding the disease is still evolving. In this article, we have outlined the basic epidemiology, pathology, presentation, and diagnosis of COVID-19 along with the considerations for operating room preparedness, personal protective equipment required, airway management, anesthesia conduct, and perioperative concerns when managing positive or suspected COVID-19 pediatric patients and have suggested ways to overcome potential hindrances based on available literature. We have also deliberated upon the specific considerations for a COVID child undergoing regional anesthesia and critically ill COVID-19 pediatric patients. Careful adaptation of working principles based on local needs can help in the prevention of disease spread when optimizing care to the patients.

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Background: Stephen–Fowler's Stage-2 (SF-2) orchidopexy for high intra-abdominal testes poses the challenge of both laparoscopic and open urogenital surgery to the pediatric anesthesiologist. Balanced anesthesia supplemented with regional analgesia remains the standard technique adopted. Studies involving intravenous (IV) dexmedetomidine as an adjuvant anesthetic in children are sparse. Aims and Objectives: The aim and objective was to study the effect of IV dexmedetomidine on intraoperative hemodynamic stability, airway reflexes, and hemodynamic responses to extubation and postoperative analgesia. Materials and Methods: This prospective randomized controlled study was conducted on thirty children undergoing laparoscopic SF-2 repair to receive balanced anesthesia with isoflurane. Group D patients received IV dexmedetomidine 1 μg/kg bolus over 10 min after induction followed by an infusion at 0.5 μg/kg/h and Group C patients received regional analgesia. Hemodynamic parameters, sedation, agitation, pain scores, time to rescue analgesia, and time to discharge were documented. Results: A significant change was discernible in the heart rate and systolic blood pressure with intraoperative hemodynamic stability in Group D patients, which was comparable to baseline values. Smoother extubation with better hemodynamic stability (P < 0.001) and decreased agitation (P < 0.05) were noted in Group D patients. Children in Group C were observed to have lower sedation scores postoperatively (P < 0.05). Time to rescue analgesia was statistically significantly prolonged in Group D (P < 0.001) without any change in time to discharge from hospital. Conclusion: IV dexmedetomidine 1 μg/kg bolus followed by an infusion of 0.5 μg/kg/h gives better intraoperative hemodynamic stability with smoother extubation and prolonged postoperative analgesia without undue side effects in children undergoing SF-2 orchidopexy.

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Introduction: the use of cuffed endotracheal tubes (ETTs) in children is debatable. Despite recent literature on the use of cuffed ETT in children, its use is relatively low even in developed world. We conducted this survey to explore the perceptions and patterns of cuffed/uncuffed ETT usage in children, <5 years of age. Materials and Methods: This descriptive cross-sectional survey was done using a specially designed Google Form that was circulated among anesthesiologists of any grade practicing in India. The questionnaire was validated by seven experts on a 4-point scale as per the standardized model of content validity index and those with an index <0.78 were modified. Thereafter, the questionnaire was circulated over a month through WhatsApp and a reminder was sent every week for a month. Results: The total response rate was 55% (99/180) and after excluding the responses of postgraduates, 96 responses were evaluated. The use of pediatric cuffed ETT was similar among institutions. Only 35.5% of the respondents routinely used cuffed tubes regularly. The common reasons for nonusage of cuffed tubes included fear of higher resistance to flow and risk of subglottic injury. Those anesthesiologists who were performing higher pediatric cases were more inclined to use a cuffed ETT. Endotracheal cuff pressure was monitored routinely by 40% of the respondents who used cuffed tube. Conclusion: Anesthesiologists practicing pediatric anesthesia are more likely to choose cuffed ETT in children aged <5 years. Safety norms such as cuff pressure monitoring are not being followed routinely when these tubes are used.

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Postpartum hemorrhage (PPH) is the leading cause of preventable maternal mortality and morbidity. Women undergoing cesarean delivery are at increased risk of PPH as compared to vaginal delivery. Improvement in obstetric care and advances in diagnostic modalities have empowered obstetricians to detect, predict, and therefore prevent catastrophic uterine bleeding. Patients at increased risk for PPH should be referred to tertiary care centers equipped with interventional radiology suite, where multidisciplinary teams are available 24 h and are prepared to deal with potential complications. This review highlights the management of PPH with special emphasis on interventional radiology procedures for the prevention of PPH. Minimally invasive interventional radiological techniques such as selective arterial embolization and arterial balloon occlusion have been effectively used to avert hysterectomy and reduce the overall incidence of blood transfusion and its associated complications while preserving reproductive functions.

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Aim: This study aims to study the effect of addition of clonidine and dexamethasone to ropivacaine for ultrasound-guided TAP block in patients undergoing abdominal surgeries. We primarily compared the quality and duration of postoperative analgesia. Materials and Methods: This randomized double-blind study was done after taking approval from Institutional Ethical Committee and written informed consent from all the patients. Sixty patients undergoing abdominal surgery under general anesthesia were enrolled in the study and randomly divided into two groups: Group-RC (n = 30) and Group-RD (n = 30). Patients in both the groups were given bilateral ultrasound-guided TAP block at the end of surgery. Patients in Group-RC received 20 ml ropivacaine 0.2% with 75 μg clonidine on each side and patients in Group-RD received 20 ml ropivacaine 0.2% with 4 mg dexamethasone on each side. Results: Visual analogue scale score for pain was significantly less in Group-RC as compared to Group-RD at all-time intervals (P <.05). Duration of pain relief in Group-RC was significantly greater than in Group-RD (16.50 ± 6.68 vs. 9.67 ± 6.46 h; P = 0.001). Requirement of rescue analgesia was also significantly less in Group-RC as compared to Group-RD (80% vs. 90%; P = 0.014). Except for a higher incidence of nausea in Group-RC, there was no other significant difference in the incidence of complications between the two groups. Conclusion: Addition of Clonidine (75 μg) to ropivacaine for ultrasound-guided TAP block provides better and prolonged postoperative analgesia as compared to addition of dexamethasone (4 mg) without any significant side-effects.

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Background and Aims: Our aim was to assess the postoperative analgesia after ultrasound-guided transmuscular “Quadratus lumborum block” (QLB) and lumbar “Erector spinae plane block” (ESPB) in hip surgeries postoperatively. Design: Double-blinded, randomized prospective study. Materials and Methods: Sixty-three patients who underwent hip surgeries were divided into three groups, with 21 patients each. Each group was given spinal anesthesia using 30 ml of 0.5% hyperbaric bupivacaine. After the completion of the surgery, Group I patients were given ipsilateral transmuscular QLB and Group II patients were given ipsilateral lumbar ESPB. No block was given in Group III. In the postanesthesia care unit (PACU), pain was assessed using the Numeric Rating Scale (NRS) scoring. The time of first analgesic requirement and the total postoperatively tramadol consumption in first 24 h was recorded. Results: No significant difference was seen between the three groups pertaining to patient's demographic data, type, and duration of surgery. Statistically significant lower NRS scores were present in QLB group and ESPB group than the control group in the first 24 h (P < 0.001). The total tramadol consumption was significantly more in the control group (346.67 ± 71.37) mg than QLB group (159.05 ± 39.74) mg and ESPB group (190.48 ± 33.83) mg with P < 0.001. Time duration of first analgesic requirement in PACU was 344.05 min, 267.86 min, and 105.24 min for QLB, ESPB, and control group, respectively. Conclusion: In conclusion, both QLB and ESPB provide good postoperative pain control in hip surgeries with QLB providing a better analgesic profile when compared to ESPB.

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Neuromyelitis optica (NMO), a rare devastating demyelinating syndrome involving optic neuritis and myelitis, poses a challenge to anesthesiologists. Here, we present the anesthetic management of a diagnosed case of NMO posted for total hip replacement. Although literature documenting adverse outcomes with both general anesthesia (GA) and spinal anesthesia (SA), more so with SA, it should always be considered if benefits outweigh the risk of GA. An uneventful perioperative period in the previous two surgeries favored SA as an anesthetic technique for consecutively third time in this case with smooth recovery.

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Background: Prevision of a potentially difficult airway in the preoperative period is imperative. The available tools are evaluation of mouth opening, Mallampati test; atlanto-occipital extension; hyomental, thyromental, and sternomental distances; and upper lip bite test; thyromental height test (TMHT) is a new indicator. Aims: To compare the effectiveness of preoperative anaesthetic airway evaluation methods of TMHT and Modified mallampati test (MMT) to predict the difficulty in intubation. Materials and Methods: A prospective observational study was aimed to compare the effectiveness of preoperative anesthetic airway evaluation methods of TMHT and modified Mallampati test (MMT) to predict the difficulty in intubation. A total of 150 subjects were included in this study. MMT and TMHT were compared, and sensitivity, specificity, predictive values, and accuracy were calculated. Results: On comparison, we found TMHT to be more sensitive (93.33%) than MMT (77.78%); both tests have high specificity (TMHT 91.43%; MMT 81.90%). Positive predictive value was 82.35% for TMHT and 64.81% for MMT. Similarly, negative predictive value was 96.97% for TMHT and 89.58% for MMT. Accuracy was 92.00% for TMHT and 80.66% for MMT. Conclusions: TMHT can predict difficult intubation better than MMT (high positive predictive value). However, both TMHT and MMT predict easy intubations effectively, their negative predictive values being high.

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Background: Arterial cannulation is increasingly becoming the standard of care in the perioperative management of complex pediatric surgeries and in patients with congenital cardiac anomalies. These indwelling arterial cannulas are used for invasive blood pressure (IBP) monitoring and blood gas analysis. With advent of ultrasound era, there is rising interest for its application in pediatric arterial cannulation. However, limited literature is available on its benefit in terms of success rate and complications. Aims: The aim of this study is to assess the success rate and complications when ultrasound guidance was used for arterial line insertion in the pediatric surgical patients. Setting and Design: Operation Theatre of Tertiary Care Centre / Prospective Observational Study. Statistics: Descriptive statistics. Materials and Methods: This study was conducted in children aged below 24 months requiring IBP monitoring during surgery. Parameters observed included rate of successful cannulation subdivided into first attempt success rate, successful cannulation within first two attempts, time to successful cannulation, and number of cannula. Complications namely hematoma and ischemic damage were also documented. Results: A total of 258 children were included in this study. We achieved successful radial artery cannulation in 95.74% patients, of which 77.9% were in first attempt while 8.1% required two attempts. The median time taken was about 168 s. In 33 (13%) cases, the site was changed before pricking based on thrombus or very narrow diameter of the artery. Hematoma formation was seen in 21 (8.1%) children, and only 2 (0.7%) children had features of ischemia in the distal part requiring removal of the cannula from radial artery. Conclusions: This study emphasized benefits of routine use of ultrasound in terms of higher chances of first-attempt success, lesser time for cannulation, lesser time taken, and more objective training benefit from ultrasound-guided radial artery cannulation in pediatric patients less than 24 months of age.

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Background and Aims: Electroconvulsive therapy (ECT) is the most effective treatment modality for severe and medication-resistant psychiatric disorders. ECT provokes generalized tonic-clonic seizures. Induction of optimal seizures (duration of motor seizures >15 s) is considered as an important goal during the ECT procedure. We compared ketofol and etomidate as induction agents in ECT with respect to the seizure duration and seizure threshold as there is less information available in the literature. Methods: One hundred and twenty patients posted for ECT were randomized into two groups. Group A received ketofol 1:1 (ketamine 0.5 mg/kg + propofol 0.5 mg/kg), while as Group B received etomidate 0.2 mg/kg. After administration of the muscle relaxant (succinylcholine 0.5 mg/kg) ECT was delivered. The primary outcome was seizure duration, and secondary outcomes such as seizure threshold, hemodynamic parameters, recovery profile, and any complications were noted. Motor seizure duration was recorded as the time interval between starting of the seizure episode until the cessation of tonic-clonic motor activity in the isolated upper limb. Data were entered in MS-Excel and analyzed in SPSS V22. Descriptive statistics were represented with percentages, and parametric data were represented with mean with standard deviation. The statistical analysis was carried out using the Chi-square test, independent t-test. A Probability (P) value <0.05 was considered statistically significant. Results: There was a statistically significant difference in seizure duration between two groups with Group A having less meantime 38 ± 14.9 s compared to Group B 45.3 ± 17.5 s with P = 0.014. Seizure threshold, hemodynamic parameters, recovery profile, and complications except myoclonus were not statistically significant between the two groups. Conclusion: Etomidate has the definite advantage of longer seizure duration compared to ketofol, and hence, etomidate is a better induction agent in patients with psychiatric disorders undergoing ECT.

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Background: Low-dose ketamine can provide effective perioperative analgesia while reducing its side effects. This study aims to estimate the effect of a low dose of ketamine administered preemptively and during the surgery on postoperative opioid requirement and the incidence of side effects of ketamine. Methods: This prospective, double-blind, randomized control trial enrolled 60 adult women (>18 years) scheduled for open abdominal hysterectomy. All patients received general anesthesia using a standard protocol. Patients were randomized to receive 0.2 mg/kg of ketamine as bolus before induction of anesthesia, followed by an infusion of 0.002 mg/kg/min for the duration of surgery (Group K) or an equivalent volume of 0.9% saline (Group C). The primary outcome was to compare the morphine requirement over the 24 h postoperatively between the two groups. The secondary outcomes were to compare the intraoperative morphine requirement, and the incidence of side effects of ketamine. Results: The intraoperative morphine requirement was significantly less (P = 0.006) in those who received ketamine (6.5 ± 1.5 mg) compared to the placebo (7.67 ± 1.7 mg). The 24-hour morphine requirement was less in the Group K (7.87 ± 4.7 mg) compared to Group C (9.2 ± 4.5 mg), but was not statistically significant. The incidence of hallucination and nystagmus was significantly higher in the ketamine group, but it lasted <2 h. Conclusion: The preemptive and the intraoperative infusion of low-dose ketamine decreases the morphine requirement intraoperatively but not during the postoperative period.

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Objectives: Cardiac arrest is a substantial public health problem. The American Heart Association recommends that those whose daily work requires knowledge and skills in advanced cardiovascular life support (ACLS) should not only be trained in ACLS but also be given a refresher course at least every 2 years. We conducted a study to find out how much knowledge and skill was improved in the participants following the workshop and also how much of it they retain after 6 months. Materials and Methods: The study, a prospective repeated measures quasi-experimental design, was done to test the knowledge and skill about basic life support (BLS) and ACLS among MBBS Interns at the entry to internship before training, posttraining and 6 months after training. This was done using a structured questionnaire containing 25 knowledge and practice questions and a checklist containing 15 points was used to assess the skills was also assessed using the Laerdal CPRQ Manikin with skill guide using parameters compression score, ventilation score, and compression fraction. Results: Knowledge mean total score for pretest, immediate posttest, and 6 months posttest was 10.9, 23.54, and 15.77, respectively, and skill mean score for pretest, immediate posttest, and 6 months posttest was 3.55, 12.99, and 9.06, respectively. Knowledge and skill assessed for immediate posttest was significantly higher than the pretest score. Six months posttest total score was significantly higher than the pretest total score but was significantly lower than posttest score in regard to both knowledge and skills. Conclusion: We found that there is gross lack of knowledge and skills among interns, which needs to be looked at with proper BLS and ACLS training and periodic reinforcement of the same with trainings as there is a significant decrease in both knowledge and skills at 6 months. The skill guide can be considered for skill assessment.

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Background and Aims: COVID-19 infection has the potential to spread exponentially during aerosol-generating procedures like intubation. The aim was to find the compliance toward the actual practice as well as the existing knowledge gap and adherence to the guidelines among the medical professionals while attempting intubation in a known or suspected COVID-19 patients. Materials and Methods: A cross-sectional web-based survey format was planned using English questionnaire in an online form (Google^® Forms). One hundred and forty valid responses for 27 questions were received. Maximum participation was received from Indian anesthesiologists working in government, semi-government, and private health facilities, performing the intubation routinely. All the valid responses were statistically analyzed by calculating the significant difference in means and proportions, with P < 0.05 being considered statistically significant. Results: Eighty percent of the respondents received training for donning and doffing and regularly wore personal protective equipment for the airway procedure. Scarce simulation training (22.1%), minimum screening before entering into a intubation scene (37.9%), frequent use of bag-mask ventilation (18.2%) or high flow nasal cannula (19.7%) use for preoxygenation, confirmation of the depth of endotracheal tube by auscultation (34.5%), and having no plan B in case of unanticipated difficult airway (27.9%) make the knowledge gap evident. The survey pointed out toward the infrastructural requirement of negative pressure intubation rooms, availability of waveform capnography, and widespread use of videolaryngoscope. Conclusion: This survey gives us an insight into the compliance with existing lacunae and nonuniform practices of the recommended guidelines for the airway management during COVID-19 pandemic with its pragmatic solution.

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Wernicke's encephalopathy (WE) secondary to hyperemesis gravidarum (HG) is a rare but a known complication. A delay in diagnosis and treatment often results in long-term neurological sequelae. Critical care management of these patients is reported in the literature, but their anesthetic management for cesarean section is lacking. We report the case of a 28-year-old parturient who presented with HG in the first trimester of pregnancy and was managed conservatively. She later developed nystagmus, weakness, and cognitive dysfunction, and a diagnosis of WE secondary to HG was established. The patient was later posted for cesarean section in view of persistent quadriparesis and cognitive impairment at term gestation. General anesthesia was the preferred anesthesia technique of choice. Obstetric patients with preexisting neurological disease for cesarean section become a special subpopulation for anesthesiologists with their unique anesthetic challenges.

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Background: Pain due to pneumoperitoneum after laparoscopic cholecystectomy (LC) may contribute to prolong hospital stay, patient discomfort, and failure of the surgery as an ambulatory procedure. A balanced multimodal analgesia regimen consisting of premedication with selective alpha-2 agonists is gaining popularity for postoperative pain relief for multiple surgeries. Although both clonidine (CLO) and dexmedetomidine (DEX) belong to this group, DEX is seen to have more selective α2 action and better sympatholytic properties. The present study aims to assess the coanalgesic effect of premedication with CLO and DEX for LC, done as an overnight stay procedure, and to compare their efficacy. Methodology: This was a prospective, randomized, single-blinded comparative study, conducted between July 2015 and July 2016. A total of 80 patients undergoing LC were randomly assigned to either CLO or DEX groups (n = 40). The patients were premedicated with low-dose (1 μg/kg) bolus intravenous drugs before induction according to the allotted group. Effect of individual drugs on the postoperative visual analog scale (VAS) score was noted, hemodynamic status was monitored, and analgesic-sparing effect to a multimodal analgesic regimen comprising intraoperative fentanyl and postoperative tramadol was noted. Results: VAS scores at 15 min postextubation, the number of patients required rescue analgesia, and the number of injections required were all found significantly low with DEX. Systolic as well as diastolic blood pressure was significantly lower in the DEX group. Conclusions: Although both the drugs were effective for short hospital stay LC, early pain relief and better hemodynamic stability were seen with DEX. Thus, routine premedication with DEX for ambulatory LC may be recommended.

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