Indian Journal of Anesthesia and Analgesia

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Esophageal perforation is a rare but potentially life-threatening condition associated with significant morbidity and mortality, particularly when diagnosis is delayed. Airway management in such patients presents unique challenges due to the risk of aspiration, mediastinal contamination, and airway compromise. We report the case of a 28-year-old male presenting with dysphagia who underwent upper gastrointestinal endoscopy. Anticipating a high aspiration risk, airway management was secured using awake fiberoptic-guided nasotracheal intubation. This approach allowed preservation of spontaneous ventilation, airway reflexes, and continuous visualisation. The procedure was uneventful, and the patient remained stable. This case highlights the importance of anticipatory airway planning and supports awake fiberoptic intubation as a proactive strategy in physiologically difficult airway scenarios.

The year 2026 marks 180 years since William Thomas Green Morton’s public demonstration of ether anaesthesia on 16 October 1846 at Massachusetts General Hospital. This event is widely regarded as the formal inauguration of modern anesthesia. Morton’s translation of experimental observations into a reproducible clinical technique enabled the development of pain-free surgery and laid the foundation for modern anaesthesia practice. This article reviews the life of WTG Morton before and after his first successful public demonstration, which is largely unknown.

Anesthesia and critical care have historically evolved alongside technology, and artificial intelligence (AI) now represents the next major step in this trajectory. By enabling prediction of perioperative and ICU complications, supporting closedloop anesthetic delivery, and synthesizing complex physiological data, AI offers powerful tools for enhancing safety, precision, and efficiency. At the same time, challenges related to local data quality, infrastructural constraints, algorithmic bias, and medico-legal accountability are particularly salient in the Indian context. This editorial outlines key current and emerging applications of AI in anesthesia and critical care, highlights ethical and implementation concerns, and emphasises the need for “clinician-in-the-loop” models, data literacy, and interdisciplinary collaboration to ensure that AI augments rather than replaces the anesthesiologist and intensivist.

Context: Laryngoscopy and intubation provoke sympathetic surges that can endanger hypertensive patients. Nebulised dexmedetomidine and lignocaine can be used to blunt this response, but their relative effectiveness remains uncertain. Aims: The study aimed to compare the effectiveness of preoperative nebulization with dexmedetomidine versus lignocaine in blunting the hemodynamic response to laryngoscopy and intubation in hypertensive patients undergoing general anaesthesia for elective surgeries. The changes in systolic blood pressure, anaesthetic, and analgesic requirements were also recorded. Settings and Design: Randomised, double-blind study with 100 ASA class II hypertensive patients (18–60 y) scheduled for elective surgery under general anaesthesia were allocated to receive either dexmedetomidine 1 µg/kg (n = 50) or 4 % lignocaine 1 mL (40 mg, n = 50) via jet-nebuliser 15 min before induction. Methods and Material: Heart rate (HR), systolic and diastolic blood pressure (SBP, DBP), mean arterial pressure (MAP) and SpO2 were recorded at baseline, after nebulization and every minute for 10 min post-intubation. Time to first rescue analgesia, intra-operative fentanyl and propofol consumption, time to extubation, and adverse events were documented. Statistical analysis used: Independent t-tests, χ² tests and repeated-measures ANOVA (SPSS v27;p < 0.05 considered significant). Results: Dexmedetomidine significantly prolonged analgesia (6.95 ± 0.06 min vs 4.94 ± 0.43 min) and lowered propofol use (100.1 ± 5.4 mg vs 104.7 ± 5.5 mg; both p < 0.001) without altering fentanyl requirement or time to extubation. HR, SBP, DBP, MAP and SpO2 trajectories did not differ between groups throughout the observation window (p > 0.05), indicating equivalent haemodynamic stability. Lignocaine showed numerically more instances of postoperative nausea, vomiting and sore throat compared to dexmedetomidine. Conclusions: Nebulised dexmedetomidine has an advantage over lignocaine in better haemodynamic stability, postoperative analgesia and anaesthetic needs, with a lower side-effect profile. Key Messages: Preoperative nebulisation with dexmedetomidine provides haemodynamic stability during laryngoscopy and intubation with fewer side effects.

Background: Pulse oximetry is a vital non-invasive method for monitoring oxygen saturation (SpO2). However, factors such as nail polish and artificial nails can potentially affect accuracy. Gel-based manicures, widely used for their durability, may interfere with SpO2 readings. This study evaluates the impact of gel manicures on pulse oximetry accuracy. Methods: A prospective observational study was conducted in Akash institutes of Medical Sciences, including 25 healthy volunteers with and without gel manicures. SpO2 was measured on gel-painted and unpainted nails using a standard pulse oximeter. A comparison was made between the two readings using paired t-tests. Results: A statistically significant difference (p < 0.05) was observed in SpO2 readings between gel-painted and unpainted nails. The mean SpO2 recorded from gel-painted nails was lower than that from unpainted nails. Conclusion: Gel-based manicures significantly impact pulse oximetry readings, potentially leading to false hypoxia alarms. Clinicians should consider alternative measurement sites (earlobe, forehead) in patients with gel manicures.

Introduction: Tetralogy of Fallot (TOF) is a common congenital cyanotic heart disease. Despite successful surgical repair, patients remain at increased risk of complications during future surgeries, especially in procedures which predispose to infective endocarditis. CaseReport:A3 – year old female patient, suffering from chronic irreversible pulpitis was posted for a full mouth rehabilitation surgery under general anesthesia. She has history of tetralogy of Fallot (TOF) repair at 22 months of age. Current clinical and echocardiographic findings showed no major abnormalities. She underwent successful oral surgery under general anesthesia with due precautions and utmost care maintaining stable hemodynamic parameters peri-operatively. Conclusion: This case highlights the successful perioperative management of a child with repaired TOF undergoing full mouth rehabilitation. Comprehensive preoperative evaluation, appropriate antibiotic prophylaxis, and tailored anesthetic technique contributed to a smooth outcome. Key Messages: (Provide appropriate messages of about 35-50 words to be printed in centre box): Anaesthetic management of patients with corrected congenital cardiac diseases requires specific and tailor-made approach taking into consideration the anatomical and physiological variations of disease, corrective surgery and ongoing medications. Team approach involving a cardiologist, surgeon, paediatrician and anaesthesiologist is essential for successful outcome.

Empyema requires careful planning and execution of anaesthesia management due to the complexity of the procedure and the patient’s underlying condition. A 6-year-old patient presented with cough and fever progressing to distress diagnosed as empyema. She was posted for right thoracotomy and decortication. Other investigations were optimal; except TLC which was 17,000 and INR of 1.36. Preoxygenated and premedicated with Inj Glycopyrrolate, induced with Inj Ketamine and Airway secured with 5 mm ID cuffed endotracheal tube under suxamethonium. Patient was put in lateral position and anaesthesia maintained with O 2 plus N2O with Isoflurane; IV paracetamol and Inj Fentanyl was given after 1 hour. Intraoperatively SpO2 was coming down to 85, so N2O was stopped for some time; Isoflurane with Intermittent Propofol was given till the Decortication was done. Smaller tidal volume (5 ml/kg) with higher respiratory rate (24 per minute) was given initially. The right lung expanded well after the procedure and O2 and N2O was restarted and PEEP of 5 cm of H 2O was given. After completion of surgery, the neuromuscular block was reversed with Inj Neostigmine and Inj Glycopyrrolate, O2 supplementation with face mask continued in the postoperative period for 6 hours then nasal prongs overnight. Post-operative period continued with incentive spirometry and was uneventful.In a case of empyema with respiratory distress in a paediatric patient, meticulous planning is required and lung Isolation is difficult and we planned for low tidal volume technique and case was managed with-out any adverse events.

Anaesthetic management in carcinoma oesophagus is particularly challenging due to the need for maintaining adequate oxygenation and ventilation during OLV, managing hemodynamic fluctuations, and addressing perioperative risks such as hypoxemia, postoperative pulmonary complications, and pain control. Our patient was a 45 year old female with carcinoma oesophagus , mild pneumonitis; other investigations were within normal limits. She was premedicated, induced and intubated with a double lumen tube; she did not tolerate one lung ventilation and changed to regular single lumen tube and low tidal volumes were tried; developed acidosis and treated and extubated uneventfully. Low tidal volumes can be used in patients with bad lung for facilitating the surgery.

Massive thyroid enlargement can significantly distort upper airway anatomy by causing tracheal compression, lateral deviation, and restricted neck mobility, thereby increasing the risk of difficult mask ventilation and tracheal intubation. Induction of general anaesthesia before securing the airway in such patients may precipitate airway collapse and catastrophic hypoxia. We report the case of a 55-year-old female presenting with a progressively enlarging anterior neck swelling and mild dyspnoea, with clinical features suggestive of an anticipated difficult airway. Preoperative assessment revealed distorted airway anatomy, limited neck extension, and possible tracheal compression. A planned strategy of awake fibreoptic intubation (FOI) was adopted following comprehensive airway topicalisation using lignocaine nebulisation and targeted superior laryngeal and transtracheal nerve blocks. Awake oral fibreoptic intubation was successfully performed while preserving spontaneous ventilation. General anaesthesia was subsequently induced, and thyroid surgery proceeded uneventfully. The patient was extubated after full recovery and monitored postoperatively without airway complications. This case highlights the importance of meticulous airway assessment. It demonstrates awake fibreoptic intubation as a safe and reliable technique in patients with massive thyroid enlargement and an anticipated difficult airway.