Indian Journal of Anesthesia and Analgesia

Aims and Objectives: To compare hemodynamic responses to direct laryngoscopy and endotracheal intubation with intravenous dexmedetomidine combined with either magnesium sulphate or lignocaine. Study Site and Design: Hospital-based, double-blinded randomized controlled study at a Municipal General Hospital.

Study Population and Sample Size: 128 adult patients (ASA I-II) scheduled for elective surgery under general anaesthesia, divided into two groups of 64 each.

Methodology: Patients received premedication with study drugs. Standardized anaesthesia induction was followed. Vital parameters like heart rate, blood pressures (SBP, DBP, MAP), SpO2, and ECG were recorded at baseline, preinduction, and at 1, 3, 5, 10, and 15 minutes post-induction. Postoperative analgesia and recovery times were monitored.

Statistical Analysis: Data were analysed using SPSS v22. Continuous variables were expressed as mean ± SD and compared using unpaired t-tests; categorical variables were analysed using Chi-square tests. Trends over time were evaluated; significance was set at p<0.05.

Results: Demographics including age, gender, ASA grade, BMI, and comorbidities were comparable (p>0.05). Both drug combinations maintained stable hemodynamics during and after intubation, with no significant differences in HR, BP, MAP, SpO2, or ECG. Postoperative analgesia and induction-to-extubation times were similar (p>0.05).

Conclusion: Dexmedetomidine combined with either magnesium sulphate or lignocaine effectively attenuates the hemodynamic response to laryngoscopy and intubation, with stable perioperative parameters and comparable safety profiles. Both combinations are suitable for ASA I-II patients.

Artificial intelligence (AI) and machine learning technologies are revolutionizing neuroanesthesia and neurocritical care through enhanced real-time monitoring, advanced neuroimaging analysis, and improved prognostic accuracy in patients with traumatic brain injury, stroke, intracranial hemorrhage, and neurosurgical conditions.1 This comprehensive review examines current AI applications including continuous physiological monitoring with predictive alerts, automated neuroimaging interpretation, outcome prognostication, personalized intraoperative management, and closed-loop anesthetic delivery systems. We address critical challenges including data quality, algorithmic bias, interpretability concerns, and regulatory barriers to clinical implementation. While AI demonstrates substantial promise in improving patient safety and outcomes in resource-constrained settings, successful integration requires rigorous validation, diverse population representation, clinician education, and establishment of clear governance frameworks. This review synthesizes evidence for Indian neuroanesthesiologists and neurocritical care specialists regarding AI implementation opportunities and necessary considerations for adoption.

Background: Nano-robotic neurosurgical procedures represent a frontier in minimally invasive surgery, offering unprecedented precision in treating neurological disorders. These procedures introduce unique anesthetic challenges that require tailored approaches to ensure patient safety and procedural success.

Aim: This review explores key anesthetic considerations for nano-robotic neurosurgery, focusing on strategies to optimize patient outcomes

Issue: Anesthetic management prioritizes stable hemodynamics and intracranial pressure (ICP) to optimize the surgical field and protect neural structures. General anesthesia using total intravenous anesthesia (TIVA), using agents like propofol and remifentanil, is preferred for rapid titration and minimal impact on cerebral blood flow. Intraoperative neuromonitoring is employed for real-time neural function assessment, avoiding neuromuscular blockers that may interfere with signal accuracy. Protocols accommodate prolonged procedure times, patient immobility for nano-robot precision, and monitoring for potential thermal or mechanical neural irritation causing seizures or autonomic responses.

Conclusion: Nano-robotic neurosurgery demands specialized anesthetic protocols to address challenges such as stable hemodynamics, ICP control, and neuromonitoring compatibility. Effective collaboration between anesthesiologists, neurosurgeons, and nano-robotics engineers is critical to ensure patient safety and procedural success. Postoperative care emphasizes early neurological assessment and balanced pain management to support rapid recovery in this evolving field

Artificial intelligence (AI) and machine learning technologies are revolutionizing the landscape of pain management through enhanced diagnostic accuracy, prognostic prediction, and personalized treatment strategies. This comprehensive review examines the current applications of AI in pain medicine, including pain diagnosis and classification, prognosis and chronicity prediction, personalized pharmacological and non-pharmacological management, and real-time monitoring systems. We explore the integration of AI-driven decision support systems in perioperative care, the role of wearable devices and telemedicine platforms, and address the challenges related to data privacy, algorithm bias, and clinical implementation. While AI demonstrates significant promise in improving patient outcomes and reducing healthcare burden, substantial barriers to clinical integration remain. This review highlights the need for rigorous validation studies, diverse population representation, and development of clinician-friendly interpretable AI models to facilitate adoption in Indian healthcare settings.

Peripartum cardiomyopathy (PPCM) is a rare form of dilated cardiomyopathy presenting as new-onset heart failure in late pregnancy or early postpartum. It is characterized by reduced left ventricular ejection fraction (≤45%) and carries significant maternal and fetal risk. Anaesthetic management is challenging due to susceptibility to arrhythmias, pulmonary edema, and hemodynamic instability, with limited evidence to guide optimal techniques.

This report describes two parturients with severe PPCM (ejection fraction 20–27%) requiring caesarean delivery. Both underwent a combined general anaesthesia and epidural approach after multidisciplinary evaluation. Induction with etomidate or propofol and succinylcholine resulted in hypotension requiring norepinephrine support. Maintenance was achieved with oxygen–nitrous oxide, and opioids were administered after delivery. Uterotonics were avoided to prevent abrupt cardiovascular changes. Neonatal outcomes were good, and maternal recovery was uneventful.

These cases demonstrate that a carefully titrated combined anaesthetic technique with meticulous hemodynamic management can facilitate safe delivery in severe PPCM.

Introduction: Carcinoma esophagus remains a major global cause of morbidity and mortality. Surgical resection, performed through transthoracic esophagectomy (TTE) or minimally invasive esophagectomy (MIE), is the primary treatment for localized disease. These surgeries require lung isolation to ensure optimal exposure, reduce contamination of the opposite lung, and limit operative lung injury. One-lung ventilation (OLV) markedly alters respiratory physiology by creating a right-to-left intrapulmonary shunt, leading to hypoxemia and increased pulmonary vascular resistance. These effects demand careful anesthetic planning and enhanced intraoperative monitoring to maintain patient safety and optimize outcomes

Case Report: A 58-year-old female (ASA II, ECOG 1), known case of moderately differentiated squamous cell carcinoma of the middle-third of the esophagus, post-neoadjuvant chemoradiotherapy (Paclitaxel + Carboplatin, 41–40 Gy in 23 fractions), was posted for VATS-assisted transthoracic esophagectomy. Preoperative evaluation revealed BMI 21 kg/m², Hb 11.2 g/dL, normal renal and hepatic profile, ECG with sinus rhythm, 2D echo with preserved LV systolic function (LVEF 60%), mild mitral valve prolapse, PASP 35 mmHg. Chest x-ray was normal.

Thoracic epidural catheter was inserted at T8–T9 (loss-of-resistance technique, 18G Tuohy needle) and test dose (Lidocaine 2% + adrenaline 3 mL) was negative. Balanced general anaesthesia was induced with IV glycopyrrolate 0.2 mg, fentanyl 60 µg, lignocaine 40 mg, propofol 80 mg, and vecuronium 3 mg. The airway was secured with a 28 Fr left-sided double-lumen endotracheal tube (DLT) under direct laryngoscopy (Cormack–Lehane Grade 1 view), tube position confirmed by auscultation and fiberoptic bronchoscopy.

Intraoperatively, the patient was placed in left lateral decubitus position and maintained on OLV with volume-controlled ventilation (tidal volume 5–6 mL/kg predicted body weight, $FiO_{2}$ 0.6, PEEP 5 $cmH_{2}O$). Hemodynamics remained stable (HR 80–85/min, MAP 75–85 mmHg, $SpO_{2}$ > 95%). ABG analysis intraoperatively showed mild respiratory alkalosis (pH 7.47) without hypercarbia. Estimated blood loss was 450 mL; replacement included crystalloids, and one unit packed red cells.

Conclusion: Anaesthetic management of esophagectomy with OLV requires comprehensive preoperative optimization, advanced airway management, lung-protective ventilation, vigilant hemodynamic monitoring, and multimodal analgesia. Elective postoperative ventilation with controlled weaning and early mobilization contribute to favourable outcomes in high-risk thoracic surgery patients.

Patients with a carcinoma presents with poor nutrition and comes with major morbidity (65%) and 30 day mortality rate of 4%. Needs multimodal treatment and work up with a multi-disciplinary team with Enhanced Recovery after Surgery (ERAS) protocols.

Our patient, 70 year old male had Hypertension, Ischaemic heart disease and Psoriasis on treatment. His preoperative investigations showed Hb of 7.8 gm%, albumin 2.9g/dl; Echo showed Mild MVP, Grade 2 AR, PASP of 25mm Hg, LV diastolic dysfunction. Others were within normal limits.

Epidural was secured at T9-T10 and GA given. A left sided double lumen tube (35 Fr) was introduced and fixed after confirmation of isolating each lung, patient had hypertension treated with Inj NTG tapered later. Epidural was activated with 8 ml of 0.25 mg Bupivacaine. During mediastinal manipulation, patient went into bradycardia and hypotension; transiently surgery was stopped and IV fluids were given and it settled. Total Blood Loss was 500ml and Replaced with one packed RBC. IV fluids RL, NS were given. Haemodynamics were stable later. After surgery he was extubated and sent to ICU for monitoring. Role of Anaesthesiologists in the perioperative period is very important for preparation, planning, conduct of Anaesthesia, one lung ventilation and for a better outcome.

Introduction: Anesthesia management for a patient with mitral valve replacement (MVR) and atrial fibrillation (AF) undergoing hernia repair (hernoplasty) requires careful consideration of the cardiovascular status, anticoagulation therapy (ASRA guidelines to be followed), and potential interactions with anesthetic agents.

Case Report: Our patient aged 51 yrs Male came to the hospital with complaints of swelling over right groin since 6 months associated with pain and was diagnosed with Inguinal Hernia. Patient has a history of Mitral Valve Replacement done 10 yrs ago and

ECG showed irregular irregular rhythm with no p waves and heart rate of 60-100 bpm.

ECG showed Atrial fibrillation. 2d Echo showed s/p mitral valve replacement with normal functioning prosthetic valve, MVG=10/5 mmhg, Dilated Left atrium mild MR, mild TR (PASP=45mmhg), mild AR, Adequate systolic funtionand LVEF=55%, other investigations under normal limit.

Patient was on T.Warfarin 3 mg, T. Atorvastatin 10 mg, T. Bisoprolol 5 mg Once Daily. T. Warfarin was replced by Inj. Enoxaparrin 0.4 Sub cutaneously twice a day till INR is less than 1.5 and that was stopped 12 hours pior to the surgery.

Patient was given Sub Arachnoid Block with 25 G quinckes Spinal needle, Inj Bupivacaine (0.5%) (heavy) 16 mg was given. Inj. Pethidine 20 mg and Inj. Midazolam 1 mg were given for Sedation.

Conclusion: The patient was successfully managed with Mitral valve replacement and atrial fibrillation with Anti Coagulants and without Cardioversion.

An 70 year old female weighing 41kg and 151 cm tall came with complaints of mass per vagina since 10 years and discharge PV since 2 months. Patient gave history of cough for which pulmonologist opinion was taken and patient was started on Tab Montair LC 0-0-1 and Inj Hydrocort 100 mg 1-0-1. No other knowncomorbidities

Preop vitals were stable Preop investigations revealed a haemoglobin of 10.3 besides which rest all investigations were within normal limits. 2D echo revealed myxomatous Mitral valve with moderate MS; AV sclerotic with mild AR. Mild TR with mild PAH with PASP-50 mmhg and EF-55%. Cardiac opinion was sought and patient was deemed fit for surgery and to be taken under moderate risk. Inj LASIX 20 mg was advised 1hr prior to surgery. Pulmonologist also gave fitness and advised patient can be taken up for surgery under moderate risk. Primary anesthetic plan was under subarachnoid block and alternative was General anaesthesia

Preoperatively patient was given Tab Anxit 0.25 mg and Tab Rantac 150 mg. Nebulisation Duolin and Budecort was advised before shifting the patient to operation theatre. 1 pint PRBC was reserved. Preop Blood pressure was 140/80 mm hg. Intraop anaesthetic plan was changed to continous spinal anaesthesia Intrathecal catheter was inserted in L3-L4 space with the help of 18 G Touhys needle. Inj Bupivacaine 0.5% heavy-0.8cc was given initially at 10 am and a dose of inj Bupivacaine 0.5% heavy-0.6cc was repeated at 11:10 am. Patient maintained sensory block till T8. Patients vitals, urine output and blood loss was closely monitored and was uneventful.