Indian Journal of Anesthesia and Analgesia

Various invasive and non-invasive techniques are used to understand the oxygenation. This study aimed to assess the correlation between Spo2/Fio2ratio to Pao2/Fio2and Sao2/ Fio2 in different invasive modes of oxygen supplementation. We hypothesized that the non-invasive index SpO2/FiO2 (SF) ratio can be used as a surrogate for to invasive index PaO2/FiO2 (PF) ratio and SaO2/FiO2 ratio in all invasive modes of ventilation. Methods and methodology: A total of 313 patients admitted to the surgical and medical intensive care unit were enrolled in this retrospective cross-sectional study. Fraction of inspired oxygen (FiO2) from the monitor, while ABG sampling, Partial pressure of oxygen (PaO2) and Arterial oxygen saturation (SaO2) were noted from the ABG, reports in the medical records. The corresponding saturation of peripheral oxygen (SpO2) was noted from the monitor while ABG sampling. Calculated SF, PF and SaO2/FiO2 ratios were recorded and correlation between the same was noted in different invasive modes of ventilation. Results: Pearson’s correlation was used to quantify the relationship between the variables. The study showed a positive correlation, r=0.6003 (P< 0.001), between SF and PF ratio and also a positive correlation, r=0.9137 (P<0.001), between SF and SaO2/ FiO2 ratio. In addition, the median values of SF ratio (P-value=0) and SaO2/FiO2 ratio (P-value=0) indicated the observed difference is unlikely to be due to chance. Conclusion: In patients who are on an invasive mode of ventilation, the non-invasive SF can be used as a surrogate for invasive PF and SaO2/FiO2 ratio.

Background: The transversus abdominis plane (TAP) block serves as a straightforward regional technique employed to alleviate postoperative pain in patients undergoing abdominal surgeries. Over the years, various additives have been utilized to prolong the analgesic effects of peripheral nerve blocks. Several studies have investigated the effectiveness of adding dexamethasone to local anesthetics such as bupivacaine, with promising results. However, there is still a lack of studies directly comparing the efficacy of dexamethasone when combined with ropivacaine. Objectives: To investigate whether combining dexamethasone 8 mg with ropivacaine 0.2% in a TAP block would result in a prolonged analgesic effect compared to using ropivacaine 0.2% alone following inguinal hernia repair. Study Design: A prospective study conducted in a teaching hospital, utilizing a randomized, double-blinded and placebo-controlled design. Methods: The study enrolled a total of 62 patients undergoing either inguinal hernia repair. Among them, 31 patients were administered a TAP block with ropivacaine combined with saline, while the remaining 31 received ropivacaine with dexamethasone immediately after the surgery. Both the proceduralist (resident) and the patient were kept unaware of the solution used. Pain levels were assessed using visual analog pain scores (ranging from 0 to 10) before and immediately after the block. Our main focus was the visual analog pain score at the 12-hour mark, with pain scores at 24 and 48 hours serving as secondary endpoints. Results: In the saline group, the average pre-block pain score was 7.8 ± 1.8 while in the dexamethasone group, it was 7.9 ± 2.3. Both groups experienced an improvement in pain scores compared to baseline at 12 hours post-block administration. Although the dexamethasone group exhibited a greater reduction in pain score (-3.2) compared to the saline group (-2.2), this discrepancy between the two groups did not reach statistical signifcance (p = 0.08). Furthermore, there were no significant variances in the change from baseline observed at 24 and 48 hours between the two groups (p values = 0.74 and 0.44, respectively). Limitations: We opted not to evaluate the cumulative dose of analgesics administered during surgery under the assumption that the impact of intraoperative analgesia would diminish by the time we assessed the 12-hour pain score. We also did not standardize for the proficiency of the block provider, considering that certain providers might have been junior residents lacking extensive experience in this domain. Furthermore, we couldn’t incorporate postoperative opioid consumption due to concerns regarding potential disparities in patient reporting and data reliability. Conclusion: In summary, our study did not demonstrate a statistically significant extension of analgesia for TAP blocks with ropivacaine when dexamethasone was included. However, there was a notable one-point reduction in pain scores at 12 hours following the addition of dexamethasone to the block solution. Despite the absence of statistical significance, this reduction in pain scores at the 12-hour mark could still contribute to enhanced patient satisfaction, especially considering the favorable side effect profile of dexamethasone. Given that ropivacaine has a lower pH compared to other local anesthetic agents, further well-designed studies are warranted to explore its combination with more alkaline drugs such as corticosteroids.

Injury to popliteal artery mostly occurs with fracture, dislocation and penetrating trauma. Isolated blunt trauma in absence of other injuries makes it difficult to diagnose. Thus, high rate of complications such as amputation are reported in injury to popliteal artery cases. In this article successful revascularisation of a patient with delayed popliteal artery injury presentation associated with compartment syndrome is reported. Emphasis is laid on vascular reperfusion injury and significance of vascular examination in blunt trauma which helps in prevention of amputation and morbidity.

Amlodipine overdose is scarcely reported from India, though rare but associated with high mortality. It can lead profound refractory hypotension and shock leading to end organ damage. Management involves early and aggressive measures and calcium in large doses to overcome competitive blockade, hyperinsulinemiaeugycemic therapy, along with some rescue therapies tried in anectodal reports. We report one such case of amlodipine overdose and was successfully managed.

Introduction: Spinal Muscular Atrophy (SMA) is a genetic disorder impacting approximately 1 in 10,000 individuals. It manifests across varying degrees of severity. Generally, the disease's onset at an earlier age corresponds to more pronounced symptoms, such as difficulty with swallowing, breathing, etc. A present case of a two-year-old male child diagnosed with SMA type 2 was planned for feeding gastrostomy under general anesthesia. This case report highlights how awareness of this rare ailment can facilitate early identification, empower parents to seek genetic counseling and help prevent potential complications. Case Report: A 2-year and 10-month-old male child was brought with cough, cold and shortness of breath persisting for three days. Medical history reveals that he had SMA type 2 and underwent Zolgensma. Provisional diagnosis of SMA type2/ bronchopneumonia with respiratory distress was made. His treatment commenced with oxygen support via nasal prongs, IV antibiotics Inj. Collistin 75K/kg/day TID, Inj. Fluconazole 100 mg iv OD, Nebu Asthalin, Nebu Budecort nebulization. Following day, i/v/o respiratory distress, he was connected to high-flow nasal cannula support. The antibiotics regimen was adjusted to include increased doses of PIPTAZ syrup azithromycin and oseltamivir. He was premedicated with Inj. Glycopyrrolate, Inj. Midazolam and Inj. Fentanyl and pre-oxygenation with 100% oxygen and intubated with 4mm uncuffed endotracheal tube and shifted to the OT. Anesthesia was induced with sevoflurane and maintained with a combination of nitrous oxide and oxygen. Skeletal muscle relaxation atracurium was given. The pediatric surgeon performed gastrostomy by inserting MIC-KEY Tube of 12FR through the anterior abdominal wall into the stomach. Throughout the procedure, his hemodynamic parameters remained stable and was transferred to the Pediatric ICU with Ambubag and ET tube ventilation and then transitioned to mechanical ventilator support. Postoperative recovery was uneventful. Conclusion: Individuals with SMA can effectively be administered with general anesthesia, using muscle relaxants and inhalation anesthetics. Addressing specific concerns and ensuring access to advanced airway and imaging equipment are pivotal for safely managing anesthesia in this specialized patient cohort.

A 75-year-old lady, weighing 23kg, presented with midshaft fracture of left humerus. She had cervical and thoracic kyphoscoliosis, with multiple level cervical IVDP. On further evaluation, hypercalcaemia due to right inferior parathyroid adenoma was found. After initial medical management, she was planned for right inferior parathyroidectomy under general anesthesia. Considering the inherent high risk and lack of consent for general anesthesia, the patient underwent right inferior parathyroidectomy and right hemithyroidectomy under bilateral superficial cervical plexus block. Postoperatively, hungry bones syndrome was managed with intravenous calcium infusions and she was discharged on 8th postoperative day.

Introduction: For safe lower abdominal and lower limb surgeries, spinal anesthesia is commonly used. Failure of Spinal Anesthesia can occur even in the expert hands. Causes of failed subarachnoid block includes technical difficulties, poor patient positioning, incorrect insertion of the spinal needle. Resistance to local anesthetic is difficult to diagnose. One of the etiology for Local Anesthetic resistance is history of scorpion bite in the past. Here we report one such case where spinal anesthesia was administered and later upon noticing a failed block, a history of scorpion sting was elicited in operating room and the procedure was carried out under general anesthesia. Case Report: A 55 year old male diagnosed with Open type III B both bone fracture of right leg. Patient gave an alleged history of RTA. With anesthetic plan of Subarachnoid block, 18G IV Cannula was secured. Lumbar puncture was done at L3-L4 Level with 23G Quincke’s Needle in sitting position. 3.5ml (15mg) of Bupivacaine and 60mcg of bupreonorphine was injected. Even after waiting for 20 minutes the patient had no sensory or motor block. There was no fall in blood pressure. During the wait, a further detailed history was taken which revealed that patient had a history of scorpion bite 5 years ago and was treated in a local hospital. Hence the surgery was done under general anesthesia. During the surgery, sudden elevation in blood pressure and ST segment elevation in chest leads was observed. Suspecting intraoperative Myocardial Infarction Inj. Loxicard 20mg and Tab. Ecospirin 150mg was given. ST segment elevations were reverted. ABG which was done to rule out any acid base disorder was within normal limits. After completion of surgery, Reversal (Inj. Neostigmine 3mg + Inj. Glycopyrolate 0.6mg) was given and patient was extubated. Once the patient was stabilised, patient was shifted to ICU for observation. Post operative orders for a chest X-ray, SOB profile, 2D ECHO for intraoperative changes were given and were normal. Conclusion: During routine preanaesthetic evaluation, we never ask about previous exposure to toxins, as in our patient it was discovered later. Now we have made it part of questionnaire in preanesthetic check. The patient was monitored carefully, therefore early detection of ST-segment elevation was possible. The presence of an anesthetic team favored the early diagnosis, so the patient was given a quick and safe intervention.

Introduction: Intubation can sometimes be difficult in patients with lesions in the mouth floor. Ameloblastoma is a frequently encountered tumor of the maxillofacial area. An extensive lesion might occupy the floor of the mouth, prevent displacement of the tongue, limiting the space for inserting a laryngoscope blade and resulting in difficult intubation even with fiberoptic bronchoscopy. Ameloblastoma is a common neoplasm affecting the jaws. It is an aggressive benign tumor of epithelial origin. Ameloblastomas are recognized for their invasive growth and tendency to recur. Reconstruction procedures are usually prolonged and require meticulous attention to fluid replacement, blood loss and prevention of hypothermia. Hence they present a challenge to the anaesthesiologist. Case Report: A 40-year-old woman weighing 36 kgs presented with pain and swelling in the right jaw/mandible that had existed for three years. Her past medical history was unremarkable. Upon airway examination, mouth opening was inadequate, restriction of head and neck movements was noted, CECT showed pneumocysts in C5, C6 and C7 vertebrae and showed a large expansile lytic lesion involving body of mandible and inferior aspect of rami bilaterally with cysts and solid components show heterogeneous post contrast enhancement with mass effect on adjacent structures. The results of general and systemic examination were within normal limits. Two large bore 16G cannulas secured for proper fluid resuscitation intraoperatively, as mouth opening is inadequate and difficult bag and mask ventilation anticipated. Planned for awake fibreoptic intubation, patient premedicated with Glycopyrrolate and Fentanyl. As expected patient had breathing difficulty during the procedure and laryngeal edema seen on fibreoptic, patient given Dexamethasone 8mg, preoxygenated with facemask for 10 minutes and opted for 6mm ID flexometallic ET tube fibreoptic intubation. Torniquet applied for 2 hours to left thigh to minimize blood loss for fibular graft patient developed hypotension after 8 hours of surgery PRBC and colloids transfused and resuscitated with fluids as surgeons opted for tracheostomy in between, after 16 hours of surgery patient shifted to ICU for observation shifted back to ward. Conclusion: Our case was anticipated difficult airway, planned for awake fibreoptic intubation,even though it was prepared, because of the tumor, airway edema present and all small size endo tracheal tube was used surgical airway was ruled out as tumor was big and was in midline.

Opioid free anesthesia in Neurosurgery is an evolving concept in light of recent era. Classic convention of using opioid as a cornerstone for provision of analgesia during neurosurgeries is now being shaken off by the ongoing emerging evidence. The present case report aims to bring out the successful usage of opioid free anesthesia during aneurysm clipping surgery. We discuss in detail the various pros and cons including pitfalls in the literature review alongwith this case report.

Gaucher`s disease is the most common form of lysosomal storage disorder. It is caused by an inherited deficiency of beta glucocerebrosidase enzyme. It results in accumulation of beta glucocerebroside leading to end organ dysfunction. Gaucher disease is an autosomal recessive inheritance by mutations in the GBA gene on chromosome 1. It affects both sexes. The incidence is estimated to be 1:40000 in Europe. Most commonly, the disease is differentiated into a non-neuronopathic form and a neuronopathic form. Gaucher disease may present a challenge to the anesthesiologist because of abnormal coagulation and multi organ dysfunction. These factors may affect the choice of anaesthesia type. We aim to report the anaesthetic management in a 25 years old male with Gaucher’s disease posted for splenectomy.

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