Indian Journal of Anesthesia and Analgesia

Background: The transversus abdominis plane (TAP) block is a regional anesthesia technique increasingly used for postoperative pain management in abdominal and pelvic surgeries. Although its use has expanded in recent years, questions remain regarding its comparative efficacy, safety, and optimal clinical application. Objective: To evaluate the effectiveness of TAP blocks in reducing postoperative opioid consumption and pain scores, as well as in minimizing opioid-related adverse events compared with systemic analgesia or placebo. Methods: A systematic review and meta-analysis of randomized controlled trials (RCTs) published between 2010 and 2023 was performed. Primary outcomes were 24-hour opioid consumption [in morphine milligram equivalents (MME)] and pain scores [measured on a Visual Analog Scale (VAS)]. Secondary outcomes included the incidence of adverse events such as nausea, vomiting, and local anesthetic systemic toxicity (LAST). Database searches were conducted in PubMed, EMBASE, the Cochrane Library, and ClinicalTrials.gov. Two independent reviewers extracted data and assessed study quality using the Cochrane Risk of Bias Tool 2.0. Data were pooled using a random-effects model (RevMan 5.4), with mean differences (MD) reported for continuous outcomes and risk ratios (RR) for dichotomous outcomes. Results: Forty-five RCTs comprising 5,200 patients met the inclusion criteria. TAP blocks reduced 24-hour opioid consumption by 45% (MD: -20.1 mg MME, 95% CI: -24.3 to -15.9; p < 0.001) and resting pain scores by 2.1 VAS points at 12 hours (95% CI: -2.7 to -1.5; p < 0.001). Dynamic pain scores over 24 hours were also significantly improved (MD: -1.8, 95% CI: -2.3 to -1.3; p < 0.001). Subgroup analysis revealed that patients undergoing colorectal surgeries experienced the greatest opioid-sparing effect (MD: -25.3 mg) compared to caesarean sections (MD: -18.2 mg). No significant differences in complications were noted (RR = 0.9, 95% CI: 0.7–1.2), with LAST occurring in only 0.04% of patients. Moderate heterogeneity (I² = 55%) was observed across the studies. Conclusion: TAP blocks provide a safe and effective opioid-sparing modality for postoperative analgesia in abdominal surgeries. Their incorporation into Enhanced Recovery After Surgery (ERAS) protocols, particularly for open abdominal procedures, is recommended. Future research should focus on standardizing the block technique and local anesthetic dosing to further optimize outcomes.

Background and Objectives: Obesity presents significant challenges in neuraxial anesthesia due to difficult surface anatomical landmarks, leading to increased failure rates and complications. Since Bier first described spinal anesthesia in 1899, the traditional method for identifying the subarachnoid space has been through anatomical landmarks. Conventional palpation techniques often prove unreliable in these patients. Neuraxial ultrasound aims to enhance accuracy by visualizing sonoanatomy, potentially improving success rates and patient outcomes. This study was done to evaluate the effectiveness of preprocedural ultrasound-assisted midline approach compared to the traditional landmark-guided technique in obese patients undergoing lumbar subarachnoid block. Methods: A prospective observational study was conducted in 90 obese patients (BMI > 25 kg/m²) aged between 18 and 80 years scheduled for elective surgery under spinal anesthesia at Travancore Medical College, Kollam. Patients were divided into two groups: ultrasound-assisted (USG) and surface landmarkguided (SLG). Detailed history, physical examination, and informed consent were obtained. A portable USG machine with curved array probe was utilised for pre procedure marking. Key variables measured included first-attempt success rate, number of needle passes, time for space identification, and total procedure time. Data was analysed using statistical package for social sciences version 25. Results: The first-attempt success rate was significantly higher in the USG group (51.1%) compared to the SLG group (15.6%). The mean time for space identification was longer in the USG group (119.64 ± 48.69 seconds) than in the SLG group (28.56 ± 15.65 seconds), but the total procedure time was shorter in the USG group (281 ±85.657 seconds) compared to the SLG group (414.44 ± 218.835 seconds). Patient satisfaction and reduced number of needle passes were also better in the USG group. Conclusion: This study demonstrates that the ultrasound-guided technique significantly improves the first attempt success rate of spinal anesthesia and enhances patient satisfaction in obese patients. Despite the longer time required for space identification, the overall procedure time is reduced with ultrasound guidance. These findings suggest that incorporating ultrasound guidance into clinical practice could enhance the efficacy of spinal anesthesia in obese patients, highlighting its potential as a valuable tool in modern anesthetic practice.

Anaesthetic management of a patient with Dilated Cardiomyopathy (DCM) or a non-cardiac surgery is always a challenge to the anaesthesiologist.1 DCM results in deterioration of the function of myocardium caused by either LV or biventricular dilatation or due to an impaired systolic function of one or both ventricles with impaired contractility2, thereby increasing the risk of perioperative cardiovascular complications. We present the successful anaesthetic management of hemiarthroplasty for a patient with severe DCM under Epidural anaesthesia. This abstract outlines the anaesthetic considerations and approach in a patient with DCM undergoing hemiarthroplasty under epidural anaesthesia. The case emphasizes the importance of preoperative optimization, including assessment of cardiac function, fluid status, and electrolyte balance. Epidural anaesthesia is a viable option in these cases due to its advantage in minimizing systemic stress responses and providing effective postoperative pain relief. Special attention was given to the titration of the epidural local anaesthetic to avoid hypotension, which could otherwise exacerbate heart failure symptoms. Continuous monitoring of cardiac output and blood pressure, alongside careful fluid management, was essential to prevent exacerbation of DCM-related complications. Postoperatively, epidural analgesia facilitated controlled pain relief, reduced the need for systemic opioids, thus lowering the risk of respiratory depression and other cardiovascular events. This report suggests that epidural anaesthesia, when carefully administered, can be a safe and effective anaesthetic technique in patients with DCM undergoing hemiarthroplasty, provided there is vigilant monitoring and individualized management of fluid balance, blood pressure, and cardiac function.

Introduction: Kyphoscoliosis, a condition characterized by forward and lateral bending of the thoracolumbar spine. The most common cause of kyphoscoliosis is idiopathic, which occurs in 70% of the population. The secondary causes may include neuromuscular, congenital, or traumatic. Patients with thoracolumbar kyphoscoliosis present unique challenges to anaesthesia. Case Report: A 72 year old male, with kyphoscoliosis diagnosed with left sided complete indirect inguinal hernia was posted for hernioplasty. He was a known case of Alzheimer’s disease. On examination vitals were stable. Airway examination showed Mallampati grade 4. An examination of the spine revealed a lateral curvature along with thoracolumbar kyphosis. Blood and routine investigations were within normal limits. The surgery was planned under spinal anaesthesia. On the day of surgery, the patient was shifted to the operation theatre, standard monitoring was ensured perioperatively. Patient was given subarachnoid block through paramedian approach. Intra operative vitals were stable. Standard monitoring was continued in post operative care unit for 30 mins. There was no surgical or anaesthetic complication. Conclusion: When both the airway and spine are involved in the disease process the anaesthetic options are limited and technically difficult. Subarachnoid block with proper preoperative planning can be a useful technique of providing safe and effective anaesthesia in patients with severe thoracolumbar kyphoscoliosis.

Introduction: Temporomandibular joint ankylosis cases serve as a challenge for both surgeons and anaesthesiologists. Trauma is the most common cause of TMJ ankylosis, followed by infection. The management goal in TMJ ankylosis is to increase the patient’s mandibular function, correct associated facial deformity, decrease pain, and prevent re-ankylosis. Case Report: A 9-year-old female presented with difficulty in mouth opening, leading to difficulty in maintaining oral hygiene. The patient had no comorbidities. She was diagnosed with left temporomandibular joint (TMJ) ankylosis and scheduled for left gap arthroplasty. On preoperative evaluation, vitals were stable, and systemic examination was normal. Airway assessment revealed restricted mouth opening, trismus, left TMJ tenderness. Neck movements were unrestricted, but a Mallampati class IV airway suggested difficulty. Investigations were normal. She was premedicated .Induction was done using Inj. Propofol 60 mg, followed by Inj. Atracurium 15 mg. After 3 failed attempts with a Macintosh and video laryngoscope, intubation was achieved using a Miller laryngoscope (size 0). Surgery lasted three hours with 150 mL blood loss. The patient remained stable intraoperatively and recovered uneventfully. Conclusion: Anaesthesia management in patients with temporomandibular joint ankylosis presents unique challenges, particularly in securing the airway and maintaining hemodynamic stability during surgery. A thorough preoperative assessment and careful planning are essential for success. With appropriate preparation and the ability to adapt to unexpected difficulties, the anaesthetic management of TMJ ankylosis can be successfully navigated, minimizing complications and ensuring optimal patient outcomes.

Introduction: Dilated Cardiomyopathy is a syndrome characterized by cardiac enlargement and impaired systolic function of one or both ventricles. A large number of cases are idiopathic. The known causes are ischemic, valve dysfunction and post viral infection. DCM can also be found in association with sickle cell disease, muscular dystrophy, excess alcohol, hypothyroidism and some chemotherapy agents or during peripartum period. Patients with dilated cardiomyopathy are regarded to be of high risk for perioperative complications, necessitating diligent anaesthetic management. Case report: A 2 year old girl child diagnosed with the cellulitis of left upper limb And left foot, with query of osteomyelitis of left elbow joint posted for incision and drainage and wound debridement. Child presented with a history of dilated cardiomyopathy diagnosed at the age of 6 months and was put on medication. 2D echocardiography showed dilated left ventricle with global hypokinesia of left ventricle with sever left ventricular systolic dysfunction, with ejection fraction of 20 percent. On examination wound to have severe anaemia with Hb of 5g%. Through pre-operative cardiovascular stabilisation done by consultation of cardiologist opinion in view of DCM and Paediatrician in view of anaemia. Standard monitoring ensured perioperatively with keen monitoring over cardiovascular status. On the day of surgery, patient Blood Pressure (BP) was 96/60 mm Hg, Heart Rate (HR) was 130/min and oxygen saturation (SaO2) was 100% on room air. Other parameters monitored were ECG, end tidal carbon dioxide and oxygen saturation. anaesthesia was induced slowly with iv ketamine 3.5mg, and iv succinylcholine 7 mg. LMA of size 2 was used. Anaesthesia was maintained with O2/N2O, servoflurane (mac 3.5-1). Surgery was completed in 60 minutes Intraoperatively total IV fluids 60 ml given. At the end of surgery LMA removed and patient was kept in Paediatrics icu for one day for observation Conclusion: As the patient posted for wound debridement with known history of DCM. Hemodynamic management and support was extremely useful to these patients. Due to short procedure, LMA was selected to avoid the post intubation responses. And maintained minimal IV fluids In this case, the anaesthetic management was handled successfully without any consequences.

Introduction: Hydrocephalus, it is an excessive accumulation of cerebrospinal fluid within the head. It can be due to congenital or acquired. It leads to increase in intracranial pressure, seizures, permanent disability and sudden death, for which patients has to undergo external ventricular drain, lumbar shunts or ventricular shunts. Patients with intracranial pathology have high risk of perioperative complications, which needs specific anaesthetic management. Case Report: A 32 year old male a case of status post right temporo-parietal craniectomy with obstructive hydrocephalus posted for ventriculo-peritoneal shunting. He sustained head injury 2 months back for which he had undergone craniectomy and also tracheostomised. Then he was newly diagnosed as diabetic and hypertensive for which he was on medication. And his blood investigations showed hyponatremia for which he was started on sodium correction. In between, he had developed left cephalic vein thrombosis for which he was started on injection Heparin. After 2 months of craniectomy he developed cerebral edema following which his GCS was also worsened. So ventriculoperitoneal shunting was done under general anaesthesia and it was uneventful. Conclusion: As the patient was posted for ventriculoperitoneal shunting with known history of status post craniectomy, hyponatremia and high blood sugars; early hemodynamic management and intensive care was extremely useful to these patient in view of anticipation of seizures, bleeding. In this case, the anaesthetic management was handled successfully without any consequences.

Introduction: Tuberous sclerosis complex (TSC) is a rare genetic disorder characterized by the development of benign tumors in multiple organs, including the brain, skin, kidneys, heart, and lungs. It is often associated with neurological manifestations such as epilepsy, intellectual disabilities, and behavioral disorders. The management of patients with TSC, particularly those with epilepsy, presents unique challenges during surgical procedures due to their complex medical history and potential for perioperative complications. Case Report: A 24 year-old female diagnosed with left renal mass plus left adnexal mass pelvis posted for left nephrectomy + left adnexal mass excision with a known diagnosis of tuberous sclerosis complex and a history of epilepsy. It was scheduled for a left nephrectomy due to a renal angiomyolipoma. The patient had a history of frequent generalized tonic-clonic seizures despite being on antiepileptic medication. On physical examination, the patient appeared well-oriented with normal cognitive function. Multiple hypopigmented macules were present on her skin, consistent with her diagnosis of TSC. Preoperative laboratory investigations were within normal limits. Preoperative evaluation by the neurologist ensured that the patient’s antiepileptic drug (AED) regimen was optimized. recommended. Epidural was places at T12-L1; General anesthesia was induced using propofol and fentanyl, with vecuronium and maintained with O2, N2O and Isoflurane. Antiepileptic medications were given. Vitals were stable and blood was transfused. Intraoperative and post-operative period patient was stable and monitored in ICU for 1 day and shifted to postoperative ward uneventfully. Conclusion: This case highlights the successful anesthetic management of a patient with tuberous sclerosis complex and epilepsy undergoing nephrectomy. A multidisciplinary approach, careful preoperative planning, and vigilant intraoperative and postoperative monitoring are essential to minimize complications and ensure positive outcomes in such complex cases. Maintaining seizure control and avoiding perioperative triggers, while ensuring hemodynamic stability, were key factors in the management of this patient.

Introduction: Kyphoscoliosis is a forward and lateral bending of the spine,. Kyphoscoliosis causes a decrease in functional residual capacity, inspiratory capacity, vital capacity, and total lung capacity leading to restrictive pattern. Restrictive lung disease, airway management, and cardiorespiratory embarrassment make general anesthesia hazardous, whereas regional anesthesia is met with technical problems due to an abnormal curvature of the spine. Case Report: A 53 year old male diagnosed as indirect inguinal hernia was posted for Hernioplasty, Patient is a Known case of Restrictive lung disease with Cor pulmonale since 3 years and was admitted and intubated in ICU 2 months before the surgery in view of respiratory distress and low GCS. On Pre-anaesthetic examination vitals were stable, airway assessment showed large tongue with MP Grade 4 with prominent anterior larynx. investigations were normal. PFT showed early small airway obstruction. Spine examination was done and there was thoracolumbar scoliosis with spine curve to left and body lean to right. Under all aseptic conditions, lumbar puncture was done at L3-L4 space with 25G quickie needle, after confirming the back flow of CSF 3.4 ml of 0.5% hyperbaric Bupivacaine with 0.2 ml of Buprenorphine was given, but it failed as motor and sensory block was not achieved after 20 minutes of observation, Sub arachnoid block was reattempted through paramedian approach, patient was made supine, sensory block was checked which was achieved till T6. surgery was performed, No major hemodynamic changes were noted. after surgery, patient was monitored in Post-anaesthesia Care Unit and then shifted towards. Conclusion: In a patient with Kyphoscoliosis and Restrictive lung disease Regional Anaesthesia is preferred over General anaesthesia considering risks and benefits.

Introduction: Spina bifida is a major birth defect that is a result of failure of the neural tube to close in the developing fetus. It is associated with varying degrees of neurologic impairment. The anatomic level of the lesion generally correlates with the neurologic motor and sensory deficit and ranges from complete paralysis to minimal or no motor deficit. Case Report: A 3 year old male child who was diagnosed with spina bifida was posted for spina bifiida surgery. The patient had swelling in the lower back region associated with right lower limb weakness since birth. Patient developed continuous dribbling of urine. An MRI Lumbar spine was done which showed defect in the S1, S2, and S3 vertebrea with posterior herniation of spinal cord, neural placode and nerve roots which is suggestive of closed spinal dysarphism, spina bifida with lipo-myelocoele. After through pre anaesthetic check-up, patient was posted for surgery. Patient was intubated with 4.5mm portex uncuffed endo tracheal tube and patient was kept in prone position. Standard monitoring was ensured intra operatively. With a total blood loss of 150ml which is within the maximum allowable blood loss limit, and total of 600ml of IV fluids were given to prevent volume overload. Neurosurgeon wanted an awake test which was a challenge for us as patient was on uncuffed tube so, electromyography was used and TIVA with propofol was maintained to check after the corrective surgery. After the surgery patient was shifted to pediatric intensive care unit with ET tube in situ. Patient was extubated the following day. Conclusion: As the pediatric patient was posted for spina bifida surgery which is a major surgery which took around 6-7 hours. Blood loss, fluid status, pain post- operative hypoxia were of major concern. Amount of IV fluids to be given intra-operatively, maximum allowable blood loss were calculated prior to surgery. The anaesthetic management was successfully done here without any adverse events.

Patient with scoliosis for major surgeries like Total abdominal hysterectomy present challenges for anaesthesia owing to long surgery duration, pulmonary complications, Intubation in case of general anaesthesia; And un-predictability of sensory blockade in case of neuraxial anaesthesia. In this case, a 56-year-old female, with Thoracic scoliosis, presenting complaints of abnormal uterine bleeding, diagnosed with multiple uterine fibroids, posted for Transabdominal hysterectomy decided to take under neuraxial anaesthesia by assessing risk benefit ratio. The anaesthetic management must address intraoperative hemodynamic stability and post operative analgesia, which achieved successfully in this case. This case highlights importance of preoperative assessment, imaging and planning in managing patient with scoliosis for major surgeries.

Introduction: Sacro-coccygeal Teratoma (SCT) is the most common tumor of the newborn, occurring in 1:35000-40000 live births. It is more common in females with a ratio of 3-4:1. The tumor is small and presents as a lump in the sacral region. It is the tumor located at the base of coccyx (tailbone). It is derived from two or three embryonic germ cell layers. Case Report: A one month 2 days old male infant's mother given complaints of abdominal distension and passage of green colour stools and vomiting. Baby was admitted in SNICU. CECT abdomen and pelvis showed multiple small round to oval cystic areas. It is in close relation with lower lumbar and sacrum from L5 to S3 level suggestive of ? primitive neuroectodermal tumor, ? Immature teratoma, ? Yolksac tumor, ? GIST. Baby was premedicated with Glycopyrrolate 0.01mg and fentanyl 5mcg. Started maintenance fluid of isolyte P 15ml/hr. Preoxygenation was done for 3 mins and Baby was induced with Thiopentone and Sevoflurane and intubation was normal with direct laryngoscope. Muscle Relaxation is achieved with Atracurium 1.3mg iv given as loading dose and 0.25mg was given as maintenance dose. Warmer is connected. Pressure points were padded and baby's eyes were covered properly with cotton rolls. Baby was shifted to SNICU with tube insitu.one day baby was ventilated and next day extubated after spontaneous trial and kept on nasal prongs with 2lts of O2. After uneventful post op recovery and utmost care, baby got discharged after 20 days. Conclusion: As most of the SCT tumors are benign in infants, it should be identified early and gets operated. The prognosis of this tumor is excellent in infants. Anaesthetic management includes specific considerations in this baby were fluid loss, posture and temperature control. Thus, early diagnosis, management of intra-operative blood loss, hypothermia and post-operative nursing can bring favourable outcome.

Introduction: Cervical spondylotic myelopathy is a degenerative condition resulting in the compression of the spinal cord. It leads to symptoms such as gait disturbances, hand clumsiness, neck pain. The presence of poliomyelitis that causes motor neuron damage and muscle atrophy adds further complexity to the management of cervical spondylotic myelopathy. Case Report: A 64 year-old male diagnosed with cervical spondylotic myelopathy was posted for limited cervical laminectomy. He came with complaints of neck pain radiating to left upper limb and left upper limb weakness for 4 months. He was a known case of poliomyelitis with right upper limb paralysis since childhood. He was short in stature. Airway examination showed Mallampati grade 2. Upon neurological examination his motor power in both lower limbs was 5/5, in right upper limb 0/5, left upper limb 3/5 with no sensory deficit. Blood & routine investigations were within normal limits. Standard monitoring was ensured perioperatively, Patient was induced as per standard anaesthesia protocol. Patient was intubated with manual inline stabilization with Video laryngoscope. Then patient was log rolled to the prone position on the operating table with pressure point precautions. Intra operative vitals were stable. Anaesthesia was maintained with isoflurane, O2 and N20. Peri operatively multimodal approach of analgesia was employed. Patient was extubated and neurological assessment was done. Standard monitoring was continued IN the post aesthetic care unit for about 1 hour. There was no surgical or aesthetic complications. Conclusion: This case illustrates the complexity of anesthetic management in patients with both cervical spondylotic myelopathy and poliomyelitis. Meticulous planning, including careful airway management and patient positioning, is critical to avoiding further neurological impairment. A tailored anesthetic approach, including preoperative evaluation and intraoperative vigilance, ensured a successful outcome in this patient.

Introduction: Congenital heart disease (CHD) pose unique challenges for anaesthetic management. These children may have impaired cardiac output, altered pulmonary dynamics and a variety of comorbidities that require careful preoperative evaluation and perioperative management. Case Report: A 4 year old boy diagnosed with Left encysted hydrocoele of cord was posted for Left sided Herniotomy. He is a known case of Atrial Septal Defect (ASD), Patient did not have any history of previous surgeries or any NICU/PICU admissions. Pre-operative systemic examination and airway examination were normal, 2d echo was done which showed situs solitus levocardia, 25mm large ASD with left to right shunt. dilated RA & RV. grade 1 TR with mild PAH, mild PR, noPS. LVEF 60%. Cardiac opinion was taken and can be taken up for surgery under moderate risk. Intraoperatively patient was induced with Inj. glycopyrolate, Inj. midazolam, Inj.Propofol and Inj.Atracurium. Patient was intubated and maintained with Isoflurane, O2 & N2O; monitoring of SBP, RR, NIBP, SPO2 were done. Post-operative vitals were stable. Pt was extubated and shifted to PACU for observation. Conclusion: Anaesthetic management of children with congenital heart disease undergoing non-cardiac surgery is complex and requires a team approach, involving paediatric anaesthesiologists, cardiologists, and surgeons. Detailed preoperative assessment, individualized anaesthetic techniques, and careful intraand postoperative management are critical to minimizing risk and optimizing outcomes in these vulnerable patients.