Indian Journal of Anesthesia and Analgesia

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Objective: To compare the onset and duration of sensory and motor block, haemodynamic responses, side effects associated with administration of thoracic epidural Levobupivacaine (0.5%) and Ropivacaine (0.5%) for modified radical mastectomy. Place and Duration of Study: Govt. Arignar Anna Memorial Cancer Hospital and Research Institute, Kanchipuram. 2023 - 24. Study Design: Randomized controlled clinical trial. Methodology: After obtaining approval from institutional ethics committee and written informed consent from all patients, a randomized controlled double blinded clinical trial was conducted on 30 ASA 3 carcinoma breast cases undergoing modified radical mastectomy. Patients were randomly allocated into two groups. Group L and Group R of 15 each. Patients in Group L were to receive Levobupivacaine 0.5% and Group R 0.5% Ropivacaine. Haemodynamic variables (heart rate, systolic and diastolic BP) and onset and duration of sensory and motor block, sensory regression time were recorded and compared using unpaired T-test. Conclusion: Levobupivacaine is better suited thoracic epidural anaesthetic drug for modified radical mastectomy surgeries than Ropivacaine.

Objective: To evaluate the efficacy and to compare the quality of peribulbar block anaesthesia of 0.5% Levobupivacaine, 0.5% Ropivacaine and 0.5% Bupivacaine for cataract surgery in post surgical/ post chemotheraphy/ post radiotheraphy oncology cases. Place and Duration of Study: Chengalpattu Medical College, Chengalpattu. 2023 - 24. Study Design: Randomized Controlled Clinical Trial. Methodology: After obtaining approval from institutional ethics committee and written informed consent from all patients, a randomized controlled double blinded clinical trial was conducted on 30 ASA 3 oncology patients undergoing cataract surgery. Patients were randomly allocated into three groups. Group L, Group R and Group B of 10 each. Patients in Group L were to receive Levobupivacaine 0.5%, Group R 0.5% Ropivacaine and Group B 0.5% Bupivacaine. Haemodynamic variables (heart rate, systolic and diastolic BP) and the onset and duration of sensory and motor block, sensory regression time, Intraocular Pressure values were recorded and compared using ANOVA test. Conclusion: Levobupivacaine is better suited for phacoemulsion surgeries of Post Surgical/ post chemotheraphy/ post radiotheraphy oncology cases.

Background and Objectives: Unexpected difficult airway is a major challenge in general anesthesia, associated with significant morbidity and mortality. Ineffective airway management can lead to rapid deterioration of oxygenation and ventilation, resulting in severe consequences such as brain injury and death. The preanesthetic evaluation of the airway is typically conducted using a variety of assessment techniques. However, these techniques often lack discriminative value when used in isolation and perform better when combined with other tests. Ultrasound, when used alongside other risk assessment methods at different levels of the neck, may help identify predictors of a difficult airway, including challenging laryngoscopy, thus enabling faster and more accurate airway assessments in both routine and emergency situations. Aim: • To assess the effectiveness of ultrasonography in preoperative airway evaluation for predicting difficult airway. Objectives: • To evaluate the correlation between preoperative sonographic airway assessment and laryngoscopic CL grading. • To identify the sonographic parameter with better predictability of difficult airway. Methods: This prospective observational study was conducted with 68 patients presenting to Travancore Medical College, Kollam, for elective surgery under general anesthesia with endotracheal intubation. The three parameters anterior neck soft tissue thickness at the level of the hyoid, anterior neck soft tissue thickness at the level of the vocal cords, and the hyomental distance ratio, which is calculated by dividing the hyomental distance in the extended position by the hyomental distance in the neutral position (HMDe/HMDn) and three physical criteria the Modified Mallampati (MPC) class, thyromental distance (TMD), and sternomental distance (SMD) were assessed and correlated with the Cormack-Lehane grading. Results and Discussion: The optimal cutoff value for ANS-Hyoid to predict difficult laryngoscopy was >0.89 cm, with 22.2% sensitivity and 96% specificity (AUC = 0.6489). For ANS-VC, the best cutoff value was >0.87 cm, showing 22.2% sensitivity and 98% specificity (AUC = 0.695). The ideal cutoff value for HMDR was <1.15, with 38.89% sensitivity and 96% specificity (AUC = 0.75). Our findings suggest that while ANS-Hyoid has high specificity, its low sensitivity indicates it may not alone be sufficient for identifying difficult intubation. The correlation between greater anterior neck soft tissue thickness at the vocal cord level and higher CL grades supports the use of sonographic measurements in predicting difficult laryngoscopy. HMDR demonstrated the best combination of sensitivity and specificity, highlighting its potential utility in improving the accuracy of pre-operative airway assessments. Conclusion: Our study found that among the USG parameters evaluated, the Hyomental Distance Ratio (HMDr) provided the most reliable prediction of difficult intubation. In summary, integrating ultrasonography (USG) with both traditional and novel assessment tools is likely to enhance preoperative evaluations and lead to more effective management of difficult airway.

Background and aims: Numerous newer Supraglottic Airway Devices (SADs) are available now a days and they are known for their reduced airway morbidity and improved hemodynamic stability. The aim of this prospective study was to compare the safety and efficacy between i-gel and Baska mask during adult short surgical procedures in terms of sealing pressure, insertion time, ease of insertion, airway pressures, hemodynamic disturbances and post-operative complications. Methodology: This randomised comparative study was conducted in adult ASA physical status I and II patients aged 18-60 years who underwent elective short surgical procedures under general anaesthesia. The patients who satisfied the inclusion and exclusion criteria were randomly classified into two groups of 40 each; Group A (i-gel group) and Group B (Baska group). The sealing pressure, insertion time, number of attempts, ease of insertion, hemodynamic variations, airway pressures and post-operative complications were recorded. Results: The mean insertion time was significantly lesser in i-gel group when compared to Baska mask group (14.1 ± 2.83 seconds vs 18.1 ± 4.24 seconds, respectively). But the sealing pressure was significantly higher with Baska mask (29.1 ± 5.13cm H2O) when compared to i-gel (24.6 ± 4.64cm H2O). The number of attempts, ease of insertion, hemodynamic variations, airway pressures and postoperative complications were similar between both the groups. Conclusion: The i-gel was better in terms of insertion time but Baska mask had higher airway sealing pressure. Both SADs were similar in other aspects. Hence,

Introduction: Tricuspid Annular Plane Systolic Excursion (TAPSE) is measured in apical 4-chamber (4CH) view in transthoracic echocardiography (TTE). In Transesophageal echocardiography (TEE), it is measured by Mid esophageal 4 chamber view (ME 4CH) and modified deep transgastric (dTG) view. The aim of our study was tocompare different methods of TAPSE measurement. Materials and methods: Patients posted for elective Off Pump Coronary Artery Bypass Graft Surgery (OPCAB) were included in the study. TAPSE was measured after induction by TTE (4CH) view preoperatively and by TEE (ME 4CH and dTG) both preoperatively and postoperatively. Result and analysis: Measurements in dTG RV view at 0° showed best agreement with standard TTE measurements with intraclass-correlation 0.987 and 95% confidence interval 0.917-0.995. In Mid Esophageal Four Chamber (ME 4CH) view showed agreement of measurements with intraclass-correlation 0.904 and 95% confidence interval - 0.096-0.977 and on average estimated TAPSE values 1.54 mm lower than TTE. TAPSE by pre-operative Mid Esophageal Four Chamber (ME 4CH) view and Deep Transgastric Right Ventricular view suggested strong positive correlation by intraclass-correlation 0.945 with a 95% confidence interval of -0.013 to 0.987. In post-operative period Mid Esophageal Four Chamber (ME 4CH) view and Deep Transgastric Right Ventricular view suggested intraclasscorrelation 0.945 and 95% confidence interval -0.015 to 0.987. Conclusion: Evaluation of RV function by means of TAPSE measurement in TEE can be performed with an excellent level of agreement compared to TTE.

Congenitally corrected Transposition of the great Arteries (cc TGA) is a rare congenital cardiac anomaly in which the aorta and pulmonary artery are transposed, presenting unique anesthetic challenges. The patient’s cardiac physiology, characterized by atrioventricular and ventriculoarterial discordance characterized by abnormal ventricular loading and potential for arrhythmias, required meticulous pre-operative evaluation and careful anesthetic planning. We report the peri-operative anesthetic management of a 3 year old child with ccTGA scheduled for a posterior sagittal anorectoplasty (PSARP) for an anorectal malformation under general anaesthesia in prone position.

This case report discusses the successful management of a pregnant patient with a twin pregnancy, Pierre Robin Sequence (PRS), and peripartum cardiomyopathy (PPCM) who underwent a cesarean section. PRS, characterized by micrognathia, glossoptosis, and airway obstruction, presents significant challenges in anesthesia management, particularly concerning difficult intubation and airway management. PPCM, a condition marked by left ventricular systolic dysfunction and reduced ejection fraction, further complicates anesthesia due to the risk of myocardial depression. The patient’s condition was exacerbated by pre-eclampsia and anemia. After a thorough preoperative evaluation, regional anesthesia was selected as the safest option, aiming to minimize hemodynamic fluctuations and reduce the risks of respiratory complications and opioid sensitivity. The use of inotropic support was crucial in maintaining cardiovascular stability throughout the perioperative period. This case highlights the importance of a multidisciplinary approach, involving obstetrics, anesthesiology, and cardiology, in the management of complex cases involving rare conditions. Regional anesthesia proved to be an effective strategy for minimizing risks and ensuring a successful outcome, emphasizing the need for individualized care in high-risk obstetric patients.

Background: Meige syndrome is a rare neurological condition characterized by oromandibular dystonia and blepharospasm. Treatment modalities includes medications like anticholinergics, dopamine antagonist, GABA agonist, physical or occupational therapy, baclofen injections, and surgical interventions like ablation or deep brain stimulation of Globus pallidus internus nuclei [GPI]. Case Details: We present a case of 31 year old male patient with abnormal involuntary movement of head, neck, left shoulder and arm since three years, diagnosed as “Meige syndrome”. Patient was planned for right GPI radiofrequency ablation [RFA]. Thorough preoperative assessment was done. Significant findings were severe head and neck dystonia, and anticipated difficult airway. Surgery was planned under monitored anesthesia care with titrated sedation to allow for intraoperative neurologic testing. On the day of surgery, patient had severe cervical dystonia, not subsiding even after sedation with dexmedetomidine, requiring change of anaesthesia plan to general anaesthesia with secured airway as an airway intervention would have been difficult after application of the head frame. Standard balanced anaesthesia with nasal endotracheal tube was administered.BIS was used to monitor depth of anaesthesia. Surgeon required intraoperative testing during RFA of right GPI. About 20 minutes prior to testing, anaesthetic agents were stopped and BIS around 90 was documented. Patient cooperated well for neurological testing during localization and RFA of right GPI. After RFA, general anesthesia was continued. Procedure was uneventful, patient was extubated and shifted to ward after observation in recovery room and discharged on postoperative day three. Discussion and Clinical relevance: RFA of GPI is a modality of treatment for patient with Meige syndrome. Anaesthesia management may be challenging due to exacerbation of the abnormal involuntary movements during surgery. Anesthesia may be in form of monitored anesthesia care with sedation or general anesthesia with intra-operative testing during lesioning. Anesthesia drugs need to be titrated to facilitate awake testing during radio-frequency ablation procedure. Conclusion: Exacerbation of dystonia may necessitate change of anesthesia plan to general anesthesia with awake testing during lesioning. Patient must be counselled in preoperative period to cooperate for testing. Team work, planning and patient counselling for cooperation during procedure, aids in safe conduct of procedure.

A 60-year-old female patient presented with breathlessness (NYHA grade II), retrosternal chest pain, and postprandial fullness, alongside heartburn symptoms. Clinical evaluation revealed prominent Q waves and ST-segment depression on ECG, while chest X-ray showed a raised right-sided hemidiaphragm with bowel loop shadows, suggesting a diaphragmatic hernia or eventration. Pulmonary function tests were unremarkable. An echocardiogram indicated a dysfunctional left ventricle with an ejection fraction of 45%, apical septal akinesia, inferior wall hypokinesia, and mild mitral regurgitation. CT imaging of the chest and abdomen confirmed a diaphragmatic defect with herniation of omental fat and a large portion of the transverse colon, causing atelectasis of the medial right middle lobe. Coronary angiography revealed lesions in the left anterior descending artery, left circumflex artery, and right coronary artery. The patient was diagnosed with both coronary artery disease and diaphragmatic hernia and was recommended for coronary artery bypass grafting (CABG) along with diaphragmatic hernia repair. Intraoperatively, the patient was managed with standard ASA monitors, rapid sequence induction, and a left-sided double-lumen tube for single-lung ventilation. The hernia was repaired with polypropylene mesh, and CABG was performed offpump after achieving adequate anticoagulation. Postoperatively, the patient showed improvement with a significant reduction in airway pressure and was extubated 8 hours post-surgery. Bowel sounds were audible by postoperative day 1, and the patient was discharged on the 7th postoperative day without complications. This case highlights the complexity of managing concomitant coronary artery disease and diaphragmatic hernia, emphasizing a multidisciplinary approach to treatment and anesthesia.

Awake fiberoptic intubation (AFI) is often preferred in patients with a difficult airway but is related to major and minor complications. Regional anesthesia can be feasible with a preformulated and resilient plan in those scenarios. We present a case report of a 54-year-old male patient of left carcinoma buccal mucosa with chest skin defect due to iatrogenic tumor implantation scheduled for defect repair. Thoracic Segmental Spinal Anaesthesia (TSSA) was planned with AFI as a preformulated strategy. Satisfactory anesthesia was achieved from T2 to T8. The hemodynamic remained stable and the patient remained awake and comfortable throughout the perioperative period. In conclusion, TSSA can be considered an alternative to general anesthesia in patients with difficult airways undergoing chest skin defect repair using a rotational flap, as long as the anesthetist has the required instinctive knowledge and awareness of the possible difficulties associated with intubation or ventilation.

Background: Dandy-Walker malformation (DWM) is a rare congenital anomaly of the posterior fossa characterized by hypoplasia or agenesis of the cerebellar vermis, cystic dilatation of the fourth ventricle, and enlargement of the posterior fossa. It is frequently associated with hydrocephalus and various neurological deficits. Early diagnosis and appropriate intervention are essential for optimizing outcomes. Case Presentation: We present the case of a 1 year old female child who presented with progressive macrocephaly, irritability, vomiting, and delayed developmental milestones. Neuroimaging revealed classical features of DandyWalker malformation, including partial agenesis of the cerebellar vermis, a large retrocerebellar cyst communicating with the fourth ventricle, and dilated lateral and third ventricles indicative of associated hydrocephalus. Management and Outcome: The patient underwent successful cystoperitoneal (CP) shunt placement to divert cerebrospinal fluid from the posterior fossa cyst to the peritoneal cavity. Postoperative recovery was uneventful, with gradual reduction in head circumference and improvement in feeding and irritability. Followup imaging demonstrated decompression of the cyst and reduced ventricular size. The patient continues to receive multidisciplinary follow-up, including neurodevelopmental monitoring and rehabilitation. Conclusion: This case underscores the importance of timely neuroimaging in infants with progressive macrocephaly and developmental delay. Cystoperitoneal shunting remains an effective surgical option in managing hydrocephalus associated with Dandy-Walker malformation. Early intervention may contribute to favorable developmental outcomes, although long-term prognosis largely depends on the extent of associated anomalies and overall cerebral development.

Background: Central venous catheter (CVC) malposition is a recognized complication of subclavian venous catheterization, with misdirection into the ipsilateral internal jugular vein (IJV) being one of the more commonly encountered mal-positions. Prompt recognition and correction of such misplacements are crucial to prevent complications such as thromboembolism, vascular injury or impaired catheter function. Objective: To report a case of inadvertent malposition of a subclavian central venous catheter into the ipsilateral internal jugular vein in a critically ill patient and its subsequent successful repositioning. Case Presentation: A 32-year-old female patient presented to the general surgery outpatient department of our hospital with complaints of acute abdominal pain, vomiting and discharge from an abdominal wound. After relevant work-up and optimisation, she underwent an exploratory laparotomy for suspected perforation peritonitis with peritoneal lavage and primary jejunal repair. Postoperatively, she was shifted to the critical care unit and required total parenteral nutrition (TPN). A right subclavian vein catheterization was done for central venous access and the catheter fixed at 12cm mark at skin. Post-insertion chest radiograph revealed mal-positioning of the catheter tip into the right internal jugular vein. The catheter was subsequently withdrawn to 10cm and 8cm at skin, successively, guided by chest radiographs and finally fixed at 8cm at skin which revealed catheter tip at the junction of subclavian vein and internal jugular vein.