Rhinosporidiosis is a chronic granulomatous disease endemic in India and Sri Lanka. The causative microorganism, Rhinosporidium seeberi, remains a poorly understood pathogen, which has been described as an aquatic protistan parasite. Rhinosporidiosis presents as multiple polypoidal lesions affecting the mucosa of the nasal cavity, nasopharynx, and oropharynx. Intralaryngeal rhinosporidiosis is a rare entity and poses a challenge for management of the airway. In this case report, we highlight our technique in the management of the airway in a case of laryngeal rhinosporidiosis using a combination of fiberoptic bronchoscope and an endoscope. The technique was atraumatic and also avoided the potential for autoinoculation, which is a frequent cause of recurrence of this disease.

Aim: To assess the effects of intravenously administered meperidine, fentanyl and tramadol in reducing the incidence, onset time and severity of the shivering response in parturients during cesarean delivery under spinal anesthesia. Secondary outcomes included patient satisfaction and sedation scores. Methods: After Ethics board approval and informed written consent, 350 parturients (ASA physical status I or II), between 20 and 40 years of age, undergoing emergency or elective cesarean delivery under spinal anesthesia were recruited. Parturients were then randomly allocated to seven study groups: normal saline (control), low-dose meperidine (0.5 mg/kg), high-dose meperidine (0.75 mg/kg), low-dose fentanyl (0.5 mcg/kg), high-dose fentanyl (0.75 mcg/kg), low-dose tramadol (0.5 mg/kg) and high-dose tramadol (0.75 mg/kg). The incidence, onset time and severity of shivering, along with patient satisfaction and sedation scores were measured. Results: All study drugs showed significant reduction in incidence, onset time and severity of shivering and greater satisfaction scores compared to the control group (P < 0.01). Within each drug class, no significant differences in shivering were found between the high-dose and low-dose groups. Among study drugs, lowdose tramadol was superior due to shivering prevention and significantly reduced sedation. Conclusion: Intravenously administered meperidine, fentanyl and tramadol reduce shivering incidence, onset time and severity in parturients undergoing cesarean delivery following spinal anesthesia. Importantly, low-dose intravenous tramadol (0.5 mg/kg) allowed shivering prevention and low sedation scores, thereby offering greater parturient satisfaction and better maternal-newborn bonding.

We report a case of a four-year-old boy with stage 1 Wilms tumour, who developed Vincristine-induced acute life-threatening hyponatremia, which presented as generalized tonic clonic seizures and coma. He was intubated and mechanically ventilated. There were no localizing neurological signs. CSF study showed no cells and CSF proteins were 20 mg%. Electrocardiography, chest X-ray, echocardiography, CT scan and liver function tests were normal. Evaluation of electrolytes and arterial blood gas showed serum sodium of 113 mEq/L with mild metabolic acidosis. Serum osmolality was 260 mOsm/L (normal value 285-295 mOsm/L) and urine osmolality was 625 mOsm/L (normal range 300-900 mOsm/L), urine sodium 280 mEq/d (normal range 100-260 mEq/d), serum potassium, blood urea, blood sugars were normal. Serial blood cultures showed no bacterial growth. Patient was treated with fluid restriction, hypertonic saline (3%) and other supportive care. Patient improved clinically over three days and was extubated on the third day and shifted to the ward on the fifth day.

Background and Aims:Evidence and utility of the individual steps of the rapid sequence induction and tracheal intubation protocols have been debated, especially in the setting of traumatic brain injury. The purpose of this survey was to determine preferences in the current approach to rapid sequence intubation (RSI) in head injury patients among a population of anaesthesiologists from South India.Methods:A questionnaire was E-mailed to all the members of the Indian Society of Anaesthesiologists’ South Zone Chapter to ascertain their preferences, experience and comfort level with regard to their use of rapid sequence intubation techniques in adult patients with head injury. Participants were requested to indicate their practices for RSI technique for a head-injured patient upon arrival at the Emergency Medical Services department of their hospital.Results:The total response rate was 56.9% (530/932). Of the total respondents, 35% of the clinicians used cricoid pressure routinely, most respondents (68%) stated that they pre-oxygenate the patients for about 3 min prior to RSI, thiopentone (61%) and propofol (34%) were commonly used prior to intubation. Rocuronium was the muscle relaxant of choice for RSI among the majority (44%), compared to succinylcholine (39%). Statistical analyses were performed after the initial entry onto a spreadsheet. Data were summarised descriptively using frequency distribution.Conclusion:In a rapid sequence intubation situation, the practice differed significantly among anaesthesiologists. Owing to disagreements and paucity of evidence-based data regarding the standards of RSI, it is apparent that RSI practice still has considerable variability in clinical practice.

Accidental intravascular injection of local anesthetic can cause central nervous system (CNS) toxicity, presenting as tremors, convulsions, dysrhythmias, and cardiorespiratory arrest. During epidural anesthesia, a test dose is used to diagnose inadvertent intravascular or intrathecal administration of drugs. We present a case where the test dose itself caused central neural toxicity. A 38-year-old woman, weighing 50 kg and 159 cm tall, with chondrosarcoma in the left femur, presented for tumor resection, irradiation, and reconstruction under a combined epidural and general anesthesia. She had no significant past or family medical history, with no associated comorbid illnesses or evidence of metastasis. She was positioned in the right lateral position for insertion of an epidural catheter under monitoring of heart rate (HR), blood pressure (BP), and oxygen saturation (SpO 2 ). The baseline HR was 100 bpm, BP 124/75 mmHg, and room-air SpO 2 98%. After inserting an epidural catheter in L2-3 interspace and carefully confirming negative aspiration, a 3-ml test dose of 1.5% lidocaine with epinephrine 1:200,000 was injected slowly, with no change in HR. Approximately 1 min later, the patient had perioral paresthesia and twitching followed by loss of consciousness and generalized convulsions. She was immediately turned to the supine position and midazolam 2 mg was given intravenously, followed by thiopentone 250 mg to control the convulsions. After mask ventilation with 100% oxygen, the trachea was intubated and lungs were ventilated. The electrocardiograph (ECG) showed sinus bradycardia with HR 34 bpm during convulsion, (before institution of mask ventilation), which failed to respond to 0.6 mg atropine administered intravenously. A short period of hypoxia may have caused failure to respond to the atropine. As the radial pulse was not palpable, cardiopulmonary resuscitation was started, and 1 mg adrenaline was given intravenously. Radial pulse was noted immediately after resuscitation (ECG showing sinus rhythm), and the patient regained consciousness within 5 min. Aspiration of the epidural catheter revealed blood, and a diagnosis of probable intravascular injection was made. Subsequently, brain magnetic resonance imaging (MRI) was normal, and the patient underwent the planned operation the following week under combined epidural and general anaesthesia without any complication.The false-negative result of the aspiration test to detect intravascular injection could have been because a multiport catheter was used, with the distal port inside the vein and proximal port in the epidural space, resulting in negative aspiration of blood due to collapsing of the vein over the distal port. The relatively small dose of lidocaine (45 mg) would not be expected to result in the systemic local anesthetic toxicity. However, one case report [1] describes doses as low as 5 ml of local anesthetic can cause CNS toxicity. Concomitant administration of epinephrine potentiates the CNS toxicity of intravenously administered lidocaine [2]. Inc...