123TEG measurement and second sample for laboratory tests. The following TEG data were obtained-reaction time, kinetic time, alpha angle, and maximum amplitude (MA). The following laboratory tests were obtained-haematology (haemoglobin, TLC, DLC, platelet count) and coagulation test [prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time (TT)]. Result Out of 100 patients enrolled in the study, 80 (80 %) had a normal coagulation profile, while remaining 20 (20 %) had hypocoagulation profile. The results show that TEG parameters have a good correlation with conventional coagulation profile and also showed excellent independent predictive efficacy for prediction of hypocoagulation. PT, aPTT, and TT were directly proportional to R-time and K-time and inversely proportional to alpha angle (p \ 0.001). Platelet count showed a strong positive correlation with MA (p \ 0.001). Conclusion By giving a global picture of haemostasis, TEG can lead to improved decision-making about safety of using regional anaesthesia. Its fast feedback time makes it ideal for monitoring in a fast moving situation such as in obstetric emergency.

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Indian J Case Reports 336Letter to Editor Management of unexpected subglottic stenosis in a neonate with congenital tracheoesophageal fistula Sir, W e present a case of 4-day-old full-term female weighing 2 kg with tracheoesophageal fistula (TEF) posted for fistula ligation and repair. On examination, the child was crying, tachypneic with drooling of saliva, and receiving intravenous fluids. Her heart rate (HR) was 165 beats/ min and SpO 2 was 85% on room air which improved to 89 with oxygen. Coarse crepitations were auscultated, bilaterally. Her investigations were found to be within normal limits. Chest X-ray showed bilateral opacities and a PaO 2 of 60 mmHg (on oxygen) on arterial blood gas.After taking high-risk consent and arranging for post-operative ventilation, the patient was taken up for surgery. On attaching monitors, HR was 154/min, blood pressure was 68/40 mmHg, and SpO 2 83% on room air which increased to 95% with FiO 2 -1.0. Premedication with injection atropine 0.1 mg and injection fentanyl 2 µg was given. After inhalational induction with sevoflurane, mask ventilation was found to be adequate. Hence, injection atracurium 1 mg was given for the best intubating conditions [1]. After ventilating for 3 min, direct laryngoscopy (DL) was performed which showed Cormack-Lehane Grade 1. Intubation with uncuffed 3 mm endotracheal tube (ETT) was attempted; however, it was getting stuck beyond the vocal cords. The same was the case with 2.5 mm internal diameter (ID) ETT; therefore, the ventilation was resumed. Laryngoscopy was done again by more experienced anesthetist. DL findings remained the same. Intubation with stiletted 2.5 mm ID ETT and 2 mm ID ETT was also attempted but was unsuccessful. Ventilation was maintained with bag mask with FiO 2 -1.0. Provisional diagnosis of subglottic stenosis was made, and otolaryngologists were called for emergency tracheostomy. Appropriate size tracheostomy tubes (TTs) were kept. Meanwhile, I-gel 1.0 was inserted to maintain ventilation. However, ventilation deteriorated and mask ventilation resumed.After tracheostomy, an uncuffed 3.0 mm ID TT was inserted. Initially, the ventilation was adequate with EtCO 2 of 25-35 mmHg and saturation between 95% and 98%. However, within 3-4 min, saturation started falling and ventilation became suboptimal. Position of TT was reconfirmed and it was slightly withdrawn. Suctioning was also attempted, but there was resistance in passing smallest catheter (5 Fr) through TT. Ventilation did not improve. Suspecting that TT was blocked, it was replaced with cuffed 3.0 mmID TT and cuff inflated with 2 ml air. Subsequently, EtCO 2 rose to 40-50 mmHg and saturation picked up to 96%. The removed uncuffed 3.0 mm TT was not blocked. Hence, it was assumed that inflated cuff of the TT sealed the fistula and helped in improving ventilation. Only gastrostomy as a life-saving procedure was done.

Background and Aims: Fluid administration during liver transplant (LT) surgery is controversial. Although adverse outcomes following positive intraoperative fluid balance have been reported, studies presenting the influence of cumulative postoperative fluid balance (CFB) on complications following LT are sparse. Patients with chronic liver disease tend to receive more fluid during and after surgery due to their unique physiological disease state. The aim of this study was to evaluate the influence of 48-hour CFB on the development of acute kidney injury (AKI) and pulmonary complications on day 4 after live donor LT. Methods: This retrospective study included 230 patients undergoing live donor LT. The effect of CFB on day 2 on AKI and pulmonary complications was analysed. Chi-square test, Fisher's exact test, samples t-test, Mann-Whitney U-test were used. Results: Bivariate analysis showed a lower graft vs recipient weight ratio (GRWR), sepsis (P < 0.001) and a higher 48-hour CFB after surgery significantly increased the development of AKI. For pulmonary complications, higher Model for End- stage Liver Disease-Na(MELD-Na) score, higher peak arterial lactate, higher 48-hour CFB (P = 0.016) and sepsis (P = 0.003) were found to be statistically significant. Upon multivariate analysis, CFB at 48 hours was significantly higher in patients suffering from pulmonary complications, and GRWR and sepsis were significant for AKI. For every one litre increase in CFB on day 2, the odds of pulmonary complications increased by 37%. Conclusion: A more positive CFB on day 2 increased the development of pulmonary complications and lower GRWR and sepsis increased the development of AKI.