It is difficult to predict the neurological outcome in survivor of cardio respiratory arrest. We report a case of 32 year old survivor of respiratory arrest who developed myoclonic jerks following overdose of sedation during spinal anesthesia. We initially thought these to be myoclonic status epilepticus (MSE). Accurate distinction between MSE and Lance-Adams syndrome (LAS) is very important as both have very different prognosis. LAS is a common occurrence in cardiac arrest survivors where the cause is respiratory arrest. Less than 150 cases have been reported in the medical literature till date. Making an early diagnosis and properly managing LAS is positively related to improving the patient's functional outcome. The aim of this manuscript is to spread awareness and knowledge of LAS among ICU doctors. The diagnosis of LAS and the controversies and difficulties that surround its diagnosis and treatment and other aspects of prognostication in cardiac arrest are reviewed.

Background: Operating room (OR) like casualty room is the most productive area of a hospital. Turnover time although is a non-productive time in the operating room, yet it is important. Its efficient utilisation require multidisciplinary team work especially supporting services which play a major role in reducing turnover time in the operating room. Since present medical college where study was being conducted is still in its evolving stage, it was considered desirable for its quality improvement to study various factors which are contributing in turnover time delay so that appropriate measures can be taken to prevent the undue turnover time delay. Materials and methods: Present prospective observational case study aims at measurement of turnover time delays during 100 working days which were completed over four months for two operation theatres. The variable chosen was the delay of turnover time from the benchmark time taken. The data were collected, compiled and analysed. Results: In orthopaedics OR 77% of turnovers were found within benchmark limits. Only in 23% cases turnovers were delayed. 47% of times hospital related issues were responsible. In surgery OR 79% of turnovers were within benchmark limits. 21% cases were delayed; of this hospital related problems caused delayed turnovers in 53% cases. Conclusions: The study concluded that reasons for delays centred on multifactorial reasons which were unavoidable and unpredictable. But if those problems that can be easily fixed are attended to, valuable time can be saved, which will ultimately keep the surgeries on schedule and will prevent cancellation of elective cases. The utilization of OT complex can be optimized by team effort, multitasking and parallel processing.

Cardiac arrest, irrespective of its etiology, has a high mortality. This event is often associated with brain anoxia which frequently causes severe neurological damage and persistent vegetative state. Only one out of every six patients survives to discharge following in-hospital cardiac arrest, whereas only 2-9% of patients who experience out of hospital cardiac arrest survive to go home. Functional outcomes of survival are variable, but poor quality survival is common, with only 3-7% able to return to their previous level of functioning. Therapeutic hypothermia is an important tool for the treatment of post-anoxic coma after cardiopulmonary resuscitation. It has been shown to reduce mortality and has improved neurological outcomes after cardiac arrest. Nevertheless, hypothermia is underused in critical care units. This manuscript aims to review the mechanism of hypothermia in cardiac arrest survivors and to propose a simple protocol, feasible to be implemented in any critical care unit.

Abstract:Background: W.H.O has introduced a surgical safety checklist as part of its Safe Surgery Saves Lives initiative. The checklist's purpose was to reduce surgical complications that resulted from inadequate safety practices and promote greater communication among surgery teams. It is made necessary to use the surgical safety checklist in the operation theatres across the world but is it really used in the actual practical setup? Material & Methods: With that idea in mind we had conducted a study to know about the awareness and practical use of surgical safety checklist among surgeons attending Haryana Chapter of Association of Surgeons in India Conference (HASICON) 2014 in there surgical practice. Printed performa with a set of questions was given to the delegates and the result was analysed. Result: Only 57% of the study group had heard about the safety checklist and only 32% of them are using it in their surgical practice. Conclusion:There is an urgent need to spread awareness about the safety checklist and one way of achieving it is by demonstration papers in conferences across the world.

Introduction: For successful management of difficult paediatric airway intubation, proper preparation of airway along with a calm and sedated child with titrated doses of sedative agents is paramount. Aim: To compare two different classes of sedative agents (Dexmedetomidine vs Fentanyl) regarding intubating conditions and comfort score of paediatric population at the time of awake fiberoptic intubation. Materials and Methods: This retrospective study was carried out among 40 paediatric patients, aged between 5-14 years those who underwent surgery for Temporo-Mandibular Joint (TMJ) ankylosis. Clinical data relevant for this study was collected from the pre-format sheets of anaesthesia technique, attached with case files of the patients. Inj. dexmetedomidine bolus of 1 mcg/kg for 10 minutes followed by infusion at the rate 0.6 mcg/kg/hr in group A and Inj. fentanyl bolus dose of 2 mcg/kg followed by infusion 1 mcg/kg/hr in group B were compared in terms of intubating conditions and patient co-operation. For data analysis Statistical Package for the Social Sciences (SPSS) version 20 (IBM Inc.) was used. Patient characteristics in the two groups were compared using mean±SD and chi-square test. Results: All the patients had successful intubation in first attempt in both the groups. In terms of airway preparation, out of total, 14 (35%) patients in group A had no secretions as compare to 4 (10%) patients of group B (p-value was 0.002). In terms of cough score, 13 (32.5%) patients in group A had no cough as compared to 3 (7.5%) patients in group B. Patients in group A were more comfortable at the time of insertion of Flexible Fiberoptic Bronchoscopy (FOB) with no or less resistance to FOB insertion (p-value was 0.043). Vocal cord conditions were favourable in both the groups and there was no difference. Conclusion: Fiberoptic nasal intubation was found to be easier and safe in terms of patient comfort and preservation of patent airway with the use of dexmedetomidine, in paediatric TMJ ankylosis.

Abstract:Pancreatic fistula is an important and possible complication of left nephrectomy performed for inflammatory or malignant lesions of kidney. This may develop due to intimate relationship of tail of pancreas to left kidney. The objective is to report this unusual case of delayed pancreatic cutaneous fistula which patient developed eight years after left nephrectomy. The patient was managed conservatively with subcutaneous injections of octreotide which led to closure of fistula and healing of excoriation.Key Words: left nephrectomy; octreotide; pancreatic fistula Corresponds to: Prof (Dr) Mohinder Kumar Malhotra. Department of Surgery, MMIMSR, Mullana, Ambala, Haryana, India. E-mail: malhotramsfrcs@yahoo.co.in 1. MK Malhotra, Professor, Department of Surgery, MMIMSR, Mullana, Ambala, Haryana, India 2. S Malhotra, Associate Professor, Departments of Anesthesia, SHKM, GMC, Mewat, Haryana, India Introduction: Close anatomical relationship of the pancreas to the left kidney may lead to pancreatic cutaneous fistula as a complication of left nephrectomy. The diagnosis was confirmed when amylase in the watery discharge was increased more than fivefold and skin excoriation healed after sub cutaneous injections of octreotide. Case Summary: A 40 year old patient presented with discharging sinus in left lumbar region with skin excoriation. (Fig.1) He underwent left sided nephrectomy for non functioning left kidney more than 10 years back. Presence of skin excoriations with watery discharge which increased on taking food led to provisional diagnosis of pancreatic fistula. The same was confirmed by measuring the amylase level of discharging fistulous content which showed more than fivefold increase in amylase level. All other investigations including CT sinogram were non diagnostic. He was treated conservatively as an outpatient, as patient refused admission. He received subcutaneous injections of somatostatin analogue i.eoctreotide along with antibiotics and local application of zinc cream for wound care. Fistula healed spontaneously with medical treatment in two weeks. (Fig.2) Discussion: Pancreatic cutaneous fistulas are rare, but a possible complication of a kidney surgery.1 Varkarakis et al found 2.1% incidence of pancreatic injuries during laparoscopic urologic surgery.2 The anatomical proximity of tail of pancreas to the left kidney plays a key role in this matter. The relevant factors are also the size of the kidney tumour

Introduction: Faculty and Residents are trained in peripheral nerve blocks guided by blind technique, Peripheral Neuro Stimulator (PNS) or Ultrasound (USG) guided technique. But due to unavailability of USG machine in all institutes and requiring special training, techniques used for peripheral nerve blocks vary from institute to institute. Aim: To analyse the effect of anaesthesiologists’ experience on preferred technique and Local Anaesthetic (LA) volume used for brachial plexus nerve block retrospectively. Materials and Methods: In this retrospective observational study, 129 adults American Society of Anesthesiologists (ASA) grade I and II patients requiring brachial plexus nerve block for upper limb orthopaedic surgical anaesthesia for both elective and emergency surgery were divided into three groups for each year depending on technique for nerve block used. Group A: Received USG guided (Micromaxx Sonosite Inc, USA) brachial plexus nerve block. Group B: Received peripheral nerve stimulator (Inmed) guided brachial plexus nerve block. Group C: Received brachial plexus nerve block by traditional anatomical landmark based paraesthesia elicitation blind technique. Patients with inadequate surgical analgesia were given general anaesthesia and were categorised as failure rate. Year wise demographic data, type of technique used for giving brachial plexus nerve block, volume of drug used, failure rate, complications observed were collected and analysed by Student’s t-test and Chi-square test. Results: USG guided technique was the most prefered technique in both years (57.6%, n=38 in year 2018 and 49.2%, n=31 in year 2019). In remaining nearly half of the patients PNS and blind technique was used (PNS 24.2%, n=16 in year 2018 and 20.6%, n=13 in year 2019; blind technique 18.2%, n=12 in year 2018 and 30.2%, n=19 in year 2019). Significantly, less volume of LA drug (mL) was used in group A in year 2019 (16.43±6.07) than in year 2018 (22.34±4.75) (p<0.001). Failure rate in group A in year 2019 (3.2%) was significantly less than in year 2018 (5.2%), but the difference was insignificant in all three groups. In group A, no complications were observed in year 2019 while one incidence of hemidiaphragm paralysis was observed in year 2018, while in group B and C, complications were observed in both years. Conclusion: USG guided nerve block was the most preferred technique for nerve block in the study institute. In 24 months observation period, with increasing experience with USG there was significant increase in success rate and decrease in the volume of LA administered and complications.

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