Background: Preoperative evaluation of anatomical landmarks and clinical factors help identify potentially difficult airway. Till date there are no criteria or absolute guidelines that can be helpful in detecting difficult airway in pediatric population. Aim: To find the predictors of difficult mask ventilation, difficult laryngoscopy and difficult intubation in pediatric population age 1-5 years. Setting and design a prospective study was conducted in 100 ASA grade I/II pediatric patients between 1-5 years, scheduled for surgery under general anesthesia. Patients with congenital upper airway malformations and those with neck or face swelling or scars were excluded from the study. Material and methods: We assessed the usefulness of interincisor gap (IIG), oropharyngeal view with mouth wide open (without tongue protrusion), modified mallampati Class (MMP) , relationship of maxillary and mandibular incisor during normal jaw closure, neck circumference(NC) , thyromental distance (TMD), sternomental distance (SMD), ratio of height to thyromental distance as preoperative predictors of difficult mask ventilation , laryngoscopy and intubation. Result: Mask ventilation was graded using difficult mask ventilation (DMV) grading, with DMV grade of 3 & 4 occurring in 3 patients (3%). Laryngoscopy was assessed using Cormack and Lehane (C&L) grading system which revealed 3 cases of CL grade III with no case falling under CL grade IV. Ease or difficulty in tracheal intubation was assessed using Intubation difficulty score (IDS) 40% cases showed mild difficulty (05) and 2% showed major difficulty (IDS>5). Conclusion: Interincisor gap, neck cicumferance, sternomental distance was found to be predictors of difficult mask ventilation. Statistically significant correlation was found between difficult laryngoscopy and intubation. Age, best oropharangeal view and thyromental distance were found to be predictors of difficult larngoscopy and intubation. Analysis proved that mask ventilation became easier after administration of muscle relaxant and difficulty decreased after 3 years age. J o u rn al of A n e s th es ia & C li n ic a l Resea rc h

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Background. This study aimed to evaluate and compare total cost of sevoflurane and propofol for 1.0 MAC-hour of anaesthesia, employing three anaesthetic techniques. Methods. Adult patients scheduled for surgical procedures under general anaesthesia anticipated to last approximately an hour were randomized into three groups (n = 15 each), to receive anaesthesia using one of the following techniques: low flow technique involving induction with propofol, followed by sevoflurane delivered using initial fresh gas flows of 6 L/min till MAC reached 1.0 and then reduced to 0.5 L/min; alternate method of low flow entailing only a difference in fresh gas flow rates being maintained at 1 L/min throughout; the third technique involving use of sevoflurane for both induction and maintenance of anaesthesia. Results. Cost of sevoflurane to maintain 1 MAC-hour of anaesthesia was clinically least with low flow anaesthesia, though statistically similar amongst the three techniques. Once the cost of propofol used for induction in two of the three groups was added to that of sevoflurane, cost incurred was least with the technique using sevoflurane both for induction and maintenance of anaesthesia, as compared to low flow and alternative low flow techniques, a 26% and 32% cost saving, respectively (P < 0.05).

Background and Aims:Patients with burns may require multiple surgeries, but poor general condition and underlying protein energy malnutrition make them unsuitable candidates for general or spinal anaesthesia. This study evaluated the role of magnesium sulphate as an adjuvant with levobupivacaine and ropivacaine used in combined femoral and lateral femoral cutaneous nerve (LFCN) blocks in burn patients with relative sparing of thigh portion.Methods:This prospective, randomised, double-blind study included 54 adult patients of 18–65 years age, undergoing split-thickness skin graft harvest from the thigh, allotted to three equal groups of 18 each. Group L patients received femoral nerve (FN) block with 15 mL of 0.5% levobupivacaine and 8 mL for LFCN block; Group LM patients received 14 mL of 0.5% levobupivacaine along with 1.0 mL of 15% magnesium sulphate for FN block, 7.5 mL of 0.5% levobupivacaine with 0.5 mL of 15% of magnesium sulphate to LFCN block and Group R patients received 15 mL of 0.5% ropivacaine for FN block and 8 mL of 0.5% ropivacaine for LFCN block. Time to block onset and complete surgical block, duration of analgesia, total analgesic dose and the overall analgesia satisfaction score were measured in the first 24 h post-operatively. Quantitative data were analysed with ANOVA and qualitative data subjected to Chi-square tests. Intergroup comparison was performed with independent t-test.Results:The duration of post-operative analgesia did not differ with the addition of magnesium (P = 0.610). Time to onset of the block was significantly decreased with the addition of magnesium (P = 0.0341), but time to complete surgical block onset was similar across the groups.Conclusion:Both ropivacaine and levobupivacaine have good perioperative analgesic efficacy. Magnesium as an analgesia adjuvant with levobupivacaine does not prolong the duration of post-operative analgesia.

Sir,A 62-year-old, 76-kg male, with a bilateral osteoarthritis knee, scheduled for right knee replacement was a known hypertensive for 4 years, controlled on tablet amlodipine 10 mg and clonidine 100 mg once daily. History, examination and investigations revealed no abnormality. Combined spinal epidural anesthesia was accomplished with an 18 G epidural catheter inserted at L 2-3 level and 2.5 ml of 0.5% heavy bupivacaine injected intrathecally at L 3-4 level, using a 27 G sprottee-type spinal needle. Maximum sensory loss up to T 10 dermatome was achieved after 7 min.A tourniquet was applied over the right thigh and pressure was maintained at 230 mmHg. After 90 min, the surgeon was reminded of the tourniquet time every 10 min. Throughout the surgery (including the cementing with methyl-methacrylate), the patient remained hemodynamically stable. Inspite of repeated reminders, the surgery lasted 155 min and then the tourniquet was released.Before tourniquet deflation, his pulse rate was 72/min, regular, blood pressure 130/76 mmHg and 97% SpO 2 . Immediately after deflating the tourniquet, his heart rate came down to 18/min and blood pressure declined to 70/42 mmHg and then became unrecordable with a complaint of uneasiness. Instantly, he was given 0.6 mg atropine intravenously and 100% oxygen by a mask. His heart rate increased to 102/min and blood pressure to 140/84 mmHg and his complaint of uneasiness subsided. The patient remained hemodynamically stable post-operatively. There was no sensory loss or motor weakness.Tourniquet deflation causes the release of blood that has low pH, low pO 2 , high pCO 2 , high lactate and K 1 into systemic circulation, which leads to a decline in blood pressure. This decline could be further aggravated by volume shift back to the limb on deflation of tourniquet, a post-ischemic reactive hyperemia (vasodilatation) and a decrease in peripheral vascular resistance. This leads to a decrease in mean systemic blood pressure of 14-19 mmHg and a mean increase in heart rate of 6-12 beats per minute (1) and can cause severe myocardial depression (as in our case) and rarely cardiac arrest. As the duration of tourniquet inflation increases, the pH and pO 2 of blood in the limb decrease significantly and adenosine, lactate and pCO 2 increase (Po0.05) (2). The maximum recommended time of tourniquet inflation is 2 h for lower limb surgery (1).Previous studies have shown that factors contributing to tourniquet-induced ischemia-reperfusion injury are activation of granulocytes (3), release of oxygen-free radicals (4) and tumor necrosis factor-a (5). The patient had taken oral clonidine pre-operatively, which has been shown to accentuate the hypotension following tourniquet deflation by inhibiting noradrenaline release (6). The release of tourniquet leads to hypotension more commonly in older patients (57 AE 8 years) vs. 50 AE 4 years (Po0.005), patients with underlying cardiovascular disease and longer duration of surgery [120 AE 14 vs. 60 AE 27 min (Po0.001) (7)]. Even our patient was elderly (62 y...

Primary tracheal tumors comprise a rare group of benign and malignant tumors. Bronchoscopy is required for diagnosis and staging of tracheal neoplasms as well as debulking of the tumor. The management of anesthesia for rigid bronchoscopy in a patient with tracheal neoplasm presents with many challenges to the anesthetist. We present anesthetic management of an 18-year-old female who presented with orthopnea. Computed tomography scan of the thorax revealed a polypoidal lesion in the trachea proximal to carina and consolidation in the right middle lobe. The patient was scheduled for rigid bronchoscopy and debulking of the tumor. Case was successfully managed by providing positive pressure ventilation and oxygenation during rigid bronchoscopy using manual ventilation through the side port of the rigid bronchoscope. The procedure was uneventful, and patient improved symptomatically in the immediate postoperative period. The successful management of this case demonstrates the airway management in a patient with tracheal tumor for rigid bronchoscopy.

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