Pregabalin is a gamma-amino-butyric acid analog shown to be effective in several models of neuropathic pain, incisional injury, and inflammatory injury. In this review, the role of pregabalin in acute postoperative pain and in chronic pain syndromes has been discussed. Multimodal perioperative analgesia with the use of gabapentinoids has become common. Based on available evidence from randomized controlled trials and meta-analysis, the perioperative administration of pregabalin reduces opioid consumption and opioid-related adverse effects in the first 24 h following surgery. Postoperative pain intensity is however not consistently reduced by pregabalin. Adverse effects like visual disturbance, sedation, dizziness, and headache are associated with higher doses. The advantage of the perioperative use of pregabalin is so far limited to laparoscopic, gynecological, and daycare surgeries which are not very painful. The role of the perioperative administration of pregabalin in preventing chronic pain following surgery, its efficacy in more painful surgeries and surgeries done under regional anesthesia, and the optimal dosage and duration of perioperative pregabalin need to be studied. The efficacy of pregabalin in chronic pain conditions like painful diabetic neuropathy, postherpetic neuralgia, central neuropathic pain, and fibromyalgia has been demonstrated.

The first joint replacement surgery was performed in 1919. Since then, joint replacement surgery has undergone tremendous development in terms of surgical technique and anesthetic management. In this era of nuclear family and independent survival, physical mobility is of paramount importance. In recent years, with an increase in life expectancy, advances in geriatric medicine and better insurance coverage, the scenario of joint replacement surgery has changed significantly. Increasing number of young patients are undergoing joint replacement for pathologies like rheumatoid arthritis and ankylosing spondylitis. The diverse pathologies and wide range of patient population brings unique challenges for the anesthesiologist. This article deals with anesthetic issues in joint replacement surgery in patients with comorbidities.

Background : The addition of clonidine to lidocaine intravenous regional anesthesia (IVRA) has been previously reported to improve postoperative analgesia in patients undergoing upper extremity surgery. Our objective was to perform a dose ranging study in order to determine the optimal dose of clonidine used with lidocaine in IVRA. Design & Setting : We performed a double-blinded randomized placebo-controlled study with 60 patients scheduled for elective endoscopic carpal tunnel release under IVRA with 50 ml lidocaine 0.5%. University-affiliated outpatient surgery center. Data collected in operating rooms, recovery room, and by telephone after discharge from surgery center. Materials &; Methods : Sixty adult ASA I or II patients undergoing outpatient endoscopic carpal tunnel release under intravenous regional anesthesia.Patients were randomized into five study groups receiving different doses of clonidine in addition to 50 ml 0.5% lidocaine in their IVRA. Group A received 0 mcg/kg, group B 0.25 mcg/kg, group C 0.5 mcg/kg, group D 1.0 mcg/kg and group E 1.5 mcg/kg of clonidine.Intraoperative fentanyl, recovery room pain scores, time to first postsurgical analgesic, total number of acetaminophen/codeine tablets consumed postsurgery, incidence of sedation, hypotension and bradycardia. Results & Conclusions : There was no benefit from any dose of clonidine compared to placebo. There were no clonidine-related side effects seen within the dose range studied. In short duration minor hand surgery, the addition of clonidine to lidocaine-based intravenous regional anesthesia provides no measurable benefit.

Background: An important requirement during functional endoscopic sinus surgery is to maintain a clear operative field to improve visualization during surgery and to minimize complications. Materials and Methods: We compared total intravenous anesthesia using propofol with inhalational anesthesia using isoflurane for controlled hypotension in functional endoscopic sinus surgery. It was a prospective study in a tertiary hospital in India. Forty ASA physical status I and II adult patients (16-60 years) were randomly allocated to one of two parallel groups (isoflurane group, n = 20; propofol group, n=20). The primary outcome was to know whether total intravenous anesthesia using propofol was superior to inhalational anesthesia using isoflurane for controlled hypotension. The secondary outcomes measured were intraoperative blood loss, duration of surgery, surgeon's opinion regarding the surgical field and the incidence of complications. Results: The mean (±SD) time to achieve the target mean blood pressure was 18 (±8) minutes in the isoflurane group and 16 (±7) minutes in the propofol group ( P = 0.66). There was no statistically significant difference (P = 0.402) between these two groups in terms of intraoperative blood loss and operative field conditions (P = 0.34). Conclusions: Controlled hypotension can be achieved equally and effectively with both propofol and isoflurane. Total intravenous anesthesia using propofol offers no significant advantage over isoflurane-based anesthetic technique in terms of operative conditions and blood loss.

Introduction: Transversus abdominis plane (TAP) block is a new regional analgesic technique for postoperative pain in abdominal surgery. Its efficacy is not clear, and thus it needs to be explored for its regular utilisation on prolonged period. The objective was to study the continuous local anaesthetic infusion effect on postoperative analgesia. Continuous use of TAP block as an analgesic technique has not been evaluated prospectively in clinical trials. This study evaluates the efficacy of ultrasound-guided TAP block in comparison with PCA fentanyl in major abdominal surgery. Materials and Methods: There were 20 patients in the study, allocated to TAP and control groups. The parameters measured were pain scores on a numerical rating scale (NRS) of 0-10 at various time intervals and the amount of fentanyl used as rescue analgesia. Patient satisfaction scores were recorded in the TAP block group and along with any complications related to the block. Results: The postoperative median pain scores on coughing on day one were 6.0 for control group and 2.0 for the TAP group (P0 = 0.02); on day two, the equivalent scores were 7.0 and 2.0 (P = 0.01). The fentanyl requirement at one hour was 203 μ for the control group and 78 μg for the TAP group (P = 0.03); at day one, the control and TAP requirements were 1237 μg and 664 μg respectively (P = 0.01). Three TAP patients rated their satisfaction as 'excellent', four as 'satisfied, and two as 'poor'. Conclusion: TAP block is a promising technique for postoperative analgesia in major abdominal surgeries. Our study demonstrated lower pain scores in the TAP group with reduced fentanyl requirement. Further, a large scale study is needed to establish the efficacy of TAP block in this setting.

Background: Various adjuvants have been used with local anesthetics in spinal anesthesia to avoid intraoperative visceral and somatic pain and to provide prolonged postoperative analgesia. Dexmedetomidine, the new highly selective α2-agonist drug, is now being used as a neuraxial adjuvant. The aim of this study was to evaluate the onset and duration of sensory and motor block, hemodynamic effect, postoperative analgesia, and adverse effects of dexmedetomidine or fentanyl given intrathecally with hyperbaric 0.5% bupivacaine. Materials and Methods: Sixty patients classified in American Society of Anesthesiologists classes I and II scheduled for lower abdominal surgeries were studied. Patients were randomly allocated to receive either 12.5 mg hyperbaric bupivacaine plus 5 μg dexmedetomidine (group D, n=30) or 12.5 mg hyperbaric bupivacaine plus 25 μg fentanyl (group F, n=30) intrathecal. Results: Patients in dexmedetomidine group (D) had a significantly longer sensory and motor block time than patients in fentanyl group (F). The mean time of sensory regression to S1 was 476±23 min in group D and 187±12 min in group F (P<0.001). The regression time of motor block to reach modified Bromage 0 was 421±21 min in group D and 149±18 min in group F (P<0.001). Conclusions: Intrathecal dexmedetomidine is associated with prolonged motor and sensory block, hemodynamic stability, and reduced demand for rescue analgesics in 24 h as compared to fentanyl.

Background: Both magnesium and clonidine are known to inhibit catecholamine and vasopressin release and attenuate hemodynamic response to pneumoperitoneum. This randomized, double blinded, placebo controlled study has been designed to assess which agent attenuates hemodynamic stress response to pneumoperitoneum better. Materials and Methods: 120 patients undergoing elective laparoscopic cholecystectomy were randomized into 4 groups of 30 each. Group K patients received 50 ml normal saline over a period of 15 min after induction and before pneumoperitoneum, group M patients received 50 mg/kg of magnesium sulfate in normal saline (total volume 50 ml) over same time duration. Similarly group C1 patients received 1 μg/kg clonidine and group C2 1.5 μg/kg clonidine respectively in normal saline (total volume 50 ml). Blood pressure and heart rate were recorded before induction (baseline value), at the end of infusions and every 5 min after pneumoperitoneum. Statistical Analysis: Paired t test was used for intra-group comparison and ANOVA for inter-group comparison. Results: Systolic blood pressure was significantly higher in control group as compared to all other groups during pneumoperitoneum. On comparing patients in group M and group C1, no significant difference in systolic BP was found at any time interval. Patients in group C2 showed best control of systolic BP. As compared to group M and group C1, BP was significantly lower at 10, 30 and 40 min post pneumoperitoneum. No significant episodes of hypotension were found in any of the groups. Extubation time and time to response to verbal command like eye opening was significantly longer in group M as compared to other groups. Conclusion: Administration of magnesium sulfate or clonidine attenuates hemodynamic response to pneumoperitoneum. Although magnesium sulfate 50 mg/kg produces hemodynamic stability comparable to clonidine 1 μg/kg, clonidine in doses of 1.5μg/kg blunts the hemodynamic response to pneumoperitoneum more effectively.

Objectives: The incidence of shivering in patients undergoing a laparoscopic procedure is stated to be about 40%. A majority of laparoscopic gynecological procedures are taken up on an outpatient basis. Postoperative shivering may delay hospital discharge and is a common cause of discomfort in patients recovering from anesthesia. Aims: To determine the effect of pre-induction, low-dose pethidine on postoperative shivering in patients undergoing laparoscopic gynecological surgeries. Setting and Design: Sixty females between 25 and 35 years of age, of American Society of Anesthesiologists (ASA) class 1 and 2, were randomly divided into three groups of 20 patients each. Group I and II patients received i.v. pethidine 0.3 mg/kg and 0.5 mg/kg, respectively, while Group III received i.v. 0.9% normal saline just before induction of general anesthesia. Temperature of the Operating Room and the Post Anesthesia Care Unit was standardized and all fluids given during the study period were warmed to 37°C. Materials and Methods: Temperature, measured with a tympanic membrane probe, was recorded preoperatively, after induction of anesthesia, on arrival at the Post Anesthesia Care Unit, and postoperatively at 15 minutes and 30 minutes. Shivering was graded (0 - 4 scale) at arrival of the patients to the PACU and every five minutes thereafter, up to 30 minutes. Statistical Analysis: ANOVA, Chi-square test, Kruskal-Wallis ANOVA and Mann-Whitney U tests were used. A P-value of less than 0.05 was considered significant. Results: Core body temperatures were statistically insignificant between groups at pre-induction, post-induction, and in the PACU (P > 0.05). At the end of surgery, shivering was present in 18 patients (30%). In groups I, II, and III, six (30%), three (15%), and nine (45%) patients shivered, respectively. The differences in incidence and grading of shivering among groups was found to be statistically insignificant (P > 0.05). The core body temperature of shiverers and non-shiverers were compared. In the PACU at 0, 15, and 30 minutes, the temperature among shiverers was significantly lower than that in the non-shiverers. Rescue drug i.v. pethidine 20 mg was given to patients with shivering grade ≥2. None of the patients had shivering after 10 minutes. Conclusions: Prophylactic pre-induction, low-dose pethidine does not have major role in preventing postoperative shivering.

Background and Objective: The purpose of the study was to evaluate the perception of influence of music among surgeons, anesthesiologist and nurses in our hospital as well as to critically evaluate whether music can be used as an aid in improving the work efficiency of medical personnel in the operation theatre (OT). Materials and Methods: A prospective, questionnaire-based cross-sectional study was conducted. A total of 100 randomly selected subjects were interviewed, which included 44 surgeons, 25 anesthesiologists and 31 nurses. Statistical package for social sciences (SPSS) Windows Version 16 software was used for statistical evaluation. Results: Most of the OT medical personnel were found to be aware of the beneficial effects of music, with 87% consenting to the playing of music in the OT. It was also found that most participants agreed to have heard music on a regular basis in the OT, while 17% had heard it whenever they have been to the OT. Conclusions: Majority of the respondent's preferred playing music in the OT which helped them relax. It improved the cognitive function of the listeners and created a sense of well being among the people and elevated mood in them. Music helped in reducing the autonomic reactivity of theatre personnel in stressful surgeries allowing them to approach their surgeries in a more thoughtful and relaxed manner. Qualitative, objective and comprehensive effect of specific music types varied with different individuals. Music can aid in improving the work efficiency of medical personnel in the OT. The study has reinforced the beneficial effects of playing music in the OT outweighing its deleterious outcomes.

Background: Inflation and assessment of the endotracheal tube cuff pressure is often not appreciated as a critical aspect of endotracheal intubation. Appropriate endotracheal tube cuff pressure, endotracheal intubation seals the airway to prevent aspiration and provides for positive-pressure ventilation without air leak. Materials and Methods: Correlations between manual methods of assessing the pressure by an experienced anesthesiologists and assessment with maintenance of the pressure within the normal range by the automated pressure controller device were studied in 100 patients divided into two groups. In Group M, endotracheal tube cuff was inflated manually by a trained anesthesiologist and checked for its pressure hourly by cuff pressure monitor till the end of surgery. In Group C, endotracheal tube cuff was inflated by automated cuff pressure controller and pressure was maintained at 25-cm H ₂ O throughout the surgeries. Repeated measure ANOVA was applied. Results: Repeated measure ANOVA results showed that average of endotracheal tube cuff pressure of 50 patients taken at seven different points is significantly different (F-value: 171.102, P-value: 0.000). Bonferroni correction test shows that average of endotracheal tube cuff pressure in all six groups are significantly different from constant group (P = 0.000). No case of laryngomalacia, tracheomalacia, tracheal stenosis, tracheoesophageal fistula or aspiration pneumonitis was observed. Conclusions: Endotracheal tube cuff pressure was significantly high when endotracheal tube cuff was inflated manually. The known complications of high endotracheal tube cuff pressure can be avoided if the cuff pressure controller device is used and manual methods cannot be relied upon for keeping the pressure within the recommended levels.

Background: Living liver donation is becoming a more common means to treat patients with liver failure because of a shortage of cadaveric organs and tissues. There is a potential for morbidity and mortality, however, in patients who donate a portion of their liver. The purpose of this study is to identify anesthetic complications and morbidity resulting from living liver donor surgery. Patients and Methods: The anesthetic records of all patients who donated a segment of their liver between January 1997 and January 2006 at University of Minnesota Medical Center-Fairview were retrospectively reviewed. The surgical and anesthesia time, blood loss, hospitalization length, complications, morbidity, and mortality were recorded. Data were reported as absolute values, mean ± SD, or percentage. Significance (P < 0.05) was determined using Student's paired t tests. Results: Seventy-four patients (34 male, 40 female, mean age = 35.5 ± 9.8 years) donated a portion of their liver and were reviewed in the study. Fifty-seven patients (77%) donated the right hepatic lobe, while 17 (23%) donated a left hepatic segment. The average surgical time for all patients was 7.8 ± 1.5 hours, the anesthesia time was 9.0 ± 1.3 hours, and the blood loss was 423 ± 253 ml. Forty-six patients (62.2%) received autologous blood either from a cell saver or at the end of surgery following acute, normovolemic hemodilution, but none required an allogenic transfusion. Two patients were admitted to the intensive care unit due to respiratory depression. Both patients donated their right hepatic lobe. One required reintubation in the recovery room and remained intubated overnight. The other was extubated but required observation in the intensive care unit for a low respiratory rate. Twelve patients (16.2%) had complaints of nausea, and two reported nausea with vomiting during their hospital stay. There were four patients who developed complications related to positioning during the surgery: Two patients complained of numbness and tingling in the hands which resolved within two days, one patient reported a blister on the hand, and one patient complained of right elbow pain that resolved quickly. Postoperative hospitalization averaged 7.4 ± 1.5 days. There was no patient mortality. Discussion: Living liver donation can be performed with low morbidity. However, postoperative respiratory depression is a concern and is perhaps due to altered metabolism of administered narcotics and anesthetic agents.

Background: This study was conducted to compare the efficacy and effects of dexmedetomidine and midazolam in preoperative sedation. Materials and Methods: A total of 125 patients in American Society of Anaesthesiologists (ASA) I-II were divided into three groups: Group I (n = 40) for controls, Group II (n = 40) for Dexmedetomidine (1 μg/kg), and group III was the midazolam group (n = 45). Group III was further divided into three subgroups according to the doses of midazolam: Group IIIA (n = 15) received 0.02 mg/kg, group IIIB (n = 15) received 0.04 mg/kg, and group IIIC (n = 15) received 0.06 mg/kg of midazolam. Drugs were infused over a 10-minute period with appropriate monitoring. Ramsay and visual analog scores, for sedation and anxiety, respectively, and mean arterial pressure, heart rate, and SpO ₂ measurement, including respiratory rates were recorded, every 5 minutes for 30 minutes following infusion. Results: There was marked sedation and a decrease in anxiety in groups II and IIIC (P < 0.01). Mean arterial pressure (MAP) and heart rate (HR) decreased significantly in group II (P < 0.01 and P < 0.05, respectively), but there was no associated hypotension (MAP <60 mm Hg) or bradycardia (HR <50 bpm) (P < 0.05). Respiratory rates and SpO ₂ values decreased in groups II, IIIA, IIIB, and IIIC. The differences in respiratory rates were not significant (P > 0.05); however, decrease in SpO ₂ was significant in group IIIC (P < 0.01). Conclusions: Dexmedetomidine was as effective as higher doses of midazolam in sedation. The hemodynamic and respiratory effects were minimal. Although dexmedetomidine caused significant decrease in the blood pressure and heart rate, it probably just normalized increased levels caused by preoperative stress.

Giant paraesophageal hernia is an uncommon morbid disorder which may present a risk of catastrophic complications and should be repaired electively as soon as possible. Laparoscopic fundoplication is the mainstay of surgical management of this disorder due to several advantages such as lower post-operative morbidity and pain. We report a case of a 70-year-old patient with a giant paraesophageal hernia, who developed subcutaneous emphysema with pneumothorax during laparoscopic fundoplication. Early diagnosis was possible by close clinical evaluation and simultaneous monitoring of end-tidal carbon dioxide levels and airway pressures. Although positive end-expiratory pressure application is an effective way of managing pneumothorax secondary to the passage of gas into the interpleural space, insertion of an intercostal drain may be used in an emergent situation.

A patient with Klippel-Feil syndrome, morbid obesity, and scoliosis required cesarean delivery. Her previous cesarean deliveries were performed under general anesthesia. She desired a regional technique. Following aspiration prophylaxis and placement of standard monitors, ultrasound was used to identify midline and L _2-3 interspace. Unintentional dural puncture occurred at 10 cm, with an inability to advance the catheter. On second attempt, an epidural catheter was placed easily. After negative test dose, 18 ml of 2% lidocaine with epinephrine was administered to the patient. A T4 level was achieved. The patient tolerated surgery well. Complete block resolution occurred at 4 hours with no neurologic sequelae.

We report a case of presumptive neuroleptic malignant syndrome requiring muscle relaxation for electro-convulsive therapy. short acting muscle relaxation without the use of succinylcholine was achieved using rocvronivm reversed with the novel reversal agent sugammadex. We suggest that this combination is a safe and effective alternative to succinylcholine in such cases.

Kimura's disease is a rare form of chronic eosinophilic inflammatory disease with vascular proliferation involving salivary gland, skin, lymph node, and kidney. Important anesthetic concerns include increased surgical bleeding due to its vascular nature, airway involvement by the mass leading to a possible difficult airway, allergic symptoms associated with high eosinophil count and elevated IgE level and nephrotic syndrome due to involvement of kidney by the inflammatory process. There is paucity of information in the literature on the anesthetic management of Kimura's disease. We describe the anesthesia technique and review the literature of such a case posted for superficial parotidectomy.

Common complications of neurolytic mandibular nerve block are hypoesthesia, dysesthesia, and chemical neuritis. We report a rare complication, prolonged severe vertigo and ataxia, after neurolytic mandibular blockade in a patient suffering from trigeminal neuralgia. Coronoid approach was used for right sided mandibular block. After successful test injection with local anesthetic, absolute alcohol was given for neurolytic block. Immediately after alcohol injection, patient developed nausea and vomiting along with severe vertigo, ataxia and hypertension. Neurological evaluation was normal except for the presence of vertigo and ataxia. Computerised tomography scan brain was also normal. Patient was admitted for observation and symptomatic treatment was given. Vertigo and ataxia gradually improved over 24 hours.

Rhinoscleroma is a rare entity encountered in anesthesia practice. We discuss the management of a patient after its recurrence, involving the upper respiratory tract i.e. nasopharynx and oropharynx, which compromised the airway. The pateint was referred for anesthesia on three different occasions with different presentations owing to the recurrence of symptoms.The presence of an oropharyngeal membrane with a small opening made airway management a challenge. The patient was successfully managed on all three occasions. Imaging facilitated assessment and subsequent airway management.

Tetany is a disorder of increased neuronal excitability usually associated with hypocalcemia. We report a patient with typical tetanic cramps and carpopedal spasm in the postoperative period, despite normal serum concentrations of calcium, which responded to intravenous infusion of calcium.

Flexible fiberoptic bronchoscope-guided awake intubation is the most trusted technique for managing an anticipated difficult airway. Even after successfully negotiating the bronchoscope into the trachea, the possibility remains that the preloaded tracheal tube might prove to be inappropriately large, and may not negotiate the nasal structures. In such a situation, the most obvious solution is to take out the bronchoscope, replace the tracheal tube with a smaller one, and repeat the procedure. Unfortunately, sometimes the second attempt is not as easy as the first, as minor trauma during the earlier attempt causes tissue edema and bleeding, which makes the subsequent bronchoscopic view hazy and difficult. We present the anesthetic management of five cases with temporomandibular joint ankylosis where, after successful, though slightly traumatic, bronchoscope insertion into the trachea, the tube could not be threaded in. We avoided a repeat bronchoscopy by making an innovative change in the plan.

Marcus Gunn phenomenon is seen in 4 to 6% of congenital ptosis patients. We report two cases of abnormal oculocardiac reflex during ptosis correction surgery. Marcus Gunn syndrome is an autosomal dominant condition with incomplete penetrance. It is believed to be a neural misdirection syndrome in which fibres of the motor division of the trigeminal nerve are congenitally misdirected into the superior pterygoid and the levator muscles. Anesthetic considerations include taking a detailed history about any previous anaesthetic exposure and any reaction to it as this syndrome has a high probability of being associated with malignant hyperthermia. It is also postulated that an atypical oculocardiac reflex might be initiated in these patients as seen in our patients, so precautions must be taken for its prevention and early detection.

Renal disease, either preexisting or occurring during gestation may impair maternal and fetal health. A 35-year-old primigravida with autosomal dominant polycystic kidney disease on hemodialysis was scheduled for emergency cesarean section. She was managed successfully with low-dose intrathecal bupivacaine and fentanyl. In the case of pregnancy in such a patient, early involvement of the nephrologists along with the obstetrician can improve maternal and fetal outcome.

Pulmonary embolism during or after regional anaesthesia is although very rare, it has been reported in cases undergoing lower limb orthopedic procedures. We presenting a 48 years old male, a known smoker since 25 years, with history of road traffic accident and open fracture right femur for external fixation. Combined spinal epidural anaesthesia was given. After 35 minutes patient complained dyspnea and chest pain. SpO2 decreased to 82% from 100%. Continuous positive airway pressure with 100% oxygen was given. SpO2 increased from 82% to 96%. Suddenly he had bouts of cough and SpO2 became 79-80% with unstable haemodynamics. On chest auscultation there was decreased breath sounds on right side with limited expansion. Trachea was intubated after inducing anaesthesia with fentanyl 70 μg and thiopental 300 mg. Chest radiograph showed right sided pneumothorax. Intercostal drain with a water seal was put. After 5 minutes HR was 80/min, BP was 110/69 mmHg and SpO2 was 97%. Pulmonary thromboembolism secondary to deep vein thrombosis was suspected and was confirmed by D-dimer Elisa and color Doppler of lower limbs. Patient was shifted to intensive care unit after completion of surgery. Anticoagulant therapy was started. He was weaned from the ventilator on 3rd day and trachea was extubated. Chest drain was removed after 9 days and he was discharged from hospital on 15th post operative day

Blunt neck trauma with an associated laryngotracheal injury is rare. We report a patient with blunt neck trauma who came to the emergency room and was sent to ward without realizing the seriousness of the situation. He presented later with respiratory distress and an anesthesiologist was called in for emergency airway management. Airway management in such a situation is described in this report.

Occurrence of tension pneumoventricle (symptomatic intraventricular air) can result in rapid clinical deterioration in an otherwise stable patient. It is a rare clinical entity, mentioned in relation to cerebrospinal fluid (CSF) diversion procedures, during the late postoperative period. We present a patient with posterior third ventricular tumor who underwent excision by midline suboccipital craniotomy in sitting position. Neurological status of the patient deteriorated rapidly in the immediate postoperative period owing to development of tension pneumoventricle. The condition improved after twist-drill burr-hole evacuation of air under water-seal. Pre-existing gross hydrocephalus, exploration of third ventricle in sitting position, and residual tumor in third ventricle were possibly the factors responsible for this complication.

Perioperative management of patients with congenital heart disease is a challenge for the anesthesiologist. We present successful anesthetic management for diagnostic laparoscopy and cystectomy for tubo-ovarian mass in a case of residual coarctation of the aorta along with bicuspid aortic valve and mild aortic stenosis.