Sodium nitroprusside has been used in clinical practice as an arterial and venous vasodilator for 40 years. This prodrug reacts with physiologic sulfhydryl groups to release nitric oxide, causing rapid vasodilation, and acutely lowering blood pressure. It is used clinically in cardiac surgery, hypertensive crises, heart failure, vascular surgery, pediatric surgery, and other acute hemodynamic applications. In some practices, newer agents have replaced nitroprusside, either because they are more effective or because they have a more favorable side-effect profile. However, valid and adequately-powered efficacy studies are sparse and do not identify a superior agent for all indications. The cyanide anion release concurrent with nitroprusside administration is associated with potential cyanide accumulation and severe toxicity. Agents to ameliorate the untoward effects of cyanide are limited by various problems in their practicality and effectiveness. A new orally bioavailable antidote is sodium sulfanegen, which shows promise in reversing this toxicity. The unique effectiveness of nitroprusside as a titratable agent capable of rapid blood pressure control will likely maintain its utilization in clinical practice for the foreseeable future. Additional research will refine and perhaps expand indications for nitroprusside, while parallel investigation continues to develop effective antidotes for cyanide poisoning.

Hydroxyethyl starch (HES) family has been one of the cornerstones in fluid management for over four decades. Recent evidence from clinical studies and meta-analyses has raised few concerns about the safety of these fluids, especially in certain subpopulations of patients. High-quality clinical trials and meta-analyses have emphasized nephrotoxic effects, increased risk of bleeding, and a trend toward higher mortality in these patients after the use of HES solutions. Scientific evidence was derived from international guidelines, aggregated research literature, and opinion-based evidence was obtained from surveys and other activities (e.g., internet postings). On critical analysis of the current data available, it can be summarized that further large scale trials are still indicated before HES can be discarded.

Background and Aims: Skill of a successful endotracheal intubation needs to be acquired by training and attaining several competencies simultaneously. It becomes more challenging when we have to deliver the key concepts in a limited period of time. The medium fidelity simulator is a valuable tool of training for such scenarios. For this purpose we aim to compare the efficacy of structured training in endotracheal intubation between real life simulation and the conventional teaching method. Materials and Methods: The year 4 medical students had their attachment in anaesthesia for a period of 6 months from Jun - Dec 2009 were randomly divided into Group (Gp) A who had conventional teaching and Group B who were taught by four simulated sessions of endotracheal intubation. Performance of both the groups was observed by a person blinded to the study against a checklist on a 7 point rating scale in anaesthetized patient. Results: Total 57 students, 29 in Gp A and 28 in Gp B were rotated in the anaesthesia during the study period. Evaluation of the individual component tasks revealed that simulated group achieved a significant difference in the scoring for laryngoscope and intubation technique. (P = 0.026, 0.012) The comparison of overall competence again showed that the 64.3% of student in Gp B achieved an excellent score in comparison to Gp A in which only 41.4% achieved excellent. (P = 0.049). Similarly the lesser number of students in Gp B (14.3%) require remediation as compared to the Gp A, in which the requirement was 40% (P=0.04). Conclusion: We conclude that all essential skills components of tracheal intubation in correct flow and sequence are acquired more efficiently by real life simulated training.

Background & Aims: Video-guided laryngoscopy, though unproven in achieving better success rates of laryngoscopy outcome and intubation, seems to provide better glottic visualization compared with direct laryngoscopy.The objective of this study was to compare the efficacy of video-guided laryngoscope (VGL) in the airway management skills of medical students. Materials and Methods: Medical students throughout their anesthesiology rotations were enrolled in this study.All students received standard training in the airway management during their course and were randomly allocated into two 20 person groups. In Group D, airway management was performed by direct laryngoscopy via Macintosh blade and in Group G intubation was performed via VGL. Time to intubation, number of laryngoscopy attempts and success rate were noted. Successful intubation was considered as the primary outcome. Statistical Analysis: All data were analyzed using SPSS 16 software. Chi-square and Fisher's exact test were used for analysis of categorical variables. For analyzing continuous variables independent t-test was used. P < 0.05 was considered as statistically significant. Results: Number of laryngoscopy attempts was less in Group G in comparison to Group D; this, however, was statistically insignificant (P: 0.18). Time to intubation was significantly less in Group G as compared to Group D (P: 0.02). Successful intubation in Group G was less frequently when compared to Group D (P: 0.66). Need for attending intervention, esophageal intubation and hypoxemic events during laryngoscopy were less in Group G; this, however, was statistically insignificant. Conclusions: The use of video-guided laryngoscopy improved the first attempt success rate, time to intubation, laryngoscopy attempts and airway management ability of medical students compared to direct laryngoscopy.

Background and Aims: Emergency medical technician (EMT) training programs for certification vary greatly from course to course, but it is necessary that each course at least meets local and national requirements. It is reasonable to expect that EMTs' performance should improve after a structured educational curriculum. We hypothesized that EMTs' performance in airway management would improve after a sequential structured educational curriculum involving airway, followed by cardiopulmonary resuscitation (CPR) modules, beyond what is achieved after only the airway module. Materials and Methods: To evaluate this, 76 EMTs were assigned to a 2-week airway module with a structured curriculum. This was followed by the 2-week CPR module, and the EMTs were tested before (preCPR test) and after (postCPR test) the CPR modules for improvement in their airway skills. EMTs also completed a questionnaire to evaluate the curriculum. Results: PostCPR test mean scores were higher than those of the preCPR test (P < 0.05) except for the bag valve mask domain. EMTs evaluated the curriculum and gave a score of 3.7/5 for perceived achievement of goals of the syllabus for improving their airway skills. Conclusion: Thus, a sequential, structured curriculum in airway management followed by CPR, improves EMTs' performance levels above what they achieved after only the airway module, except for bag valve mask ventilation.

Background and Aims: Computer-integrated patient-controlled epidural analgesia (CIPCEA) is a novel epidural drug delivery system. It automatically adjusts the basal infusion based on the individual's need for analgesia as labor progresses. Materials and Methods: This study compared the time-weighted local anesthetic (LA) consumption by comparing parturients using CIPCEA with no initial basal infusion (CIPCEA0) with CIPCEA with initial moderate basal infusion of 5 ml/H (CIPCEA5). We recruited 76 subjects after ethics approval. The computer integration of CIPCEA titrate the basal infusion to 5, 10, 15, or 20 ml/H if the parturient required respectively, one, two, three, or four patient demands in the previous hour. The basal infusion reduced by 5 ml/H if there was no demand in the previous hour. The sample size was calculated to show equivalence in LA consumption. Results: The time-weighted LA consumption between both groups were similar with CIPCEA0 group (mean [standard deviation (SD)] 8.9 [3.5] mg/H) compared to the CIPCEA5 group (mean [SD] 9.9 [3.5] mg/H), P = 0.080. Both groups had a similar incidence of breakthrough pain, duration of the second stage, mode of delivery, and patient satisfaction. However, more subjects in the CIPCEA0 group required patient self-bolus. There were no differences in fetal outcomes. Discussion: Both CIPCEA regimens had similar time-weighted LA consumption and initial moderate basal infusion with CIPCEA may not be required.

Background and Aims: Admission to an intensive care unit (ICU) is considered as an objective marker of severe maternal morbidity. The aim was to assess the incidence and possible risk factors of obstetric patient admissions in the multidisciplinary ICU of a tertiary care center with emphasis on standardized mortality ratio (SMR). Material and Methods: A retrospective five year ICU record analysis was done for all pregnant women, who were admitted to multidisciplinary ICU of a tertiary care hospital during June 2007-12. Results: During this 5-year period, 21,943 deliveries took place and 164 women required ICU admission. Out of these, the data of 151 patients were analyzed. Maternal mortality rate was 31.1% (47 deaths) for patients admitted to ICU. The simplified acute physiologic score (SAPS) II was 62 (55-68) in nonsurvivor versus 34.00 (28-46) in survivor group (P value < 0.001). The receiver operated characteristic curve was plotted using SAPS II scores and the area under the curve was 0.93 with 95% confidence interval (0.89-0.96). The calculated SMR was 0.97. Conclusions: Women admitted to ICU with diagnosis of puerperal sepsis and intrauterine death (IUD) with coexisting sepsis had higher mortality as compared to women with hypertensive disease of pregnancy and hemorrhage. The calculated SMR was less than one which is a predictor of good ICU care.

Background and Aims: Critical illness may complicate any pregnancy. Timely intensive care management of critically ill obstetric patients has better outcomes than expected from the initial severity of illness. The aim was to study the indications of transfer of post-cesarean section patients to post-anesthesia intensive care unit (PACU). (PACU transfer indicated that the patient required intensive care). Materials and Methods: This was a prospective observational study carried out in the PACU of a tertiary care teaching public hospital over a period of 2 years. Sixty-one postoperative lower segment cesarean section (LSCS) females admitted consecutively in PACU were studied. The study included obstetric PACU utilization rate, intensive care unit interventions, outcome of mother, Acute Physiology and Chronic Health Evaluation (APACHE II) score, and its correlation with mortality. Results: Postanesthesia intensive care unit admission rate was 2.8% and obstetric PACU utilization rate was 3.22%. Of 61 patients, four had expired. Obstetric indications (67.2%) were the most common cause of admission to PACU. Among the obstetric indications hemorrhage (36.1%) was found to be a statistically significant indication for PACU admission followed by hypertensive disorder of pregnancy (29.5%). Cardiovascular disease (16.4%) was the most common nonobstetric indication for PACU transfer and was associated with high mortality. The observed mortality was 6.557%, which was lower than predicted mortality by APACHE II Score. Conclusion: Obstetric hemorrhage, hypertensive disorders of pregnancy and cardiovascular diseases are the leading causes of PACU admission in post LSCS patients. Prompt provision of intensive care to critically ill obstetric patients can lead to a significant drop in maternal morbidity and mortality.

Background and Aims: We designed a study to compare the effectiveness of dexmedetomidine plus ketamine combination with dexmedetomidine alone in search of an ideal sedation regime, which would achieve better intubating conditions, hemodynamic stability, and sedation for awake fiberoptic nasotracheal intubation. Materials and Methods: A total of 60 adult patients of age group 18-60 years with American Society of Anesthesiologists I and II posted for elective surgery under general anesthesia were randomly divided into two groups of 30 each in this prospective randomized controlled double-blinded study. Groups I and II patients received a bolus dose of dexmedetomidine at 1 mcg/kg over 10 min followed by a continuous infusion of dexmedetomidine at 0.5 mcg/kg/h. Upon completion of the dexmedetomidine bolus, Group I patients received 15 mg of ketamine and an infusion of ketamine at 20 mg/h followed by awake fiberoptic nasotracheal intubation, while Group II patients upon completion of dexmedetomidine bolus received plain normal saline instead of ketamine. Hemodynamic variables like heart rate (HR) and mean arterial pressure (MAP), oxygen saturation, electrocardiogram changes, sedation score (modified Observer assessment of alertness/sedation score), intubation score (vocal cord movement and coughing), grimace score, time taken for intubation, amount of lignocaine used were noted during the course of study. Patient satisfaction score and level of recall were assessed during the postoperative visit the next day. Results: Group I patients maintained a stable HR and MAP (<10% fall when compared with the baseline value). Sedation score (3.47 vs. 3.93) and patient satisfaction score were better in Group I patients. There was no significant difference in intubation scores, grimace scores, oxygen saturation and level of recall when compared between the two groups (P > 0.05). Conclusion: The use of dexmedetomidine plus ketamine combination in awake fiberoptic nasotracheal intubation provided better hemodynamic stability and sedation than dexmedetomidine alone.

Background and Aims: Neurosurgeons routinely instill vasopressors, with or without local anesthetics, to prepare nasal passages prior to transsphenoidal surgeries. As there is a paucity of data comparing the effect of intramucosal nasal infiltration of different concentrations of adrenaline that is, 1:200,000 and 1:400,000 in patients undergoing transsphenoidal surgery, we conducted this study to evaluate the effect of these two concentrations of adrenaline with 2% lignocaine on hemodynamics as well as bleeding. Materials and Methods: Fifty-two American Society of Anesthesiologists I/II patients, aged 15-70 years, undergoing transsphenoidal surgery for pituitary or sellar masses were enrolled. Prior to surgical incision, nasal septal mucosa was infiltrated with lignocaine-adrenaline solution, after randomly allocating them to one of the two groups, with patients in Group A receiving intramucosal infiltration using 2% lignocaine with 1:200,000 adrenaline and those in Group B receiving 2% lignocaine with 1:400,000 adrenaline. Following infiltration, hemodynamic parameters were recorded every 1 min for 5 min and thereafter at every 5 min interval. Results: Fewer patients (3/24 [12.5%]) in Group B had a rise of >50% in systolic blood pressure, from baseline values, after nasal mucosa infiltration as compared with patients in Group A (9/24 [37.5%]). In addition, mean rise in systolic, diastolic and mean arterial pressure was also significantly lower in Group B as compared with Group A. Conclusion: Adrenaline in a concentration of 1:400,000 added to 2% lignocaine for nasal mucosa infiltration produces less hemodynamic response as compared with adrenaline 1:200,000 added to 2% lignocaine while at the same time providing similar operating conditions.

Background & Aims: The Combitube^; and EasyTube™ enable effective ventilation whether placed in the trachea or esophagus and can be used in prehospital settings, as well as in "Cannot Ventilate Cannot Intubate" situations in the operating room. Whether they can be continued to provide general anesthesia, if required, is not established.Thus the efficacy of Combitube and EasyTube was evaluated and compared with the tracheal tube for general anesthesia using controlled ventilation. Materials and Methods: Combitube, EasyTube and tracheal tubes were used in 30 patients each to secure the airway in a randomized controlled manner. Ventilatory parameters were measured along with hemodynamic variables, and characteristics related to device placement. Results: There was no significant difference in the various ventilatory parameters including minute ventilation requirement to maintain eucapnia amongst the three groups at any time point . There was no hypoxia or hypercarbia in any patient at any time. Placement of EasyTube was more difficult (P = 0.01) as compared with both Combitube and tracheal tube. EasyTube and Combitube resulted in higher incidence of minor trauma than with a tracheal tube (P = 0.00). Conclusion: Combitube and EasyTube may be continued for general anesthesia in patients undergoing elective nonlaparoscopic surgeries of moderate duration, if placed for airway maintenance. Given the secondary observations regarding placement characteristics of the airway devices, it, however cannot be concluded that the devices are a substitute for endotracheal tube for airway maintenance per se, unless specifically indicated

Background and Aims: Clonidine has been used as an adjuvant to local anesthetic to extend the duration of block. The present study was aimed to compare the onset and duration of sensory and motor blockade of 0.75% ropivacaine alone or in combination with clonidine during ultrasound guided supraclavicular brachial plexus block for upper extremity surgeries under tourniquet. Materials and Methods: Sixty four adult American Society of Anesthesiologist grade 1 and 2 patients, scheduled for upper extremity surgeries were randomized to receive either 19.8 mL of 0.75% ropivacaine with 0.2 mL of normal saline (Group R) or 0.2 mL (30 μg) of clonidine (Group RC) in supraclavicular block. Onset and duration of sensory and motor blockade was compared. The hemodynamic variability, sedation, respiratory adequacy and any other adverse effects were also recorded. Result: Ultrasound helped to visualize the nerves, needle and spread of local anesthetic at the brachial plexus block site. There was no statistically significant difference in the onset of sensory and motor blockade between the groups. Surgical anesthesia was achieved at the mean time of 20 min in all patients. Prolonged post-operative analgesia (mean duration 956 min) was observed in RC group as compared with R group (736 min). No complication of technique or adverse effect of ropivacaine and clonidine was reported. Conclusion: Clonidine as an adjuvant to ropivacaine for ultrasound guided supraclavicular brachial plexus enhanced duration of post-operative analgesia. There was no incidence of vessel puncture or pneumothorax.

Background and Aims: This prospective, randomized, double-blind study was undertaken to establish the effect of addition of magnesium or dexmedetomidine, as an adjuvant, to epidural bupivacaine in lower limb surgeries. Materials and Methods: One hundred and twenty ASA (American Society of Anesthesiologists) class I and II patients undergoing lower limb surgeries were enrolled to receive either magnesium sulfate (Group M) or dexmedetomidine (Group D) along with epidural bupivacaine for surgical anesthesia. All the study subjects received an epidural anesthesia with 14 ml of 0.5% bupivacaine along with either MgSO ₄ 50 mg (Group M) or dexmedetomidine 0.5 μg/kg (Group D) or saline (Group C). The onset of motor and sensory block, duration of block, hemodynamic parameters, and any adverse events were monitored. Results: Analgesia in the postoperative period was better in Group D, duration of sensory and motor blockade was significantly prolonged in Group D and incidence of sedation was more in Group D. Conclusion: Hence, addition of dexemedetomidine to epidural bupivacaine can be advantageous with respect to increased duration of motor and sensory blockade and arousable sedation.

Background and Aims: We studied the state entropy to monitor the sedative effect of subarachnoid block (SAB) using bupivacaine alone or combination of bupivacaine and fentanyl. The effect of use of fentanyl via the subarachnoid route on the sedation level was also studied using the entropy scores and the decrease in the requirement of propofol used as an adjuvant sedative drug. Materials and Methods: In this prospective randomized double-blind study, 30 patients of age 18-70 years requiring SAB were enrolled for the study. Patients with any known allergy to study drugs, contraindication for SAB, obesity, neurological or psychiatric disease on concurrent medication and refusal were excluded from the study. Patients were randomly allocated into two groups: Group C: SAB was administered with 2.5 mL (12.5 mg) of 0.5% hyperbaric bupivacaine; Group D: SAB was administered with 2.5 mL of 2 mL (10 mg) of 0.5% hyperbaric bupivacaine and 0.5 mL (25 μg) fentanyl. Propofol infusion was started if the state entropy (SE) value was ≥75, at the rate of 100 μg/kg/min till the SE value reaches in the range of 60-75 (recorded as onset time). Thereafter the infusion rate was titrated to maintain SE value between 60 and 75. The level of sedation was measured with SE and Ramsay sedation (RS) scale. Results: The demographic profile and baseline parameters, were comparable in two groups (P > 0.05). After SAB, decrease in SE and response entropy was noted in both the groups and fall was significant in Group D (P < 0.0001). The total propfol required in thew two groups were comparable being 3.97 ± 2.14 mg/kg in Group C and 3.41 ± 2.34 mg/kg in Group D (P = 0.342). The change in the mean RS values was from 1.17 ± 0.38 to 1.69 ± 0.47 in Group D (P = 0.06), whereas in Group C it was from 1.03 ± 0.18 to 1.43 ± 0.50 (P = 0.041) within 20 min of SAB. Conclusion: Subarachnoid block causes sedation per se, but the level of sedation is not clinically significant and the sedation caused is not enough to avoid sedative agents for allaying anxiety in patients intraoperatively. The sedative effect of SAB was enhanced by adding intrathecal fentanyl probably because of better quality of SAB. SE showed good correlation with RS scaling system. Therefore, SE may be used as reliable tool to titrate sedation in patients undergoing surgery under SAB.

Background and Aims: Intravenous agents such as propofol are commonly used to maintain adequate depth of anesthesia. Dexmedetomidine which has an anesthetic sparing effect is being considered for maintaining intraoperative depth of anesthesia. We hypothesized to compare the effect of dexmedetomidine on depth of anesthesia with propofol and evaluated whether dexmedetomidine can be used as sole anesthetic agent in maintaining depth of anesthesia. Materials and Methods: Sixty patients of ASA PS I, 18-65 years of age, scheduled for laparotomy under general anesthesia were randomly divided into two groups of 30 each. Group A received propofol 1 mg/kg bolus followed by infusion (50 mcg/kg/min) and Group B received dexmedetomidine 1 mcg/kg bolus followed by infusion (0.5 mcg/kg/h) . Both the groups were administered standard general anesthesia with routine monitoring along with Bispectral index (BIS) and values were recorded at intervals of 10 min. In all patients Ramsay sedation score was recorded after extubation and they were assessed for recall of intraoperative events using Modified Brice questionnaire. Results: Heart rate and mean arterial pressure were less in Group B than Group A. Intraoperative BIS values were significantly lower in Group B (P < 0.0001). Although sedation score was more in Group B it did not prolong recovery. No recall was found in any patient. Conclusion: Dexmedetomidine was comparable with propofol in maintaining anesthesia and it can produce better control of hemodynamics and BIS value. Thus dexmedetomidine can be used as the sole maintenance anesthetic agent.

Malignant Hyperthermia is a pharmacogenetic disorder. Classical manifestations comprise of tachycardia, increase in expired carbon dioxide levels, muscle rigidity, hyperthermia (>38.8°C) and unexpected acidosis. Here we report a case of 16-year-old female patient, ASA-I with chronic rhino-sinusitis and slight strabismus of the left eye posted for functional endoscopic sinus surgery, developing a rise in ETCO ₂ and temperature immediately following anesthesia induction. She was aggressively managed to an uneventful recovery. We present a case of intra-operative post-induction hyperthermia possibly MH, its anesthetic implications, challenges encountered and its management.

Management of an anticipated difficult airway in Hurler syndrome. Hurler syndrome is a subtype of Mucopolysaccharidosis (MPS) type 1. Mucopolysaccharidosis (lysosomal storage diseases) are a group of inherited disorders caused by deficiency of specific lysosomal enzyme required for a normal degradation of glycosaminoglycons (GAGs). Administration of general anaesthesia in patients who have congenital syndromes such as Hurler's is often a challenge because of progressive airway, craniofacial and skeletal abnormalities that may make both the ventilation and intubation difficult. We encountered difficult mask ventilation and endotracheal intubation was not possible and finally ventilated with laryngeal mask airway in a known case of Hurler syndrome posted for umbilical hernia repair.

Anesthesia for partial glossectomy in a premature child with Beckwith-Wiedemann syndrome presents as a unique challenge to the Anesthesiologist. Airway management in patients presenting with macroglossia is especially significant and requires meticulous preparation and pre-operative assessment. This report delineates the anesthetic concerns such as an anticipated difficult airway due to a large tongue, prematurity, hypoglycemia and an oral cavity surgery and their management.

Fibrodysplasia ossificans progressiva (FOP), or Stone man syndrome, is rare and one of the most disabling genetic conditions of the connective tissue due to progressive extraskeletal ossification. It usually presents in the first decade of life as painful inflammatory swellings, either spontaneously or in response to trauma, which later ossify and lead to severe disability. Progressive spinal deformity including thoracolumbar kyphoscoliosis leads to thoracic insufficiency syndrome, increasing the risk for pneumonia and right sided heart failure. We present the airway management in a 22-year-old male, diagnosed with FOP with severe disability, who required urgent airway intervention as a result of respiratory failure from pnuemonia. Tracheostomy triggers ossification and consequent airway obstruction at the tracheostomy site and laryngoscopy triggers temporomandibular joint ankylosis. Therefore, awake fiber-optic endotracheal intubation is recommended in these patients. Use of an airway endoscopy mask enabled us to simultaneously maintain non-invasive ventilation and intubate the patient in a situation where tracheostomy needed to be avoided.

The role of various airway adjuncts in the management of difficult airway has been described in the literature. Bonfils rigid fiberscope is one of the airway assist devices widely used for endotracheal intubation in the individuals with cervical instability warranting limited neck movements. With our experience in the utilization of Bonfils for single lumen endotracheal tube placement, we are increasingly using for double lumen endobronchial (DLT) intubation as well. We would like to describe our experience in the use of Bonfils for DLT placement and outline the merits and limitations of the other suitable airway assist devices in this report. The double lumen tube has to be modified by decreasing the length of DLT to accommodate the Bonfils fiberscope and this is applicable only in certain type of double lumen tubes for e.g. Bronchocath.