Although, opioids are advocated in various guidelines their use for chronic non-cancer pain is controversial because evidence of long term benefit is weak. The potential for serious adverse effects and local regulations promote caution in both the prescribers and users. However, opioids have a place in the management of chronic non-cancer pain in carefully selected patients with regular monitoring and as a part of the multimodal therapy. It is important for the treating physician to be up-to-date with this form of therapy, in order to have the necessary confidence to prescribe opioids and manage adverse effects. The common adverse effects should be treated promptly to improve patient compliance. We believe that opioid therapy in low doses is beneficial to some patients. It should not be denied but carefully considered on case by case basis.

Endotracheal intubation in children is usually performed utilizing uncuffed endotracheal tubes for conduct of anesthesia as well as for prolonged ventilation in critical care units. However, uncuffed tubes may require multiple changes to avoid excessive air leak, with subsequent environmental pollution making the technique uneconomical. In addition, monitoring of ventilatory parameters, exhaled volumes, and end-expiratory gases may be unreliable. All these problems can be avoided by use of cuffed endotracheal tubes. Besides, cuffed endotracheal tubes may be of advantage in special situations like laparoscopic surgery and in surgical conditions at risk of aspiration. Magnetic resonance imaging (MRI) scans in children have found the narrowest portion of larynx at rima glottides. Cuffed endotracheal tubes, therefore, will form a complete seal with low cuff pressure of <15 cm H ₂ O without any increase in airway complications. Till recently, the use of cuffed endotracheal tubes was limited by variations in the tube design marketed by different manufacturers. The introduction of a new cuffed endotracheal tube in the market with improved tracheal sealing characteristics may encourage increased safe use of these tubes in clinical practice. A literature search using search words "cuffed endotracheal tube" and "children" from 1980 to January 2012 in PUBMED was conducted. Based on the search, the advantages and potential benefits of cuffed ETT are reviewed in this article.

Thematic or topical philately deals with stamp collection based on a particular topic or theme. This article deals with a thematic depiction of the history of anesthesia from ancient to modern times using stamps, postal stationery and cancellations.

Purpose: Maintaining systolic blood pressure (SBP) at 100% of baseline is best for fetal and maternal outcome. We hypothesized that irrespective of the vasopressor used, maintaining SBP at 100% of baseline with phenylephrine (P), metaraminol (M), or ephedrine (E) will produce the best fetal pH after cesarean section (LSCS) under subarachnoid block (SAB). Materials and Methods: Ninety ASA 1 women scheduled for elective LSCS were randomly allocated to receive P, M, or E. SAB was established with patient in left lateral position using 2.5 cc of 0.5% hyperbaric bupivacaine. Immediately following SAB, patients received a bolus of the study drug (E = 5 mg, M = 0.5 mg, P = 30 mcg) followed by infusion (E = 2.5 mg/min, M = 0.25 mg/min, P = 15 mcg/min) to maintain SBP at 100% baseline. Umbilical blood gases, maternal hemodynamic parameters, and complications were recorded. Results: The umbilical pH was comparable in all the three groups (P > 0.05). The mean SBP from spinal block until delivery was similar over time for all the three groups. The incidence of reactive hypertension was more in group M (P < 0.05) than in group E and group P. Total drug consumption to meet target blood pressure till delivery was 39.3 ± 14.6 mg in group E, 1.7 ± 0.9 mg in group M, and 283.6 ± 99.8 mcg in group P. The incidence of nausea and vomiting was comparable in the three groups. Conclusion: All the three vasopressors were equally effective in maintaining maternal blood pressure as well as umbilical pH during spinal anesthesia for cesarean section without any detrimental effects on fetal and maternal outcome.

Background: Oxytocin is routinely administered during cesarean delivery for uterine contraction. Adverse effects are known to occur after intravenous oxytocin administration, notably tachycardia, hypotension, and electrokardiogram (EKG) changes, which can be deleterious in high-risk patients. Aims and Objectives: To compare the hemodynamic changes and uterotonic effect of equivalent dose of oxytocin administered as an intravenous bolus versus intravenous infusion. Study Design: Randomized, double-blind, active controlled trial. Materials and Methods: Eighty parturients undergoing elective cesarean delivery, under spinal anesthesia, were randomly allocated to receive 3 IU of oxytocin either as a bolus intravenous injection over 15 seconds (group B, n = 40) or as an intravenous infusion over 5 minutes (group I, n = 40). Uterine tone was assessed as adequate or inadequate by an obstetrician. Intraoperative heart rate, non-invasive blood pressure, and EKG changes were recorded. These data were compared between the groups. Any other adverse events like chest pain, nausea, vomiting, and flushing were noted. Results: There was significant rise in heart rate and significant decrease in mean arterial pressure in bolus group compared to infusion group. Three patients in bolus group had EKG changes in the form of ST-T depression and 5 patients complained of chest pain. No such complications were found in infusion group. Conclusion: Bolus oxytocin (at a dose of 3 IU over 15 seconds) and infusion of oxytocin (at a dose of 3 IU over 5 minutes) have comparable uterotonic effect. However, the bolus regime shows significantly more adverse cardiovascular events.

Context: Morbidly obese patients are prone for intraoperative hemodynamic disturbances and postoperative airway complications. Aim: Comparison of intraoperative hemodynamics and postoperative recovery characteristics of desflurane versus sevoflurane in morbidly obese patients undergoing laparoscopic bariatric surgery. Settings and Design: Randomized controlled trial Materials and Methods: After institutional ethics committee approval and written informed consent, 40 morbidly obese patients (BMI > 35 kg/m ² ) were randomized to receive desflurane or sevoflurane as part of a standardized general anesthesia technique. Volatile anesthetic concentration was titrated to maintain electroencephalographic bispectral index score (BIS) in the range of 40-60. Mean arterial pressure (MAP) and heart rate (HR) were recorded preoperatively, at induction and intubation, then at regular intervals. After extubation, early recovery was recorded by time to emergence and orientation to time and place. In post anesthesia care unit, intermediate recovery was assessed by modified Aldrete Score and Digit Symbol Substitution Test (DSST). Results: Intraoperative MAP and HR did not differ between the two groups ( P > 0.05). The time to response to painful stimuli, obeying verbal commands and spontaneous eye opening was shorter ( P = 0.001) and modified Aldrete Score was higher after desflurane anesthesia than after sevoflurane anesthesia ( P = 0.049). DSST also returned towards normal faster after desflurane (28.50 ± 6.30 min vs. 35.0 ± 5.62 min, P = 0.03). Conclusions: Both desflurane and sevoflurane produce similar hemodynamic changes but the immediate and intermediate recovery was significantly faster after desflurane thus contributing to fast tracking and early discharge of patients.

Context: Present knowledge about intraoperative management, morbidity, and mortality of patients with undiagnosed catecholamine-producing tumors is mostly based on published case reports and anecdotal evidence. Aims: The aim was to summarize the management and outcomes of reported cases and analyze for practice patterns, deduct useful management recommendations as applicable. Settings and Design: The Medline database was searched with specific keywords for the period of 1988-2010 for cases of incidental pheochromocytomas and paragangliomas. Materials and Methods: Case reports in the English language with a postoperative diagnosis of pheochromocytoma and paraganglioma by histopathology were included. Systematic data extraction from case reports was done. Statistical analysis used: Descriptive statistics were applied. Results: Of 823 retrieved records, 62 case reports met inclusion criteria. Hemodynamic instability occurred primarily during mass manipulation/intraoperatively (52%, n = 32) and induction/laryngoscopy (18%, n = 11). In cases reporting specific antihypertensive treatments, nitrates (67%, n = 30) represented the majority of medications used, followed by beta-blockers (47%, n = 21). Alpha receptor blockers were administered in 33% (n = 15). The perioperative mortality was 8% (n = 5), and none of these patients received intraoperative alpha blockade. A catecholamine-secreting tumor was suspected intraoperatively in 26% of cases. Conclusions: The perioperative mortality based on the reviewed cases of incidental catecholamine producing tumors was less than would traditionally be expected. Intraoperative alpha receptor blockade to treat hypertension was reported in 33% of cases, and none of the patients with a fatal outcome had received it. A higher intraoperative index of suspicion and a lower threshold to consider alpha blocking medications for severe intraoperative hypertension may improve outcomes.

Background: The ProSeal ^TM laryngeal mask (PLMA) is increasingly being used as an airway device for laparoscopic surgery. Its silicone cuff allows diffusion of nitrous oxide, carbon dioxide and other gases with resultant rise in its intracuff pressure during anesthesia. The present study was designed to investigate the intracuff pressure changes during anesthesia with and without nitrous oxide in patients undergoing laparoscopic surgery lasting up to two hours. Materials and Methods: One hundred patients, American Society of Anesthesiologists physical status 2 and 3, undergoing general anesthesia with muscle paralysis, were randomized into two groups of 50 patients each to receive an anesthetic gas mixture containing either oxygen and nitrous oxide (group N) or oxygen and air (group A). Following insertion of an appropriate size PLMA, its cuff was inflated with air to an intracuff pressure of 45 mm Hg. The cuff pressure was measured every 10 minutes for the entire course of anesthesia. The position of the device was also assessed fiberoptically and postoperative airway complications were recorded. Results: The maximum intracuff pressure recorded in group N was 103 ± 4.7 mm Hg vs. 45.5 ± 1.5 mm Hg in group A. The percentage rise in cuff pressure every 10 minutes was also highly significant ( P < 0.001) being maximum in first 10 min in group N. The incidence of postoperative airway complications was comparable between the two groups. Conclusion: The results of this study demonstrate that the intracuff pressure of the PLMA increases progressively over time when the breathing gas mixture contains nitrous oxide.

Background: Though fiberoptic intubation (FOI) is considered the gold standard for securing a difficult airway in a child, it may be technically difficult in an anesthetized child. The hypothesis for this study was that it would be easier to perform FOI via a laryngeal mask airway (LMA) than a modified oropharyngeal airway with the advantage of maintaining anesthesia and oxygenation during the process. Materials and Methods: 30 children aged 6 months to 5 years undergoing elective surgery under general anesthesia were randomized to two groups to have fiberoptic bronchoscope (FOB) guided intubation either via a modified Guedel airway (FOB-ORAL) or a classic LMA (FOB-LMA). In the FOB-LMA group, the LMA was removed when a second smaller endotracheal tube was anchored to the proximal end of the tracheal tube in place. Results: Oral fiberoptic intubation was successful in all children. The first attempt success rate was 11/15 (73.33%) in the FOB-LMA group and 3/15 (20%) in the FOB-ORAL group ( P = 0.012). Subsequent attempts at intubation were successful after 90° anticlockwise rotation of the endotracheal tube over the FOB. The time taken for fiberoptic bronchoscopy was significantly less in FOB-LMA group (59.20 ± 42.85 sec vs 108.66 ± 52.43 sec). The incidence of desaturation was higher in the FOB-ORAL group (6/15 vs 0/15). Conclusion: In children, fiberoptic bronchoscopy and intubation via an LMA has the advantage of being easier, with shorter intubation time and continuous oxygenation and ventilation throughout the procedure. Removal of the LMA following intubation requires particular care.

Aim: To compare insertion characteristics of 2 different supraglottic devices [I-gel and Proseal laryngeal mask airway (PLMA)] and to observe any associated complications. Study Design: This prospective, randomized study was conducted in 80 patients [Group I - I-gel insertion (n = 40) and Group P - LMA Proseal insertion (n =40)] of ASA grades I/II, of either sex in the age group 18-65 years. Both groups were compared with respect to ease of insertion, insertion attempts, fiberoptic assessment, airway sealing pressure, ease of gastric tube placement, and other complications. Materials and Methods: All patients were asked to fast overnight. Patients were given alprazolam 0.25 mg orally at 10 p.m. the night before surgery and again 2 hours prior to surgery with 1-2 sips of water. Glycopyrrolate 0.2 mg, metoclopramide 10 mg, and ranitidine 50 mg were administered intravenously to the patients 45 minutes prior to the surgery. Once adequate depth of anesthesia was achieved either of the 2 devices, selected using a random computerized table, was inserted by an experienced anesthesiologist. In group I, I-gel was inserted and in patients of group P, PLMA was inserted. Statistical Analysis: Student t-test and Mann-Whitney test were employed to compare the means; for categorical variables, Chi-square test was used. Result: Mean insertion time for the I-gel (11.12 ± 1.814 sec) was significantly lower than that of the PLMA (15.13 ± 2.91 sec) (P = 0.001). I-gel was easier to insert with a better anatomic fit. Mean airway sealing pressure in the PLMA group (29.55 ± 3.53 cm H ₂ O) was significantly higher than in the I-gel group (26.73 ± 2.52 cm H ₂ O; P = 0.001). Ease of gastric tube insertion was significantly higher in the I-gel group (P = 0.001). Incidence of blood staining of the device, sore throat and dysphagia were observed more in PLMA group. No other complications were observed in either of the groups.

Background: Reduction of postoperative nausea and vomiting (PONV) continues to be a major challenge in perioperative care in spite of introduction of newer antiemetics with better efficacy and safety profiles. Therefore, we evaluated the additive effect of oral midazolam and clonidine for PONV prophylaxis in granisetron premedicated patients undergoing laparoscopic cholecystectomy. Materials and Methods: In a prospective, randomized fashion, 120 selected cases were randomized into three groups: I, II or III to receive a tablet of midazolam (15 mg, n = 36), clonidine (150 mcg, n = 40), or glucose as placebo (5 g, n = 44) orally, 1 h before anesthesia. Occurrence of PONV along with need for rescue antiemetic during the first postoperative day was compared between groups as a primary outcome. Results: Episodes of PONV reduced significantly in Group II (15%) as compared to group I and III (22.2%, 59%) at various time points during the period of observation (P = 0.002). Need for rescue antiemetic was significantly lower in group I (13.88%) and II (5%) as compared to group III (52.27%, P < 0.001). Conclusion: Oral clonidine is better adjuvant for PONV prophylaxis, as compared to midazolam, in granisetron premedicated patients undergoing laparoscopic cholecystectomy.

Background: Clonidine is added to intrathecal local anesthetics to improve intraoperative analgesia and to increase the duration of sensory and motor block. Aim of this study was to evaluate and compare the effects of addition of two different doses of clonidine (15 and 30 mcg) to 11 mg hyperbaric bupivacaine in patients undergoing inguinal herniorrhaphy surgery under spinal anesthesia. Materials and Methods: Seventy-five patients enrolled in the study were randomly divided into three groups of 25 each. Group I patients received 11 mg hyperbaric bupivacaine, whereas groups II and III received 15 mcg and 30 mcg clonidine, respectively, as an adjuvant to 11 mg hyperbaric bupivacaine. The volume of solution was kept constant to 2.4 ml by adding saline wherever needed. Results: Highest level of sensory block, time to achieve this level, and highest Bromage scale recorded were comparable among the groups. The mean time to two-segment regression, regression of sensory block to L3 dermatome, and mean duration of motor block were the greatest in group III followed by group II and group I. There was significant fall in mean arterial pressure (MAP) in groups II and III as compared to group I (P = 0.04). Episodes of hypotension were more in group III than in group II. Conclusion: 30 mcg clonidine was associated with more incidence and duration of hypotension than 15 μg of clonidine. 15 mcg clonidine added to 11 mg hyperbaric bupivacaine provides better sensory and motor blockade for inguinal herniorrhaphy.

Background: Transversus abdominis plane block is a safe, simple and effective technique of providing analgesia for lower abdominal surgeries with easily identifiable landmarks. Aims: To compare the analgesic efficacy of transversus abdominis plane block with that of direct infiltration of local anesthetic into surgical incision in lower abdominal procedures. Settings and Design: Prospective randomized controlled trial in lower abdominal surgeries done under general anesthesia. Materials and Methods: 52 ASA I-II patients undergoing lower abdominal gynecological procedures under general anesthesia were divided randomly into two groups each after written informed consent. A bilateral TAP block was performed on Group T with 0.25% bupivacaine 0.6 ml/kg with half the volume on either side intra-operatively after skin closure before extubation using a short bevelled needle, whereas Group I received local infiltration intra-operatively after skin closure with the same amount of drug. The time taken for the first rescue analgesic and visual analog score (VAS) was noted, following which, the patient was administered intravenous morphine 0.1 mg/kg and connected to an intravenous patient controlled analgesia system with morphine for 24 hrs from the time of block administration. 24 h morphine requirement was noted. VAS and sedation scores were noted at 2, 4, 6 and 24 h postoperatively. Statistical Analysis Used: The results were analyzed with SPSS 16. A P value < 0.05 was considered significant. Duration of analgesia and 24 h morphine requirement was analysed by Student's t-test. VAS scores, with paired comparisons at each time interval, were performed using the t-test or Mann-Whitney U-test, as appropriate. Categorical data were analyzed using Chi square or Fisher's exact test. Results: In Group T, the time to rescue analgesic was significantly more and the VAS scores were lower ( P = 0.001 and 0.003 respectively). The 24 hr morphine requirement and VAS at 2, 4, 6 and 24 h were less in the Group T ( P = 0.001). Incidence of PONV was significant in Group I ( P = 0.043), whereas Group T were less sedated at 2 and 4 h ( P = 0.001 and 0.014). Conclusions: Transversus abdominis plane block proved to be an effective means of analgesia for lower abdominal surgeries with minimal side-effects.

Background: Presence of major depressive syndrome (MDS) in chronic pain patients (CPPs) requires more attention from the clinicians because of its clinical nature, association of suicidal thoughts and their actual completion, and treatment difficulties. The prevalence of MDS among Indian CPPs is not well studied. Aim: To determine the prevalence of MDS among Indian CPPs visiting pain clinic. Materials and Methods: In this prospective study, 476 patients who attended a pain clinic in a metropolitan city of India for chronic pain (pain more than six months) were included. They were assessed by 'PHQ-9 depression scale' for presence of MDS. Intensity of pain was assessed by 'Visual analogue scale' (VAS). Patient details (viz. age, sex), duration and site of pain, and scores of PHQ-9 depression scale and VAS, were noted and statistically analyzed. Results: 146 out of 476 CPPs (30.67%) were found to suffer from MDS. Women were more prone (F: M =3:2) to develop MDS while suffering from chronic pain. Among 146 CPPs who were suffering from MDS, 108 (73.97%) patients also had suicidal thought. The prevalence of suicidal thought among all CPPs was found to be 22.69%. The depression severity was found to be strongly associated with intensity of pain ( P = 0.005 < 0.05) but not associated with the duration of pain ( P = 0.159 > 0.05) and age of the patient ( P = 0.24 > 0.05). Conclusion: We found a high prevalence of MDS among CPPs from India and majority of them also harbored suicidal thought. Therefore, for successful outcome in chronic pain management routine psychological assessment in CPPs should be done to exclude the presence of MDS and suicidal thought.

Background: Cross hypersensitivity to inhalation anesthetics has not been studied. The aim of this study was to investigate it by comparing liver and renal function after repeated anesthesia with sevoflurane and isoflurane retrospectively. Materials and Methods: The adult patients who received general anesthesia twice within the interval of 14 days to 1 year were retrospectively analyzed. Those who received sevoflurane anesthesia twice (SS group, 53 cases), isoflurane anesthesia twice (II group, 31 cases), sevoflurane followed by isoflurane anesthesia (SI group, 29 cases), isoflurane followed by sevoflurane anesthesia (IS group, 35 cases), and propofol-fentanyl anesthesia twice (PP group, 58 cases) were enrolled. Serum concentrations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin (Bil), gamma-glutamyl transpeptidase (γ-GTP), blood urea nitrogen (BUN), and creatinine (Cr) measured 1-3, 5-8, and 12-16 days after surgery were investigated. Results: In the IS group, the number of the patients with abnormal values of ALT and γ-GTP 5-8 days after surgery were significantly smaller at second anesthesia compared to the first anesthesia. The number of the patients with abnormal values of AST, ALT, and γ-GTP were significantly larger in the II group than the SS and PP groups. The number of patients who had higher values in each parameter at second anesthesia compared to the first anesthesia was not different among the groups. Conclusions: Sevoflurane and isoflurane might have no cross hypersensitivity. Both anesthetics might not have any additional risks to increase liver and renal damage by second anesthesia.

Background: Prolonged preoperative fasting in children is a common problem, especially in highvolume centers. All international professional society guidelines for preoperative fasting recommend 2 h for clear fluids, 4 h for breast milk and 6 h for solids, nonhuman and formula milk in children. These guidelines are rarely adhered to in practice. Aims: An audit was undertaken to determine the length of preoperative fasting time in children and its causes. Settings and Design: Cross-sectional study of 50 children below 15 years posted for elective surgeries. Materials and Methods: An initial audit was performed at our institution on preoperative fasting time in 50 children below 15 years of age for elective surgeries. The mean preoperative fasting times were found to be much longer than the recommended times. Ward nurses were then educated about internationally recommended preoperative fasting guidelines in children. Anesthesiologists started coordinating with surgeons and ward nurses to prescribe water for children waiting for more than 2 h based on changes in surgery schedule by instructing ward nurses through telephone on the day of surgery. A reaudit was done 6 months after the initial audit. Statistical Analysis Used: SPSS 16 software. Results: The initial audit revealed a mean preoperative fasting time of 11.25 h and 9.25 h for solids and water, respectively. Incorrect orders by ward nurses (74%) and change in the surgical schedule (32%) were important causes. After changing the preoperative system, mean preoperative fasting times in children decreased to 9 h and 4 h for solids and water, respectively in reaudit. Change in surgical schedule (30%) was the major cause for prolonged preoperative fasting in reaudit. Conclusions: Simple steps such as education of ward nurses and better coordination among the anesthesiologists, surgeons and nurses can greatly reduce unnecessary preoperative starvation in children.

Over the past two decades, there has been an increased use of extracorporeal membrane life support (ECLS) for critically ill neonates and infants. Approximately 20% of these children will experience seizures as a complication of ECLS or the comorbid condition which necessitated extracorporeal support. While phenobarbital is one of the most common drugs used to treat seizures in children, little is known about its dosing while on ECLS. We present a 3-month-old girl who required ECLS after cardiac arrest in the postoperative period following surgery for complex congenital heart disease. The patient subsequently developed seizure activity, which was treated with phenobarbital. Following an initial loading dose of 30 mg/kg, the serum concentration was 47.9 mcg/ml. A supplementary loading dose of 10 mg/kg was administered 8 h later with an increase of the maintenance dose to 8 mg/kg/day. The phenobarbital serum concentrations were 65.9 and 72.8 mcg/ml on the subsequent days. Despite therapeutic levels of phenobarbital, the patient continued to exhibit clinical and electroencephalographic evidence of seizure activity and a midazolam infusion was started at 0.3 mg/kg/h. Because of continued seizure activity, the patient ultimately required titration of midazolam to 1.2 mg/kg/h by day 7 of ECLS to control seizure activity. Due to severe intracerebral bleeding on day 9, ECLS was withdrawn and the patient expired. Our experience demonstrates some of the challenges of medication titration during ECLS. Previous reports of phenobarbital dosing during ECLS are reviewed and considerations for the dosing of anticonvulsant medications during extracorporeal support are discussed.

Marfan syndrome is an inherited, connective-tissue disorder transmitted as an autosomal dominant trait. Cardinal features of the disorder include tall stature, ectopia lentis, mitral valve prolapse, aortic root dilatation, and aortic dissection. Pectus excavatum may exist as an isolated lesion or in association with a genetic syndrome such as Marfan syndrome. We report the successful management of a simultaneous correction of pectus excavatum and the underlying cardiovascular diseases.

Management of neuraxial anesthesia/analgesia in anticoagulated patient can be challenging. The shortest safe time to remove epidural catheter, after a patient receives long-acting dual antiplatelet agents (clopidogrel and aspirin), is unclear. American Society of Regional Anesthesiology (ASRA) guidelines recommend seven days interval for the epidural placement after clopidogrel administration. However ASRA Guideline did not specify the time for epidural catheter removal, and did not specify how much time elapse necessary after dual antiplatelet therapy with clopidogrel and aspirin. We report a case of safe removal of epidural catheter 72 hours after oral dose of clopidogrel and aspirin with a normal platelet function analysis and normal thromboelastography before removal.

Chronic renal failure is rare in pregnancy and often results in significant maternal and neonatal morbidity. When possible, preoperative dialysis is useful to optimize fluid and electrolyte balance. We describe the perioperative management of a parturient who persistently refused dialysis, had an uneventful cesarean delivery under graded epidural anesthesia.

The Montgomery silicone t-tube used for post-procedural tracheal stenosis has advantage of acting as both stent and tracheostomy tube. The anesthetic management of patient with t-tube in situ poses a challenge. Safe management of such patients requires careful planning. We describe anesthetic management for direct laryngoscopy of a patient with t-tube in situ.

Rebreathing of carbon dioxide caused by incompetent 'cage and disc' unidirectional valves has been reported earlier. Some manufacturers have changed the design of unidirectional valves to 'flexible leaflets'. We report a series of cases where a deformed membrane leaflet in expiratory unidirectional valves led to rebreathing of carbon dioxide.

Hydatid cyst disease of lungs may not be symptomatic. It may present as spontaneous rupture in pleura or a bronchus. During spontaneous breathing, cyst content of endobronchially ruptured pulmonary hydatid cyst is mostly evacuated by coughing. However, during positive pressure ventilation such extruded fragments may lodge into smaller airway leading to an airway catastrophe. We present such accidental endobronchial rupture of pulmonary hydatid cyst during surgery, its prompt detection, and management by rigid bronchoscopy.

Coffin Lowry syndrome is a rare disease involving multiple organ systems. From the anesthesiologists point of view it involves mental retardation, seizures, difficult airway, cardiac abnormalities (pediatric dilated cardiomyopathy) and skeletal deformities. We share our experience of management of a child with Coffin Lowry syndrome and also discuss the problems faced during perioperative period.

Intracranial hemorrhage in patients with hemophilia is associated with high mortality and sequelae. We report the case of 50-year-old man with Hemophilia A, who presented with spontaneous acute subdural hematoma and underwent craniotomy for clot evacuation. The patient received Factor VIII infusions perioperatively along with other measures to decrease blood loss. The patient presented with signs of high intracranial tension and received 3% saline intraoperatively and postoperatively to prevent brain edema. Recommendations for perioperative preparation and management of hemophilia, especially in the setting of emergency major surgery are reviewed.

Pyrethroid insecticides are very widely used in agriculture and household due to their high effectiveness and low toxicity in humans. Despite their extensive worldwide use, there are a few reports of human pyrethroid poisoning. The poisoning has a varied presentation and its symptoms overlap with those of other compounds, which can lead to misdiagnosis. We present a case of poisoning with prallethrin, a pyrethroid compound, commonly available as All-Out.