It is widely reckoned that the human airway is an inhospitable terrain, and without a proper airway assessment, embarking on induction of anesthesia becomes a deadly vendetta. Difficult laryngoscopy, intubation and mask ventilation following induction continue to harass the anesthesiologists worldwide, and are unequivocally regarded as the major causes of anesthetic related morbidity and mortality.
The incidence cited in the books is only the tip of the ice-burg as many cases are not reported and many countries do not have a reliable database and databank or else are wary of issuing the correct figures.
The existing bedside airway assessment tests such as Patel's measurement of the thyromental distance [1], the Mallampati test [2], and the Wilson scoring system [3] have all been shown in various studies to have high false positive rates, which obviously commutes from their clinical utility. In addition, other such tests, modifications and scoring systems have been evolved and evaluated in different randomized clinical trials to help us in providing a solution to the ever present risk of encountering a difficult airway and managing it successfully, but it seems that a logical and a practical panacea is a distant and perhaps a fond hope. A test that could help us to overcome the conundrum of the airway difficulties is the need of the hour, but at present no single test is available or in the offing to guarantee us a relatively greater success in assessing the airway with greater accuracy.
The upper lip bite test introduced recently as a simple new technique by khan et al [4] assesses a combination of jaw subluxation and the presence of buck teeth simultaneously obviously enhancing its predictive value and reliability. Exposure of the glottis predominantly depends on forward protrusion of the mandible which requires adequate and proper physiological functioning of the temporomandibular joint. The upper lip bite test adequately addresses this issue as well thus providing sufficient authenticity to the test when used alone as an airway screening test. Multivariate composite risk indexes [5-6] appear to be promising but results so far published have not been convincing to achieve tentative data in terms of high sensitivity, specificity and minimal false positive and false negative outcomes.
In search for further credibility and reliability, the anesthesiologists recently have veered from simple airway assessment tests to more sophisticated means employing magnetic resonance imaging, computed tomographic scanning and sonographic techniques in the hope of getting a true picture of the airway. But such tests not only entail time but are cost effective and thus detract from their usefulness.
Although fiberscope is a distinct improvement in airway management, it is not a garden hose you can tum on and off, and furthermore does not give you the guarantee that nothing will go wrong.
I personally would err on the side of boldness, not on the side of caution in most matters of life, but while assessing the airway I would observe all the precautions and go ahead gingerly since to me airway is the darkest Africa with much of it unknown and untouched hitherto.

Background: Anaesthesiologists undergo shear stress during the perioperative period, which was further increased during the COVID 19 pandemic. Many observational studies were done to find out the stress levels of the residents.
Methods: This was a prospective observational cohort study of Anaesthesiology residents in a tertiary care academic institution. We have measured the minute to minute heart rate variability which can be an indirect measure of stress level with the help of wrist band MI 4 which works on the principle of PPG.
Results: The difference between baseline HR and resting HR was observed to be substantial (p value 0.115 and 0.000 respectively). The percentage rise in heart rate during intubation from resting heart rate was 42.79 ± 25.54 percentage points.
Conclusion: Users can use this type of ongoing information as a feedback option to increase their work efficacy. Understanding how to use these smart devices will assist us in balancing our stress-free day-to-day activities.

Background: The current study attempts to evaluate the effect of intravenous (IV) infusion of magnesium sulfate during spinal anesthesia on postoperative pain and postoperative analgesic requirements in lower limb surgeries.
Methods: In this double blind, randomized controlled study, 60 patients undergoing elective lower limb surgeries, were selected and randomly divided into two groups. Group I received isotonic saline and group II was administered magnesium sulfate 50 mg Kg-1 IV for 15 min and then 15 mg Kg-1 h-1 by continuous IV infusion till the end of surgery or 2 hours, whichever was earlier. Ramsay sedation scores, VAS scores for pain, time of first administration of rescue analgesic and total analgesic requirement were noted in both the groups.
Results: Statistically significant difference was observed in the VAS score between the two groups at 1st, 2nd, 3rd, 6th, 9th and 12th hour intervals; with VAS scores being lower in the magnesium group (p<0.05). The mean time of first rescue analgesic requirement in control group was 144.00 mins, while in magnesium group was 246.00 mins (p<0.05). The total rescue analgesic requirement was found to be 251.67 mg and 181.67 mg at the end of 24 hours, in control and magnesium groups, respectively (p<0.05).
Conclusion: This study demonstrates statistically significant lowering of postoperative VAS scores, delayed need of postoperative analgesia and reduced total postoperative analgesic requirement in patients receiving intraoperative IV magnesium sulfate compared to the control group. Magnesium sulfate did not cause sedation or any other significant adverse effect in the doses used in the study.

Background: The incidence of unanticipated difficult airway is 14.3-17.5% in obese. Preoperative difficult airway prediction is important to avoid postoperative morbidity and mortality. USG guided measurement of anterior neck soft tissue thickness can be used to predict difficult laryngoscopy in obese patients and we thus undertook this study to determine the role of USG guided measurement of anterior neck thickness at the level of vocal cords in difficult laryngoscopy prediction.
Methods: Sixty obese patients (BMI≥30kg/m2), 18-70 years of age of either sex, were included. Anterior neck soft tissue thickness was measured by ultrasound as the distance from the skin to the anterior commissure of vocal cord. Neck circumference was measured at mid neck just below the laryngeal prominence with the subjects standing upright and facing forward with shoulders relaxed. Thyromental distance, sternomental distance, Mallampatti score and neck circumference were also recorded.
Results: The cut off values of BMI (46.94 kg/m2), neck circumference (41.5 cm) and anterior neck soft tissue thickness (22.1mm). Four patients in the morbidly obese and 80% of the superobese patients had a difficult laryngoscopy. Sixteen (26.67%) patients had an anterior neck soft tissue thickness of >22.1mm. Of these, 11 (91.67%) patients had difficult laryngoscopy while one (8.33%) patient with anterior neck soft tissue thickness ≤ 22.1mm had difficult laryngoscopy (P<0.05). There was also significant association between neck circumference and BMI.
Conclusion: The USG guided measurement of anterior neck soft tissue thickness, BMI and neck circumference can reliably predict difficult laryngoscopy in obese patients.

Background: Hemodynamic monitoring its early stabilization is very important in critically ill patients. Evaluating the Internal jugular vein diameter during respiratory cycles by the means of Point-of care ultrasound provides an important, easily available and precise index for monitoring hemodynamic status; a new method which is called Internal Jugular Vein Collapsibility Index (IJV-CI). Any events that alters intrathoracic volumes and pressures may affect this index. In this study we investigate the effects of various levels of positive end-expiratory pressure on this index.
Methods: Thirty mechanically ventilated patients were studied. We used three different PEEP levels (0, 5 and 10 cmH2o) and point-of-care ultrasound evaluation of IJV (Internal Jugular Vein) diameter to determine the IJV-CI. The analysis were performed using SPSS V.25.0.
Results: Patients were included men (76.6%) and women (33.3%). The mean age of patients was 39.65±3.4 for men and 42.71± 9.34 for women. The IJV-CI were 20.71±11.77 and 24.25±11.46 in PEEP=0 and PEEP=10 cmH20 groups respectively. In 5cmH20-PEEP group median and interquartile range were 16.45(14.8). The IJV-CI in three different PEEP levels were not statistically significantly different.
Conclusion: According to the finding of this study, we found no evidence of an optimal PEEP level to measure The IJV-CI.

Background: Dexmedetomidine is a highly selective alpha 2 agonist with dose dependent sedative sympatholytic analgesic properties and is used as an anaesthetic adjuvant. We have evaluated the effect of dexmedetomidine on hemodynamic responses to critical incidences such as laryngoscopy, endotracheal intubation, creation of pneumoperitoneum and extubation in patients undergoing laparoscopic cholecytectomy.
We have used a loading dose of 0.5mcg/kg over 10 minutes followed by infusion of 0.3mcg/kg/hour for the control of hemodynamic response to laparoscopy.
Methods: Patient of either sex aged between 18-50 yrs, belonging to ASA (American society of anaesthesiology) I and II posted for laparoscopic cholecystectomy were included. Institutional ethical committee clearance was obtained prior to study. After enrolment written valid consent was taken. 60 patients were enrolled and a written valid informed consent was taken. The patients were divided into two groups 30 each with computerized randomization. Base line parameters were noted. Observer and patient was blinded for the content of syringe. Group A received injection dexmedetomidine and group B received bolus and infusion of normal saline at same rate. Routine general anaesthesia was instituted. Parameters were noted after induction, after intubation, after co2 insufflation, after 20 min, after 40 min, after co2 deflation, after extubation, after 1 and 2 hrs post-extubation.
Results: Group A showed significantly less rise in HR and MAP than Group B. Requirement of intraoperative propofol was more in Group B. There was no significant difference for time taken to awakening in both groups.
Conclusion: We found Injection Dexmedetomidine in given doses gave good hemodynamic control with minimal undesired effects during laparoscopy.

Background: Cancellation of elective surgical treatments is a quality-of-care issue as well as a huge waste of health-care resources. Patients may experience emotional distress as a result of this, as well as difficulty for their families.
Aim: To find the significant reasons of cancellation of scheduled surgical cases.
Methods: A total of 300 elective operations in our institution were chosen. The completed surgeries were planned on the scheduled operation day, and the anaesthesiologist noted down a list of cancellations along with their reasons.
Results: A total of 300 patients were scheduled for surgery. A total of 60 patients were cancelled, resulting in a 20% cancellation rate. Lack of operational time was the most prevalent reason for cancellation.
Conclusion: The majority of the reasons for cancellation should have been avoided with proper list preparation and the surgical team's meticulous planning.

Background: Manage and deal with the pregnant patient undergoing anesthesia for surgical non-obstructed surgery, assess the effects of non-obstetric surgeries on both fetus and mother during pregnancy, and measures to prevent it.
Methods: A review search study was currently managed in PubMed, MEDLINE, Embase, Science gate, Elsevier, Scientific report, Google Scholar, and Cochrane Evidence-Based Medicine Reviews, after obtaining approval from the ethics committee of Tehran University of Medical Sciences. All the reviews identified were restricted to human studies and available in English.
Results: Elective surgery ideally should be avoided during pregnancy while emergency surgery should proceed with consideration for the anesthetic implications of the altered physiology of pregnancy. Caution must be taken during anesthetic application and Airway management.
Conclusion: Pre-oxygenation is essential and consider the rapid-sequence induction accompanied with cricoid pressure to lower the incidence of aspiration.  lower MAC values of the volatile anesthetic should be used and medications titrated to preferably produce beneficial effects only.

Background: Post spinal anesthesia headache (PSAH) is a headache occurring after spinal anesthesia induction due to Dura and arachnoid puncture and has a significant effect on the patients’ post operative well being.
Methods: We run a cross sectional descriptive study on patient under spinal anesthesia that suffer from post spinal anesthesia headache parallel with a review on observational and experimental studies in the medical databases of PubMed, Scopus, Embase, Cochrane for preparing a strategy in prevention and treatment of post spinal anesthesia headache. Aim of this study was adapting different treatment method and prevention system of Post Spinal Anesthesia Headache (PSAH) according to our facilities base on our observation and experiences.
Results: The overall incidence of post-Spinal Anesthesia headache has a very wide range. Its incidence obtained 17.3% by spinal needle 25G Quincke in our observation. Under hydration and tension headaches could be a factor influencing the incidence of PSAH. Intravenous administration of caffeine may be effective for prophylaxis of PSAH. Pregabalin has also been shown to alleviate PSAH. Drugs that have been used to treat PSAH include caffeine, NSAIDs, vasopressin, hydrocortisone, dexamethasone, theophylline, sumatriptan, gabapentin and adrenocorticotropic hormone (ACTH).
Conclusion: A combination of keeping patients normovulemic during the spinal anesthesia induction and prophylaxis prescription of caffeine and Dexamethone before and; Aminophylline and NSAIDS after the procedure could have a main role in keeping and treatment of the patient from PSAH.

At the end of 2019, Sars-CoV-2 was identified and has since spread in the world. Coronavirus is commonly caused by the upper respiratory tract and severe acute respiratory syndrome in humans. Due to the novel nature of the virus and high mortality among high-risk people, today health care providers used several medications with different mechanisms to overcome this virus. The course of COVID-19 represents three stages that have different symptoms and used different drugs depends on each stage.  Ultimately the minority of patients progress to stage III with high mortality.

The aim of this study is a comprehensive review of COVID-19 adjuvant therapies. We explained the current study on the use of Glucocorticoids, Interferon, Vitamin C, Tocilizumab, Anakinra, Pentoxifylline, IVIG, Allopurinol, Ivermectin, and Selenium in sepsis, pneumonia, and ARDS and we suggested a new protocol for prescribing each medication currently used in COVID-19 Outbreak.

At the end of 2019, Sars-CoV-2 was identified and has since spread in the world. Coronavirus is commonly caused by the upper respiratory tract and severe acute respiratory syndrome in humans. Due to the novel nature of the virus and high mortality among high-risk people, today health care providers used several medications with different mechanisms to overcome this virus. The course of COVID-19 represents three stages that have different symptoms and used different drugs depends on each stage.  Ultimately the minority of patients progress to stage III with high mortality.

The aim of this study is a comprehensive review of COVID-19 adjuvant therapies. We explained the current study on the use of Glucocorticoids, Interferon, Vitamin C, Tocilizumab, Anakinra, Pentoxifylline, IVIG, Allopurinol, Ivermectin, and Selenium in sepsis, pneumonia, and ARDS and we suggested a new protocol for prescribing each medication currently used in COVID-19 Outbreak.

Background: Endotracheal intubation is known as the best and challenging procedure to airway control for patients in shock or with unprotected airways. Failed intubation can have serious consequences and lead to high morbidity and mortality of the patients. Videolaryngoscope is a new device that contains a miniaturized camera at the blade tip to visualize the glottis indirectly. Fewer failed intubations have occurred when a videolaryngoscope was used. Other types of videolaryngoscopes were then developed; all have been shown to improve the view of the vocal cords. It may be inferred that for the professional group, including emergency physicians, paramedics, or emergency nurses, video laryngoscopy may be a good alternative to direct laryngoscopy for intubation under difficult conditions. The incidence of complications was not significantly different between the C-MAC 20% versus direct laryngoscopy 13%.
The main goal of this review was to compare the direct laryngoscopy with the (indirect) video laryngoscopy in terms of increased first success rate and good vision of the larynx to find a smooth induction of endotracheal intubation.
Methods: Currently available evidence on MEDLINE, PubMed, Google scholar and Cochrane Evidence Based Medicine Reviews, in addition to the citation reviews by manual search of new anesthesia and surgical journals related to laryngoscopies and tracheal intubation.
Results: This review of recent studies showed that the laryngoscopic device design would result in smooth approach of endotracheal intubation by means of good visualization of glottis and the best success rates in the hands of both the experienced and novice. Video laryngoscopes may improve safety by avoiding many unnecessary attempts when performing tracheal intubation with DL compared to VL as well as easy learning of both direct and indirect laryngoscopy.
Conclusion: The comparative studies of different video laryngoscopes showed that DL compared with VL, reveal that video laryngoscopes reduced failed intubation in anticipated difficult airways, improve a good laryngeal view and found that there were fewer failed intubations using a videolaryngoscope when the intubator had equivalent experience with both devices, but not with DL alone. And therefore, knowledge about ETI and their skills, are crucial in increasing the rate of survival.

Bilateral lumbar hernias are rare. There is a paucity of literature regarding the anaesthesia techniques used and challenges faced. In the present era of minimally invasive surgery, laparoscopy has gained name and fame and is the modality of choice for hernia repairs. Methods: We report a series of 4 cases of bilateral lumbar hernia operated in our institute, using 4 different anaesthesia techniques over a period of 2 years and 9 months with the aim to focus on the varied anaesthetic techniques and the advantages and disadvantages of each. Results: General anaesthesia supplemented with epidural anaesthesia is recommended for laparoscopic repair, while in very high risk cases, combined segmental spinal- epidural anaesthesia may be a better option. Low dose segmental spinal provides commendable cardiovascular stability. It is a useful alternative in patients with multiple comorbidities, cardiac and respiratory diseases and aids early recovery and ambulation. Conclusion: Irrespective of the type of anaesthesia technique administered, patients’ safety and comfort should be of prime importance, while maintaining optimum haemodynamics and physiology.

Patients with nasal polyposis frequently have associated bronchial asthma and hypersensitivity to NSAIDs. When the three conditions co-exist, it is referred to as the Samter’s triad. Patients with Samter’s triad are an important subset of those with aspirin-exacerbated respiratory disease (AERD). We present a case of a young female patient undergoing endoscopic sinus surgery for nasal polyps, who although did not show any other features of AERD, went on to develop florid anaphylaxis to diclofenac administration intra-operatively. After adequate resuscitation and intensive care stay, the patient made a complete recovery. NSAIDs must be avoided in patients with nasal polyps, despite showing no other features of this syndrome. Other analgesic agents that can be used include IV paracetamol and opioids like tramadol.

The year 2020 saw the rise of an influenza-like illness from SARS-nCoV2 (Severe Acute Respiratory Illness by novel Coronavirus 2), which causes myriad of symptoms in patients, ranging from mild upper respiratory symptoms to severe ARDS (Acute Respiratory Distress Syndrome). It is, however, known to cause high morbidity and mortality in patients with underlying comorbidities like diabetes, hypertension, kidney disease, obesity and malignancies. Amongst these, the subset with haematological malignancies has an especially poor prognosis possibly as a result of immune suppression, due to underlying bone marrow depression as well as effects of chemotherapeutic agents. These patients need frequent visits and admissions to the hospital for treatment, thus exposing them to the risk of acquiring the infection. Also, a high index of suspicion, with low threshold for testing is needed in view of possible atypical presentation and symptoms. These patients may also warrant an early ICU admission, as they tend to develop severe disease with ARDS more frequently, with an overall poor prognosis and high mortality rate.

We hereby present a series of six patients with underlying haematological malignancies who were admitted in our ICU with a serious COVID-19 illness and a grave outcome.

Takotsubo cardiomyopathy(TC) is a reversible, yet underdiagnosed cause of mortality and morbidity in the intensive care units. It occurs secondary to sudden catecholamine surge precipitated by any form of emotional or pathological stress. Association between central nervous system disorders and Takotsubo cardiomyopathy is being increasingly reported. Epilepsy is the second most common CNS disorder to trigger TC, SAH being the first. We report a case of TC in an elderly man with prolonged, recurrent seizure episodes refractory to the commonly used antiepileptic drugs (AEDs), who developed unexplained tachycardia, hypotension and elevated cardiac enzymes.

Crimean-Congo hemorrhagic fever (CCHF) is an acute tick-borne viral hemorrhagic zoonotic disease with increasing human health impact [1]. It is a fatal emerging infectious disease characterized by fever and hemorrhagic manifestations. CCHF virus is a single-stranded RNA Nairovirus from the Arbovirus group. This virus is endemic in Iran [1].
CCHF has four steps in the clinical presentation including; incubation period, pre-hemorrhagic stage, hemorrhagic state, and convalescence. The incubation period following a tick bite is usually between 3-7 days and 14 days after blood transfusion. The onset of the illness is sudden, with fever, myalgia, dizziness, headache, neck stiffness, and vomiting, followed by development to the hemorrhagic state. Actually, the CCHF clinical manifestation is variable from asymptomatic to the mild or severe form. The hemorrhagic state develops from the 3rd to the 5th day and presents with petechial rash and purpura on the skin. Hemorrhagic phenomena may include melena, hematuria, epistaxis, and bleeding from mucosal surfaces or needle punctured sites [1-2].
Although Thrombocytopenia and Leukopenia are the main laboratory findings in CCHF disease and Lymphocyte count varies according to the host’s immune response, patients with progressive fatal clinical manifestations have a relative increase in neutrophil and a decrease in lymphocyte and monocyte counts. The relative increase in neutrophil counts leads to excessive cytokine release. This excessive secretion of cytokines has toxic effects on the activation of endothelial cells and vascular permeability, which cause vascular dysfunction, disseminated intravascular coagulation, hemorrhage, hypotension, and shock. The decrease in lymphocyte counts results in humoral antibody response depletion [3].
During CCHF progression, some patients present a clinicopathologic condition characterized by higher fever, hepatosplenomegaly, hyperferritinemia, and increased hemophagocytic macrophage proliferation, and activation in the reticuloendothelial system. This condition could be considered as secondary Hemophagocytic lymphohistiocytosis (HLH) [3-4]. Secondary HLH is a fatal hyper-inflammatory condition involving a cytokine cascade, with elevations of cytokines secreted by T-lymphocytes and macrophages (IL2, IL6, TNFα, IFNγ), which lead to the over-activation of antigen-presenting cells and CD8+ T cells, and hematopoietic cells devoured by activated macrophages. Uncontrolled T-lymphocytes (CD4+) activation and overproduction of proinflammatory cytokines with macrophagic-based hemophagocytosis are well established in secondary HLH [4-6].
CCHF is not a recurrent or relapsing disease, and it does not impose any long-term sequelae, with the only relevant outcome being survival. There are four major important aspects in the treatment of CCHF; close monitoring, supportive treatment, early antiviral agents, and the treatment of complications like the hemorrhagic state [1-2].
Some studies did not support Ribavirin (a synthetic purine nucleoside analog) as an effective antiviral agent in the CCHF treatment, however, a majority of researchers consider the significant role of Ribavirin [1,2,5]. We prescribe Ribavirin to our patients in the early stage, and consider steroids in the hemorrhagic period before disseminated intravascular coagulopathy (DIC) development. Platelet count, fibrinogen, and D-dimer levels are important for the early detection of DIC, which also allows the early correction of coagulation parameters [2-3].
Platelet (Plt) transfusion is reserved for patients with Plt count lower than 20000 or a hemorrhagic state with Plt count lower than 100000. We prescribe Intravenous immunoglobulin and Methylprednisolone for the severe form of CCHF with refractory thrombocytopenia. Even though immunosuppression is known to exacerbate viremia, however, the use of immunosuppressive agents along with intravenous immunoglobulin and Methylprednisolone might be considered in the treatment of the patients with CCHF, who have uncontrolled hemophagocytosis and severe bleeding symptoms.

Fresh Frozen Plasma (FFP) transfusion is indicated for the correction of coagulopathy. We transfuse FFP when PTT, PT and the international normalized ratio (INR) are at least 3 times greater than the upper limit of the normal range and are accompanied by a hypocoagulopathy state. We prescribe 15 ml/kg FFP and evaluate the patient’s condition after 4 hours. FFP could be repeated every 8-12 hours, if necessary. The prothrombin complex concentrates (PCC), which contains the human coagulation factors including II, VII, IX and X together with the endogenous inhibitor proteins S and C, must be considered when faced with severe coagulopathy in a patient having limited cardiovascular reserve (low cardiac output condition) or when we have an observed target.
Packed red blood cell transfusion is necessary only if the hemoglobin concentration becomes lower than 8 mg/dL, or if there is significant documentation indicating tissue oxygen delivery disturbance, like a rise in the arterial blood lactate.
It is presumed that the electrolyte balance, fluid substitution, hemodynamic support, appropriate blood product transfusion, and augmentation of the patient's hemostasis profile all have a significant effect on the patient's outcome, and careful attention should be accorded to these aspects.

Baska Mask (BM), the second-generation supraglottic airway device (SGAD), has many novel features, which should improve safety when used in both spontaneously breathing and IPPV anesthesia [1]. These include a noninflatable cuff, which reduces the risk of oropharyngeal tissue and/or nerve damage induced by cuff overinflation, a known complication with other supraglottic airways [2]. It also has an additional gastric channel and a bite block. We recently encountered an unusual case of Baska mask failure.