Background: Spinal anaesthesia is the most common technique used for lower segment caesarean sections(LSCS). but it has own disadvantages too. Maternal haemodynamic changes is more profound in pregnant population. Aim of the study was to compare the maternal haemodynamic changes with crystalloid preloading and co-loading in patients undergoing elective lower segment caesarean section under spinal anaesthesia.
Methods: 80 obstetric patients with period of gestation (POG) more than 37 weeks, in the age between 18 to 35 years, belonging to ASA class I and II and scheduled for elective LSCS were randomized into two groups. Group P - Patient receiving preloading with Ringer Lactate at a dose of 15ml/kg. Group C – Patient receiving Co-loading with Ringer Lactate at a dose of 15ml/kg. Primary objectives of the study were haemodynamic changes like Heart rate (HR), Systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) and these parameters were recorded baseline, at 1 min interval for first 10 minutes, after that at 5 minutes till 20 minutes and then every 15 min till completion of procedure.
Results: The demographic data were comparable in group P and group C. The mean (SD) HR was significantly higher in group P as compared to group C at 5,6,7,8 and 9 minutes (p <0.05). The mean (SD) SBP, DBP and MBP was significantly lower in group P as compared to group C at 5,6 and 7 minutes (p <0.05). Significant difference was seen in the distribution of nausea/vomiting score between group P and C. (p value<.05).
Conclusion: We conclude that co-loading with crystalloids is provide more Maternal Hemodynamics stability after subarachnoid block rather than preloading with crystalloids.

Background: The change in patients' positions has a bold effect on the ventilation and hemodynamic parameters during surgery. In this study, we evaluated the changes in hemodynamic and ventilator values resulting from conversions in the position of patients under the thoracotomy from supine to lateral position and vice versa, to determine the most favourable position with the best hemodynamic stability and ventilation conditions.
Methods: In this pre and that post interventional clinical trial, 50 patients scheduled for thoracotomy were included. Following general anesthesia induction and 5 minutes later, hemodynamic data before thoracotomy and after the surgical intervention was measured, the patient was placed in the supine position and all hemodynamic data were recorded. Then, the position of the patient was slightly changed to the lateral recumbent position. Then, at the end of the surgery, the position was changed to supine.
Results: Regarding the change in study indices (including HR, SBP, DBP, MAP, SVV, CO, and PVI), changes in supine to lateral status led to only a decrease in systolic blood pressure, diastolic blood pressure, and mean blood pressure and other indicators did not show a statistically significant change. Similarly, the change in the above indices by changing the lateral to the supine state was only an increase in systolic blood pressure, diastolic blood pressure, mean blood pressure, and other data remained unchanged.
Conclusion: Changing the position of patients during surgical thoracotomy from supine to lateral position or vice versa is associated only with significant changes in patient's blood pressure and has no significant effect on other ventilatory and cardiovascular parameters.

Background: This study aimed to assess the effect of virtual reality technology on knowledge, attitude, and skills of first-year anesthesia residents in spinal anesthesia procedure training.
Methods: 25 anesthesia residents were enrolled in this experimental study. They were randomly divided into two groups of virtual reality (n =11) and conventional training (n = 14). The virtual reality (VR) group received a combined virtual and clinical training environment while the conventional group received only a clinical training environment for one month. A Similar content (herein, spinal anesthesia procedure) was trained to the both groups. The participants were the anesthesia residents in the academic year 2020-2021. Similar exams assessed knowledge, attitudes, and skills in both groups and data were analyzed using t-test and ANCOVA.
Results: The mean knowledge score acquired by residents in the VR group was higher than the conventional learning group (16.45 ± 2.5 vs 13.57 ± 2.1). The method of training had also a significant effect on the post-test score; F (1) = 6.16, P = 0.02. In addition, the mean attitude score acquired by residents in the VR group was higher than the conventional learning group (110.63 ± 14.7 vs 107.64 ± 12.3), although the method of training had not a significant effect on residents’ attitude score; T (23) = 0.55, P = 0.58). The mean skills score acquired by residents in the VR group was higher than the conventional learning group (100.4 ± 3.17 vs 88.14± 11.8); While the method of training had a significant effect on residents’ skill score. T (23) = 3.34, P < 0.05), too.
Conclusion: The combined virtual and clinical training environment was superior to a conventional method for enhancement of knowledge and skill in spinal anesthesia procedure training in anesthesiologist residents. This study can help the educational designers of the University of Medical Sciences to improve the competence of residents by using a combined learning environment.

Background: Despite advances in anaesthesia care postoperative nausea and vomiting (PONV) remains a vexing problem. Objectives to determine the efficacy of Granisetron and Granisetron plus dexamethasone in preventing the incidence of PONV, also assess the requirement of rescue antiemetic and adverse effects in the postoperative period AIM: To determine the efficacy of Granisetron and Granisetron plus dexamethasone in preventing the incidence of Nausea and Vomiting in 70 patients undergoing Laparoscopic Surgeries.
Methods: Prospective, Randomized, Double Blind Study among 70 Patients aged between 18 to 50 years, ASA class Grade I and II was conducted. 35 patients were recruited in two groups using randomization method. Post operatively data was collected using a questionnaire at 4 hrs and 24 hrs. Episodes of PONV were recorded by three points ordinal scale (TPOS). Intensity of nausea graded verbally with an eleven-point score (0-10).
Results: In group G, at 0-4 hours 11.4% patients had nausea and 25.7% had vomiting/retching. In group G+D, 8.6% had nausea and 2.9% had vomiting/ retching. There was significant difference (p =0.018) on Three point ordinal scale (TPOS) between the two groups.     
In group G, at 4-24 hours 5.7% patients had nausea and 20.0% had vomiting and retching. In group G+D 11.4% had nausea and there was no vomiting / retching.  There was significant difference (p =0.017) on Three point ordinal scale (TPOS) between the two groups.
Conclusion: We concluded that Granisetron + Dexamethasone had lower incidence of PONV compared to Granisetron group alone in Laparoscopic surgeries.

Background: Exaggerated hemodynamic response has been linked to laryngoscopy and intubation. This reaction might have negative consequences on the respiratory system, the nervous system, and the heart. It might show up as tachycardia, hypertension, and dysrhythmias. The oral, pharyngeal, and laryngeal axes, all need to be aligned, which is largely responsible for the laryngoscopy reaction. Hence video laryngoscope was developed to overcome this response which does not require the alignment of these three axes. Thus, it can provide this ameliorating effect with less suspension and distension force, which will probably result in less hemodynamic changes during laryngoscopy. Comparing the hemodynamic response during laryngoscopy and intubation using the conventional McIntosh direct laryngoscope and the Truview® video laryngoscope was the primary objective of this study. Intubation time and glottic opening using Cormack Lehane grade were the secondary objectives.
Methods: This randomized controlled trial was conducted in 60 patients who were scheduled to undergo elective surgeries requiring conventional GA. Random allocation into two groups was done. Patients in Group ML (n=30) underwent laryngoscopy and intubation using a conventional McIntosh laryngoscope. Patients in Group VL (n=30) underwent laryngoscopy and intubation using a Truview video laryngoscope. Before and after endotracheal intubation, as well as 2, 5, and 10 minutes later, both groups were monitored for changes in hemodynamic parameters such as heart rate, systolic and diastolic pressure, and mean arterial pressure. Intubation time and glottic view was also assessed using the Cormack Lehane grade.
Results: Heart rate, systolic blood pressure, mean arterial blood pressure, and intubation time were significantly different between the two groups (p=0.00). The diastolic blood pressure did not significantly differ between the two groups (p=0.203). There was no statistically significant correlation between the type of laryngoscopy and the glottic view with Cormack Lehane Grade favouring certain groups (p=1).
Conclusion: We conclude that tracheal intubation with Truview video laryngoscope is advantageous in preventing cardiovascular stress response but with longer intubation time.

Background: Off-pump coronary artery bypass grafting (OPCABG) is associated with hemodynamic fluctuations which usually require the use of various vasoactive drugs like norepinephrine and phenylephrine The aim of this study was to evaluate the effect of low dose vasopressin on hemodynamics in patients undergoing Off-pump Coronary Artery Bypass Graft Surgery (OPCABG).
Methods: Sixty patients undergoing elective Off pump coronary artery bypass grafting (CABG) having triple vessel coronary artery disease (CAD). were randomly divided into two groups: group A (n=30), patients received Vasopressin 0.03 IU/min via infusion pump (diluted in 50 ml syringe) during the LIMA extraction and continued till the end of surgery; group B (n==30), patients received normal saline infusion pump during the LIMA extraction and continued till the end of surgery. The anesthetic technique was the same in both the groups. Hemodynamic parameters were recorded at various time intervals during the surgery.
Results: HR, CO and CI were lower and MAP, SVR and SVRI were higher in vasopressin group. CVP was stable with no significant difference in SV and SVV.
Conclusion: To achieve better intra operative hemodynamic stability during the triple vascular coronary anastomosis and to cope up with post-operative vasodilatory shock, low dose vasopressin infusion is a safe option.

Background: In this study, we try to determine which of this two criteria (height or weight) is a better for determining the appropriate size of the laryngeal mask airway for Iranian women.
Methods: This randomized controlled trial was performed on 300 females with ASA I-II who were candidate for eye surgery. In the weight group, the size of the laryngeal mask airway was selected according to the classical method and in the height group (height less than 170 cm: size 3, height above 170 cm: size 4) based on researcher’s experience. Number of attempts, leakage and complications were evaluated during surgery, recovery and 24 hours later. Data was analyzed with SPSS v.16 and P<0.05 was meaningful.
Results: There weren't significant difference between 2 groups for demographic parameters. Our study shows significant decrease in the number of laryngeal mask airway insertion attempts, the amount of air leakage, the sore throat at recovery and the day after the surgery, and the bloody laryngeal mask airway cuff, in the height group than weight group.
Conclusion: We concluded that laryngeal mask airway size based on the patients’ height leads to faster and easier application and fewer side effects than choosing the size based on the patients’ weight.

Background: Hip fractures in elderly patients is common and occurs with trivial fall. Continuous epidural anesthesia (CEA) and Continuous spinal anesthesia (CSA) are available modalities for lower extremities surgeries. This study was done to compare the effectiveness of CEA and CSA.
Methods: A prospective open-label randomized control trial was carried out in the Department of Anaesthesiology and Critical care at GMC, Kadapa, from January 2019 to July 2020. One hundred patients were enrolled and divided into Group A and B, with 50 participants in each group. Group A received continuous spinal anesthesia, and Group B was given continuous epidural anesthesia. VAS score, Onset of sensory block, the Onset of motor block and no. of rescue analgesia, etc., were considered as the primary outcome variable. coGuide statistical software was used for analysis.
Results: There was a statistically significant difference between the study groups (Group A vs. Group B) in the Onset of sensory block (7.6 ± 1.6 min, 17.5 ± 1.62 min), the start of motor block (10.1 ± 1.11 min,20.28 ± 1.36 min), duration of sensory block (108.7 ± 16.84 min, 147.4 ± 20.39 min), duration of motor block (175.8 ± 12.47 min, 219.4 ± 18.56 min) and analgesia duration (199.2 ± 11.92 min, 327.6 ± 18.8 min) respectively. The Difference in the number of rescue analgesia in 24 hrs between the study group was significant with a P-value of <0.001.
Conclusion: The current study revealed that CSA is more effective than CEA in Hip surgeries.

Background: Intubation and laryngoscopy may raise blood pressure and heart rate unnecessarily. To investigate the effect of Pregabalin premedication on hemodynamic responses to laryngoscopy and intubation.
Methods: A Prospective Observational study was carried out in academic year December 2013 to July 2015 on 60 ASA physical status I or II patients undergoing elective surgery under general anesthesia at tertiary care hospital. 60 patients were divided into two equal groups of 30 each who received either fentanyl (Group A) or oral Pregabalin 150 mg (Group B) 1 hour prior to surgery. Pulse rate, Systoli and diastolic blood pressure were recorded preoperative, and 0,1,3,5 and 10 minutes after induction. Confidentiality of the subject was maintained. Descriptive and inferential statistics for quantitative and categorical variables were analysed using IBM SPSS version 22.
Results: SBP, DBP, and MAP rise during laryngoscopy and during intubation in a similar way in both groups at laryngoscopy (BL) and at 1 and 3 minutes following laryngoscopy before levelling off after 10 minutes in both groups. At baseline and one minute after laryngoscopy, HR increased in both groups. At 3 min, 5 min, and 10 min following laryngoscopy, the rise was reduced in the FL group, however the differences were statistically significant, p 0.005.
Conclusion: Oral Pregabalin premedication at a dose of 150 mg one hour prior to surgery attenuates pressor response associated with laryngoscopy and endotracheal intubation.

Background: The term “surgical stress response” refers to the physiologic response to surgery. The study aimed to evaluate effects of transversus abdominal plane (TAP) block on post-surgical stress responses.
Methods: This is a randomized, parallel-group clinical trial consisting of 60 patients undergoing laparoscopic cholecystectomy. Participants were randomized into two groups receiving either general anesthesia or general anesthesia plus TAP block. Blood samples for stress responses evaluating were obtained before anesthesia induction, 6 hours after extubation, and 24 hours after surgery termination. Pain levels were assessed after discharge from the recovery room and at intervals of 6, 12, and 24 hours after surgery.
Results: The trend in mean levels of blood sugar, cortisol, and WBC in each group was significant in the course of 24 hours. The mean levels of blood sugar and CRP was not significantly different between two groups; however, serum cortisol and WBC levels were different. Moreover, levels of IL-1 at 6 and 24 hours after surgery were significantly lower in the TAP block group. In Spearman’s rank-order correlation analysis, age, BMI, pain level, cortisol, baseline IL-1, and TNF-α level had a significant linear correlation with IL-1 levels. There was a significant difference in pain scores between the two groups at 6 and 12 hours; however, at 24 hours, the difference was not statistically significant. The mean opioid consumption was significantly lower in the TAP block group.
Conclusion: This study showed the remarkable effects of TAP block on stress responses and pain scores.

Background: In present anaesthesia practice to prolong postoperative analgesia use of various adjuvants is routinely done. Magnesium sulphate is one of the widely used adjuvant used in different routes along with regional anaesthesia to prolong postoperative analgesia. We compared perineural magnesium sulphate and intravenous magnesium sulphate when used as an adjuvant with bupivacaine in   supraclavicular block under USG guidance for upper limb surgeries.
Methods: We enrolled ninety patients with physical status I or II, age ranging from 20-60 years, scheduled for upper limb surgeries under USG guided brachial plexus block were categorised into 3 groups (n-30). In study all patients were received 28 ml 0.5% injection Bupivacaine in addition patients in Group 1 and 2 were received 2 ml of Normal Saline (NS) and in Group 3 were received 1.5 ml of NS with 250 mg of Magnesium sulphate. Along with this intravenously 30 minutes prior to block patients in Group 1 and 3 were received 100 ml of 0.9% of NS and patients in Group 2 were received 100 ml of 0.9% normal saline with injection Magnesium Sulphate 50 mg/kg. They were evaluated for block characteristics and total dose of rescue analgesic required in post-operative period for 24 hours were noted.
Results: We found that sensory, motor block and postoperative analgesia duration was significantly longer in both study groups (2 and 3) compared to group 1 (control) but significantly prolonged in perineural group compared to intravenous group. Postoperative analgesic consumption was less in both study group with insignificant difference between them.
Conclusion: We concluded that in supraclavicular block magnesium sulphate was more effective when used perineurally  as compared to intravenous route as an adjuvant to Bupivacain 0.5% regarding to provide prolong duration of postoperative analgesia with insignificant side effects.

Plasminogen (PLG) is a serum protein, a precursor of plasmin, in addition to its functions in the coagulation pathway, it also plays an important role in wound healing. PLG deficiency is a rare condition and has been associated with pseudomembranous (ligneous) lesions on mucous membranes, for example: ligneous gingivitis, endometritis and mostly conjunctivitis in the literature. In our case, the patient was a 30-years-old pregnant woman who was diagnosed with PLG deficiency and was at 39+4 week of pregnancy. We chose the neuraxial anesthesia (NA) to avoid possible airway obstruction due to difficult intubation and mucosal damage of upper airways. So, we administered single shot atraumatic spinal anesthesia (SA) for emergency cesarean section (C/S). Herein, preoperative optimization, a good preliminary assessment and selection of the type of anesthesia are important in terms of preventing complications in these patients.

Achondroplasia is a congenital autosomal dominant disease which has fibroblast growth factor receptor -3 mutation (FGFR-3). Anesthetic management of achondroplastic patients warrants special anatomical and physiological considerations because of important variations in the airway as well as the spine in regional techniques. In our case, 37-years-old male dwarf with achondroplasia has end stage renal disease (ESRD) and received cadaveric renal transplantation (RT). Preoperative assessment revealed the Mallampati score IV airway with a cervical instability, thoracolumbar kyphoscoliosis and spinal deformities. We aim to highlight anesthetic management of achondroplastic dwarf with difficult airway during operation.

In patients with cardiac disease, it’s always a challenge for the anaesthetist to administer general anaesthesia as well as central neuraxial blockade. The major perioperative task in these patients with low cardiac output is maintaining hemodynamic stability. Here, we are discussing a case of successful management of a geriatric patient having ischemic heart disease with ejection fraction of 25% posted for bilateral total knee replacement under graded epidural anaesthesia.

Bilateral radial dysplasia is a rare condition and usually associated with familial malformation syndromes and spectrum of cardiac anomalies. These patients often require corrective orthopedic surgeries in early age. Radial dysplasia associated with cardiac abnormalities is particularly seen in certain syndromes such as Holt-Oram (HOS) syndrome and TAR (thrombocytopenia, anemia, and radial aplasia) syndrome. We report a successful management of twelve months old male child with rare combination of bilateral radial dysplasia with isolated patent ductus arteriosus (PDA), for corrective orthopedic surgery. A comprehensive approach, which includes an extensive preoperative evaluation and pre-defined perioperative hemodynamic goals for PDA, plays a pivotal role in its perioperative management.

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