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Background: One of the most prevalent regional methods in paediatric anaesthesia is the caudal epidural block. It is a safe, simple procedure that has proven to be quite beneficial in children following infra-umbilical surgery. Ropivacaine causes differential neuraxial blockade, which is associated with less motor block and lower cardiovascular damage. To extend the duration of action of local anaesthetics, several adjuvants are administered. Our goal was to see how fentanyl affected the duration of postoperative analgesia when used in conjunction with ropivacaine in a paediatric population of children aged 3 to 8 years following infraumbilical operations.
Methods: On 100 paediatric patients receiving elective infraumbilical operations, a prospective, comparative, and randomised investigation was done. Patients were randomised into two 50-person groups at random. Caudal anaesthesia was administered once the airway was secured. 0.2 percent ropivacaine 0.5ml/kg was given to Group R, while 0.2 percent ropivacaine 0.5ml/kg with fentanyl 0.5mcg/kg was given to Group RF. Face, legs, activity, cry, and consolability pain rating scales were used to measure postoperative pain for 24 hours. The length of the motor blockage and any negative effects were recorded. Hemodynamics, post-operative analgesia duration, and the number of rescue analgesics required were all recorded and statistically evaluated.
Results: The mean duration of analgesia in ropivacaine group was 440.60±101.29 minutes (7.25hrs) and in ropivacaine fentanyl group was 891±312.84 (14.76hrs). Statistically, the difference was highly significant.
Conclusion: In children having infraumbilical surgery, using fentanyl as an adjuvant to ropivacaine for caudal block enhanced analgesic effectiveness and extended post-operative analgesia.

Background: The current study is aimed to compare the effect of fixed cuff volume and fixed cuff pressure technique on hemodynamic parameters and on postoperative complications.
Methods: The prospective, randomised, controlled study was conducted in a tertiary care hospital with 100 patients aged between 18 to 60 yrs. The patients who are undergoing for elective surgeries under general anaesthesia were enrolled after obtaining ethical committee approval. Patients were randomized based on computer generated random numbers into two groups, fixed volume (7ml) group (group V, n-50) and fixed cuff pressure group (group P, n-50). The ETT cuff was filled with 7 ml of air in the fixed volume technique, and in the fixed cuff pressure group -cuff pressure was maintained at 20 cmH2O, after intubation. Tracheal tube cuff pressures were measured by AMBU cuff pressure gauge manometer. Hemodynamic parameters SBP, DBP, MAP and PR were noted at the time of cuff inflation, after extubation in the both the groups. Post-operative sore throat, hoarseness and cough was assessed at the time of extubation in the both the groups.
Results: Mean age in both the groups was 41 years. Statistical significance (P< 0.0001) was observed in Group P in systolic blood pressure (SBP), diastolic blood pressure (DBP), MAP, HR whereas no significance was seen in group V. The percentage of post-operative complications like hoarseness, cough, sore throat, and dysphagia were seen to be less in group P when compared to group V.
Conclusion: With present data we could conclude that the fixed minimal cuff pressure (20 mm H2O) is an ideal and reliable technique in reducing the post-operative complications along with maintenance of hemodynamic parameters.

Background: The utility of Neuromuscular monitoring (NMT) has not been studied in Indian scenario till date. We did a survey to evaluate the knowledge, attitude, practices of NMT among Indian anesthesiologists.
Methods: A questionnaire-based google form was sent to 350 anesthesiologists over 3-months. Demographic data was collected in initial questions, followed by data on their concepts, practices, and knowledge of NMT and postoperative residual nerve block (PRNB). Data were descriptively analysed using frequencies and percentages. Descriptive statistical testing was done using software package IBM SPSS 23.
Results: 88.9% of participants reported the use of clinical assessment. Though majority used clinical parameters, they were well-versed about Train-of-Four criteria. 75.9% stated the use of objective NMT in < 25 % of patients. The reasons for not using objective monitoring were scarcity of neuromuscular monitors, non-familiarity, and complexity of monitors. In regards to PRNB, 79.6 % participants considered PRNB to be an important clinical issue. Although in their clinical practice they rarely encountered PRNB, 74% responded that routine NMT can decrease PRNB.  The cross-tabulation table reflected that the use of objective tools (P= 0.014), knowledge about the essentiality of NMT (p=0.003), correctly stating PRNB as an important clinical issue (p=0.006), and their understanding about unreliability of clinical tests (p=0.001) showed significant improvement with increasing anesthesia experience.
Conclusion: Participants showed great understanding of clinical and qualitative tests but not of quantitative tests, with low rate of usage of objective NMT. A lacuna in understanding of quantitative parameters must be addressed considering high incidence of PRNB and lack of sensitivity of clinical parameters.

Background: Post-operative pain is a matter of great concern for anaesthesiologists and surgeons. We compared the efficacy of oral Gabapentin and intravenous Paracetamol for postoperative analgesia in patients undergoing laparoscopic surgeries.
Methods: After obtaining written informed consent and ethical committee approval, a total of 70 patients undergoing laporoscopic surgeries were randomly allocated into two groups- 35 patients included in Group A were given 600 mg oral Gabapentin 2 hours before the surgery and Group B patients were given 1gm I.V. PCM 30 minutes before the surgery.  The NRS scores at 30 min, 2 hours, 6 hours, 8 hours, 12 hours, and 24 hours were recorded. The time at which first rescue analgesic given and Different hemodynamic parameters like heart rate, blood pressure and oxygen saturation were also recorded at different time intervals.
Results: NRS scores and MAP was higher in Group B with a significant p-value at 8 and 12 hours. The need of first rescue analgesic required was at 7.79±3.49 hours in Group A. In Group B requirement of first rescue analgesia was at 6.09±2.75 hrs. The total dose of tramadol used was significantly higher in Group B with mean 92.86±36.67 than Group A 64.29±28.62 with statistically significant p-value (p=0.001).
Conclusion: Both oral Gabapentin and intravenous Paracetamol are effective modes of postoperative analgesia hence both can be used as preemptive analgesic agents. Oral Gabapentin has a longer duration of action up to 12 hours in the postoperative period while intravenous Paracetamol is effective up to 6 hours postoperatively.

Background: Pain is defined as a subject’s conscious perception of modulated nociceptive impulses that generate an unpleasant experience associated with actual or potential tissue damage. General anaesthesia, when combined with regional anaesthesia provides effective perioperative analgesia. Aim of the study was to study the effect of intravenous dexamethasone on duration of post-operative analgesia when given along with intra operative caudal block in paediatric day care infra umbilical surgeries under general anesthesia.
Methods: Sixty paediatric patients, American Society of Anesthesiologist’s class I and II, patients were randomly divided in to two groups. In Group D - 30 paediatric patients who were given intravenous dexamethasone in a dose of 0.2 mg/kg iv in 5 ml normal saline along with caudal block with 0.75ml/kg of 0.25% bupivacaine. Group S - 30 paediatric patients who were given 5 ml of normal saline intravenously along with caudal block with 0.75ml/kg of 0.25% bupivacaine. Primary objective of the study was to determine the duration of post-operative analgesia.
Results: The demographic data were comparable in both groups. There were no significant difference of mean (SD) Heart Rate and Mean arterial pressure (mmHg) at baseline, post-operative 1st hour, post-operative 2nd hour, post-operative 3rd hour, post-operative 4th hour (p value >0.05). Time for rescue analgesia (minutes) to be given was more in group D when compared to group S (190.67 ± 41.76 versus 181.17± 37.97) however it was not statistically significant. Total duration of analgesia(minutes), i.e., including both intra-operative and post-operative period was more in group D when compared to group S (266.83 ± 37.69 versus 255.73 ± 42.83). However, there was no significant difference between them. (p value=0.188).
Conclusion: We conclude that a single bolus dose of intravenous dexamethasone (0.2 mg/kg) given along with caudal block with 0.75 ml/kg of 0.25% bupivacaine did not prolong the duration of postoperative analgesia in paediatric patients.

Background: The pandemic of COVID-19 since its beginning has created havoc all-round the globe. The role of oxygen therapy remains constant. Various modalities have been studied for oxygen delivery to hypoxic patients but high flow nasal oxygen (HFNO) has lately gained importance in terms of non-invasive oxygen delivery, easy administration and great improvement in patient’s recovery. 
We conducted this retrospective analysis with the primary objective of looking for the proportion of patients who were successfully weaned off of HFNO or non-invasive ventilation (NIV) and the secondary aim was to look for duration of hospital stay and its effect on clinical recovery based on laboratory parameters.
Methods: All patients, positive for COVID-19 infection by real-time reverse transcriptase polymerase chain reaction (RTPCR) were admitted to covid ICU or ward with oxygen requirement and were treated with either NIV or HFNO were enrolled for the study.  Patients were grouped under H group (HFNO) or N group (NIV). Daily ABG readings, chest x-ray, respiratory rate, hemodynamic parameters and urine output were noted on 12 hourly intervals. Any changes in above parameters along with need for intubation were assessed.
Results: Patients from both the groups showed significant improvement in their oxygen saturation by the fifth day of their treatment.
Fourteen patients from the NIV group and 10 from the HFNO group had saturation >90% by Day 5. Of those who presented with saturation of <85%, 2 out of 5 in the NIV group (40%) and 1 of the 2 patients in the HFNO group (50%) showed improvement in their oxygen saturation. The P/F was statistically comparable (p 0.928) in both groups. The levels of bio markers, and the improvement was comparable and correlated with clinical improvement as well.
Conclusion: We conclude that though HFNO is accepted better than NIV, the improvement in the respiratory status of the patient was comparable with both the treatment modalities and hence we do not recommend use of HFNO, especially in a situation of gross deficit of oxygen availability as compared to the exponential rise in the demand.

Background: Intravenous regional anesthesia (IVRA) has been used as a common anesthetic technique for several types of operations. However, there are various concerns regarding the efficacy of this anesthetic method. The aim of this study was to evaluate the effects of lidocaine alone versus concomitant use of lidocaine and pethidine for the IVRA in upper limb surgery.
Methods: In this randomized, double-blind, controlled clinical, 50 eligible individuals were randomly divided to receive either a combination of 1.5 mg/kg lidocaine 2% and 1.5 mg/kg pethidine or placebo (3 mg/kg lidocaine 2%) for IVRA. After the surgery, the onsets and durations of sensory and motor block, the pain intensity in recovery room, the subjects' first demand of morphine, and the total amount of morphine injected within 24 hours were measured.
Results: The combination of lidocaine and pethidine was significantly effective in accelerating the onset of both sensory and motor blocks [(P=0.001), (P=0.001), respectively]. However, no differences were found between groups in sensory and motor block durations after surgery. Intervention with lidocaine plus pethidine caused a significant reduction of the pain intensity in recovery room (P=0.02). Also, concomitant use of lidocaine and pethidine led to a longer time of the first demand of morphine (P=0.04). Moreover, the total amount of morphine injected within 24 hours after surgery was considerably lower in individuals treated by lidocaine plus pethidine (P=0.003).
Conclusion: The results of the current study suggest that adding pethidine to lidocaine can be considered as an appropriate approach for better management of IVRA.

Background: Sevoflurane is preferred for induction of general anesthesia in pediatrics. We examined the minimum duration of sevoflurane administration resulting in most optimal intubation conditions.
Methods: We included 75 children, aged 2-12 years, undergoing tonsillectomy under general anesthesia at Amir-Alam Hospital. They were given midazolam 0.05 mg/kg and fentanyl 2 mic/kg IV, five minutes before induction with sevoflurane 8% in 60% N2O and 40% O2 with total gas flow of 10 lit/min via face mask for 90 seconds (group I), 120 sec (group II) or 150 sec (group III), randomly. After tracheal intubation, intubation condition was assessed using Steyn's modification of Helbo Hansen scoring system. The total scores were divided into clinically acceptable (≤10) or unacceptable (>10).
Results: There was no statistically significant difference among the three groups in demographic characteristics. Mean ± SD of intubation scores were 10.04±2.9, 8.12±3.2, and 5.64±1.15 in groups 1-3, respectively (P<0.001) with statistically significant differences between all three groups: between groups I and II (P=0.044), I and III (P<0.001), as well as II and III (P=0.004). Intubation conditions were acceptable in 11, 16, and 25 patients in each group, respectively (P<0.001).
Conclusion: Inhalation induction by sevoflurane 8% in 150s provides acceptable clinical situation for intubation in pediatrics.

Background: Laparoscopic Cholecystectomy (LC) as a minimally invasive surgery has become extremely common in recent decades. Despite being less invasive, these surgeries require postoperative analgesia. In this regard Ketamine, can reduce postoperative pain and opioid consumption.
Owing to the wide heterogeneity of studies on efficacy of ketamine in pain management in different operations, anesthetics methods, and the way and dose of consumption, the present study sought to evaluate the effects of intraoperative low-dose ketamine on postoperative pain, opioid consumption, and hemodynamic changes of patients undergoing LC in the 5th Azar hospital of Gorgan in 2019.
Methods: 66 patients with the need for LC were randomly selected. After induction of anesthesia and intubation, and before surgical incision, 0.5 mg/kg of Ketamine was injected as a bolus for target group (n=33), and the equivalent volume of normal saline for control group (n=33). Systolic, diastolic and mean arterial pressure were recorded before, during, after anesthesia and during surgery at 5-minute intervals. Postoperative pain was evaluated through Visual Analog Scale(VAS). We recorded the time of the first dose of opioid, total amounts of opioid consumption during the first 24 hours after surgery and doses of antihypertensive drug.
Results: VAS score (opioid requirement) were lower in the intervention group only in the recovery period (p=0.049). There was no difference between two groups in total amounts of opioid consumption during 24 hours even in cases with increase of the length of surgery (p= 0.742). Blood pressure trend increased from the beginning of induction to the end of anesthesia (p-value<0.001); however, there was no statistically significant difference between two groups (p=0.786). The need for labetalol was higher in control group (p<0.0001).
Conclusion: Although 0.5 mg/kg ketamine could not reduce overall opioid consumption within 24 hours after surgery, it had significant pain relief during awakening and recovery. Additionally, it reduced the need for further interventions, such as labetalol and other drugs and therefore was associated with lower costs.

Background: This study aimed to compare the effect of dexmedetomidine-fentanyl (DF) and midazolam-ketamine (MK) combination on the level of sedation in children undergoing bone marrow biopsy.
Methods: This study was a single-blind randomized clinical trial. The patients were divided into two groups of 35. Five minutes before undergoing bone marrow biopsy, the first group underwent sedation with a combination of 0.1 mg/kg midazolam with 1 mg/kg ketamine, and the second group underwent sedation with a combination of 2 μg/kg dexmedetomidine with 1 μg/kg fentanyl. The mean arterial pressure (MAP), heart rate, SpO2, the level of sedation, and the incidence rates of complications were recorded in both groups and compared to each other.
Results: There was no significant difference between the two groups in terms of age (P= 0.687), gender (P= 1.00), and weight (P= 0.839). However, there was a significant difference in the average length of stay in recovery (P= 0.015) and surgeon satisfaction (P= 0.000), with a longer recovery period in the midazolam-ketamine (MK) group. The Repeated measures ANOVA showed significant differences in heart rate (P= 0.008), sedation score (P = 0.038), and the percentage of oxygen saturation (P= 0.00) during surgery.
Conclusion: The combination of dexmedetomidine and fentanyl (DF) compared to the combination of midazolam and ketamine (MK) can provide more patient sedation and surgeon satisfaction along with more stable hemodynamics for patients undergoing bone marrow biopsy.

Situs inversus totalis is a rare congenital positional anomaly with a predicted incidence of 1: 10,000 amongst the general population described by the transposition of the abdominal and thoracic visceral structures. Local infiltration of the breast is a common technique for fibroadenoma of small sizes. However, its efficacy, including duration of action as well as the extent, can be unreliable and surgeon dependent. Unless otherwise contraindicated, the regional technique of thoracic segmental spinal anesthesia has been proven to be a safe and effective method for even major surgeries including laparoscopic cholecystectomy, breast lumpectomy and abdominal surgeries. Multiple regional anesthetic techniques are available and should be used according to the requirement of the surgery as well as the skill and knowledge of the performing anesthetist. We discuss here, a case of fibroadenoma in a patient with isolated situs inversus totalis, operated under thoracic segmental spinal anesthesia.

The use of arthroscopic shoulder surgery for diagnosis and treatment is increasing. Although some complications may occur during the operation, subcutaneous emphysema, pneumomediastinum and pneumothorax are rare complications. In this case, we present a patient who developed subcutaneous emphysema, pneumomediastinum and pneumothorax. A 53-year-old female patient presented with right shoulder pain for 8 months. The patient's body mass index is 20. Additional diseases are rheumatoid arthritis (RA) and vertigo. There was no other systemic disease or comorbidity. She was assigned an American Society of Anesthesiologists (ASA) score of 2. Arthroscopic rotator cuff repair was planned. She was operated under general anesthesia (GA). Subcutaneous emphysema, pneumothorax and pneumomediastinum developed at 6 hours after this surgery. The patient was discharged without any complaints on the 6th day of follow-up. No problem was detected in the follow-up of the patient. After shoulder arthroscopy under GA, subcutaneous emphysema, pneumothorax and pneumomediastinum can occur due to the procedure itself, the pleural and alveolar trauma, the endotracheal intubation or extravasation of irrigation fluid during shoulder arthroscopy. In our case, it was not possible to determine the exact cause. However, it is important to keep in mind that subcutaneous emphysema, pneumothorax and pneumomediastinum can occur after arthroscopic shoulder surgery. Although shoulder arthroscopy is a safe procedure, surgeon familiarity with the risk factors for this complication and close monitoring can aid in its identification and allow for appropriate treatment.

The incidence of postpartum hemorrhage (PPH) is increased in multiple pregnancies and is an important cause of maternal death. Controlling bleeding and correct anesthesia management during this period are essential.
In our 35-year-old patient with triple pregnancy, hemorrhage due to uterine atony developed during C/S surgery. We aimed to discuss the anesthesia management of PPH in our patient who underwent a total abdominal hysterectomy and bilateral salpingectomy (TAH BS) due to continued bleeding during and after C/S, with literature.
We think that morbidity and mortality rates can be reduced in the perioperative period for PPHs with the help of multidisciplinary approach, rapid action, and close follow-up.

Cerebral palsy (CP) refers to a spectrum of nonprogressive neurological disorders with disturbances in posture and movement, resulting from perinatal intrauterine insult to developing infant brain. Many conditions associated with CP require surgery. Such cases pose important gastrointestinal, respiratory, and other perioperative considerations. Anaesthetic management in these cases is delicate. Intraoperative complications including hypovolemia, hypothermia, muscle spasms, seizures, and delayed recovery might complicate the anaesthetic management. A thorough preanesthetic evaluation allows for a better intra- and post-operative care. Perioperative analgesia is important, particularly in orthopaedic surgeries one for pain relief. Here, we have discussed the successful management of a case of spastic CP for orthopaedic lower limb surgery.

Crigler Najjar syndrome(CNS); is a disease in which the diphosphate glucuronosyltransferase (bilirubin-UGT) enzyme function, which plays a role in the glucuronidation of bilirubin, is deficient as a result of mutation in the uridine 5'-diphosphate-glucuronosyltransferase 1A1 (UGT1A1) gene.1 As a result, non-hemolytic unconjugated hyperbilirubinemia is seen. Orthotopic liver transplantation (OLT) is seen as a curative treatment option in Crigler Najjar syndrome type 1 (CNS1). In this case report, we present our patients who were 11 months old and 8 years old with a diagnosis of CNS1, whose bilirubin levels were controlled by preoperative daily phototherapy and plasmapheresis, and who had OLT from their parents to two siblings. We wanted to show the importance of a close follow-up and multidisciplinary treatment approach in the early period before OLT in CNS1 patients and thus the benefit to the patient's prognosis in the postoperative period.

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