Background: Airway management and tracheal intubation in the ICU is a difficult procedure that may be concomitant with major complications. The purpose of this study was to evaluate the effect of the SANYAR ® video laryngoscope(S-VL) on laryngeal view and first Pass Success of tracheal Intubation compared with direct laryngoscopy.
Methods: This comparative, prospective clinical study was conducted on 120 adult patients in a single-center, in a surgical ICU under the supervision of an anesthesiologist in a university hospital. Difficult airway predictors, glottic view, first Pass Success of tracheal Intubation and time of intubation were evaluated with Macintosh laryngoscopy (ML) or the SANYAR® Video Laryngoscope(S-VL).
Results: Tracheal intubation was performed in 58 critically ill patients using ML and 62 patients using S-VL. According to Cormack and Lehane (C&L) grading glottic visualization was more difficult using ML (41%, C&L grade 3 and 4) compared with S-VL (13%, C&L grade 3 and 4) p<0.001. Intubation of trachea was more successful in the first attempt, in patients with at least one difficult airway predictor with a S-VL compared to ML (87% vs. 38%; P = 0.001), time of intubation was also shorter by using S-VL.
Conclusion: Among critically ill patients in the intensive care unit, who require intubation, the SANYAR video laryngoscopy improved glottis view compared to the Macintosh direct laryngoscopy and first-pass orotracheal intubation rate especially in patients with potentially difficult airways.

Background: Primary objective:

1. Duration of block
2. Post-operative pain score
3. Post-operative rescue analgesic consumption

Secondary objective:

1. To observe patient satisfaction score
2. Occurrence of post-operative complications if any.
   Methods: A total of 60 patients, aged between 18-60yrs, belonging to ASA I & II with hip osteoarthritis requiring total hip arthroplasty (THA) were divided into two groups of 30 each. Patients were randomized into two groups and were given ipsilateral USG guided anterior QLB in the fascial plane between QL and psoas major muscles after surgery. Group C received 30ml NS and group T received 30ml of inj. Ropivacaine 0.2%. Post operatively patient received inj. PCM 1G TDS. Duration of block, requirement of rescue analgesia, VAS score and side effects were the parameters those were monitored and compared.

Results: Mode pain score by VAS was significantly lower in T group(p<0.05) than C group which required more analgesia. (The chi-square value-5.9341, p=0.0148). Duration of block was more in T group. Patient satisfaction was noted to be better in T group.
Conclusion: Use of post-operative USG guided Ant. QLB reduced VAS score in patient undergoing THA. It also significantly decreased the requirement of post- operative rescue analgesia and improved patient satisfaction.

Background: Preoperative airway assessment is necessary to identify airway difficulties to the earliest, ensure adequate preparation to airway management before induction and to avoid airway related complications. Various Imaging techniques have been studied for prediction of the difficult airway. the ultrasound is a quick and simple technique. Aim of the study was to evaluate ultrasound guided measurement of tongue thickness in predicting difficult tracheal intubation in patients undergoing elective surgery.
Methods: Sixty-one patients American Society of Anesthesiologist class I and II,18-65 years of age, either sex, were included. Tongue thickness was measured by ultrasound as the distance from the surface of tongue to the submental skin. Modified mallampatti score was also recorded.
Results: Receiver operating characteristic (ROC) curve of tongue thickness showed an AUC of 0.879 for a cut off value of >6 cm. This shows it has an excellent predictive value. Tongue thickness (>6cm) was found to have 90.16% combined diagnostic accuracy with 75% sensitivity and 94.74% specificity for prediction of difficult intubation. No correlation between tongue thickness and modified mallampatti score. (Correlation coefficient was 0.013, p value 0.920).
Conclusion: We conclude that ultrasound guided measurement of tongue thickness> 6 cm can reliably predict difficult tracheal intubation in patients undergoing elective surgery.

Background: Trigeminal neuralgia is a sudden, severe condition characterized by stabbing and recurrent pain. Radiofrequency thermocoagulation (RFT) and pulsed radiofrequency (PRF) are common surgical interventions used to treat trigeminal neuralgia. This study aimed to investigate the therapeutic effects and associated complications of PRF in the treatment of trigeminal neuralgia.
Methods: Pulsed radiofrequency was performed on 20 patients with primary trigeminal neuralgia. One months later, pain relief and complication status were evaluated. All patients who referred to the pain clinic of Amir Alam Hospital with a diagnosis of primary TN and after failure of conservative treatment or intolerance to drug side effects were candidates for trigeminal ganglion destruction by PRF method were the study population.
Results: In this study, the female to male ratio was 1.5. The mean age of patients was 50.70 years. The highest prevalence was reported in 50-75 years (45%). 7 patients (35%) had pain in the right and 13 patients (65%) had pain in the left. In 18 patients there was involvement in one nerve root and in 2 patients there was involvement in 2 nerve roots. 1 patient (5%) had V1 root involvement, 13 patients (65%) had V2 root involvement and 8 patients (40%) had V3 root involvement. The mean pain score of patients before the procedure was 8.8. The mean pain of patients one hour after surgery was 3.95 and on days 7 and 30 after surgery were 3.3 and 4.25, respectively. One hour after the operation, effective pain relief was observed in 75% of patients. The effective response rate was observed one week after the procedure in 80% of patients and one month later in 60% of patients. There was no significant relationship between patients' gender and the effectiveness or ineffectiveness of the procedure after one month. With age, the effective response to treatment in patients increases. In 2 patients, infection was reported at the procedure site. Four patients reported paresthesia at the procedure site one month after surgery.
Conclusion: PRF treatment was an effective, safe and non-destructive method for patients with TN. Primary PRF treatment can be considered as a first-line option before more invasive treatments, such as neurodegenerative procedures and MVD surgery.

Background: Most of the lumbar spine surgeries cause severe post-operative pain. Poorly controlled postoperative pain is associated with increased morbidity and increased health-care costs. Recently, erector spinae plane (ESP) block has been introduced in our clinical practice as a part of the multimodal pain strategy after lumbar spine surgery. This case series is to analyse the efficacy and safety of erector spinae block for lumbar spine surgery.
Methods: In this study eight patients, who were posted for lumbar spine surgeries, ultrasound (US) guided bilateral erector spinae block was given post-operatively. Post-operative pain was assessed using Visual analogue scale (VAS), score at 4, 8, 12 and 24 hrs. Rescue analgesia inj tramadol 50gm IV was given when VAS score was more than or equal to 5. Time when the first rescue analgesia was given was noted.
Results: Erector spinae block was successfully performed in all the cases. The mean duration of the procedures was 175.6±31.7 mins (Table 1). None of the patients complained of pain in the immediate postoperative period. The mean time of first rescue analgesia was 11.3±2.3 mins.
Conclusion: ESP block with dexamethasone offer a good postoperative analgesia in lumbar spine surgeries for acute postoperative pain reducing the opioid consumption.

Background: Two major difficulties in critical care are muscle weakness and malnutrition. Their prevalence in critically ill patients is about 30-50% during hospital stays, and they can also affect routine patient life after discharge, even leading to recurrent infection and death. Metabolic responses to injury have specific effects on metabolic phases in patients.
Methods: This study is a randomized, double-blind, clinical trial on critically ill patients in two groups. Both groups were checked for metabolic markers and demographic characteristics during admission and before discharge. In the nandrolone group, 25mg of nandrolone (IM) was injected weekly for three weeks. In the control group, normal saline was used as a placebo. To assess metabolic responses, albumin, total protein, and testosterone levels were checked, in addition to static measures such as cross-sections of rectus femur and mid-upper arm circumference.
Results: There were no significant differences in SOFA and APACHE 2 scores, PSA, ESR, CRP, and PTC levels between the two groups (p<0.05). Results also showed no significant differences between the mean of length of hospital stay, serum albumin, total protein, hemoglobin, testosterone, and HDL between the two groups (p<0.05). LDL and TG had P-values of 0.01 and 0.012, respectively. MUAC and sonographic findings of rectus femoris muscle were better in the case group (P-values 0.008 and 0.012).
Conclusion: Nandrolone had no significant effects on metabolic markers in critically ill patients, except for TG and LDL. The changes in muscle characteristics were significant. However, more study is needed to assess muscular power.

Background: The diagnostic efficacy of lung ultrasonography (LUS) has been widely investigated. However, the clinical value of LUS for perioperative monitoring has rarely been reported. The aim of this study was to evaluate the ability of LUS to assess lung aeration status after one-lung ventilation (OLV) using a validated scoring system.
Methods: In this prospective observational study, patients undergoing elective video-assisted thoracic surgery (VATS) with OLV underwent a lung ultrasound examination just after induction of anesthesia and at the end of the surgery. After each lung ultrasound examination, a semiquantitative score, the LUS score, was calculated to assess lung aeration on the ventilated dependent side and the non-dependent side separately. The relationship between the LUS scores and various patient-related factors was also investigated.
Results: Twenty-five patients were studied. All lung ultrasound examinations were successfully completed. LUS scores after OLV on the dependent side (median [IQR]: 2 [1–4]) increased significantly from baseline (1 [0–1.5], P < 0.001). Further, LUS scores on the non-dependent side (2 [1.5–3.5]) increased significantly from baseline (1 [0–1.5], P < 0.001). None of the factors analyzed was significantly correlated with LUS scores after OLV.
Conclusion: LUS examination is possible after VATS with OLV on both sides of the thorax. Ultrasonography-measured lung aeration scores increased from baseline on both sides.

Background: We assessed postoperative analgesic effect of ultrasound guided ilioinguinal and iliohypogastric nerve block, duration of action of the said block as well as the overall analgesic consumption in the first 24 hours of postoperative period after addition of dexamethasone.
Methods: After approval from the institutional ethics committee, hospital based randomized prospective study was carried out in patients of age group 40-60 years by dividing them into two groups A and B, posted for unilateral inguinal hernioplasty, comparing ilioinguinal and iliohypogastric block with ropivacaine 0.375% and ropivacaine 0.375% with dexamethasone 4mg respectively. The aim of the study was to assess the postoperative analgesia with visual analogue scale (VAS) and satisfactory score and total analgesic consumption and time till rescue analgesia.
Statistical Analysis: We used Chi-square test and paired t test and P<0.05 was considered statistically significant.
Results: Mean of duration of analgesia was significantly prolonged in group B (14.13±3.461 h) as compared to group A (5.77±2.161 h). Patients in group B had significantly lower VAS score and less number of rescue analgesic requirements in first 24 hours (h) postoperatively. No adverse effects recorded in any group.
Conclusion: Dexamethasone as an adjuvant with ropivacaine in ultrasound guided ilioinguinal and iliohypogastric block provided profound prolongation of duration of postoperative analgesia and reduces analgesic consumption of patients undergoing subarachnoid block for unilateral inguinal hernioplasty.

Background: Central venous catheters are inserted in internal jugular vein during cardiac surgeries in all patients. However, the length of the catheter should be correctly estimated and the tip of the CVC should be correctly placed to avoid various complications. 
The primary objective of this study is to compare anatomical landmark technique versus using ECG-guided technique for the correct insertion length of the Central Venous Catheter.
Methods: Prospective, randomized, interventional study was conducted on 72 patients of <12 years age. Patients were randomly allotted to two groups of 36 patients each (landmark and ECG).
After induction, CVC cannulation was performed using either of the techniques in right IJV in all patients. Correct position of CVC was checked by obtaining post operative chest X rays in all patients. CVC tip position within 0.5cm above/below or at carina was considered as correct position. Using student t-tests and Chi square-tests analyses were performed.
Results: In landmark group, CVC was positioned correctly in 22(61.11%) out of 36 patients as compared to 33 (91.67%) in the ECG group, (P = 0.006). The mean depth of CVC insertion was 9.05±1.66 and 8.26±1.41 in the landmark and ECG group respectively (P= 0.032). The landmark group had 12 (33.33%) patients with complications during the procedure, as compared to 3(8.33%) in the ECG-guided group, (P = 0.020).
Conclusion: ECG-guided CVC insertion, a simple bedside technique was found more accurate with lesser complications for CVC tip placement than the landmark technique. ECG-guided CVC placement is therefore relatively more accurate, efficient, and safe.

Background: Cytokine storm in severe Covid-19 disease is one of the leading causes of death in these patients. Hemoperfusion is a method used to purify the blood from toxins and inflammatory factors. The aim of this study was to evaluate the effect of hemoperfusion on mortality and morbidity in patients with severe Covid - 19 disease.
Methods: This was a retrospective study which performed by reviewing the files of 30 patients with severe Covid-19 disease referred to Sina Hospital affiliated to Tehran University of Medical Sciences in 2020. Thirty patients with severe covid-19 disease and positive PCR participated in the study. All patients received routine treatment protocol for covid-19. Hemoperfusion was used for 15 patients in addition to receiving routine care. The remaining 15 patients were included in the control group. Patients in the hemoperfusion group underwent four sessions of hemoperfusion using continuous renal replacement therapy with continuous venovenous hemofiltration.
Results: the ICU length of stay in the control and hemoperfusion groups was 3.40 ± 11.40 and 9.65 ± 16.33 days, respectively (P= 0.075). 8 patients died and 7 patients were discharged in the control group, but 11 patients died and 4 patients were discharged in the hemoperfusion group (P= 0.256). The respiratory rate of patients in the control and hemoperfusion groups decreased from 7.43 ± 29.40 to 4.03 ± 24.60 and from 6.11 ± 31.60 to 5.04 ± 24.46, respectively (P < 0.001). The percentage of arterial blood oxygen saturation in the control and hemoperfusion groups increased from 90.86 ± 5.61 to 93.06 30 4.30 and from 92.33 26 3.26 to 92.06 31 5.31, respectively (P= 0.456).
Conclusion: Hemoperfusion could not prevent the mortality of patients and finally out of 15 patients, 11 patients died and 4 patients were discharged. Also, no significant difference was observed between the two groups in terms of arterial blood oxygen saturation.

Background: Pain is associated with increased sympathetic activity leads to tachycardia, elevated blood pressure and myocardial insults so pain control is necessary during the surgery and in the postoperative period. Aim of the study was to study the effect of intravenous dexamethasone on the duration of analgesia provided by supraclavicular block (SCB) for upper limb surgery.
Methods: 75 patients, age between 18 to 70 years of either sex, ASA class I and II, who were undergoing upper limb surgery randomized into three groups of 25 patients each by computer generated random number. Group S - 25 patients were given 5ml of normal saline intravenously along with ultrasound-guided SCB with 25ml 0.5% bupivacaine. Group DF - 25 patients were given 4mg intravenous dexamethasone in 5ml normal saline along with ultrasound-guided SCB with 25ml 0.5% bupivacaine. Group DE - 25 patients were given 8mg intravenous dexamethasone in 5ml normal saline along with ultrasound-guided SCB with 25ml 0.5% bupivacaine.
Results: The demographic data were comparable in all groups. The VAS score was significantly lower in Group DF and DE compared to Group S at 3,4,6,8,10,12 and 24 hours, with p values < 0.0001 at 3,4,5,6,8,10 and 12 hours and p value 0.0002 at 24 hours. The VAS scores between the groups DF and DE were comparable at 3,4,5,6,8,10,12 and 24 hours without any significant difference. The time for first rescue analgesia was significantly in Group DF and DE compared to Group S (p value <0.0001). There was no significant difference between the groups DF and DE in the time for first rescue analgesia (p value 0.75).
Conclusion: We conclude that dexamethasone used intravenously even in lower doses as 4mg along with supraclavicular brachial plexus block effectively increases the duration of analgesia and motor blockade, shortens the onset of sensory and motor blockade, reduces the total analgesic requirement in the first 24 hours after surgery.

Background: Laparoscopic cholecystectomy is usually performed as a day care procedure for diseases involving the gall bladder. Pain in the immediate post-operative period is due to multiple factors and hence different modalities of pain relief are used. The present study was conducted to study the effectiveness of Peri-operative Multi-Modal Analgesia with Ultrasound guided Bilateral Subcostal TAP block for Post-operative analgesia in 60 patients undergoing elective laparoscopic cholecystectomy.
Methods: In this hospital based, randomized prospective interventional study patients were randomly allocated into 4 groups of 15 in each group, Group B received Bilateral Ultrasound guided Subcostal TAP Block with 20 ml of 0.25% Bupivacaine, Group P received Tab Pregabalin tablet 150 mg, Group D received Inj Dexamethasone 8 mg IV and Group C was the control group. The hemodynamic changes like heart rate, blood pressure, saturation was monitored both intra and post operatively. The post-operative VAS scoring, duration of analgesia, time for first rescue analgesic and the total dose of analgesics in 24 hours were noted.
Results: The VAS Scores indicated that Group B> P> D> C provided better analgesia to the patients with a P Value of < 0.01. Group B took the longest mean duration (6.8± 1.15 hours) to take the 1st rescue analgesic and least mean total dose of rescue analgesic in 24 hours followed by Group P, Group D and Group C which was statistically significant.
Conclusion: USG guided B/L TAP Block was superior to other modalities in providing postoperative analgesia for patients undergoing laparoscopic cholecystectomy.

Background: The novel coronavirus has spread rapidly worldwide, with exceptionally high mortality in the elderly. Patients with hip fracture have an average age of 80 years, with an estimated 2.8 comorbidities per patient. This study aims to assess the impact of the COVID-19 pandemic on hip fracture care services and the associated mortality rate.
Methods: PubMed, Medline, and Google Scholar databases were searched for relevant studies linked to mortality in COVID-19 patients who have undergone hip surgeries using the keywords “COVID-19” OR “SARS-cov-2” OR “Coronavirus Infections”; AND “Surgery” OR “Hip” OR “Fracture” OR “Orthopedics.” We included all patients with hip fractures but excluded pathological fractures and other non-traumatic hip pathologies 30 studies for the final review were selected according to the inclusion and exclusion criteria.
Results: 30 studies were included in the review. The overall mortality was 10.52%. There was a significant difference in the mortality rate between patients with positive and negative tests and between the operative patients who tested positive and the operative patients who tested negative.
Conclusions: COVID-19-infected elderly patients with hip fractures have a higher mortality rate than non-COVID-19 infected cases. Further studies are warranted to examine the morbidity and mortality rates in COVID-19-positive patients with hip fractures and investigate how these outcomes can be improved.

Administering anaesthesia in ruptured hydatid cyst of lung/liver has always been challenging. The major perioperative goal of management in such patients include protection of healthy lung, chance of anaphylaxis, deranged liver enzymes and coagulation profile, hepatic resection, postoperative management of bronchopleural fistula, blood loss and analgesic management of large incision. We report a case of successful management of a 40-year-old male with hepatic and pulmonary ruptured hydatid cyst with bronchopleural fistula under general anaesthesia (using double lumen tube) and thoracic epidural.

Ebstein anomaly is a challenge to the anaesthetist in terms of large right atrium, atrialised right ventricle and various valve abnormalities associated with it like Tricuspid Regurgitation(TR), Mitral Stenosis(MS), Mitral Regurgitation(MR).
In this case study, we report a 14-year-old female child presented with ebstein anomaly and cleft palate in our institution, SMS medical college & hospitals, Jaipur, Rajasthan. Cone’s operation was planned but due to multiple fenestrations in tricuspid leaflet only tricuspid and mitral valves were replaced. Patient was extubated next day with uneventful recovery.

Compartment syndrome (CS) is caused by an excessive increase in compartment intramuscular pressure, which measurement is the reference diagnostic tool. We examine the case of a 44yearold man with invasive bladder cancer who underwent an open radical cystectomy. After extubation, the patient is transferred from the operating room to the Intermediate Care Unit, where he complains of severe lumbar pain on a visual analog scale of 10 that is unresponsive to opioids and is diagnosed with rhabdomyolysis due to compartment syndrome. Multidisciplinary care and multimodal analgesia approaches were used; no fasciotomy was performed; and a favourable outcome was achieved.

Supraclavicular brachial plexus block is well established regional anaesthesia technique for upper limb surgeries. USG guided supraclavicular brachial plexus block provides many advantages but is also associated with the rare complication of recurrent laryngeal nerve palsy, seen in 1.3% of cases. Recurrent laryngeal nerve palsy is mostly documented in right sided supraclavicular blocks than left sided supraclavicular blocks. Here, we report a case of 28 years old male undergoing right upper arm surgery under supraclavicular block who developed hoarseness of voice due to ipsilateral recurrent laryngeal nerve involvement which was followed up properly and managed successfully.