Background: Sepsis and septic shock are leading cause of mortality in ICU patients. Prognostication and early intervention forms most integral part of management of septic shock. There many validated score to assess the critical state of septic shock patients. APACHE2 and SOFA scores are widely used world over. Multiple parameters used in the score and complexity involved have lead researchers to search for more convenient and simple markers. Lactate albumin Ratio (L/A ratio) turns out to be one such marker, combining two easily available parameters and abbreviating fallacies associated with both parameters when assessed individually. We aimed to assess L/A ratio as predictor of all cause 28 days’ mortality in septic shock patients and correlated L/A ratio to the SOFA score to assess organ dysfunction.
Methods: It was a prospective observational study. 130 patients admitted in the state of septic shock were studied. L/A ratio was obtained at 24 hours after admission in the ICU. SOFA score was also calculated at 24 hours. ROC curve was plotted for L/A ratio to evaluate diagnostic accuracy, as predictor of 28 days’ mortality. Multivariable analysis of L/A ratio with other significant parameters was performed. Spearman rank correlation coefficient was used for correlation of L/A ratio with SOFA score.
Results: L/A ratio at 24 hours (AUC 0.99; 95% CI: 0.95 to 0.99), p value =0.0001, was significant predictor of mortality at 28 days, at cut off point of >1.15. Significant positive correlation was found between L/A ratio and SOFA score at 24 hours, with correlation coefficient of 0.828, p value=0.0001.
Conclusion: L/A ratio was found to be independent predictor of 28 days’ Mortality in Septic Shock Patients. Also strong correlation was obtained of L/A ratio to SOFA score to assess organ dysfunction in septic shock patients.

Background: Pre-operative airway assessment for predicting difficult intubation is of utmost importance for anaesthesiologists to ensure adequate oxygenation and ventilation which is a priority.
Aims & Objectives: To evaluate the effectiveness of neck circumference (NC) to thyromental distance (TMD) ratio (NC/TMD) as a predictor of difficult intubation and its correlation with established predictors namely Mallampatti grading (MPC grading), Modified Cormack Lehane’s Score (MCLS grading).
Methods: 140 patients of age between 18 to 60 years with ASA I, II were selected. Pre-operative, MPC grading and NC to TMD ratio was measured. Intra-operatively, MCLS grading, time taken for intubation, number of attempts taken for intubation, any additional use of equipment required and grading ease of intubation were noted. Correlation was done between them.
Results: Out of 140 patients, NC/TMD ratio of >5 was found in 20 patients in which 19 patients required an adjuvant during intubation. NC/TMD ratio had significantly higher sensitivity (75.20) and specificity (99.02) as compared to sensitivity (56.31) and specificity (92.38) of MPC grading. ROC curve for NC/TMD ratio had higher area under curve (AUC = 0.74) than Mallampatti grading (AUC = 0.66).
Conclusion: As compared to MPC grading, NC/TMD has emerged out as a better predictor of difficult intubation.

Background: Knee osteoarthritis (OA) is the most common reason for orthopedic secondary care referral. And it is one of the main causes of disability in adults worldwide. It is estimated to affect between 10 to 25% of patients over the age of 60. Intra-articular corticosteroid injection (IA CS) and physical therapy were the two choices in an attempt to provide symptomatic management or deferred surgery. There is a growing trend is intra-articular platelet-rich plasma (IA PRP) injection to reduce pain and improve function in OA patients. PRP is divided into two types: leukocyte-poor platelet-rich plasma (LP-PRP) and leukocyte-rich platelet-rich plasma (LR-PRP). It was shown that LR-PRP increases pro-inflammatory factors and also decreases anti-catabolic mediators, and LP-PRP has the opposite aspect.
Methods: In our research 40 patients were divided into two equal groups, IA corticosteroid and leukocyte-poor platelet-rich plasma (LP-PRP) 40 cc of blood from the basilic vein of the upper limb is used with two step centrifugation. The final samples were 4 millilitres product injected intra-articular. group two (corticosteroid (CS)) received an intra-articular injection of triamcinolone acetate (Kenalog) 40 mg/ml along with 4 ml of lidocaine 0.02% (Abureyhan Co.) for a total of 5 ml. The needle used is a 22-gauge pencil-point Quincke needle (Dr. Japan Co, Ltd), which is performed with the Sonosite Edge II ultrasound guide and in an anterior-lateral manner in the knee joint. Pain was assessed on a visual analogue scale (VAS range 0-10 points) before, one week, one month, two month and 3 months after the operation. The WOMAC questionnaire was also filled before injection and three months following injection and other variables were examined.
Results: There were no significant differences between the groups across all the baseline parameters including age, sex, body mass index and comorbidities including high blood pressure, diabetes and smoking. Both injection groups were effective in reducing patients' pain from one week to three months after injection. The level of pain in the first week after injection was significantly lower in the corticosteroid group than in the PRP group. In the first month and the third month after the injection, the pain reduction according to mean scores of VAS was the same in both groups.
Conclusion: In short, one injection of PRP can reduce the pain of patients with osteoarthritis of the knee as much as corticosteroids during a three-month treatment process. Considering the possible side effects of corticosteroids, this alternative treatment can be considered with further investigation.

Background: In the majority of cases, the treatment method for Cleft lip is surgery. Providing adequate pain control during and after surgery for children, is too important. Also, different methods are used for pain relief like analgesic prescription and nerve block and different adjuvants can be added to anesthetics to reduce pain.
Aims: This trial was aimed to compare the analgesic effect of Bupivacaine with or without dexmedetomidine or dexamethasone for cleft lip surgery.
Methods: This study is a prospective, double-blinded, randomized trial which conducted on 75 pediatrics, aged between 3 to 10 months, who needed unilateral cleft lip surgery. Patients were divided into 3 groups (n=25 in each group). Children in group A, were given a combination of bupivacaine and 0.5 µg/kg of dexmedetomidine, those in group B, 0.1 mg/kg of dexamethasone as an adjuvant to bupivacaine, and in group C, plain 1 cc of bupivacaine 0.5% was injected in the operation site. Outcomes were assessed via FLACC and WATCHA scores.
Results: The mean age among children was 4.3 ±1.29 months and mean weight was 6.3± 1.09 kg. Pain score and frequency of analgesic request intra and post-operation in group A was lower than others (p<0.0001). Also, FLACC and WATCHA scores were significantly lower in group A (p<0.0001) and parental and surgeon satisfaction was higher in group A (p<0.05).
Conclusion: Our study showed that, dexmedetomidine as an adjuvant to bupivacaine 0.5% is more effective to improve the analgesia, in children who underwent unilateral cleft lip surgery.

Background: Dexmedetomidine and Fentanyl both possess hypnotic, sedative, analgesic properties and have been utilised as an additive in epidural anaesthesia. The purpose of this study is to compare the sedative and analgesic effects of Dexmedetomidine and Fentanyl when added epidurally with Ropivacaine (0.75%) during lower limb orthopaedic surgery.
Methods: The study comprised of 60 patients, both male and female, aged 18 to 60, who had ASA classification I or II for tibia fibula surgery. Two groups of patients were split up at random: Group RD contains– Ropivacaine (0.75%) 15ml + Dexmedetomidine (1microgm/kg) 0.5ml + 0.5ml sterile water (Total volume-16ml) and Group RF - Ropivacaine 15ml (0.75%) + 1ml Fentanyl (1microgm/kg) (Total volume-16 ml). The epidural space was maintained 4 cm within and situated between L3 and L4 space. Investigations were conducted on parameters such as sensory and motor block features, sedation score, hemodynamic factors and pain assessment. Using the student `t` test, statistical analysis was performed using STATAIC13 software.
Results: Onset of sensory analgesia at L1 and Complete sensory and motor blockage occurred much earlier in the RD group. Higher sedation scores and significantly prolonged postoperative analgesia was observed in RD group.
Conclusion: Dexmedetomidine is a safer and more effective epidural adjuvant than fentanyl because it provides stable hemodynamics, extended post-operative analgesia, early onset and development of sensory and motor effects and sedation.

Background: The depth of anesthesia is an important consideration during sleeve surgery, as it can impact patient safety and surgical outcomes. Proper depth of anesthesia can help to ensure patient comfort and reduce the risk of complications such as respiratory depression and hemodynamic instability. This study aimed to determine the association between the depth of anesthesia and the Surgical Rating Score in sleeve surgery.
Methods: This study was conducted as a cross-sectional study. Twenty patients who were candidates for sleeve surgery by the laparoscopic method and were referred to Dr. Shariati Hospital from 1394 to 1395 were recruited in this study. Informed consent was obtained before the start of the study. Surgical rating scale (SRS) used to assess surgeon satisfaction. Bispectral Index (BIS) monitoring used to assess the depth of anesthesia. Patients demographics along with hemodynamic, medications, and depth of anesthesia were recorded
Results: Twenty patients, including four men (20%) and sixteen women (80%), were examined in two groups of 10 people who underwent laparoscopic sleeve surgery (Mean age 40.20 ±8.87). The depth of anesthesia has a direct relationship with the improvement of the patient's condition and the SRS during the operation. As the observations showed, in the first group, the surgeon's satisfaction decreased as a result of the decrease in the depth of anesthesia, but this decrease was not statistically significant (P = 0.064), but in the second group, with the change of conditions and the increase in the depth of anesthesia from 60–65 to 40–45, the surgeon's satisfaction increased significantly (P = 0.018).There was no significant difference between the two groups in terms of age, sex, drugs (fentanyl, etc.), PEEP, TV, BMI, and fluid intake.
Conclusion: In conclusion, the findings of this study suggest that the depth of anesthesia has a significant impact on the improvement of the patient's condition and surgeon's satisfaction (SRS) during surgery.

Background: Diabetic patients are known to have gastroparesis and consequent delayed gastric emptying which predisposes them to an increased risk of aspiration as compared to the general population. This study compares the gastric volumes in diabetic and non-diabetic patients using point-of-care ultrasound and correlates it with the HbA1c levels in diabetic patients.
Methods: This cross-sectional study included 180 patients, 90 diabetic (>5 years) and 90 nondiabetic, aged >40 years, American Society of Anaesthesiologists' physical status I–II kept fasting for 8 hours. Before induction, gastric ultrasound was performed to measure craniocaudal (CC) and anteroposterior (AP) diameters followed by calculation of antral cross-sectional area (CSA) and gastric volume (GV) in right lateral decubitus (RLD) position using curved array probe. In diabetic patients, the gastric volumes were correlated with HbA1c values.
Results: In the RLD, the mean CC and AP diameters were higher in diabetic Group. The calculated CSA in RLD in diabetics (8.014 ± 2.412 cm²) were significantly higher than non-diabetic (6.314± 2.894 cm²) (p < 0.0001). The calculated GV of 71.501 ± 35.937 ml in the diabetic group was significantly higher than 48.0022± 41.587 ml in the non-diabetic group (p < 0.0001). In diabetics, the gastric volumes showed significant correlation with HbA1c.
Conclusion: Diabetic patients show higher residual gastric volume as compared to non-diabetic patients indicating gastroparesis. The gastric volumes are further increased in those with poorly controlled disease with high HbA1C levels. Ultrasound is an effective tool in assessing the risk of aspiration and altering anaesthetic management accordingly.

Background: The combined spinal-epidural (CSE) anesthesia technique gives a reliable subarachnoid block as well as the flexible epidural block. One of the modified technique of CSE is epidural volume expansion (EVE) in which normal saline or local anesthetic (LA) is instilled though epidural catheter leading to increase in level of sensory blockade. Aim of the study was to compare two different volumes of normal saline for enhancing the effects of spinal anaesthesia in adult patients undergoing elective lower limb surgeries.
Methods: 90 patients were randomly divided into two group. Group A - 45 patients who were received intrathecal 2.0ml of 0.5% hyperbaric bupivacaine and epidural 10ml of 0.9% normal saline for EVE using CSE technique. Group B - 45 patients who were received intrathecal 2.0ml of 0.5% hyperbaric bupivacaine and epidural 15ml of 0.9% normal saline for EVE using CSE technique.
Results: The demographic data were comparable in both groups. Significant difference was seen in total duration of sensory blockade between group A (192.11±9.80) and group B (Mean ± SD 215.33±17.57minutes) (p<0.0001). Total duration of motor blockade was longer in group B (Mean± SD: 181.91± 16.42) as compared to group A (Mean ± SD: 162.48 ± 9.35 minutes) (p<0.0001).
Conclusion: We conclude that epidural volume expansion (EVE) with 15 ml epidural normal saline was associated with faster onset, higher level and early achieve maximum level of sensory blockade, longer two segment regression time, early onset and longer duration of motor blockade as compared to EVE with 10 ml epidural normal saline.

Background: Laryngoscopy, endotracheal intubation, pneumoperitoneum creation and extubation is stressful event marked by hemodynamic changes during laparoscopic procedures. This increases secretion of many biochemical stress markers for example, cortisol levels, TNF-alpha levels, CRP levels, blood Sugar levels. Aim of the study was to compare magnesium sulphate and dexmedetomidine for attenuation of stress response in patients undergoing laparoscopic cholecystectomy under general anaesthesia by measuring biochemical markers of stress response.
Methods: 60 patients, age between 18 to 60 years of either sex, who were undergoing Laparoscopic cholecystectomy randomized into two groups of 30 patients each by computer generated random number. Group M- received magnesium sulphate 50 mg/kg and group D -  received dexmedetomidine 1 µg/kg.
Results: The demographic data were comparable in both groups. Cortisol levels rise in both the groups but significantly more in group M than group D at 30 minute (p-value < 0.001) and 4 hours (p-value < 0.001). CRP levels rise in both the groups but significantly more in group M than group D at 30 min (p-value 0.013) and 4 hours (p-value 0.020). Blood sugar levels rise in both the groups but significantly more in group M than group D at 30 min, 4 hours and 24 hours (p-value <0.001). TNF-alpha levels rise in both the groups but significantly more in group M than group D at 30 min (p-value 0.005) and 4 hours (p-value 0.007).
Conclusion: We conclude that biochemical stress marker levels (Cortisol levels, TNF-alpha, levels, CRP levels, Blood Sugar levels) were more increased in the magnesium sulphate group compared with the dexmedetomidine group. Heart rate and Mean arterial pressure   were higher in the Magnesium sulphate group than the Dexmedetomidine group. Dexmedetomidine is better than magnesium sulphate in attenuating the stress of surgery in patients undergoing laparoscopic cholecystectomy.

Background: Although epidural analgesia (EA) is a popular and effective method for pain relief during labor, significant controversy exists in terms of the impact of EA on labor outcomes and the best time for initiation of EA. Here, we aim to explore the effects of early initiation EA on the labor process in nulliparous at-term pregnant women.
Methods: A total of 240 nulliparous women enrolled in this study. The early epidural (EE) group (n=120) consisted of women in the latent phase of labor and the late epidural (LE) group (n=120) were in the active phase of labor. Each group received 16 ml of 0.125% preservative-free isobaric bupivacaine with 50 µg fentanyl (total: 17 ml) as a primary bolus dose in the epidural space for labor analgesia and an intermittent bolus of 5-10 ml of the primary solution was administered via a catheter. The length of labor, rate of cesarean section (CS), neonatal well-being, and infant Apgar scores were recorded.
Results: There were no statistically significant differences between the two groups regarding the duration of the first (p=.43) and second (p=.54) phases of labor. No statistically significant differences were observed between the two groups in terms of the rate of CS (p=.21), causes for CS (p=.24), and neonatal Apgar scores (p=0.84).
Conclusion: Initiation of EA during early labor did not result in increased CS or instrumental vaginal deliveries, and did not prolong labor duration.

Background: Radial arterial cannulation is a commonly done procedure in ICU. Multiple cannulation attempts can lead to radial artery spasm resulting in low pulse volume, decreased pulse palpability and cannulation failure. This study evaluates the effects of periarterial nitroglycerine infiltration with lignocaine vs lignocaine alone in USG guided radial artery cannulation in ICU patients.
Methods: A total of 60 ICU patients in age group 18-65 years who required radial artery cannulation for ABG analysis and invasive blood pressure monitoring were enrolled. They were randomly allocated to Group LN (periarterial infiltration with 0.2ml nitroglycerine+0.8 ml lignocaine 2%) and Group L (periarterial infiltration with 1ml of lignocaine 2%) of 30 patient each. Both groups were compared with respect to radial artery dimensions before and after infiltration of drug, pulse palpability score, no of attempts, time of cannulation and failure rates.
Results: There was significantly greater increase in radial artery dimensions in group LN as compared to group L after intervention. Pulse palpability score was also better in group LN. Mean time required for cannulation, number of attempts and insertion failure were significantly lesser in group LN as compared to another group. No hemodynamic adverse effect was reported in either group.
Conclusion: Periarterial infiltration with lignocaine and nitroglycerine combination increase radial artery dimension with improved cannulation success rate.

Background: Bloodless surgical field obtained by controlled hypotension reduces the bleeding, the surgical time and improves outcome of rhinoplasty and other facial plastic surgeries.
Since acupuncture is used for epistaxis, this study was designed to investigate its effectiveness in reducing the bleeding in open rhinoplasty.
Methods: In a triple-blinded randomized clinical trial, 88 patients with ASA I and II physical status, aged between 20 – 48 years, who were candidates of open rhinoplasty were enrolled in the study.
After randomization, 44 patients were assigned to each group of acupuncture or control. They were given identical anesthesia. In addition to the hemodynamic monitoring, blood loss was assessed in all patients and compared between the two groups.
Results: There were statistically significant differences between two groups in terms of the amount of bleeding (P = 0.001) and surgeon satisfaction (P = 0.010). Coagulation indicators were similar in both groups (All P > 0.05). Mean SBP and DBP, average HR and average MAP in both acupuncture and control groups did not show significant differences (All P > 0.05). Adverse events such as bradycardia or hypotension requiring treatment were not seen.
Conclusion: Our findings demonstrated that acupuncture could reduce bleeding during rhinoplasty without side effects.

General anesthesia is used in modern surgical practice to achieve low-reactivity consciousness, involving analgesia, hypnosis, amnesia, and immobility. Recently, studies have revealed a complex correlation between general anesthesia and postoperative sleep disturbances. In the days following surgery, patients who have undergone anesthesia may experience an increased level of Rapid Eye Movement (REM) sleep due to the suppression of REM sleep during anesthesia. Postoperative complications, such as delirium, may be caused by these disturbances. In particular, anesthesia can exacerbate sleep disorders among vulnerable populations, including those with preexisting disabilities. Insomnia, somnolence, appetite loss, and social withdrawal can be symptoms of preexisting sleep disorders that can worsen postoperative outcomes. There is still considerable uncertainty surrounding the relationship between general anesthesia and sleep disturbances. This scoping review aims to shed light on the incidence of sleep disturbances following surgical and dental anesthesia procedures and investigate the intricate connection between postoperative sleep and general anesthesia. A pioneering study in the field of anesthesia and perioperative care is embarked upon by exploring this critically important topic.

Warfarin ought to be utilized for an extended duration in individuals with a predisposition to thromboembolism, such as those with atrial fibrillation or aortic valve replacement. While the primary complication of long-term warfarin usage is the potential for bleeding, there are also infrequent complications like vascular and tracheal calcification. We present a case of a patient who experienced diffuse tracheal calcification as a result of long-term warfarin usage.

A 74-year-old female patient, who had been receiving chronic warfarin treatment for atrial fibrillation, required intubation and was admitted to the intensive care unit due to aspiration pneumonia. As the patient was unable to be extubated during the hospital stay, she became a candidate for Percutaneous dilution tracheostomy (PDT). It was discovered during the PDT procedure that all available spaces of the trachea above the sternum were calcified, preventing the passage of the trach needle. The presence of tracheal calcification was confirmed by both a radiologist and ultrasound examination.

Currently, individuals are compelled to employ oral anticoagulants, like warfarin, in order to avert thromboembolic diseases. Nevertheless, the protracted utilization of warfarin is linked with infrequent adverse outcomes, such as disseminated calcification. Consequently, meticulous scrutiny of these side effects is requisite for patients with enduring warfarin consumption.

Diaphragmatic hernias are rare and mostly congenital, rarely spontaneous. Perforation and other complications of diaphragmatic hernias are even rarer and associated with significant morbidity and mortality. We report a patient presenting to the emergency department with features of empyema requiring intercostal drainage. However, on clinical worsening, radiological imaging showed features of diaphragmatic hernia and a subsequent thoracostomy revealed a herniated gastric perforation. Such cases are very rare and need a high index of suspicion for the diagnosis and early appropriate surgical management. Otherwise, it is associated with very high rates of mortality.

We report a case of 30-year male who presented with Acquired Tracheoesophageal Fistula with subglottic stenosis and Aspiration Pneumonitis. Patient was managed with Feeding Jejunostomy, Tracheoesophageal Fistula repair and Tracheoplasty, after which patient recovered well. Difficult airway was managed by Awake Fiberoptic Intubation and cross-table ventilation through flexometallic tube intraoperatively during TEF repair.

Complete remaining guide wire in the vascular system after CVC is very rare. For which the maximum symptom-free reporting time in studies was five months, and in our case, the patient was symptom-free for one year. The only finding was one session complaining of ear pain and mastoid tenderness two weeks after catheter placement.
A 42-year-old male patient with the diagnosis of necrotizing pancreatitis and a retroperitoneal abscess was a candidate for laparotomy after ERCP. The patient was a candidate for central venous catheter insertion through the internal jugular vein before the surgery in the operating room by a third-year anesthesia resident. After one year, discovered that incidentally remaining guide wire during a follow-up MRI before pancreatitis. Which has been asymptomatic during this period. And despite the risk of rupture of the right heart and blood vessels due to possible fibrosis due to a long stay in the cardiovascular system, it is successfully removed by an endovascular surgeon.
The main reasons for the incident were the non-observance of scientific and safety principles at the time of catheter insertion and the failure to perform CXR after that.

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