There has been a renewed interest in matters relating to Medical Negligence since the Consumer Protection Act (CPA) was made applicable to the Medical Profession. Cases of medical negligence are now being filed in consumer courts instead of the regular courts. The Supreme Court judgement in Indian Medical Association Vs V. P. Shantha& Ors. has brought a radical change in the interpretation of CPA. This article reviews the situation in the light of cases decided by various courts in India and Abroad including the Consumer Courts.

Traumatic brain injury (TBI) occurs when a sudden trauma causes brain damage. Depending on the severity, outcome can be anything from complete recovery to permanent disability or death. Emergency medical services play a dominant role in provision of primary care at the site of injury. Since little can be done to reverse the initial brain damage due to trauma, attempts to prevent further brain damage and stabilize the patient before he can be brought to a specialized trauma care centre play a pivotal role in the final outcome. Recognition and early treatment of hypoten­sion, hypoxemia, and hypoglycemia, objective neurological assessment based on GCS and pupils, and safe transport to an optimal care centre are the key elements of prehospital care of a TBI patient.

Paediatric spinal anesthesia is not only a safe alternative to general anaesthesia but often the anaesthesia technique of choice in many lower abdominal and lower limb surgeries in children. The misconception regarding its safety and feasibility is broken and is now found to be even more cost-effective. It is a much preferred technique especially for the common daycase surgeries generally performed in the paediatric age group. There is no require­ment of any additional expensive equipment either and this procedure can be easily performed in peripheral centers. However, greater acceptance and experience is yet desired for this technique to become popular.

One of the greatest challenge to the anaesthesiologists is management of child with difficult airway. Sometimes serious anaesthetic accidents have occurred due to mismanagement of airway. Management of even normal airway in a neonate is different and complex as compared to airway of two year old child and that of adult. Airway manage­ment of neonates and babies with difficult and compromised airway is being discussed.

The combined spinal epidural (CSE) technique is gaining popularity as it is associated with rapid onset of analgesia and it has a flexibility of an epidural catheter insertion. Though both epidural and CSE technique provide effective analgesia, epidural technique is reported to be associated with prolonged labour. By contrast, CSE technique is observed by many workers to be associated with shortened labour and increased rate of cervical dilatation. How­ever, it is not clear whether rapid rate of cervical dilatation is the physiologic effect of the CSE technique or it is an artifact of patient selection, as CSE technique is usually used in the patient in advanced stage of labour requiring rapid analgesia. We hypothesized that rapid cervical dilatation seen with CSE technique is physiologic effect of the technique and not mere an artifact and compared the CSE and epidural techniques with regard to progress of labour with special emphasis on rate of cervical dilatation and duration of labour. Sixty healthy nulliparous parturients in spontaneous labour with singleton fetus were randomized in a prospec­tive double blinded manner to receive either CSE analgesia or epidural analgesia. The epidural group (n= 30) received 10 ml bolus of 0.0625% bupivacaine+ 0.0002% fentanyl& the CSE group (n= 30) received intrathecally 25 mcg fentanyl + 1.25 mg bupivacaine. The rate of cervical dilatation was significantly greater in the CSE group as com­pared to the epidural group (3.5 ± 0.752 cm / hr vs. 2.0 ± 1.122, P = 0.000)& the duration of active stage of first stage of labour was significantly shorter in-group CSE (117.5 ±25.57 min vs. 192.5 ± 12 min, P = 0.000).

The ProSeal ^TM laryngeal mask airway (PLMA) has been especially designed for positive pressure ventilation and protection against aspiration. We tested the efficacy and safety of the PLMA as a ventilatory device for a variety of commonly performed laparoscopic surgeries. The PLMA was used for the airway management of one thousand; consecutive anaesthetized, paralysed patients, aged 13-86 years belonging to ASA physical status I-III scheduled for elective laparoscopic and extraperitoneal endoscopic surgeries. Details of insertion, oropharyngeal seal pressure (OSP), ventilatory performance and safety data of the PLMA were recorded. During surgery, oxygenation and ventilation variables were adjusted to maintain SpO₂ > 95 %, as measured by pulse oximetry and EtCO₂ < 46 mm Hg, respectively. The success rate of PLMA insertion and gastric tube placement was 100 %. One patient had short lived SpO₂ of 94 % while three patients showed transient increase in EtCO₂ > 55 mm Hg. Twenty five (2.5%) patients showed gastric regurgitation, suctioned through the oesophageal channel of the PLMA, but no case of pulmonary aspiration was detected. Median OSP was 36 cm H₂O. The median peak inspiratory pressure (PIP) before and after CO₂- insufflation were 10 and 18 cm H₂O, respectively (P < 0.001). Our study demonstrated that the PLMA, in experienced hands, is an efficient and safe airway tool for the airway management of patients undergoing elective laparoscopic surgery.

Training in resuscitation is done worldwide by a dedicated council who is responsible for training and frequent recertification. Nigeria has no Resuscitation council and training is the responsibility of individual health institutions. There is no mandatory law on resuscitation training or recertification. This study sought to investigate how much training in CPR occurs, how effective this training is and how confident our anaesthetic trainees are in implementing present guidelines. A detailed questionnaire was anonymously filled by trainee anaesthetists who attended a revision course prior to postgraduate examinations. They answered questions on their length of training in anaesthesia, CPR training re­ceived, confidence in implementing existing guidelines and suggestions for improvement. Thirty -six trainees responded. Mean length of anaesthetic training was 3.55 ±2.39 years. 55.6% of trainees had received some CPR training. 75% of this was conducted by their anaesthetic department. Eleven trainees (30.6%) were confident in their ability to perform CPR according to 2005 guidelines, twelve (33.3%) had ever defibrillated a patient and only ten (27.8%) were confident in their ability to interpret ECG There is low confidence among junior anaesthetists in Nigeria in performance of CPR, poor knowledge of ECG interpretation of cardiac arrest rhythm and little practice in defibrillation. The establishment of a Resuscitation council would ensure adequate and frequent training which would improve knowledge, boost confidence and result in better patient care.

Fifty ASA grade I/II patients scheduled for elective lower abdominal, lower limb and urological procedures were divided into two groups of 25 each .The first group (Group S) received 2.5 ml of heavy bupivacaine with 0.2. ml sufentanil made up to 3 ml with saline. The second group (Group F) received 2.5 ml of heavy bupivacaine with 0.5 ml of fentanyl. From our study it can be concluded that bupivacaine sufentanil combination although had shorter onset of action, but had more side effects especially nausea, vomiting and headache. The time for rescue analgesia in both groups was however similar.

Use of steroids for different airway morbidities is common. This retrospective analysis was aimed at justifying the use of dexamethasone in preventing postoperative airway morbidities during extubation in paediatric age group. Recorded data of all paediatric surgeries in a particular institute was analyzed for incidences of post extubation airway problems in patients who received dexamethasone and compared with those who did not receive any steroid perioperatively. Three hundred and thirty one patients were considered out of which 226 received intravenous dex­amethasone preoperatively, and 105 did not receive any steroids peri-operatively. Out of 52 children (15.7%) who had post-extubation airway problems, only 14 (6.1%) belonged to the dexamethasone group while 38 (36.1%) be­longed to the non-dexa group. The difference noted in the incidence between the two groups was statistically signifi­cant (p< 0.05).There was no significant incidence of any systemic adverse effects while a large number of children developed severe perianal and vulval pruritus immediately after the bolus dexamethasone injection. There was no significant difference in the incidence of subglottic or supraglottic airway morbidities when compared between both the groups. In conclusion, a single bolus preoperative intravenous dose of dexamethasone, in paediatric patients, is of immense help in reducing the airway morbidities faced at the time of extubation in the post operative period.

Maxillofacial injuries are the result of high velocity trauma arising from road traffic accidents, gunshots and missile injuries. These injuries require emergency airway management in prehospital and hospital settings and as well as for reconstruction of fractures subsequently. Anaesthesiologist must be conversant with the alternative techniques and appliances. One hundred twenty seven cases of maxillofacial injuries, treated over a period of three years in a service hospital were reviewed. Fracture mandible was most common injury (51%) followed by fractures of maxilla and zygoma (35%). Nasal intubation with direct visualization of vocal cords was most common (56%) and this was followed by oral intubation (17%). Blind awake nasal intubation was carried out in 20%. Fibreoptic bronchoscope and preoperative tracheostomy were other methods of airway management. Maxillofacial injuries need special attention since it involves difficult airway due to fracture to facial bones, Further the airway is shared with surgeon and restrictions are imposed during surgery. Issues involved are time of surgery, preoperative airway assessment, type of intubation and way to achieve it, alternative methods available and their complications.

We as anaesthesiologist at times encounter patients with mandibular dystocias, and oral/oropharyngeal lesions for surgical management. Such patients pose a challenge for airway management and intubation and at times proce­dure may end with tracheostomy. The Macintosh curved blade laryngoscopy is gold standard for intubation. This technique may be technically flawed in conditions like vallecular cyst, tonsillar growth, mandibular dystocias and hemifacial microsmia. However the experience of otolaryngologists to visualize the glottis using a straight blade direct laryngoscope (Jackson type) in cases where anaesthesiologist fails, prompted us to use straight blade laryngoscope (Miller's) for intubation. Here we describe, review and discuss an alternative technique of paraglossal straight blade intubation. We have tried this technique in five patients of difficult intubation and were able to avoid emergency cricothyrotomy and tracheostomy.

The rare congenital heart defect of Ebstein's anomaly is characterized by downward displacement and elonga­tion of the tricuspid valve with poorly contractile right ventricle, an enlarged right atrium along with tricuspid regurgi­tation. Supra ventricular and ventricular arrythmias are common. Here we describe the successful management of a pregnant patient undergoing an urgent LSCS under epidural anaesthesia. There was inadvertent dural puncture while performing the block, which was treated with sterile epidural boluses of saline. Perioperative management was uncomplicated and both the mother and newborn were discharged without any untoward problem.

A 35-year-old male patient with ischaemia of the right lower limb due to peripheral vascular disease, with comorbid conditions such as coronary artery disease, hypertension and COPD, was posted for a femoro femoral crossover graft. A continuous spinal anaesthesia technique was used, wherein bolus doses of bupivacaine 0 .5% was delivered intermittently in the subarachnoid space, via a 20 gauge epidural catheter. The benefits of this technique were the rapidity of action, minimal of the amount of drug used., and an ability to achieve the desired segmental level of anaesthesia. A review of literature, analysis of benefits and drawbacks of this underused technique is presented.

Tracheomalacia is weakness of tracheal wall caused by softening of supporting cartilage and hypotonia of myoelastic elements. In patients with huge thyroid, following thyroidectomy it is due to extrinsic compression by enlarged thyroid in which previously normal cartilage undergoes degeneration. We report a case of tracheomalacia following total thyroidectomy for malignant neoplasm of thyroid gland who was diagnosed and managed.

Myoclonic movements under anaesthesia are a less recognized phenomenon. We report here a case of 24-year old man who underwent varicose vein stripping and ligation procedure under spinal anaesthesia and developed spinal myoclonus.The movements gradually decreased in frequency and finally disappeared on the third postoperative day. The case warrants awareness about its occurrence, and anaesthetists must watch out for and recognize it.

The Bonfils retromolar fibrescope is a rigid fibrescope with an angled end. A 35-years- male with restricted mouth opening was scheduled to undergo reconstruction of fractured zygoma. We decided to try oral intubation under local anaesthesia with the Bonfils intubation fibrescope with a size 8.0 endotracheal tube loaded over it. This assembly was introduced from the right corner of the mouth till the curved tip had entered well inside the mouth. The scope was then brought to the midline and introduced further inside. Intubation was achieved easily.

Malpositioning of central venous catheter inserted into subclavian vein is a known and dreaded complication. Malpositioning of catheter tip into contralateral subclavian is an extremely unusual occurrence. The author describes two cases, one of subclavian central venous catheter and another of a peripherally inserted central catheter, in which the catheter malpositioned into contralateral subclavian vein.