Postoperative renal dysfunction is a relatively common and one of the serious complications of cardiac surgery. Though off-pump coronary artery bypass surgery technique avoids cardiopulmonary bypass circuit induced adverse effects on renal function, multiple other factors cause postoperative renal dysfunction in these groups of patients. Acute kidney injury is generally defined as an abrupt and sustained decrease in kidney function. There is no consen­sus on the amount of dysfunction that defines acute kidney injury, with more than 30 definitions in use in the literature today. Although serum creatinine is widely used as a marker for changes in glomerular filtration rate, the criteria used to define renal dysfunction and acute renal failure is highly variable. The variety of definitions used in clinical studies may be partly responsible for the large variations in the reported incidence. Indeed, the lack of a uniform definition for acute kidney injury is believed to be a major impediment to research in the field. To establish a uniform definition for acute kidney injury, the Acute Dialysis Quality Initiative formulated the Risk, Injury, Failure, Loss, and End-stage Kidney (RIFLE ) classification. RIFLE , defines three grades of increasing severity of acute kidney injury -risk (class R), injury (class I) and failure (class F) - and two outcome classes (loss and end-stage kidney disease). Various perioperative risk factors for postoperative renal dysfunction and failure have been identified. Among the important preoperative factors are advanced age, reduced left ventricular function, emergency surgery, preoperative use of intraaortic balloon pump, elevated preoperative serum glucose and creatinine. Most important intraoperative risk factor is the intraoperative haemodynamic instability and all the causes of postoperative low output syndrome com­prise the postoperative risk factors. The most important preventive strategies are the identification of the preoperative risk factors and therefore the high risk groups by developing clinical scoring systems. Preoperative treatment of congestive cardiac failure and volume depletion is mandatory. Avoidance of nephrotoxic drugs and prevention of significant hemodynamic events that may insult the kidney are essential. Perioperative hydration, aggressive control of serum glucose, haemodynamic monitoring and optimization of ventricular function are important strategies. Several drugs have been evaluated with inconsistent results. Dopamine and diuretics once thought to be renoprotective has not been shown to prevent renal failure. Mannitol is probably effective if given before the insult takes place. Some of the newer drugs like fenoldopam, atrial natriuretic peptide, N-acetylcysteine, clonidine and diltiazem have shown some promise in preventing renal dysfunction but more studies are needed to establish their role of renoprotection in cardiac surgery.

In vitro fertilization is an upcoming speciality. Anaesthesia during assisted reproductive technique is generally required during oocyte retrieval, which forms one of the fundamental steps during the entire procedure. Till date variety of techniques like conscious sedation, general anaesthesia and regional anaesthesia has been tried with none being superior to the other. However irrespective of the technique the key point of anaesthesia for in vitro fertilization is to provide the anaesthetic exposure for least duration so as to avoid its detrimental effects on the embryo cleavage and fertilization.

Supraglottic devices have changed the face of the airway management. These devices have contributed in a big way in airway management especially, in the difficult airway scenario significantly decreasing the pharyngolaryngeal morbidity. There is a plethora of these devices, which has been well matched by their wider acceptance in clinical practice. ProSeal laryngeal mask airway (PLMA) is one such frequently used device employed for spontaneous as well as controlled ventilation. However, the use of PLMAat tunes maybe associated with certain problems. Some of the problems related with its use are unique while others are akin to the classic laryngeal mask airway (eLMA). However, expertise is needed for its safe and judicious use, correct placement, recognition and management of its various malpositions and complications. The present article describes the tests employed for proper confirmation of placementto assess the ventilatooy and the drain tube functions of the mask, diagnosis of various malpositions and the management of these aspects. All these areas have been highlighted under the heading of troubleshooting PLMA. Many problems can be solved by proper patient and procedure selection, maintaining adequate depth of anaesthesia, diagnosis and management of malpositions. Proper fixation of the device and monitoring cuff pressure intraopera­tively may bring down the incidence of airway morbidity.

Critical incident monitoring is useful in detecting new problems, identifying `near misses' and analyzing factors or events leading to mishaps, which can be instructive for trainees. This study was aimed at investigating potential risk factors and analyze events leading to pen-operative critical incidents in order to develop a critical incident reporting system. W conducted a one year prospective analysis of voluntarily reported 24- hour-perioperative critical inci­dents, occurring in patients subjected to anaesthesia. During a one year period from December 2006 to December 2007, 14,134 anaesthetics were administered and 112(0.79%) critical incidents were reported with complete recov­ery in 71.42%(n=80) and mortality in 28.57% (n=32) cases. Incidents occurred maximally in 0-10 years age (23.21%), ASA 1(61.61%), in general surgery patients (43.75%), undergoing emergency surgery (52.46%) and during day time (75.89%). Incidence was more in the operating theatre (77.68%), during maintenance (32.04%) and post-operative phase (25.89%) and in patients who received general anaesthesia (75.89%). Critical incidents occurred clue to fac­tors related to anaesthesia (42.85%), patient (37.50%) and surgery (16.96^°lo). Among anaesthesia related critical incidents (42.85% n=48/112), respiratory events were maximum (66.66%) mainly at induction (37.5%) and emer­gence (43.75%), and factors responsible were human error (85.41%), pharmacological factors (10.41%) and equip­ment error (4.17%). Incidence of mortality was 22.6 per10, 000 anaesthetics (32/14,314), mostly attributable to risk factors in patient (59.38%) as compared to anaesthesia (25%) and surgery (9.38%). There were 8 anaesthesia related deaths (5.6 per 10, 000 anaesthetics) where human error (75%) attributed to lack of judgment (67.50%) was an important causative factor. We conclude that critical incident reporting system may be a valuable part of quality assurance to develop policies to prevent recurrence and enhance patient safety measures.

Choice of an appropriate anaesthetic technique and adequate pain relief during laparoscopic living donor ne­phrectomy (LDN) is likely to make the procedure more appealing to kidney donors. Various analgesic regimens proposed to relieve pain after laparoscopic surgery include: opioids, non-opioid analgesics followed by opioids for the breakthrough pain and intra-peritoneal normal saline irrigation and instillation of local anaesthetics at surgical sites. Thorough literature review and medline search did not reveal any study where a combination of orogastrie aeetazolamide along with intraperitoneal saline irrigation and bupivacaine instillation techniques have been tried in these patients. In a prospective, double blind, randomized trial, eighty healthy adults undergoing LDN under general anaesthesia were enrolled to compare the efficacy of an acetazolamide based multimodal analgesic approach (Group A) with conventional pain management (Group B). Donors' demographics, intra-operative variables, early allograft function and recovery characteristics were evaluated for 72 hours. The primary end points were postoperative pain intensity on a visual analog scale and the incidence of shoulder tip pain (SIP). The secondary end points included the latency of the rescue analgesia request rate, total analgesic consumption and patient satisfaction. Consistently lower mean pain scores were observed in Group A (p <0.03 for visceral pain). Frequency as well as the total dose of rescue analgesics administered was significantly less in Group A (p=0.001). Twelve patients (30.7%) in Group B complained of STP compared to three (7.5%) in Group A(p=0.025). Shoulder pain also presented earlier (8 hours versus 12 hours) and persisted for longer period in Group B (72 hours versus 48 hours, p 0.025). To conclude, a multimodal analgesic approach consisting a combination of orogastric acetazolamide, intraperito­neal saline irrigation and use of bupivacaine in the operated renal fossa, pfannenstiel incision and laparoscopic port sites provide significant reduction in postoperative pain after LDN.

Prophylactic steroid therapy to reduce the occurrence of postextubation laryngeal edema is controversial. Only a limited number of prospective trials involve adults and children in an intensive care unit. The purpose of this study was to ascertain whether administration of multiple doses of dexamethasoneto critically ill, intubated patients reduces or prevents the occurrence of postextubation laryngeal edema / stridor and its risk factors .Another specific objective of our study was to investigate whether an after-effect (that is, a transient lingering benefit) exists 24 hours after the discontinuation of dexamethasone In a prospective, randomized, double-blind control study, a total of 120 patients were randomly allocated both in children and adult population, who were ventilated more than 24 hours in ICU; into study and Control group. Study group comprising 60 patients with 30adults and 30 children. Study group adults received 8mg dexamethasone 4 doses i.e 4 hours prior to planned extubation, at extubation and 6 and 12 hours after extubation. Children received 0.5 mg.Kg ^-1 dose with maximum of 8mg at similar intervals. Control group comprising of 30 adults and 30 children who received placebo or saline at similar intervals. There was statistically significant difference (p = 0.019) in comparison of failed extubation (those who cannot withstand extubation and reintubated) in children with respect to adults. Moreover, duration of intubation (p =0.014) and female gender were also risk factors for failed extubation. We concluded that prophylactic use of intravenous dexamethasone is useful in preventing postextubation laryngeal edema/stridor in children but not in adults.

We evaluated the analgesic efficacy, hemodynamic and respiratory safety of Clonidine when added to bupivacaine for caudal block. Forty children undergoing inguinal hernia repair were randomly given caudal injection with 0.75 ml.kg ^-1 of bupivacaine (0.25%) and clonidine 2 µg.kg ^-1 in Group C or 0.75 ml.kg ^-1 of bupivacaine (0.25%) alone in Group B after induction of anaesthesia. Postoperatively duration of analgesia, OPS score (observational pain / dis­comfort scale), Sedation score, heart rate and blood pressure were recorded. Duration of analgesia was significantly longer (p< 0.001) in Group C (10.25 hours) as compared to 4.55 hours in Group B. Bradycardia, hypotension and sedation were not observed in Group C. The addition of Clonidine in caudal blocks prolongs postoperativepain relief in children and is safe alternative to bupivacaine alone in paediatric daycare surgeries.

A perioperative anaesthetic management that aims to facilitate tracheal extubation of patients within 1-6 hrs after cardiac surgery is called "fast-track'. Main advantage of 'fast-track" method is better usage of medical resources and lowering hospital costs without increasing morbidity and mortality of the patients. Standard fast-track protocols contain short acting anaesthetic agents, smaller incisions and decreased pump times without hypothermia. In this study we compared two short acting opioid drugs, fentanyl versus Sufentanil when used as a part of the balanced anaesthesia technique for fast track in cardiac surgery patients& evaluated the time taken for extubation, haemodynamic stability, analgesia requirements& incidence of awareness. The results from the study show thatboth agents provide good haemodynamic stability and postoperative analgesia. Although Sufentanil provides earlier extuba­tion, both agents reduce the ICU stay equally. In conclusion both agents can be used effectively for fasttrack cardiac anaesthesia.

Thirty children, ASAI-II, aged between 2yrs-5yrs, undergoing sub umbilical operation (inguinal and penile surgery) were selected for this double blind study. They were randomly divided in two groups, group Aand group B. Group A(n15) received 0.25%bupivacaine 0.5ml.kg ^-1 and Group B (n=15) received 0.25% bupivaeaine 0.5ml.kg ^-1 and tramadol 2mg.kg ^-1 as single shot caudal block. Postoperative pain was assessed by a modified TPPPS (Toddler­Preschool Postoperative Pain Scale) and analgesic given only when the score was more than 3. In the first 24 hrs it was observed that the mean duration of time interval between the caudal block and first dose of analgesic was significantly long(9. lhrs) in Group B as compared to Group A (6.3hrs) which was much shorter(p<0.01).There was no significant haemodynamie changes, motor weakness or respiratory depression in both groups. This study con­cluded that addition of tramadol 2mg.kg ^-1 to caudal 0.25% bupivacaine 0.5ml.kg ^-1 significantly prolong the duration of postoperative analgesia in children withoutprodueing much adverse effects.

Sufentanil is an excellent adjuvant in total intravenous anaesthesia (TIVA). The present study evaluates effec­tiveness of differentconeentrations of Sufentanil mixed in propofol for TI VAin laparoscopic cholecystectomy. Sixty adult patients of ASA physical status I or II (randomly divided into 3 groups of twenty each) undergoing elective laparoscopic cholecystectomy were included in this randomised control study. At induction, patients in all groups received i.v. bolus of Sufentanil 1ìg kg^-1 and continuous infusion of 100 ìg kg^-1 min ^-1 . Anaesthesia was maintained with propofol infusion titrated in a range of 75 to 125ìg kg^-1 min ^-1 . Groups S 1 and S2 received propofol with Sufentanil added at 1ìg ml ^-1 and 2 ìg ml ^-1 concentrations respectively, while group Preceived propofol without Sufentanil. Additional Sufentanil boluses (10 ìpg) were given to patients in all groups when there was an increase in the heart rate by more than 20 beats per minute or mean arterial pressure by more than 15% above baseline. Perioperative haemodynamic parameters, recovery times and postoperative analgesia were compared across the three groups of patients. Haemodynamie parameters (heart rate, systolic and diastolic blood pressures) were not significantly differ­ent across the three groups of patients in the perioperative period. Fewer Group S2 patients required additional Sufentanil boluses to maintain adequate depth of anaesthesia compared to other two groups. Group S2 patients had better post-operative analgesia (p=0.01) but prolonged recovery time (p=0A01) compared to the other two groups. Sufentanil mixed with propofol provides better haemodynamic stability in laparoscopic eholecystectomies, with lesser requirementfor additional Sufentanil boluses, and good postoperative analgesia.

Unilateral pulmonary edema of the dependant lung was observed in three patients during laparoscopic donor nephrectomy. Patients were treated with 02 supplementation by face mask, fluid restriction and diuretic. All the patients were relieved of symptoms with radiological improvement. The possible causes of this unusual complication following laparoscopic surgery appear to be prolonged lateral decubitus position and high intraoperative fluid infusion.

We report three cases where BiPAP (bi-level positive airway pressure) was used with CSEA (combined spinal epidural anaesthesia) to over come the hypoventilation due to preoperative poor respiratory reserves and additive effect of sedation. Combination of BiPAP with spinal, epidural and CSEA have been used successfully in patients of severe COPD (chronic obstructive pulmonary disease) for various surgical procedures. This combination provides safe alternative to conventional general anaesthesia, as it avoids need for postoperative ventilatory support and its deleterious effects.

Congenital lobar emphysema (CLE) characterized by over distension and air-trapping in the affected lobe is one of the causes of infantile respiratory distress requiring surgical resection of affected lobe. At induction, positive pressureventilation can expand the emphysematous lobe compressing the normal lung resulting in severe cardiovascular compromise. We report a case of 28 day old baby with CLE posted for emergency lobeetomy. Strategies to prevent hyperinflation and anaesthetic considerations of various techniques adopted for lung separation in infants have been reviewed.

Perioperative pulmonary oedema is one of the most challenging complications faced by anaesthesiologists. In most of the instances, coronary artery disease, valvular heart diseases, hypertension may precipitate pulmonary oedema due to increased hydrostatic pressure while acid aspiration, airway obstruction may cause it due to increased vascular permeability. In a few instances, acute pulmonary oedema can present in an otherwise healthy patient to cause diagnostic difficulties. We report two such cases of intra operative pulmonary oedema with the use of ketamine which were identified and managed successfully. The most probable cause is also described.

Takayasu's arteritis is described to be the single most important cause of renovascular hypertension. Anaesthetising a child with Takayasu's arteritis for auto renal transplantation is a challenge as it is complicated by severe uncon­trolled hypertension, end-organ dysfunction resulting from hypertension, stenosis of major blood vessels affecting regional circulation, and difficulties encountered in monitoring arterial blood pressure. Abalanced anaesthetic tech­nique, maintenance of stable haemodynamics with monitoring is required for a successful outcome. We describe the anaesthetic management of a child with Takayasu's arteritis and severe hypertension refractory to medical treatment requiring auto renal transplantation.

Primary hyperparathyroidism is a disease characterized by hyperealeaemia attributable to autonomous overpro­duction of parathormone. Many patients with primary hyperparathyroidism are asymptomatic. Osteoporosis and nephrolithiasis are some of the major sequelae seen in the symptomatic patients. Parathyroidectomy is the only curative therapy. However anaesthetic management of such patients may be problematic with associated cardiac arrhythmias and skeletal muscle weakness. Low serum albumin and alteration in the acid base status in the perioperative period can affect the serum calcium level and thus adds to the existing problem. We present the successful anaes­thetic management of a patient with primary hyperparathyroidism who initially presented with pathological fractures, and discuss the anaesthetic issues involved.

Treacher-Collins syndrome is a rare congenital disease known to be associated with a difficult airway and presents some of the most hazardous and difficult challenges that anaesthetists may encounter within the entire practice of paediatric anesthesia. Successful anaesthetic management in a case of Treacher-Collins syndrome posted for cleft palate repair is presented in this report.

Peters' anomaly occurs as an isolated ocular abnormality, in association with other systemic abnormalityor one component of a number of well-defined syndromes. We review our experience of anaesthetic management and systemic association of peters' anomaly. To the best of our knowledge there are no reports in the literature of Peters' anomaly with relevant to anaesthesia.