Cardiopulmonary exercise testing is a non-invasive, objective method of assessing integrated response of heart, lungs and musculoskeletal system to incremental exercise. Though it has been in use for a few decades, the recent rise in its use as a preoperative test modality is reviewed. A brief account of cardiopulmonary exercise test, as it is carried out in practice and its applications, is given. The physiological basis is explained and relationship of pathophysiology of poor exercise capacity with various test variables is discussed. Its use for prediction of postoperative morbidity in various noncardiopulmonary surgical procedures is reviewed.

Anterior cervical discectomy and fusion is a commonly performed procedure for prolapse of cervical intervertebral disc. It involves retraction of soft tissue of neck for adequate exposure of anterior spinal canal. Increased cuff pressure with retractor application may affect the postoperative vocal cord function. Cuff pressures of tracheal tube were measured continuously in 37 patients using air-filled pressure transducer connected to the pilot balloon. Changes of pressure from baseline values were noted after application of cervical retractor. At the end of procedure, vocal cord movement was observed using fibreoptic bronchoscope. Significant increase in cuff pressure (168% of baseline values) and airway pressure of tracheal tube during cervical retraction was observed. The vocal cord function was assessed using fibreoptic laryngoscope. One patient developed right vocal cord palsy (2.7%) and two patients had postoperative hoarseness of voice (5.4%). All these complications improved over a period of time. It is suggested that the cuff of tracheal tube should be inflated to achieve 'just seal', with adequate cuff pressure monitoring. Intermittent release of cervical retraction may help to prevent laryngeal morbidities.

Modified electroconvulsive therapy (ECT) is a safe and most effective treatment modality for major depressive disorders with suicidal tendencies. For this, one must have an ideal intravenous anaesthetic agent for induction which provides rapid onset, short duration of action, attenuates adverse physiological effect of ECT, rapid recovery without adverse shortening of seizure duration and minimum rise in serum potassium. The studies in search of an ideal intravenous anaesthetic agent are limited. Aim is to compare the effect of iv thiopentone, propofol and midazolam on induction time and quality, haemodynamics, Seizure duration, recovery time and changes in serum potassium level. 90 patients of ASA I and II of either sex having major depressive illness were randomly allocated into three groups (n = 30) based on iv induction agent used. Group I, Group II and Group III patients were induced with iv thiopentone 5 mg/kg, propofol 2 mg/kg and midazolam 0.2 mg/kg, respectively. The induction time, quality of induction, haemodynamic changes, seizure duration, recovery time and change in serum potassium level were measured and analyzed by Z test. Induction was quicker in propofol group i.e., 41.03 ± 6.11 sec than in thiopentone (50.6 ± 6.32 sec) and midazolam group (77.30 ± 6.67 sec). Seizure duration was significantly shorter in midazolam group compared to propofol and thiopentone groups. Though significant rise in HR, SBP DBP was observed in all the three groups following ECT, but rise was significantly higher in thiopentone group compared to other two groups. Significantly, faster recovery was observed with propofol. Rise in serum potassium after ECT was not significant in any of the groups. Propofol is a safe and suitable intravenous anaesthetic agent for induction of anaesthesia for modified ECT.

In India, acute aluminium phosphide poisoning (AAlPP) is a serious health care problem. This study aimed to determine the characteristics of AAlPP and the predictors of mortality at the time of patients' admission. We studied consecutive admissions of patients with AAlPP admitted to the intensive care unit (ICU) between November 2004 and October 2006. We noted 38 parameters at admission to the hospital and the ICU and compared survivor and non-survivor groups. A total of 27 patients were enrolled comprising5 females and 22 males and the mean ingested dose of poison was 0.75 ± 0.745 grams. Hypotension was noted in 24 patients (89%) at admission and electrocardiogram abnormalities were noted in 13 patients (48.1%). The mean pH on admission was 7.20 ± 0.14 and the mean bicarbonate concentration was 12.32 ± 5.45 mmol/ L. The mortality from AAlPP was 59.3%. We found the following factors to be associated with an increased risk of mortality: a serum creatinine concentration of more than 1.0 mg % (P = 0.01), pH value less than 7.2 (P = 0.014), serum bicarbonate value less than 15 mmol/L (P = 0.048), need for mechanical ventilation (P = 0.045), need for vasoactive drugs like dobutamine (P = 0.027) and nor adrenaline (P = 0.048) and a low APACHE II score at admission (P = 0.019). AAlPP causes high mortality primarily due to early haemodynamic failure and multi-organ dysfunction

For treatment of intra and postoperative pain, no drug has yet been identified that specifically inhibits nociception without associated side effects. Magnesium has antinociceptive effects in animal and human models of pain. The current prospective randomised double-blind study was undertaken to establish the effect of addition of magnesium or clonidine, as adjuvant, to epidural bupivacaine in lower abdominal and lower limb surgeries. A total of 90 American Society of Anesthesiology (ASA) grade I and II patients undergoing lower abdominal and lower limb surgeries were enrolled to receive either magnesium sulphate (Group B) or clonidine (Group C) along with epidural bupivacaine for surgical anaesthesia. All patients received 19 ml of epidural bupivacaine 0.5% along with 50 mg magnesium in group B, 150 mcg clonidine in Group C, whereas in control group (Group A), patients received same volume of normal saline. Onset time, heart rate, blood pressure, duration of analgesia, pain assessment by visual analogue score (VAS) and adverse effects were recorded. Onset of anaesthesia was rapid in magnesium group (Group B). In group C there was prolongation of duration of anaesthesia and sedation with lower VAS score, but the incidence of shivering was higher. The groups were similar with respect to haemodynamic variables, nausea and vomiting. The current study establishes magnesium sulphate as a predictable and safe adjunct to epidural bupivacaine for rapid onset of anaesthesia and clonidine for prolonged duration of anaesthesia with sedation.

Endotracheal tube (ETT) should have intracuff pressure (ICP) in the range of 20 to 30 cm water (H ₂ O). In this observational study, we studied the trend amongst anaesthesiologist in choosing the type of ETT and their ability to assess optimum ICP clinically. After institutional ethics committee approval, we observed 75 patients under general endotracheal anaesthesia in Government Medical College. Anaesthesiologists were blinded to study purpose. The type of ETT used and magnitude of ICP was recorded. ICP was measured using simple aneroid manometer. Once the pressure was measured, it was readjusted to normal range and nitrous oxide was allowed to start. Red rubber tube was used in 18.7% and polyvinyl chloride (PVC) in 81.3% cases. The anaesthesiologists were not able to assess ICP in the recommended range clinically in 100% cases when red rubber ETT was used and in 40% cases when portex ETT was used. Red rubber ETT (reusable) with low-volume high-pressure cuff is still in use, though the trend is shifting towards more of using PVC ETT. Anaesthesiologists were not able to inflate the ETT cuff to the recommended range in spite of their clinical expertise (more than 5 years of teaching experience) in significant number of cases. We recommend the use of simple aneroid manometer for objective monitoring of ICP over subjective assessment, not only in red rubber, but also in PVC ETT.

This study was designed to compare the intra-operative and post-operative analgesic requirements and side effects of using fentanyl infusion versus remifentanil infusion during short-duration surgical procedures in children. The study comprised of 40 children randomly allocated into two equal groups: fentanyl (F-group) or remifentanil (R-group). Both were administered a continuous intravenous (i.v.) infusion. Anaesthetic recovery was assessed using the Brussels sedation scale every 5 min from the time of entry till discharge from recovery room. Post-operative analgesia was assessed throughout the first three post-operative (PO) hours using observational pain-discomfort scale (OPS) and adverse events were recorded. Haemodynamic variables showed a non-significant difference between both the groups. Patients who received remifentanil showed significantly shorter time to spontaneous respiration, eye opening, extubation and verbalization compared to those who received fentanyl. Discharge time was significantly shorter in R-group, and 18 patients fulfilled criteria for recovery-room discharge at ≤25 min with a significant difference in favour of remifentanil. Fentanyl provided significantly better PO analgesia than remifentanil and children in F-group showed a significantly lower mean cumulative OPS record than those in R-group; however, the number of patients requiring rescue analgesia did not show a significant difference between both the groups. Two cases in F-group and one in R-group had bradycardia, one case in R-group had mild hypotension and PO vomiting had occurred in three patients in the F-group and two patients in the R-group. In conclusion, remifentanil is appropriate for opioid-based anaesthesia for paediatric patients as it provides haemodynamic stability and rapid recovery with minimal post-operative side effects.

Intra-arterial injection of a local anaesthetic during stellate ganglion blockade may cause life-threatening complications. The usual complications are apnoea, unconsciousness and seizures. However, occasionally an unusual complication, 'locked-in' syndrome, has also been reported. In this syndrome the patients remain conscious despite their inability to move, breathe or speak. Here we describe a patient who developed features akin to the locked-in syndrome along with severe hypotension and bradycardia, after an injection of only 2 ml of lignocaine during a stellate ganglion block.

Bartter's syndrome is a rare inherited anamoly with defect in the thick segment of the ascending limb of the loop of Henle, with reduced reabsorption of potassium. Growth is affected with worsening renal function, hypokalaemia, hypochloraemic metabolic alkalosis, hypocalcemia, hypomagnesemia, increased levels of aldosterone, renin and angiotensin without hypertension and lack of responses to vasopressors. Treatment consists of potassium supplementation along with other medications. We present the case report, probably the first, of a child suffering from Bartter's syndrome with gall stones posted for laparoscopic cholecystectomy. The pre-operative correction of hypokalemia and successful anaesthetic and fluid and electrolyte management of the patient are discussed.

Spontaneous glottis closure during expiration in infants is a normal protective reflex that helps prevent alveolar and small airway collapse (due to compliant chest wall) and thereby maintains functional residual capacity. Endotracheal intubation eliminates this protective mechanism and puts the infant into the risk of hypoxaemia and hypercarbia. This report sums up the early detection of airway closure in a series of three intubated small infants undergoing surgery with general anaesthesia, by the appearance of typical pigtail shaped capnogram, associated with decreased end tidal carbon dioxide and mild hypoxaemia, which was successfully managed by early institution of positive end expiratory pressure.

A 20-year-old female in her third month of pregnancy, presented with generalised tonic clonic seizures, metabolic acidosis and coma following suicidal ingestion of antitubercular medication. We successfully managed the case with pyridoxine, sodium bicarbonate and mechanical ventilation.

Non-cardiogenic pulmonary oedema (NCPE) is a clinical syndrome characterized by simultaneous presence of severe hypoxemia, bilateral alveolar infiltrates on chest radiograph, and no evidence of left atrial hypertension/congestive heart failure/fluid overload. The diagnosis of drug-related NCPE relies upon documented exclusion of other causes of NCPE like gastric aspiration, sepsis, trauma, negative pressure pulmonary oedema, etc. We describe two cases (45-year male and 6-year male), who had undergone elective surgery under general anaesthesia. They developed NCPE within 3-5 minutes after administration of 'neostigmine-glycopyrrolate' used to reverse residual neuromuscular blockade. Both patients were treated successfully with mechanical ventilatory support, and adjuvant therapy, viz., frusemide, dopamine, steroids. This report emphasizes that this fatal complication may be seen with neostigmine, the pathogenic mechanism remains unknown, and it probably is a drug-related NCPE.

Myocardial infarction (MI) is uncommon in patients undergoing noncardiac surgery without a history of coronary artery disease. But, patients with compromised pulmonary function and coexisting anaemia superimposed by precipitating factors like prolonged hypotension and tachycardia can culminate in myocardial catastrophe even in the absence of risk factors. We are herewith reporting an unusual case of postoperative non-ST elevation MI without any pre-existing ischemic heart disease. A 39-year-old female patient who was submitted for diagnostic video-assisted thoracoscopy and chemical pleurodesis for recurrent pneumothorax developed postoperative MI. After review of all the factors, it was found that the patient developed Type 2 MI as a sequel to oxygen supply and demand mismatch secondary to hypoxia and prolonged hypotension. This was evident in the 12-lead electrocardiogram and was confirmed by elevated cardiac biomarkers and regional wall motion abnormality on echocardiography.

Guillain-Barrι syndrome with ventricular septal defect is rare finding. Delayed diagnosis,often leading to increased complications. This report describes an Guillain-Barrι syndrome case and the special approaches required during anaesthesia. 4 yrs old male pt with Guillain-Barrι syndrome diagnosed at time of ward admission, submitted to video-assisted thoracic surgery under uneventful general anaesthesia with sevoflurane, without neuromuscular blockers. The case highlights the frequency with which this syndrome so important for anaesthetic practice is diagnosed, adverse events, the best choice for the anaesthetic team and complications of pediatric Guillain-Barrι syndrome.

Liver transplantation in small children poses perioperative challenges that are different from those seen in adults. We present our successful anaesthetic experience in a 7-month-old infant who has been the youngest case of successful living donor liver transplant performed in our institution till the day this article was being prepared.