There is considerable useful information about anaesthesia available on the World Wide Web. However, at present, it is very incomplete and scattered around many sites. Many anaesthetists find it difficult to get the right information they need because of the sheer volume of information available on the internet. This article starts with the basics of the Internet, how to utilize the search engine at the maximum and presents a comprehensive list of important websites. These important websites, which are felt to offer high educational value for the anaesthesiologists, have been selected from an extensive search on the Internet. Top-rated anaesthesia websites, web blogs, forums, societies, e-books, e-journals and educational resources are elaborately discussed with relevant URLs.

Free radicals are highly reactive and unstable compounds. These highly reactive molecules cause oxidative damage to cellular components such as DNA, proteins and lipids. They play central role in the mechanism of cell injury and cell death. Free radical scavengers either prevent these reactive species from being formed, or remove them before they can damage vital components of the cell. Oxidative stress defines an imbalance in production of oxidizing chemical species and their effective removal by protective antioxidants and scavenger enzymes. Evidence of massive oxidative stress is well established in critical illnesses characterized by tissue ischaemia-reperfusion injury and by an intense systemic inflammatory response such as during sepsis and acute respiratory distress syndrome, acute lung injury. Several clinical trials have been performed in order to reduce oxidative stress by supplementation of antioxidants alone or in combination with standard therapies. Antioxidant supplementation at an early stage of illness may lead to improved therapies in the treatment of critically ill patients. Several intravenous anaesthetic drugs act as reactive oxygen species scavengers. Anaesthetic preconditioning is of particular interest to anaesthesiologist, in which lasting protection of myocardium is elicited by brief exposure to a inhalational anaesthetic agent. These anasthetics may also mediate protective effects in other organs, such as the brain and kidney It is important for the anaesthesiologist to understand the mechanism of damage caused by free radicals and how free radical scavengers work so that this knowledge can be applied to varied pathological conditions. The topic was hand searched in text books and electronically searched from PubMed and Google scholar using text words.

Background: Allogenic blood transfusion is associated with several potential complications, especially in patients with cancer. The objective of this prospective single-centre study was to identify the rates of perioperative blood transfusion and overtransfusion in a tertiary-level cancer hospital. Methods: Between March and May 2008, we studied all adult patients undergoing elective major cancer surgery under anaesthesia and recorded intra- and immediate post-operative (within 24 h) blood transfusions and post-operative investigations. Overtransfusion was defined as post-transfusion haemoglobin (Hb) exceeding 10 g/dL. Results: One hundred and eighty-six of 1175 (16%) patients received perioperative blood transfusion. The main trigger for intraoperative transfusion was blood loss exceeding the patient's maximum allowable blood loss (92, 49%). Ninety-five (51%) transfused patients had post-transfusion Hb more than 10 g/dL. The rate of overtransfusion was not higher in patients who received single-unit transfusions. Conclusion: The perioperative transfusion rate in patients undergoing cancer surgery was 16%. More than half of these patients were overtransfused. Following this audit, point-of-care facilities for intraoperative haemoglobin measurement have been introduced.

Background: Closed loop anaesthesia delivery systems (CLADSs) are a recent advancement in accurate titration of anaesthetic drugs. They have been shown to be superior in maintaining adequate depth of anaesthesia with few fluctuations as compared with target-controlled infusion or manual titration of drug delivery. Methods: Twenty patients scheduled to undergo general abdominal or orthopaedic procedures under general anaesthesia at Leh (3505 m above sea level) were recruited as subjects. Anaesthesia was delivered by a patented closed loop system that uses the Bispectral Index (BIS ^TM ) as a feedback parameter to titrate the rate of propofol infusion. All vital parameters, drug infusion rate and the BIS ^TM values were continuously recorded and stored online by the system. The data generated was analysed for the adequacy of anaesthetic depth, haemodynamic stability and post-operative recovery parameters. Results: The CLADS was able to maintain a BIS ^TM within ±10 of the target of 50 for 85.0±7.8% of the time. Haemodynamics were appropriately maintained (heart rate and mean arterial blood pressure were within 25% of baseline values for 91.2±2.2% and 94.1±3% of the total anaesthesia time, respectively). Subjects were awake within a median of 3 min from cessation of drug infusion and achieved fitness to recovery room discharge within a median of 15 min. There were no adverse events or report of awareness under anaesthesia. Conclusions: The study demonstrates the safety of our CLADS at high altitude. It seeks to extend the use of our system in challenging anaesthesia environments. The system performance was also adequate and no adverse events were recorded.

Background and Objectives: Alpha-2 agonists are mixed with local anaesthetic agents to extend the duration of spinal, extradural and peripheral nerve blocks. We compared clonidine and dexmedetomidine as an adjuvant to local anaesthetic agent in supraclavicular brachial plexus block with respect to onset and duration of sensory and motor block and duration of analgesia. Methods: Sixty ASA I and II patients scheduled for elective upper limb surgeries under supraclavicular brachial plexus block were divided into two equal groups in a randomized, double-blinded fashion. Group C received clonidine 1 μg/kg and Group D received dexmedetomidine 1 μg/kg added to bupivacaine 0.25% (35 cc). Onset and recovery time of sensory and motor block, duration of analgesia and quality of block were studied in both the groups. Results: Duration of sensory block and motor block was 227.00±48.36 and 292.67±59.13 min, respectively, in group C, while it was 413.97±87.13 and 472.24±90.06 min, respectively, in group D. There was no statistically significant difference in onset of sensory and motor block between the two groups. The duration of analgesia (time to requirement of rescue analgesia) in group D was 456±97 min, while in group C, it was 289±62 min. Statistically, this difference was significant (P=0.001). The number of patients achieving grade IV quality (excellent) of block was higher in group D (80%) as compared with group C (40%) (P<0.05). Conclusion: Dexmedetomidine when added to local anaesthetic in supraclavicular brachial plexus block enhanced the duration of sensory and motor block and also the duration of analgesia. The time for rescue analgesia was prolonged in patients receiving dexmedetomidine. It also enhanced the quality of block as compared with clonidine.

Background: Neuraxial anaesthesia, despite being a common technique, may pose some technical challenges leading to complications such as post-dural puncture headache, trauma to neural structures and neuraxial haematoma. We hypothesised that the interspinous gap (ISG) and the spinous process width (SPW) could be used as objective measures to predict ease of access to the neuraxial space. Methods: Two hundred and two consecutive patients scheduled to have spinal anaesthesia for various surgical procedures were enrolled prospectively after institutional approval. Following proper positioning for the neuraxial blockade, the ISG and SPW at the intended level were measured with calipers. The number of attempts, and redirections at the selected spinal level, and the number of levels required for successful needle placement were also recorded. Results: Group-wise analysis of the data into patients requiring >1 attempt, >1 level and ≥3 redirections showed that the single independent predictor of a difficult neuraxial block was the ISG. Twenty-three percent of the patients required more than one attempt, with a mean gap of 6.35 (±1.2) mm, in contrast to 8.15 (±2.4) mm in those with a single attempt (P=0.000). In addition, 16% of the patients needed more than one level, with a mean gap of 6.03 (±2.01) mm in contrast to 8.07 (±2.37) mm for a single level (P=0.000). Conclusions: The single independent predictor of ease or difficulty during spinal anaesthesia was the ISG (P=0.000).

Aims: The laryngeal mask airway-ProSeal™ can be inserted digitally, by introducer tool, or by railroading it over a bougie placed first in the patient's oesophagus, which is highly successful, but as originally described, requires an assistant. An unassisted bougie-guided placement technique has also been described, but no data on its effectiveness have been reported. Methods: We reviewed data collected during a randomized, controlled trial comparing the air-Q^® Intubating Laryngeal Airway and LMA-Proseal™, in which all LMA-Proseal™ devices were inserted using the unassisted (one-operator), bougie-guided placement technique. Results: Forty-eight devices were placed. All devices were placed successfully. Successful placement was achieved in 47 (98%) patients on first attempt and in one (2%) patient on the third attempt. Mean (SD) time required for insertion establishing ventilation was 28 (11) s. Mean (SD) airway seal pressure was 30 (6) cmH ₂ O. Gross blood was found on four (8%) devices upon removal, but no oropharyngeal injuries were noted on oral exam in the recovery unit prior to discharge. The most common complaints in recovery and 24 h post-operatively were sore throat [discharge: mild = 18/48 (38%); 24 h: mild = 9/38 (19%), moderate = 1/38 (3%)] and pain on swallowing [discharge: mild = 7/48 (15%); 24 h: mild = 2/38 (6%)]. Conclusions: Our data confirm that in experienced hands, bougie-guided placement of the LMA-Proseal™ without the aid of an assistant can be accomplished quickly and successfully without affecting the expected clinical performance of the device.

Purpose: It is sometimes difficult for our patients to acquire recommended flexion of their back to perform subarachnoid block upon them. The aim of this study was to find out the degree of procedural success and patient preference when subarachnoid blocks were performed on patients with suboptimal flexion of the back. Methods: Subarachnoid blocks were performed on 160 adult patients from both sexes without any spinal deformity. Procedures were performed with patients in the lateral or seated position with the back either straight or flexed. This approach divided the study population into 4 equal groups: Lateral with back straight (LS) or flexed (LF) and seated with back straight (SS) or flexed (SF). The primary endpoint was correct needle placement. Numbers of attempts, needle redirections and patients' preferred posture were determined to compare the outcome in different groups. Results: For both positions, the overall success rates were 95% and 100% in patients who had straight or flexed back, respectively (P=0.81). In the lateral position, significantly more patients of the LF group (40) than those of the LS group (32) had successful placement of spinal needle at first attempt (P=0.03). Altogether, 34 and 21 patients in the SS and SF groups, respectively, required cephalad redirections of the needle (P=0.003). Most patients preferred the straight back position (69.7-88%). Conclusion: With a higher preference by patients for the straight back posture, the overall success rate of correct spinal needle placement was comparable among the groups who had their back placed in a straight or in a flexed posture for subarachnoid block.

Background: Opioid analgesics used for analgesia are associated with sedation, respiratory depression and post-operative nausea and vomiting. Non-steroidal anti-inflammatory drugs such as diclofenac are a safe and effective alternative with opioid-sparing effect. Objective: To evaluate the effectiveness of pre-operative rectal diclofenac suppository (1 mg/kg) in cleft palate repair for post-operative analgesia and reduction in post-operative opioid requirements. Study Design: A randomized clinical trial. Methods: After obtaining approval from the institutional ethical committee, 60 children were allocated by a computer-generated randomisation into two groups of 30 each; group D (Diclofenac group) and group C (Conventional group). Children in group D and group C were similar in all aspects except for the fact that group D children received 1 mg/kg diclofenac suppository after induction. Pain was evaluated using modification of the objective pain scale by Hannallah and colleagues for 6 h post-operatively by an anaesthesiology resident or nursing staff who was blinded to the group. If the pain score was more than 3, rescue analgesic I.V. fentanyl 0.5 μgm/kg was administered. The pain scores at different intervals, number of doses and quantity of rescue analgesic required were noted. Results: We observed that pre-operative rectal diclofenac provided effective analgesia in the immediate post-operative period, as evidenced by reduced pain scores and reduced opioid requirement (P=0.00002). There was no evidence of any increased perioperative bleeding in the diclofenac group. Conclusion: Pre-operative rectal diclofenac reduces opioid consumption and provides good post-operative analgesia.

Background: Regional analgesia is widely used for total knee replacement surgeries (TKR) as it has lesser side-effects and better analgesic efficacy when compared with traditional oral analgesics. Peripheral nerve blockade has also been utilized, including continuous infusion techniques. With the use of ultrasound, the needle and catheter placement can be done accurately under real-time guidance. This may prove a more suitable approach compared with the epidural technique. Aims: Post-operative analgesia in TKR patients was compared between continuous epidural analgesia (CEA) and continuous femoral block (CFB) techniques. VAS scores and use of rescue analgesic were used as parameters. Secondary aims included comparison of rehabilitation scores and side-effects in the form hypotension, vomiting, itching and urinary retention. Settings and Design: Randomised, controlled, non-blinded study done in a tertiary care private hospital. Methods: Forty-two patients fulfilling the study criteria were randomised into the CEA and CFB groups. In total, four patients: three in the CFB group and one in the CEA group, were excluded because of catheter migration. Statistical Analysis: Mean VAS score at 6, 6-24, 24-48 and 48-72 h were considered. Significance was assessed at the 5% level. Results and Conclusion: VAS scores were significantly high (P=0.001) in the femoral group at 6 h, after which there was a declining trend, and scores were essentially similar from 24 h. Common side-effects were more common in the CEA group. Our study shows that CFB gives equivalent analgesia compared with CEA in TKR patients with clinically meaningful decrease in side-effects.

Background: The maintenance of oxygenation is a commonly encountered problem in obese patients undergoing laparoscopic cholecystectomy. There is no specific guideline on the ventilation modes for this group of patients. Although several studies have been performed to determine the optimal ventilatory settings in these patients, the answer is yet to be found. The aim of this study was to evaluate the efficacy of pressure-controlled ventilation (PCV) in comparison with volume-controlled ventilation (VCV) for maintaining oxygenation during laparoscopic cholecystectomy in obese patients. Methods: One hundred and two adult patients of ASA physical status I and II, Body Mass Index of 30-40 kg/m ² , scheduled for laparoscopic cholecystectomy were included in this prospective randomized open-label parallel group study. To start with, all patients received VCV. Fifteen minutes after creation of pneumoperitoneum, they were randomized to receive either VCV (Group V) or PCV (Group P). The ventilatory parameters were adjusted accordingly to maintain the end-tidal CO ₂ between 35 and 40 mmHg. Respiratory rate, tidal volume, minute ventilation and peak airway pressure were noted. Arterial blood gas analyses were done 15 min after creation of pneumoperitoneum and at 20-min intervals thereafter till the end of the surgery. All data were analysed statistically. Results: Patients in Group P showed a statistically significant ( P < 0.05) higher level of PaO ₂ and lower value of PAO ₂ -PaO ₂ than those in Group V. Conclusion: PCV is a more effective mode of ventilation in comparison with VCV regarding oxygenation in obese patients undergoing laparoscopic cholecystectomy.

Protein C deficiency is a rare autosomal-dominant disorder of varying severity. Patients with homozygous and compound heterozygous protein C deficiency present with neonatal purpura fulminans (NPF). Other presentations usually include disseminated intravascular coagulation and venous thromboembolism. This disorder usually poses a unique anaesthetic challenge to the anaesthesiologist, requiring special precautions to prevent various intra- and post-operative complications. We hereby report the successful anaesthetic management of a 1-month-old infant who presented with NPF.

We report a case of "dry tap" during spinal anaesthesia in a patient posted for incision and drainage of lower limb with cellulitis. When the patient was being given sub-arachnoid block (SAB) for regional anaesthesia, it turned out to be a case of pyogenic ilio-psoas abscess extended up to the paravertebral and epidural spaces. The causative organism was Staphylococcus aureus. This is probably the first case reported when epidural abscess is diagnosed during SAB.

Eisenmenger's syndrome is a cyanotic congenital heart disease that includes pulmonary hypertension with reversed or bidirectional shunt associated with septal defects or patent ductus arteriosus. The decreased systemic vascular resistance associated with pregnancy increases the degree of right to left shunting, thereby carrying substantial risk to both the mother and the foetus. The maternal mortality rate of pregnancy in the presence of Eisenmenger's syndrome is reported to be as high as 30-70%. We present a case of a 22-year-old primigravida with Eisenmenger's syndrome who gave birth at 37 weeks of gestation via caesarean section to a live female baby under general anaesthesia. On the third post-operative day, the patient developed tachycardia, tachypnoea, hypotension and decrease in oxygen saturation despite supplemental oxygen, clinically suspected pulmonary thromboembolism. We describe the anaesthetic management for caesarean section and its complications in a patient with Eisenmenger's syndrome. Although pregnancy should be discouraged in women with Eisenmenger's syndrome, it can be successful.

Situs inversus totalis is a rare condition with a predicted incidence of one in 10,000 among the general population, the aetiologic factors for which are still not completely understood. In a patient with situs inversus totalis, not just the diagnosis of any acute abdomen pathology is difficult due to distorted anatomy and transposition of thoraco abdominal viscera but equally challenging is the anaesthetic management during the respective surgical procedure. We are reporting a patient who had situs inversus totalis and was operated for open cholecystectomy. The present case report lays an emphasis on the potential difficulties during anaesthetic management and its various implications.

Thoracic paravertebral block (TPVB) is gaining popularity for female breast surgeries due to various advantages like less nausea and vomiting and better post-operative pain relief, which helps in early ambulation and discharge from the hospital. Use of nerve stimulator during this block has further enhanced its success and safety profile. Male breast surgery is usually done either under general anaesthesia or local infiltrative anaesthesia combining with intravenous sedation. We postulated that the advantages of TPVB could be helpful for early mobilization and discharge of minor breast surgery in male patients. However, to our knowledge, there is no such report suggestive of TPVB for exclusive male breast surgery. We used nerve stimulator-guided TPVB for gynecomastia surgery in two patients where general anaesthesia was not feasible. Both patients had successful block and showed good post-operative recovery and were discharged on the same day. They had long post-operative pain relief without any block-related complication. A case report of two such cases of gynecomastia surgery (male breast surgery) done under TPVB is presented.