Liver resection is an effective modality of treatment in patients with primary liver tumour, metastases from colorectal cancers and selected benign hepatic diseases. Its aim is to resect the grossly visible tumour with clear margins and to ensure that the remnant liver mass has sufficient function which is adequate for survival. With the advent of better preoperative imaging, surgical techniques and perioperative management, there is an improvement in the outcome with decreased mortality. This decline in postoperative mortality after hepatic resection has encouraged surgeons for more radical liver resections, leaving behind smaller liver remnants in a bid to achieve curative surgeries. But despite advances in diagnostic, imaging and surgical techniques, postoperative liver dysfunction of varied severity including death due to liver failure is still a serious problem in such patients. Different surgical and non-surgical techniques like reducing perioperative blood loss and consequent decreased transfusions, vascular occlusion techniques (intermittent portal triad clamping and ischaemic preconditioning), administration of pharmacological agents (dextrose, intraoperative use of methylprednisolone, trimetazidine, ulinastatin and lignocaine) and inhaled anaesthetic agents (sevoflurane) and opioids (remifentanil) have demonstrated the potential benefit and minimised the adverse effects of surgery. In this article, the authors reviewed the surgical and non-surgical measures that could be adopted to minimise the risk of postoperative liver failure following liver surgeries with special emphasis on ischaemic and pharmacological preconditioning which can be easily adapted clinically.

Background: The square root of time (SqRT) model had been used to predict the uptake of volatile agents. Methods: We studied the rate of uptake of isoflurane in 10 patients using liquid isoflurane infusion through syringe pump into the closed circuit. The infusion rates were titrated to maintain a constant end tidal concentration of isoflurane of 1.5%. The predicted uptake values were also calculated from the square root principle and compared with the derived uptake. Results: The observed rate of uptake was higher than predicted from the Lowe and Ernst equation (P<0.001). There exists considerable inter-individual variability in uptake pharmacokinetics and it showed statistically significant correlation with ideal body weight, body weight (P<0.01), body surface area, and body weight ^3/4 from 30 min of start of isoflurane infusion (P<0.05). Conclusion: SqRT model is inaccurate in predicting isoflurane uptake and underestimates it during closed circuit anaesthesia.

Background: During the routine practice in the institution, it was observed that there were persistent incidents of inadequate/failed spinal anaesthesia in patients with a history of single or multiple scorpion bite/s. To test any possible correlation between scorpion bite and the altered response to spinal anaesthesia, a case control study was conducted involving patients with a history of scorpion bite/s and without such a history. Methods: Randomly selected 70 (n=70) patients of either sex and age range of 18-80 years, were divided into two equal groups, giving past history of one or multiple scorpion bites and giving no such a history. The anaesthetic management was identical inclusive of subarachnoid block with 3.5 ml. 0.5% bupivacaine heavy. The onsets of sensory, motor and peaks of sensory and motor blocks were observed with the pin-prick method and Bromage scale. After waiting for 20 min, if the block was inadequate, then balanced general anaesthesia was administered. The analysis of the data and application of various statistical tests was carried out using Chi-square test, percentages, independent sample t-test and paired t-test. Results: Demographically both groups were comparable. In scorpion bite group, the time of onsets of both sensory and motor blocks and time for the peak of sensory and motor blocks were significantly prolonged, 4 patients had failed/inadequate sensory block and 5 patients had failed/inadequate motor block while all the patients in non-bite group had adequate intra-operative block. Conclusion: We conclude that there appears to be a direct correlation between the histories of old, single or multiple scorpion bites and development of resistance to effect of local anaesthetics administered intra-thecally.

Background: Organ retrieval from brain dead patients is getting an increased attention as the waiting list for organ recipients far exceeds the organ donor pool. In our country, despite a large population the number of brain dead donors undergoing organ donation is very less (2% in our study). Aims: The present study was undertaken to address issues related to organ donation and share our experience for the same. Methods: A retrospective case record analysis of over 5 years from September 2007 to August 2012 was performed and the patients fulfilling brain death criterion as per Transplantation of Human Organs and Tissue (Amendment) Act were included. Patient demographics (age, sex), mode of injury, time from injury to the diagnosis of brain death, time from diagnosis of brain death to organ retrieval and complications were analysed. Statistics Analysis: Student's t test was used for parametric data and Chi square was used for categorical data. Results: Out of 205 patients who were identified as brain dead, only 10 patients became potential organ donors. Conclusion: Aggressive donor management, increasing public awareness about the concept of organ donation, good communication between clinician and the family members and a well-trained team of transplant coordinators can help in improving the number of organ donations.

Background: The ProSeal laryngeal mask airway (PLMA) is a unique laryngeal mask with a modified cuff to improve seal and a channel to facilitate gastric tube placement. This is a better device in difficult airway situations compared to classic laryngeal mask airway. This prompted us to study the ease of insertion and positioning of PLMA in patients with simulated restricted neck mobility while using gum elastic bougie (GEB) group or introducer tool (group IT) to aid insertion. Methods: Sixty ASA I or II patients, aged between 18 years and 60 years, undergoing minor non-head and neck surgeries in the supine position were studied. A rigid neck collar was used to simulate restricted neck mobility in all patients. After anaesthetising the patients with a standard protocol, the PLMA was inserted using either of the technique using the tongue depressor to open the mouth. The ease of insertion, positioning, haemodynamic responses to insertion and other complications related to the procedure were noted. Results: Regarding demographic variables, both groups were similar. The mean time taken for insertion of PLMA in group GEB was 67.80 s as compared to 46.79 s in group IT ( P<0.05). Patients of group GEB had better positioning assessed by an intubating fiberscope with less end tidal carbon-di-oxide (ETCO ₂ ) values. Systolic and diastolic blood pressures were similar. The incidence of sore throat, dysphagia, and dysphonia were higher in IT group in the 12 h, but similar in 24 h. Conclusion: Guided insertion technique with GEB took a longer time, but had a better positioning and lower ETCO ₂ values when compared to IT technique.

Background: Laparoscopic donor nephrectomy is a routine practice since 1995. Until now, the recipient has always undergone open surgery for transplantation. In our institute, laparoscopic kidney transplantation (LKT) started in 2010. To facilitate this surgery, the patient must be in steep Trendelenburg position for a long duration. Hence, we decided to study the effect of CO2 pnuemoperitoneum and Trendelenburg position in chronic renal failure (CRF) patients undergoing LKT. Methods: A total of 20 adult CRF patients having mean age of 31.7±10.36 years and body mass index 19.65±3.41 kg/m ² without significant coronary artery disease were selected for the procedure. Cardiovascular parameters heart rate (HR), mean arterial pressure (MAP), Central venous pressure (CVP) and respiratory parameters (ETCO ₂ , peak airway pressure) were noted at the time of induction, after induction, 15 min after creation of pnuemoperitoneum, 30 min after Trendelenburg position, 15 min after decompression of pnuemoperitonuem and after extubation. Arterial blood gas analysis was carried out after induction, 15 min after creation of pnuemoperitoneum, 30 min after Trendelenburg position and 15 min after clamp release. Total duration of surgery, anastomosis time, time for the establishment of urine output and total urine output were noted. Serum creatinine on the 1 ^st and 7 ^th post-operative day were recorded. Results: Significant increase in HR was observed after creation of CO ₂ pneumoperitoneum and just before extubation. Significant increase in the MAP and CVP was noted after creation of pneumoperitoneum and after giving Trendelenburg position. No significant rise in the ETCO ₂ and PaCO ₂ was observed. Significant increase in the base deficit was observed after the clamp release, but none of the patients required correction. Conclusion: LKT performed in steep Trendelenburg position with CO ₂ pneumoperitoneum significantly influenced cardiovascular and respiratory homeostasis; however, measured parameters remained within clinically acceptable range without affecting early function of the transplanted kidney.

Background and Aim: Exchanging endotracheal tube (ETT) with classic laryngeal mask airway ^TM (CLMA ^TM ) prior to emergence from anaesthesia is a safe technique to prevent the coughing and haemodynamic changes during extubation. We had compared CLMA ^TM and AMBU laryngeal mask ^TM (ALM ^TM ) during ETT/laryngeal mask (LM) for haemodynamic changes and other parameters. Methods: A total of 100 American Society of Anesthesiologist Grade I and II adult female patients undergoing elective laparoscopic cholecystectomy under general anaesthesia were selected and randomly divided into two groups of 50 patients each. In Group I, CLMA ^TM and in Group II, ALM ^TM was placed prior to tracheal extubation. Haemodynamic parameters were recorded during ETT/LM exchange. Glottic view was seen through the LM using flexible fibrescope. Coughing/bucking during removal of LM, ease of placement and post-operative sore throat for both groups were graded and recorded. Statistical Analysis: Data within the groups was analysed using paired t-test while between the groups was analysed using unpaired t-test. Chi-square test was used to analyse grades of glottic view, coughing, and post-operative sore throat. Results: In Group I, there was a significant rise in systolic blood pressure and heart rate in contrast to insignificant rise in Group II. Glottis view was significantly better in Group II. Incidence of coughing, ease of placement and post-operative sore throat was identical between both groups. Conclusion: ALM ^TM is superior to CLMA ^TM for exchange of ETT before extubation due to greater haemodynamic stability during exchange phase and is better positioned.

Aims: Intravenous (IV) dexmedetomidine with excellent sedative properties has been shown to reduce analgesic requirements during general anaesthesia. A study was conducted to assess the effects of IV dexmedetomidine on sensory, motor, haemodynamic parameters and sedation during subarachnoid block (SAB). Methods: A total of 50 patients undergoing infraumbilical and lower limb surgeries under SAB were selected. Group D received IV dexmedetomidine 0.5 mcg/kg bolus over 10 min prior to SAB, followed by an infusion of 0.5 mcg/kg/h for the duration of the surgery. Group C received similar volume of normal saline infusion. Time for the onset of sensory and motor blockade, cephalad level of analgesia and duration of analgesia were noted. Sedation scores using Ramsay Sedation Score (RSS) and haemodynamic parameters were assessed. Results: Demographic parameters, duration and type of surgery were comparable. Onset of sensory block was 66±44.14 s in Group D compared with 129.6±102.4 s in Group C. The time for two segment regression was 111.52±30.9 min in Group D and 53.6±18.22 min in Group C and duration of analgesia was 222.8±123.4 min in Group D and 138.36±21.62 min in Group C. The duration of motor blockade was prolonged in Group D compared with Group C. There was clinically and statistically significant decrease in heart rate and blood pressures in Group D. The mean intraoperative RSS was higher in Group D. Conclusion: Administration of IV dexmedetomidine during SAB hastens the onset of sensory block and prolongs the duration of sensory and motor block with satisfactory arousable sedation.

Context: Infectious complications of invasive procedures affect patient outcomes adversely. Choice of antiseptic solution at the time of insertion is one of the major factors affecting their incidence. Aims: This study was undertaken to compare efficacy of chlorhexidine 2% and povidone iodine 10% for skin disinfection prior to placement of epidural and central venous catheters (CVCs). Settings and Design: A prospective randomised trial in the operating rooms of a tertiary referral cancer centre. Methods: Sixty consecutive adult patients undergoing elective oncosurgery requiring placement of epidural and CVCs were enrolled. Paired skin swabs were collected before and after application of the antiseptic solution. The samples were incubated in McConkey's media and blood agar at 35°C for up to 24 h. Any bacterial growth was graded as: <10 colonies - poor growth, 10-50 colonies - moderate growth and >50 colonies as heavy growth. Data on demographics and antibiotic prophylaxis and costs was collected for all patients. Statistical Analysis: Student's t-test and Mann-Whitney tests were used to analyse data, P>0.05 was considered significant. Results: Demographics and antibiotic prophylaxis use was similar in both groups. Before application of antiseptic solution, a variety of micro-organisms were grown from most patients with growth ranging from none-heavy. No organism was grown after application of either antiseptic solution from any patient. Conclusions: We found no differences between 2% chlorhexidine and 10% povidone-iodine for skin disinfection in regard to costs, efficacy or side-effects.

Background: The Truview EVO2(C) laryngoscope (TL) is a recently introduced optical device designed to provide an unmagnified anterior image of the glottic opening and allow indirect laryngoscopy. Aim: This study is designed to determine whether the TL is a better alternative to the Macintosh laryngoscope (ML) for routine endotracheal intubations in patients with usual airway characteristics. Methods: We compared the Truview EVO2(C) and MLs in 140 elective surgical patients requiring general anaesthesia and intubation in a prospective crossover fashion. The two blades were compared in terms of Cormack and Lehane grades, time required for intubation, anaesthetists' assessment of ease of intubation, intubation difficulty score, attempts at intubation, success rate, soft tissue damage and arterial oxygen saturation during laryngoscopy. The Student t test and Chi-square test were used to determine the statistical significance of parametric data and categorical data, respectively. Results: The Truview EVO2(C) blade provided a better laryngoscopic view than the Macintosh blade as suggested by improved Cormack and Lehane grades (in 48 patients), but required a longer time for intubation than the Macintosh blade (34.1 vs. 22.4 s), i.e., an improved view at the cost of longer mean intubation time. In spite of lower intubation difficulty scores, Truview EVO2(C) was considered as difficult to use on subjective assessment by the anaesthesiologist when compared with Macintosh. There was no difference observed between the two groups in attempts at intubation, success rate, soft tissue damage and arterial oxygen saturation during laryngoscopy. Conclusion: We opine that although Truview provides a better laryngoscopic view than Macintosh in difficult cases, it does not have an extra benefit over Macintosh otherwise, further indicating the need for more experience with the use of a Truview laryngoscope.

"Kounis syndrome" refers to acute coronary syndromes of varying degree (myocardial ischaemia to infarction) induced by mast cell activation as a result of allergic and anaphylactic reactions. ST-segment elevated myocardial infarction is a rare complication that can occur even in patients with normal coronary arteries due to anaphylactic reactions. We present a case that developed acute myocardial infarction following a diclofenac sodium-induced anaphylaxis. The patient did not have any previous coronary artery disease, but there was a temporal relationship with development of the anaphylactic reaction due to diclofenac sodium and the cardiac event. The patient was managed conservatively and the recovery was uneventful.

We report on a 70-year-old patient who underwent ventral fusion of the cervical spine (C3/4 and C4/5) for spinal canal stenosis performed by the neurosurgery department. The patient suffered an exceedingly rare complication of the surgery - laryngeal dislocation. Had the deformed laryngeal structures been overlooked and the patient extubated as usual after surgery, reintubation would have been impossible due to the associated swelling, which might have had disastrous consequences. Leftward dislocation of the larynx became apparent post-operatively, but prior to extubation. Extubation was therefore postponed and a subsequent computed tomography (CT) scan revealed entrapment of laryngeal structures within the osteosynthesis. A trial of repositioning using microlaryngoscopy performed by otolaryngology (ears, nose and throat) specialists failed, making open surgical revision necessary. At surgery, the entrapped laryngeal tissue was successfully mobilised. Laryngeal oedema developed despite prompt repositioning; thus, necessitating tracheotomy and long-term ventilation. Laryngeal dislocation may be an unusual cause of post-operative neck swelling after anterior cervical spine surgery and should be considered in the differential diagnosis if surgical site haematoma and other causes have been ruled out. Imaging studies including CT of the neck may be needed before extubation to confirm the suspicion and should be promptly obtained to facilitate specific treatment.

We present a case of dexmedetomidine toxicity in a 3-year-old child. The case report describes the features and outlines the treatment strategy adopted. The child presented with bradypnoea, bradycardia, hypotension, deep hypnosis and miosis. He was successfully managed with oxygen, saline boluses and adrenaline infusion. He became haemodynamically stable with adrenaline infusion. He started responding to painful stimuli in 3 h and became oriented in 7 h. Dexmedetomidine, a selective α₂ adrenoceptor agonist, is claimed to have a wide safety margin. This case report highlights the fact that dexmedetomidine administered in a toxic dose may be life-threatening may present with miosis and adrenaline infusion may be a useful supportive treatment.

Kasabach-Merritt syndrome is characterised by giant haemangioma, thrombocytopenia and coagulopathy. Triggering of disseminated intravascular coagulation along with the need for massive blood transfusion is the major intraoperative complication. A 1-month-old boy was scheduled for excision and split skin grafting of a giant haemangioma over the left thigh. Investigations revealed severe anaemia with thrombocytopenia that was uncorrected despite multiple blood transfusions. Other treatment modalities were also unsuccessful and the neonate was taken up for excision of the haemangioma in order to correct the consumptive coagulopathy. Standard anaesthesia was administered and all appropriate measures to reduce blood loss were instituted. Massive blood transfusion was required but the intraoperative and post-operative period was uneventful and followed by a significant improvement in the haemoglobin and platelet counts in the post-operative period.

A 39-year-old male, post nephrectomy and adrenalectomy (right), was planned for adrenalectomy (left) and radiofrequency ablation of left renal mass. Clinical evaluation indicated a possibility of phaeochromocytoma, whereas biochemical parameters were found to be within normal limits. Intraoperatively, massive fluctuations in haemodynamic parameters were noticed while the tumour was being handled. Patient was stabilised with inotropes, vasopressors, fluids and careful titration of anaesthetic agents. Preoperatively diagnosed coronary disease could have complicated anaesthetic care. Optimum and modern anaesthetic care leads to safe execution of surgery.