The practice of regional anaesthesia is rapidly changing with the introduction of ultrasound into the working domain of the anaesthesiologist. New techniques are being pioneered. Among the recent techniques, notable are the truncal blocks, for example, the transversus abdominis plane block, rectus sheath block, hernia block and quadratus lumborum block in the abdomen and the pectoral nerves (Pecs) block 1 and 2, serratus anterior plane block and intercostal nerve block. This narrative review covers the brief anatomical discourse along with technical description of the ultrasound-guided truncal blocks.

Background and Aims: Laryngoscopy and endotracheal intubation are considered as potent stimuli which lead to an increase in heart rate and blood pressure. Melatonin (N-acetyl-5-methoxytryptamine) has been studied for pre-operative anxiolysis and sedation in Intensive Care Unit. We made a hypothesis that melatonin can provide haemodynamic stability during laryngoscopy and intubation when given 120 min before the procedure. Methods: Sixty American Society of Anesthesiologists physical status Grade I and II patients of either gender, 20-45 years old, 40-65 kg body weight, scheduled to undergo elective surgical procedures under general anaesthesia were assigned into two equal groups - Group C (control) and Group M (melatonin). They received oral placebo or melatonin tablets 6 mg, respectively, 120 min before surgery. The haemodynamic parameters were recorded preoperatively, during laryngoscopy and endotracheal intubation and thereafter at 1, 3, 5 and 10 min. Unpaired t-test was used for between-group comparison of ratio and interval scale data. For within-group comparison of ratio and interval scale data, repeated-measures ANOVA and post hoc Bonferroni t-tests were used. Results: It was observed that in the control group, there was a significant increase in heart rate and blood pressure at laryngoscopy and intubation and persisted till 10 min post-intubation. In melatonin group, there was an insignificant increase in heart rate at the time of laryngoscopy and intubation which however settled within 1 min post-intubation. Conclusion: Melatonin is an effective drug for attenuation of cardiovascular responses to laryngoscopy and endotracheal intubation.

Background and Aims: Lactate levels predict outcomes after hepatectomy. We compared metabolic effects of lactated versus lactate free solutions in living donor hepatectomy. Methods: Consecutive right lobe donors (n = 53) were alternatively allotted to lactated Ringer's solution and normal saline (Group L-control) or acetated crystalloid (Sterofundin B Braun ^® Group S -study group) in an observational prospective randomised study. The primary outcome measure was lactate level, and secondary outcomes were base excess, bicarbonate, glucose and chloride intra- and post-operatively. Mann-Whitney and Chi-square tests were used for analysis. Results: The intraoperative, post-operative lactate levels and the time for normalisation were comparable. Group L had significantly lower intraoperative bicarbonate levels (mmol/L) at 6 and 8 h (20.0 ± 2.14 vs. 21.3 ± 1.6, P = 0.0471; 18.68 ± 2.04 vs. 20.39 ± 17, P = 0.002), base excess at 4 and 6 h (mmol/L) (−3.64 ± 2.73 vs. −3.0 ± 1.52, P = 0.031; −6.64 ± 2.76 vs. −4.35 ± 1.7 P = 0.006). The intraoperative chloride levels (mmol/L) were higher in group L at 4 and 8 h (108 ± 5.9 vs. 105.99 ± 2.76, P = 0.0471; 109.51 ± 3.86 vs. 106.93 ± 3.09, P = 0.002). Intraoperative glucose (mg/dL) at 6 h was higher in group L, 160.55 ± 31.52 vs. 145.5 ± 24.29, P = 0.043. The highest post-operative chloride (mmol/L) was higher in Group L (112.3 ± 3.86 vs. 109.81 ± 3.72, P = 0.034). Post-operative base excess and bicarbonate showed an improved profile in Group S (−7.37 ± 2.99 vs. −5.06 ± 1.71 P = 0.001 and 17.79 ± 2.23 vs. 19.68 ± 1.51 P = 0.005). Conclusion: Acetated fluids were associated with higher levels of bicarbonate, lesser base deficit, glucose and chloride but no difference in lactate levels in comparison with Ringer's lactate and normal saline in living donor hepatectomy.

Background and Aims: i-gel™ is a newer supraglottic airway device with a unique non-inflatable cuff. We aimed to compare i-gel™ with ProSeal™ laryngeal mask airway (PLMA™) in children scheduled for surgery under general anaesthesia (GA) with controlled ventilation. Methods: This prospective, randomised controlled study was conducted in 100 surgical patients, aged 2-6 years of American Society of Anesthesiologists Physical Status I-II scheduled under GA. Patients were randomly allocated to receive either size 2 i-gel™ or PLMA™ as an airway device. The primary aim was oropharyngeal leak pressure assessed at 5 min following correct placement of the device. Secondary outcomes measured included number of attempts, ease of insertion, time of insertion, quality of initial airway, fibre-optic grading and effects on pulmonary mechanics. Statistical analysis was done using paired t-test and Chi-square test. Results: The demographic data were similar in both the groups. The oropharyngeal leak pressure in the i-gel™ group was 29.5 ± 2.5 cmH ₂ O as compared to 26.1 ± 3.8 cmH ₂ O in PLMA™ group (P = 0.002). The time taken for successful insertion in PLMA™ was longer as compared to i-gel (12.4 ± 2.7 vs. 10.2 ± 1.9 s, P = 0.007). The quality of initial airway was superior with i-gel™. The number of attempts, ease of insertion of supraglottic device, insertion of orogastric tube and pulmonary mechanics were similar in both the groups. Conclusion: Size 2 i-gel™ exhibited superior oropharyngeal leak pressure and quality of airway in paediatric patients with controlled ventilation as compared to PLMA™ although the pulmonary mechanics were similar.

Background and Aims: C-MAC ^® video laryngoscope (VL) with Macintosh blade has been found to improve Cormack-Lehane (C-L) laryngoscopic view as well as intubating conditions for orotracheal intubation. However, studies done on the performance of C-MAC ^® VL for nasotracheal intubation (NTI) are very few in number. Hence, we compared laryngoscopy and intubating conditions between Macintosh direct laryngoscope and C-MAC ^® VL for NTI. Methods: Sixty American Society of Anesthesiologists Physical Status I, II patients, aged 8-18 years, posted for tonsillectomy surgeries under general anaesthesia with NTI were randomised, into two groups. Patients in group 1 were intubated using Macintosh direct laryngoscope and group 2 with C-MAC ^® VL. C-L grading, time required for intubation, need for additional manoeuvres and haemodynamic changes during and after intubation were compared between the groups. Results: C-L grade 1 views were obtained in 26 and 29 patients in group 1 and group 2, respectively (86.7% vs. 96.7%). Remaining patients were having C-L grade 2 (13.3% vs. 3.3%). Duration of intubation was less than a minute in group 2 (93.3%). Need for additional manoeuvres (M1-M5) were more in group 1 (97% vs. 77%). M1 (external manipulation) was needed more in group 2 compared to group 1 (53.3% vs. 30%). Magill's forceps alone (M4) and M4 with additional external manipulation (M5) were needed more in group 1 compared to group 2 (60% vs. 16%). Conclusion: The overall performance of C-MAC ^® VL was better when compared to conventional direct Macintosh laryngoscope during NTI in terms of glottis visualisation, intubation time and need for additional manoeuvres.

Background and Aims: Considering the paucity of regional data, this study was designed to investigate the prevalence of post-operative pain and determine if there exists any correlation between the intensity of post-operative pain and patient's level of satisfaction with their pain management after inpatient abdominal surgery at an academic tertiary care government centre. Methods: Pain intensity was measured in 120 patients with numeric rating scale at the fifth post-operative hour, second and third post-operative day. A questionnaire was used to measure the level of satisfaction with nurse's and doctor's response to their pain and overall pain management. Results: The prevalence of post-operative pain was 84.17%, 92.5% and 96.66% at the fifth post-operative hour, second and third post-operative day, respectively. Less number of patients experienced severe intensity pain on the third post-operative day (P = 0.00046), whereas the number of patients experiencing mild pain increased (P < 0.000) compared to the fifth post-operative hour. The number of patients with complete analgesia decreased on the third post-operative day (P = 0.001 compared to fifth post-operative day). The Spearman correlation coefficient between pain score on the third post-operative day and level of satisfaction with nurse's response, doctor's response to pain and the overall pain management was − 0.0218 (P = 0.8107), 0.1307 (P = 0.1553) and 0.0743 (P = 0.4195), respectively. Conclusion: There is a high prevalence of acute post-operative pain in patients undergoing inpatient abdominal surgery at our institute. There is a weak correlation between the intensity of pain and level of satisfaction with pain management.

Background and Aims: Melatonin (MT), a naturally occurring pituitary hormone has a sleep promoting effect. There are very few studies on pre-operative oral MT (0.2-0.5 mg/kg) in children. We planned a study to assess the efficacy of oral MT in two doses and compare it with oral midazolam and placebo for pre-operative anxiolysis, sedation, maintenance of cognition and psychomotor skills, parental separation behaviour and venepuncture compliance. Methods: This prospective double-blind randomised study was conducted after ethical committee approval on 100 children aged 5-15 years, American Society of Anaesthesiologists physical status I and II undergoing elective surgery at our hospital from January 1, 2014, to December 31, 2014. Mentally disordered children were excluded from the study. They were randomised into four groups of 25 each (A, B, C, D) to receive either oral MT 0.5 mg/kg or 0.75 mg/kg or oral midazolam 0.5 mg/kg or placebo 45-60 min, respectively, before induction. The child's anxiety, cognition and psychomotor function before and after pre-medication, behaviour during the parental separation and venepuncture were appropriately scored. Kruskal-Wallis analysis of variance for intergroup and Wilcoxon matched pairs tests for intragroup comparisons of data were applied. Results: The four groups were comparable regarding mean age, weight and sex. The anxiety score reductions in the three groups when compared to placebo were statistically significant. Children receiving MT 0.75 mg/kg had maximum anxiolysis and venepuncture compliance (P < 0.05). Cognition was decreased with maximum sedation, successful parental separation and psychomotor impairment in the midazolam group (P < 0.05). Conclusion: Oral MT (0.5 mg/kg and 0.75 mg/kg) in children decreases pre-operative anxiety without impairing cognitive and psychomotor functions, the 0.75 mg/kg dose being most effective.

Background and Aims : With the availability of modern workstations and heightened awareness on the environmental effects of waste anaesthesia gases, anaesthesiologists worldwide are practicing low flow anaesthesia (LFA). Although LFA is being practiced in India, hard evidence on the current practice of the same from anaesthesiologists practicing in India is lacking and hence, we conducted this survey. Methods : A questionnaire containing 16 questions was distributed among a subgroup of anaesthesiologists who attended the 2014 National Conference of Indian Society of Anaesthesiologists. The filled-in questionnaires were computed and analysed with SPSS version 11. Results: The response rate to the survey was 82%. About 73% of the respondents practiced LFA routinely, with 65% having workstations. Most of the anaesthesiologists used fresh gas flows <1.5 L/min with 45.1% using O ₂ concentrations at a range of 30-40%. ETCO ₂ monitoring was used routinely by most whereas use of agent analysers and bispectral index monitoring were restricted. The availability of scavenging system was also limited to only 33.5%. Majority preferred N ₂ O as carrier gas and sevoflurane as volatile agent of their choice. Conclusion: Our survey revealed that practice of LFA in India has numerous lacunae. Provision of better monitoring facilities, workstations as well as awareness regarding the environmental issues of waste anaesthetic gases need to be addressed.

Background and Aims: In laparoscopic surgeries, intraperitoneal instillation of local anaesthetics and opioids is gaining popularity, for better pain relief. This study compared the quality and duration of post-operative analgesia using intraperitoneal tramadol plus bupivacaine (TB) or magnesium plus bupivacaine (MB). Methods: In this study, 186 patients undergoing laparoscopic cholecystectomy were randomly divided into two groups: group TB received intraperitoneal tramadol with bupivacaine and group MB received intraperitoneal magnesium sulphate (MgSO ₄ ) with bupivacaine. The visual analogue scale (VAS) to assess pain, haemodynamic variables and side effects were noted and compared at different time points. The primary outcome was to compare the analgesic efficacy and duration of pain relief. The secondary outcomes included comparison of haemodynamic parameters and side effects among the two groups. The data analysis was carried out with unpaired Student's t-test and Chi-square test using software SPSS 20.0 version. Results: The mean of VAS pain score after 1, 2, 4, 6 and 24 h of surgery was more in TB group compared to MB group, and the difference was statistically significant (P < 0.05). The total rescue analgesia consumption in 24 h after surgery was 2.4 g (mean) of paracetamol in TB group and 1.4 g (mean) of paracetamol in MB group which was statistically significant (P < 0.05). There were no statistically significant differences in the secondary outcomes. Conclusion: Intraperitoneal instillation of bupivacaine-MgSO ₄ renders patients relatively pain-free in first 24 h after surgery, with longer duration of pain-free period and less consumption of rescue analgesic as compared to bupivacaine-tramadol combination.

Hyperglycaemia following surgical and anaesthetic stress is a well-established entity which might have undesirable clinical consequences in known diabetics. We encountered a rare event where an undiagnosed diabetic patient developed ketoacidosis in the immediate post-operative period which was her initial presenting symptom of deranged glucoregulation. Presumably, the stress induced by surgery and anaesthesia lead to the genesis of this event. We discuss the management of this case. In addition, we highlight the importance of glycosylated haemoglobin as a subject of future research in identifying such "at risk" patients and for stratifying the risk of hyperglycaemic complications in perioperative settings.