Cardiovascular complications are a major cause of morbidity and mortality in patients with end-stage liver disease (ESLD) undergoing liver transplantation. Identifying candidates at the highest risk of postoperative cardiovascular complications is the cornerstone for optimizing the outcome. Ischaemic heart disease contributes to major portion of cardiovascular complications and therefore warrants evaluation in the preoperative period. Patients of ESLD usually demonstrate increased cardiac output, compromised ventricular response to stress, low systemic vascular resistance and occasionally bradycardia. Despite various recommendations for preoperative evaluation of cardiovascular disease in liver transplant candidates, a considerable controversy on screening methodology persists. This review critically focuses on the rapidly expanding body of evidence for diagnosis and risk stratification of cardiovascular disorder in liver transplant candidates.

Background and Aims: Transfusion of blood and blood products poses several hazards. Antifibrinolytic agents are used to reduce perioperative blood loss. We decided to assess the effect of tranexamic acid (TA) on blood loss and the need for transfusion in head and neck cancer surgery. Methods: After Institutional Review Board approval, 240 patients undergoing supramajor head and neck cancer surgeries were prospectively randomised to either TA (10 mg/kg) group or placebo (P) group. After induction, the drug was infused by the anaesthesiologist, who was blinded to allocation, over 20 min. The dose was repeated every 3 h. Perioperative (up to 24 h) blood loss, need for transfusion and fluid therapy was recorded. Thromboelastography (TEG) was performed at fixed intervals in the first 100 patients. Patients were watched for post-operative complications. Results: Two hundred and nineteen records were evaluable. We found no difference in intraoperative blood loss (TA - 750 [600–1000] ml vs. P - 780 [150–2600] ml, P = 0.22). Post-operative blood loss was significantly more in the placebo group at 24 h (P - 200 [120–250] ml vs. TA - 250 [50–1050] ml, P = 0.009), but this did not result in higher number of patients needing transfusions (TA - 22/108 and P - 27/111 patients, P = 0.51). TEG revealed faster clot formation and minimal fibrinolysis. Two patients died of causes unrelated to study drug. Incidence of wound complications and deep venous thrombosis was similar. Conclusion: In head and neck cancer surgery, TA did not reduce intraoperative blood loss or need for transfusions. Perioperative TEG variables were similar. This may be attributed to pre-existing hypercoagulable state and minimal fibrinolysis in cancer patients.

Background and Aims: Propofol is widely used for induction of anaesthesia, although the pain during its injection remains a concern for all anaesthesiologists. A number of techniques have been adopted to minimise propofol-induced pain. Various 5-hydroxytryptamine-3 antagonists have shown to reduce propofol-induced pain. Hence, this placebo-controlled study was conducted to compare the efficacy of ondansetron, ramosetron and lignocaine in terms of attenuation of propofol-induced pain during induction of anaesthesia. Methods: Hundred and fifty adult patients, aged 18–60 years, posted for various elective surgical procedures under general anaesthesia were randomly assigned to three groups of 50 each. Group R received 0.3 mg of ramosetron, Group L received 0.5 mg/kg of 2% lignocaine and Group O received 4 mg of ondansetron. After intravenous (IV) pre-treatment of study drug, manual occlusion of venous drainage was done at mid-arm with the help of an assistant for 1 min. This was followed by administration of propofol (1%) after release of venous occlusion. Pain was assessed with a four-point scale. Unpaired Student's t-test and Chi-square test/Fisher's exact test were used to analyse results. Results: The overall incidence and intensity of pain were significantly less in Groups L and R compared to Group O (P ≤ 0.001). The incidence of mild to moderate pain in Groups O, R and L was 56%, 26% and 20%, respectively. The incidence of score '0' (no pain) was significantly higher in Group L (76%) and Group R (72%) than Group O (34%) (P < 0.001). Conclusion: Pre-treatment with IV ramosetron 0.3 mg is equally effective as 0.5 mg/kg of 2% lignocaine in preventing propofol-induced pain and both were better than ondansetron.

Background and Aims: Caudal analgesia is one of the most popular regional blocks in paediatric patients undergoing infra-umbilical surgeries but with the drawback of short duration of action after single shot local anaesthetic injection. We evaluated whether caudal dexamethasone 0.1 mg/kg as an adjuvant to the ropivacaine improved analgesic efficacy after paediatric herniotomies. Methods: Totally 128 patients of 1–5 years age group, American Society of Anaesthesiologists physical status I and II undergoing elective inguinal herniotomy were randomly allocated to two groups in double-blind manner. Group A received 1 ml/kg of 0.2% ropivacaine caudally and Group B received 1 ml/kg of 0.2% ropivacaine, in which 0.1 mg/kg dexamethasone was added for caudal analgesia. Post operative pain by faces, legs, activity, cry and consolability tool score, rescue analgesic requirement and adverse effects were noted for 24 h. Results: Results were statistically analysed using Student's t-test. Pain scores measured at 1, 2, 4, and 6 h post-operative, were lower in Group B as compared to Group A. Mean duration of analgesia in Group A was 248.4 ± 54.1 min and in Group B was 478.046 ± 104.57 min with P = 0.001. Rescue analgesic requirement was more in Group A as compared to Group B. Adverse effects after surgery were comparable between the two groups. Conclusion: Caudal dexamethasone added to ropivacaine is a good alternative to prolong post-operative analgesia with less pain score compared to caudal ropivacaine alone.

Background and Aims: Bilateral superficial cervical plexus block (BSCPB) is effective in reducing pain following thyroid surgeries. We studied the effect of dexmedetomidine on duration and quality of analgesia produced by BSCPB with 0.5% ropivacaine in patients undergoing thyroid surgeries. Methods: In this prospective double-blinded study, 60 adults undergoing thyroid surgeries were randomised into two equal groups to receive BSCPB, either with 20 ml 0.5% ropivacaine (Group A) or 20 ml 0.5% ropivacaine with 0.5 μg/kg dexmedetomidine (Group B) after induction of anaesthesia. Visual analogue scale (VAS) was used to assess analgesia postoperatively at 0, 2, 4, 6, 12 and 24 h and patient satisfaction at 24 h. Haemodynamics were recorded peri-operatively. Wilcoxon signed rank test and Mann–Whitney U-test were applied for VAS and sedation scores. Unpaired t-test was applied for age, weight, duration of surgery and duration of post-operative analgesia. Results: There was significantly longer duration of analgesia in Group B (1696.2 ± 100.2 vs. 967.8 ± 81.6 min; P < 0.001) and higher patient satisfaction at 24 h (7 [7–9] vs. 5 [4–6]; P < 0.001). While VAS score for pain were similar up to 6 h, they were lower in Group B at 12 h (0 [0–1] vs. 2 [1–2]; P < 0.001) and 24 h (2 [2–2] vs. 5 [5–6]; P < 0.001). Haemodynamic stability and sedation scores were similar across the groups. There were no adverse events. However, pain during swallowing persisted in both the groups. Conclusion: Combination of 0.5% ropivacaine and dexmedetomidine for BSCPB provided significantly prolonged and better quality of postoperative analgesia and patient satisfaction than with 0.5% ropivacaine alone in patients undergoing thyroidectomy.

Background and Aims: Scalp blocks combined with general anaesthesia reduce pin and incision response, along with providing stable perioperative haemodynamics and analgesia. Clonidine has proved to be a valuable additive in infiltrative blocks. We studied the efficacy and safety of addition of clonidine 2μg/kg to scalp block with 0.25% bupivacaine (Group B) versus plain 0.25% bupivacaine (Group A) for supratentorial craniotomies. Methods: Sixty patients were randomly divided into two groups to receive scalp block: Group A (with 0.25% bupivacaine) and Group B (with 0.25% bupivacaine and clonidine (2μg/kg). Bilateral scalp block was given immediately after induction. All the patients received propofol based general anaesthesia. Intraoperatively, propofol infusion was maintained at 75 to 100 μg/kg/h up to dura closure and reduced to 50-75 μg/kg/h up to skin closure with atracurium infusion stopped at dura closure. Heart rate (HR) and mean arterial pressure (MAP) were monitored at pin insertion, at 5 minute intervals from incision till dura opening and again at 5 minute interval from dura closure up to skin closure. Fentanyl 0.5 μg/kg was given if a 20% increase in either HR and/or MAP was observed. Postoperative haemodynamics and verbal rating scores (VRS) were recorded. When the VRS score increased above 3, rescue analgesia was given. Any intraoperative haemodynamic complications were noted. Results: Group A showed a significant increase in haemodynamic variables during the perioperative period as compared to group B (P < 0.05). Addition of clonidine 2 μg/kg in the infiltrative block also provided significantly prolonged postoperative analgesia. Conclusions: Addition of clonidine to scalp block provided better perioperative haemodynamic stability and significantly prolonged analgesia.

Background and Aims: Bupivacaine is available in isobaric and hyperbaric forms for intrathecal use and opioids are used as additives to modify their effects. The aim of this study was to compare the efficacy and haemodynamic effect of intrathecal isobaric bupivacaine-fentanyl mixture and hyperbaric bupivacaine-fentanyl mixture in common urological procedures. Methods: One hundred American Society of Anesthesiologists physical status 1 and 2 patients undergoing urological procedures were randomized into two groups. Group 1 received 3 ml of 0.5% isobaric bupivacaine with 25 μg fentanyl while Group 2 received 3 ml of 0.5% hyperbaric bupivacaine with 25 μg fentanyl. The parameters measured include heart rate, blood pressure, respiratory rate, onset and duration of motor and sensory blockade. Student's unpaired t-test and the χ² test were used to analyse the results, using the SPSS version 11.5 software. Results: The haemodynamic stability was better with isobaric bupivacaine fentanyl mixture (Group 1) than with hyperbaric bupivacaine fentanyl mixture (Group 2).The mean onset time in Group 1 for both sensory block (4 min) and motor block (5 min) was longer compared with Group 2. The duration of sensory block (127.8 ± 38.64 min) and motor block (170.4 ± 27.8 min) was less with isobaric bupivacaine group compared with hyperbaric bupivacaine group (sensory blockade 185.4 ± 16.08 min and motor blockade 201.6 ± 14.28 min). Seventy percent of patients in Group 2 had maximum sensory block level of T₆whereas it was 53% in Group 1. More patients in Group 1 required sedation compared to Group 2. Conclusion: Isobaric bupivacaine fentanyl mixture was found to provide adequate anaesthesia with minimal incidence of haemodynamic instability.

Propionic acidemia (PA) is an autosomal recessive disorder of metabolism due to deficiency of the enzyme propionyl-CoA carboxylase (PCC) that converts propionyl-CoA to methylmalonyl-CoA with the help of the cofactor biotin inside the mitochondria. The resultant accumulation of propionyl-CoA causes severe hyperammonaemia and life-threatening metabolic acidosis. Based on the positive outcomes, liver transplantation is now recommended for individuals with recurrent episodes of hyperammonaemia or acidosis that is not adequately controlled with appropriate medical therapies. We report anaesthetic management of two children with PA for liver transplantation at our institution. It is essential for the anaesthesiologist, caring for these individuals to be familiar with the manifestations of the disease, the triggers for decompensation and management of an acute episode.

Robotic thyroidectomy (RT) is a new gasless, scarless technique which utilises the da Vinci^™ surgical robot to excise thyroid tumours. Anaesthetic management must be modified according to the patient position and robotic surgery equipment. Anaesthesiologists need to be geared up to face the new challenges posed by advancements in surgical techniques in order to maintain patient safety. Another vital aspect of this surgery is documenting possible recurrent laryngeal nerve palsy, for which a C-Mac D-Blade^™ video laryngoscope serves as a valuable tool. Post-operative pain management in RT also merits special attention.