Advances in ultrasound guided regional anaesthesia and introduction of newer long acting local anaesthetics have given clinicians an opportunity to apply novel approaches to block peripheral nerves with ease. Consequently, improvements in outcomes such as quality of analgesia, early rehabilitation and patient satisfaction have been observed. In this article we will review some of the newer regional anaesthetic techniques, long acting local anaesthetics and adjuvants, and discuss evidence for key outcomes such as cancer recurrence and safety with ultrasound guidance.

Background and Aims: Head and neck movements alter the shape of the pharynx, resulting in changes in the oropharyngeal leaking pressures and ventilation with supragottic airway devices. We compared the effect of the different head-and-neck positions on the oropharyngeal leak pressures and ventilation with the I-Gel™ and ProSeal™ laryngeal mask airway (PLMA) in anaesthetised paralysed children. Methods: A total of 70 children were randomly assigned to receive PLMA (n = 35) or I-Gel™ (n = 35) for airway management. Oropharyngeal leak pressure in maximum flexion, maximum extension and the neutral position was taken as the primary outcome. Peak inspiratory pressures (PIPs), expired tidal volume, ventilation score and fibreoptic grading were also assessed. Results: No significant difference was noted in oropharyngeal leak pressures of PLMA and I-Gel™ during neutral (P = 0.34), flexion (P = 0.46) or extension (P = 0.18). PIPs mean (standard deviation [SD]) were significantly higher (17.7 [4.03] vs. 14.6 [2.4] cm H₂O, P = 0.002) and expired tidal volume mean [SD] was significantly lower (5.5 [1.6] vs. 6.9 [2] ml/kg, P = 0.0017) with I-Gel™ compared to PLMA. Fibreoptic grading and ventilation score were comparable in both the groups in all the three head-and-neck positions. Conclusion: PLMA and I-Gel™, both recorded similar oropharyngeal leaking pressures in all the three head-and-neck positions. However, higher peak pressures and lower expired tidal volume in maximum flexion of the neck while ventilating with I-Gel may warrant caution and future evaluation.

Background and Aims: Low-volume high-concentration bupivacaine irrigation of the peritoneal cavity has been reported to be ineffective for short-term analgesia after laparoscopic cholecystectomy (LC). This study was conducted to evaluate the effectiveness of intraperitoneal instillation of high-volume low-concentration bupivacaine for post-operative analgesia in LC. Methods: Sixty patients undergoing LC were included in this prospective, double-blind, randomised study. Patients were divided into two (n = 30) groups. In Group S, intraperitoneal irrigation was done with 500 ml of normal saline. In Group B, 20 ml of 0.5% (100 mg) bupivacaine was added to 480 ml of normal saline for intraperitoneal irrigation during and after surgery. Post-operative pain was assessed by numeric pain rating scale (NRS) at fixed time intervals. Duration of analgesia (DOA), total rescue analgesic requirement (intravenous tramadol), presence of shoulder pain, nausea and vomiting were recorded for the initial 24 h post-operatively. Results: Mean DOA in Group S was 0.06 ± 0.172 h (3.6 ± 10.32 min) and that in Group B was 19.35 ± 8.64 h (P = 0.000). Cumulative requirement of rescue analgesic in 24 h in Group S was 123.33 ± 43.01 mg and that in Group B was 23.33 ± 43.01 mg (P = 0.000). There was no significant difference in incidence of shoulder pain, nausea and vomiting between the groups. Conclusion: High-volume low-concentration of intraperitoneal bupivacaine significantly increases post-operative DOA and reduces opioid requirement after LC.

Background and Aims: There is a paucity of clinical practice guidelines for the ideal approach to airway management in patients with cervical spine instability (CSI). The aim of this survey was to evaluate preferences, perceptions and practices regarding airway management in patients with CSI among neuroanaesthesiologists practicing in India. Methods: A 25-item questionnaire was circulated for cross-sectional survey to 378 members of the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC) by E-mail. We sent four reminders and again submitted our survey to non-responders during the 2017 annual ISNACC meeting. Apart from demographic information, the survey captured preferred methods of intubation and airway management for patients with CSI and their justification. Regression analysis was used to identify factors associated with the use of indirect technique for intubation. Results: Only 122 out of the 378 anaesthesiologists responded to our survey. Most respondents were senior consultants, working in training hospitals, and performed ≥25 intubations per year for CSI patients. The majority of neuroanaesthesiologists (78.7%; n = 96) preferred indirect techniques for elective intubation. However, 45 anaesthesiologists (36.9%) preferred indirect techniques for emergency intubation. In an adjusted analysis, preference for patients to be conscious during intubation was significantly associated with the use of indirect techniques (odds ratio = 3.79; confidence interval = 1.52–9.49, P < 0.01). Conclusions: Among ISNACC members, indirect techniques are preferred for elective intubation of patients with CSI, while direct laryngoscopy is preferred for emergency intubation.

Background and Aims: Etomidate-induced myoclonus (EM) is observed in 50%–80% of unpremedicated patients. Low-dose lignocaine has been shown to attenuate but not abolish the EM. The aim of this prospective, randomised controlled study was to compare the different doses of lignocaine on the incidence and severity of EM. Methods: Two hundred adult patients were randomly assigned into four groups to receive saline placebo (Group I) or IV lignocaine 0.5 mg/kg (Group II), 1 mg/kg (Group III) or 1.5 mg/kg (Group IV) 2 min before injection etomidate 0.3 mg/kg IV. The patients were assessed for the EM using a four-point intensity scoring system. Our primary outcome was the incidence of myoclonus at 2 min (EM2). The incidence of myoclonus at 1 min (EM1) and severity of myoclonus constituted the secondary outcomes. ANOVA and Pearson Chi-square test were used for statistical analysis and P < 0.05 was considered as statistically significant. Results: The incidence of EM was significantly reduced in Groups III [(EM1: 32% vs. 60%, P = 0.009); (EM2: 42% vs. 76%, P = 0.001)] and IV (EM2: 54% vs. 76%, P = 0.035) compared with Group I. Lignocaine 1 mg/kg and 1.5 mg/kg significantly reduced the incidence of severe myoclonus at 2 min (14% each) compared to Groups I (42%, P = 0.003) and II (32%, P = 0.032). Conclusion: Lignocaine 1 mg/kg and 1.5 mg/kg IV pretreatment significantly reduces the incidence of EM, with maximum attenuation observed with 1 mg/kg.

Background and Aims: Fast tracking (FT) for more efficacious use of resources may be difficult after living donor liver transplantation (LDLT) due to a partial liver graft, complex vascular anastomoses and longer operating time. Our study was aimed at reporting our experience with FT (on table extubation) in LDLT recipients. A secondary objective of our study was to look at defining a subgroup of patients who could be prospectively planned for FT. Methods: We studied the demographics and outcomes of 15 LDLT recipients extubated immediately in the operating suite based on an uneventful intraoperative course, haemodynamic stability after graft reperfusion and improvement of metabolic parameters post-implantation and vascular anastomoses. Results: Twelve recipients were males, and mean age, body mass index (BMI) and Model for End Stage Liver Disease (MELD) score were 43 ± 12 years, 23 ± 3 kg/m² and 15.5 ± 6, respectively, most were Child–Turcotte–Pugh Class B. Diabetes and hypothyroidism were present in 1 and 2 patients, respectively. Post-extubation, none required immediate re-intubation and one patient needed non-invasive ventilation for 2 h. Conclusion: Fast tracked recipients were young, with a low BMI, low MELD scores, minimal comorbidities and good immediate graft function post-reperfusion.

Background and Aims: Renal transplant is the best possible treatment for patients suffering with end-stage renal disease (ESRD). Cardiovascular events are the commonest factors contributing to perioperative morbidity and mortality in this population. These patients have a high incidence (up to 60%) of pulmonary hypertension (PH) and that may affect the perioperative outcome. Methods: In this study, we aimed to study the impact of PH on perioperative outcome after renal transplant. PH was defined as patients with pulmonary artery systolic pressure ≥35 mmHg on pre-operative echocardiography. Medical records of 170 patients who had undergone renal transplantation in the past 3 years were reviewed. Primary outcome was delayed graft functioning and secondary outcomes were perioperative complications such as hypotension, arrhythmias, need of post-operative mechanical ventilation, atelectasis and pulmonary oedema. Results: We observed 46.5% incidence of PH in ESRD patients. Compared to patients without PH, more patients with PH had postoperative hypotension (26.58% vs. 9.89%, P = 0.004) and delayed graft functioning (8.8% vs. 1.1%, P = 0.026). On multivariate analysis, however, PH was not an independent predictor of delayed graft functioning. Conclusion: In ESRD patients, although PH is not an independent predictor of delayed graft functioning, patients having PH are more prone for perioperative hypotension and delayed graft functioning after renal transplant.

Eventration of the diaphragm is a rare entity, characterised by abnormal elevation of a dome of diaphragm. In this condition, the diaphragm is composed of fibrous tissue with few or no interspersed muscle fibres. Eventration can be congenital or acquired. Congenital eventration results from inadequate development of muscles or absence of phrenic nerve. The common cause of acquired eventration is injury to the phrenic nerve from traumatic birth injury or surgery for heart disease. The perioperative anaesthetic management of diaphragmatic eventration along with ventricular septal defect with severe pulmonary hypertension makes this case both challenging and unique.

Uncontrolled pain in patients with rib fracture leads to atelectasis and impaired cough which can progress to pneumonia and respiratory failure necessitating mechanical ventilation. Of the various pain modalities, regional anaesthesia (epidural and paravertebral) is better than systemic and oral analgesics. The erector spinae plane block (ESPB) is a new modality in the armamentarium for the management of pain in multiple rib fractures, which is simple to perform and without major complications. We report a case series where ESPB helped in weaning the patients from mechanical ventilation. Further randomised controlled studies are warranted in comparing their efficacy in relation to other regional anaesthetic techniques.