Diabetes mellitus is the most common medical condition and with increased awareness of heath and related issues, several patients are getting diagnosed with diabetes. The poor control of sugar and long-standing status of disease affects the autonomic system of body. The autonomic nervous system innervates cardiovascular, gastrointestinal, and genitourinary system, thus affecting important functions of the body. The cardiovascular system involvement can manifest as mild arrhythmias to sudden death. Our search for this review included PubMed, Google Search and End Note X6 version and the key words used for the search were autonomic neuropathy, diabetes, anesthesia, tests and implications. This review aims to highlight the dysfunction of autonomic system due to diabetes and its clinical presentations. The various modalities to diagnose the involvement of different systems are mentioned. An estimated 25% of diabetic patients will require surgery. It has been already established that mortality rates in diabetic patients are higher than in nondiabetic patients. Hence, complete workup is needed prior to any surgery. Diabetic autonomic neuropathy and its implications may sometimes be disastrous and further increase the incidence of in hospital morbidity and mortality. Overall, complete knowledge of diabetes and its varied effects with anaesthetic implications and careful perioperative management is the key guiding factor for a successful outcome.

Background and Aims: Capstesia is a software designed for smartphones (Android^TM/iOS^TM) to estimate the cardiac output and other haemodynamic variables from the waveform obtained from an invasive arterial cannula. The technology has been validated by studies in simulated environmental conditions. We compared the cardiac output (CO) and stroke volume variation (SVV) obtained by conventional cardiac output monitor Vigileo^TM with CO and pulse pressure variation (PPV) extracted from Capstesia^TM, under clinical conditions, intraoperatively. Methods: In a Samsung smartphone in which the Capstesia software had been downloaded, the application was opened and a snapshot of the arterial waveform from the monitor screen of anaesthesia workstation was taken. The application instantaneously calculates the CO and PPV after inputting the heart rate and the systolic and diastolic blood pressure variables. These values were then compared with readings from the Vigileo^TM monitor. Data was collected from 53 patients and analysed. Results: Five hundred and thirty data pairs of CO and an equal number of SVV and PPV pairs were analysed. Cardiac index by Capstesia (CIcap) was found to have a positive correlation with cardiac index by Vigileo (CIvig) using the intraclass correlation for raters, the strength of correlation being 0.757. Upper and lower 95% confidence limits were 1.43 l/min/m² and − 1.14 l/min/m² (Bland Altman's plot). A positive correlation was found between SVV and PPV using the Pearson's correlation (r = 0.732). Conclusion: Capstesia^TM is a reliable and feasible alternative to Vigileo^TM for intraoperative CO monitoring in oncosurgical patients.

Background and Aims: Anaesthetics are implicated in cognitive dysfunction, taste and odour deficits in the postoperative period. We aimed to assess the effect of isoflurane, sevoflurane, propofol and regional anaesthesia on the olfactory threshold, olfactory identification and endocrine regulation of associative memory in the postoperative period. Methods: In this observer-blinded randomised controlled study, 164 patients (>50 years) with the American Society of Anesthesiologists I and II status were randomised into one of four groups to receive regional anaesthesia, general anaesthesia with sevoflurane, general anaesthesia with isoflurane and total intravenous anaesthesia with propofol. Hindi Mental State Examination, olfactory threshold and olfactory identification were tested at 12 h preoperatively (T0), at 3 h postoperatively (T1) and at the time of discharge or postoperative day 3 (T2). In addition, serum melatonin levels were estimated at T0 and T1. The olfactory threshold was tested with n-butyl alcohol and olfactory identification with the University of Pennsylvania Smell Identification Test (UPSIT). Data were analysed using the one-way analysis of variance, Kruskal-Wallis or Mann-whitney tests. Results: The olfactory identification scores were lower with patients receiving sevoflurane-based anaesthesia at 3 h postoperatively (T1) when compared to preoperative (T0) (median 19.5 vs. 22; P = 0.01). This was accompanied by a significant postoperative reduction of plasma melatonin levels in sevoflurane group when compared to other groups (17.34 ± 4.8 pg/ml vs 23.2 ± 3.5 pg/ml; P < 0.001). Conclusion: Sevoflurane was associated with short-term olfactory identification impairment with a concomitant reduction in melatonin levels illustrating a possible humoral mechanism.

Background and Aims: The preservation of recurrent laryngeal nerve (RLN) is an essential part of thyroid surgery. The various methods to test the normal functionality of vocal cords (VCs) include direct visualisation under the fiber bronchoscope, indirect laryngoscopy, laryngeal muscles electromyography, computed tomography (CT), and magnetic resonance imaging (MRI). We aimed to assess the usefulness of ultrasound (USG) in the examination of VC morphology and movement. Methods: After Institutional Ethical Committee (IEC) clearance, 65 American Society of Anesthesiologists physical status I/II patients between the age group 18 and 60 years scheduled for thyroid surgery were enrolled in this observational study. All patients underwent USG examination before, immediately after and 2 days after thyroidectomy. The vocal fold (VF) displacement velocity (VFDV) was recorded and analysed. If any VF disorder was detected, the patients underwent two additional examinations: 2 and 3 months after thyroidectomy. All the findings were correlated with those of video rhinolaryngoscope (VRL). Results: The visualisation rate of the VCs with USG was 96.9% whereas with VRL was 100%. Two patients had preoperative VC palsy that was picked up by USG and confirmed by VRL. The sensitivity and specificity of USG as a tool to detect paralysis were 100% CI = (0.34, 1.00) and 93.44% CI = (0.84, 0.97), respectively. Conclusion: USG examination can prove to be a good, noninvasive, cheap alternative to VRL in examination for functionality of VCs perioperatively.

Background and Aims: Thyromental height test (TMHT) is a recently described anatomical bedside screening tool in predicting difficult laryngoscopy. It has been shown to be more accurate than the modified Mallampati score, thyromental distance (TMD), and sternomental distance with regard to sensitivity and positive predictive value (PPV). Airway assessment studies based on the anatomic parameters of the upper airway are limited in the subcontinent population. We attempted this study to evaluate and validate the predictive value of TMHT at 50 mm in an Indian population in predicting difficult laryngoscopy. Methods: This prospective observational study was conducted in a tertiary teaching hospital on 340 patients. TMHT along with other bedside predictors of difficult intubation, including modified Mallampati score, interincisor gap (IIG), TMD, neck circumference (NC), and neck extension were assessed. We compared the sensitivity, specificity, PPV, negative predictive value (NPV), and diagnostic accuracy of TMHT with other bedside tests such as the modified Mallampati score, IIG, TMD, NC, and neck extension individually in predicting difficult laryngoscopy. Any Cormack and Lehane's intubation grade II b and above was considered to be difficult laryngoscopy. Results: TMHT had the highest sensitivity (84.62%) and specificity (98.97%), and had the most PPV (88%) and NPV (98.63%) when compared with the modified Mallampati score, IIG, TMD, NC, and neck extension. TMHT was followed by the modified Mallampati score and IIG. Conclusion: TMHT appears promising as a single anatomical measure to predict the risk of difficult laryngoscopy, however, validation will require further studies in more diverse patient populations.

Background and Aims: The existence of several methods for proper placement of nasogastric tube (NGT) and introduction of various novel methods day-by-day indicates that no method is perfect or universally accepted. However, the quest for the best is still on. Application of cold in various forms to stiffen the NGT has been tested inconsistently over the last three decades. In the recent past, frozen NGT has been compared only with conventional methods. Hence, the present study was designed to evaluate the efficacy of the frozen technique in comparison with conventional and reverse Sellick's manoeuvre. Methods: A total of 195 adult patients undergoing abdominal surgeries in anaesthetised and intubated state requiring NGT insertion were allocated to three groups to have their NGT placement using either the conventional method (Group A) or using frozen NGT (Group B) or applying reverse Sellick's manoeuvre (Group C). The number of successful placements of NGT within two attempts, procedure time, and incidences of adverse events were noted. Results: The highest success rate regarding the successful placement of NGT was observed using reverse Sellick's manoeuvre (95.2%), closely followed by the frozen NGT technique (84.6%) in comparison with conventional method (69.2%). The procedure time was the least with reverse Sellick's manoeuvre (31.5 ± 9.5 s) compared with conventional (42.2 ± 21.4 s) and frozen technique (42.1 ± 13.2 s). Conclusion: Nasogastric tube insertion using reverse Sellick's manoeuvre shows the highest success rate and having the least adverse events among the compared three methods in anaesthetised, intubated adult patients.

Background and Aims: Arteriovenous (AV) fistula surgery is commonly performed for AV access for hemodialysis. However the ideal anaesthetic technique of choice remains debated. We aimed to assess operative conditions, vascular patency, and complication rate following AV fistula surgery with isolated brachial plexus block among end-stage renal disease (ESRD) patients. Methods: This prospective, observational study included 214 patients undergoing AV fistula surgery under isolated supraclavicular brachial plexus block between January and December 2017. The diameters of the vessels both before and after the block, and the patency of the AV fistula in the immediate postoperative period and after 3 months were assessed using ultrasound Doppler. The change in the vessel diameter both before and after block was compared using independent sample t-test. Results: The mean brachial artery diameter increased by 0.09 mm (P = 0.002), and cephalic vein diameter at elbow, radial artery, and cephalic vein at wrist diameters increased by 0.5 mm (P < 0.001), 0.08 mm (P = 0.031), and 0.48 mm (P < 0.001), respectively. Overall, 93.45% had immediate patency, 85.51% had primary, and 47.19% had functional patency at 3 months. In the brachiocephalic group, 96.24% had immediate patency, 87.21% had primary, and 27.06% had functional patency at 3 months. Among the radiocephalic group, 91.35% had immediate patency, 82.71% had primary patency, and 71.60% had functional patency at 3 months. Conclusion: Ultrasound-guided isolated brachial plexus block results in good vasodilation and achieves good immediate and long-term patency in AV fistula surgery.

The most common congenital central airway anomaly, a tracheal bronchus is of concern during airway management especially if previously undetected. If present, it can lead to inadequate ventilation both during intubation with a normal endotracheal tube and an attempted double lumen tube insertion for one lung ventilation. Meticulous preoperative assessment and use of adjuncts like bronchoscopy before lung isolation can safely and successfully assist the anaesthetic management of such cases.

Topicalisation of the airway by various techniques has routinely been recommended for awake fibre-optic bronchoscopy in cases of difficult airway. However, topicalisation by itself can cause airway obstruction by decreasing the tone of the laryngeal muscles and causing a dynamic air inflow obstruction. Two cases of difficult airway are illustrated where anaesthetising upper airway with nebulisation with 4% lignocaine (Xylocaine™) or 2% lignocaine (Xylocaine™) jelly resulted in stridor and upper airway obstruction. This is the first reported case of airway obstruction after lignocaine (Xylocaine™) jelly. We would like to highlight that topicalisation of airway, once thought as a relatively safe technique, can cause airway collapse if not detected and anticipated at the earliest. Pre-operative spirometry and airway ultrasonography can be useful in detecting the patients at risk of developing airway obstruction. Using a nasopharyngeal airway during topicalisation can serve as a valuable device in preventing total airway obstruction in susceptible patients.

Cold haemagglutination is a primary or acquired autoimmune disease involving antibodies that lead to agglutination of red blood cells at low temperature followed by complement fixation and haemolysis on rewarming. This disease can lead to adverse consequences in patients undergoing cardiothoracic surgery, especially when hypothermic cardiopulmonary bypass is applied. The authors discuss the management of two patients who underwent mitral valve replacement surgery while cold agglutinins were detected in the perioperative period. In the first patient, the diagnosis was made preoperatively followed by administration of glucocorticoids to achieve acceptable level of antibody titers. The second patient experienced haemoglobinuria during her intensive care unit stay. The case report describes the pathophysiology of cold agglutination, relevant laboratory investigations such as antibody titers and thermal amplitude, identification of at-risk patients, and management strategies to avoid serious complications.