Despite advances in pharmacotherapy, electroconvulsive therapy (ECT) remains a mainstay treatment option in psychiatry since its introduction in 1930s. It can be used primarily in severe illnesses when there is an urgent need for treatment or secondarily after failure or intolerance to pharmacotherapy. The 'unmodified' technique of ECT was practised initially, with a high incidence of musculoskeletal complications. Several modifications including general anaesthesia and muscle relaxation are used to increase the safety and patient acceptability of ECT. Various anaesthetic techniques including medications are considered to provide adequate therapeutic seizure, simultaneously controlling seizure-induced haemodynamic changes and side effects. A brief review of literature on choice of these anaesthetic techniques is discussed. This article is intended to reinforce the knowledge of clinicians, who may have limited exposure to ECT procedure. Importance is given to the recent updates on the role of induction agents in potentiating therapeutic response to ECT in psychiatric disorders.

Background and Aims: Modified radical mastectomy (MRM) may be associated with severe post-operative pain, leading to chronic pain syndrome. We compared the post-operative analgesic profile of two ultrasound-guided nerve blocks: Paravertebral block (PVB) and serratus plane block (SPB). Methods: This double-blind, randomised study was conducted on fifty adult females, scheduled for MRM with axillary dissection. After inducing general anaesthesia with intravenous midazolam 1 mg, fentanyl 1.5 mcg/kg, propofol 1–2 mg/kg and vecuronium 0.1 mg/kg, patients were administered either ultrasound-guided thoracic PVB at T4 (n = 25) or SPB at 5^th rib (n = 25) with 20 ml of 0.5% bupivacaine, both as a single level injection. Time to first rescue analgesia and morphine consumption in 4, 6, 24, 48 and 72 h by PCA pump, visual analogue scale score and any adverse effects were recorded. Quantitative variables were compared using the unpaired t-test or the Mann–Whitney U test between the two groups. Qualitative variables were compared using the Chi-square test or Fisher's exact test. Results: The duration of analgesia (mean ± Standard deviation [SD]) was significantly longer in the PVB group compared to SPB group (346 ± 57 min vs. 245.6 ± 58 min, P< 0.001). The post-operative 24 h morphine consumption (mean ± SD) was significantly higher in the SPB group (9.7 ± 2.1 mg) compared to PVB group (6.5 ± 1.5 mg) (P < 0.001). Conclusion: Ultrasound-guided SPB is an alternative analgesic technique to thoracic PVB for MRM although PVB provides a longer duration of analgesia.

Background and Aims: Anaphylaxis during anaesthesia is a rare but serious problem. In contrast to the developed countries where databases of perianaesthetic anaphylaxis are preserved, none exist in India. We conducted a survey amongst Indian anaesthesiologists to study the incidence and aetiology of anaphylaxis during anaesthesia in India. Methods: A written questionnaire comprising 20 items was mailed electronically or distributed personally to 600 randomly selected Indian anaesthesiologists. The responses were compiled and analysed. Results: We received responses from 242 anaesthesiologists. One hundred and sixty-two (67%) anaesthesiologists had encountered anaphylaxis during anaesthesia. Anaesthetic drugs led to 40% of reactions, and 60% of reactions were attributed to non-anaesthetic drugs. Opioids were the most common anaesthetic drugs implicated in anaphylaxis during anaesthesia, and non-depolarising muscle relaxants were the second most commonly implicated agents. Colloids, antibiotics and blood transfusion were the common non-anaesthetic agents thought to be responsible for anaphylactic reactions during anaesthesia. There were five deaths due to anaphylaxis during anaesthesia. Only 10% of anaesthesiologists ordered for allergy testing subsequently though 38% of anaesthesiologists had access to allergy testing facilities. Conclusions: Our survey reveals that two-thirds of participating Indian anaesthesiologists had witnessed anaphylaxis during anaesthesia. Commonly implicated anaesthetic drugs were opioids and non-depolarising muscle relaxants while colloids, antibiotics and blood transfusion were the common non-anaesthetic agents causing anaphylactic reactions during anaesthesia. Further, our survey reveals low utilisation and paucity of referral allergy centres to investigate suspected cases of anaphylaxis during anaesthesia.

Background and Aims: Left double-lumen endobronchial tube (DLT) sizes are selected using tracheal diameters and left mainstem bronchial diameters (LMBDs) determined from chest radiographs or computed tomography (CT) scans. In Western women, 35-Fr or 37-Fr DLTs are often selected. However, difficulties can be encountered when inserting 32-Fr or 35-Fr DLTs in Japanese women. We investigated success rates for 32-Fr or 35-Fr DLT insertion in Japanese women and determined the causes of unsuccessful DLT insertion. Methods: We searched anaesthesia records of Japanese women aged ≥20 years who underwent thoracic surgery with 32-Fr or 35-Fr DLTs between April 2010 and March 2015 in our hospital. In the successful group (SG), patients were intubated using the initially selected DLTs. By contrast, in the unsuccessful group (UG), the DLT size had to be changed. The Mann–Whitney U-test and Fisher's exact test were used to compare groups. Results: The SG included 149 (96.1%) of 155 cases of 32-Fr DLT use and 119 (95.2%) of 125 cases of 35-Fr DLT use. Patient height was significantly lower in the UG than in the SG for the 35-Fr DLT (P = 0.0036). In seven of 12 UG patients (three for 32-Fr and four for 35-Fr), the transverse diameters of cricoid cartilages were smaller than the DLTs' tracheal diameters, thereby preventing passage through the cricoid cartilages. Conclusion: Along with LMBDs, transverse diameters of cricoid cartilages based on CT scans or ultrasonogram findings may help in selecting the appropriate left DLT size.

Background and Aims: The ProSeal™ laryngeal mask airway (PLMA) has advantages of providing better cuff seal and the presence of a gastric drain tube. The manufacturer recommends actual body weight (ABW) for size selection. Pharyngeal area reduces with increase in body mass index (BMI); hence, in overweight patients, PLMA selected on ABW may not fit well. We hypothesised that the ideal body weight (IBW) would be more appropriate in size selection of PLMA. Methods: This randomised, single-blind study included 124 patients of 20–60 years and American Society of Anesthesiologists Class I–II, with BMI >25. Patients were randomly divided into two groups. In Group ABW, PLMA was selected based on ABW (62 patients) and in Group IBW, PLMA was selected based on IBW (62 patients). The primary outcome was the first-attempt insertion success rate. Oropharyngeal air leaks, gastric air leaks, drain tube air leaks, insertion difficulty scores and postoperative complications were assessed. Fibre-optic view (Grade I–IV) was assessed for proper placement by a blinded assessor. Statistical analyses were performed using Chi-square test or Fisher's exact test. Results: First-attempt insertion success rate and overall insertion success rates were similar in both the groups. Group IBW patients had significantly less resistance during insertion, lower peak airway pressures, successful nasogastric tube insertions, better fibre-optic views and less post-operative complications. Oropharyngeal leak pressure and instrumentation used for insertion were comparable. Conclusion: IBW is preferable for the size selection of the PLMA in overweight and obese patients compared to the ABW.

Background and Aims: Neonates and infants are prone to oxygen desaturation during the induction of general anaesthesia. Pharyngeal oxygen insufflation has been shown to delay the onset of desaturation and hypoxaemia during apnoea. We tested the hypothesis that deep laryngeal oxygenation with Oxiport^® Miller blade would delay the onset of desaturation compared to laryngoscopy without supplemental oxygen (Miller blade). Methods: One hundred neonates and infants undergoing general anaesthesia with endotracheal intubation for surgery were recruited and randomly assigned to one of the two groups: Miller or Oxiport group (laryngoscopy performed with Miller or Oxiport^® blade, respectively). Primary outcome measure was the lowest oxygen saturation (SpO₂) attained during intubation. Secondary outcomes were the incidence of severe desaturation (SpO₂<85%), correlation between SpO₂and time to intubation in each group. Pearson's correlation coefficient was used to measure the correlation between time to intubation and desaturation in each group. P< 0.05 was considered statistically significant. Results: Data from 95 patients were available for the final analysis: Miller group (n = 48) and Oxiport group (n = 47). Mean lowest SpO₂was 95.9% ± 5.75% in Miller group and 97.55% ± 2.93% in Oxiport group (P = 0.049). Correlation between time to intubation and SpO₂was −0.110; P = 0.459 in Miller group and −0.468; P = 0.001 in Oxiport group. Severe desaturation occurred in 12.5% patients in Miller group and none in Oxiport group. Conclusion: Apnoeic laryngeal oxygen insufflation with Oxiport^® laryngoscope blade decreases the incidence of severe desaturation during neonatal and infant intubations.

Background and Aim: Transnasal transsphenoidal resection of pituitary tumours is associated with blood loss and wide fluctuations in haemodynamic parameters. The aim of the present study was to compare the effect of dexmedetomidine and magnesium sulphate during the transsphenoidal resection of pituitary tumours. Methods: The study was a double-blind, randomised study and included 152 patients classified randomly into two groups: Group D: Dexmedetomidine was given as a loading dose 1 μg/kg over 10 min before induction followed by an infusion at 0.5 μg/kg/h during the surgery. Group M: Magnesium sulphate was given as loading dose of 50 mg/kg over 10 min followed by an infusion at 15 mg/kg/h during the surgery. The systolic, diastolic and mean arterial blood pressures, in addition to the amount of blood loss were measured at specific timepoints. Data were described in terms of mean ± standard deviation, median, frequencies, 95% confidence of interval of mean and percentages. Results: Mean bleeding score was lower in Group D than Group M (1.36 ± 0.48 vs. 3.05 ± 0.65, respectively; P = 0.002). Mean blood loss was lower in Group D (157.43 ± 48.79 ml vs.299.47 ± 77.28 ml in Group M; P < 0.001)Heart rate, mean arterial pressure, fentanyl requirements, end-tidal sevoflurane concentration, and extubation and emergence times were lower, while incidence of bradycardia and hypotension were higher in Group D. Conclusions: During transsphenoidal pituitary resection, dexmedetomidine, compared to magnesium, is associated with lower blood loss and better operating conditions but with more hypotension and bradycardia

Background and Aims: Controlled hypotension with balanced anaesthesia minimises blood loss. This study was done to evaluate the effectiveness of intravenous clonidine as a single bolus dose to establish controlled hypotension during functional endoscopic sinus surgery (FESS). Methods: This randomised, double-blind, placebo-controlled study was done in a tertiary hospital in India. Sixty American Society of Anesthesiologists physical status I and II patients (18–65 years) undergoing FESS were randomly allocated to one of the two groups. Placebo group (group A, n = 30) received sterile water whereas the clonidine group (group B, n = 30) received 3μg/kg of clonidine intravenously, 30 min prior to induction of anaesthesia. The primary outcome was to achieve a target mean arterial blood pressure (MAP) of 55–65 mmHg intraoperatively. The secondary outcomes measured were requirement of additional fentanyl and metoprolol, intra-operative blood loss, surgeon's opinion on the surgical field, pain, sedation score and complications requiring treatment. Results: Target MAP was easily achieved in clonidine group as against the placebo group (P < 0.001). Significant reduction in intra-operative blood loss (P = 0.0449), a better surgical site scoring (P = 0.02), less requirement of additional hypotensive drugs and good analgesia (P = 0.01) were seen in clonidine group. The complication rates were similar in both the groups. Conclusion: Clonidine is effective in achieving controlled hypotension in patients undergoing FESS. It reduces intra-operative blood loss, requirement of additional hypotensive drugs, improves the surgical field and offers good analgesia without significant side effects.

Background and Aims: Carotid endarterectomy (CEA) reduces the risk of stroke in patients with significant carotid stenosis and may be performed under general anaesthesia (GA) or regional anaesthesia (RA). This study aimed to compare RA and GA with regard the jugular venous bulb blood lactate and pyruvate levels. Methods: This randomised-controlled trial was done between October-2013 and September-2015. Thirty-six patients were randomised into either GA or RA groups, with six excluded after randomisation. In the RA group, combined deep and superficial cervical plexus blocks were performed. In the GA group, anaesthesia was induced with propofol and fentanyl. In both groups, monitoring of neurological function was done. Sampling of the contralateral jugular bulb blood was done. The main outcome measures were lactate and pyruvate in the jugular venous blood. For comparing categorical data, Chi-square test was used, and for the numerical variables, t-test was used. Results: Demographics were comparable in the two Groups. Serum lactate and pyruvate levels were higher in the GA group than RA group. At 120 min under anaesthesia, lactate and pyruvate levels under RA vs. GA, respectively were 0.76±0.03 mEq/L vs. 1.14±0.06, p-0.001 mEq/L, and 0.08± 0.00 mEq/L vs. 0.10±0.01 mEq/L, p=0.006. Lactate/ pyruvate ratios were normal in both groups. The mean blood pressure was significantly lower in the GA group during anaesthesia. Conclusion: In patients undergoing Carotid endarterectomy, serum levels of both lactate and pyruvate were higher under general versus regional anaesthesia.

Extreme degree of rotation and flexion of the head during posterior fossa surgeries can lead to acute post-operative submandibular sialadenitis that can cause respiratory compromise. Identification of this problem is vital to prevent deterioration in the early post-operative period. This condition responds well to conservative management provided airway obstruction is taken care of. We discuss a case of a 63-year-old female, with a left side vestibular schwannoma who developed airway obstruction in post-operative period due to swelling of right submandibular gland. Various possible mechanisms leading to this condition and related literature are briefy reviewed.

Timely administration of dopamine agonists is of the essence in Parkinson's disease. The perioperative period especially for abdominal surgeries under general anaesthesia poses a challenge to oral drug administration. Alternatives such as rotigotine patches and subcutaneous apomorphine administration have been described but unavailability restricts their use. Sublingual administration of tablet levodopamine as an alternative worked well in our patients and we would like to describe the same.