Trauma to the cervical spine may have devastating consequences. Timely interventions are essential to prevent avoidable neurological deterioration. In the initial stabilization of patients with acute cervical spine injuries, physiological disturbances, especially those involving cardiac and respiratory function require careful attention. Early surgery, which facilitates rapid mobi­lization of the patient, is fraught with important management considerations in the intraopoerative period and the subsequent critical care. Airway management poses a crucial challenge at this stage. Those patients who survive the injury with quadriplegia or quadriparesis may present themselves for incidental surgical procedures. Chronic systemic manifestations in these patients require attention in providing anaesthesia and postoperative care at this stage. The current review provides an insight into the physiological disturbances and the management issues in both acute and chronic phases of traumatic cervical spine injury.

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Tracheostomy is a commonly performed surgical procedure in the intensive care units. Indications for tracheostomy are mainly four-fold namely airway obstruction, aspiration of secretions, airway protection from aspiration and provision of mechani­cal ventilation. Anaesthesia technique used for tracheostomy is varied and is dictated by the general condition of the patient. Percutaneous tracheostomy is an alternative to the surgical approach that can be done at the bedside and has several advan­tages. Though a simple procedure, tracheostomy can be associated with a number of life-threatening complications like hypoxia, cardiac arrest, injury to structures immediately adjacent to the trachea, pneumothoax and haemothorax.

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Acute renal failure in the perioperative setting is a significant complication of anaesthesia and surgery. Preventive strate­gies may be considered the best strategy to prevent renal impairment and consequent renal failure. The anaesthesiologist must identify high risk patients preoperatively to prevent postoperative renal dysfunction along with optimizing intravascular volume status and cardiac output as well as renal function and avoiding nephrotoxins in the perioperative period. This can best be accomplished if the clinician understands the pathophysiological basis of the disease process.

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A 60-year-old female patient posted for discectomy of lumbar region L ₃ -L ₄ was accidently diagnosed to have chronic atrial fibrillation of rheumatic aetiology.This is a case report of this patient of critical mitral stenosis with mild mitral regurgitation with chronic atrial fibrillation managed successfully under lower thoracic epidural anaesthesia,in prone position without any compli­cation.

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The classic laryngeal mask airway (cLMA), though popular in anaesthesia practice provides low oropharyngeal seal pressure and there are concerns with its use during positive pressure ventilation for fear of gastric distension with subsequent gastric regurgitation and pulmonary aspiration. The ProSeal laryngeal mask airway (PLMA) is a modified LMA with a larger, wedge shaped cuff and a drain tube. This modification improves the seal around glottis when compared to a cLMA and its drain tube prevents gastric distension and offers protection against aspiration when properly placed. We compared PLMA and cLMA in 100 anaesthetized, paralysed children with 50 patients in each group with respect to ease of insertion, oropharyngeal seal pressure and pharyngolaryngeal morbidity. Gastric tube insertion was also assessed for the PLMA. The ease of insertion and the number of attempts at insertion were found to be comparable in the two groups while the oropharyngeal seal pressure was significantly higher in the PLMA group (P < 0.001). The pharyngolaryngeal morbidity was comparable in both the groups. There was no incidence of regurgitation or aspiration in either group. The PLMA offered high reliability of gastric tube placement and significantly increased oropharyngeal seal pressure over the cLMA. This might have an important implication for use of this device for positive pressure ventilation in children.

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Intubating a patient with temporomandibular joint ankylosis is always a challenge particularly when fibreoptic laryngo­scope is not available. In a 20-year-old male patient we successfully carried out endotracheal intubation with 7 mm portex cuffed PVC tube with the help of two flexible J tipped guide wires. One guide wire was passed into the airway from cricothyroid puncture site and another from subcricoid site. Both were brought out through the nose. The first guide wire was used for retracting the epiglottis and the second as a guide for passing the endotracheal tube.

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Endovascular coiling (EC) is being increasingly used as an alternative to surgical clipping (SC) for intracranial aneurysms, although the relative benefits of these two approaches have yet to be established. Purpose of this study was to review the anaesthetic and definitive management of patients with intracranial aneurysms in the interventional neuroradiology suite (INR) and compared with in the operation theatre. Retrospective review of first 100 consecutive patients in either mode of treatment (endovascular coiling and surgical clipping) was done. Data compared and analyzed included demographic profile, preoperative medical and surgical record, aneu­rysm characteristics, neurosurgical grading, intra and postoperative complications and clinical outcome at discharge from hospi­tal. P < 0.05 was considered significant. In INR group, aneurysms were located in both anterior and posterior circulation, but in SC group all they were in anterior circulation. There was no significant difference in Subarachnoid haemorrhage (SAH) grading in regards of Hunt and Hess and World Federation of Neurological Surgeons(WFNS). Clinical outcome at discharge was significantly better in patients treated with endovascular coiling as compared to surgical clipping(P = 0.042). We conclude that for the anaesthesiologist, one needs to be aware that the patient presenting for endovascular treatment may have more complex aneurysm anatomy and pathophysiology, premorbid systemic disorders (cardiac, respiratory & renal) and may be older. In our study, overall outcome in patients who underwent endovascular coiling (in terms of Glasgow outcome scale) was significantly better then surgical clipping. In most of the time, whatever the complications occurred during the procedure were related to the procedure itself.

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This study was done on sixty adult males scheduled to have an epidural analgesia for elective inguinal hernia repair. The study was designed to compare propofol and midazolam with regard to their suitability for the patient-controlled sedation (PCS) technique during epidural analgesia. Patients were divided into three equal groups and premedicated with 0.2mg.kg ^-1 oral midazolam. Group I (G1) served as control. Using PCS technique, the pump was programmed to deliver on demand a bolus dose of 0.5 mg.kg^­ 1 of propofol in Group II (G2) or 0.1mg.kg ^-1 midazolam in Group III(G3). Patient's sedation status was assessed by sedation score, comfort scale and by psychometric testing. The total delivered dose of each tested drug was calculated. Serum concentrations of propfol and midazolam, plasma cortisol and free fatty acids were measured. Propofol and midazolam PCS technique produced excellent and easily controllable sedation. The dose needed to produce steady state sedation was 2.8±1.42 and 0.11±0.6 mg.kg ^-1 .h^­ 1 for propofol and midazolam respectively. Propofol was more suitable than midazolam for PCS because of its rapid onset, favorable recovery profile and low side effects. PCS proved to be a stress-free and acceptable technique.

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Presence of appropriate equipment and actual procedure employed, greatly affect the outcome in Difficult Airway situation. Medical Colleges being torchbearers in this, have been studied. Consultant presence during intubation in 54% Medical Colleges is commendable. Gum Elastic Bougie is rejected as first choice option by 71% Medical Colleges, though 88% Medical Colleges have mentioned Metal or PVC stylets as first choice options. Blind Nasal Intubation at 33% is the highest 2 ^nd choice option. The Fibreoptic Bronchoscope and Intubating Laryngeal Mask Airway at 29% and 17% respectively, obtain the third highest choice option. 67% Medical Colleges postpone the difficult airway case for investigations. It facilitates planning and preparation. Planned tracheostomy at combined 4 ^th and 3 ^rd choice option of 42% indicates handling of more complicated cases. Flexible fibreoptic stylets and Glidescope are not in the running. Development of low skill procedures for difficult airway is yet to catch up, as does that for invasive airway devices. We believe that this survey is the first such study carried out in Medical Colleges in India.

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Asystole in a non laparoscopic upper abdominal surgery following intense vagal stimulation is a rare event. This case report highlights the need for awareness of such a complication when a thoracic epidural anaesthetic has been given in addition to a general anaesthetic for an upper abdominal procedure. A combined thoracic epidural and general anaesthetic was given. The anterior abdominal wall was retracted forty minutes after administration of the epidural bolus. This maneuver resulted in a profound vagal response with bradycardia and asystole. The patient was resuscitated successfully with a cardiac massage, atropine and adrenaline and the surgery was resumed. Surgery lasted eleven hours and was uneventful.

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Critically ill patients who require prolonged intensive care support are at high risk of developing multiple organ failure and death. Hyperglycaemia and resistance to insulin are closely associated with major illness or major surgery. This is true irrespective of whether patients are diabetic or not. It has been shown that tight glycaemic control using exogenous intensive insulin therapy improves outcome in critically ill patients. We review the pathophysiology of hyperglycaemia and examine the clinical and economic benefits of such therapy.

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The management of a case of difficult extubation due to inability to deflate the endotracheal tube cuff as a result of failure of pilot balloon assembly is presented. The importance of checking the endotracheal tube cuff and pilot system before adminis­tration of anaesthesia even in the case of a new endotracheal tube is emphasized.

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A prospective observational cohort study was done to compare recovery profile of elderly patients as compared to young population and validate the new discharge criteria applied to them. Twenty one elderly patients (>65 yrs) having intertrochanteric fracture posted for open surgery were compared with similar number of young patients (20-40 yrs). Both the groups were operated under spinal anaesthesia with 2.5 ml of 0.5% hyperbaric bupivacaine in L3-4 inter-space. Orthostatic challenge was given at 0, 30, 60 and 90 min in recovery room (RR) and variation in pulse rate & MAP was compared. Highest sensory level achieved was similar in both study groups but vasopressor requirement was more in elderly for maintaining haemodynamic stability. Sensory level was slow to regress in elderly patients. Despite having greater MAP fall in the elderly patients it was never more than 10% at any point of time till 90 min in RR. Shivering was common postoperative complica­tion in elderly patients. It was concluded that new discharge criteria could be safely applied to elderly patients and can lead to significant time saving in recovery room.

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A 54 year-old-male, a case of squamous cell carcinoma of right pyriform fossa, treated with radical radiotherapy & chemo­therapy in 2004, presented in January 2007, with difficulty in swallowing. He was diagnosed to have squamous cell carcinoma of upper third of oesophagus & surgery was planned. Patient had history of recurrent blackouts which were attributed to general­ized weakness and diarrhoea. During induction, he developed Hypotension & on evaluation, was diagnosed to have primary adrenal insufficiency.

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Difficult to ventilate, difficult to intubate cases are the most challenging to anaesthesiologists. We present a case of thalassaemia with difficult airway who underwent splenectomy surgery. The severe maxillary prominence with protruded upper incisors, limited mouth opening, depressed nasal bridge and narrow anterior nares posed a problem in mask ventilation and subsequent tracheal intubation. The patient was intubated successfully using fibreoptic bronchoscope aided with intubating laryngeal mask airway (Fastrach).

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The use of mobile phones has long been controversial in the operation theatres citing various incidences wherein aberration of the electronic equipments has occurred due to their use. We hereby report a case where we used mobile phone to capture a dysrrhythmia occurring intra-operatively in a patient via multimedia messaging service (MMS) technology, and sending it to the consultant in charge and a cardiologist via multimedia messaging service(MMS technology) and taking immediate remedial action.

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