Despite ongoing preventive and rehabilative efforts at the local and international level, substance abuse by adolescents has crossed social, economic, and geographic borders and - throughout the world remains one of the major problems facing society today. The diverse clinical manifestation of drug abuse combined with physiologic changes may significantly have impact on the anaesthetic management. Moreover, it is always difficult to predict the exact anaesthetic implications in chemically dependent patients. Therefore, a complete understanding of the pathophysiology and anaesthetic implications of drug abuse in adolescent is essential to tailor a safe anaesthetic plan for these high-risk groups of patients.

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Noninvasive ventilation has been shown to reduce acute postoperative hypoxaemia, with significant reduction in the incidence of re-intubation, complications and a trend towards lower mortality. The aim of the study was to determine the effectiveness of CPAP vs venturi therapy in early achievement of oxygenation goals and in prevention of re-intubation for management of postoperative hypoxaemia following laparoscopic cholecystectomy. Forty adult patients of ASA physical status I& II, scheduled for elective laparoscopic cholecystectomy, those were unable to maintain SpO₂ > 95% breathing room air after extubation, were recruited for a prospective, randomized comparative study. Patients with PaO₂ / FiO₂ between 250 and 300 were included in the study and were randomly allocated to one of the two groups to receive oxygen therapy either using a CPAP of 10 cm of water and a FiO₂ of 0.5 (Group A) or using a venturi mask of FiO₂ of 0.5 (Group B) . All patients were observed postoperatively upto 18 h and were screened by ABG analyses at 6, 12 and 18 h of treatment. SpO₂, ECG, heart rate, respiratory rate, temperature and NIBP were monitored throughout the study period. Patients in Group A showed significant improvement in early achievement of adequate oxygenation than those in Group B, although, due to intolerance to CPAP therapy two patients in Group A needed reintubation to maintain adequate oxygenation. To conclude, oxygenation using continuous positive airway pressure is a safe and effective means in improving gas exchange to treat acute postoperative hypoxaemia in conscious and cooperative patients.

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Obstructive sleep apnoea (OSA) is a sleep disorder of particular concern to anaesthetist. Its exact prevalence is not known but it is said to affect 5% of the population in the west. It is a syndrome characterized by periodic, partial, or complete obstruction of the upper airway during sleep. The diagnostic gold standard is polysomnography. The anaesthetic implications include the presence of comorbidities like cardiovascular, respiratory and cerebrovascular sequelae. Obesity is a commonly associated condition. Effects of sedatives, hypnotics and other anaesthetic drugs are of major concern and there are potential complications associated with the postoperative period. The purpose of this review is to update the readers on the recent literature available on the topic. The American Society of Anesthesiologists has recently suggested guidelines on the perioperative management of these patients.

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No large data based, or randomized controlled studies are available in reference to pneumonia in ICU especially in adult population, in India. Moreover the types of ICU infrastructure, sterilization& disinfection protocols, empirical antibiotics and antibiotics policy are standardized in the country. Hence this review article has mainly utilized available literature from developed countries. This review article briefly discusses the definition of various pneumonia, epidemiology, causative organism, patho­genesis, risk factors, diagnostic strategies and management modalities. By this article, authors hope that a certain guidelines or standardization of protocols in India will be formulated.

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A 38-year-old lady posted for laparoscopic cholecystectomy in a peripheral hospital met with a near fatal cardiac arrest when subjected to anaesthetic induction for the surgery. She was resuscitated, surgery deferred and later referred to our hospital. Here we describe the anaesthetic management of a case of pulmonary hypertension for laparoscopic cholecystectomy in a middle-aged lady.

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We present the case of 32-year-old female with chronic sinusitis undergoing functional endoscopic sinus surgery(FESS), who developed ventricular tachycardia following intranasal adrenaline pledgets which was successfully treated with defibrilla­tion.

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Use of spinal anaesthesia is gradually increasing in ambulatory setting. With the continuing controversy over the use of lidocaine for spinal anaesthesia, other local anaesthetics are being explored to achieve reliable spinal anaesthesia with rapid recovery and minimal side-effects. This study explored the use of long acting local anaesthetic bupivacaine in ambulatory setting. One hundred patients presenting for endoscopic uro-gynaecological surgeries were randomized to four groups according to dose of bupivacaine they received keeping the volume constant. Maximum level of sensory block, intensity of block, time to two segment regression, time to S₂ regression and time to discharge were recorded. Results of our study indicate that spinal anaesthe­sia with 7.5 mg of 0.5% bupivacaine in 8% dextrose diluted with equal volume of saline provides an optimal combination of adequate anaesthesia with recovery profile acceptable for ambulatory endoscopic uro-gynaecological surgeries.

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We are presenting a case report on the anaesthetic management of a case of ankylosis of temporomandibular joint for corrective surgery in a 7 year old child. Anticipated difficult airway in paediatric population has always been a perplexing problem, awake fibreoptic intubation almost impossible due to obvious difficulties with co-operation. Here we are describing a new approach to this problem, in which the patients were kept under GA with spontaneous ventilation while retrograde intubation was done quite comfortably by the conventional method.

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Transfusion Related Acute Lung Injury (TRALI) has been recently recognized as one of the serious risks associated with transfusion, presenting as respiratory distress during or after transfusion of blood products. The symptoms can be confused with other transfusion-related events such as anaphylaxis, haemolysis, or circulatory overload, or with non-transfusion-related co­morbidities such as cardiac failure. TRALI varies in severity, and mortality is not uncommon. TRALI is now the leading cause of transfusion-associated mortality, even though it is probably still under-diagnosed and under-reported due to lack of awareness of its entity.

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Clinical experience suggests that acute postoperative pain after radical surgery for breast cancer can be managed by bupivacaine irrigation. This prospective randomized double blind controlled study was designed to test the hypothesis that bupivacaine irrigation will reduce the 24 hour requirement of tramadol (400 mg + 100 mg) by one fourth (100+25mg). Forty six patients were allocated randomly to receive intravenous tramadol (Group T) (0.25mg.kg ^-1 .hr ^-1 ) and bupivacaine drain irrigation(Group B) (0.4% 20 ml 8 hourly) for postoperative pain. Pain was monitored independently by the APS and PACU nursing staff. APS residents were allowed to give intravenous boluses of tramadol of 50 mg on complaints of pain. Pain scores, nausea, vomiting, sedation, urinary retention ECG and haemodynamic changes were monitored for 24 hours and analysed by Mann-Whitney u test and Fisher's exact test. Both groups had good pain relief. The T group had significantly more nausea (P<0.007). The T group patients had a higher incidence of vomiting, catheterisation and delayed oral intake, but this was not significant statistically. Bupivacaine administered through the surgical drain offered equivalent postoperative pain relief to intravenous tramadol, with significantly less nausea.

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This study was conducted to evaluate the incidence of early- and late-onset nosocomial pneumonia, gastric colonization, and gastrointestinal bleeding in 50 orotracheally intubated, mechanically ventilated patients treated with sucralfate or ranitidine for stress ulcer prophylaxis in the intensive care unit. Patients received either iv ranitidine (50 mg every 6h) in Ranitidine group or nasogastric sucralfate suspension (1 g every 6h) in Sucralfate group. The overall incidence of pneumonia and incidence of early-onset pneumonia was comparable between the two groups (p > 0.05). Late- onset pneumonia was observed in 10 (23.8%) patients in the Ranitidine group and 2 (4.8%) patients in the Sucralfate group (P= 0.001). The mean gastric pH (6.04 ± 1.34 and 3.64 ± 1.55, respectively; P= 0.001)), rate of gastric colonization (92% and 16%, respectively; P=0.000), and gastric source of pneumonia (10 patients and 1 patient, respectively; P= 0.017) was higher in the Ranitidine group as compared to the Sucralfate group. Mortality and gastrointestinal bleeding were comparable between groups. We concluded that stress ulcer prophylaxis with ranitidine increases the risk for late- onset pneumonia in mechanically ventilated critically ill patients by favoring gastric colonization by gram- negative bacilli compared with sucralfate. In patients receiving mechanical ventilation, the use of sucralfate may be preferable to H ₂ blockers.

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Previous studies have confirmed the usefulness of Bispectral index (BIS) and spectral entropy in non-neurosurgical patients. The effects of thiopentone or propofol on BIS and entropy in patients with supratentorial tumours have not been studied. To address the above issue, we carried out a prospective, randomised controlled trial to determine the correlation between BIS, Response entropy and State entropy during different stages of induction of anaesthesia in neurosurgical patients. Twenty ASA I/II patients of either gender, aged 19-58 years undergoing excision of supratentorial tumour were selected for the study. The BIS was recorded using A-2000 BIS monitor (Aspect medical systems, Newton, MA) and entropy monitored with Datex-Ohmeda S/5 entropy module (Helsinki, Finland) at various stages of induction of anaesthesia, using either thiopentone or propofol as the induction agent. We found that BIS and Entropy parameters correlated strongly at different stages of induction. The correlation was significant between BIS and Entropy at baseline, after fentanyl administration, after induction, and after intubation. We also noted that Entropy parameters unlike BIS are not affected by haemodynamic response due to intubation. To conclude, Entropy may be considered a valid indicator of the effects of thiopentone and propofol during different stages of induction of general anaesthesia neurosurgical patients.

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Endoluminal dilatation and stenting is an alternative management strategy in patients with tracheal stenosis. Providing anaesthesia and maintaining oxygenation during tracheal stenting can be difficult. There are various anaesthetic techniques available for this procedure, based on the characteristics of stenosis and anaesthesiologist experience. A good knowledge about the procedure and communication with the radiologist are essential for the safe conduct of anaesthesia. In patients with near total obstruction and respiratory insufficiency, airway manipulation or coughing can result in complete loss of the airway. Herewith we report the anesthetic management of two cases with tracheal stenosis for stenting.

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Frey syndrome occurs following surgeries around the parotid. A 61-year-old woman post superficial parotidectomy pre­sented after 2 years with symptoms of gustatory sweating. Minor test was positive (9cm² area). Topical antihyperhydrotics and stellate ganglion blocks provided no benefit. Botulinum toxin was administered intracutaneously. Symptoms resolved with in 48 hours. Minor test was negative at 10 month follow up. Most of the surgical and medical techniques described to treat Frey syndrome have high failure rate with short term relief. Botulinum toxin injection is minimally invasive and produces a long lasting effect.

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Several drugs cause methaemoglobinemia which can lead to pulse oximeter desaturation and hypoxemia.Children with immune thrombocytopenic purpura are being treated with dapsone which is known to cause methaemoglobinemia and many of these can be planned for elective splenectomy. Preoperative knowledge of drug intake and their adverse effects is essential so is the early detection of the cause of intraoperative hypoxemia and the remedial measures taken. We present a child on dapsone therapy for treatment of immune thrombocytopenic purpura planned for elective splenec­tomy developed intraoperative pulseoximeter desaturation. The cause of desaturation was identified as methaemoglobinemia caused by dapsone therapy. Case signifies the importance of knowledge of any preoperative drug intake and its anaesthetic implications. Also patients on dapsone therapy especially children should be monitored for methaemoglobin levels. Since children with immune thrombocy­topenic purpura are being treated with dapsone these days and many of these patients would be planned for splenectomy, monitoring of preoperative methaemoglobin levels and methaemoglobinemia as a cause of intraoperative pulse oximeter desaturation should be kept in mind.

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The laryngeal mask airway - LMA classic has been widely used in clinical practice. A new disposable supraglottic airway device, the soft seal LMA has been introduced recently. We have compared the LMA classic with the disposable soft seal LMA in terms of various clinical parameters. Two hundred patients aged 20-50 years, body weight 50 to 70 kg, ASA I and II were randomly assigned into two equal groups for airway management during surgery with size 4 LMA, Group A (n=100) for classic LMA and Group B (n=100) for disposable soft seal LMA. Anaesthesia was induced with fentanyl 2mcg.kg^-1 + propofol 3mg.kg^-1, maintained with nitrous oxide 66%, oxygen 33% and halothane 2 to 3%. The variables studied were ease of insertion and insertion time, cuff pressure changes during nitrous oxide anaesthesia, presence of blood on the LMA on withdrawal and postoperative sore throat at 2 and 24 hours. LMA classic and disposable LMA showed similar clinical performance as shown by their insertion time, successful insertion at first attempt achieved within 15 seconds in 98% of Group A and in 97% of Group B. LMA cuff pressure increased from 45.01 ± 8.0 mm of Hg to 68.40+ 10 mm of Hg in Group A and from 45.02 ± 2.0 to 48.10±6.0 mm of Hg in Group B (P<0.05). Macroscopic blood was seen on 8 occasions in Group A and never in Group B. Incidence of sore throat at 2 hours post operatively was 30% in Group A and 10% in Group B (P< 0.05). However, there was no such difference at 24 hours postoperatively. So LMA disposable soft seal is a useful alternative to LMA classic, there is less trauma and less incidence of sore throat in the postoperative period.

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To identify the risk factors associated with postoperative vomiting (POV) in paediatric population undergoing common surgeries. The risk factors studied for association with POV were age >5 years, female gender, previous history of POV/motion sickness, type of surgery and duration of anaesthesia >45 min. A total of 100 ASA grade I and II patients of either sex aged between 2-12 years undergoing elective surgical procedures were screened for the study. All patients underwent similar anaesthe­sia protocol and received two antiemetic agents (ondansetron 0.05mg.kg^-1 and dexamethasone 0.15mg.kg^-1) in premedication. The patients were observed for 24 hours postoperatively for the incidence of vomiting, number of times rescue antiemetic given and any adverse reaction to antiemetic.Overall 34% patients (34/100) developed POV of which 26 had only one episode and 8 patients had 2 episodes during first 24 h. Incidence of POV was 13% (13/100) in first 4 h whereas it was 29% (29/100) in late postoperative period. In early post operative period, POV was not associated significantly with any predicted risk factors. However, age>5years, duration of anaesthesia>45 minutes and history of motion sickness/POV were significantly associated in late postoperative period(4-24h). Female gender and type of surgery were not associated with increased POV. The combination antiemetic effectively prevented POV in early postoperative period (0-4h) only but not in late postoperative period(0-24h).

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Bispectral index (BIS) is commonly used as an index of depth of anaesthesia and sedation. BIS can provide an additional benefit in detecting a critical neurological event, especially if the change of neurological status is caused by the critical illness itself. We encountered such an incident where the BIS value was decreased in a patient with Guillain Barre Syndrome, possibly due to cerebral hypoperfusion. The present report emphasises that BIS can be used not only as an indicator of cerebral ischaemia, but also as a tool to judge adequacy and efficacy of interventions targeted to restore the same.

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Maxillary prognathism(excess) is a congenital anomaly characterized by facial disfigurement. Accidental perforation of endotracheal tube during corrective surgery is not an uncommon complication. A case of accidental perforation of endotracheal tube during surgery and its management is presented here.

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