Intra Aortic Balloon Pump (IABP) is the most commonly used mechanical circulatory assist device in cardiac patients. IABP can improve ventricular function by decreasing the preload and increasing systolic output with signifi­cant improvement in myocardial oxygen supply/demand ratio. Pre-operative IABP therapy in 'high-risk' coronary patients has been shown to reduce hospital mortality and shorten ICU stay significantly, compared with controls. The introduction of sheathless insertion kits has reduced the incidence of vascular complication rates. Pro-Active Counter Pulsation is a new IABP system which automatically detects the irregular pattern and result is an improvement in the haemodynamic effect of IABP during periods of arrhythmia. Today, continued improvements in IABP technology permit safer use and earlier intervention to provide haemodynamic support. These developments have made the IABP a mainstay in the management of ischemic and dysfunctional myocardium. This review article aims to provide basic concept of IABP to hospital doctors especially anaesthetists, intensivists cardiologists and cardiac surgeons. It discusses the common indications, contraindications, the physiologic aspects of IABP, the equipment needed to facilitate IABP, the use of the IABP in special situations and complications of its use.

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Cerebral palsy (CP) is the result of an injury to the developing brain during the antenatal, perinatal or postnatal period. Clinical manifestation relate to the areas affected. Patients with CP often present for elective surgical proce­dures to correct various deformities. Anaesthetic concerns of anaesthesia are intraoperative hypothermia , and slow emergence. Suxamethonium does not cause hyperkalaemia in these patients, and a rapid sequence induction may be indicated. Temperature should be monitored and an effort made to keep the patient warm. Cerebral abnormalities may lead to slow awakening; the patient should remain intubated until fully awake and airway reflexes have returned. Pulmonary infection can complicate the postoperative course. Postoperative pain management and the prevention of muscle spasms are important and drugs as baclofen and botulinum toxin are discussed. Epidural analgesia is particu­larly valuable when major orthopaedic procedures are performed.

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Gastric bypass procedure (GBP) is one of the effective operative methods for weight loss in patients with morbid obesity. The anaesthesia team has a crucial role to play in managing these patients. Therefore it is important for anaesthesiologists to be familiar with the anatomical and physiological changes along with pharmacological alter­ations associated with obesity.So that they can offer optimal perioperative care to these patients. This study describes the anaesthetic management of a series of 100 consecutive patients with an average body mass index (BMI) of 46.5 kg.m ^-2 who underwent laparoscopic GBP over a period of three years (September'04 to September'07) in the hands of nonbariatric surgeons.Patients were aged between 16 - 36 years with more female preponderance (73: 27) and had mean duration of the procedure of 2.82 ± 1.44 hours under standard endotracheal balanced anaesthesia tech­nique. The initial mortality is 1% along with 4% incidence of both difficult intubation and postoperative respiratory failure in this series which is quite comparable with world famous bariatric surgical centers.

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Anaphylactic reactions to intraoperative antibiotics are rare events and reactions after a negative intradermal skin testing are even rarer. We are reporting a case of grade V anaphylactic reaction to ceftriaxone, which occurred inspite of a negative skin testing preoperatively. Despite of the treatment along the established guidelines, patient suffered hypoxic brain damage ultimately having a fatal outcome 7 days later. This case highlights the limits of the screening test done preoperatively for antibiotic sensitivity and also the difficulty in resuscitating anaphylactic reac­tions when patient is on B blocker and under spinal anaesthesia.

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Many serious problems can occur in children due to unrelieved postoperative pain. Intrapleural regional analge­sia is a new postoperative pain relief technique. The aim of the present study was to evaluate the efficacy of intrapleural bupivacaine administration either by bolus or by continuous infusion method for providing postoperative pain relief in children following upper abdominal surgery. The study was carried out on 30 children scheduled for upper abdominal operations and randomly divided into two equal groups. Group A received a single dose of 1.5 mg. kg ^{- 1} of 0.25% bupivacaine while the other Group B received 0.125 mg. kg ^{- 1} . hour ^{- 1} of 0.25% bupivacaine infusion after an initial bolus dose of 0.4 mg. kg ^{- 1} of 0.25% bupivacaine. The results showed a significant decrease in haemodynamic parameters under designed techniques with significant improvement of respiratory functions. Pain relief score and Prince Henry scale were significantly decreased in both groups with longer periods of postoperative analgesia in Group B. Both techniques proved to be convenient and safe postoperative pain-relief methods in children following upper abdominal surgical interventions. Either method had its own advantages and disadvantages.

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Acute respiratory failure due to chronic obstructive pulmonary disease presents an increasing problem for both health and economics in the modern world. The goal of this study was to compare invasive and noninvasive mechani­cal ventilation for patients with COPD. A prospective, randomized trial was performed in a multidisciplinary intensive care unit. Of 614 patients requiring mechanical ventilation (MV) longer than 24h, after excluding those who didn't meet the inclusion criteria, 72 patients with COPD remained the research sample. The MV procedure was per­formed using standard methods, applying two MV methods: invasive MV and noninvasive MV. Patients were ran­domized into two groups for MV application using closed, non transparent envelopes. Comparison was made based on patient characteristics, objective parameters 1h, 4h, 24h, and 48h after admission and finally treatment outcome. In patients with COPD NIMV had statistically better outcome compared to IMV with MV duration NIMV:IMV 102:187h, p <0.001, time spent in ICU 127:233h, p <0.001. Need for intubation/reintubation 16 (42.1%):34 (100%)/4 (11.8%), p <0.001, hospital pneumonia 2 (5.3%):18 (52.9%), p =0.001. Applying strict application protocols, and based on com­parison of objective parameters of pulmonary mechanics, biochemistry and finally treatment outcome, high advantage of NIMV method was confirmed.

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Gabapentin, a structural analogue of gamma-amino butyric acid, has been used as an anticonvulsant and antinociceptive drug but its mode of action is not well understood. Gabapentin has been demonstrated in various clinical studies to be of value as preemptive analgesic, and has shown to reduce the postoperative requirement of opioids. This study was conducted to evaluate the role of gabapentin as preemptive analgesic in patients undergoing total abdominal hysterectomy. Fifty patients with ASA grade I and II were assigned to receive 300mg gabapentin or placebo 2hr before surgery. Surgeries were conducted under combined spinal epidural anaesthesia. Post operatively, pain was assessed by visual analogue score (VAS) at 2, 4,8,12 and 24hrs. Patients were given epidural boluses of bupivacaine (0.125%) on demand. Total numbers of epidural boluses during first 24 hrs postoperatively were noted. Patients in gabapentin group have significantly lower VAS score 2, 4,8,12 and 24hrs postoperatively as compared to the placebo (1.3 ± 1.3, 2.3±1.4, 3.2 ± 2.1, 1.8 ± 1.7, 1.2 ± 1.3 vs. 2.1 ± 1.7, 3.2±1.6, 4.4 ± 1.2, 3.3 ± 1.1, 2.1 ± 1.2 respectively; P <0.05). Total numbers of epidural boluses were significantly less in gabapentin group (3.4±1.6 vs. 5.6±2.1, P<0.05). We conclude that preemptive use of gabapentin 300mg orally significantly reduces the number of postoperative epidural bolus requirement and postoperative pain in patients undergoing total abdominal hysterectomy under combined spinal epidural anaesthesia.

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The drug related complications are on the rise warranting special attention towards patient safety in Intensive Care Unit (ICU) setup. Pharmacovigilance is the science about the detection, assessment and prevention of drug related problems. This review is aimed to highlight significant problems arising from medication errors with emphasis on special drugs used in ICU (oxygen, antibiotics, sedatives, analgesics and neuromuscular blocking drugs) and their risk reduction strategies in ICU utilizing practice of pharmacovigilance. Human error, lack of communication among various health providers, inadequate knowledge about drugs, failure to follow protocols or recommended guidelines are important causes of drug related problems in ICU. It is imperative that ICU administrators and medical directors of hospitals consider adverse drug events (ADEs) as system failures. Pharmacovigilance, an observational science is the need of the hour for patients admitted in ICUs. We need to give more emphasis on prevention rather than treating the potentially fatal complications arising from ADEs. Eternal vigilance is the key. Protocol based management, improvement of medication system, frequent audits, improved communication, good team work, a blame free environ­ment, inclusion of a pharmacist, leadership involvement and use of information technology in the ICU are possible solutions.

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Treatment of intraoperative hypotension in a patient on chronic tricyclic antidepressant therapy(TCA) is contro­versial. Evidence based guidelines for the management of psychotropic drugs during perioperative period are lacking. We present a patient who was subjected to bilateral total knee replacement under combined spinal epidural anaesthe­sia. She developed refractory hypotension after release of tourniquet and responded only to large dosage of norepi­nephrine along with acid base correction. We believe that chronic TCA therapy led to depleted catecholamine re­serves and down regulation of its receptors. Release of tourniquet led to metabolic acidosis and subsequently in­creased free clomipramine concentration in blood leading to severe refractory hypotension.

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Previous reports indicate that the analgesic effect of opioids is due to both closure of specific voltage-gated calcium channels (N- and P/Q-types) and opening of G protein-coupled inwardly rectifying potassium channels (GIRKs) in neurons concerned with transmission of pain. However, administration of opioids leads to unacceptable levels of side effects, particularly at high doses. Thus, current research is directed towards simultaneously targeting other voltage­gated calcium channels (VGCCs) like the L-type VGCCs or even other cell signaling mechanisms, which would aug­ment opioid-mediated analgesic effect without a concurrent increase in the side effects. Unfortunately, the results of these studies are often conflicting considering the different experimental paradigms (variable drug selection and their doses and also the specific pain test used for studying analgesia) adopted by researchers. The present review focuses on some of the interesting findings regarding the analgesic effect of Opioids + L-VGCC blockers and suggests that time has come for a clinical trial of this combination of drugs in the treatment of cancer pain.

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Cases of Mucopolysaccharidoses (MPS), though rare, may pose many challenges for the anaesthesiologist. Maintaining the airway may be extremely difficult even in the most experienced hands. We present here, two breath taking airway securing experiences-one emergency and the other elective- in a 10 year old child of Mucopolysaccharidoses (MPS) who presented to us for repair of an irreducible umbilical hernia.

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Fixed flexion deformity is a sequel of burns and their release under anaesthesia pose difficulty during intubation. Various modalities are used for airway management in such cases. Here we present the successful airway manage­ment in a patient with post burn contracture who was managed with use of intubating laryngeal mask airway (ILMA) introduced in reverse direction with 180 ⁰ rotation for insertion.

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The study was designed to compare the efficacy of interpleural and thoracic epidural analgesia after thorac­otomy with regard to quality of analgesia and complications. Sixty patients undergoing elective thoracotomy were randomly and equally placed into either interpleural (IP) or thoracic epidural (TE) group. In IP group an interpleural catheter was placed in paravertebral space under direct vision during surgery and received 0.25% bupivacaine 20 ml with buprenorphine 150 mcg. In TE group an epidural catheter was inserted in the T6-7 / T7-8 interspace and received 0.25% bupivacaine 10 ml with buprenorphine 150 mcg. Dosage were repeated in both the groups to keep a VAS score <40 for 48 hours post-operatively. Spirometry was done preoperatively and 12, 24 and 36 hours post-opera­tively. Vital parameters were monitored for 48 hours. The mean analgesia time was 331.73±94.03 min and 567.33±127.33 min in IP and TE groups respectively. The VAS score was significantly reduced within the first 30 minutes of injection in both the groups. Post injection VAS was significantly better in TE group. Mean time taken for interpleural and epidural catheter placement was 5.0±0.0 min and 33.83±3.39 min respectively. Postoperative forced expiratory volume in 1 second(FEV1), forced vital capacity (FVC) and forced expiratory ratio (FER) were similar in both the groups while peak expiratory flow rate (PEFR), maximal expiratory flow (MEF) and F50 were slightly better in TE group. Vital parameters showed similar changes in both the groups. The TE group had more complications. Interpleural analgesia, though of shorter duration, is a safe and effective alternative technique for post-thoracotomy analgesia and has a low complication rate.

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Epidural infusion of local analgesic and opioid are commonly used for postoperative pain relief. This combina­tion gives excellent anlgesia but nausea and vomiting remains a major concern. Low dose epidural naloxone prevents PONV induced by spinal opioids like morphine, fentanyl and sufentanil. However, it is not known that epidural naloxone administration prevents PONV induced by epidural buprenorphine. We have reported three cases of major abdominal operation in which lowdose epidural infusion of naloxone releived the symptom of buprenorphine induced severe PONV and improved the quality of analgesia.

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Pulmonary oedema developes acutely during perioperative period and is usually due to unknown cause,but this life threatening complication if managed on time ,leads to rapid and full recovery. Here a case of 70 year old man is reported who developed acute pulmonary oedema after conclusion of surgery due to unknown cause.

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