Attempts at organ transplantation have been made since the 19 ^th century. Renal transplantation is the preferred treatment for end stage renal disease. Renal transplant anaesthesia requires a thorough understanding of the meta­bolic and systemic abnormalities in end stage renal disease, familiarity with transplant medicine and expertise in managing and optimizing these patients for the best possible outcome. Also, the associated co-morbid conditions increase the complexity of anaesthesia, pain management and perioperative morbidity and mortality. Hence, a good perioperative management of these patients includes a multidisciplinary collaboration with well-planned anaesthetic strategies.

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Awareness is the postoperative recall of sensory perception during general anaesthesia. The incidence is quoted at 1-2 per every 1000 patients. This rare but serious adverse event can be extremely distressing for both the patient as well as the anaesthesiologist. Awareness during anaesthesia may occur despite apparently sound anaesthetic management and is usually not associated with pain. However, a few cases may experience excruciating pain and have long term neuropsychiatric sequelae like post-traumatic stress disorder. This adverse event can also have serious medicolegal implications. This article addresses the various contributory factors that may predispose to intra­operative awareness. Preventive measures in the preinduction period as well as intraoperatively are discussed, in­cluding the use of depth of anaesthesia monitors. Remedial steps to be taken when such an event occurs are also discussed.

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Cardiovascular collapse following use of methylmethacrylate for lower limb surgeries has been reported. How­ever there are no reports of cement reaction following shoulder arthroplasty. We report series of four patients exhibiting cement reaction. Two of our patients had cardiovascular collapse following cement insertion during hip arthroplasty. Severe hemodynamic derangement and transient hypoxemia was observed during cemented arthro­plasty of shoulder and knee respectively. Peripheral vasodilatory effects of the cement monomer, fat and marrow embolism and activation of the clotting cascade in the lungs, all contribute to cement reaction. Early and aggressive resuscitation with use of vasopressors, establishment of invasive hemodynamic monitoring and surgical modifications are the key to prevention of catastrophic outcome.

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Laryngeal mask airway (LMA) is increasingly being used in children as it is less invasive compared to endotra­cheal intubation and causes less discomfort in the postoperative period. However, some concerns remained about its safety during positive pressure ventilation in children. In a prospective randomized trial, 100 ASA I and II children weighing between 10-20 kg in the range of 2-10 years of age, scheduled for elective surgery were randomly allocated to one of the two groups of 50 patients each. The efficacy of LMA in children during positive pressure ventilation, its haemodynamic changes and postoperative complications were compared to endotracheal intubation. Insertion of LMA was easier in 94% patients while endot­racheal intubation was done easily in 53% of patients only (p<0.05). The changes in haemodynamic parameters were significantly higher after endotracheal intubation as compared to LMA placement. Furthermore these changes per­sisted for longer duration after endotracheal intubation in comparison to LMA insertion (5 min vs 3 min). Incidence of postoperative complications i.e. bronchospasm, laryngospasm and soft tissue trauma was significantly higher (p<0.05) after endotracheal intubation as compared to LMA insertion. To conclude, the laryngeal mask airway is a suitable alternative to endotracheal intubation for positive pressure ventilation in children.

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We report the anaesthetic management of a patient with hypokalemic periodic paralysis who underwent hepaticojejunostomy for stricture of the common bile duct. Patients with this disorder, who are apparently normal, can develop sudden paralysis as they are exposed to many of the predisposing factors, perioperatively. The complications due to this rare genetic disorder, the factors that can precipitate these problems and preventive measures are dis­cussed.

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Chronic low back pain (CLBP) is challenging to treat with its significant psychological and cognitive behavioural element involved. Mindfulness meditation helps alter the behavioural response in chronic pain situations. Significant body of research in the filed of mindfulness meditation comes from the work of Dr Kabat-Zinn. The current evidence in the field, though not grade one, shows that there is a place for mindfulness meditation in managing chronic pain conditions including CLBP. Further research to test the usefulness of mindfulness in CLBP should involve good quality randomized controlled trials of pure mindfulness based technique in matched subjects.

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During first stage of labour, many women suffer from lower back pain. Since cutaneous afferents from the lower back converge to the dorsal horns in the same segments there is anatomical support for the lower back pain being a referred pain. Intracutaneous injections of sterile water in the skin over the sacrum have been shown to relieve the pain of labour and it is free from negative side effects associated with use of other methods. The study was conducted after approval of institutional ethical committee on 100 pregnant patients admitted to the labour room of Lok Nayak hospital, New Delhi. Patients received 4 intracutaneous injections of sterile water or normal saline 0.5ml in the lumbo-sacral region. Pain scores, progress of labour and fetal outcome were studied. There was significant reduction of pain scores in the sterile water group but not in the normal saline group at 10, 45 and 90 minutes after injection. There was no difference in the progress of labour and fetal outcome between the two groups. To conclude intracutoneous sterile water injections over the sacrum is a simple and effective method to control pain during labour.

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Anaesthesiologists are playing a decisive role in patient management. Present day anaesthesiology is based on the use of newer and safer drugs, better patient monitoring, pain management and critical care. But the general public knows little of these developments. The study was undertaken to assess the perception regarding the anaesthesiology and anaesthesiologists among the general population. The present study was conducted on 300 persons (patient, patient's attendant and medical undergraduates) between 18-75 years of age to assess the knowl­edge regarding anaesthesiology and the anaesthesiologists. All collected data were categorized into 5 groups as per the educational status of the study population. Perception of anaesthesiologist as a doctor in illiterate, graduate and postgraduate population was 19.51%, 58.57% and 87.88% respectively. Anaesthesiology as a separate medical discipline was not known to 100%, 73.87%, 64.29% and 51.52% of the illiterate, upto matriculation, graduate and postgraduate population respectively. Among the population who knew something about general anaesthesia, none from upto matriculation and 33.87%, 44.83% and 100% from the graduate, post graduate and medical undergraduate groups respectively knew that anaesthesia is administered with specialized equipments along with monitoring. Illiter­ates did not know about regional anaesthesia, while most of others had some knowledge about it. The results of the study reflect the wide spread ignorance and misconceptions about anaesthesiology and anaesthesiologists still preva­lent in public in India.

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The aim of the study was to assess and compare laryngoscopic view of Truview evo2 laryngoscope with that of Macintosh laryngoscope in patients with one or more predictors of difficult intubation (PDI). Moreover ease of intubation with Truview evo2 in terms of absolute time requirement was also aimed at. Patients for elective surgery requiring endotracheal intubation were initially assessed for three PDI parameters - modified Mallampati test, thyro­mental distance& Atlanto-occipital (AO) joint extension. Patients with cumulative PDI scores of 2 to 5 (in a scale of 0 to 8) were evaluated for Cormack& Lehane (CL) grading by Macintosh blade after standard induction. Cases with CL grade of two or more were further evaluated by Truview evo2 laryngoscope and corresponding CL grades were assigned. Intubation attempted under Truview evo2 vision and time required for each successful tracheal intubation (i.e. tracheal intubation completed within one minute) was noted. Total fifty cases were studied. The CL grades assigned by Macintosh blade correlated well with the cumulative PDI scores assigned preoperatively, confirming there predictability. Truview evo2 improved laryngeal view in 92 % cases by one or more CL grade. Intubation with Truview evo2 was possible in 88% cases within stipulated time of one minute and mean time of 28.6 seconds with SD of 11.23 was reasonably quick. No significant complication like oro- pharyngeal trauma or extreme pressor response to laryngoscopy was noticed. To conclude, Truview evo2 proved to be a better tool than conventional laryngoscope in anticipated difficult situations.

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Gastroschisis is a congenital anomaly with a high perioperative mortality. Administration of general anaesthesia to these high risk neonates is associated with several problems including postoperative apnoea and the need for mechanical ventilation. Central neuraxial blocks, and more recently, combined spinal epidural have been administered for major abdominal surgery in neonates. We present the case of a neonate posted for gastroschisis repair conducted under combined spinal epidural anaesthesia and discuss the several advantages of this technique.

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Hypomagnesaemia is a common complication after cardiopulmonary bypass (CPB) and predisposes to the development of cardiac arrhythmias. Previous studies showed that intravenous magnesium reduces the incidence of postoperative cardiac arrhythmias but it also inhibits platelet function. Our aim was to compare the postoperative blood loss in patients not receiving magnesium after CPB with the group who received magnesium and to compare the requirement of blood, fresh frozen plasma (FFP) and platelets within 24 hours after surgery. This prospective randomized controlled study was conducted in 80 adult patients on oral aspirin undergoing elective CABG requiring CPB. Group A patients had not received magnesium infusion after recovery from CPB. Group B patients received magnesium infusion after recovery from CPB. Postoperative bleeding was assessed in both the groups. All the data were statistically analyzed. There was a insignificant increase in 24 hours postoperative drainage in magnesium recipient group compared to control group ( p>0.05). Requirements of blood and blood products to maintain haematocrit and coagulation profile revealed insignificant ( p > 0.05).Increase in requirement of PRC, FFP and platelets in magnesium recipient patients than the control group. Incidence of atrial fibrillation ( Gr A 2.5%, Gr B 2.5%) and atrial extrasystoles (Gr A 2.5%, Gr B 10%) revealed comparable ( p > 0.05) between the groups, but incidence of ventricular arrhythmias were significantly ( p<0.05) high in the patients of Gr A(17.5%) than Gr B(5%). To conclude, magnesium may be administered to patients who continue pre-operative aspirin to undergo on-pump CABG surgery.

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Laryngoscopy and tracheal intubation (LTI) increase blood pressure and heart rate (HR). Intensity of these changes is influenced by the anaesthetic depth assessed by the bispectral index (BIS). We determined the effect of phenytoin on anaesthetic depth and its influence on haemodynamics following LTI. Fifty patients of ASA grades I and II on oral phenytoin 200 to 300mg per day for more than one week were compared with 48 control patients. Standard anaesthesia technique was followed. BIS, non invasive mean blood pressure (MBP) and HR were recorded 30, 60, 90 and 120 sec after LTI. Phenytoin group needed lesser thiopentone for induction, 5 mg (1.1) vs. 4.3 mg (0.7) [p=0.036]. BIS was significantly lower in the phenytoin group vs. the control 30, 60, 90 and 120 sec after LTI [43.1 (16.0) vs. 48.9 (14.9), p=0.068, 56.3 (16.7) vs. 64.3 (14.4), p=0.013, 59.8 (15.8) vs. 67.5 (12.1), p=0.008, 62.6 (14) vs. 68.9 (11.2), p=0.017, and 64.2 (11.3) vs. 69 (11.7), p=0.033], respectively. MBP was also lower in the phenytoin group 30, 60, 90 and 120 sec after LTI [112.8 mmHg (13.8), vs. 117.9 mmHg (18) p=0.013, 108.6 (12.8) vs. 117.5 (16) p=0.003, 106.1 mmHg (14.1) vs. 113.2 mmHg (14.9), p=0.017, 101.8 mmHg (13.8) vs. 109.5 mmHg (14.1), p=0.007], respectively. HR was lower in phenytoin group at 30 sec. (p=0.027), 60 sec (p=0.219), and again at 120 sec (p=0.022). Oral phenytoin therapy for over a week results in greater anaesthetic depth as observed using BIS, which also attenuated haemodynamic response of LTI.

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TRALI is a rare but fatal complication of blood transfusion usually under diagnosed and under reported. An interesting case of hemolysis and lung injury developing in a single patient following blood transfusion during perioperative period is reported hereby. Great amount of suspicion about TRALI and supportive care such as mechanical ventila­tion has saved this patient.

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Any anaesthesiologist handling a paediatric airway must have a detailed understanding of the differences in airway anatomy, signs and symptoms of airway compromise and common paediatric airway abnormalities. In addition to various equipments needed to manage a difficult airway, there should be a clear plan for evaluation, preparation and management of life threatening complications. We share our experience of successfully managing a difficult airway of a 5 year old child with Tessier 7 facial cleft syndrome. We emphasize the importance of preoperative evaluation, preparation and use of various airway adjuncts.

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Tetanus is an acute often fatal disease produced by the Gram-positive, obligate anaerobic bacterium Clostridium tetani. Prolonged intensive care is required in severe tetanus, with the associated complications including nosocomial sepsis. Autonomic dysfunction in severe tetanus is difficult to manage and is a significant cause of mortality. We present here, use of clonidine in a case of severe tetanus with acute renal failure who was successfully managed.

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Endobronchial blood clot is an unusual cause of airway obstruction leading to lung collapse in the postoperative period. It is not always easy to pin point the exact etiology in the presence of multiple risk factors. Pulmonary collapse can herald the onset of severe haemodynamic derangements and hypoxemia. So, early identification and manage­ment is crucial for preventing catastrophic complications. Various modalities have been described in the literature for removing the obstructing clot and re-expansion of the lung. We present a case of postoperative left lung collapse by an obstructing endobronchial blood clot in a patient undergoing coronary artery bypass graft surgery.

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The study was carried out randomly in 20 patients of ASA grade I and II of either sex, between the ages of 25 and 65 years scheduled for laparoscopic cholecystectomy. We studied the effect of intraperitoneal CO ₂ insufflation with head up position, on RR interval, QT interval, QTc interval, QT Dispersion, QTc Dispersion using computerized measurement with the help of 12 lead ECG. The RR interval did not change significantly during the study but there was statistically significant increase in QT interval, QTD and QTcD.

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Galactosaemia is an autosomal recessive metabolic disorder that occurs due to galactose-1-phosphate uridyl transferase enzyme deficiency that leads to hepatic, ophthalmic, neural and renal derangements. Association of cyanotic congenital heart disease with galactosaemia is a rare occurence and a matter of great concern for the anaesthesiologist during open heart surgery. In this case report, the perioperative management of a newborn with galactosaemia operated for correction of transposition of great arteries (TGA) is discussed.

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