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Clonidine, an alpha-2 agonist is a known antihypertensive agent. Because of its sedative and analgesic effects, it is gaining popularity in anaesthesiology. It can be used to premedicate children, as an adjuvant to regional and general anaesthesia and it has several other applications in paediatric anaesthesia. It has also found use in the paediatric intensive care as a sedative, analgesic and to ensure haemodynamic stability. As in the case ol'any other anaesthetic drug, its use has to be vigilantly monitored.

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Sepsis is a leading cause of mortality in critically ill patients. The pathophysiology of sepsis involves a highly complex and integrated response, including the activation of various cell types, inflammatory mediators, and the haemostatic system. Recent evidence suggests an emerging role ofthe microcirculation in sepsis, necessitating a shift in our locus away Irom the macrohaemodynamics to ill icrohaemodynanmics in a septic patient. This review article provides a brief overview of the microcirculation, its assessment techniques, and specific therapies to resuscitate the microhaemodynamics.

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Transplantation provides a near normal life and excellent rehabilitation compared to dialysis and is the pre­ferred method oftreatment for end stage renal disease patients. We describe our experiences through a retrospec­tive analysis ol'anaesthesia management of 350 cases of both living related and cadaveric renal transplantation conducted between Jan 2004 -April 2008 at Jaslok Hospital And Research Center. Areas ol'our interest include preoperative patient status, fluid management, hemodynamic stability, anaesthesia management, and perioperative complications. Recent advances in surgical techniques; anaesthesia management and immunosuppressive drugs have made renal transplantation sale and predictable. Preoperative patient optimization, intraoperative physiologi­cal stability and postoperative care of'renal transplant patients have contributed to the success of'renal transplant programme in our hospital.

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Anaesthesia for conjoined twins, either for separation surgery, or for MRI or other evaluation procedures is an enormous challenge to the paediatric anaesthesiologist. This is an extra challenging surgery because we the anaesthesiologists need to care for two patients at the same time instead of just one. Anaesthesia for conjoined twins 'separation surgery mainly centered on the following concerns: 1.Conjoined Twins' physiology like crossed circulation. distribution of blood volume and organ sharing with their anaesthetic implications. 2.Long marathon surgery with massive fluid shifts and loss of blood & blood components and their rapid replenishment. 3.Meticulous planning for organized management of long hours of anaesthetic administration in two paediatric subjects simultaneously with multi surgical specialties involvement and their unique requirements.We report the anaesthetic and intensive care management of one pair of Pygopagus separation surgery and also the review of literature and world statistics.

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Sixty ASA grade I& II adult patients of either sex were randomly assigned into two groups .Group I (n=30) for I-gel and Group P (n=30) I'or LMA - ProSeal . We assessed the airway sealing pressure, ease of insertion, success rate of insertion, ease of gastric tube placement, airway trauma by post operative blood staining ofthe device, tongue, lip and dental trauma, hoarseness, regurgitation / aspiration and cost effectiveness. Although the airway sealing pressure was higher with Group P (29.6 cm H ₂ O) than with Group I (25.27 cm H ₂ 0) (p < 0.05), but the airway sealing pressure of Group I was very well within the normal limit to prevent aspiration.The ease of insertion was more with Group I (29/30) than with Group P (25/30) (p <0.05). The success rate of first attempt of insertion and ease of gastric tube placement was more with Group I (p> 0.05). Blood staining of the device& tongue, lip and dental trauma was more with Group P (p >0.05). There was no evidence of bronchospasm, laryngospasm, regurgitation, aspiration or hoarseness in either group. To conclude I-gel is a novel supraglottic device with an acceptable airway sealing pressure (25.27 cm H ₂ O). It is easier to insert, requires less attempts of insertion, has easier gastric tube placement and is less traumatic as compared to LMA-ProSeal.

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Shivering-the "Big Little Problem" has an incidence of 60% in early recovery phase following general anaesthe­sia. A number of techniques have been tried to prevent postoperative shivering. Previous study showed that, ondansetron in higher doses reduces postoperative shivering. Therefore, this study was done to compare the efficacy of prophy­lactic granisetron, pethidine and placebo in preventing postoperative shivering. Ninety patients aged 20-60yrs, ASA physical status I and II, scheduled for laparoscopic surgery under general anaesthesia were randomly allocated to receive either normal saline (Group S, n=30) as negative control, pethidine 25mg (Group P, n=30) as positive control or granisetron 40mcg.kg ^-1 (Group G, n=30) intravenously before induction. The anaesthesia was induced with fentanyl 2mcg.kg ^-1 , propofol 2mg.kg ^-1 and atracurium 0.5mg.kg ^-1 and maintained with sevoflurane 1-1.5%. Nasopharyngeal temperature was measured throughout the procedure. An investigator, blinded to the treatment group, graded postoperative shivering in a scale of 0 to 4. (0= no shivering, 1= piloerection or peripheral vasoconstriction but no visible shivering, 2= muscle activity in only one muscle group 3= muscle activity in more than one muscle group, 4= shivering involving the whole body). Prophylaxis was regarded as ineffective if shivering was greater than grade 3 and intravenous pethidine 25 mg was administered as rescue medication. The three groups did not differ significantly regarding patient characteristics. The numbers of patients shivering on arrival in the recovery room at 15 minutes after operation were significantly less in Group P (7%) and Group G (17%) than in Group S (60%). Groups P and G differ significantly than in Group S (p<0.05).However, the difference between Groups P and G was not statistically significant (p>0.05). The prophylactic use of granisetron (40mcg.kg ^-1 ) and pethidine(25mg) intravenous were found to be effective in preventing postoperative shivering.

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During suicidal hanging, death takes few minutes to occur. Patient, if rescued, may develop respiratory distress, pulmonary oedema, convulsions, raised intra cranial pressure and unconsciousness immediately after incidence. We report a young male of suicidal hanging, brought to hospital in unconscious state with decerebrating movements. He developed pulmonary oedema after two hours of incidence. He was resuscitated and treated successfully.

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Propofol and isoflurane have well proven roles as intravenous and inhalational anaesthetics respectively in neurosurgery. We conducted this study to know the outcome using butorphanol as an intraoperative analgesic. Sixty craniotomy patients randomly divided into two groups of 30 each were included in this study. Group A patients were induced and maintained with propofol. Group B patients were induced with thiopentone and maintained with isoflurane. All patients were administered 30µg.kg ^-1 butorphanol intravenously 10 minutes before induction of anaesthesia, fol­lowed by slow injection of 30µg.kg ^-1 midazolam. All were assessed for sedation, respiratory insufficiency, postopera­tive nausea and vomiting (PONV) and other side effects in the recovery room. We found no difference in demo­graphic parameters between the groups. The fall in HR was maintained in the post induction / intubation period and throughout the intraoperative period in Group A, unlike Group B patients in whom it rose significantly following intubation. Butorphanol was found to be a safe intraoperative analgesic in neurosurgical patients. In addition, it was associated with statistically better haemodynamics and earlier recovery when used with propofol as compared to thiopentone-isoflurane anaesthesia.

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Prolonged ventilation leads to a higher incidence of ventilator associated pneumonia(VAP) resulting in ventilator dependency, increased costs and subsequent weaning failures. Prevention and aggressive treatment of VAP alongwith patient friendly newer modes of ventilation like adaptive support ventilation go a long way in successful management of these cases.

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Rupture of an abdominal aortic aneurysm (AAA) is a lethal event associated with a high mortality rate. In addition, the risk is compounded if the patient is on anticoagulants. Due to the recent advance in anaesthetic, operative and postoperative care, the patient if recovers from their emergency repair has a good long term survival. We de­scribe the anaesthetic management of an elderly male on anticoagulant therapy presenting with ruptured AAA.

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Anaesthetic management of surgery for tumors involving the carina is very challenging for an anaesthesiologist and has been associated with guarded prognosis. We describe the management of carinal resection and reconstruc­tion due to a tracheal tumor involving the carina. The various anaesthetic issues involved and experienced in this clinical setting are described.

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Pulmonary alveolar proteinosis (PAP) is a rare disorder characterized by accumulation of amorphous acellular phospholipid material in the lungs. Whole lung lavage is the standard therapy which gives dramatic clinical improve­ment and offers a long term survival to these patients. A 43-year-old man suffering from PAP presented to casualty with NYHA grade IV dyspnoea with oxygen saturation (SaO ₂ ) on pulseoximetry 67% on room air and 78% with O ₂ 6 L/min. He underwent whole lung lavage under general anaesthesia using one lung ventilation with 37 F left end bronchial double lumen tube. The lung lavage was initially performed for the left lung and for the right lung 4 days later. The patient was discharged home with oxygen saturation of 96 % on room air.

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Carotid endarterectomy(CEA) is being increasingly performed under regional anaesthesia supplemented with sedation, the world over. Deep or superficial cervical plexus blocks or a combination of both have been found to be equally effective. Various imaging modalities like fluoroscopy, computed tomography (CT), CT-fluoroscopy, ultra­sound etc have been used to increase the success rates of the technique and to reduce the rate of complications associated with the block. These are especially useful given the varying landmarks quoted by various authors as also inter-individual differences in anatomy. We present a case report of how fluoroscopy aided us in administering cervical plexus block.

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Direct trauma to the airway is a rare injury which can lead to disastrous consequences due to compounding effect of bleeding, aspiration of blood, airway obstruction and severe sympathetic stimulation. Here we are presenting two cases of open tracheal injury in two adult males following assault with sharp weapon. Two different techniques of securing the airways were employed depending upon the severity and urgency of the situation. In the first case, orotracheal intubation helped the surgeon to repair airway around the endotracheal tube whereas in the second patient this stenting effect was absent as he was intubated through the distal cut-end of trachea in the face of airway emergency.

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Hypothermia is a common occurrence under anaesthesia and may prolong the duration of action of neuromus­cular blockade . By limiting fall in temperature, an infusion of amino acid enriched solution may speed the recovery from neuromuscular blockade. We studied 60 ASA Grade - I/II patients of aged between 20 to 60 years scheduled for elective surgery under general anaesthesia. The patients were randomly divided into four groups to receive amino acid infusion with vecuronium bromide AV, normal saline with vecuronium bromide(CV), amino acid with atracurium besylate(A-At) and normal saline with atracurium besylate(C-At). Although there was a significantly lesser decrease in the core temperature from the baseline in all the patients receiving amino acid infusion (p<0.05), it significantly reduced the time to 25% recovery from the time of injection of vecuronium only. (60.59 ± 11.39 in CV vs 51 ± 14.72 min in AV) (P < 0.05), and not for atracurium.

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Tracheal and esophageal compression is a well-recognized complication of aneurysms of the aortic arch. Most of the patients present with dysphagia and/or respiratory insufficiency. In the adult population a right-sided aortic arch is often asymptomatic unless aneurysmal disease develops. This usually occurs at the level of the take-off of an aberrant left subclavian artery and is known as a Kommerell's aneurysm.In spite of its rarity, this condition is clinically relevant because of the mortality associated with rupture, the morbidity caused by compression of mediastinal struc­tures, and the complexity of surgery. In many cases, surgical resection of the aneurysm relieves the symptoms. We present a case in which tracheal compression and bilateral vocal cord palsy caused by an aneurysm arising from Kommerrell's diverticulum .The patient developed respiratory embrassement after extubation and was subsequently treated with continue positive airway pressure (CPAP) with a favorable result.

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The LMA CTrach is a variant of the intubating LMA. It provides visualization of larynx during intubation and is a promising addition to airway management cart. A preliminary study of 20 patients posted for elective surgery requiring GA were enrolled for the study. Their age ranged from 16-60 years, weight ranged from 45 to 65 kg, and they were belonging to ASA PS I& II with normal airways. Conventional general anaesthesia was administered in all the cases. The success rate and attempt of insertion of CTrach and ETT were observed. Viewing of larynx was graded as good, acceptable and poor. Require­ment of manipulations was also noted down. Time for insertion of CTrach and ETT, view of larynx and complete procedure were noted down. We successfully inserted LMA CTrach at first attempt in all the patients within 36.75 ± 2.12 sec and ventilation was possible in all cases. We were able to view larynx in majority of cases (95%), while in 1 patient (5%), we could not view the larynx even after manipulations, although ET intubation was successful in that case. Time required for viewing of larynx was 240.2 ± 10.5 sec. Manipulation of LMA was required in 40% cases to obtain good view. ET intubation was done at first attempt in all the patients within 60.5 ± 5.15 sec. The time required for complete proce­dure was 347.75 ± 10.55 seconds. None of our patient had any complications and haemodynamic parameters and SpO ₂ remained within normal limits throughout the procedure. The post operative period was uneventful. We suc­cessfully ventilated and intubated all the patients using LMA CTrach.

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