Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for primary peritoneal malignancies or peritoneal spread of malignant neoplasm is being done at many centres worldwide. Perioperative management is challenging with varied haemodynamic and temperature instabilities, and the literature is scarce in many aspects of its perioperative management. There is a need to have coalition of the existing evidence and experts' consensus opinion for better perioperative management. The purpose of this consensus practice guideline is to provide consensus for best practice pattern based on the best available evidence by the expert committee of the Society of Onco-Anaesthesia and Perioperative Care comprising perioperative physicians for better perioperative management of patients of CRS-HIPEC.

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Background and Aims: Hypotension following spinal anaesthesia for caesarean section is common in spite of adequate fluid loading. Phenylephrine is the recommended drug to treat spinal hypotension during caesarean section. Recently, norepinephrine boluses are being suggested as an alternative to phenylephrine boluses. The aim of our study was to compare the effectiveness of bolus doses of norepinephrine with phenylephrine to treat spinal hypotension during caesarean section. Methods: Fifty patients undergoing elective caesarean section under spinal anaesthesia were randomly assigned into two groups. Group P patients received phenylephrine 50 μg as an intravenous bolus and group N received 4 μg of norepinephrine as intravenous bolus to treat spinal hypotension. The primary objective of our study was to compare the number of bolus doses of norepinephrine or phenylephrine required to treat spinal hypotension. The secondary objectives were to compare the incidence of bradycardia, hypertension, nausea and vomiting in mother and foetal outcomes. Results: The number of boluses of vasopressors required to treat hypotension was significantly lower in group N (1.40 ± 0.577 vs. 2.28 ± 1.061, P = 0.001). The frequency of bradycardia was high in group P, but this difference was not statistically significant (4%vs. 20%, P = 0.192). Maternal complications such as nausea and vomiting and shivering were comparable between the groups. The foetal parameters were also comparable between the two groups. Conclusion: Intermittent boluses of norepinephrine are effective in the management of spinal-induced hypotension during caesarean section. The neonatal outcomes were similar in both the groups. Norepinephrine boluses can be considered as an alternative to phenylephrine boluses.

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Background and Aims: BlockBuster^® Laryngeal Mask Airway, a newer supraglottic airway device, is claimed to be an efficient conduit for endotracheal intubation. Intubating laryngeal mask airway (LMA) is an established device for the same. This randomised study was undertaken to evaluate the success rate of blind intubation using either of these LMAs. Methods: Sixty patients of age group 20-60 years undergoing general anaesthesia were randomised in 2 groups, of 30 patients each, for tracheal intubation using either BlockBuster^® LMA (Group B) or the Intubating LMA Fastrach^® (Group F). After induction of anaesthesia, LMAs were inserted and on achieving adequate ventilation with the device, fibreoptic scopy was performed to assess the glottis visualisation score. Blind intubation was attempted through the supraglottic airway devices (SAD). The primary objective was first pass successful intubation and secondary outcomes were ease, time for LMA insertion, oropharyngeal seal pressure (OSP), LMA removal time, fibreoptic scoring and complications. Data was analysed using SPSS V22 software. Results: The first-attempt success rate of tracheal intubation was 90% in Group B and 66.6% in Group F (P = 0.028), while the overall success rate of intubation was 96.6% in Group B and 89.9% in Group F (P = 0.3). The OSP in Group B was 33.7 ± 1.8 and 22.7 ± 1.5 cm H₂O in Group F (P = 0.001). Complications such as sore throat and blood stain were reduced with BlockBuster^® LMA. Conclusion: BlockBuster^® LMA provides higher first pass success rate of blind tracheal intubation with less complications like sore throat and blood staining.

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Background and Aims: Thoracic paravertebral block (TPVB) provides effective analgesia in breast surgery. Recently, use of erector spinae plane block (ESPB) in controlling post-operative pain has proved effective. This study aimed to compare the effect of ESPB with TPVB in post-mastectomy acute pain control. Methods: A prospective, randomised double-blinded study enrolled 70 adult female patients, scheduled for modified radical mastectomy. Patients were randomised into two groups, receiving 20 ml of 0.25% bupivacaine: group I (TPVB) and group II (ESPB). Post-operative 24 h morphine consumption, intra-operative fentanyl consumption, time of the first request for analgesia and post-operative visual analogue scale (VAS), heart rate (HR), mean blood pressure (MBP) and complications were recorded. Results: Post-operative 24 h morphine consumption and time of the first request for analgesia were comparable between both groups (P = 0.32 and 0.075, respectively). There was no significant difference in the intra-operative fentanyl consumption. There was also no significant difference in VAS between both groups over the 24 h of study. Four patients in group I developed pneumothorax with no significant differences between both groups (P = 0.114). Incidence of nausea and vomiting was comparable between both groups. All patients displayed a stable haemodynamic profile. Conclusion: Both TPVB and ESPB can be effectively used in controlling post-mastectomy pain and reduce intra-operative and post-operative opioid consumption.

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Background and Aims: Point of care ultrasound has the potential to become reliable airway assessment tool by accurate prediction of difficult laryngoscopy. We aimed to determine the feasibility of ultrasound in preoperative airway assessment. Methods: This prospective, observational study was conducted on 200 patients requiring general anaesthesia and tracheal intubation. The thickness of anterior soft tissue neck at the level of hyoid bone (DSHB), epiglottis (DSEM), and Pre-E/E-VC[depth of the pre-epiglottic space (Pre-E)/distance from the epiglottis to the midpoint of the distance between the vocal cords (E-VC)] were measured sonographically. The hyomental distance ratio (HMDR) was measured utilising distances with head in neutral and extended position. The primary outcome was the efficacy of the parameters in predicting difficult laryngoscopy[Cormack Lehane 3,4]. The secondary outcome was to correlate the parameters to CL grading. Results: Utilising receiver operating curves, cutoff value of HMDR for predicting difficult laryngoscopy was ≤1.0870 with sensitivity of 65%, specificity of 77%. The cutoff value, sensitivity andspecificity for Pre-E/E-VC were ≥1.785, 82.8% and 83.8%., respectively. The cutoff value of DSHB was ≥0.99 with sensitivity of 48% and specificity of 82%. The cutoff, sensitivity and specificity for DSEM were ≥1.615, 89.7%, and 64.8%, respectively. There was moderate positive correlations of DSHB, DSEM, and Pre-E/E-VC (r = 0.551 and 0.701, 0.787: P = 0.00), whereas moderate negative correlation observed with HMDR (r = -.0671: P = 0.00). Conclusion: The strong positive correlation of Pre-E/E-VC, DSEM, and moderate negative correlation of HMDR makes these ultrasound parameters reliable predictors for difficult laryngoscopy.

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The increasing focus on and importance of surgical care in achieving universal health coverage requires the development of safe and accessible anaesthesia services. Increasing access to care by supporting the necessary inputs to the anaesthesia system, including medications, equipment and personnel, must be accompanied by processes that support high-quality care, including support for education, and guidelines for standards, and training. As safe, high-quality care requires an integrated approach, each element must be supported together, i.e., in an integrated manner to ensure that anaesthesia care reaches those who need it, and in the safest possible manner. Several important efforts have been undertaken globally to address and foster these elements, and resources to guide these processes exist for low- and middle-income countries to improve them. This review highlights both the needs and resources for safe and high-quality care that patients deserve.

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Background and Aims: Cardiovascular diseases and cancer are among the leading causes of mortality worldwide. The aim of this study is to evaluate the efficacy and safety of preoperative administration of levosimendan in patients with chronic heart failure (CHF) scheduled for major abdominal oncologic surgery. Methods: This study included 60 patients with abdominal malignancy, ejection fraction (EF) <35% and CHF scheduled for surgery under isoflurane-fentanyl anaesthesia and were managed in the surgical intensive care unit perioperatively. They were randomised to receive levosimendan infusion (n = 30) at a dose of 0.1 μg/kg/min or placebo (n = 30) for 24 hours before surgery. Results: The risk of hypotension (RR: 0.40, 95% CI: 0.19-0.83) or decompensated heart failure (RR: 0.31, 95% CI: 0.12-0.76) was significantly lower in the levosimendan group. The ejection fraction, cardiac index and stroke volume index were significantly higher in the levosimendan group after surgery (P < 0.001). Duration of postoperative ventilation and hospital stay were significantly shorter in the levosimendan group (P < 0.001) while the frequency of dysrhythmia, deterioration of renal function and sepsis was comparable. Conclusion: In patients with low EF <35% and CHF, administration of levosimendan for 24 hours before major abdominal oncologic surgeries may reduce the risk of hypotension and decompensated heart failure and may improve cardiac function.

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Anaesthetic management of tracheal resection and reconstruction in patients with difficult tracheal pathologies, poses unique challenges—such as pre-operative assessment and preparation, the induction of general anaesthesia, airway sharing with surgeons during the intra-operative period while performing resection and reconstruction, emergence from general anaesthesia, and post-operative care. While there are no guidelines on choosing the ideal airway technique for the intra-operative period, we describe a simple-yet-effective airway modality, viz. spontaneous ventilation, as a key airway technique during the crucial open airway phase during tracheal reconstruction.

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Background and Aims: Human plasma protein fraction 5% (PPF5%) is an albumin-based colloid used to expand the plasma volume during volume deficiency. The current basic medical experimental study assessed in vitro coagulation of PPF5% solution and its effects on blood coagulation and chemistry. Methods: The study involved 20 volunteers, and each volunteer donated 20–50 ml of fresh blood. Three dilutions of blood with PPF5% dilutions were prepared (30, 50, and 70%). The fibrinogen dose required to correct coagulation in the 50% diluted samples was assessed (two doses used). The thromboelastogram (TEG) measured the haemostatic parameters (fibrinogen level, initiation of coagulation [R time], kinetics [K], acceleration of coagulation [α angle], maximum amplitude [MA] and coagulation index [CI]), and the ABL gas analyser measured the blood chemistry changes. Results: All dilutions showed significant TEG and blood chemistry changes when compared to controls. The two doses of fibrinogen corrected the clot formation speed with no significant difference in speed between the two doses. Acidosis measured by the strong ion gap (SID) and pH were significant for all dilutions when compared with the baseline. The 30% dilution remained within the lower normal acceptable value while 50% dilution was beyond the critical normal values. Conclusion: In vitro PPF5% to replace blood loss up to 50% dilution did not have significant coagulation and blood chemistry effects while coagulopathy should be expected in extreme dilutions (70%). Fibrinogen in a dose equivalent to 4 gm/70 kg adult improved clot strength at 50% dilution.

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Klippel-Trenaunay syndrome (KTS) is a rare congenital disorder characterised by cutaneous capillary malformations, soft tissue and bone hypertrophy and venous varicosities. The coexistence of Chiari 1 malformation and an intracranial tumour has been rarely reported in the literature. Multisystem involvement of this syndrome mandates adequate preparation and planning, with meticulous conduct of anaesthesia to achieve favourable outcomes. We report a case of KTS syndrome with Chiari 1 malformation who had presented for craniotomy, and thereby discuss the challenges faced during anaesthetic management of these patients for major surgeries.

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