The process of formulating a good research question can be challenging and frustrating. While a comprehensive literature review is compulsory, the researcher usually encounters methodological difficulties in the conduct of the study, particularly if the primary study question has not been adequately selected in accordance with the clinical dilemma that needs to be addressed. Therefore, optimising time and resources before embarking in the design of a clinical protocol can make an impact on the final results of the research project. Researchers have developed effective ways to convey the message of how to build a good research question that can be easily recalled under the acronyms of PICOT (population, intervention, comparator, outcome, and time frame) and FINER (feasible, interesting, novel, ethical, and relevant). In line with these concepts, this article highlights the main issues faced by clinicians, when developing a research question.

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Background and Aims: Airway ultrasound is an emerging tool to predict difficult laryngoscopy. This study aimed to determine the utility of ultrasound measurement of the anterior soft tissue neck thickness at the level of hyoid, thyrohyoid membrane and thickness of tongue to predict difficult laryngoscopy and compare them with clinical parameters for airway assessment. Methods: The distance from skin to hyoid bone, skin to the thyrohyoid membrane in neutral and sniffing position and maximum tongue thickness was measured by ultrasound and correlated with Cormack Lehane (CL) laryngoscope view in 310 adult surgical patients. Receiver operating characteristic curve was plotted and the area under the curve was calculated for each parameter. The sensitivity and specificity of ultrasound-guided parameters were compared with clinical parameters like the inter-incisor gap, modified Mallampatti classification, thyromental, sternomental distance and neck circumference. Results: Incidence of difficult laryngoscopy (CL grade-III and IV) was 11.3%. A significant difference was observed in the ultrasound parameters between the easy and difficult laryngoscopy (P-value = 0.001). Sensitivity and specificity to predict difficult airway was 69.6% and 77% for tongue thickness, 68% and 73% for the skin to hyoid bone distance in a neutral position and found to be higher than clinical parameters. Conclusion: The ultrasound measurements of soft tissue thickness of the anterior neck and tongue thickness along with the clinical assessment of airway can be useful in predicting difficult laryngoscopy.

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Background and Aims: Patients undergoing breast cancer surgeries face significant post-operative pain. We aimed to compare pectoral nerve (PECS) block with erector spinae (ESP) block in these patients in terms of analgesic efficacy and adverse effects. Methods: Sixty four American Society of Anesthesiologists' status I and II female patients between age 18 to 60 years scheduled for unilateral modified radical mastectomy (MRM) under general anaesthesia, were enrolled in this prospective randomised study. Patients in group I received ultrasound guided (USG) ESP block (20 cc 0.2% ropivacaine) while group II received USG guided PECS II block (25 cc 0.2% ropivacaine). General anaesthesia was administered in a standardised manner to both the groups. The various parameters observed included sensory blockade, duration of analgesia and any adverse effects. The primary outcome was the total morphine consumption in 24 hours. Results: The total morphine consumption in 24 hours was less in group II (4.40 ± 0.94 mg), compared to group I (6.59 ± 1.35 mg; P = 0.000). The mean duration of analgesia in patients of group II was 7.26 ± 0.69 hours while that in the group I was 5.87 ± 1. 47 hours (P value = 0.001). 26 patients in group II (PECS) had blockade of T2 as compared to only 10 patients in group I. (P value = 0.00). There was no incidence of adverse effects in either group. Conclusion: PECS II block is a more effective block when compared to ESP block in patients of MRM in terms of postoperative analgesia and opioid consumption.

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Background and Aims: Obstructive sleep apnoea (OSA) has an estimated prevalence of 2%–4% in adult population and is increasing. Most of these are detected late which is the cause for higher perioperative morbidity. This survey was aimed to seek the level of knowledge and attitude of Indian anaesthesiologists towards OSA. Methods: The OSA Knowledge and Attitude (OSAKA) questionnaire (23-statements) was distributed to the anaesthesiologists attending the difficult airway conference in December 2017. The first section has 18 statements pertaining to OSA knowledge. The second section consists of five statements to evaluate self-confidence in the management of OSA. Age, gender, professional title, type of hospital, years of experience, and bariatric experience were analysed. Results: 205 out of 350 participants responded. In all, 201 (57.4%) fully completed responses were analysed. The mean ± standard deviation knowledge and attitude scores were 12.01 ± 2.88 (66.72% ± 16%) and 18.16 ± 3.75 (72.64% ± 15%) respectively. On exclusion of junior residents (n = 56), knowledge and attitude scores of qualified anaesthesiologists were 12.7 ± 2.55 (70.55% ± 14.16%) and 18.78 ± 3.91 (75.12% ± 15.64%), respectively. Anaesthesiologists with bariatric experience had a significantly higher attitude score when compared with those who do not practice bariatric surgeries (P < 0.01). There is weak but significant, positive linear correlation between knowledge and attitude score (r_s= 0.370, P < 0.01). Conclusion: Deficit of adequate knowledge about OSA exists among Indian anaesthesiologists. Experience of managing cases with OSA seems to improve knowledge and attitude towards OSA.

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Background and Aims: Central neuraxial block and general anaesthesia in patients with significant comorbidities are associated with considerable peri-operative morbidity and mortality. This study aims to delineate peripheral nerve block as a suitable alternative technique in high-risk patients posted for below-knee surgery. Methods: Twenty patients with the American Society of Anesthesiologist's (ASA) physical status grade III and IV, aged 30–80 years, scheduled for below-knee surgery from May 2018 to February 2019 were enrolled in this prospective study. All patients received ultrasound-guided popliteal sciatic block with 20 ml 0.5% ropivacaine and adductor canal block with 10 ml 0.375% ropivacaine. The peripheral nerve block success rate, sensory and motor block onset time, haemodynamic parameters, duration of post-operative analgesia and patient's satisfaction were recorded. Descriptive statistics of the study were calculated and the data was analysed using an SPSS statistics 21.0 program. Result: Surgery was performed successfully with no additional analgesic requirement in all patients. The mean duration for sensory and motor block onset time was 3.35 ± 0.49 (mean ± standard deviation) and 4.65 ± 0.48 (mean ± standard deviation) minutes respectively. Haemodynamic parameters were maintained stable throughout the procedure. The average duration of postoperative analgesia was 7.5 ± 0.8 (mean ± standard deviation) hours. Patient overall satisfaction as assessed, by three-point Lickert's scale, was satisfactory. Conclusion: Ultrasound-guided combined popliteal sciatic and adductor canal block is an effective alternative anaesthetic technique for below-knee surgeries with stability of haemodynamic parameters and pain management in high-risk patients.

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The significance of coronary artery calcification noted on noncontrast chest computed tomography (CT) scan is unknown. We report a case where coronary artery calcification on chest CT scan incidentally detected in an asymptomatic patient who was found to have significant coronary artery disease which resulted in perioperative morbidity.

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Background and Aims: Glasgow Coma scale (GCS), the most widely used tool for evaluation of the level of consciousness has various limitations. The Full Outline of UnResponsiveness (FOUR) score is a possible alternative. The present study was designed to examine the inter-rater reliability and outcome predictability of these scores in the Intensive Care Unit (ICU). Methods: The GCS and FOUR scores of 111 adult patients with altered sensorium, admitted to the ICU, were assessed as early as possible after admission by the Senior Resident (SR), Junior Resident (JR) and Staff Nurse (SN) of ICU. The outcomes measured survival and modified Rankin Scale (mRS) and Glasgow outcome scale (GOS) of the patients at discharge. Results: The inter-observer agreement was measured using the kappa ('k') statistic. For GCS it was higher (k = 0.472 to 0.555) than FOUR score (k = 0.352 to 0.448). A higher 'k' score in either score was recorded between SR and JR. Linear regression analysis showed no significant association of either score with the duration of ICU stay or mechanical ventilation. Survival in ICU was correlated with both GCS and FOUR scores on logistic regression. GOS and mRS were correlated with either GCS or FOUR scores on ordinal regression. Conclusion: The inter-observer agreement with FOUR score was not superior to GCS in this study, possibly due to lack of familiarity with the FOUR score. Both the scores were statistically correlated with the rate of survival.

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Background and Aims: Fentanyl can facilitate controlled intraoperative hypotension by its sympatholytic effect in patients undergoing functional endoscopic sinus surgery (FESS). We investigated the effects of different doses of pre-induction fentanyl on controlled hypotension profile during FESS. Methods: This prospective, randomised study included 120 patients randomly allocated to three groups (40 each) based on administration of pre-induction fentanyl; 2 μg/kg group, 3 μg/kg group and 4 μg/kg group. The primary objective was to assess effect on intraoperative heart rate and mean arterial pressure. Use of additional hypotensive agents, surgical field condition and surgeon satisfaction were also analysed. Results: Controlled hypotension was achieved adequately in all participants. Patients belonging to fentanyl 4 μg/kg group had significantly lower heart rate for the duration of controlled hypotension intraoperatively versus fentanyl 2 μg/kg group (P < 0.05). Trinitroglycerin [TNG] and metoprolol were administered to 3 [7.5%] and 9 [22.5%] patients respectively in the fentanyl 3 μg/kg group, and to 3 [7.5%] and 5 [12.5%] patients respectively in the 4 μg/kg group, compared to 14 [35%] and 20 [50%] in the fentanyl 2 μg/kg group, respectively (TNG, P < 0.001). Surgical field conditions and surgeon satisfaction scores were significantly superior in fentanyl 3 μg/kg and 4 μg/kg groups than in fentanyl 2 μg/kg group. Conclusion: Pre-induction fentanyl 3 μg/kg and 4 μg/kg group showed superior controlled hypotension facilitation than 2 μg/kg fentanyl during FESS in terms of measurable haemodynamic endpoints and favourable operative conditions, surgeon's satisfaction and sparing of additional hypotensive agents.

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After a quadratus lumborum (QL) block, the course of QL plane catheter is unpredictable. This case series discusses the course and fate of trans-muscular QL catheters by following and discussing the contrast spread through the fascial planes. Intrao-peratively, the catheters were tracked by the surgeons and were checked for integrity of anterior thoracolumbar fascia (ATLF) by injecting sterile 0.9% saline. The ATLF was intact upon injection and there was cephalad and medial saline spread with slight bulging of ATLF. On day 3 after written informed consent from all patients, computed tomography (CT) contrast studies were performed. Post-operative contrast spread was variable and was visualised in transversus abdominis plane, QL plane, lower thoracic paravertebral space, inter-vertebral foramina and anterior epidural space. CT contrast images demonstrated a variable spread. In conclusion, injection in ATLF of QL can spread along the path of least resistance and is unpredictable.

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Background and Aims: Dexmedetomidine is a drug that is being widely used as an adjuvant to anaesthesia because of its unique pharmacodynamic and pharmacokinetic properties. We aimed to assess the recovery of psychomotor function from balanced anaesthesia including intravenous dexmedetomidine infusion as adjunct. Methods: Ninety American Society of Anesthesiologists I and II patients were randomised to group D (n = 45), to receive 1 μg/kg of dexmedetomidine loading dose over 10 min, with maintenance infusion of 0.5 μg/kg/h, and group S (n = 45), to receive an equal volume of 0.9% normal saline. Objective parameters were recovery of psychomotor function assessed by Trieger dot test (TDT), digit symbol substitution test (DSST) and intraoperative opioid requirement. the total fentanyl used intraoperatively in the two groups. Statistical analysis was performed using unpaired Student's t-test, Chi-squareor Fisher's exact test. Results: Psychomotor recovery assessed by TDT showed statistically significant early recovery in group D compared with group S. This was seen in the maximum distance of dots missed at 30 min, 60 min, 90 min and 120 min as well as in the average distance of dots missed at identical time points. Similarly, DSST revealed early recovery at 30 min (12.4 ± 5.3 vs. 10.4 ± 3.9 P = 0.04) postoperative interval but not at other time intervals. There was significant decrease in the intraoperative opioid requirement in group D compared with group S. Conclusion: The addition of dexmedetomidine to balanced anaesthetic technique significantly hastened the psychomotor recovery compared with placebo.

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A 7-day-old 600 grams baby with a post-conceptual age of 29 weeks presented with features suggestive of hollow viscous perforation, and was posted for an emergency laparotomy. In addition, she had a fractured indwelling umbilical arterial catheter which was planned for extraction in the same sitting. Radiological imaging showed that the catheter extended into the stump of the umbilical cord. She underwent exploratory laparotomy and ileal resection anastomosis, following which the stump was explored. However, the catheter could not be identified, and we suspected that it had embolised into the aorta. Using ultrasound guidance, we identified the catheter within the aorta. The aorta was cross-clamped, and the catheter extracted through an aortotomy which was later sutured.

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