Introduction: Shivering is one of the most common encountered little big problems with spinal anesthesia. There are only few published studies comparing intravenous (iv) dexamethasone and dexmedetomidine for the prevention of postspinal shivering (PSS). Aim: The aim of the study is to compare the effectiveness and safety of iv dexamethasone and iv dexmedetomidine in the prevention of PSS during lower segment cesarean section. Methods: Total 160 parturients were randomly allocated into 2 groups by a Sequentially Numbered Opaque Sealed Envelope technique, namely Group Dx and Dm (n = 80). Group Dx received iv dexamethasone 0.1 mg/kg whereas Group Dm received iv dexmedetomidine 1 μg/kg. Incidence of shivering and shivering score were the primary outcomes and the secondary outcomes were sedation score, level of blockade, duration of surgery, axillary temperature, adverse effects, Apgar score, and hemodynamic parameters. Results: Incidence of shivering was significantly low in dexmedetomidine compared to dexamethasone (13.75% vs. 31.25%; P = 0.00468). Group Dx also had comparatively higher shivering score. Overall incidence of sedation was higher in Group Dm compared to Group Dx (15% vs. 3.75%; P = 0.0022). Five parturients in Group Dm (6.25%) had bradycardia compared to none in Group Dx. Respiratory rate, oxygen saturation, and Apgar score were statistically comparable between the 2 Groups. Conclusion: iv dexmedetomidine is more effective in preventing PSS compared to dexamethasone. Additional sedation with dexmedetomidine aids more comfort to the parturients.

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Context: Hand hygiene is the most important measure to prevent healthcare-associated infections. As part of a major global effort to improve hand hygiene in health care, the SAVE LIVES: Clean Your Hands annual global campaign was launched by the World Health Organization (WHO) in 2009. The “My 5 Moments for Hand Hygiene” approach by the WHO defines the key moments when health-care workers should perform hand hygiene. Aims: This is a preliminary observational study to monitor the level of adherence to hand hygiene practice by health-care workers (HCWs) in an operating room. Materials and Methods: This study was conducted in the surgery operation theater (OT) of our hospital. Direct observation of various personnel working in the OT was done by a single-trained observer. The time of observation was taken from the transfer of the patient on the OT table to the draping of the patient by the surgeon. The hand hygiene opportunities (HHO) as stated by WHO My 5 moments of hand hygiene were noted. Results and Conclusion: A total of 524 HHO were observed among health-care workers, among which 301 were missed and 223 were utilized. Out of the opportunities used were moments 3 and 4, which are primarily for the personal protection of Healthcare workers. Overall compliance of hand hygiene is very low among health-care professionals in the OT. There is an urgent need to educate the health-care personnel about “5 moments of hand hygiene” and ensure strict compliance to ensure patient's safety.

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Background: Circulatory factors modify the onset time of neuromuscular-blocking drugs. Therefore, we hypothesized that a bolus of saline flush immediately after rocuronium administration would shorten the onset time without influencing the duration of the rocuronium effect. Methods: A total of 84 patients were randomly allocated to either the control or saline flush group. Anesthesia was induced with propofol and fentanyl and maintained with isoflurane <1% and all patients received 0.6 mg/kg rocuronium in 10 mL of normal saline. In the saline flush group, 20 mL normal saline was immediately infused after rocuronium administration. Neuromuscular blockade was assessed using TOF-WATCH device at the adductor pollicis muscle using stimulation of ulnar nerve. The neuromuscular indices recorded were latent onset time, onset time, and clinical duration of bolus dose of rocuronium. Results: The measured latent onset time and onset time were significantly shorter within the saline flush group than the control group (P < 0.001). In addition, the clinical duration was significantly prolonged within the saline flush group (P < 0.001). Conclusion: A 20-mL saline flush administered immediately after slow intravenous 0.6 mg/kg rocuronium shortens the onset time and prolongs the clinical duration of neuromuscular blockade.

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Introduction: The study aimed to study the impact of the COVID-19 pandemic on surgical practice in a tertiary care setup in India and the future implications of the pandemic. Methodology: This observational cross-sectional study was conducted at a tertiary-care hospital. The case series consisted of a snapshot search of all operating theatre activity at AIIMS, Rishikesh between the 1^st of March 2020, and 31^st August 2020. Observations: A total of 790 patients were operated on in the first 6 months of the covid era while 5308 patients had undergone surgery in the 6 months preceding the onset of covid-19. In the precovid era, 73.71% of the cases were performed under General Anaesthesia while 62.6% of the cases were performed under general anaesthesia in the covid era. 18.83% of the cases in precovid era were performed under spinal anaesthesia and 3.5% under combined spinal and epidural anaesthesia in the precovid era. Conclusion: This study has shown the extent to which general surgical practice was affected during the covid pandemic. With the lessons learnt during this period, we can implement a more robust plan in the eventuality of another pandemic and be more thoroughly prepared the next time around.

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While it is now conclusively established that subarachnoid block (SAB) for cesarean section has distinct advantages, its administration in a parturient with a ventriculoperitoneal (VP) shunt in situ has been controversial. Over the years, experience with regional anesthesia techniques for labor and operative delivery in patients with VP shunt is accumulating, and various workers have reported safe outcomes with successful administration. In the absence of clinical evidence pointing to significant risks and complications, neuraxial anesthesia may be a safe and suitable alternative alternative to general anesthesia for Cesarean delivery in parturients with VP shunt, provided due considerations are followed. The indications for SAB in a parturient with VP shunt should be based on obstetrics considerations and neurological status.

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Being an aerosol-generating procedure (AGP), tracheostomy for patients infected with severe acute respiratory syndrome-coronavirus-2 poses a great risk of infection for health-care workers. We present a series of four COVID-19-infected cases who underwent surgical tracheostomy and discuss the anesthetic concerns regarding the same.

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Trepopnea, a rare form of dyspnoea observed in lateral decubitus position is a crucial clue towards diagnosis. It indicates either cardiac or respiratory pathology that may warrant immediate attention. Usually, it has been reported the patient with congestive cardiac failure or diseased left lung who prefers the right lateral decubitus position. Only in a few cases with the unilateral lung disease it has been described. We present one such case report of trepopnea in a patient recovering from pneumonia was observed having trepopnea, which was later confirmed due to unilateral diaphragmatic palsy.

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In the present time of severe acute respiratory syndrome coronavirus-2 pandemic, there are various systemic complications reported as its sequelae. We hereby report a rare presentation of opsoclonus-myoclonus syndrome as a neurological complication in a COVID-19-positive pregnant patient posted for emergency cesarean section.

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Airway anomalies such as laryngomalacia, laryngeal webs, micrognathia, and retrognathia cause respiratory distress in infants and pose a significant challenge in anesthetic management. We report the case of a 2-month-old infant with laryngomalacia on continuous positive airway pressure support since birth, posted for laryngeal surgery, who was found to have micro-retrognathia during pre anaesthesia checkup. Securing the airway and preventing hypoxia were the main challenges in this child. Adequate measures were taken for continuous oxygenation during induction of anesthesia. The child underwent supraglottoplasty with an uneventful intraoperative course. However, the airway obstruction persisted in the postoperative period requiring a surgical tracheostomy. The child subsequently underwent mandibular distraction surgery after 1 month and was discharged with a tracheostomy tube. Although various anesthetic options have been described to manage the difficult pediatric airway, the anesthetic technique should be customized to ensure airway patency and oxygenation in the perioperative period as illustrated in this case report.

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Supraglottic airway obstruction due to airway malignancy resulting in respiratory distress is a medical emergency requiring urgent re-establishment of airway patency, with tracheostomy to alleviate the stridor and threat to life. We report a 61-year-old male patient who presented with acute stridor, dyspnea, and a left-sided metastatic neck mass to the emergency room. The patient was rushed to the operation theater for emergency tracheostomy under monitored anesthesia care. We hereby discuss a successful surgical cricothyroidotomy, post failed emergency tracheostomy under dexmedetomidine infusion.

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Methaemoglobinemia is a condition that occurs when red blood cell contains higher than 1% methaemoglobin (MHb). It can be congenital or acquired. The condition is generally asymptomatic until the serum MHb level reaches as high as 40%. Dyspnea, acidosis, cardiac dysrhythmias, heart failure, seizures, and coma may occur at levels exceeding 45%, and a high mortality rate is seen with levels above 70%. We report a rare association of a case of rheumatic heart disease with severe mitral stenosis with congenital methemoglobinemia diagnosed incidentally during mitral valve replacement procedure under cardiopulmonary bypass.

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Background and Aims: Addition of dexamethasone to levobupivacaine in the peripheral nerve block provides improved pain scores, prolonged pain relief, and reduced postoperative opioid requirement. However, the evidence regarding its efficacy in the transversus abdominis plane (TAP) block is limited. Therefore, we conducted this study to evaluate the potential benefits of combining dexamethasone with levobupivacaine in the subcostal TAP block during the first 24 h after laparoscopic cholecystectomy. Materials and Methods: Seventy-six patients were enrolled in the study and divided into two groups to receive 20 ml of 0.25% levobupivacaine with 1 ml NS bilaterally (Group LS) or 20 ml of 0.25% levobupivacaine with 4 mg dexamethasone bilaterally (Group LD). Each patient received a standard multimodal analgesic regimen. Pain scores were recorded at rest and during coughing at 0, 2, 4, 6, 12, and 24 h postoperatively. Total opioid consumption and associated complications were recorded during the first 24 h. Results: Pain scores were lower in the LD group as compared to the LS group at all time points. Reduction in Numeric Rating Scale values was statistically significant at 4, 6, and 12 h both at rest and during coughing. Estimated P values on coughing at these time points were 0.000, 0.001, and 0.017, respectively. Postoperative opioid requirement was also significantly reduced between 2 and 24 h (P = 0.007). We did not record any complications in our study population. Conclusion: The combination of dexamethasone and levobupivacaine in the subcostal TAP block significantly improves the efficacy of multimodal analgesic regimen during the first 24 h after laparoscopic cholecystectomy.

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Bi-spectral index (BIS) is a common but an important tool in anaesthesiologist's armamentarium across the world which helps to assess the level of sedation and effect of hypnotic drugs. A value between 40-60 in BIS is considered as optimal level of sedation during general anaesthesia. However, numerous factors can interfere with accurate BIS value. Electrocardiogram (ECG), has been mentioned as a factor resulting into fallacious BIS values in the literature, which may have significant implications on appropriate dosage of hypnotic drugs. ECG inferences are usually filtered by proprietary algorithm of BIS, and few cases have been documented wherein ECG interference resulted in fallacious BIS readings. Our case reports a less frequently reported interference in BIS values by ECG, which resulted into lower BIS values.

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Isolated subarachanoid hemorrhage (SAH) could be one of the few causes of xanthochromia or yellow coloured cerebrospinal fluid (CSF). An incidental finding of yellow coloured CSF poses a dilemma to the anaesthesiologist in proceeding with the subarachnoid block (SAB) The present case report discusses the causes and implication of this incidental finding and highlights upon the evidence in literature in this context.

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Background: Continuous epidural anesthesia (CEA) is commonly used in routine practice even though it needs a higher dose of local anesthetics (LA) and is sometimes associated with a patchy or unilateral block. Despite advantages, continuous spinal anesthesia (CSA) is underutilized because of concern related to infection and postdural puncture headache. Our aim was to compare the block characteristics and hemodynamic changes following CSA and CEA in lower limb orthopedic surgeries. Materials and Methods: After approval from the Institutional Scientific and Ethics Committee and Registration with (Clinical Trials Registry of India/2021/02/031575), a prospective, double-blind, randomized study was conducted in 144 patients, American Society of Anesthesiologists I-II, aged 18–65 years, scheduled for lower limb orthopedic surgeries. Patients were randomly divided into two groups according to anesthesia technique used (n = 72), i.e., Group CSA and Group CEA. Block characteristics, hemodynamic variables, intraoperative LA requirement, and complications were recorded. Results: Demographic and surgical data, grade of sensory and motor blockade, and incidence of complications were comparable in both the groups. Induction time was significantly shorter in CSA (8.14 ± 0.88 min vs. 15.75 ± 3.29 min, P < 0.0001). Performance time (5.31 ± 0.92 min vs. 4.92 ± 1 min; P = 0.008), duration of blockade (68.3 ± 4.23 min vs. 65.54 ± 4 min; P < 0.0001), and analgesia (230.48 ± 40.76 min vs. 222.86 ± 39.79 min; P = 0.024) were significantly longer in CSA. A significant fall in diastolic blood pressure and mean arterial pressure occurred in CEA. LA requirement was significantly lower in CSA (11.62 ± 2.5 mg vs. 65.35 ± 7.71 mg; P < 0.00001). Conclusions: Considering shorter induction time, prolonged sensory blockade, and analgesia with greater hemodynamic stability, CSA could be preferred over CEA for lower limb orthopedic surgeries.

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Situs inversus totalis (SIT) is a rare, autosomal recessive congenital anomaly, in which the major visceral organs are reversed from their normal position. Their unique anatomy and association with various congenital anomalies may present various challenges during anesthetic management. We report a case of SIT with aortoiliac occlusive diseases who underwent axillobifemoral bypass grafting surgery. We aim to discuss the anesthetic considerations and implications associated with such patients.

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We report a case of primigravida posted for emergency lower segment cesarean section (LSCS). She had to be administered general anesthesia due to failure of the spinal blockade. While the intraoperative period remained uneventful, the patient could not be extubated after the procedure due to poor respiratory efforts and motor power. She was shifted to the intensive care unit where, after several hours, she could be extubated. On follow-up and further workup, the pseudocholinesterase enzyme was found to be deficient in the patient's blood reports. This case report aims to highlight the importance of considering the deficiency of pseudocholinesterase while managing obstetric patients while suggesting deliberations and relevant management.

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Rubinstein − Taybi Syndrome (RTS) is a rare genetic syndrome caused by a mutation in the cAMP response element binding protein gene or EP300 gene or as the result of microdeletion from short (p) arm of chromosome 16. The diagnosis of RTS is made primarily through physical appearance. It may be associated with the disorders of multiple organ systems. Anesthetic management might be challenging in RTS due to various factors. A thorough preoperative evaluation and careful preparation for difficult airways before anesthesia is mandatory for successful case management. Here, we report the case of a 9-year-old child with RTS posted for cystoscopy.

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Background: The abdominal insufflation in the laparoscopic surgery has been reported to result in an increase in endotracheal tube (ETT) cuff pressure (Pcuff). However, the effect of Trendelenburg, lithotomy and pneumoperitoneum on the ETT Pcuff in robotic urogynaecology surgeries are not well established. Aim: Analyse the changes in ETT cuff pressure during robotic urognaecological surgery. Primary Objective: 1. The changes in ETT cuff pressure after creation of pneumoperitoneum. 2. The changes in ETT cuff pressure after change in position of the patient. Secondary Objectives: 1. To correlate the changes in ETT cuff pressure with airway pressure. 2. To correlate the changes in ETT cuff pressure with BMI. Methods: Sixty patients undergoing elective robotic urogynaecology surgeries were enrolled in the study. ETT Pcuff during different time points was measured and analysed. Also, the change in ETT Pcuff was correlated with the airway pressure (Paw). Results: The difference in ETT Pcuff, before and after lithotomy, pneumoperitoneum and the Trendelenburg position were 1.1 ± 0.7 cmH₂O, 4.6 ± 1.0 cmH₂O and 1.8 ± 0.8 cmH₂O respectively and were statistically significant (probability: P < 0.05). Results obtained after reversing patient position from Trendelenburg position to supine, abdominal deflation and from lithotomy to supine respectively were -2.2 ± 1.4 cmH₂O, -4.1 ± 1.0 cmH₂O and -0.4 ± 0.8 cmH₂O respectively (P < 0.05). The Karl Pearson coefficient of correlation (r) between Pcuff and Paw after lithotomy, pneumoperitoneum, and Trendelenburg position respectively were 0.606, 0.661 and 0.309. Freidman's nonparametric repeated-measures analysis of variance (ANOVA) was used to analyze differences between related Pcuff values over different time points. Overall P value was significant (P < 0.00001). Conclusion: An increase in ETT cuff pressure is seen in robotic laparoscopic surgeries after abdominal insufflation, Trendelenburg position and lithotomy position.

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