Background: Postoperative pain is of greatest concern in parturients undergoing cesarean section. Low-dose intravenous (IV) ketamine infusion has been considered to be an effective postoperative analgesia and resurged again as a substitute of opioid analgesics. This study aims to evaluate the efficacy of low dose iv ketamine versus iv tramadol infusion in reducing postoperative pain and rescue analgesic requirements. Materials and methods: This prospective study was conducted on 150 parturients with American Society of Anesthesiologists (ASA) grades I and II, aged 18 to 35 years scheduled to undergo elective or emergency cesarean section under regional anesthesia. All the parturients were randomly allocated into three groups of 50 patients each. Group C (control group) received 5 mL saline; group K (ketamine group) received 5 mL of ketamine (0.05 mg/kg/hour); and group T (tramadol group) received 5 mL of tramadol (120 mg/24 hours) in 500 mL of Ringer's lactate. Tramadol (1 mg/kg) was given as rescue analgesic. Pain scores, patient satisfaction scores, time to first demand of rescue analgesic, the total number of doses, and total consumption of rescue analgesic along with side effects were recorded. Results: The cumulative visual analog scale (VAS) noted at rest, cough, and movement was significantly less in groups K and T as compared with group C (p < 0.001). The time of requirement of first rescue analgesic dose was significantly prolonged in group K (6.17 ± 3.05 hours) and group T (4.04 ± 1.26 hours) as compared with group C (2.16 ± 0.84 hours) (p < 0.001). The total number of doses of rescue analgesic given in 24 and 48 hours was significantly decreased in groups K and T as compared with group C (p < 0.001). The satisfaction scores were significantly better in groups K and T (p < 0.001). Conclusion: We concluded that low-dose IV ketamine infusion was associated with significantly lower pain scores, reduced rescue analgesic requirement along with better patient satisfaction so that it could be used as a useful adjunct to multimodal postoperative analgesia.

Introduction: Ambulatory anesthesia aims at early discharge with minimal side effects. The study aimed to establish the efficacy of 7.5 vs 10 mg of hyperbaric bupivacaine (bupivacaine H) for spinal anesthesia (SA) for inguinal hernia repair in terms of onset of block, maximum surgical level achieved, motor block, hemodynamic parameters, recovery profile, and complication rate. Materials and methods: Anesthesia records of 200 male patients who underwent inguinal hernia repair under SA were studied. About 100 patients who received SA with 1.5 mL of 0.5% bupivacaine H + 25 μg fentanyl + 1 mL normal saline (NS) were labeled group L and 100 patients who received 2 mL of 0.5% bupivacaine H + 25 μg fentanyl + 0.5 mL NS were labeled group H. All patients were given SA using 25G Quincke's needle at L3/4 or L4/5 level. Sensory level was assessed with pinprick and motor blockade using modified Bromage scale (MBS). Hemodynamic parameters, sensory level, and motor blockade were noted every 5 minutes for first 15 minutes and every 15 minutes till the complete recovery of motor blockade. Analgesic requirement and rate of conversion to general anesthesia (GA) were noted. Results: The time for onset of action in group L vs group H was 4.7 ± 1.57 minutes vs 4.46 ± 0.95 minutes, which was not significant. However, the two segment regression time was 71.84 ± 8.02 minutes vs 93.70 ± 6.60 minutes in groups L vs H (p-value < 0.05), time to return to S1 was 158.5 ± 13.8 minutes vs 196 ± 31.68 minutes (p-value < 0.05), time to ambulation was 182 ± 15.80 minutes vs 304 ± 47.88 minutes (p-value 0.05), time to void was 198.37 ± 18.15 minutes vs 325.4 ± 53.73 minutes (p-value < 0.05), and time to home readiness was 293.4 ± 29.39 minutes vs 440.20 ± 37.93 minutes (p-value < 0.5). The rate of complications was comparable in both groups and the rate of conversion to GA was nil. Group L had superior hemodynamic stability. Conclusion: About 7.5 mg of 0.5% bupivacaine H with fentanyl offers excellent anesthesia for inguinal hernia repair in terms of adequate anesthesia, better hemodynamic stability, reduced complications, and early discharge vs 10 mg of bupivacaine H with fentanyl; hence it is ideal for ambulatory surgery.

Introduction: The anesthesia goals for transsphenoidal pituitary surgeries include intraoperative hemodynamic stability and early postoperative recovery for cranial nerve evaluation. In this study, we aim to compare the intraoperative hemodynamics and postoperative recovery of sevoflurane with desflurane in a dexmedetomidine-based general anesthesia. Materials and methods: Sixty patients, 18 to 65 years, American Society of Anesthesiologists (ASA) grades I and II, with Glasgow Coma Scale 15/15 were included. Thirty patients each were randomly divided into group S (sevoflurane) and group D (desflurane). The primary objective was to compare the intraoperative hemodynamics. Secondary objectives were to assess the total dose of dexmedetomidine, number of propofol doses, time to extubate, agitation score at emergence, and modified Aldrete score. The anesthesia management included an intravenous induction followed by maintenance with inhalational agent in oxygen: Nitrous oxide mixture (50%), dexmedetomidine infusion, and rescue doses of propofol. Results: Heart rate (HR) and mean arterial pressure (MAP) were similar in both the groups except MAP just 5 minutes postincision, which was higher in group S (p < 0.001). There were no differences in intraoperative dexmedetomidine use, propofol bolus doses or time to extubate. But the agitation score was higher in group S (p < 0.001). The modified Aldrete score was higher in group D at 5, 15, 30, and 60 minutes (p < 0.001). Conclusion: Both desflurane and sevoflurane produce a similar intraoperative hemodynamic response in a dexmedetomidinebased general anesthesia except sevoflurane, in the doses used in our study was insufficient to attenuate the hypertensive response to incision. With regard to emergence agitation and recovery profile, desflurane appears to be a superior agent.

Ankylosing spondylitis (AS) is a chronic inflammatory disease of the axial skeleton in which the inflammatory process starts from the sacroiliac joints and spreads cephalad to affect the spine up to the cervical level along with costovertebral joints. These changes make administration of both general and regional anesthesia difficult. Patients with chronic diseases of the spine and altered anatomy pose technical challenges to the anesthesiologist. Hence, airway management and achieving central neuraxial blockade may be impossible. Complications of difficult intubation can be avoided by regional anesthesia with an added advantage of postoperative analgesia and faster recovery of the patient.

Background: Rheumatic valvular stenosis is the most common valvular heart disease which is encountered in pregnant patients in our country. Combination of severe mitral or aortic stenosis (AS) and physiological changes that accompany pregnancy amplifies problems. Case report: Two patients with severe rheumatic valve stenosis underwent simultaneous cesarean section (CS) and valve replacement (VR) surgeries. Heart rate (HR) control with diltiazem was required in one patient who was in atrial fibrillation (AF). Anesthesia was induced with etomidate and rocuronium. Cesarean section was performed followed by VR. Conclusion and clinical significance: Management of anesthesia for such cases is a challenge, as there is a risk of worsening cardiac failure at multiple stages, increasing maternal and fetal morbidity and mortality. The conventional high-dose opioid-based anesthesia strategy followed for VR in stenotic lesions may cause neonatal respiratory depression requiring ventilatory support. A tight balance between maintaining maternal hemodynamics, uterine blood flow, and fetal oxygenation is required for good maternal and fetal outcomes.

Tracheostomy is a routine airway procedure performed by surgeons and anesthesiologists. However, it is a life-saving procedure in cases of severe tracheal stenosis secondary to traumatic airway injuries, or prior tracheal surgeries. Tracheostomy is challenging in these situations even in experienced hands, especially in an emergency setting, and there can be a fatal loss of airway. Cook's pediatric airway exchange catheter can be successfully used in such cases to safely achieve an appropriatesized tracheostomy even in adults. Initial transtracheal airway access is achieved with a smaller (internal diameter 3.5–4.5 mm) uncuffed endotracheal tube (ETT) to relieve obstruction and improve oxygenation. Railroading of bigger tubes over a Cook's pediatric airway exchange catheter inserted into the smaller ETT is then sequentially done to achieve a desired size of tracheostomy without loss of airway or compromised oxygenation. We describe five cases of difficult tracheostomy with the use of this technique.

There is a rising trend in obesity in the general population, thus it is not uncommon to have an obese obstetric parturient. The anesthesiologist should be well equipped to provide regional anesthesia. Ultrasonography is a useful tool to guide anesthesiologists in providing a successful regional block in obese parturient. We have successfully performed regional block in a severely obese parturient with use of point-of-care ultrasound (POCUS).