Context: Intramuscular (IM) butorphanol can be a convenient postoperative analgesia compared to epidural (EP) route. Aims: Compare the efficacy and safety of IM vs EP butorphanol (1 mg/2 mg) as postoperative analgesia. Settings and design: A randomized-controlled study. Materials and methods: This study was conducted on 120 adult patients of either sex in the age group of 20–60 years, undergoing lower abdominal or lower limb surgeries (American Society of Anesthesiologists [ASA] class-I/II). Patients were randomized to butorphanol intramuscularly (IM group) or EP injection (EP group). Each group had two equal subgroups where patients received either 1 mg or 2 mg by the respective route. The primary outcomes were onset of analgesia, peak time of analgesia, and duration of analgesia. Pain was assessed on a 0–10 visual analog scale (VAS), and vital parameters were assessed at baseline and after 10, 20, 30, 60, 90, 120, and 180 minutes. Clinical safety was assessed by the adverse events. Results: The duration of analgesia provided by both the routes was comparable (293.0 minutes IM and 270.25 minutes EP). However, duration of analgesia was longer (p, 0.043) with 2 mg compared to 1 mg. Similarly, the onset of analgesia, pain scores, and peak time of analgesia were similar (p > 0.05) in the two groups. No differences in the hemodynamic parameters and respiratory rate were observed in the two groups. Higher incidence of all the side effects (sedation, somnolence, pruritus) was observed with IM administration. All side effects were clinically insignificant. Conclusion: Intramuscular butorphanol is as effective as an EP for the management of immediate postoperative pain. Keymessages: Intramuscular analgesics could be more convenient and safer compared to EP administration. Butorphanol administered by the IM route is as effective and safe compared to EP administration.

Tetralogy of fallot (TOF) is a cyanotic congenital heart disease (CHD) characterized by aortic over riding, right ventricular outflow tract (RVOT) obstruction, pulmonary stenosis, and ventricular septal defect (VSD). We report a case of a neonate with TOF and anorectal malformation posted for a transverse colostomy. During this procedure, our objectives were to prevent cyanotic spells, balance pulmonary vascular resistance, and systemic vascular resistance.

Congenital complete heart block in pregnancy is rare. Fetal distress permits no time for neuraxial blockade. Twenty-two years antenatal clinic diagnosed atrioventricular dissociation and complete heart block at 6 months of pregnancy, presented with fetal distress at 36 weeks. General anesthesia was given with transcutaneous pacemaker standby. Healthy baby was delivered. One episode of bradycardia occurred which responded to Inj atropine 0.6 mg IV however blood pressure was stable. We managed lower segment cesarean section (LSCS) in complete hearth block with fetal distress uneventfully with general anesthesia.

Posterior fossa tumor surgeries are challenging from the point of view of both surgeons and anesthetists owing to the proximity of the tumor to vital centers, the difficulty faced in approaching the tumor, and complications associated with the positioning. The challenge in this patient undergoing a sitting-position craniotomy for a left-sided acoustic schwannoma was further augmented by the presence of a complete heart block in our patient (for which a pacemaker had been inserted) and the co-existence of a moderate aortic regurgitation.

We describe a child of hyperimmunoglobulin-E syndrome (HIES) with bilateral pneumatoceles for an elective right thoracotomy for pneumatocele excision. HIES is a rare primary immunodeficiency characterized by the triad of markedly elevated serum levels of immunoglobulin E (>2000 IU/mL) with peripheral eosinophilia, recurrent staphylococcal infections of the skin and lungs, and chronic eczema. A 10-year-old male child was presented with recurrent skin abscesses and lung infections, leading to extensive bilateral pneumatocele formation. Such children present unique anesthetic challenges in terms of immunodeficiency, multiple hospital admissions, difficult intravenous (IV) access, and poor pulmonary compliance affecting intraoperative ventilation. Along with pediatric lung isolation techniques, thorough asepsis, good perioperative analgesia and high index of suspicion for pneumothorax are essential components of successful anesthetic management.

Coffin–Siris syndrome (CSS) is a rare genetic condition with characteristic musculoskeletal abnormalities and growth restrictions, coarse facial features, feeding abnormalities, systemic malformation, and developmental and cognitive delay.^1–3 Main anesthetic concerns should be difficult airway that tends to get worse with age, risk of aspiration, and periop pulmonary complications in uncooperative and mentally retarded patients. We report a case of 9-years-old male patient with CSS for dental extraction and restoration under general anesthesia.

Freeman–Sheldon syndrome¹ is a rare progressive myopathic disorder. The presence of difficult airway, poor venous access, and possible susceptibility to malignant hyperthermia make anesthesia management challenging in these patients.² We report the case of a child with Freeman–Sheldon syndrome with microstomia posted for posterior release of clubfoot.

Percutaneous device closure of atrial septal defect (ASD) is an alternative to traditional surgical closure. Various advantages of percutaneous correction are less invasive, early recovery, less hospital stay. Yet the complications such as arrhythmia, cardiac tamponade, and device embolization cannot be ignored. We report a case of ASD device embolization in case of ostium secondum ASD with deficient aortic rim. The embolized device was stuck in the main pulmonary artery at bifurcation in the vertical position, which required surgical intervention for retrieval.

Neurological deficit post central neuraxial blockade is rare but considered for highest compensation. We present a case of S1 mononeuropathy presented as foot drop after combined spinal epidural. A 30-years-old male with lower limb fracture was posted for plating. Patient was ASA grade I and all his investigations were normal. Combined spinal epidural was planned. The procedure was performed following all standard operating procedures. Surgical procedure was uneventful, epidural catheter was removed 12 hours postoperatively. 24 hours postoperatively foot drop was noted. Patient was evaluated by neurologist. Ankle dorsiflexion power-1/5, extensor hallucis longus and extensor digitorum brevis were weak. MRI spine was done, which was normal. Neurologic impairment after subarachnoid block is rare, but multifactorial. The causes can be divided into iatrogenic or idiopathic. In some cases it could be a coincident to clinical presentation of any other organic disease. Trauma by the needle or catheter are the commonest causes for the neurological deficit. Regular follow-up and supportive treatment is important in these patients. Medicolegal issues is a big worry in such cases.

Mediastinal hematomas following internal jugular vein (IJV) cannulation is relatively a rare complication with a very few cases reported in the literature. We hereby report a case of posterior mediastinal hematoma in a 21-year-old primigravida who underwent exploratory laparotomy postcesarean section. In this patient, anatomical landmark guided central venous catheter insertion through the right IJV was attempted using modified Seldinger's procedure in intensive care unit (ICU) after the surgery. A total of three attempts were made. The procedure was abandoned since there was resistance felt during guidewire insertion. A routine postprocedural chest radiograph and subsequent high-resolution computed tomography (HRCT) showed a large posterior mediastinal hematoma that developed as a result of injury to the IJV and carotid artery during the procedure. The patient was hemodynamically stable throughout and hence managed conservatively. The hematoma resolved completely over a duration of 6 weeks. This case is being reported for its relative rarity and to signify the importance of obtaining a routine postprocedure chest radiograph and to state that even mediastinal hematoma can be managed conservatively in asymptomatic patients.