Objective: To analyze the positive predictive value (PPV) and negative predictive value (NPV) of upper lip bite test (ULBT), ratio of patient's height to thyromental distance (RHTMD), and Mallampati classification (MPC) anticipating difficult intubation. Materials and methods: Adults undergoing elective intubation procedures under general anesthesia were graded using MPC, ULBT, and RHTMD in this prospective study. Cormack and Lehane (CL) were compared to three approaches. Grades III and IV are believed to be the most challenging to intubate. Calculations were made to determine each method's sensitivity, specificity, PPV, and NPV, as well as accuracy. Results: Out of 60 patients, 18 (30%), 21 (35%), and 21 (35%) were from CL grade I, grade II, and grade III, respectively. ULBT was found to be the least useful test to predict difficult intubation with 0% sensitivity. MPC and RHTMD had a sensitivity of 61.9% and 95.2%, respectively. Conclusion: In assessing and preparing for anticipating a problematic endotracheal intubation airway, RHTMD as a single preoperative bedside test offers a high level of accuracy when compared to MPC and ULBT.

Background: Modified Mallampati test is a standard method of assessing the airway for predicting potentially difficult laryngoscopy and intubation. It is performed in sitting position, while intubation is done in supine position. It is unclear whether a change in position while assessment of the Mallampati class causes significant changes in prediction of a difficult airway, and if it does, then whether we need to change our guidelines currently in place. Materials and methods: This prospective study was conducted in 350, ASA I and II patients undergoing various routine surgical procedures under general anesthesia, over a period of 18 months. The airway assessment was done using modified Mallampati grade in sitting and supine positions. Mallampati grade of III or IV was defined as the predictor of difficult airway. The laryngoscopy grade was assessed using the Cormack and Lehane grading scale. Grade III or IV of Cormack and Lehane grades was defined as the difficult laryngoscopy and assumed as the predictor of difficult intubation. Statistical measures including sensitivity, specificity, positive and negative predictive values, and accuracy were used for comparing the two positions for predicting difficult or ease of intubation. Results: Out of 350 patients, Mallampati grade III or IV was observed in more patients in a supine position compared to sitting position (12.29 vs 4.57%). Difficult laryngoscopy was observed in 23 (6.57%) patients. Sensitivity of modified Mallampati test was comparable in both the positions (sitting 97.55 vs supine 92.66%). Specificity was better in supine position as compared to sitting, 65.22 and 34.78%, respectively. Positive predictive value for difficult intubation in sitting position and supine positions were 95.5 and 97.43%, respectively, while negative predictive values were 50 and 38.46%. The diagnostic accuracy in both positions was comparable; sitting 93.43% and supine position 90.86%. The kappa agreement was 0.377 for sitting position and 0.437 for supine position, hence shows a fair agreement for both the sitting and supine positions in the prediction of difficult intubation. Conclusion: There was no statistically significant difference between airway assessment conducted in sitting and supine positions. The modified Mallampati classification (MMC) in supine position can be used to predict difficult tracheal intubation with comparable efficacy as in the sitting position.

Background: Several adjuvants have been used to improve the efficacy of transversus abdominis plane (TAP) block because it has been used as an effective component of multimodal analgesic treatment for infraumbilical surgeries. Here, we evaluated the effectiveness of dexamethasone as an additive to local anesthetic in TAP block for infraumbilical surgeries under general anesthesia in terms of time to first rescue analgesia, verbal numeric rating scale (VNRS) pain score, and mean total analgesic consumption over 24 hours. Materials and methods: This study was conducted on 60 adult patients who were randomly allocated into two groups of 30 patients each. In group A, 2 mL of normal saline and in group B, 8 mg (2 mL) dexamethasone was used with 20 mL of 0.25% ropivacaine in ultrasound (USG) guided TAP block bilaterally after induction of general anesthesia. Statistical analysis was done using chi-square test, Student's t-test, and Mann–Whitney U test. Results: The duration of analgesia was significantly longer in group B than group A (619.4 ± 21.4 minutes and 240.3 ± 18.6 minutes, respectively) (p < 0.001). VNRS was lower in both the groups, except at 4th, 5th, and 8th hours in group A and 12th hours in group B. Total mean analgesic consumption over 24 hours postoperatively was also significantly lower in group B than group A (p < 0.001). Conclusion: Using dexamethasone as an additive to 0.25% ropivacaine improves the efficacy of TAP block in terms of duration and quality of analgesia with significant reduction of postoperative analgesic requirement without any adverse effects.

Introduction: Bullae are thin-walled, air filled intraparenchymal lung spaces caused by the loss of alveolar structural tissue. Giant bulla refers to the one that occupies more than 30% of the hemithorax. After the thorough clinical and radiological assessment, patients with bulla can be taken up for surgeries like local excision/bullectomy, lobectomy, segmental resection, and minimal access surgery technique with laser and videoscopy. Case presentation: An atypical case of a 48-year-old female with a giant bulla measuring 14.2 x 9.7 x 13.7 cm almost completely involving left lung with passive collapse of left upper lobe, managed successfully using lung isolation technique and a well planned post-operative pain management. Conclusion: Anesthetist should consider an extensive preoperative evaluation to identify the high risk factors, reversibility of underlying lung disease and stratify a successful perioperative management with a smooth, pain free post-operative recovery in such patients.

The current coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on our healthcare system. Still, very little is known about the treatment modalities in the context of severe COVID in pregnancy. We describe a case of a 28-year-old patient who presented with severe COVID-19 and was admitted to our intensive care unit (ICU) in her third-trimester pregnancy with a progressive increase in oxygen requirement. Remdesivir may prove beneficial in reducing the inflammatory response and controlling the direct viral damage due to severe COVID-19 pneumonia resulting in favorable maternal and fetal outcomes.

Background: Thyrotoxicosis associated with molar pregnancy is rare to see, and anesthesia management of such patients for the emergency procedure is extremely challenging. Case description: A 22-year-old primigravida with 17 weeks of amenorrhea presented with bleeding per vaginum and pain abdomen, diagnosed as molar pregnancy, posted for emergency suction evacuation. Primary examination and lab investigation showed features of thyrotoxicosis, and the Burch–Wartofsky score was highly suggestive of an impending thyroid storm. The endocrinologist advised the evacuation of molar pregnancy as it is the definitive management of thyrotoxic state in this condition, and optimum stabilization after initiation of an antithyroid drug is still not known. The patient was given preoperative β-blockers and steroids. The suction evacuation was done under low-dose spinal anesthesia successfully. The patient was symptomatically better and discharged after 1 week. Conclusion: Knowledge of dangerous complications of molar pregnancy and safe anesthesia choices are important for an anesthesiologist for successful perioperative management of such patients.

Background: Pregnant women are uniquely susceptible to severe illnesses with a viral infection, possibly due to the shift from cellular to humoral immunity during pregnancy and puerperium. The relationship between clinically evident polyhydramnios in coronavirus disease 2019 (COVID-19) infection and poor perinatal outcome has not been evaluated. Case description: We describe as case of 28-year-old pregnant female with mild systemic disease (ASA-II) having COVID-19 with moderate polyhydramnios underwent an emergency cesarean section under spinal anesthesia due to fetal distress. She had class II obesity, cough, and fever with moderate COVID-19. Conclusion: Since COVID-19 is a viral infection, it may have caused placental insult due to cytokine storm during the pregnancy and resulted in polyhydramnios.

Patients with coexisting head and maxillofacial injuries present with unique challenges to the anesthesiologist. Providing an adequate and clear operative field for the surgeon for optimal surgical correction is of prime importance. At the same time, maintaining secure airway control throughout the completion of the surgery is mandatory, which the anesthesiologist has to balance, considering the options available. It is always good to expand the available options for airway control to suit the individual needs of patients and surgery. Submental intubation (SMI) is one such technique that can be very useful in such a scenario. We report one such case of zygomatic arch plate fixation, for which we opted for SMI.

Neurofibromatosis type 1 (NF1) is an autosomal dominant neurocutaneous disorder with an incidence rate of 1 in 3,500 individuals at birth. The involvement of nasal, sinus or maxillofacial cavities creates airway challenges for anesthesiologists. During the perioperative period, anesthesiologists must be aware of the multisystemic complications of the disorder. Here we report a neglected case of giant NF with deformity of the anterior chest wall (pectus carinatum) and thoracic spine scheduled for tumor resection located at the posterior aspect of the thoracolumbar region. In this case, both anesthesiologists and surgeons faced unique challenges during the perioperative period.