Introduction: Gas Man® is a computer simulation program used for understanding the pharmacokinetics of volatile agents. On entering the patient details, fresh gas flow (FGF), volatile anesthetic concentration, and ventilatory details, it can predict the end-tidal concentration of volatile agents. ICOLLECT software is available for collection of real-time data from the workstation as well as hemodynamic parameters as it functions as a multichannel monitor. It is an electronic anesthetic record. We have used both these computer-based programs to study low flow anesthesia (LFA) in clinical practice. Aims: The primary purpose of this study was to compare the expired volatile anesthetic concentrations predicted by the Gas Man® simulation model with those actually occurring during general anesthesia (GA) using isoflurane, sevoflurane or desflurane in clinical practice using low FGF. Material and methods: Study area—the study was conducted in the Department of Anesthesiology, CARE Hospital, Hyderabad, Telangana, India. Study population—all patients who are posted for surgery under GA between the age groups 18–65 years, of either sex, and those belonging to the American Society of Anesthesiologists physical status I–II will constitute the study population. Sample size—a total of 30 patients undergoing GA with isoflurane, sevoflurane, and desflurane have undergone the validation trial using LFA. Our sample size calculation is based on a similar validation study. Study design—observational. Study duration—the proposed study was conducted over a period of 1 month (September 2016). Data collection techniques and tools—we collected relevant data directly from the Datex CS2 workstation via the ICOLLECT software for 30 anesthetics (isoflurane, sevoflurane, and desflurane) during the maintenance phase employing LFA. The measured concentration of volatile agent as well as the calculated concentration obtained by the Gas Man® equation were tabulated for each patient at 5-minute intervals. The performance error (PE), divergence, median predictive error, and wobble were determined for all three agents using the actual measured concentration end tidal agent against the predicted concentration. The statistics used for predicting the accuracy of volatile anesthetics uptake have been described by Varvel et al. Their model is based on those described for intravenous drug delivery systems. Multiple studies have validated this as a reliable model for predicting the accuracy of volatile anesthetics too. We calculated the median absolute performance error (MDAPE) median predictive error (MDPE) divergence, and wobble from the PE for all our cases. We calculated the MDAPE, MDPE, divergence, and wobble from the PE for all our cases. Results: Mann–Whitney U test done for each study group demonstrated that there was no statistically significant difference between the median measured end-tidal concentrations of volatile agents versus that predicted by the Gas Man® anesthesia simulator. The three groups were similar with respect to the measured and predicted end-tidal concentration of the anesthetic agent. Kruskal–Wallis test was undertaken to study the intergroup variability with respect to measured and predicted end-tidal concentration of volatile agents. We obtained a p-value of <0.01, confirms a statistically significant difference between the three groups. This is expected as the minimum alveolar concentration (MAC) requirements of the three agents studied are different. Discussion: In spite of the oversimplification of volatile kinetics, the Gas Man® simulation is an accurate predictor of the actual volatile agent's end-tidal concentrations achieved during LFA. It can serve as a useful educational tool for the implementation of LFA. Conclusion: There is good correlation between measured and predicted end-tidal concentrations of all three volatile anesthetics during LFA.

Functional endoscopic sinus surgery (FESS) is a common procedure performed in the ear, nose, and throat (ENT) operating room under general anesthesia (GA). Patients usually experience discomfort and pain postoperatively due to nasal packing. Aims and objectives: Our study is aimed to evaluate the effect of a bilateral intraoral infraorbital block with bupivacaine on postoperative pain in patients undergoing FESS under GA. Materials and methods: A total of 60 patients were randomly allocated to either the control group or study group of 30 each. After the establishment of the standard GA technique, bilateral intraoral infraorbital nerve block (IOB) was performed with 1 mL of either normal saline (control group) or 0.5% bupivacaine (study group). Fentanyl dose was repeated with a rise in mean arterial pressure of >10% of the baseline. Postoperative pain intensity, duration of analgesia, analgesic requirement, intraoperative hemodynamics, and patient satisfaction to pain were evaluated. Results: Postoperative pain scores in the control group were 3 and 2 and the study group was 2 and 1 and were statistically significant (p = 0.000). Duration of analgesia and the total analgesic requirement (first 24-hour postoperative period) were 513.5 ± 151.14 and 236.00 ± 65.20 and 92.50 ± 30.19 and 167.50 ± 32.26 in the study group and control groups, respectively and were significant statistically (p < 0.05). The hemodynamic and patient satisfaction scales were also significantly better in the study group. Conclusion: General anesthesia (GA) with bilateral intraoral infraorbital block provided stable hemodynamics, prolonged duration of analgesia, less pain scores, fewer analgesic need, and more patient satisfaction scores in the postoperative period.

Background: Diabetic ketoacidosis (DKA) is one of the serious acute complications of diabetes. Euglycemic diabetic ketoacidosis (EDKA) is one of the side effects associated with sodium-glucose cotransporter 2 (SGLT2) inhibitors. It is very difficult to diagnose due to the absence of hyperglycemia, thereby leading to delayed diagnosis and treatment. Case: The author did a case of a diabetic patient who underwent coronary artery bypass grafting (CABG) and developed EDKA during the intraoperative period, most likely due to the use of dapagliflozin.

Introduction: The placement of central venous catheters (CVC) is an invasive procedure done routinely in patients undergoing surgical procedures for therapeutic and diagnostic purposes. It is associated with several documented complications either during insertion of the catheter (e.g., arterial puncture, pneumothorax, arrhythmias); and/or during maintenance of the line (e.g., infection, thrombosis, or other mechanical risks). The use of postprocedure chest radiographs to confirm the correct position of the catheter and to detect other complications, such as pneumothorax or hematoma, is a regular practice.¹ We report a case of intrapleural hematoma caused by the insertion of CVC in the right internal jugular vein (IJV). Case description: A 32-year-old G2P1L1IUFD1 patient with abruption of the placenta presented with hypotension [blood pressure (BP) 76/50]. The coagulation profile, including bleeding time, clotting time, international normalized ratio, prothrombin time, partial thromboplastin time, platelet count, D dimers, and fibrinogen levels of the patient, was normal. The patient underwent an emergency lower-segment C-section under general anesthesia. Since it was an emergency, the patient did not undergo routine preanaesthetic investigations. The patient was managed intraoperatively with two wide-bore (18G) intravenous (IV) cannulas. The patient was transfused with 1000 mL colloid and one polypoidal choroidal vasculopathy (PCV) intraoperatively. Ionotropic supports were started intraoperatively. Intraoperative blood loss was 1300 mL, and urine output was 250 mL. The patient was not extubated and was shifted to intensive care unit (ICU) for further management. Placement of a triple lumen CVC through the right IJV was planned under ultrasound (USG) guidance to monitor postoperative central venous pressure (CVP) and to guide fluid therapy. Well-informed written consent from the patient's relative was taken for the same. Insertion of a 7Fr triple lumen CVC was attempted through the right IJV under USG guidance using a 16G needle. Venous blood was aspirated. There was resistance felt during guidewire insertion. Hence entire assembly was removed. The second attempt was again abandoned due to failure to advance the guidewire. One more attempt was made on the right side, but there was a spurt of blood through the distal port of the triple lumen. Hence the catheter was removed, and the pressure was applied for 5 minutes. Finally, the catheter was placed through the left IJV. The patient was stable after the procedure with a heart rate of 88 beats/minute, blood pressure of 98/76 mm Hg on injection (Inj) of noradrenaline 4 mg in 50 cc at a rate of 3 mL/hour, saturation 100% on ventilatory support and CVP of 6–8 cm of H₂O. As per our institutional protocol, the patient underwent a routine chest radiograph in the postoperative period. There was a well-defined radiopaque shadow in the right upper lung field. The patient also had dextrocardia, and a fundic shadow was visible on the left side. The patient was hemodynamically stable. A bedside USG chest was done, which revealed right-sided mild to moderate pleural effusion and situs inversus. The patient underwent high-resolution computed tomography (HRCT) chest, the report of which showed a fairly large hyperdense hematoma in the right pleural space of upper hemithorax with underlying compressive atelectasis of the right lung. Hypodense filling defect in the right IJV in the supraclavicular region, 5 cm in length, was seen along with near complete luminal occlusion of the vein. Dextrocardia with a right-sided aortic arch was seen. A few sections of the upper abdomen revealed a liver on the left side and a spleen on the right side, suggestive of situs inversus. A chest medicine and cardiothoracic opinion were sought. A CT angiography of the chest showed no active bleeding. Intercostal drainage (ICD) tube was inserted on the right side. The patient was transfused with six solvent/detergent-treated plasma (SDP), four fresh-frozen plasma (FFPs), and three PCVs. The patient was weaned off the ventilatory and ionotropic supports on day 4 and extubated the next day. The patient was hemodynamically stable. ICD was removed after 15 days. The patient was discharged on the 19th postoperative day. Conclusion: Central venous catheter (CVC) cannulation is associated with the above-mentioned complications. These complications decrease when image-guided assistance is used. However, the anatomic variation in our patient made it difficult for the guide wire to pass along smoothly. Hence the presence of such anomalies, though rare, should be kept in mind. Keeping this in mind, IJV insertion, especially in emergency situations, should be performed only by an experienced anesthetist. The number of attempts on any one side should not exceed two.

Background: Stroke is a devastating perioperative complication impacting the final surgical outcome. Maintenance of adequate cerebral perfusion pressure with normovolemia has become a standard anesthetic goal across specialties. Methods: We describe two cases of perioperative ischemic stroke to highlight risk factors which increase vulnerability amidst patients undergoing major surgical interventions. Conclusion: High index of suspicion and detailed clinical examination postoperatively are vital for early diagnosis to mitigate morbidity and mortality related to stroke.

Dengue fever (DF) is a prevalent arboviral illness in developing nations. Pulmonary manifestation in dengue is mainly due to involvement of the upper airway; however, in severe forms, the lower respiratory tract may involve resulting in diffuse alveolar hemorrhage.¹ Here, we present a case report of a young female who presented in the stage of dengue hemorrhagic fever (DHF). The high-resolution computed tomographic (HRCT) study revealed bilateral and symmetrical ground glass opacities (GGO) involving perihilar regions and upper lobes of the lungs. The lung findings add to the complications of DHF.

Mechanisms of coronavirus disease 2019 (COVID-19) induced acute kidney injury (AKI) include local tissue inflammation due to immunological responses and activation of coagulation pathways following endothelial damage. It has been shown that reduced oxygen supply and renal hypoxia are significant risk factors for the development of AKI in postcardiac surgery patients. The urinary oxygen partial pressure (PuO₂) of the first discharged urine is comparable to that of the renal medulla. Therefore, the real-time monitoring of PuO₂ can be used to predict renal hypoxia and the risk of AKI in COVID-19 patients who are hospitalized [intensive care unit (ICU)]. In this observational study, we did a single time point measurement of blood–urine gas analysis in addition to routine arterial blood gas analysis in 20 critically ill COVID-19 patients. In this case series, we couldn't find an association between stagnant urine PuO₂ and renal hypoxia. However, serial monitoring of PuO₂ by urinary oximeter can be used for early detection of medullary hypoxia.

The anesthetic management of patients presenting with laryngeal tumors and airway obstruction is difficult. We present the case of a 22-year-old female, 30 weeks of gestation, who underwent surgical removal of a vocal cord polyp under general anesthesia using awake intubation with airway blocks.

A unique regional anesthetic technique called erector spinae plane block (ESPB) is utilized to treat thoracoabdominal chronic neuropathic pain and postoperative pain. In our short communication, we have discussed the effectiveness of the ESPB for breast augmentation with silicone gel implantation surgery, particularly in transgender community patients.