Background and aims: The study compared the effect of bilateral ultrasound-guided erector spinae plane block (ESPB) with varying bupivacaine concentrations on postoperative pain, shoulder tip pain, surgical stress response, dermatomal spread, and patient satisfaction in patients undergoing laparoscopic cholecystectomy (LC). Materials and methods: Patients were randomly assigned in three groups—group C (no block), group E2 [bilateral ultrasound-guided (USG) ESPB with 0.25% bupivacaine], and group E3 (bilateral USG ESPB with 0.375% bupivacaine). Results: Patients receiving ESPB had significantly lower numerical rating scale (NRS) scores at rest, during deep breathing, and on movement compared to the control. The E3 group had a reduced need for postoperative analgesics in a larger number of patients and also resulted in lower diclofenac consumption on the first postoperative day compared to the E2 group. A significant reduction in shoulder pain (SP) was seen in the E3 group compared to patients who did not receive any block. More than half of the patients in the E3 group did not require any analgesic in the 24 hours postoperative. A reduction in surgical stress with E3 was also indicated, and patients were more satisfied with their pain relief in ESPB groups compared to the control. In a first, dermatomal spread of ESPB in LC patients was studied and found to spread up to 8 and 10 dermatomes in the E2 and E3 groups, respectively. Conclusion: ESPB with 0.375% bupivacaine provides us with a much-desired alternative in LC patients in whom both opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) should be used cautiously, such as obese patients with reactive airway disease or renal dysfunction. The dose of bupivacaine should be calculated cautiously.

Aim and background: Breakage of the epidural catheter remains an infrequent complication of a commonly performed anesthetic procedure and poses a dilemma for management. Visualization of the retained epidural catheter is aided by radiological imaging techniques, and active surgical intervention may be necessary. Case description: A 41-year-old male underwent emergency implant removal under epidural and spinal anesthesia. Epidural insertion was done on the third attempt using an 18G Tuohy needle in L3/L4 interspace after multiple bony contacts, and epidural catheter was fixed at 10 cm at the skin, followed by spinal at L4/L5 interspace using a 25G Quincke spinal needle. Epidural was successfully used intraoperatively. On attempting to remove the catheter postsurgery with gentle traction, it was found to be sheared off at the 8 cm mark. Magnetic resonance imaging of the spine in coronal and sagittal reconstruction was done, which showed catheter at L3/L4 posterior epidural space and superior endplate of L3. After multidisciplinary discussion and as per the patient's wishes, as there was a retained long segment (8 cm) of catheter near the nerve root, successful surgical removal under general anesthesia was done. Conclusion: A combination of patient and technical factors can lead to shearing of epidural catheter, and it is important to follow conventional guiding principles for insertion and removal. Despite the above measures, if such a complication arises, intimating the surgeons and explaining to the patient and relatives is of utmost importance. Appropriate radiological evaluation is mandatory, and surgical intervention may be necessary to remove the catheter. Clinical significance: A severed epidural catheter can be troublesome to anesthesiologist and patient due to the possibility of neurological complications. Radiological evaluation may be difficult though it is radiopaque. It may remain inert in epidural space or may need multidisciplinary approach for its removal if a complication arises.

Anticipated or unanticipated pediatric airway difficulty is always challenging for a nonpediatric anesthetist. Improper difficult airway management is the main reason for pediatric anesthesia-related mortality and morbidity. Concepts and protocols for managing difficult airways must be well established for this reason. There are several algorithms for managing difficult airways. Fiberoptic intubation (FOI) is an effective technique for establishing airway access in patients with both anticipated and unanticipated difficult airways. This article seeks to review the clinical technique of managing the airway in a 7-year-old child with left temporomandibular joint (TMJ) ankylosis. The child has a history of recurrent ear infections following a small injury to the face 3 months prior to admission. Infection, trauma, rheumatoid arthritis, and congenital deformity could be the leading cases of narrowing of the oropharyngeal airway.

Retrograde intubation (RI) can be successfully used in awake, sedated, obtunded, or apneic patients who have either an anticipated or unanticipated difficult airway. The American Society of Anesthesiologists (ASA) describes RI as an alternative approach to difficult intubation in the nonemergent pathway as per their difficulty airway algorithm. It is also used as an alternative when fiberoptic scope is not available. We discussed a case of nasopharyngeal carcinoma with a difficult airway, who developed fibrosis of neck soft tissue postradiotherapy. We managed to do the RI and found it to be an effective and safe alternative in the management of a nonemergent, difficult airway.

This case report outlines the successful anesthetic management of a 78-year-old patient with rhino-orbital mucormycosis, uncontrolled diabetes mellitus (DM), cardiac autonomic neuropathy (CAN), and coronary artery disease (CAD) who underwent an emergency surgical debridement. The challenges included an anticipated difficult airway due to fungal debris, palatal perforation, and glottic edema, exacerbated by the patient's complex medical history. The presence of CAN heightened the risk of perioperative cardiovascular complications. The successful approach involved invasive monitoring, careful administration of medications, and a multidisciplinary strategy to address both anatomical and physiological airway difficulties. This report contributes to the understanding and preparation for anesthetic challenges in similar emergency scenarios involving elderly patients with multiple comorbidities.

The author describes a successful perioperative management of 76-year-old male posted for holmium laser enucleation of the prostate (HoLEP) surgery. The patient was diagnosed with case of multiple myeloma and is on treatment with chemotherapeutic agents. Associated comorbidities include hypertension with ischemic heart disease (IHD), status postcoronary artery bypass grafting (CABG) with permanent pacemaker in situ.