The Anaesthesiologist is the official publication of the Kerala state chapter of the Indian Society of Anaesthesiologists which will be published biannually. We aim to publish articles after a thorough peer review process and are focused at improving the academics and research of our anaesthesiologists.
Smart Anaesthesia Monitoring: Why the Conox System is Redefining Depth of Anaesthesia Assessment
The operating room (OR) is a highly complex and dynamic environment where constant vigilance, situational awareness, and effective teamwork are crucial to ensure patient safety. Despite this, anaesthesia providers frequently encounter distractions that can divert attention from critical patient care tasks.
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Distractions in the Operating Room (OR): An Emerging Threat to Patient Safety
The operating room (OR) is a highly complex and dynamic environment where constant vigilance, situational awareness, and effective teamwork are crucial to ensure patient safety. Despite this, anaesthesia providers frequently encounter distrac-tions that can divert attention from critical patient care tasks.
BEDSIDE ASSESSMENT AND MANAGEMENT OF MICROCIRCULATION IN SEPTIC SHOCK
Abnormalities of microcirculation in septic shock is one of the highlighted features of the condition. Tissue hypoperfusion and inadequate oxygen delivery at the cellular levels contributes to an oxygen debt and the multi-organ dysfunction seen in this condition. Clinically, the tissue oxygen delivery is manipulated using a combination of fluids, vasopressors and inotropes and this is measured using stroke volume, cardiac output and mean arterial pressure. These parameters indicate the oxygen delivery to the tissues. The downstream parameters including the centra venous oxygen saturation and the mixed venous oxygen saturation indicates the oxygen content of the venous blood. The difference between the two is assumed to be consumed by the tissues. However, in sepsis this may be an oversimplification of the situation. In such situations, bedside evaluation of the microcirculation becomes important. Although some sophisticated evaluation techniques are available which is being used on experimental basis, bedside evaluation of the microcirculation is something that can be done in any intensive care unit. This is a narrative review of some of these simple bedside tests that can be used for assessment of the microcirculation.
A Fallot feat : When the shunted heart meets the obstructed abdomen
Tetralogy of Fallot (TOF) remains the most prevalent cyanotic congenital heart disease, typically requiring early surgical correction to enable survival into adulthood. Despite successful repair, adult patients may still harbour residual structural or functional anomalies that significantly complicate anaesthetic management. Emergency non-cardiac procedures, introduce unique perioperative risks including abrupt hemodynamic instability, hypoxia, and arrhythmias. The interplay between altered cardiovascular physiology and surgical stress mandates vigilant perioperative planning. A multidisciplinary, individualized anaesthetic approach is essential to mitigate complications and ensure hemodynamic stability in this high-risk population.
Anaesthetic management of a patient with morvans syndrome
Morvan syndrome is a rare condition distinguished by hyperactivity within the central, autonomic, and peripheral nervous systems. Due to the limited number of cases, this presents clinical challenges stemming from the scarcity of published literature. We present a successful anesthetic approach for a patient diagnosed with Morvan syndrome scheduled for elective TURP. The patient had being diagnosed 6 months before the surgery when he was evaluated for insomnia, hyperhidrosis, generalized body pain, paresthesia more in bilateral lower limbs.
Anaesthetic Management of a Patient with Lennox– Gastaut Syndrome
Lennox–Gastaut Syndrome (LGS) is a rare childhood-onset epileptic encephalopathy characterized by multiple seizure types, cognitive dysfunction, and a distinctive electroencephalographic pattern. Anaesthetic management in these patients is challenging due to altered drug metabolism, potential interactions with antiepileptics, and risk of perioperative seizures. We present the case of a 23-year-old woman with LGS undergoing vagal nerve stimulator (VNS) implantation under general anaesthesia. Thiopentone was chosen for induction due to its anticonvulsant and neuroprotective properties, and sevoflurane was used for maintenance owing to its smooth titration and hemodynamic stability. Intraoperative BIS monitoring guided anaesthetic depth. The perioperative course was uneventful with no seizure episodes. This case highlights the importance of individualized anaesthetic planning, vigilant monitoring, and multidisciplinary collaboration in patients with refractory epilepsy undergoing neurosurgical procedures.
Anaesthetic Challenges in Neuronal Ceroid lipofuscinoses for Percutaneous Endoscopic Gastrostomy
Neuronal ceroid lipofuscinoses are rare inherited lysosomal storage diseases with multisystem involvement. Here we describe the anesthetic management of a six-year-old female patient who presented with recurrent aspiration pneumonia, multidrug resistant seizures, progressive deterioration of milestones. She was mute with impaired vision and was posted for Percutaneous Endoscopic Gastrostomy. Presence of uncontrolled seizures, difficulty in communication, cognitive impairment, predisposition to bradycardia, hypothermia, risk of aspiration with persistent lung infection were few of the challenges we faced. Optimization of seizure therapy, antibiotics, chest physiotherapy, nebulization with broncho dilators helped in preoperative preparation. Use of glycopyrrolate helped prevent bradycardia and reduce secretions. Propofol and midazolam for induction of anaesthesia helped prevent seizures during the procedure which was done under intravenous sedation with monitored anaesthesia care. Patient was positioned slight head up to prevent aspiration and we were ready to intubate if necessary. Warmers and warm fluids helped prevent hypothermia. The procedure was completed uneventfully
A race against time: The unforeseen embolic event
Pulmonary embolism (PE) is a life-threatening event that may occur even in individuals with negligible or absent risk factors [1]. PE is typically linked with surgeries of long duration, prolonged immobilization, obesity, patient with h/o malignancy and on treatment for malignancy, thrombophilic disorders . There are reports of pulmonary embolism occurring in individuals with low-risk , suddenly in the preop and post op period with dramatic symptoms. This report describes two postoperative cases of PE linked to unusual factors which require extensive research.
Quadratus Lumborum Block Type II Versus Transversus Abdominis Plane Block For Postcesarean Analgesia: A Randomized Double Blinded Trial.
Multimodal analgesia including neuraxial opioids, systemic opioids, nonsteroidal anti-inflammatory drugs, local wound infiltration and regional blocks are preferred after cesarean section to reduce opioid consumption and to provide synergistic or additive analgesia. There have been studies comparing analgesic efficacy of quadratus lumborum block (QLB) type II over transversus abdominis plane (TAP) after cesarean delivery, which however fail to provide consistent results in terms of significant difference in post operative analgesia while comparing both blocks. Aims: To identify a superior analgesic technique for post cesarean analgesia by comparing QLB type 2 with TAP block as part of multimodal analgesia. Methods: Eighty parturients scheduled for elective caesarean section under spinal anaesthesia during 2022 to 2023 in a tertiary care hospital in Ernakulam were randomized to receive QLB type 2 (group1) and TAP block (group 2). The primary outcome was to compare cumulative tramadol consumption at predetermined time intervals. Secondary outcomes included the quality of postoperative analgesia using pain rating scale, duration of postoperative analgesia, cumulative supplemental analgesic consumption, sensory dermatomal involvement, comparison of side effects. Results: The study showed statistically significant differences between the two groups with respect to cumulative tramadol consumption 12 h and 24 h; Numerical Pain Rating scores (NRS) at 12 h and 24 h; the duration of post operative analgesia; cumulative supplemental analgesic dose consumption up to 24 h; sensory dermatomal spread six hours and 12 h and sedation scores and nausea.Conclusions: QLB type II reduced opioid and other analgesic requirements and provided with longer lasting analgesia, as compared to TAP Block after cesarean section.
Comparative Evaluation of Bupivacaine Plain Versus Bupivacaine with Fentanyl in Spinal Anaesthesia for Lower Abdominal and Lower Limb Surgeries.
Spinal anaesthesia is a safe, effective, and widely used technique for lower abdominal and lower limb surgeries. Bupivacaine, a long-acting amide local anaesthetic, provides satisfactory anaesthesia but limited postoperative analgesia. The addition of opioids such as fentanyl to intrathecal bupivacaine has been shown to enhance sensory blockade and prolong analgesia due to synergistic interaction at the spinal cord level without significantly affecting motor recovery or haemodynamic stability. Objectives: To compare the clinical efficacy of intrathecal plain bupivacaine and bupivacaine with fentanyl in terms of onset and duration of sensory and motor block, duration of postoperative analgesia, haemodynamic stability, and adverse effects in patients undergoing lower abdominal and lower limb surgeries. Methodology: Patients were divided into two equal groups. Group A received 2.5 mL of 0.5% hyperbaric bupivacaine with 0.5 mL of normal saline, while Group B received 2.5 mL of 0.5% hyperbaric bupivacaine with 25 μg (0.5 mL) of fentanyl intrathecally. Sensory and motor block characteristics, haemodynamic changes, and duration of analgesia were recorded. Data were analysed using Student’s t-test and Chi-square test, with p < 0.05 considered statistically significant. Results: The onset of sensory and motor block was similar in both groups. The duration of sensory block and postoperative analgesia was significantly longer in the fentanyl group (p < 0.01). No significant difference was found in motor block or haemodynamic parameters. Minor side effects, including pruritus and nausea, were observed only in the fentanyl group, with no respiratory depression reported. Conclusion: The addition of 25 μg fentanyl to 0.5% hyperbaric bupivacaine prolongs sensory blockade and postoperative analgesia without increasing side effects or compromising haemodynamic stability, making it a superior combination for spinal anaesthesia in lower abdominal and lower limb surgeries.
Intrathecal adjuvant; Postoperative analgesia; Haemodynamic stability
Current understanding and perception of pre anaesthesia check-up among patients. A prospective observational study.
Background and Aims: Pre anaesthesia evaluation and optimisation varies from patient to patient, depending on the type of surgery. Therefore each and every patient should be questioned in order to understand their knowledge and perception regarding preanaesthesia check-up and anaesthesiologists. An incomplete preanaesthesia check-up shows incomplete history and general physical examination, affecting patient care. This study explores the understanding and knowledge among patients undergoing elective surgeries.The primary objective is to assess the patient perception regarding pre anaesthesia check-up and role of anaesthesiologists. The secondary objective is to assess the factors contributing towards lack of perception. Methods: This observational study was conducted in a tertiary care teaching hospital, in 320 patients, between the age group of 18-60 years, posted for elective surgical procedures over a period of two years. Patients were asked to fill a questionnaire consisting of multiple choice pattern, in which patient had to choose the most appropriate to him/her. Quantitative variables were expressed in terms of percentage, or in terms of mean and standard deviation. Correlation studies were performed by one way ANOVA test. All analysis was two tailed and the significance level was set as 0.05. The data was collected, compiled and analyzed using EPI info (version 7.2). Results: Only 14.06% of patients knew that they had come to preanaesthesia clinic for preanaesthesia assessment. Similarly, only 38.75% of patients knew that, anaesthesiologists perform preanaesthesia examination. Conclusion: Patients had insufficient knowledge about preanaesthesia check-up and the role of anaesthesiologists. Educated and employed patients showed better awareness.
Prospective Analysis of epidural analgesia in oncosurgeries in a tertiary cancer centre - An analysis of 600 cases.
The aim of the study is to improve individual epidural practice outcome and to ensure the best safe practice outcome in our institution. The primary objective is to assess the efficacy and outcome of epidural analgesia (EA) and the secondary objective is to assess complications of EA.
Guest Editorial: The Dangerous Intersection Phenomenon: Why We Act Only After an Adverse Event.
Every town has one — that dangerous intersection everyone talks about. Vehicles speed past it every day, drivers aware of its risk but cautious only after a serious accident occurs. In anaesthesia, we have many such intersections — places where danger is recognised but not addressed until an adverse event forces our attention. Whether it is a missing monitor, a non-functioning alarm, or an unsafe practice normalized by routine, we often wait for harm to happen before initiating change. This “Dangerous Intersection Phenomenon” is not new — it reflects the gap between awareness and action that continues to challenge our profession. Anaesthesia history is filled with examples of safety advances born out of mishaps. The oxygen pipeline was colour-coded only after cross-connection accidents.
Multi-modal Anaesthesia: The Significance of Integrating Regional and General Techniques in Contemporary Practice.
The modern perioperative pathway is decisively shifting towards multimodal anaesthesia—namely, a synthesis of general anaesthesia or total intravenous anaesthesia alongside regional anaesthesia techniques aimed at ensuring stable intra operative conditions and enduring postoperative benefits. This approach is now regarded as a rational, evidence-based strategy for numerous patients when expertise and resources are accessible. When executed proficiently, this methodology enhances haemodynamic stability, diminishes perioperative opioid exposure, and may mitigate the progression towards persistent postsurgical pain (including phantom limb pain), all while facilitating rapid recovery and ensuring high patient satisfaction. The advancement of regional anaesthesia techniques, particularly through the implementation of ultrasound-guided approaches, has afforded enhanced precision and safety, thereby fostering its widespread clinical acceptance.
Air Embolism After Endoscopic Retrograde Cholangio Pancreatography (ERCP)
ERCP is a routine non operating room procedure done for biliary tract abnormalities. Our main stay of the article is to give an insight in to the potential life threatening complication that can happen in endoscopic suites. We present a case of young female of 35 years who is a known case of Extrahepatic portal vein obstruction [EHPVO] with obstructive jaundice due to portal cavernoma cholangiopathy posted for endoscopic retrograde cholangio pancreatography. Immediately after the procedure patient developed sudden cardiac arrest, peri procedural echocardiography revealed massive air embolism
endoscopic retrograde cholangio pancreatography
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Anaesthetic Management For Emergency Caesarean Section In A Pregnant Woman With Severe Mitral Stenosis And Decompensated Heart Failure
This report describes the anaesthetic management of a 30-year-old pregnant woman at 37 weeks of gestation with severe mitral stenosis and decompensated heart failure who presented for an emergency caesarean section. The patient presented with New York Heart Association (NYHA) Class III symptoms and pulmonary oedema. Given the severity of her cardiac condition, a general anaesthesia with tight hemodynamic control was planned and executed with successful maternal and foetal outcomes. The case highlights the importance of meticulous cardiovascular management and multidisciplinary coordination in high-risk obstetric patients.
pulmonary artery hypertension in pregnancy
Airway Management in Tracheobronchopathia Osteochondroplastica -A Case Report
Tracheobronchopathia osteochondroplastica (TO), a rare large airway disorder, is a rare cause of unanticipated difficult airway. A 36years old male, known case of Tracheobronchopathia osteochondroplastica , was posted for laparoscopic cholecystectomy. CT thorax taken in 2019 showed nodular calcifications in tracheal wall and bilateral main stem bronchi. Upper Airway examination was normal. Patient was induced and endotracheal tube was placed just below the vocal cords and Fibreoptic bronchoscope was passed through and tube was positioned in such a way that nodules were avoided and unobstructed ventilation was confirmed. Intraoperative period was uneventful, check bronchoscopy postoperatively showed no bleeding/edema. Patient was reversed and extubated. TO patients experience unexpected difficulties in subglottic intubation, which creates a difficult situation. Assessment of the subglottic airway should also be taken seriously in order to avoid unexpected intubation impediment.
Tracheobronchopathia osteochondroplastica
fiberoptic bronchoscopy-assisted tracheal intubation
Fractionated Spinal Anaesthesia in an Achondroplastic Dwarf
A 57-year-old dwarf with achondroplasia was posted for open reduction and internal fixation with bone grafting of right tibia. He weighed 24 kg and his height was 114 cm. His blood parameters were normal. He had mild thoracic kyphosis. Echocardiography showed a non obstructive hypertrophic cardiomyopathy. Airway was also normal with normal neck movements. The anaesthetic plan was fractionated subarachnoid block (SAB). After obtaining venous access and initiating the standard monitors he was turned to right side and prepared for SAB. A volume of 2.5 mL of hyperbaric 0.5% Bupivacaine was kept ready and SAB was performed with a 25 G Quincke’s needle. The drug was administered in two fractions with an interval of 90 seconds between the two injections....
Anaesthetic Management Of Bilateral TMJ Replacement In Case Of Ankylosis Of TMJ And Micrognathia
Temporomandibular joint (TMJ) ankylosis is defined as bony or fibrous adhesion of the anatomic joint components accompanied by limitation of mouth opening, causing difficulty in mastication, speech, and oral hygiene. This may also influence symmetry of the facial skeleton. This interferes with mastication, speech, oral hygiene, and normal life activities, sleep related breathing disorder characterized by repeated episodes of apnoea and hyperpnea during sleep and can be potentially life threatening when struggling to acquire an airway in an emergency. Severe OSA with repeated nocturnal hypoxia associated with pulmonary hypertension may result in right heart failure, biventricular dysfunction and congestive cardiac failure, significantly increase the risk of haemodynamic instability in perioperative period
Perioperative Management of Hip Fracture Patients - Are We Following The AAGBI Guidelines? - A Retrospective Observational Study
Objective Several guidelines are available for management of hip fracture patients. Western nations conduct annual audits to regulate their practises. There is lack of studies done at institutional or national level in our country. So this study was done to evaluate the adherence to the recommendations at our centre. Methods Records of patients operated for proximal hip fracture from January 2020 to January 2021 were examined to extract the details of perioperative care, postoperative complications and 30 day outcomes. The compliance with the recommendations was assessed. Twelve key performance indicators were identified. Score of 1 was assigned for adhering to each indicator and total score for each patient was calculated. Results One hundred and twenty eight patents were included in the final analysis. Seventy one percent of the patients were operated in <48 hours of admission. Less than 40% of the patients received a nerve block for postoperative analgesia. Mortality at 30 days was 7.03%. Conclusion Several areas of perioperative care showed good compliance with the recommendations though some areas with major deficits were identified. The high mortality associated with hip fracture patients was also seen in our study.
Anesthetic challenges of Allgrove’s triple A syndrome
Allgrove’s Triple A syndrome is an autosomal recessive disorder characterized by the triad of primary adrenal insufficiency, achalasia cardia and alacrima. The perioperative period poses significant anesthetic challenges due to the risk of adrenal crisis and aspiration related to achalasia. The possible presence of autonomic dysfunction (4A syndrome) further complicates the anesthetic management. Here we describe the successful perioperative management of an adult with Allgrove syndrome, highlighting the importance of stress-dose corticosteroids and meticulous perioperative care.
INTRAVENOUS ONDANSETRON ON SPINAL ANESTHESIA - INDUCED HYPOTENSION IN PATIENTS UNDERGOING CAESAREAN SECTION: A RANDOMIZED CONTROLLED DOUBLE - BLINDED STUDY
Introduction: Spinal anaesthesia, a safe anaesthetic technique commonly practiced is associated with hypotension (33%), bradycardia (13%) and shivering induced by hypovolemia, sympathetic blockade and Bezold Jarisch reflex through intracardiac serotonin (5HT3) receptors and vagus nerve. Hypotension in caesarean section is triggered by many factors including pharmacological sympathectomy leading to reduced peripheral vascular resistance, venous return and cardiac output; aorto-caval compression by pregnant uterus in supine position. Ondansetron can inhibit Bezold Jarisch reflex triggered by chemoreceptors that are sensitive to serotonin. Ondansetron decreases the intensity of signs related to Bezold Jarisch reflex. This might lead to lower decreases in blood pressure after subarachnoid block. This study is designed to investigate effects of intravenous ondansetron on spinal anaesthesia induced hypotension in patients undergoing caesarean section. Objectives: To assess the effect of intravenous ondansetron on spinal anaesthesia induced hypotension after induction of spinal anaesthesia in caesarean section by serial blood pressure monitoring and recording the ephedrine requirement. Methodology: A randomized controlled double blinded study with 60 patients undergoing Caesarean section who satisfy the inclusion, exclusion criteria. Random sampling was done by chit in box method, and patients were divided into either group A or B. Group A received IV Ondansetron and Group B received IV Normal Saline as placebo. Sequential blood pressure recordings were taken, ephedrine doses were noted. Data analysis was by Chi square test and Unpaired t test. Probability value p< 0.05 is considered statistically significant. Results: Out of 60 patients, 30 in Group A received 2ml of intravenous ondansetron 2mg/ml and 30 in Group B received 2ml intravenous normal saline as placebo. There was no statistically significant difference in SBP, DBP and MAP. 7 patients (23.3%) in Group A and 19 (63%) in Group B required ephedrine with P value- 0.01. Conclusion: Our study indicates that prophylactic use of ondansetron before spinal anaesthesia significantly reduces the requirement of ephedrine in caesarean section.
Building on Foundations, Reaching New Heights: Research, Mentorship, and Road to quality of academic life
It is with immense pleasure and a profound sense of responsibility that I address you as the new editor of “The Anaesthesiologist”, the official journal of the Kerala State Chapter. This journal carries the strong legacy left by my predecessors, and I am deeply aware of the responsibility it entails. I would like to take this opportunity to express my gratitude to the previous editors Dr. Sugu Varghese, Dr Abdul Vahab, Dr. Muraleedharan A.K., Dr. Paul O. Raphael, and Dr. Suneel P.R.—whose dedication has nurtured this journal from its inception, sowing the seeds for its growth. The realization of their vision to bring together academics for constructive discourse and to promote excellence in anaesthesiology has led to “The Anaesthesiologis” becoming a respected and well-accepted publication within the anaesthesia community in Kerala. So now from the foundations we want “The Anaesthesiologist” to become something which would be a very useful resource for our anaesthesia community in Kerala. This means more than simply maintaining high standards of relevancy, quality, and standards; but also involves ways to improve its impact and reach. We the editorial board members will work hard to ensure that the journal is indexed in more databases. The Power of Publication and Mentorship: A Catalyst for Growth and Innovation While going on this journey towards academic excellence, for our younger colleagues may seem daunting, it can be a very standard learning of critical curiosity and the courage to share ideas out with the world. The path to publication may be challenging, but the rewards are immeasurable. Publishing a research work is not only a requirement for academic advancement but also is the way of giving back to your medical fraternity where you belongs to. It is important to collaborate with your senior colleagues who can guide you through the process of writing and publishing. Every published article assists in your professional profile building. For the senior faculties, one very important element is to support and guide the younger generation with proper mentorship. You bring invaluable assets and wisdom to the table that will help to build the future of our specialty. Mentorship in academic publication is a lifelong association and a lasting gift!! So I call upon our aspiring academicians to commit to the scholarly journey filled with passion and focus. On “The Anaesthesiologists”, you can share your experiences, your insights, and your research findings. Feedback and support through the publication process will always be constructive. We are as well committed to extending the reach of the journal and increasing the general quality of the journal. Let us start this journey together and employ to the best of our abilities - the spirit of mentorship, commitment to excellence, and innovation.
A Comparison Between Oral Melatonin and Oral Dexmedetomidine As Pre medication In Paediatric Anesthesia
Background: Preoperative anxiety in children is a common challenge, often triggered by the anticipation of pain, separation from parents, and fear of surgery. Effective premedication can significantly improve perioperative experiences and outcomes. This study aimed to compare the efficacy of oral dexmedetomidine and melatonin in alleviating preoperative anxiety in paediatric patients. Materials and methods: This prospective observational study was done in 92 children aged 2-10 years, belonging to ASA I and II, undergoing elective infraumbilical surgeries under general anesthesia. Patients were allocated into two groups: Group D received oral dexmedetomidine 3 µg/kg, and Group M received oral melatonin 0.5 mg/kg, administered orally 40 minutes prior to induction. Vital signs were monitored at 5-minute intervals. Sedation levels were assessed using the Ramsay Sedation Score and ease of parental separation by the Child–Parent Separation Score. Prior to induction, mask acceptance was assessed with Mask acceptance score. Postoperative sleep disturbances were assessed two weeks later using Post-Hospitalization Behaviour Questionnaire. Results: Group D demonstrated significantly higher sedation levels, smoother parental separation, and better mask acceptance compared to Group M (p < 0.001). No significant difference was observed in postoperative sleep disturbances between the groups as per Post-Hospitalization Behaviour Questionnaire findings. Conclusion: Oral dexmedetomidine provides superior preoperative sedation, facilitates easier parent–child separation, and improves mask acceptance in pediatric patients compared to melatonin.