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.
The discovery of ultrasound has revolutionized the practice of anaesthesiology. Over the past few years, we have witnessed many promising changes brought by the introduction of ultrasound into our practice. We share a few experiences of using ultrasound in our operating rooms that improved the quality of care in our patients. Ultrasound is a safe, relatively inexpensive, portable and easily accessible imaging modality. The applications of ultrasound in the field of anaesthesiology are numerous.
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Beyond AI: Why Human Compassion and Skill Matter More in Anaesthesia
Artificial Intelligence (AI) is the newest “kid on the block” in modern medicine. It is becoming an integral part of almost every aspect of our lives, from the moment we wake up to the systems that accompany us throughout our day. Medicine has also enthusiastically embraced AI, utilising large datasets to aid in diagnosis and management 1 .Anaesthesia is no exception; we are exploring various methods to incorporate AI to make our work safer, more efficient, and more accurate.
Anaesthetic Management for Transurethral Resection of the Prostate in a Patient with Previously Undiagnosed Ebstein’s Anomaly.
Improved survival among patients with congenital heart disease has resulted in a growing number of adults presenting for non-cardiac surgery. Ebstein’s anomaly is a rare congenital malformation of the tricuspid valve characterised by right ventricular dysfunction, susceptibility to arrhythmias, and intracardiac shunting, each of which poses distinct anaesthetic challenges. We report the perioperative management of an elderly patient with previously undiagnosed Ebstein’s anomaly undergoing transurethral resection of the prostate (TURP). A 70-year-old man with hypertension and chronic kidney disease was scheduled for elective TURP. Preoperative electrocardiography demonstrated right atrial enlargement and right bundle branch block, prompting further evaluation. Transthoracic echocardiography identified Ebstein’s anomaly with severe tricuspid regurgitation, an ostium secundum atrial septal defect with bidirectional shunting, severe pulmonary arterial hypertension, and borderline right ventricular dysfunction. Following multidisciplinary review, a decision was made to proceed with intrathecal ropivacaine under continuous invasive haemodynamic monitoring and appropriate precautions against paradoxical embolism.The patient’s cardiovascular stability was successfully managed with carefully titrated phenylephrine, allowing the surgery to proceed without any adverse events. An elderly patient with previously undiagnosed Ebstein’s anomaly was managed successfully through proper preoperative assessment, multidisciplinary planning, and vigilant intraoperative monitoring. Anaesthetic management in this case highlights that spinal anaesthesia is a viable strategy for TURP in carefully selected patients with complex right-heart physiology. This case also emphasises the importance of maintaining a broad differential diagnosis during preoperative evaluation, particularly in elderly patients in whom congenital cardiac pathology may be ignored in favour of more common acquired conditions.
Bilateral Parotitis after Caesarean Section under Spinal Anaesthesia
We describe the case of a 32-year-old (Gravida2, Para1, Live1) woman who had late-onset foetal growth restriction (FGR) at 36 weeks gestation and had a history of lower segment caesarean section (LSCS) and gestational diabetes mellitus (GDM) treated with oral hypoglycaemic medications. She experienced a non-reassuring non-stress test (NST) in spite of normal Doppler indices, necessitating emergent LSCS under spinal anaesthesia. Intraoperatively, she had acute hypertension and headache, which were treated with intravenous labetalol and magnesium sulphate. Postoperatively, she suffered transitory bilateral parotid swelling that reduced with fluids and corticosteroids. Both the mother and the newborn were discharged in a stable state. This example emphasizes the necessity of careful peripartum surveillance and the significance of identifying uncommon postoperative complications like parotitis, even after regional anaesthesia.
Anaesthetic Management of Upper Limb Fracture in a Patient With Cleidocranial Dysplasia
Background: Cleidocranial dysplasia (CCD) is a rare autosomal dominant skeletal disorder which is characterised by defective skeletal ossification, mainly affecting the clavicles and skull, along with dental abnormalities. Case Presentation: This study reports the anaesthetic management of a 12 year old boy with cleodocranial dysplasia with traumatic fracture of both bone right forearm without any neurovascular deficits. Ultrasound guided Supraclavicular brachial plexus block was administered under intravenous sedation. Vitals were monitored throughout the case which was stable and surgery was completed. Conclusion: Considering the ease, safety and potency of ultrasound guided supraclavicular block, it may be used for patients with CCD with absent clavicle. Peripheral nerve block under intravenous sedation avoids airway manipulation in patients with CCD characterized by generalised skeletal and orofacial defects.
ultrasound guided supraclavicular brachial plexus block
Haemodynamic Outcome And Recovery Time Using Propofol And Ketamine For Procedural Sedation In Children For Minor Cardiac Procedures – A Prospective Observational Study
The ideal anaesthetic technique for the management of pediatric patients scheduled to undergo cardiac catheterization should be safe, easy to administer, provide adequate sedation, amnesia, immobility, cardiovascular stability and fast recovery without residual complications. Anesthetic technique for such procedures has not been standardized. Deep sedation with pain free and spontaneously breathing patient on room air is preferred by the interventionist. There are not many studies in India about the haemodynamic outcome of single or combinations of anaesthetic agents. This study was done to note and observe the haemodynamic outcome and recovery time using propofol and ketamine for procedural sedation for pediatric cardiac catheterization laboratory procedures.
Incidence of Post-Dural Puncture Headache with Quincke versus Whitacre Spinal Needles in Arthroscopic Knee Surgeries: A Prospective Observational Study.
Background and Aims:Post-dural puncture headache (PDPH) is a well-recognized complication of spinal anaesthesia and can significantly affect postoperative recovery. Needle design and gauge play an important role in determining its incidence. The incidence of Postdural puncture headache in adults, especially young adults is much higher than other age groups (14 % vs 7 %). This is because with increasing age, the dura may be less elastic and less likely to gape. The incidence of post dural puncture headache is high among patients who are mobilised early after the surgery(1). In arthroscopic knee surgeries, patients are advised early mobilisation mostly immediately 12 to 18 hours after surgery. This study includes adults in the age category of 18 to 45 years of age (younger age group) and also who have undergone arthroscopic knee surgeries where early mobilisation after surgery is done.Studies in this population are very limited .Hence this study was undertaken to address this gap. . It would also be helpful in the proper post-operative management of adults undergoing arthroscopic knee surgeries and prevent development of postdural puncture headache.The primary objective is to find out the incidence of post dural puncture headache following subarachnoid block using Quincke and Whitacre spinal needles among patients undergoing arthroscopic knee surgeries.The secondary objective is to to compare the severity of post dural puncture headache with Quincke and Whitacre spinal needles among patients undergoing arthroscopic knee surgeries.
Collaborative Decision Making in High-Risk Cases: An Anesthesia Perspective
Collaborative decision making (CDM) has become an essential component of modern anesthetic practice, particularly in the management of patients undergoing high-risk surgical procedures. It expands the concept of informed consent into a multidimensional process that actively engages clinicians, patients, and their families in transparent and evidence-based dialogue. CDM allows anesthesiologists to align technical expertise with patient values, preferences, and contextual factors, integrating multidisciplinary input and structured tools such as risk calculators and decision aids. Evidence increasingly supports that such collaborative frameworks improve clinical outcomes, enhance satisfaction, and uphold ethical standards. However, implementation remains challenged by institutional inertia, time constraints, and variability in communication skills. Facilitators include standardized education, interdisciplinary engagement, and integration of digital technologies, including artificial intelligence. CDM represents the convergence of ethical responsibility and clinical precision—offering a patient-centered model that strengthens perioperative safety, equity, and trust in complex anesthetic care.
ECPR (Extra Corporeal Cardio Pulmonary Resuscitation): Challenges and Future in India
Extra Corporeal Cardiopulmonary Resuscitation is an growing modality in refractory cardiac arrest by which adequate circulation and oxygen delivery is restored and helps to improve the overall outcomes overcoming the limitations of conventional CPR. Evidence from international studies points to improved survival and neurological outcomes in selected patients specifically in in-hospital cardiac arrests,; But its benefit in out-of-hospital settings remains variable and highly dependent on many other factors and not without limitations. ECPR is a time-sensitive, resource-intensive intervention requiring a well-coordinated multidisciplinary team and robust infrastructure.In India, the adoption of ECPR is still in its developing stage with limited data, absence of regional guidelines, and significant challenges and barriers. Despite these limitations, increasing ECMO experience, especially post-pandemic, gives us an opportunity to expand ECPR programs in tertiary centers. Establishing national registries and improving public health measures such as CPR training may ultimately determine the broader impact of ECPR in India.
Extracorporeal cardiopulmonary resuscitation
Rethinking “Good Quality Anaesthesia”: Beyond Surrogate Endpoints to Meaningful Outcomes
Defining endpoints and outcomes is important for research planning, execution, and publication. Historically, anaesthesia-related research has focused mainly on surrogate endpoints such as pain scores, opioid consumption, haemodynamic stability, time to discharge, length of hospital stay, etc. (1,2) The use of such surrogate outcomes primarily depends on their ease of measurement, timeliness, statistical responsiveness, and feasibility within a short study window. Though these markers may seem feasible, simpler, and more practical, the critical question is “whether these markers truly represent quality in anaesthesia care, or merely approximate fragments of it.”
Challenges and Opportunities for Our Journal
The Kerala Journal of Anaesthesia has established a strong national presence and is increasingly gaining international recognition. By addressing contemporary clinical practice within our healthcare context, the journal continues to make a meaningful academic contribution. | congratulate the promoters for advancing this important scholarly platform.
The Anaesthesiologist as the Guardian of Asepsis
The role of the modern anaesthesiologist has evolved far beyond the administration of hypnotic agents. Today, we function as perioperative physicians, pain specialists, and most critically the principal custodians of the sterile operation theatre environment. As regional anaesthesia continues to advance from conventional neuraxial techniques to increasingly sophisticated ultrasound-guided blocks, the mandate for rigorous aseptic practice has never been more crtitical.
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.
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....