Synopsis: Awake intubation is considered a technique of choice in anticipated difficult airway. Similarly, awake airway control should be considered in anticipated difficult mask ventilation to maintain continuous oxygenation. Placement of nasopharyngeal airway prior to induction of anaesthesia can help to optimise face mask ventilation following induction of anaesthesia without patient discomfort. Also nasopharyngeal airway itself can be used for ventilation instead of face mask for induction of anaesthesia after manually closing the other side nostril and mouth as we did in the present case.
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Synopsis: Endoscopic Endonasal Trans-sphenoid Surgery (EETS) aided by avant-garde neuro-navigation techniques, ultrasonic aspirators and bone curettes has come of age. Endoscopic surgery supersedes conventional microscopic approach due to better visualization, avoidance of craniotomy, brain retraction and undue neurovascular manipulation with less morbidity, blood loss and improved safety. Anaesthetic techniques must be tailored to cater for such advances in surgery.
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Synopsis: Endotracheal intubation using flexometallic tubes are often required in anaesthesia practice for a variety of reasons. It is preferred in the head and neck region surgeries due to its relative resistance to kinking forces. At times, these patients postoperatively may need to be shifted to ICU or HDU without extubation for further stabilization/management and extubation after adequate recovery. We present an unusual accident where a new flexometallic endotracheal tube was permanently tapered, transected and migrated proximally due to patient's bite on tube leading to airway emergency in post-operative recovery period.
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Synopsis: Congenital afibrinogenemia is a very rare inherited bleeding disorder that results from fibrinogen deficiency and is associated with bleeding manifestations of varying severity. A 21 Year-old, diagnosed case of congenital afibrinogenemia, was admitted to the hospital with blunt injury to both the eyes. He was posted for right eye enucleation. Main modality of treatment during bleeding episodes is transfusion of fibrinogen. Alternatively, cryoprecipitate can also be used for minor bleeding episodes or to maintain a base line fibrinogen level. Team work involving haematologists, surgeons and anaesthetist is needed for good pre-operative preparation, to form a protocol for intraoperative management and for optimum post-operative care. It is mandatory to arrange blood and blood products even for minor surgeries in view of the possibility of excessive blood loss.
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Synopsis: A patient of stage III squamous cell carcinoma of mandible with hemi-mandibulectomy, modified radical neck dissection and radiotherapy required Ryle?s Tube (RT) insertion for feeding. This case report describes use of fibreoptic bronchoscope to place an endotracheal tube in oesophagus through nasal route which was then used as a conduit to pass a RT into stomach.
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Synopsis: A 12 year old child presented with crush injury of forearm and hand. He was diagnosed as a case of uncorrected large Ventricular Septal Defect (VSD). Tendon repair, debridement and nailing were done using regional technique. Risks associated with a cardiac patient undergoing non-cardiac emergency procedure are discussed in this report.
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Synopsis: Distal limb amputations and respiratory complications are common in patients with Buerger's disease. Nicotine in cigarette is arrhythmogenic as it blocks cardiac potassium channels. Preoperative Holter ECG monitoring may be useful if preoperative electrocardiogram is normal. If the patient is undergoing major surgery, preservative free lignocaine & amiodarone infusions and a cardioverter defibrillator should be available for the intraoperative cardiac rhythm disturbances.
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Synopsis: Immune Thrombocytopenic Purpura (ITP) accounts for 4-5% of cases of pregnancy with thrombocytopenia. Their clinical condition may deteriorate during pregnancy subjecting these patients at high risk of bleeding. We report anaesthetic management of a parturient with chronic ITP for caesarean section.
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Synopsis: von Hippel-Lindau (VHL) disease is a rare autosomal dominant genetic disorder with retinal and nervous system haemangioblastomas, phaeochromocytoma, renal, pancreatic and endolymphatic tumours. These patients usually present for surgeries involving cerebellar or adrenal tumours. In this article, intraoperative management of a case of VHL, operated for coronary artery bypass grafting is discussed.
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Synopsis: A 69 year old woman, operated for right modified radical mastectomy under general anaesthesia, developed Acute Gastric Dilatation (AGD) on the second postoperative day. The possible causes and management are discussed.
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Synopsis: Thoracic surgery requires lung isolation which is usually achieved by placing a double lumen tube (DLT). Correct placement of DLT is crucial for lung isolation. In this case report incomplete lung isolation with DLT was corrected using a Fogarty catheter to achieve lung isolation successfully.
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Synopsis: Difficult airway management in paediatric patients may require a technique different from the standard one. We report the use of an adult fibreoptic bronchoscope and J tipped guidewire to intubate a child having temporo-mandibular joint ankylosis. Spontaneous respiration was maintained and local anaesthesia was provided to the upper airway during the procedure and the successful use of this technique avoided the requirement of surgical airway.
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Synopsis: Ultrasound (US) guided Transversus abdominis plane (TAP) block is commonly used for postoperative analgesia and there are case reports of its use for providing surgical anaesthesia in emergency procedures. We report its use as a regional anaesthetic technique in inguinal hernia and epigastric hernia repair in an elective setting and discuss issues during the intra and postoperative period.
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Synopsis: Intestinal obstruction due to strangulated hernias, adhesive bands or superior mesenteric artery (SMA) occlusion is treated with immediate surgical intervention. To restore the blood flow of the ischemic bowel, surgical exploration followed by supportive intensive care is important. A sixty years old hypertensive female, with previous history of ischemic heart disease and thrombosis of right axillary artery underwent emergency exploratory laparotomy uneventfully followed by supraventricular tachycardia in the immediate postoperative period. Generalized atherosclerosis, athero-thrombosis of right axillary artery and superior mesenteric artery (SMA) can be correlated with the pro-thrombotic state and the possible deficiency of anticoagulant factors led to embolism and life threatening cardiac dysrhythmias.
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Synopsis: Sturge-Weber Syndrome (SWS), also called as encephalo trigeminal angiomatosis, is a rare congenital syndrome, characterized by lepto meningeal haemangioma, a facial port-wine stains distributed over the trigeminal nerve area, (usually involving one side) and glaucoma. During cataract surgery, there may be rupture of choroid haemangioma, leading to excessive bleeding, or of haemangioma involving the airway, leading to difficult mask ventilation, laryngoscopy and intubation. We discuss the anaesthetic management of the patient with SWS for cataract surgery.
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Synopsis: A 63 year old male hypertensive and diabetic patient, with coronary artery and chronic obstructive pulmonary disease, presented with bilateral both bone forearm fracture. Open reduction and internal fixation was done successfully with bilateral ultrasound guided supraclavicular block. The problems associated with peripheral nerve block in an Ischemic Heart Disease (IHD) patient on antiplatelet therapy are discussed.
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Synopsis: Dislocation of temporomandibular joint (TMJ) during airway manipulation in anaesthesia is not unusual. Direct laryngoscopy, intubation, supraglottic airway device insertion, Ryle's tube insertion and fibreoptic intubation are some of the procedures which require varying degree of jaw manipulation which may sometimes act as triggering factor, dislocating the otherwise normal joint. We report a case of TMJ dislocation during "Easy Tube" insertion under general anaesthesia, which was recognized only after its removal. Closed reduction was done and there was no residual sequel.
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Synopsis: Accidental inhalation of foreign body in the airway of children continues to be a significant cause of morbidity and mortality. Rigid bronchoscopy for removal has been the mainstay of treatment in these patients. Anaesthesia for bronchoscopy is challenging in paediatric patients as the airways are narrower and desaturation is faster compared to adults. Cooperation and communication between the surgeon and anaesthesiologist is the key to safe and successful outcome in such situations. This case report describes an unconventional method of the foreign body removal from airway of a 9 year old child and the role of spontaneous ventilation.
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Synopsis: Transverse Rectus Abdominis Musculocutaneous (TRAM) flap surgery is a prolonged and extensive procedure that requires multiple incisions. Recently, Transverse Abdominis Plane (TAP) blocks have been found to be reliable method of providing regional analgesia for lower abdominal surgery and paravertebral block for pain management after breast surgery. Since the TRAM flap surgery involves both abdomen and thorax, the combination of these two blocks to manage post operative pain could be effective. This manuscript is one of the initial cases reporting of the use of these techniques in which triple catheters with ropivacaine infusion in breast reconstruction surgery were successfully used with reduced pain scores and opioid consumption.
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Synopsis: Cricoid pressure is widely used during anaesthesia induction to prevent regurgitation of gastric contents and subsequent aspiration. Recently its role has become debatable due to reports of associated complications and lack of efficacy. This article aims to critically examine the arguments for and against cricoid pressure.
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Synopsis: For many years Cricoid pressure (CP) has been a standard of care during induction of anaesthesia in emergency situations and where the patient is deemed at risk for aspiration of stomach contents (Rapid Sequence Induction or RSI). This review will examine the technique and its history; discuss the usual arguments presented as justification for abandoning CP and review recent evidence of its usefulness and efficacy.
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Synopsis: Laparoscopic renal autotransplantation has serious perturbations on the body's homeostasis due to its non physiological positioning, use of pneumoperitoneum, changing fluid strategy at different points of time and on-going steps to maintain optimal environment for the transplanted kidney. Generally speaking, the anaesthetic management of renal auto-transplantation by open technique is not very complex and the perioperative management can be categorized in the intermediate level of clinical skill requirement. Adding to the comfort of the anaesthesiologist is the fact that these patients are not in end stage renal disease state and does not manifest the comorbidities, multisystem involvement and technical complexities of long term renal dysfunction and renal replacement therapy. In our case report surgeons used the da Vinci surgical robotic system for laparoscopic transplantation of the kidney at a new site. In this article we discuss the anaesthetic challenges of robot assisted laparoscopic renal auto-transplantation along with a description of our index case.
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Synopsis: Myasthenia gravis is a chronic autoimmune disease affecting voluntary skeletal muscles. The altered sensitivity of acetylcholine receptors to muscle relaxants and concomitant treatment with anticholinesterase in these patients affect their anaesthetic management. Patients who have undergone bowel anastomosis and are on regular anticholinesterase treatment are susceptible to anastomotic leaks. We report successful anaesthetic management of class I myasthenic patient with coexisting small bowel intussusception operated for jejuno-ileal anastomoses using regional, inhalational and intravenous (i.v) anaesthesia based on train of four responses, and avoiding the use of reversal (anticholinesterase).
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Synopsis: Portal hypertensive gastropathy occurs both in cirrhotic and non cirrhotic patients leading to haemetemesis secondary to oesophageal varices. The hyper dynamic circulatory state of pregnancy in these patients poses special problems necessitating specialised care preferably in a tertiary care centre. We report the perioperative anaesthetic management for elective caesarean section in a 32-year-old pregnant lady at 39 weeks gestation with portal gastropathy secondary to periportal fibrosis of the liver.
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Synopsis: Gilbert's syndrome is a hereditary condition with the genetic mutation of the enzyme uridine diphosphate glucuronosyltransferase, characterized by intermittent jaundice in the absence of hemolysis or underlying liver disease. These patients develop jaundice when subjected to fasting, stress and exercise. Majority of anaesthetics are metabolized by liver. Anaesthesia, surgery and cardiopulmonary bypass (CPB) can act as triggers to hepatic injury. The successful perioperative management of an adult congenital heart disease patient for atrial septal defect closure under cardiopulmonary bypass was discussed in this report.
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Synopsis: Foreign body aspiration is a serious medical condition that demands prompt diagnosis and treatment to prevent fatal complications. This is a case report of a 42 year male with history of surgery for carcinoma tongue, hemiglossectomy and tracheostomy. He presented with dislodged fractured metallic tracheostomy tube in left main bronchus. Patient was breathing through stenosed tracheostomy stoma with bilateral normal air entry in chest. He was haemodynamically stable. Rigid bronchoscopic removal was impossible due to no mouth opening. After securing airway, general anaesthesia was induced and thoracotomy was performed to remove dislodged tube. Proper planning and coordinated team work resulted in good outcome.
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Synopsis: A 45yr old woman diagnosed with dysfunctional uterine bleeding and incisional hernia was planned for total abdominal hysterectomy with bilateral salpingo-oophorectomy and mesh repair under combined spinal and epidural anaesthesia. Using VYGON® epidural catheter with its recommended introducer, the catheter was inserted but it snapped off at 11cm mark while positioning the catheter. After radiological confirmation, the neurosurgeon removed the catheter under general anaesthesia, which was followed by the scheduled surgery.
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Synopsis: Awake craniotomy was historically advocated for resistant epilepsy surgery. Presently, its role has widened for resection of lesions abutting or invading the eloquent cortex. It aims at maximizing resection while minimizing neurological damage. Anaesthetic challenges include providing sufficient depth of anaesthesia, full cooperation and consciousness during cortical mapping, smooth transition between anaesthesia and consciousness, airway protection, haemodynamic stability, patient immobility and co-operation. Communication and co-operation between the patient and surgical and anaesthesia teams is vital. We report safe conduct of monitored anaesthesia care by the combined use of dexmedetomidine and scalp nerve blocks for tumour resection. This technique ensured haemodynamic stability, decreased stress response to painful stimuli and improved patient tolerance. As awake craniotomy is an upcoming technique, knowledge about anaesthetic implications, challenges and techniques will help in optimum management.
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Synopsis: Deep brain stimulator (DBS) devices are used for unilateral or bilateral stimulation of thalamus, subthalamus and globus pallidus to treat movement disorders. DBS can interfere with domestic and medical equipment such as electrocardiography (ECG), slow wave diathermy, electrocautery, peripheral nerve stimulators, pacemakers, external and implantable cardioverters and defibrillators. This case report describes a patient with such a device who presented for bilateral (B/L) cataract surgery.
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Synopsis: Anaesthesia management for proximal femoral fractures of high risk patients with debilitating systemic co-morbidities is a challenging task. It is generally done under the effect of regional anaesthesia or general anaesthesia (GA), with systemic analgesics for alleviation of pain after surgery. A combination of lumbar plexus and sciatic nerve blocks can provide anaesthesia and analgesia to the entire lower extremity including the hip. Analgesic potency of lumbar plexus and sciatic nerve blocks is similar to epidural analgesia for hip surgery without the undesirable side effects. We describe here two cases of proximal femoral fractures which were done under combined lumbar plexus and sciatic nerve block.
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Synopsis: Accelerated hypertension following therapeutic arterial embolization is a rare phenomenon. A patient of left upper limb chronic lymphedema was posted for shoulder disarticulation under general anaesthesia. Coil embolization of the left subclavian artery was done prior to surgery. Following the intervention, patient?s blood pressure increased by more than 30% of the base line value and was managed with antihypertensives for the next 3 hours to get the blood pressure optimised prior to taking the patient for surgery.
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Synopsis: A 26 year-old primigravida at 30 weeks of pregnancy presented with frequent seizures, headache and vomiting. On examination she had a right sided hemiparesis. Magnetic Resonance Imaging (MRI) findings were suggestive of infective aetiology with possibility of tuberculoma. Emergency surgery was decided in view of rapid deterioration in patient?s neurological state and uncontrollable headache and vomiting. Anaesthetic management was tailored for both pregnancy and an intracranial space occupying lesion. Foetal heart rate (FHR) was monitored prior to operation and throughout the surgery and periodically for 24 hours postoperatively. An obstetrician was requested to remain as standby for FHR assessment and for an urgent caesarean section if required in case of foetal distress. The major concerns for the anaesthesiologist are maternal and foetal monitoring and utero-placental drug transfer.
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Synopsis: Pregnancy with kyphoscoliosis is a challenge to both, the obstetrician and the anaesthesiologist. Regional anaesthesia is technically difficult and the spread of the local anaesthetic drug is unpredictable due to the deformity. The pulmonary reserve of a parturient with kyphoscoliosis is poor and hence the risk of general anaesthesia is more. The severity of kyphoscoliosis is assessed by measuring the Cobb angle. A careful preoperative evaluation of cardio-respiratory status would be a guide to plan and execute anaesthesia care. We report a case with severe kyphoscoliosis which was managed with subarachnoid block with a successful outcome.
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Synopsis: Systemic hypotension, cardiac dysrhythmia especially bradycardia, apnoea, and gastric hypermotility occurring presumably after stimulation of any of the sensory branches of trigeminal nerve is coined as trigeminocardiac reflex (TCR). It has been described to occur in various surgeries like cerebello-pontine angle and pituitary fossa surgeries. Such bradycardic reflex responses have also been observed during maxillofacial surgeries. The TCR presents as a challenge to both the Anaesthesiologist and the Surgeon in view of its varied presentations, diagnosis, prevention and appropriate management.
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Synopsis: An autistic child of eight years age, with attention deficit hyperactivity syndrome presented for tooth extraction under general anaesthesia. Ketamine was used for induction and the child developed seizures following its administration. Seizures were controlled, extraction done and post-operative period was uneventful. Ketamine was suspected to have caused seizures though safe use of Ketamine has been reported in autistic patient.
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Synopsis: Anaesthetising a patient with severe coronary artery disease for non-cardiac surgery especially one who has not undergone any revascularization in the form of angioplasty or coronary artery bypass grafting is very challenging. Preoperative risk stratification, optimisation, judicious selection of anaesthesia technique, perioperative management of pain and intravascular volume status are crucial factors in avoiding adverse outcomes in such patients. We describe successful anaesthesia management of a patient with triple vessel disease recommended for CABG, who underwent per-anal excision of a rectal adenoma under regional anaesthesia. We?ve also discussed the ECG criteria for diagnosis of LBBB and the diagnosis of myocardial infarction in presence of LBBB as the intrinsic rhythm.
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Synopsis: Labour is an intensely painful experience and puts considerable physiological stress on the circulation. A case of rheumatic valvular heart disease with severe mitral stenosis in atrial fibrillation is discussed here in which analgesia with intrathecal fentanyl proved beneficial given during the advanced first stage of labour.
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Synopsis: Arthrogryposis multiplex congenita first described in 1905, is a rare congenital syndrome affecting 1 in 3000 births. It is characterized by multiple joint contractures found throughout the body and may be associated with multiple congenital anomalies like cleft palate, genitourinary defects, gastroschisis and cardiac defects. Hence appropriate evaluation should be done to rule out congenital abnormalities. Anaesthetic management may be complicated by difficult intravenous access, difficult positioning, difficult regional blockade and difficult airway. Anticipating difficulties and keeping alternate arrangements and preparation is required.
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Synopsis: The survival of children with congenital heart disease into adulthood has increased. These patients may require primary cardiac surgical repair, repair after prior palliation, revision of repair for residual lesion, or non-cardiac surgery. Preoperative cardiac evaluation consists of review of laboratory data, echocardiography, cardiac MRI, CT, cardiopulmonary exercise testing, arrhythmia monitoring, and cardiac catheterization. Perioperative complications are more frequently seen in high-risk patients i.e. those with pulmonary hypertension, cyanosis, heart failure, and poor general health. Guidelines for the management of patients with grown up congenital heart (GUCH) diseases suggest that such patients are best treated in dedicated tertiary care centres by a multidisciplinary team, knowledgeable about the anatomy and pathophysiology of the lesion.
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Synopsis: Anaesthesiologists very often face the challenging task of providing anaesthesia to patients on oral anticoagulant therapy, for elective and emergency surgeries. Rapid reversal of anticoagulation for emergency surgery can be achieved by replacement of coagulation factors with fresh frozen plasma or prothrombin complex concentrate and simultaneous administration of vitamin K for sustained reversal. The present case report of a 26 year female, on warfarin for thromboprophylaxis, scheduled for laparotomy, is followed by a brief discussion on anticoagulation reversal and anaesthesia.
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Synopsis: Vallecular Cysts (VC) are laryngeal cysts found most frequently at true vocal cords followed by epiglottis and vallecula, which develops due to obstruction of the submucosal gland. In children, they present with stridor, respiratory distress, feeding difficulty, failure to thrive or as an incidental finding on laryngoscopy. The anaesthesiologist can face the risk of obstructed breathing during mask holding, obscured laryngeal view, loss of airway, rupture of cyst and potential aspiration of cyst contents. Various techniques of airway management have been described in literature. We report a series of three cases with VC where we managed the airway successfully. We also discuss the relevant literature review.
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Synopsis: Primary hyperparathyroidism is a rare endocrinal disorder of excess production of parathormone. A wide array of presenting symptoms may occur from parathormone induced hypercalcaemia leading to nephrolithiasis, osteoporosis, muscle weakness and cardiac arrhythmias. We present a case of young female who presented with non union of an operated fracture femur and generalized bony pains and frequent complaints of vomiting, polyuria and polydipsia. She was diagnosed to have primary hyperparathyroidism with hypercalcaemia and underwent parathyroidectomy. The potential perioperative problems and anaesthetic concerns are discussed.
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Synopsis: Gestational Trophoblastic Disease (GTD) is a spectrum of tumours with a wide range of biologic behaviour and potential for metastases, which were often fatal in the past. However, with better understanding of patho-physiology in the last few years, most women can now be cured. A Hydatidiform Mole (or Molar Pregnancy) is a benign Gestational Trophoblastic Disease that originates from the placenta. Treatment consists of vacuum evacuation but rarely hysterectomy may be required. Anaesthetic management is often complicated by the associated systemic derangements.
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Synopsis: Scleroderma (progressive systemic sclerosis) is a multisystem disease involving the skin, airway, musculoskeletal, gastrointestinal, pulmonary, renal and cardiac systems that can pose a significant challenge for the anaesthetist. The multisystem involvement of scleroderma can impact on every aspect of anaesthetic care especially airway management. There are no specific contraindications to the use of any type of anaesthesia, although the selection must be guided by identification of organ dysfunction. The anaesthetist must be aware of the organs involved, the severity of the disease and the associated anaesthetic considerations and potential risks in order to safely & skilfully manage the patient with scleroderma. We hereby present a case report of a patient with scleroderma for emergency orbital decompression because of orbital cellulitis.
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Synopsis: A 15yr old patient with diagnosis of frontal gliosis having refractory seizures, on treatment with antiepileptics was admitted for cortical stimulation guided removal of epileptic foci. The craniotomy was done and a 32 grid subdural electrode was placed to identify the ictal onset zone with cortical stimulation to identify the functional areas. The patient received the relaxant for intubation after which the mapping and further stimulation was done with continuous infusion of dexmedetomidine. After the surgery the pre-resection evaluation was done for the epileptic foci and after two days the patient was again taken for surgery and the corresponding foci was resected.
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Synopsis: Conjoined twins are rarely encountered in the clinical practice of the anaesthetist and only a few cases are reported in the literature. We present the case of one and half month old male pygopagus conjoined twins who were joined together dorsally in lower lumbar and sacral region and shared a single thecal sac for separation surgery.
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Synopsis: Central venous catheter (CVC) hub fracture is a rare complication of central venous cannulation. We report a case where catheter hub fracture was detected immediately after CVC insertion. Causes of catheter hub fracture and its complications are discussed.
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Synopsis: Atrial Fibrillation is commonly associated with Mitral Valve Disease. Valve replacement, associated with surgical correction of atrial fibrillation, is considered as a definitive cure for such condition. In this article, anaesthesia management of four cases is discussed where AF was surgically treated using Ultrasound energy. Patients were diagnosed cases of Mitral Stenosis and/or Regurgitation. Procedure for ablation of AF was done after midline sternotomy on beating heart followed by Mitral valve replacement on Cardio-Pulmonary bypass.
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Synopsis: A 60 year-old-male with inferoposterior ST-elevation myocardial infarction developed reperfusion induced Bezold Jarisch Reflex (BJR) during angioplasty with profound bradycardia and hypotension. This report focuses on BJR and cough-CPR specific to interventional cardiology practice.
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Synopsis: This case report describes the successful perioperative management of a 27 years primi gravida female with Limb girdle muscular dystrophy (LGMD) with peripheral neuropathy having PIH (pregnancy induced hypertension) posted for elective caesarean. Muscle biopsy was consistent with End Stage Muscle Disease. Electroneuromyography (ENMG) was suggestive of sensory motor neuropathy involving lower limbs and having primary muscle disease. She was euthyroid with normal cardiac functions. The surgery underwent uneventfully under Epidural Anaesthesia, and she was shifted to room after 24 hours observation in the Surgical ICU.
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Synopsis: This case report describes airway management of a patient of post burn neck contracture with fixed flexion deformity and restricted mouth opening. Attempt to intubate the patient with fiberoptic bronchoscope failed so the neck contracture was released under tumescent anaesthesia. The patient was then intubated with the help of stylet.
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Synopsis: Hydatid disease is quite common in temperate climate like in India. The most common organs involved are liver and lung. We report a child in whom three major organs lungs (both), liver and spleen were involved which is quite a rare occurrence. He underwent cyst excision through simultaneous sternotomy and laparotomy.
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Synopsis: Super Vasmol 33 is a hair dye commonly used as suicidal poisoning in India. Paraphenylene Diamine (PPD) is a major component of the hair dye which when ingested in a dose-dependent manner results in severe cervicofacial oedema causing airway obstruction. Endotracheal intubation in early stages of oedema can avoid the need for tracheotomy.
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Synopsis: A 17 years old primigravida with pre-eclamptic toxaemia, operated for caesarean became unconscious postoperatively. MRI suggested PRES (Posterior Reversible Encephalopathy Syndrome) with poor prognosis.
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Synopsis: A mass in the neck could be associated with diifficult intubation, difficult mask ventilation, or both. We are reporting a case of lipoma of neck excision, with difficult airway, successfully managed by superficial cervical plexus nerve block.
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Synopsis: This case describes an unintentional interpleural placement of an attempted thoracic epidural catheter for a subtotal oesophagectomy. The interpleural catheter was left in situ and effectively used for post operative pain relief.
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Synopsis: Peripartum cardiomyopathy (PPCM) is a rare but life threatening condition and anaesthetic management of a patient with PPCM for caesarean section is often a major challenge. There is a growing literature suggesting that low dose CSE preserves the maternal hemodynamics and hence may be a suitable regional anaesthesia technique for CS in high risk obstetric patients with cardiac disease.
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Synopsis: Boric acid is commonly used as pesticide, disinfectant and wood preservative. Acute boron poisoning may manifest with vomiting, diarrhea, abdominal pain, headache, altered sensorium, seizure etc. Treatment of acute boron poisoning is conservative, no specific antidote is available.
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Synopsis: A 75 years old hypertensive male patient with diagnosis of parkinsonism with movement disorder was admitted for radiofrequency ablation of globus pallidus and subthalamic neuclei. The procedure was done under conscious sedation using Dexmedetomidine infusion, where in the patient was frequently asked to respond to various commands while undergoing the surgery.
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Synopsis: Laryngeal fracture can occur following direct trauma to the neck region and may lead to potential life-threatening airway emergency. The author presents the successful management of a typical "clothesline" type injury.
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Synopsis: Palatal swelling is a rare condition presenting with a difficult airway or airway obstruction. These swellings can range from epulis, encephalocoele, dermoid cysts or teratoma to benign and malignant neoplasms. Airway management of such patients, especially in children is difficult and challenging.
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Synopsis: It is surprising that in the 21st century clinicians still associate levels of Bicarbonate with acidosis or alkalosis and believe that low Bicarbonate 'is in itself the cause of acidosis and vice versa'. Its levels are used to 'diagnose' acidosis or alkalosis. These 'traditional' methods of acid-base interpretation have various limitations. The Stewart approach allows for proper quantification of the disorder as well as pointing towards appropriate therapeutic options.
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Synopsis: A 46-year old male, a known case of IHD, hypertension with dilated cardiomyopathy, post CABG and double valves replacement, peripheral vascular disease with past history of failed aorto-femoral bypass, DM with nephropathy and neuropathy, Budd Chiari syndrome with significant ascites, bed ridden with multiple bed sores was admitted for huge irreducible obstructed incisional hernia. The surgery - abdominal double layer repair was successfully conducted under Bilateral Transversus Abdominis Plane (TAP) block.
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Synopsis: Xenon is a colourles, odourles, tasteless noble gas and has anaesthetic properties under normobaric conditions. As an anaesthetic, xenon's safety and efficacy profile is unmatched and its xenon's relative high cost which has precluded its widespread clinical use.
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Synopsis: Reinforced tubes are routinely used in Oro-maxillary surgeries. In spite of its advantages, any intra-operative deformity in reinforced tubes can at times lead to occlusion of a patent airway. To change this tube intraoperatively with distorted oral anatomy could be an anaesthetic challenge.
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Synopsis: Patients with cardiac interventions have been on the rise and anaesthesiologists are now likely to encounter more patients who have been treated with angioplasty and stent. Patients with Coronary Stents are at increased risk of major perioperative cardiovascular events.
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Synopsis: Branchial-oto-renal syndrome (BOR) is a dominant genetic condition which can result in hearing loss, ear pits, branchial cysts or fistulae and renal anomalies. Palatal and upper airway abnormalities may make intubation difficult.
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Synopsis: Achondroplasia is the most common form of dwarfism. Underdevelopment and premature ossification of bones result in characteristic craniofacial and spinal abnormalities resulting in difficulties in both - airway management and in regional anaesthesia. In this case report, we describe the anesthetic management of an achondroplastic dwarf for caesarean section.
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Synopsis: Congenital Tracheoesophageal fistula is an abnormal communication between the trachea and the esophagus with or without esophageal atresia. We report a patient who was a preterm, low birth weight neonate with multiple congenital malformations like hypoplasia of the right lung and right pulmonary artery, dextroposition of the heart, patent ductus arteriosus and atrial septal defect. Interestingly, despite a normally draining right pulmonary vein, his chest X-ray showed "Scimitar sign".
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Synopsis: Multiple sclerosis (MS) is an uncommon autoimmune demyelinating disease of central nervous system characterized by periodic attacks of varied neurological symptoms eventually progressing to fixed neurological deficits and disability. The symptoms may get worsen with surgery, anaesthesia, emotional instability and increased body temperature.
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Synopsis: A two years old child developed pneumomediastinum in the postoperative period after foreign body removel from oesophagus. He was managed conservatively without a thoracostomy tube.
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Synopsis: Epidural abscess is a potentially life-threatening disease which can lead to medical-surgical emergency. Idiopathic spinal epidural abscess (SEA) with atypical manifestations is extremely rare. We describe such a case which led to severe neurological compromise and was not associated with any known risk factors.
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Synopsis: A 55yr old hypertensive female patient with diagnosis of left sided diaphragmatic eventration was admitted for laproscopic repair. Postoperatively she was put on elective ventilation for next 18hrs. The patient complained of phonation difficulty and cough with expectoration following extubation. The patient was found to have bilateral adductor cord palsy on direct laryngoscopy.
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Synopsis: Ankylosing Spondylitis (AS) is a chronic inflammatory rheumatic disease primarily affecting the axial joints manifesting as stiffnesss of the spine. Patient with ankylosing spondylitis is a challenge to anaesthesiologists in terms of airway management and neuraxial blocks. Modified paramedian approach (Taylor approach) of spinal anaesthesia can be used as an alternative to technically difficult cases in patients undergoing lower limb surgeries.
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Synopsis: The use of hypothermia for therapeutic purposes is an established technique in children with complex congenital cardiac lesions and in adults for aortic arch reconstruction. Deep hypothermia decreases brain metabolism and oxygen requirement, whereas circulatory arrest provide bloodless surgical field.
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Synopsis: We report a case a 11 year old girl who was referred to the hospital with destroyed lung due to an unusual foreign body, the patients own deciduous tooth. After pneumonectomy, the foreign body was found in the contra lateral lung with nearly catastrophic consequences. The aspects of lung isolation in pediatric age groups, the implications of a foreign object in the residual lung and the attempts to recover it are discussed.
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Synopsis: Restrictive cardiomyopathy is a rare heart muscle disease resulting in impaired ventricular filling, low cardiac output and a propensity for development of heart failure with minimal fluid overload. Anaesthetizing such patients presents considerable challenges. We present the Anaesthetic management of a case of Idiopathic restrictive cardiomyopathy undergoing Laparoscopic cholecystectomy.
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Synopsis: Any major cardiac mass, by virtue of their anatomic location, is capable of producing a myriad of cardiac, embolic and systemic symptoms, sometimes with fatal consequences. We report a case of 37 year old patient with anterior wall MI with EF of 40%, and a large linear mass attached to apex in the left ventricular cavity. Coronary artery bypass grafting with left ventricular mass excision was done.
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Synopsis: We present a case report where thoracic paravertebral block and brachial plexus block were used in a sick elderly patient with poor cardiopulmonary reserve, to cover a post traumatic raw area of the upper limb by raising flap from lateral abdominal wall. The residual raw area of abdomen was then covered with the split skin graft taken from thigh.
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Synopsis: We report a case of interscalene brachial plexus block supplemented with superficial cervical plexus block in a patient with dilated cardiomyopathy with ejection fraction of 24% scheduled for surgery of fracture mid-shaft of clavicle.
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Synopsis: Choanal atresia is an uncommon congenital anomaly of nose caused by failure of resorption of the bucco-pharyngeal membrane during embryonic development. Bilateral choanal atresia presents with severe respiratory distress and cyanosis at birth and is alleviated by crying. Surgery is the definitive treatment. We discuss successful management of a neonate with bilateral choanal atresia.
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Synopsis: This case report is an interesting presentation of renal cell carcinoma with involvement of the right atrium. Radical Nephrectomy was done with right atrial thrombectomy under Cardiopulmonary Bypass. In this report we have tried to enumerate the anaesthetic implications of renal cell carcinoma with cavoatrial thrombus and its management during surgical resection.
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Synopsis: Dilated cardiomyopathy (DCM) is characterized by dilatation and impaired systolic function of one or both ventricles. Malignant arrhythmias are the most common cause of death in DCM. Around 50% of cases of non-ischemic dilated cardiomyopathy are idiopathic. Anaesthetic management of these patients is quite challenging. The anaesthesiologist must have the knowledge of its pathophysiology, clinical features, diagnostic evaluations and the treatment modalities. This is a report of successful anaesthetic management of a patient with severe DCM just recovered from cardiac failure with septic foci undergoing splenectomy under general anaesthesia
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Synopsis: Angioedema is a rare event which can lead to a life threatening airway emergency in a very short time and this necessitates urgent intervention. We present a case of potentially life-threatening postoperative swelling of the tongue, oro-pharynx and submandibular area that developed in a patient after giving second dose of antibiotic.
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Synopsis: Hypercalcemia may prove to be deadly if decompensation occurs from a chronic state and if is compounded by fluid depletion then the situation could possibly get out of hand. We present a case highlighting the above mentioned statement in a case of emergency parathyroidectomy where the wide variations in blood pressure caused due to insufficient patient preparation led to very unstable intraoperative course
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Synopsis: Left Atrial Myxomas present as a wide variety of symptoms. We describe one such case which initially presented with hemiparesis and was diagnosed as cerebral infarction. On retrospective work up, the main cause was found to be a left atrial myxoma. The myxoma has embolised to give rise to cerebral infarction. The LA myxoma was then successfully operated under general anaesthesia and Cardiopulmonary bypass.
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Synopsis: Fluid resuscitation is the most critical intervention during initial phase of management in septic patients. We used some simple non invasive method which can be followed easily for estimation of fluid status and response to fluid therapy. We used ultrasonography of IVC & Echocardiography evaluation of velocity time integral through aortic valve flow to guide fluid administration as surrogate markers of CVP. Periodic estimation of lactate concentration to assess tissue oxygenation with aim of lactate reversal of 10% per hour was used in place of central venous oxygen saturation.
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Synopsis: The neurofibromatosis is an autosomal dominant disease that has widespread effects on ectodermal and mesodermal tissue. The commonest member of the group is neurofibromatosis type 1 (NF1) which varies in severity but which can affect all physiological systems.
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Synopsis: This is a case report of 40 year old patient, posted for dacryocystorhinostomy (DCR), who suffered ventricular tachycardia and pulmonary oedema, after sub mucosal intranasal application of epinephrine soaked pellets under general anesthesia.
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Synopsis: A 3-year-old girl with Pierre Robin Syndrome, having complaints of respiratory distress in supine position and disturbance during sleep due to airway obstruction, was scheduled for adenoiodectomy. Gas induction without muscle relaxation was done and intubation was successful on fourth attempt. Five teeth were avulsed & one tooth was lodged in right main bronchus.
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Synopsis: The world?s population is aging with proportionately larger increase at the upper extremes of age. Elderly patients not only exhibit age related renal changes and dysfunction, they also suffer from multiple comorbidities. Age related morphological changes in the kidney, functional alterations and accompanying comorbidities make elderly more vulnerable to AKI. Early diagnosis of AKI in these patients is vital as is its prevention. Awareness of the possibility of development of AKI, identifying patients at risk and its prompt recognition are keys to anaesthesia and critical care management of elderly patients.
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Synopsis: Scoliosis is often associated with other congenital anomalies including cardiovascular. We report the successful management of two paediatric patients who presented with severe mitral regurgitation due to mitral valve prolapse and who also had scoliosis of their thoracic spine.
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Synopsis: Central venous thrombosis, although rare, is a recognized cause of puerperium stroke. We present a case of successfully managed sagittal sinus thrombosis (SST) developed in a parturient after Caesarean delivery under spinal anaesthesia.
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Synopsis: Although extremely rare, paraparesis can be a complication following spinal anaesthesia, in a patient with unrecognized spinal tumor. We describe a 45-year old female patient who underwent arthroscopy under spinal anesthesia and developed paraparesis in the postoperative period.
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Synopsis: We describe anaesthesia in a child suffering from Treacher Collins Syndrome (TCS) posted for craniofacial reconstruction by mandibular distraction with external fixator
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Synopsis: Adrenocortical tumors are rare in children. An 8 months, 8kg child with Cushingoid features with persistent severe hypertension was admitted in pediatric surgery ward.Blood pressure was controlled by ACE inhibitors & calcium channel blockers. Diagnosis of adrenal tumor was confirmed by abdominal CT Scan. We report the management of this patient posted for laparoscopy adrenalectomy
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Synopsis: Scimitar syndrome, a rare congenital cardiopulmonary anomaly, consists of partial anomalous pulmonary venous connection of the right lung to the inferior vena cava, right lung hypoplasia and anomalous systemic arterial supply to the right lung. A 5 month old child with scimitar syndrome and pulmonary hypertension, underwent stenting of anomalous pulmonary vein, and coil embolization of systemic collateral artery to the right lung. Surgical ligation of large patent ductus arteriosus was performed to further decrease pulmonary artery pressure. Child was discharged after a successful combined therapy of surgical and transcatheter intervention.
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Synopsis: Pheochromocytoma is a rare catecholamine secreting tumour arising from chromaffin cells in the adrenal medulla or in the extra adrenal sites. They may produce receptor mediated effect on myocardium causing pressure induced cardiomyopathy leading to left ventricle dilatation, hypokinesia and eventually cardiac failure. Anaesthetic management of a patient with pheochromocytoma and dilated cardiomyopathy posted for open adrenalectomy using proseal laryngeal mask is reported.
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Synopsis: A 45 year male operated for meningioma developed breathlessness on 6th day after surgery and was found to have pulmonary embolism due to DVT in right leg. Despite of being on anticoagulants, patient developed thrombosis in left leg too. Fortunately we had placed a Greenfield filter in inferior vena cava; else a single embolus could be fatal. Follow up of patient for 6 months showed resolution of thrombus with no filter related complications.
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Synopsis: Laryngeal Mask Airway is used for airway management in anaesthesia and in emergency medicine. Aspiration of gastric contents with LMA occurs in 2 per 10000 patients. It is almost similar to tracheal intubation in elective patients with the incidence of 1.25 per 10000 patients
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Synopsis: Recombinant activated factor VII (rFVIIa) enhances haemostasis in individuals, with its predominant action limited to areas of injury, apparently without systemic activation of the coagulation cascade. We report here the successful use of rFVIIa in a patient with a history of polytrauma.
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Synopsis: This is a case report of a 19 year young male presented with swelling and blackening of right upper limb and abdominal pain since 10 days. He was a known case of protein C and protein S deficiency on warfarin therapy, with deranged coagulation parameters posted for amputation fingers in emergency
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Synopsis: Porphyrias are inherited disorders, each involving a specific enzyme in heme biosynthetic pathways. Acute intermittent porphyria, one of the hepatic porphyria is the most severe form of the disease, with gastrointestinal and neuropsychiatric manifestations. Proper management will dramatically improve the outcome in this otherwise debilitating and potentially life-threatening disease.
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Synopsis: Neuroleptic Malignant Syndrome (NMS) is a life threatening, neurological disorder most often caused by an adverse reaction to neuroleptic or anti psychotic drugs. A case of Neuroleptic Malignant Syndrome who was posted for an incidental surgery and its anesthetic management is reported.
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Synopsis: Annually about 6 million articles related to the field of medicine are published worldwide. However, only 15% of these are of any use. Average quality score of randomized controlled trials (RCTs) is <50%.
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Synopsis: Myasthenia gravis is an immunologic disorder characterised by polyclonal antibodies directed against nicotinic acetylcholine receptors at postneuromuscular junction. This case describes perioperative management of a patient suffering facial trauma with underlying myasthenia gravis with thymic mass
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Synopsis: Advances in preoperative risk assessment, anesthetic techniques and medical therapy have served to decrease the frequency of cardiovascular complications associated with noncadiac surgery. Despite this, cardiovascular complications are the most treatable adverse consequences of noncardiac surgery. Detailed evaluation are therefore preliminary and the most important step in patient care. Perioperative management of a case is discussed here, in which, the occurrence of arrhythmias was anticipated but not expected.
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Synopsis: Accidental hypermagnesemia is a common and often missed complication during treatment in a postpartum eclamptic patient. As symptomatic hypermagnesemia leads to neuromuscular junction blockade, neuromuscular junction monitoring serves the purpose of vigilant monitoring and prevents iatrogenic overdose of magnesium.
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Synopsis: WPW syndrome commonly presents with supraventricular tachyarrhythmia. This case presented with ventricular tachycardia without any known illness and after revival it was diagnosed as having WPW syndrome.
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Synopsis: Anaesthetizing a patient who has co-existing lung disease, difficult airway and obesity is a major anesthetic challenge. This case report describes the successful anesthetic management of such a patient under segmental epidural anaesthesia who underwent laparotomy for excision of a large mesenteric cyst
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Synopsis: Chronic perineal pain is a debilitating condition with a significant impact on the quality of life. Often, the pain localised to the perineum can be a warning sign of acute or chronic tissue injury to the abdominal and pelvic organs or structures,with no identifiable pathology. The management of a case of perineal pain with combination of treatment modalities is presented.
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Synopsis: Continuation of antihypertensives preoperatively and their influence on intraoperative hemodynamics is a big concern among anesthesiologists. The Peri Operative Ischaemia Study Evaluation (POISE) trial showed a significant reduction of myocardial infarction, need for coronary revascularization and the incidence of atrial fibrillation with metoprolol started 2-4 hours prior to surgery but a significant increase in total mortality and clinically significant hypotension and bradycardia. This is a case report of intraoperative severe bradycardia in a young patient on recently started beta blocker.
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Synopsis: Malposition of central venous catheter is well known technical complication. A case with unusual placement of right subclavian vein catheter into contralateral subclavian vein, when inserted through infraclavicular approach, is reported.
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Synopsis: Thalassemias are genetically determined heterogeneous group of disorders with reduced production of globin. We report anaesthetic management of a case of ß-Thalassemia syndrome for LSCS.
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Synopsis: Brachial plexus block is a useful anaesthetic technique for the upper limb surgery using Bupivacaine hydrochloride as anaesthetic agent for the block. A case of extraordinary prolonged block after administration of 0.375 % plain bupivacaine by the supraclavicular route is reported.
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Synopsis: Drug errors are common in Anaesthetic practice. It may be either syringe swap, ampoule swap, wrong drug errors, and wrong dose errors. Most anaesthetists experience at least one drug error in their career. We discuss a case of wrong dose of Morphine injected intrathecally
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Synopsis: The usage of rubber and its products are not uncommon in various walks of life. A continuous exposure or contact may sensitize the human body, causing reactions from mild to fatal. Despite the availability of the literature, medical personnel are still unaware of the implications of the use of latex materials.
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Synopsis: Hypocalcemia is a known complication following total thyroidectomy which usually manifests about 36 hours postoperatively. We describe the rare manifestation of hypocalcemia as refractory hypotension and its successful management following total thyroidectomy
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Synopsis: We present a case of massive pheochromocytoma planned for surgical resection. The case was taken up for surgery after preoperative catecholamine blockade and intravascular volume resuscitation. The major challenge was profound hypotension after tumour resection which was refractory to catecholamine therapy but responded successfully to the application of vasopressin therapy
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Synopsis: Peripartum cardiomyopathy (PPCM) is an uncommon but life threatening disease that affects women in the last month of pregnancy or within the first five months after delivery. Very few Indian case reports are available. However, it is essential for the practitioner dealing with such population to have a high degree of clinical suspicion for early diagnosis and management. Echocardiography is used to diagnose this entity and monitor the therapy.
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Synopsis: Scorpion sting is a major health problem in underdeveloped countries like India. It may present with mild local pain to severe systemic symptoms and need of I.C.U. care and mechanical ventilation.Scorpion envenomation presents with increased systemic vascular resistance and hypertension, but in cases of severe envenomation it may present with hypotension and pulmonary oedema
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Synopsis: Cardiogenic shock continues to be the leading cause of death in patients of acute myocardial infarction (AMI) despite improvement in coronary care. Conventional medical therapy is associated with an 80-90% mortality rate. The presence of multi organ failure makes the prognosis worse
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Synopsis: Laparoscopy which was once confined to gynaecologists has now become a technique of choice for almost all abdominal surgeries and even demanded by majority of patients. Key-hole surgery has become the norm today. Endoscopic procedures help with visualization and manipulations of all organs including thoracoscopy, neuro and spine endoscopy. After the first diagnostic laparoscopy in 1910 by Hans Christian Jacobaeus, we have come a long way that there is hardly any contraindication for laparoscopic surgery. In 1999 Lobe et al. reported the first repair of oesophageal atresia entirely thoracoscopically, this was accomplished on a 2-3 kg neonate.
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Synopsis: Gastric tube placement for enteral feeding and gastric drainage is very commonly performed procedure in the ICU. The placement may sometimes be difficult or impossible in intubated and paralyzed patients due to impaction and/or coiling in the mouth. The recognition of the site/s of impaction and methods to overcome them have been described variously in literature with different degrees of success. Knowledge and practice of these alternative methods can be sometimes of great help particularly while facing difficulty
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Synopsis: One of the objectives of modern anaesthesia is to ensure adequate depth of anaesthesia to prevent awareness without inadvertently overloading the patients with potent drugs.
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Synopsis: Acute fatty liver of pregnancy, characterized by microvesicular fatty infiltration of hepatocytes, is a disorder which is unique to human pregnancy. We describe the successful intensive care management of a parturient who was admitted with the signs and symptoms of acute fatty liver of pregnancy associated with preeclampsia
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Synopsis: Cardiac herniation is one of the rare conditions associated with a high mortality rate. We describe a case report of cardiac herniation with cardiogenic shock and right heart failure after left pneumonectomy in a young patient who had been treated for carcinoma breast [right side] two years back.
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Synopsis: Middle ear microsurgery is one of the several types of surgeries where bloodless operative field is desired, and is usually achieved through deliberate hypotension
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Synopsis: Moyamoya disease or syndrome is an unusual form of chronic, progressive occlusive cerebrovascular disorder, first described in Japan and now reported from all over the world that usually presents as transient, recurrent hemispheric or ischaemic attacks ? strokes, mostly in children, during the first decade of life
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Synopsis: Managing a patient with Parkinson's disease presenting for anaesthesia is relatively rare and can be challenging, especially in the developing world. A patient with Parkinson's disease who had total abdominal hysterectomy and salpingoophorectomy is presented. The anaesthetic management options are discussed
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Synopsis: Postoperative lung complications(PPC) may occur in up to 20% in emergency surgeries. We present a case of 73 year old male who presented with an entire left lung collapse in the postoperative period after repair of duodenal perforation despite adequate analgesia,aggressive chest physiotherapy and deep breathing exercises
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Synopsis: For nearly 3,000 years, it has been recognized that apparently healthy infants could die suddenly and unexpectedly during their sleep .Throughout most of history, it was believed that these infants somehow suffocated, implying that these babies died a respiratory death. Nearly one infant per thousand live births continues to die suddenly and unexpectedly from sudden infant death syndrome (SIDS)
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Synopsis: COPD is a common respiratory problem amongst the masses and when these patients present for a surgical procedure, they may require high tidal volumes, generating high inspiratory pressures during one lung ventilation with an increased probability of lung injury,particularly in patients with lung carcinoma resulting in a bad prognosis
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Synopsis: Carotid body tumours (CBTs) or chemodectoma are rare non- chromaffin paragangliomas arising from the chemoreceptor cells found at the carotid bifurcation. About 1000 cases have been reported in the literature
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Synopsis: A known case of testicular tumour underwent bilateral orchiectomy under spinal anaesthesia. He developed headache and altered sensorium postoperatively. CT scan head showed secondaries in the brain with intra-cerebral bleed
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Synopsis: A five year old female with complex congenital heart disease developed gastrointestinal hemorrhage following VSD closure, RV-PA conduit, ligation of aneurysmal right MAPCA and clipping of modified pott-shunt. All conservative measures from cold saline lavage to left gastric artery embolisation were tried but none was successful
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Synopsis: Conn's syndrome or primary hyperaldosteronism is a disease of the adrenal gland involving excess production of aldosterone from zona glomerulosa. It can also be caused by adrenal tumours or an enlarged gland due to hyperplasia.
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Synopsis: Undiagnosed cerebral and spinal meningiomas can give rise to grave post anaesthetic and postoperative complications. Here we present two such cases in which paraparesis after a spinal anaesthetic occurred in one case and medullary coning resulting in respiratory failure and death in the second case.
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Synopsis: Patients of Ankylosing Spondylitis (AS) are difficult to intubate as a result of cervical spine rigidity; leading to inadequate extension of head and nonalignment of oral/pharyngeal and laryngeal planes. They are usually managed along the awake limb of difficult airway algorithm.
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Synopsis: Morbid obesity is a problem not only for the person himself but also to the whole treating medical team. The problem associated with bariatric surgery for these morbid persons are multifactorial even if it is an elective routine procedure with other wise healthy lungs.
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Synopsis: Anaesthesia for the deaf-mute could be a taxing experience for the anaesthetist due to ineffective communication. The Bispectral index (BIS) monitor has been validated to measure the hypnotic component of anaesthesia. We report the use of the BIS monitor in the anaesthetic management of a deaf-mute undergoing general anaesthesia for myomectomy.
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Synopsis: Airway obstruction is the primary mechanical emergency of respiratory system in patients with malignancy. The airway patency relies on a spontaneously breathing technique. We report airway management in a patient with Acute Lymphoblastic Leukemia (ALL) that was complicated by spontaneous bleeding in oro-pharyngeal tissues.
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Synopsis: Pain, either acute or chronic, is defined as an unpleasant sensory and emotional experience that is associated with the potential for real acute or ongoing tissue damage. It is an extremely complex process that involves interrelated neurotransmitter and neuromodulator systems in ascending and descending spinal pathways and supraspinal sites.
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Synopsis: We report the anaesthetic management of a female patient with Spinal Muscular Atrophy (SMA) presented for laparoscopic cholecystectomy. In order to avoid prolonged recovery; we chose to use total intravenous anaesthesia (TIVA) with propofol and remifentanil. No neuromuscular blocking agent was used.
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Synopsis: We describe a case of a young woman, operated for perforation peritonitis who was admitted postoperatively in ICU for deranged consciousness level, hypotension and inadequate respiration. She developed symmetrical peripheral gangrene (SPG) supposedly due to multifactorial association of shock, septicemia, DIC and Dopamine.
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Synopsis: Patient presenting for surgical procedures of the spine are a diverse population undergoing a wide variety of operative procedures and present diverse challenge to the anesthesiologists. The anesthetic management depends on the operative site; spine pathology; surgical approach and the anesthesiologists experience & expertise.
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Synopsis: One of the natures gift to mankind is rubber. The usage of rubber and its products are of daily occurrence in modern life. It is not uncommon to have a regular daily exposure to rubber products from birth in all walks of life.
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Synopsis: Brain tumours constitute the majority of neurosurgical conditions that present for elective operations. The nature of the lesions varies from benign tumours like meningiomas and schwannomas to highly malignant tumours like glioblatomas. About 80% of the tumors are located in the supratentorial compartment and about 20% in the posterior fossa.
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Synopsis: Science and technology have offered medical therapies the potential to treat serious illnesses where once the medical professionals could only provide comfort. Physicians feel the need to aggressively fight against illness and death. Many physicians and health care workers have come to believe that they have failed if they do not save the patient from death. We frequently attempt to prolong life at all cost. Unfortunately we often only succeed in prolonging the dying process.
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Synopsis: The points of thought are why common people divert to use the Ayurvedic; Chinese and other herbal medicines? Though it is used all over the world; in India, its use is much more because of their easy accessibility; no expert consultation required, are considered safe to use and also because primary health care services fall short of peoples? need both in qualitative and quantitative terms. We should make all these easily marketed ayurvedic, and other herbal medicines FDA approved and increase public awareness about pros and cons of their uses. The common belief that anything natural is safe is not correct.
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Synopsis: Background: Opitz-Frias syndrome also known as hypertelorism-hypospadias syndrome or G-syndrome was first reported by Opitz & co-workers in 1969. Syndrome is inherited as X-linked or autosomal dominant trait with male sex limitation. This is a developmental defect with multiple malformations. Interestingly, the birth defects are the defects of midline structures, i.e. telecanthus; hypospadias; congenital heart defects; laryngotracheoesophageal (LTE) defects; cleft lip and palate etc.
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Synopsis: Peripartum cardiomyopathy is a rare form of heart failure of unknown etiology occurring during pregnancy or within five months of postpartum period1-3; with a potential for fatal outcome in about 20 percent. It has an incidence of 1 in 30004;5 patients and 1 in 30,000 deliveries6. The majority recover partially or completely, with some, requiring heart transplant. Although the advocacy for these patients is not to conceive, because of an increased risk of recurrence of cardiomyopathy with worsening signs and symptoms; it is not uncommon for these women to have subsequent pregnancies in societies that do not encourage family planning measures. These women with subsequent pregnancies do pose a challenge to their anesthetic management.
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Synopsis: A 10 year old girl presented with diminished vision in both eyes for 1.5 months & was diagnosed to be a case of bilateral spherophakia with right subluxated lens. Patient had history of convulsions associated with fever at the age of one year whereupon there was evidence of mental retardation .On further investigation, patient was found to have homocystinuria as confirmed by urine chromatography.
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Synopsis: Antibiotic prophylaxis before surgical procedures is commonly practiced. Hypersensitivity reactions to antibacterial drugs are most feared complications; which have varying grades of presentation. Skin testing are commonly applied to detect allergy but that can have false negatives. We report a case of severe anaphylaxis leading ultimately to fatal outcome after negative skin testing. Prior history of allergy of any kind and exposure to ceftriaxone was excluded. Even the best antishock management could not help. This observation clearly demonstrates the limit of screening tests for the diagnosis of sensitization against drugs.
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Synopsis: The most important role of an anaesthetist in the conduct of general anaesthesia is endotracheal intubation and confirmation of its correct placement. Failure of this can happen and it mostly occurs due to misplacement; endobronchial intubations; disconnection; leaks; and obstruction either in the tube or in the circuit.
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Synopsis: Maternal oxygen supplementation during regional anaesthesia for caesarean section has been routinely practiced for many years. It was Crawford who advocated the ?use of maternal oxygen therapy until the time of delivery? in the 1984 edition of his book on obstetric anaesthesia. This opinion of Crawford established the practice of supplementing oxygen in all elective caesarean sections (1), the basic aim being to prevent maternal haemoglobin desaturation and improve maternal and neonatal oxygenation and overall neonatal outcome.
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Synopsis: It is a mode of renal replacement therapy for hemodynamically unstable ;fluid overloaded; catabolic septic patients and finds its application in management of acute renal failure especially in the critical care /intensive care unit setting. The popularity of ?slow continuous therapies? for the treatment of critically ill patients with renal failure is increasing. The techniques most commonly used are slow continuous hemodialysis and hemodiafiltration. Slow continuous hemofiltration and slow continuous ultrafiltration also are commonly used.
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Synopsis: A 45 years old male patient was diagnosed as a case of motor neuron disease. With in four years he became paralyzed and bed ridden. Due to severe respiratory tract infection, the patient developed respiratory failure and was placed on ventilator. Later on the infection was successfully treated but the patient could not be removed from the ventilator because of the paralysis of respiratory muscles. It was obvious that the patient would require life long ventilatory support so the same was arranged at the patient?s home and he was discharged from the hospital after nine months. Now, for the past six years the patient is on ventilatory support.
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Synopsis: Iontophoretic drug delivery is now an accepted method of drug therapy which is gaining wide popularity especially in the area of pain relief. This technique provides a means for regulated non-invasive systemic administration of minute amounts of drug transdermally which is especially useful in patients who require long-term medication as in chronic pain, diabetics, hypertensives, rheumatoids etc. It negates the need for needle sticks, the pain and anxiety involved and minimises the trauma and risks of infection associated with it. This mode of drug delivery is simple, versatile, effective, reliable and can be tailored for individual needs.
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Synopsis: Sweating is a physiological response of the body for thermal regulation influenced by the change in skin temperature (1) mediated by sympathetic nervous system. In about 1% of the population, the sympathetic nervous system is overactive, causing certain areas of the body to sweat at inappropriate times and beyond what is necessary to maintain thermal regulation. This disorder is known as primary hyperhidrosis (2). The definition of hyperhidrosis as excessive sweating is subjective. It is defined quantitatively as the production of more than 100 mg of sweat in 1 axilla over 5 minutes (3). Excessive sweating (hyperhydrosis) or its absence (anhydrosis) are distressing, often attributed to organic causes requiring investigation and treatment (4). Hyperhidrosis may be focal or generalized. Focal hyperhidrosis is most often essential, or idiopathic, and results from a neurogenic overactivity of the sweat glands in the affected area.
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Synopsis: Negative pressure ventilators (Tank and Cuirass ventilators) were the only non-invasive methods of assisting ventilation for many years mainly for ventilating large number of victims of Polio during their acute illness. In 1980s it was recognized that delivery of continuous positive airway pressure by close fitting nasal masks for treatment of obstructive sleep apnoea could also be used to deliver an intermittent positive pressure. This was followed by improvements in the interface and establishment of role of NIMV in patients of COPD. The use of NIMV has increased in last decade in various conditions to avoid complications of intubation.
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Synopsis: The ultimate goal of minimally invasive coronary artery bypass grafting is to perform the anastamosis entirely endoscopically. Significant technological advances have enabled the development of minimally invasive endoscopic operative techniques in a variety of disciplines. These procedures are ultimately aimed at reducing patient morbidity, length of hospital stay, and overall costs.
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Synopsis: A successful renal transplant in women of child bearing age is on an increase in recent years. A successful renal transplantation reverses the altered reproductive and sexual function of the recipient. The resumption of regular menstruation and ovulation correlate closely with the level of function achieved by the graft (1-3). These parturients present a unique challenge with their altered physiology and immunosuppression associated with the desire to have a normal child, to the obstetrician, the nephrologist and the anaesthesiologist. The anaesthesiologist is called to meet the challenges of the management at parturition for a successful outcome.
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Synopsis: Central nervous system (CNS) trauma is a significant cause of morbidity and mortality all over the world. In USA, each year, 500,000 patients with head injury are seen in the emergency department and of these more than 50,000 die from their injuries (1). Major cause of this menace is cerebral ischemia that ensues minutes to hours after the primary head injury. This is commonly known as secondary injury. Secondary brain lesions resulting from cerebral metabolic and hemodynamic reactions can be prevented by neurocritical care management. It must be initiated as early as possible, ideally in a prehospital setting.
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Synopsis: Obesity means excessive body fat. The term obese, derived from Latin word means fattened by eating. The amount of fat tissue may increased to such an extent that mental and physical health is affected and life expectancy is reduced.
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Synopsis: Tissue injury results in SIR, release of mediators leading to increase in vascular permeability and tissue edema. On top of this, a concurrent haemorrhage causes further reduction in intravenous volume. The initial fluid redistribution that occurs following trauma is related more to the degree of tissue trauma and ischemia than to blood loss per se. With mild hypovolemia, blood in the venous capacitance vessels is mobilised to ensure adequate venous return.
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Synopsis: India receives about 10 lakhs new cancer patients every year. As statistical data suggest approximately 60-80% patients, when they are diagnosed, are advanced cases and hence incurable. Often, their major symptom is moderate to severe pain. According to present estimates about 56% cancer patients in India require relief of symptoms (palliative care) at any given time, however, only 28% are provided some sort of palliative care before they die. There is an immediate need to address this issue at all levels. Clinicians should reassure patients and their families that most pain could be relieved safely & effectively. Clinicians should assess patients and provide optimal relief throughout the course of illness. Health professionals should be properly educated about pain and its management in the treatment plan and encourage patients to be active participants in pain management. State regulatory bodies should not hamper the supply and appropriate use of opioid analgesics for cancer pain.
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Synopsis: Alpha 2-adrenoceptor agonists are being increasingly used in anaesthesia and critical care as they not only decrease sympathetic tone and attenuate the stress responses to anesthesia and surgery; but also cause sedation and analgesia.
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Synopsis: Pain is among the most common symptom in cancer patients. It is estimated that 4 million cancer patients suffer pain globally and for most of these patients pain is not satisfactorily relieved. For over a decade; World Health Organization (WHO) has taken a lead in establishing a consensus for a scientifically valid method of relieving cancer pain that is relatively simple; inexpensive and easy to apply at community level; known as the WHO Three step Analgesic Ladder method.
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Synopsis: Since the first transesophageal echocardiography examination in 1975 using M-mode imaging with mechanical scanner contained in oil bag having limited control of direction; there have been a lot of modifications and technical advances in the equipment.
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Synopsis: According to UNAIDS/WHO estimates, 11 men, women and children around the world were infected per minute during 1998 (nearly six million). More than 95% of all HIV infected people now live in the developing world, which has likewise experienced 95%of all deaths to date from AIDS. In India, the first HIV positive case was reported in 1986.The magnitude of disease has been found to be varied in various parts of the country. Maharashtra accounts for close to 50% of reported HIV and AIDS cases in India. Tamil Nadu, Andhra Pradesh Karnataka and Manipur are the other hard hit states.
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Synopsis: Back pain is the second most frequent chronic pain problem, just after headache, as a reason for patients to seek medical help. Suffering from back pain ranges from transient discomfort to frank incapacitation. Approximately 80% of the adult population will suffer from pain related to the lower back during their lifetime. The Agency for Health Care Policy (AHCPR) document states that 90% of patients with acute back pain are better in about one month (spontaneous recovery), but more than half who recover from a first episode of acute pain will have another episode within a few years.
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Synopsis: In the last hundred years Continuous Spinal Anaesthesia (CSA) has been in and out of anaesthesiology practice at least three times, and of late the fourth resurgence is around the corner. The practice of CSA has remained controversial mainly because of neurological complications associated with it. HP Dean1 described this technique initially in 1906, about seven years after the first reports of spinal anaesthesia. However it was not accepted into practice till. WT Lennin2 rediscovered it in 1940 and described the procedure by using a special malleable needle for this purpose.
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Synopsis: Patients with cardiac disease presenting for noncardiac surgery are at increased risk of intraoperative complications such as myocardial infarction (MI); cardiac arrhythmias; pulmonary insufficiency, and death. It is well established that the number of patients with cardiac disease presenting for anaesthesia and surgery are on the increase.
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Synopsis: Cancer is an increasing health problem. Each year, nine million people develop cancer, and by the year 2030, this figure is expected to have risen to 15 million. Two thirds of these cases of cancer will be in the developing countries, which have only 5% of the global cancer control resources. Cancer pain relief was recognized as major public health problem in the mid 1980s. Pain is reported at diagnosis in 20-50% of cancer patients, and is experienced by at least 75% of those with advanced cancers. Worldwide at least 4 million people suffer from cancer pain every day.
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Synopsis: The eclamptic patients pose an uncommen yet foreboding challenge for the obstetric anaesthesiologist. Selection of regional anaesthesia for severely pre-eclamptic patients requiring caesarian section is still controversial. In this review, we attempt to outline the advantages and disadvantages of various anaesthetic techniques used for severely pre-eclamptic patients undergoing caesarian section.
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Synopsis: The oesophagus is a muscular tube measuring 23-25cm in adults. It enters the superior mediastinum posterior to the trachea; continues down posterior to the pericardium and left atrium and anterior to the descending aorta. Its right side is adjacent to the right mediastinal pleura and lung; and on the left side lies the left mediastinal pleura and lung; along with common carotid artery; subclavian artery and descending aorta. There is a sphincter at both the proximal and distal ends of the oesophagus.
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