The industrial sector especially the aviation industry has shown the world that by using check lists and protocols, disasters could be prevented. It is now a common practice in many fields to establish protocols to standardize the practices. Such standardization makes the processes similar despite various users practicing the procedure. Although in anesthesia, there are several guidelines suggested by bodies such as the American society of anesthesiologists and Indian society of anaesthetists, strict protocols are not available even for the commonly undertaken procedures. Anesthesia is akin in many respects to flying an aircraft. The induction of anesthesia compared to take off of an aircraft, maintenance to cruising and extubation to landing. It was therefore thought that anesthesia similar to aircraft flying could be made safer by using protocols and checklists. However it may take a while for the practice of anesthesia to get to the “6 Sigma” safety that the airline industry currently enjoys. It is our effort to standardize the commonly performed surgeries at our institution. “The protocols in Anesthesia” emerged as a result of the back breaking work of the consultants in the department of anesthesia. The intention of this effort was to standardize the practice of anesthesia in our institution and to showcase the benefits of such standardization. It is hoped that other institution interested in standardizing their practice could formulate their own protocols. It is also desirable that a “copy and paste” of other protocols in unlikely to benefit the end users. The authors wish to bring forth the point that customized protocols should emerge with the efforts of the users themselves. It becomes more pertinent to suit one's protocol to the prevailing infrastructure, availability of therapeutic agents and economic conditions. The authors sincerely hope this endeavour might stimulate others to put their systems in place, if not pre-existing

Background: The most persistent criticisms for epidural analgesia for surgery are the latency of onset and marginal intensity of sensory and motor block, so clinical trials were carried out to find out a method to decrease the latency of onset of epidural block. The present study was carried out to determine the effect of increasing pH of 2% lignocaine hydrochloride with adrenaline (1:200000) and 0.5% bupivacaine hydrochloride by addition of sodium bicarbonate administered for epidural anesthesia in inguinal herniorrhaphy. Methods: Eighty male patients aged 18–60 years physical status American Society of Anesthesiology I and II posted for inguinal herniorrhaphy, were enrolled in this study. After placing epidural catheter in epidural space at L3–L4, test dose of 2% lignocaine with adrenaline 3ml was given. After making patient supine, epidural dose is given with local anesthetic according to the group. Group I - 15 ml of 2% lignocaine hydrochloride with adrenaline (1:200000) +0.5 ml normal saline (pH 3.58), Group II - 15 ml of 2% lignocaine hydrochloride with adrenaline (1:200000) +0.5 ml of 7.5% (w/v) sodium bicarbonate (pH 6.78), Group III - 15 ml of 0.5% bupivacaine hydrochloride (pH 5.5) and Group IV - 15 ml of 0.5% bupivacaine hydrochloride + 0.1 ml of 7.5% (w/v) sodium bicarbonate (pH 7.5). In Groups II and IV, pH of solution was increased by addition of sodium bicarbonate. All patients were monitored for the onset of sensory and motor block, intensity of sensory and motor block, highest level of analgesia, duration of sensory and motor blockade, and effects on cardiovascular and respiratory parameters. Results: Onset of sensory and motor block was significantly faster in study Groups (II and IV) as compared to control Groups (I and III). Intensity of block even duration of block was significantly better in pH adjusted group. Conclusion: Increase in pH of local anesthetic solutions used in epidural blockade improves the quality of epidural block.

Background: Functional endoscopic sinus surgery (FESS) enjoys the privilege of being a minimally invasive intervention for nasal disorders. Intraoperative bleeding is the major problem in these endoscopic surgeries. Excessive bleeding impairs operative visibility, prolongs the duration of surgery and anesthesia, and increases the risk of complications. Controlled hypotension is a method wherein the arterial blood pressure is lowered in a deliberate but predictable manner to reduce the intraoperative bleeding and enhance the surgical field visibility. Aim: The aim of this study was to compare the mean change in heart rate (HR), systolic blood pressure, diastolic blood pressure, mean arterial pressure (MAP), surgical bleeding, and duration of hypotensive anesthesia caused by nitroglycerin (NTG) or esmolol (ESM), when performing FESS. Materials and Methods: Sixty patients of American Society of Anesthesiologists I and II undergoing FESS under general anesthesia were divided into two groups– the NTG and the ESM group. Vitals were recorded at regular intervals. Hemorrhage was estimated by volumetric and gravimetric estimation. Visibility of the surgical field was rated by the surgeon Fromme et al, with 0 being the driest and 5 making surgery impossible. Results: Intraoperative HR, surgical bleeding, and duration were less in the ESM group. Visibility was much superior in this group too. Conclusions: Both drugs are safe and effective in providing optimal operating conditions, but ESM is superior because it provides superior surgical dryness at higher MAPs and reduces the surgical blood loss and duration more than NTG. Absence of reflex tachycardia was the added advantage of ESM over NTG.

Context: Tracheostoma stenosis is a common problem after laryngectomy. Stenosis of trachea stoma leads to respiratory complications. Preservation of stoma patency by implanting a silicon prosthetic device in tracheal stoma could affect the outcome in these situations. Aims: To evaluate tracheal stoma patency in postlarngectomy patients with the silicon prosthetic device. Settings and Design: This is a case series of seven patients who received the device. Materials and Methods: Seven adult patients American Society of Anesthesiologists Grade IV who had undergone laryngectomy for carcinoma larynx received a silicon airflow prosthetic device which was devised for each patient in the prosthodontic laboratory. All the patients were followed at 3 and 6 months to observe the efficiency and potency of device. Results: The average stoma size and average peak expiratory flow 25-75% in litres/sec at first patient visit, 3 and 6 months after receiving the device was 13.42 ± 0.71, 12.55 ± 0.82, 12.7 ± 0.92 mm and 3.08 ± 0.19, 3.10 ± 0.13, 2.89 ± 0.15 mm, respectively. Conclusions: The silicon airflow prosthetic device continued to maintain uninterrupted airflow and prevented tracheal stoma stenosis which encouraged us to place it for longer time after laryngectomy without any eventuality.

Context: It is not uncommon for fentanyl to induce cough at the time of induction. Aims: To evaluate the effect of subhypnotic dose of propofol on the incidence of occurrence and intensity of fentanyl-induced cough (FIC). Settings and Design: This is a prospective, randomized controlled study. Subjects and Methods: A total of 150 patients of the American Society of Anesthesiologists Classes I and II were assigned to one of the two groups: Group A received normal saline as placebo and Group B received low dose propofol (20 mg) before fentanyl given at a dose of 1.5 μg/kg through a peripheral intravenous catheter. The incidence of occurrence and intensity of cough were observed for the two groups. Statistical Analysis Used: One-way ANOVA, Chi-square test, Fisher's exact test, and Mann–Whitney U-test were used for statistical analysis. P<0.05 was considered statistically significant. Results: The incidence of occurrence of FIC was 29.3% and 6.6%, respectively, for placebo and propofol groups (P = 0.0000). Further, there was statistically significant difference between the groups for different grades of intensity (P = 0.032). There were 21% of patients who suffered desaturation and 1.3% chest wall rigidity in placebo group while no such cases were recorded for the propofol group. Conclusions: Subhypnotic dose of propofol can effectively attenuate FIC. It reduces not only the incidence of occurrence but also the intensity of the cough.

Placenta percreta is one of the most dangerous conditions that eventually result in maternal mortality. A young female with placenta percreta presented for fetal distress. Investigations revealed placenta invading entire abdominal wall, extending up to the urinary bladder and surrounding intestine. Surgery planned was extraction of fetus, leaving placenta in situ and hysterectomy at a later date, once placental vascularity is decreased. The patient was given spinal anesthesia which was later converted to general anesthesia. The patient was monitored for saturation, noninvasive blood pressure (BP), continuous electrocardiography, invasive BP, central venous pressure, urinary output, and temperature. Vitals were maintained within + 20% of the baseline. Healthy fetus was extracted, later followed by placental bed bleeding with massive bleeding of around 3500–4000 mL blood. It was managed with fluids, blood, pressure mops kept in the uterus, and placenta kept in the uterus. The patient was shifted to intensive care unit with elective ventilation. Postoperative day 3, the patient was taken for cesarean hysterectomy. The patient underwent hysterectomy after bilateral internal iliac artery ligation, repair of the bladder wall, and bilateral stenting of ureters. Bleeding of around 1500–2000 mL of blood was managed with fluids and blood. Postoperatively, the patient was managed in the intensive care unit for three days and was discharged from the hospital with a healthy baby without any complications. Antenatal recognition of placenta percreta and multidisciplinary approach by a team of experienced obstetricians, anesthesiologists, nurses, interventional radiologists, neonatologists, and urologists, as well as a blood bank, would decrease blood loss, reduce serious complications, and ensure favorable outcomes. We do here present a case of perioperative management of placenta excreta managed successfully.

We describe a patient with postpoliomyelitis residual paralysis with thoracolumbar kyphoscoliosis who presented for an emergency endoscopic retrograde cholangiopancreatography and interval laparoscopic cholecystectomy. This case report emphasizes on the adequate perioperative optimization and the meticulous anesthetic management of a long-standing kyphoscoliotic patient with respiratory compromise.

Systematic approach to a paediatric trauma victim who has sustained life threatening injuries calls for good pre-hospital care, triaging in the emergency room and effective management consisting of primary survey along with skilled resuscitation followed by secondary survey. After stabilization, it is essential to know the severity of injury and soft tissue defect by vigilant clinical examination, coupled with assessment by established scoring systems, such as GANGA and MESS, in order to plan further management. Recent guidelines in polytrauma management stress on initial damage control surgery for achieving haemostasis and debridement, followed by definitive reconstructive procedure. The procedure involves essential management of type 3c compound fracture with vascular involvement by damage control surgery along with vascular repair by saphenous graft followed by unique method of BERAM flap in continuity with Lattismus dorsi myocutaneous flap subsequently. Because of its role in hemodynamic stability and regional blood flow, anaesthesia is an important determining factor in the success of microvascular free flap surgeries. Stabilizing haemodynamic and achieving normal metabolic and biochemical parameters is essential. Our case report is aimed at reviewing the relevant aspects of anaesthetic practice in a procedure involving microvascular flaps.

Ascending aortic pseudoaneurysms are rare and occur infrequently from anastomotic dehiscence of suture lines and cannulation sites from previous aortic surgery. It is managed by open surgical approach but carries a high risk of pseudoaneurysm rupture at the time of sternotomy. We describe a successfully managed case of ascending aortic pesudoaneurysm presenting as a pulsatile mass in the neck. Its orifice was located on the lateral wall of the ascending aorta,which was caused by the cardioplegia cannula inserted during a previous cardiac surgery. We also summarize the anesthetic challenges and complications of such a case.