Elderly patients with serious cardiac problems are presenting for major orthopedic surgeries. We present a case of an elderly male patient posted for total hip replacement having a permanent pacemaker in situ in ventricle paced, ventricle sensed, pacing inhibited (VVI) mode. The patient, on preoperative examination, was found to have a complete atrioventricular (AV) block on electrocardiogram (ECG) and electrophysiology study showed degenerative AV conduction disease and symptomatic complete AV block. The patient had seizure disorder and anemia, for which the patient was treated accordingly and optimized before surgery. The pacemaker mode changed to vesiculo-vacuolar organelle (VVO). Combined spinal-epidural was given. Arterial line was secured and the patient was monitored hemodynamically. The patient tolerated the procedure of total hip replacement well; vitals were maintained within 20% of the baseline. Phenylephrine infusion was given to maintain blood pressure. After operation was shifted to the intensive care unit (ICU), pacemaker was reprogrammed to VVI mode, and epidural infusion for pain and vigilant monitoring was done. The patient was shifted to the ward on the 3^rd day and was discharged on the 5^th day. To conclude, combined spinal-epidural along with invasive cardiac monitoring is a reasonable choice for elderly patients with permanent pacemakers coming for major orthopedic surgeries.

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In the scenario of gastroendoscopic setup, sedation is meant to enhance the comfort of the patient and to allay anxiety associated with the procedure. Most of the procedures under gastroendoscopic setup are performed on daycare basis; hence, the drugs with shorter half-life and which are easily metabolized are preferred. Dexmedetomidine is an attractive alternative to sedatives when the patient needs to be spontaneously breathing and easily arousable from sedation.

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The spectrum of electrical injury ranges from minor skin lesions to severe multiorgan damage, at times associated with occult or delayed complications and even death. High-voltage electrical injury is characterized by skin lesions that are confined in comparison to the profound destruction of deeper tissues involved and masked by the good general condition of the patient. In light of the limited existing literature, we share our experience of managing a patient who survived a high-voltage electrical injury (6000 V) 5 days prior to scheduled laparoscopic interval appendicectomy, and discuss the factors that influence the degree of injury, probable complications, and our perioperative management.

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Background: Unexpected difficult intubation is probably the result of inadequate preoperative examination of airway and a lack of accurate predictive tests for difficult intubation. Preoperative evaluation forms basis to suspect and be prepared for a difficult airway situation. Aim: The aim of our study was to identify the ideal preoperative predictors of difficult intubation. Materials and Methods: It was a Prospective Observational study done on 350 patients in a community-based hospital. Preoperative airway assessment included: Mallampati Class (MC), Mouth opening (MO), Thyromental distance (TMD), Ability to prognath (AP) and Neck mobility and size (NM). Monitors were attached, anesthesia induced and laryngoscopy performed. Intubation Difficulty Scale (IDS) score was used to grade difficulty in intubation. Results: The overall incidence of Difficult Intubation was 24.6 %. A slight difficulty in 24% (IDS = 1-5) and moderate to major difficulty (IDS >5) in 0.6% cases was noted. Intubation was possible in all the patients. Mallampati class III & Mouth opening was less than 4 cm in about 6% cases and Thyromental distance less than 6 cm in 5.4%. 12.5% were unable to prognath and Neck mobility was restricted in 4.6% patients. Sensitivity and specificity of MC- 16.3 % and 97%, MO- 16.3% and 96.6%, TMD - 12.8% and 97%, AP - 33.3% and 93.9% , NM - 10.5% and 97.3%. Positive and Negative Predictive Values for MC, MO, TMD, AP and NM were 63.6% and 78%, 60.9% and 78%, 57.9 and 77.3 %, 62.8% and 81.9%, 56.3% and 76.9% respectively. Conclusion: We concluded that Mallampati grading and ability to prognath are the most important of the variables studied.

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Hysterical paralysis is an uncommon, psychogenic, nonorganic loss of motor function precipitated by some type of traumatic event. Typically, it is a diagnosis of exclusion after all the organic causes have been ruled out. The purpose of this case report is to highlight the phenomenon of hysterical paralysis.

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Background: Preoperative preparation of children to alleviate the stress and anxiety related to surgery is an important aspect of balanced anesthesia care, it can not only affect the smoothness of induction and emergence from anesthesia but also the emotional and psychological make-up of the child, considering the pharmacological profile, midazolam is widely considered to be the ideal premedicant. The purpose of our prospective randomized observer-blinded study is to compare the effect of midazolam through oral and intranasal routes and determine the safer, more effective, and acceptable route by children. Subjects and Methods: Sixty patients aged 2–8 years, belonging to the American Society of Anesthesiologist I and II undergoing various surgeries were randomized into two groups of 30 each. Group O received 0.5 mg/kg of oral midazolam syrup, and Group N received 0.2 mg/kg of midazolam intranasal spray. Hemodynamic variables, sedation scores, ease of parental separation, and mask acceptance at the time of induction were studied. Results: Onset of sedation was shorter and the sedation scores were higher in intranasal group, separation from parents and acceptance to mask were satisfactory but statistically insignificant in both the groups. There was no statistical difference in hemodynamic parameters, and no major adverse effects were seen in either group. Conclusion: Both oral and intranasal midazolam are safe and effective as sedative premedication in children.

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Craniopharyngiomas constitute about 2–6% of all the intracranial tumors in the pediatric age group. Management of craniopharyngiomas in children is challenging for not only surgeons and endocrinologists but for anesthesiologists as well, owing to the developing neurological and physiological status, handling of a growing brain, perioperative endocrinological complications, and the management of hydration. We report a case of a 4-year-old child who had presented to our hospital with progressive loss of vision over a period of 2 months.

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Huntington's chorea is a hereditary disorder characterized by continuous involuntary movements. Symptoms usually occur between the ages of 30 and 45 years and include choreatic movements, progressive mental deterioration, and ataxia. Various anesthetic techniques have been tried in these patients, both regional as well as general anesthesia. These patients are of special concern to anesthesiologists with respect to preoperative assessment and securing intravenous access due to their continuous movements. Such patients have to be managed with respect to providing airway protection and ensuring rapid and safe recovery. We report a case of Huntington's chorea who was anesthetized successfully for removal of foreign body cricopharynx without any deleterious postoperative outcome.

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Background: Lumbar spine surgery in adults is associated with significant blood loss, often requiring allogeneic blood transfusion. The objective of this study was to evaluate the efficacy of tranexamic acid (TXA) in reducing perioperative blood loss and transfusion requirements in patients undergoing lumbar spine fixation. Materials and Methods: Sixty adult patients were randomized to receive either a bolus of 10 mg/kg IV of TXA after induction followed by a maintenance infusion of 1 mg/kg/hr of TXA up to closure of skin, or an equivalent volume of normal saline. Outcome measures included perioperative blood loss, amount of blood transfusion, as well as postoperative hemoglobin and hematocrit levels. Results: The mean intra-operative blood loss and the amount of blood in the drains post-operatively was less in the tranexamic acid group compared to the placebo group (P =0.0001). The blood transfusions received in both the groups was not statistically significant (P = 0.362).However, clinically there was reduction of transfusion requirement in the tranexamic acid group. The drop in post-operative hemoglobin levels was statistically significant in the control group as compared to tranexamic acid group (P = 0.002). The mean duration of surgery was less in tranexamic acid group compared to the control group (P = 0.008). Conclusion: Thus, tranexamic acid is effective in reducing peri-operative blood loss and transfusion requirements .Furthermore, TXA administration was not associated with any significant complications including DVT.

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A 26-year-old, 155 cm height, 72 kg primigravid female was admitted for safe confinement on December 3, 2015. She was posted for emergency lower segment cesarean section under regional anesthesia for the indication, cephalopelvic disproportion nonprogression of labor. The patient and her husband had given their consent for surgery owing to the patients' fear that she may pass out if she wept start due to pain during induced labor. Spinal anesthesia was performed at L₃L₄space using 27-gauge needle and 0.5% heavy bupivacaine 1.9 ml along with buprenorphine 0.1 ml. The patient was very stable hemodynamically throughout the surgical procedure which lasted for 50 min and gave birth to male baby weighing 3.2 kg. The immediate postoperative period was uneventful with stable vital signs except the patient was under deep sleep. Three hours after shifting, the patient had vomiting and three more hours later, she neither recalled having given birth nor did she recognize her baby. She exhibited violent psychiatric behavioral movements at the intervals of 3 h thereafter. Hence, the diagnosis of postpartum psychosis was suspected and managed meticulously. The patient was discharged on 7^th postoperative day.

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Difficult and failed intubations, although rarely encountered, are major causes of morbidity and mortality in the current anesthetic practice. To reduce the incidence of difficult and failed intubations, several devices including the recently developed video laryngoscopes are available. In this paper, we evaluated the role of newly developed McGrath^® video laryngoscope in a case of postburn contracture neck, with limited neck extension and mouth opening. Anticipating difficulty in securing airway with conventional laryngoscopy, we hereby successfully used the McGrath^® video laryngoscope to secure the airway. The quality of laryngoscopy and intubation showed that this portable device can be very helpful in difficult airway management.

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Ebstein anomaly along with restrictive cardiomyopathy is a rare entity characterized by apical displacement of the septal and posterior tricuspid valve leaflets, leading to atrialization of the right ventricle with a variable degree of malformation and displacement of the anterior leaflet along with the restriction of diastolic filling of ventricles. If patients with this anomaly present to us along atrial fibrillation and liver dysfunction due to right-sided heart failure, it would be a challenge for anesthesiologist to give anesthesia. Herein, we are providing a brief review of the clinical presentation and anesthetic consideration in these types of patients if they present for noncardiac surgeries.

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We report a 40-year-old male patient who underwent thoracolaprotomy for liver and lung hydatid cyst. The patient had severe intraoperative anaphylaxis, which was managed successfully.

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The perioperative management of a patient diagnosed with ruptured cerebral aneurysm and aortic stenosis (AS) is a challenging task for the anesthesiologist. Continuous cardiac output (CO) monitoring devices such as the FloTrac^™/Vigileo^™ system is a reliable measure to avoid and minimize the adverse complications of hemodynamic instability, thus favoring the outcome.

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