Sedation and analgesia are frequently administered to paediatric patients for procedures done outside the operating room. Both diagnostic and therapeutic procedures are now being increasingly done outside the oper­ating room partly due to time constraints, partly in an effort to decrease cost and partly due to fear of compli­cations of sedation. So children are often subjected to sedation by unskilled personnel with little or no training in resuscitation. In other cases children who would have benefited by sedation are being denied sedation and/ or left with long term psychological scars. The fear of undergoing a painful procedure or a procedure in unfamiliar surroundings remains considerably high. This is especially true in young children and mentally handicapped children. The whole issue is compounded by parental anxiety, separation from parents and pain or anticipation of pain during the procedure. It is poorly understood that procedures done outside the operat­ing room require the same attention to anxiolysis, analgesia, sedation and safety guidelines as procedures performed in the operating room. To this end we require appropriate definitions, goals, guidelines, monitoring and adequately trained personnel. In this review and update we have examined the international guidelines, looked at the drugs which may be used, and safety constraints. We also have enunciated guidelines for proce­dural sedation in children which may be adapted to the Indian scenario.

Ultrasound technology is a rapidly emerging science and the field of anaesthesia has not remained un­touched by its widespread applications. It is playing an increasing role in vascular access, in regional anaes­thesia for nerve blocks and as a transoesophageal echocardiography tool for cardiac imaging and viewing blood flows. It has special applications to assess the depth of epidural space in cases of difficult anatomy or in an otherwise high risk patient where interventional procedure is required. As the ultrasound guidance is becom­ing standard practice of future, anaesthesiologists need to develop a thorough understanding of this technol­ogy& practical skills by training themselves.

Herbal medicines are the oldest known remedies to mankind. Herbs have been used by all cultures throughout history but India has one of the oldest, and most diverse cultural living traditions associated with the use of medicinal plants. The use of these agents may have perioperative implications, which often is a result of various factors. The constituents of these medications may not be adequately described. Conventional agents like ste­roids, oral hypoglycaemic agent, nonsteroidal anti-inflammatory agents and antihistamines are frequently added to herbal medicines. Toxic materials like arsenic, mercury, lead, etc. have been detected from time to time in some herbs. The use of herbal medicines can result in drug interactions, most of which are less well defined. The interactions that are most important in the perioperative period include sympathomimetic, sedative, and coagulopathic effects. Less than 50% of patients admit to taking these medicines, which compounds the prob­lem. It is imperative that anaesthesiologists obtain a history of herbal medicine use from patients and anticipate the adverse drug interactions. In case of any doubt, it may be prudent to stop these herbal medicines atleast 2­3 weeks prior to anaesthesia and surgery.

Designing of an operation theatre complex is a major exercise and is mainly intended to benefit the patient. The need for safety, convenience and economy will guide the planning of a modern operation theatre complex, whatever the size, number or the speciality. Guidelines based on current and widely accepted recom­mendations as also ones for possible expansion of the operation theatre complex are dealt with in this article.

Neurosurgery is generally believed to be associated with major blood loss and large volumes transfusion of blood and blood product. Recent advances in neurosurgical techniques and concepts relating to blood transfusions have helped to decrease the need for intraoperative transfusions. In the present audit conducted in an advanced tertiary neurological centre performing the entire range of neurosurgery, 31% of patients undergoing surgery required blood product transfusion. Surgery on inracranial tumors was associated with a significantly higher blood loss (P<0.006) and transfusion than surgery on other lesions. Spinal surgery re­quired the lowest rates of transfusion. Among the intracranial tumors, meningiomas required the highest vol­umes of transfusion (P<0.001). Rates of blood transfusion in paediatric patients were the same as those for the entire group. In children less than 15 years, surgery for intracranial tumors and craniosynostosis were the main procedures requiring blood transfusion, while no blood transfusion was required for surgical procedures for hydrocephalus and spinal myelomeningoceles. Single unit transfusions, which accounted for 34% of all blood products transfused, were more frequent in paediatric patients (22 out of 45 in children ≤15 years) and intrac­ranial tumors(24 out of 45).

Clonidine has been shown to reduce perioperative haemodynamic instability. The aim of the study was to investigate the clinical efficiency of oral clonidine premedication in prevention of haemodynamic response associated with pneumoperitoneum. Sixty adult patients of ASA physical status I& II, scheduled for elective laparoscopic cholecystectomy were recruited for a prospective randomized, double-blinded comparative study. They were randomly allocated to one of the two groups to receive either oral clonidine 150 gg (Group C) or ranitidine 150 mg (Group P), 90 minute before induction of anaesthesia. Significant rise in heart rate was observed following pneumoperitoneum in Group P as compared to Group C (99.23±14.02 Vs 81.26±8.40 bpm). Similarly, rise in systolic arterial pressure (143.63±19.60 Vs 119.6±10.06 mm Hg), diastolic arterial pressure (99.23±14.02 Vs 81.26±8.40 mm Hg) and mean arterial pressure (114.13±16.57 Vs 93.83±8.107 mm Hg) was more in Group P following pneumoperitoneum. Nitroglycerine drip was started in 33.3% patients in Group P to control intraoperative hypertension. Incidence of postopera­tive nausea-vomiting and shivering was also less in Group C. To conclude, clonidine premedication provides perioperative haemodynamic stability, hence it can be recommended as a routine premedication for laparoscopic procedure.

Advantages and disadvantages of newer agent like propofol need to be evaluated with time tested inducing drug - thiopentone in neuroanaesthesia. The aim of the study was to compare effects of propofol with thiopentone on intracranial pressure, cerebral perfusion pressure and haemodynamics during induction in neurosurgical pa­tients. Fifty adult patients of ASA grade I& II scheduled for elective craniotomy were randomly assigned to receive induction of anaesthesia with either propofol 1.5-2.5 mg.kg ^-1 i.v. (Group A, n=25) or thiopentone 4-5 mg.kg ^-1 , i.v. (Group B, n=25). Vecuronium bromide 0.1 mg.kg ^-1 i.v. was used as intubating muscle relaxant. Both groups received fentanyl 2 pg.kg ^-1 i.v., lidocaine(preservative free) 1.5 mg.kg ^-1 i.v. and supplementary dose of same inducing agent before intubation. Changes in mean arterial pressure (MAP), cerebrospinal fluid pressure (CSFP), cerebral perfusion pressure (CPP) and heart rate (HR) were noted during induction and endotracheal intubation. On statistical analysis it was found that CSFP decreased significantly (P<0.001) in both groups after induction but endotracheal intubation did not provoke any significant rise in CSFP. Maximum decrease of CSFP was 35.26% in Group A and 35.20% in Group B. Fall in MAP was more significant in Group A (P<0.001), as a result CPP was significantly less in Group A than in Group B. The lowest mean CPP (71.12±5.86 mm Hg) was observed 2 minutes after induction dose in Group A when maximum drop in MAP occurred. Heart rate did not change significantly in Group A but in Group B fluctuation of heart rate was more.

Aim of this study was to study the vibration sense testing with 128 Hz tuning fork as a tool to determine timing for analgesic in post operative pain relief in 60 male patients who underwent inguinal herniorrhaphy under subarachnoid block (SAB). After evaluating the time interval of recovery of vibration sense after SAB in 30 patients(Group I), tramadol 100 mg IM was given once the patient actually complained of pain at the surgical site, whereas in Group II (n=30) similar dose was given with the return of vibration sense at anterior superior iliac spine (ASIS). In Group I statistically significant rise in all the cardio respiratory parameters and VAS score were found especially near to timings for first request of analgesics (TRA 1 ^st ) whereas in Group II all these parameters remained near to basal values except at 360 ^th minute. Time for second request of analgesics (TRA 2 ^nd ) was significantly delayed (P<0.001) in Group II (723.33 ±12.68 min) as compared to Group (358.33±9.12 min) Our result indicates that return of vibration sense at ASIS can be used as an indication for administration of parenteral analgesic for better post operative pain relief.

There are several issues that influence the anaesthetic care of children with cerebral palsy such as sei­zures, spasticity, and sensitivity to pain medications, scoliosis, mental retardation, inability to communicate, respiratory infections, variable patterns of breathing, excessive drooling and other associated medical condi­tions. A series of 62 cases of cerebral palsy scheduled for limb deformity correction is described. Midazolam 0.5mg.kg ^-1 was given orally half an hour prior to induction. Glycopyrrolate 0.02 mg.kg ^-1 IV was administered. Propofol 3 mg.kg ^-1 was given to facilitate LMA placement. They breathed nitrous oxide and oxygen spontaneously through the LMA. Subsequent to this, infusion of propofol 2 mg.kg ^-1 .min ^-1 was com­menced. They received regional blocks such as continuous lumbar epidural for bilateral lower limb proce­dures, continuous sciatic& fascia iliaca compartment block for unilateral lower limb procedures and single shot infraclavicular block for upper limb, for below the elbow surgeries . Adequacy of the block was assessed by the necessity of any rescue analgesic, recovery was evaluated by Alderte score on table, and the time of first feed was noted. Postoperative analgesia was assessed by CHEOPS pain score. Aldrete score was 8 (SD=0.7) by the end of plaster application. Additional drugs for the analgesia were not required in any of the patients. First oral feed was possible 1 ½ hr (SD=1.1) after the procedure. CHEOPS score of 4-6 (Satisfactory levels of analgesia) was achieved into the postoperative period by top ups.

A 22-year-old female, known asthmatic since seven years, developed severe bronchospasm in the preop­erative period. Bronchospasm remained unresponsive to the inhaled beta-agonist plus anticholinergic, IV ami­nophylline and hydrocortisone but responded quickly with magnesium sulfate® ( PSI, KSA) infusion 1.25gm in 100ml normal saline over 20 minutes and another 1.25 gm over next 30 minutes as the initial infusion showed improvement in her clinical symptoms. Within half an hour of administering the 1st infusion of magnesium sulfate (1.25 gm) the respiratory rate started reducing, rhonchi became less, SpO ₂ came upto 92% and re­mained always above 90%. Encouraged by this result IV magnesium sulfate 2.5 gm in 500 ml normal saline was infused over next 24 hours along with alternate salbutamol and ipratropium nebulization every 6 hourly. With this treatment regimen the patient became asymptomatic within next 24 hours with normal clinical parameters and FEV ₁ value. Hence it may be concluded that IV magnesium sulfate can be considered for patients with acute severe asthma who do not respond to standard therapeutic medications.

We report a case of a forty-five year old male who was admitted fifteen days prior with biliary pancreatitis. He developed pulmonary thromboembolism (PTE) after uneventful laparoscopic cholecystec­tomy. He was initially treated with intravenous (IV) heparin and inferior vena cava (IVC) filter. Later on he underwent emergency pulmonary embolectomy due to haemodynamic deterioration. There is less incidence of PTE after laparoscopic cholecystectomy, but it becomes high-risk for postoperative thromboembolic complications when it is associated with other risk factors. The purpose of this report is to highlight that preoperative detection of risk factors and thromboprophylaxis in indicated cases can prevent this complication. We also review the incidence of PTE, risk factors and thromboprophylaxis.

Laparoscopic procedures are becoming increasingly widespread as more and more surgical procedures are becoming amenable to laparoscopic repairs. As the spectrum of the procedures widens, so are the likely complications. It is imperative for the discerning anaesthesiologists to be vigilant for the possible complications related to this technique.

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. Here, we present the management of a case of restrictive cardiomyopathy undergoing arthroscopy and anterior cruciate liga­ment (ACL) reconstruction.

Phaeochromocytoma is a catecholamine secreting tumour that typically occurs in patients of 30 - 50 years age. A female patient 28-year-old with bilateral phaeochromocytoma presented with hypertension and hyperg­lycemia. Diagnosis was confirmed by CT scan of the abdomen and raised 24 hrs urinary catecholamine and vanillylmandelic acid. The patient was scheduled for excision of tumour. Pre-operative blood pressure was controlled with prazosin and metoprolol, hyperglycemia was controlled with soluble human insulin. The anaesthetic technique used was general anaesthesia with control of blood pressure during operation and manipulation of tumour with sodium nitroprusside (SNP) infusion and after removal of tumour with noradrenaline infusion and fluid replacement.

An 8-week old 3-kilogram male baby was brought to this tertiary care hospital with respiratory distress, marked tracheal tug, poor feeding and a heart rate of 46/minute. The child had been referred from a peripheral hospital as a case of neonatal lupus with complete congenital heart block. The mother was seropositive for systemic lupus erythematosus with a history of two abortions. Evaluation on admission revealed a heart rate between 40-60/ minute, respiratory rate 40-50/ minute, inspiratory stridor, bilateral crepitations, chest retrac­tion and a marked tracheal tug that improved with prone positioning. Electrocardiography and echocardiography confirmed complete congenital heart block with cardiomegaly and mild left ventricular dysfunction. Keeping in view the impending congestive heart failure, possible early cardiomyopathy and the bad obstetric history ur­gent pacemaker implantation was planned to allow early recovery of the child. The anaesthetic risk was high due to the heart block, ventricular dysfunction, laryngomalacia, severe tracheal tug and anticipated difficult weaning from controlled ventilation. General anaesthesia was administered with endotracheal tube and con­trolled ventilation using ketamine, rocuronium and sufentanil. For patient safety invasive monitoring was pro­vided and external pacing was kept standby. Epicardial pacemaker leads were implanted onto the left ventricu­lar wall through a left anterior 6th intercostal space thoracotomy. The child was electively ventilated for two post operative days. The tracheal tug and secretions gradually subsided over 2 weeks with oxygen, antibiotics, steroids, bronchodilators and physiotherapy. At the time of discharge from hospital 2 weeks after the implant the child was feeding well, tracheal tug was minimal and the lungs were clear.

The incidence of tuberculosis in pregnancy ranges between 1-2% amongst hospital deliveries in the trop­ics. Tuberculosis of central nervous system accounts for about 5% of extra pulmonary cases and manifests as meningitis or uncommonly as tuberculoma. The management of intracerebral tuberculoma diagnosed during pregnancy should be same as that in non-pregnant subjects with antituberculous treatment. Emergency caesar­ean section in a patient with intracerebral tuberculoma poses unique challenges to the anaesthesiologist. There are no published reports on anaesthetic management of pregnancy with tuberculoma. We report the case of a woman with intracerebral tuberculoma presenting for emergency caesarean section. The anaesthetic goals in this patient were combined to that of principles of obstetrical anaesthesia to ensure a favourable maternal and fetal outcome. The anaesthetic technique chosen should prevent aspiration, avoid fluctuations in intracranial pressure, maintain stable haemodynamics, provide a sufficient depth of anaesthesia and good postoperative analgesia. We believe that general anaesthesia is the safest approach in such patients. We suggest general anaesthesia to be preferred over regional anaesthesia technique.