The outbreak of Middle East respiratory syndrome (MERS) is reported from Saudi Arabia and the Republic of Korea. It is a respiratory disease caused by coronavirus. Camels are considered as a source for MERS transmission in humans, although the exact source is unknown. Human-to-human transmission is reported in the community with droplet and contact spread being the possible modes. Most patients without any underlying diseases remain asymptomatic or develop mild clinical disease, but some patients require critical care for mechanical ventilation, dialysis and other organ support. MERS is a disease with pandemic potential and awareness, and surveillance can prevent such further outbreaks.

Background and Aims: Midazolam-fentanyl (MDZ:FEN) combination has been routinely used for intravenous sedation in ophthalmic surgeries. Dexmedetomidine (DEX), a recent α₂ adrenoreceptor agonist indicated for sedation for ophthalmic use at a loading dose of 0.5 μg/kg over 10 min, can cause deeper plane of sedation and surgeon dissatisfaction. Therefore, we proposed to evaluate the efficacy and safety of two different loading doses of DEX. Methods: In a prospective study, 60 patients aged 50-70 years, scheduled for retinal surgery under peribulbar block were divided equally to receive either MDZ:FEN or DEX 0.5 μg/kg (DEX full) or DEX 0.25 μg/kg (DEX half) loading dose over 10 min followed by titrated maintenance dose of DEX 0.25-0.4 μg/kg/h. Vital parameters, level of sedation (Ramsay Sedation Scale 1–6), effect on respiration and surgeon satisfaction were assessed at regular intervals. Surgeon satisfaction score (0–3) was noted. Results: 'DEX half' group patients had predominantly stable haemodynamics, level 3 sedation and surgeon satisfaction score of 2–3 (good to excellent operating conditions). This group had no vomiting and no respiratory depression. 'DEX full' group had a higher incidence of bradycardia, hypotension, level 4 sedation (Ramsay Sedation Scale) and lower surgeon satisfaction. Incidence of nausea and vomiting was higher in MDZ:FEN group compared to other two groups. Conclusion: DEX 0.25 μg/kg loading dose over 10 min followed by titrated maintenance dose is an effective alternative to MDZ:FEN and provides controlled (level 3) sedation and stable haemodynamics maximising surgeon satisfaction. Avoiding narcotic analgesics with its associated post-operative nausea and vomiting is an additional benefit.

Background and Aims: Tranexamic acid (TA) is used for prophylactic antifibrinolysis in coronary artery bypass surgeries to reduce bleeding. We evaluated the efficacy of two different doses of TA for prophylactic antifibrinolysis in patients undergoing primary coronary artery bypass grafting (CABG) surgery in this retrospective cohort study at a tertiary care referral centre. Methods: One-hundred eighty-four patients who underwent primary CABG with cardiopulmonary bypass (CPB) via sternotomy between January 2009 and June 2011 were evaluated. Pre-operative patient characteristics, intraoperative data, post-operative bleeding, transfusions, organ dysfunction and 30-day mortality were compared between high-dose TA (30 mg/kg loading dose followed by infusion of 15 mg/kg/h until the end of surgery along with 2 mg/kg priming dose in the bypass circuit) and low-dose TA (15 mg/kg loading dose followed by infusion of 6 mg/kg/h until the end of surgery along with 1 mg/kg priming dose in the bypass circuit) groups. Univariate comparative analysis of all categorical and continuous variables was performed between the two groups by appropriate statistical tests. Linear and logistic regression analyses were performed to control for the effect of confounding on the outcome variables. Results: Chest tube output, perioperative transfusion of blood products and incidence of re-exploration for bleeding did not differ significantly (P> 0.05) between groups. Post-operative complications and 30-day mortality were comparable between the groups. The presence of cardiogenic shock and increased pre-operative creatinine were found to be associated with increased chest tube output on the post-operative day 2 by multivariable linear regression model. Conclusions: Low-dose TA protocol is as effective as high-dose protocol for antifibrinolysis in patients undergoing primary CABG with CPB.

Background and Aims: Although both frailty and low cerebral oxygen saturation increase the risk of post-operative complications, their relationship is yet to be investigated. The purpose of this observational study was to investigate the association between frailty, intraoperative cerebral oxygen saturation and post-operative complications in elderly patients undergoing non-cardiac surgery. Methods: After approval from the Institutional Review Board, 25 elderly patients (>65 years) undergoing non-cardiac major surgery were included in this study. Pre-operatively, all included patients were assessed for frailty and classified into frail and non-frail groups. All patients had routine intraoperative monitors, and a cerebral oximeter applied during anaesthesia. The 'intraoperative' anaesthesiologist and the post-operative study investigator were blinded to cerebral oximeter readings throughout the study. The incidence of significant intraoperative cerebral oxygen desaturation, adverse post-operative outcomes and length of hospital stay were compared. Statistical significance was defined as a value of P < 0.05. Results: We found that the frail group had more intraoperative cerebral desaturation (odds ratio [OR] [95% confidence interval [CI]]: 1.75 [1.11–2.75]) and longer median (interquartile range) length of hospital stay compared to the non-frail group (13.5 days [8.75–27.5] and 8 days [6–11], respectively). Furthermore, in patients with a low-baseline cerebral oxygen saturation (<55%), intraoperative cerebral desaturation (OR [95% CI]: 2.10 [1.00–4.42]), adverse post-operative outcomes (OR [95% CI]: 1.80 [1.00–3.23]) and median (interquartile range) length of hospital stay (15 days [9–31.5] vs. 9 days [6.25–13.75], P = 0.04) were significantly higher compared to subjects with higher baseline (≥55%) cerebral oxygen saturation. Conclusions: Frail patients have more intraoperative cerebral desaturation and longer lengths of hospital stay compared to non-frail patients.

Background and Aims: Tertiary care teaching hospitals remain referral centres for victims of trauma and mass casualty. Often specialists from various disciplines manage these crowded casualty areas. These age old casualty areas are being replaced, throughout the country by Emergency Medicine Departments (EMDs), presumed to be better planned to confront a crisis. We aimed to gather basic data contributive in setting up of an EMD at a tertiary care teaching hospital from the lessons learned from functioning existent systems. Methods: This is primarily a questionnaire-based descriptive study at tertiary care referral centres across the country, which was purposively selected.The study models included one from a hospital without designated EMD and the other four from hospitals with established EMDs. Direct observation and focus group meetings with experienced informants at these hospitals contributed to the data. In the absence of a validated hospital preparedness assessment scale, comparison was done with regard to quantitative, qualitative and corroborative parameters using descriptive analysis. Results: The EMDs at best practice models were headed by specialist in Emergency Medicine assisted by organised staff, had protocols for managing mass casualty incident (MCI), separate trauma teams, ergonomic use of infrastructure and public education programmes. In this regard, these hospitals seemed well organised to manage MCIs and disasters. Conclusion: The observation may provide a preliminary data useful in setting up an EMD. In the absence of published Indian literature, this may facilitate further research in this direction. Anaesthesiologists, presently an approved Faculty in Emergency Medicine training can provide creative input with regard to its initial organisation and functioning, thus widening our horizons in a country where there is a severe dearth of trained emergency physicians.

Background and Aims: Low concentration local anaesthetic improves uteroplacental blood flow in antenatal period and during labour in preeclampsia. We compared neonatal outcome after epidural ropivacaine plus fentanyl with intramuscular tramadol analgesia during labour in high-risk parturients with intrauterine growth restriction of mixed aetiology. Methods: Forty-eight parturients with sonographic evidence of foetal weight <1.5 kg were enrolled in this non-randomized, double-blinded prospective study. The epidural (E) group received 0.15% ropivacaine 10 ml with 30 μg fentanyl incremental bolus followed by 7–15 ml 0.1% ropivacaine with 2 μg/ml fentanyl in continuous infusion titrated until visual analogue scale was three. Tramadol (T) group received intramuscular tramadol 1 mg/kg as bolus as well as maintenance 4–6 hourly. Neonatal outcomes were measured with cord blood base deficit, pH, ionised calcium, sugar and Apgar score after delivery. Maternal satisfaction was also assessed by four point subjective score. Results: Baseline maternal demographics and neonatal birth weight were comparable. Neonatal cord blood pH, base deficit, sugar, and ionised calcium levels were significantly improved in the epidural group in comparison to the tramadol group. Maternal satisfaction (P = 0.0001) regarding labour analgesia in epidural group was expressed as excellent by 48%, good by 52% whereas it was fair in 75% and poor in 25% in the tramadol group. Better haemodynamic and pain scores were reported in the epidural group. Conclusion: Epidural labour analgesia with low concentration local anaesthetic is associated with less neonatal cord blood acidaemia, better sugar and ionised calcium levels. The analgesic efficacy and maternal satisfaction are also better with epidural labour analgesia.

Background and Aims: Dynamic parameters such as the respiratory variation in aortic flow peak velocity (ΔVpeak) and inferior vena cava distensibility index (dIVC) are accurate indices of fluid responsiveness in adults. Little is known about their utility in children. We studied the ability of these indices to predict fluid responsiveness in anaesthetised and mechanically ventilated children. Methods: This prospective study was conducted in 42 children aged between one to 14 years scheduled for elective surgery under general endotracheal anaesthesia. Mechanical ventilation was initiated with a tidal volume of 10 ml/kg. ΔVpeak, dIVC and stroke volume index (SVI) were measured before and after volume expansion (VE) with 10 ml/kg of crystalloid using transthoracic echocardiography. Patients were considered to be responders (R) and non-responders (NR) when SVI increased to either ≥15% or <15% after VE. ΔVpeak and dIVC were analysed between R and NR. Results: The best cut-off value for ΔVpeak as defined by the receiver operator characteristics (ROC) curve analysis was 12.2%, for which sensitivity, specificity, positive predictive value and negative predictive value were 100%, 94%, 96% and 100%, respectively, the area under the curve was 0.975. The best cut-off value for dIVC as defined by the ROC curve analysis was 23.5%, for which sensitivity, specificity, positive predictive value and negative predictive value were 91%, 89%, 91% and 89%, respectively, the area under the curve was 0.95. Conclusion: ΔVpeak and dIVC are reliable indices of fluid responsiveness in children.

The loss of oesophageal length or obliteration of oesophageal lumen due to stricture acquired by accidental caustic ingestion is more common in children that may require major operative reconstruction. A number of procedures have been developed for anatomic replacement of oesophagus of which thoracoscopic assisted gastric transposition has shown the best outcome in children. This demands an extensive pre-operative evaluation, preparation and anaesthetic management since this is challenging and prolonged procedure done under one lung ventilation (OLV). Though it is a minimally invasive procedure, providing OLV and management of complications associated with it are the anaesthetic challenges among these children. We report anaesthetic management of an 8-year-old boy with oesophageal stricture following corrosive injury posted for thoracoscopic assisted gastric transposition.

Pancreatic grafts have been successfully used in patients with diabetes and are combined with kidney transplantation in patients with renal failure. The propagation of awareness in organ donation in India has increased the donor pool of transplantable organs in the last few years making multi visceral transplants feasible in our country. We present the anaesthetic management of a 32-year-old male with diabetes mellitus and end-stage renal failure who was successfully managed with a combined pancreas and kidney transplantation.