The use of transcutaneous electrical nerve stimulation (TENS) as non-pharmacological therapeutic modality is increasing. The types of TENS used clinically are conventional TENS, acupuncture TENS and intense TENS. Their working is believed to be based on gate control theory of pain and activation of endogenous opioids. TENS has been used in anaesthesia for treatment of post-operative analgesia, post-operative nausea vomiting and labour analgesia. Evidence to support analgesic efficacy of TENS is ambiguous. A systematic search of literature on PubMed and Cochrane Library from July 2012 to January 2014 identified a total of eight clinical trials investigating post-operative analgesic effects of TENS including a total of 442 patients. Most of the studies have demonstrated clinically significant reduction in pain intensity and supplemental analgesic requirement. However, these trials vary in TENS parameters used that is, duration, intensity, frequency of stimulation and location of electrodes. Further studies with adequate sample size and good methodological design are warranted to establish general recommendation for use of TENS for post-operative pain.

Video laryngoscope (VL) provides excellent laryngeal exposure in patients when anaesthesiologists encounter difficulty with direct laryngoscopy. Videolaryngoscopy, like flexible fibreoptic laryngoscopy demands a certain level of training by practitioners to become dexterous at successful intubation with a given instrument. Due to their cost factors, VLs are not easily available for training purposes to all the students, paramedics and emergency medical services providers in developing countries. We tried to develop a cost-effective instrument, which can work analogous to various available VLs. An inexpensive and easily available instrument was used to create an Airtraq Model for VL guided intubation training on manikin. Using this technique, successful intubation of manikin could be achieved. The Airtraq Model mimics the Airtraq Avant ^® and may be used for VL guided intubation training for students as well as paramedics, and decrease the time and shorten the learning curve for Airtraq ^® as well as various other VLs.

Background and Aims: i-gel^®, a recently introduced supraglottic airway device (SAD) has been claimed to be an efficient supraglottic airway. It can also be used as a conduit for endotracheal intubation. However, LMA Fastrach^® frequently used for this purpose; hence in this randomized study, success rate of blind tracheal intubation through two different SADs i-gel^® and LMA Fastrach^® was evaluated. The complications if any were also studied. Methods: A total of 100 patients undergoing elective surgery under general anaesthesia were randomised in two groups comprising of 50 patients each to tracheal intubation using either i-gel (I group) or LMA Fastrach (F group). After induction of anaesthesia SAD was inserted and on achieving adequate ventilation with the device, blind tracheal intubation was attempted through the SAD. Success at first-attempt and overall tracheal intubation success rates were evaluated, and tracheal intubation time was measured. Data were analysed using IBM SPSS Statistics 20.0 software (Statistical Package for Social Sciences by International Business Machines Corporation). P < 0.05 was considered as statistically significant. Results: There was no difference in the incidence of adequate ventilation with either of the SAD. The success rate of tracheal intubation in first attempt was 66% in Group I and 74% in Group F, while overall success rate of tracheal intubation was 82% in Group I when compared to 96% in Group F. Time taken for successful tracheal intubation through LMA Fastrach was lesser (20.96 s) when compared to i-gel (24.04 s). Complication rates were statistically similar in both the groups. Conclusion: i-gel^® is a better device for rescue ventilation due to its quick insertion but an inferior intubating device in comparison to LMA Fastrach^®.

Background and Aims: Studies have already compared propofol and midazolam as sedatives during regional anaesthesia. A few studies have focused on recovery characteristics and very few have utilised both instrumental and clinical sedation monitoring for assessing recovery time. This study was designed primarily to compare arousal time from sedation using propofol with that of midazolam during spinal anaesthesia for infraumbilical surgeries, while depth of sedation was monitored continuously with bispectral index (BIS) monitor. The correlation between the BIS score and observer's assessment of awareness/sedation (OAA/S) score during recovery from sedation was also studied. Methods: A total of 110 patients were randomly assigned to receive either propofol (Group P, n = 55) or midazolam (Group M, n = 55). Patients in the Group P received bolus of propofol (1 mg/kg), followed by infusion at 3 mg/kg/h; Group M received bolus of midazolam (0.05 mg/kg), followed by infusion at 0.06 mg/kg/h and titration until BIS score 70 was achieved and maintained between 65 and 70. OAA/S score was noted at BIS 70 and again at BIS 90 during recovery. The time to achieve OAA/S score 5 was noted. Spearman's correlation was calculated between the arousal time from sedation and the time taken to reach an OAA/S score of 5 in both the study groups. Results: Arousal time from sedation was found lower for Group P compared to Group M (7.54 ± 3.70 vs. 15.54 ± 6.93 min, respectively, P = 0.000). The time taken to reach OAA/S score 5 was also found to be lower for Group P than Group M (6.81 ± 2.54 min vs. 13.51 ± 6.24 min, respectively, P = 0.000). Conclusion: A shorter arousal time from sedation during spinal anaesthesia can be achieved using propofol compared with midazolam, while depth of sedation was monitored with BIS monitor and OAA/S score. Both objective and clinical scoring correlate strongly during recovery from sedation.

Background and Aims: Neuraxial anaesthesia has become popular for the renal surgeries during the last few years. This study was aimed at comparing general anaesthesia (GA) with epidural anaesthesia in patients undergoing renal surgeries. Methods: One hundred American Society of Anaesthesiologists (ASA) physical status-I and II adult consenting patients of both gender in the age group of 25-55 years undergoing renal surgeries were randomly assigned to two groups of 50 patients each: Group G and Group E. Group G patients were administered conventional GA while Group E received epidural anaesthesia (EA) with 3 mg/kg of ropivacaine and 1 μg/kg of dexmedetomidine. Besides cardio-respiratory parameters, surgeon's satisfaction, patient's satisfaction and side effects were observed. Parametric data were analysed by ANOVA while non-parametric data were compared with Mann-Whitney U-test and Wilcoxon test. Value of P < 0.05 was considered statistically significant. Results: The demographic profile, total anaesthesia time, surgical time and haemodynamic parameters and surgeon's satisfaction scores were comparable in both groups. Patient's satisfaction scores were better in Group E during the post-operative period. Incidence of side-effects such as nausea and vomiting and shivering were higher in Group G (P < 0.001) while the incidence of dry mouth was higher in Group E (P < 0.001). Conclusion: Epidural anaesthesia with ropivacaine and dexmedetomidine can be safely and effectively used in patients undergoing renal surgeries.

Background and Aims: Cervical spine immobilisation with rigid cervical collar imposes difficulty in intubation. Removal of the anterior part of the collar may jeopardize the safety of the cervical spine. The effect of restricted mouth opening and cervical spine immobilisation that result from the application of rigid cervical collar on intubation using Airtraq ^® was evaluated. Methods: Seventy healthy adults with normal airways included in the study were intubated Using Airtraq® with (group C) and without rigid cervical collar (group NC). The ease of insertion of Airtraq ^® into the oral cavity, intubation time, intubation difficulty score (IDS) were compared using Wilcoxon sign ranked test and McNemar test, using SPSS version 13. Results: Intubation using Airtraq ^® was successful in the presence of the cervical collar in 96% which was comparable to group without collar (P = 0.24). The restriction of mouth opening resulted in mild difficulty in insertion of Airtraq ^® . The median Likert scale for insertion was - 1 in the group C and + 1 in group NC (P < 0.001). The intubation time was longer in group C (30 ± 14.3 s vs. 26.9 ± 14.8 s) compared to group NC. The need for adjusting manoeuvres was 18.5% in group C versus 6.2% in group NC (P = 0.003) and bougie was required in 12 (18.5%) and 4 (6.2%) patients in group C and NC, respectively, to facilitate intubation (P = 0.02). The modified IDS score was higher in group C but there was no difference in the number of patients with IDS < 2. Conclusion: Tracheal intubation using Airtraq ^® in the presence of rigid cervical collar has equivalent success rate, acceptable difficulty in insertion and mild increase in IDS.

Background and Aims: Ondansetron is one of the most widely used drugs for postoperative nausea and vomiting (PONV) prophylaxis. Orally disintegrating film (ODF) formulations are relatively recent innovations. We evaluated the efficacy of ODF of ondansetron for the prophylaxis of PONV. Methods: One hundred and eighty American Society of Anaesthesiologists-I or II women, in the age group 18-65 years, scheduled for elective gynaecological laparoscopic procedures were studied in a prospective randomised, double-blind, placebo-controlled trial. The patients were randomised into four groups: Placebo, intravenous (IV) ondansetron 4 mg, ODF of ondansetron 4 mg (ODF4) and 8 mg (ODF8) groups. PONV was assessed in two epochs of 0-6 and 7-24 h. Primary outcome measure was the incidence of PONV and secondary outcome measures were severity of nausea, need for rescue anti-emetic, analgesic consumption, time to oral intake, overall patient satisfaction and side effects such as headache and dizziness. PONV was compared using analysis of variance or Mann-Whitney U-test as applicable. Results: Data of 173 patients were analysed. The incidence of postoperative nausea was significantly lower (P = 0.04) only during the 0-6 h in the ODF8 group when compared with the placebo group. During the 0-6 h interval postoperatively, the ODF8 group had a significantly lower incidence of vomiting when compared with the placebo (P = 0.002) and the IV group (P = 0.044). During the 0-24 h interval postoperatively, ODF4 (P = 0.01) and ODF8 (P = 0.002) groups had a significantly lower incidence of vomiting compared to the placebo group. Conclusions: Orally disintegrating film of ondansetron is an efficacious, novel, convenient and may be a cost-effective option for the prophylaxis of PONV.

Background and Aims: The potentiating effect of short acting lipophilic opioid fentanyl and a more selective α₂ agonist dexmedetomidine is used to reduce the dose requirement of bupivacaine and its adverse effects and also to prolong analgesia. In this study, we aimed to find out whether quality of anaesthesia is better with low dose bupivacaine and fentanyl or with low dose bupivacaine and dexmedetomidine. Methods: This prospective randomised double-blinded study was carried out in a tertiary health care centre on 150 patients by randomly allocating them into two groups using a computer generated randomisation table. Group F (n = 75) received bupivacaine 0.5% heavy (0.8 ml)+fentanyl 25 μg (0.5 ml) + normal saline 0.3 ml and Group D (n = 75) received bupivacaine 0.5% heavy (0.8 ml) + dexmedetomidine 5 μg (0.05 ml) + normal saline 0.75 ml, aiming for a final concentration of 0.25% of bupivacaine (1.6 ml), administered intrathecally. Time to reach sensory blockade to T10 segment, peak sensory block level (PSBL), time to reach peak block, time to two segment regression (TTSR), the degree of motor block, side-effects, and the perioperative analgesic requirements were assessed. Results: There were no significant differences between the groups in the time to reach T10 segment block (P > 0.05) and TTSR (P > 0.05);time to reach PSBL (P < 0.05) and modified Bromage scales (P < 0.05) were significant. PSBL (P = 0.000) and time to first analgesic request (P = 0.000) were highly significant. All patients were haemodynamically stable and no significant difference in adverse effects was observed. Conclusion: Both groups provided adequate anaesthesia for all lower abdominal surgeries with haemodynamic stability. Dexmedetomidine is superior to fentanyl since it facilitates the spread of the block and offers longer post-operative analgesic duration.

Background and Aims: Gag reflex is unwanted during upper gastrointestinal endoscopy (UGIE). Experimental studies have demonstrated that N-methyl-D-aspartate receptor antagonism prevents gag reflex. We conducted a study to determine if sub-anaesthetic doses of ketamine, added to propofol, reduce the incidence of gag reflex. Methods: This prospective, randomised, double-blind and placebo-controlled study was done in a tertiary care hospital. A total of 270 patients undergoing UGIE, were randomised to propofol (P) group (n = 135) or propofol plus ketamine (PK) group (n = 135). All patients received propofol boluses titrated to Ramsay sedation score of not <4. Patients in PK group in addition received ketamine, 0.15 mg/kg immediately before the first-propofol dose. Top-up doses of propofol were given as required. Stata 11 software (StataCorp.) was used to calculate the proportion of patients with gag reflex and the corresponding relative risk. Propofol consumed and time to recovery in the two groups was compared using Student's t-test and Cox proportional hazards regression respectively. Results: Significantly, fewer patients in the PK group had gag reflex compared to the P group (3 vs. 23, risk ratio = 0.214, 95% confidence interval [CI], 0.07-0.62; P = 0.005). The incidence of hypotension (6 vs. 16, risk ratio = 0.519, 95% CI = 0.25-1.038; P = 0.06), number of required airway manoeuvres (4 vs. 19, risk ratio = 0.32, 95% CI = 0.13-0.74; P = 0.014), median time to recovery (4 min vs. 5 min, hazard ratio = 1.311, 95% CI = 1.029-1.671; P = 0.028) and propofol dose administered (152 mg vs. 167 mg, 95% CI = 4.74-24.55; P = 0.004) was also less in the PK group compared to the P group. Conclusion: Ketamine in sub-anaesthetic dose decreases gag reflex during UGIE.

Background and Aims: Intrathecal bupivacaine results in complete anaesthetic block of longer duration than ropivacaine. Fentanyl as an adjuvant may improve the quality of spinal block of ropivacaine while maintaining its advantage of early motor recovery. In this study, we proposed to compare the efficacy and safety of intrathecal ropivacaine-fentanyl (RF) with bupivacaine-fentanyl (BF) for major lower limb orthopaedic surgeries. Methods: Sixty patients were randomly allocated to receive either intrathecal 15 mg 0.5% ropivacaine with 25 mcg fentanyl (Group RF) or 15 mg 0.5% bupivacaine with 25 mcg fentanyl (Group BF). The onset, duration, spread of sensory and motor block, haemodynamic parameters and side effects were recorded. Statistical Package for Social Sciences 20 software was used for statistical analysis. Results: Time to reach highest sensory level and complete motor block were comparable. Sensory regression to L1 dermatome was 226 ± 46.98 min in Group RF and 229.33 ± 50.51 min in Group BF, P = 0.36. The motor recovery to Bromage scale 1 was faster in Group RF (242.8 ± 47.06 min) than Group BF (268 ± 49.9 min) P = 0.023. Time for rescue analgesia was prolonged in Group BF (263.33 ± 63 min) when compared to Group RF (234.44 ± 58.76 min), P = 0.021. The haemodynamic stability was better in Group RF than Group BF. Conclusion: Intrathecal RF provided satisfactory anaesthesia with haemodynamic stability for major lower limb orthopaedic surgery. It provided similar sensory but shorter duration of motor block compared to BF which is a desirable feature for early ambulation, voiding and physiotherapy.

Background and Aims: Pentax airway scope (AWS) has been successfully used for managing difficult intubations. In this case series, we aimed to evaluate the success rate and time taken to complete intubation, when AWS was used for awake tracheal intubation. Methods: We prospectively evaluated the use of AWS for awake tracheal intubation in 30 patients. Indication for awake intubation, intubation time, total time to complete tracheal intubation, laryngoscopic view (Cormack and Lehane grade), total dose of local anaesthetic used, anaesthetists rating and patient's tolerance of the procedure were recorded. Results: The procedure was successful in 25 out of the 30 patients (83%). The mean (standard deviation) intubation time and total time to complete the tracheal intubation was 5.4 (2.4) and 13.9 (3.7) min, respectively in successful cases. The laryngeal view was grade 1 in 24 and grade 2 in one of 25 successful intubations. In three out of the five patients where the AWS failed, awake tracheal intubation was successfully completed with the assistance of flexible fibre optic scope (FOS). Conclusion: Awake tracheal intubation using AWS was successful in 83% of patients. Success rate can be further improved using a combination of AWS and FOS. Anaesthesiologists who do not routinely use FOS may find AWS easier to use for awake tracheal intubation using an oral route.

A 15-year-old boy with Noonan's syndrome was admitted for emergency ventriculo-peritoneal shunt. Intraoperative course was complicated by hypertensive urgency, which was effectively managed with high doses of esmolol (500 μg/kg/min). Difficult airway was anticipated due to presence of webbed neck and facial dysmorphism. Tracheal intubation was however successfully accomplished with the aid of a bougie. This report thus highlights the unique anaesthetic problems encountered during anaesthetic management of such a case, which is worth sharing.

The spectrum of presentation of a victim of neurotoxic snake bite can range from mild ptosis to complete paralysis and ophthalmoplegia. We report a case of snake bite in a 10-year-old child who was comatosed with bilateral fixed dilated pupils and absent doll's eye movement that was interpreted as brain death. Physicians need to be aware of the likelihood of snakebite presenting as locked in syndrome.

A 63-year-old man with severe Parkinson's disease (PD) who had been implanted with deep brain stimulators into both sides underwent radical nephrectomy under general anaesthesia with standard monitoring. Deep brain stimulation (DBS) is an alternative and effective treatment option for severe and refractory PD and other illnesses such as essential tremor and intractable epilepsy. Anaesthesia in the patients with implanted neurostimulator requires special consideration because of the interaction between neurostimulator and the diathermy. The diathermy can damage the brain tissue at the site of electrode. There are no standard guidelines for the anaesthetic management of a patient with DBS electrode in situ posted for surgery.

Horner's syndrome is not rare during labour epidural analgesia or in pregnant patients receiving epidural anaesthesia for caesarean section as thought previously. It occurs due to blockade of sympathetic fibres supplying the eye and face area. Most of the times it is a benign and self-limiting condition; however, it may become a serious systemic manifestation. We present a case where patient had weakness of upper-limb and Horner's syndrome of same side with visual disturbances. These symptoms were transient and resolved spontaneously without any treatment.

Takayasu's arteritis (TA) is a rare, chronic progressive panendarteritis involving the aorta and its main branches. Anaesthesia for patients with TA is complicated by their severe uncontrolled hypertension, end-organ dysfunction, stenosis of major blood vessels, and difficulties encountered in monitoring arterial blood pressure. In a patient with Cushing's syndrome (CS), the anaesthesiologist needs to deal with volume overload, hyperglycaemia, hypokalaemia, difficult airway and ventilation. Anaesthetic management of a patient with concomitant TA and CS undergoing adrenalectomy has hardly ever been reported. We present the successful anaesthetic management of a 15-year-old child with coexisting TA and CS undergoing open adrenalectomy.

Routine investigation of serum calcium is not recommended in ASA one and two patients unless abnormalities of calcium metabolism are clinically suspected. The clinical features of hypocalcaemia can often be subtle and may manifest in the presence of associated factors. Hypoparathyroidism, an important cause of hypocalcaemia, often presents as soft tissue calcification (ostosis). Ligamentum flavum ostosis can present with compressive myelopathy requiring laminectomy. We report a case of ligamentum flavum ostosis and subclinical hypocalcaemia due to hypoparathyroidism, who went undetected pre-operatively resulting in significant post-operative morbidity.