Scrub typhus is an acute febrile illness caused by orientia tsutsugamushi, transmitted to humans by the bite of the larva of trombiculid mites. It causes a disseminated vasculitic and perivascular inflammatory lesions resulting in significant vascular leakage and end-organ injury. It affects people of all ages and even though scrub typhus in pregnancy is uncommon, it is associated with increased foetal loss, preterm delivery, and small for gestational age infants. After an incubation period of 6-21 days, onset is characterized by fever, headache, myalgia, cough, and gastrointestinal symptoms. A primary papular lesion which later crusts to form a flat black eschar, may be present. If untreated, serious complications may occur involving various organs. Laboratory studies usually reveal leukopenia, thrombocytopenia, deranged hepatic and renal function, proteinuria and reticulonodular infiltrate. Owing to the potential for severe complications, diagnosis, and decision to initiate treatment should be based on clinical suspicion and confirmed by serologic tests. A therapeutic trial of tetracycline or chloramphenicol is indicated in patients in whom the diagnosis of scrub typhus is suspected. The recommended treatment regimen for scrub typhus is doxycycline. Alternative regimens include tetracycline, chloramphenicol, azithromycin, ciprofloxacin, rifampicin, and roxithromycin. Treatment of pregnant women with azithromycin was successfully done without relapse and with favorable pregnancy outcomes. Hence, early diagnosis and treatment are essential in order to reduce the mortality and the complications associated with the disease. We searched the English-language literature for reports of scrub typhus in children, pregnant women, and non-pregnant patients with scrub typhus, using the MEDLINE/PubMed database, which includes citations from 1945 to the present time. We used the search terms 'scrub typhus', 'scrub typhus' and 'pregnancy', 'scrub typhus' and 'children', 'scrub typhus' and 'complications', 'scrub typhus' and 'treatment'.

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Melatonin is a neurohormone secreted by the pineal gland. It is widely present in both plant and animal sources. In several countries, it is sold over the counter as tablets and as food supplement or additive. Currently, it is most often used to prevent jet lag and to induce sleep. It has been and is being used in several clinical trials with different therapeutic approaches. It has sedative, analgesic, anti-inflammatory, anti-oxidative and chronobiotic effects. In the present review, the potential therapeutic benefits of melatonin in anaesthesia and critical care are presented. This article aims to review the physiological properties of melatonin and how these could prove useful for several clinical applications in perioperative management, critical care and pain medicine. The topic was handsearched from textbooks and journals and electronically from PubMed, and Google scholar using text words.

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Background: Different additives have been used to prolong brachial plexus block. We performed a prospective, randomised, double-blind study to evaluate the effect of dexamethasone added to lidocaine on the onset and duration of supraclavicular brachial plexus block as this is the most common type of brachial block performed in our institute. Methods: Sixty American Society of Anaesthesiologist's physical status I and II patients undergoing elective hand, forearm and elbow surgery under brachial plexus block were randomly allocated to receive either 1.5% lidocaine (7 mg/kg) with adrenaline (1:200,000) and 2 ml of normal saline (group C, n=30) or 1.5% lidocaine (7 mg/kg) with adrenaline (1:200,000) and 2 ml of dexamethasone (8 mg) (group D, n=30). The block was performed using a nerve stimulator. Onset and duration of sensory and motor blockade were assessed. The sensory and motor blockade of radial, median, ulnar and musculocutaneous nerves were evaluated and recorded at 5, 10, 20, 120 min, and at every 30 min thereafter. Results: Two patients were excluded from the study because of block failure. The onset of sensory and motor blockade (13.4±2.8 vs. 16.0±2.3 min and 16.0±2.7 vs. 18.7±2.8 min, respectively) were significantly more rapid in the dexamethasone group than in the control group ( P=0.001). The duration of sensory and motor blockade (326±58.6 vs. 159±20.1 and 290.6±52.7 vs. 135.5±20.3 min, respectively) were significantly longer in the dexamethasone group than in the control group ( P=0.001). Conclusion: Addition of dexamethasone to 1.5% lidocaine with adrenaline in supraclavicular brachial plexus block speeds the onset and prolongs the duration of sensory and motor blockade.

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Context: Literature suggests glottic view is better with straight blades while tracheal intubation is easier with curved blades. Aims: To compare glottic view and ease of intubation with Macintosh, Miller, McCoy blades and the Trueview^® laryngoscope. Settings and Design: This prospective randomised study was undertaken in operation theatres of a 550 bedded tertiary referral cancer centre after approval from the Institutional Review Board. Methods: We compared the Macintosh, Miller, McCoy blades and the Trueview^® laryngoscope for glottic visualisation and ease of tracheal intubation; in 120 patients undergoing elective cancer surgery; randomly divided into four groups. After induction of anaesthesia laryngoscopy was performed and trachea intubated. We recorded: Visualisation of glottis (Cormack Lehane grade), ease of intubation, number of attempts; need to change the blade and need for external laryngeal manipulation. Statistical Analysis: Demographic data, Mallampati classification were compared using the Chi-square test. A P<0.05 was considered significant. Results: Grade 1 view was obtained most often (87% patients) with Trueview^® laryngoscope. Intubation was easier (Grade 1) with Trueview^® and McCoy blades (93% each). Seven patients needed two attempts; one patient in Miller group needed three attempts. No patient in McCoy and Trueview^® Groups required external laryngeal manipulation. Conclusions: We found that in patients with normal airway glottis was best visualised with Miller blade and Trueview^® laryngoscope however, the trachea was more easily intubated with McCoy and Macintosh blades and Trueview^® laryngoscope.

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Through evolving research, recent years have witnessed remarkable achievements in neuromonitoring and neuroanesthetic techniques, with a huge body of literature consisting of excellent studies in neuroanaesthesiology. However, little of this work appears to be directly important to clinical practice. Many controversies still exist in care of patients with neurologic injury. This review discusses studies of great clinical importance carried out in the last five years, which have the potential of influencing our current clinical practice and also attempts to define areas in need of further research. Relevant literature was obtained through multiple sources that included professional websites, medical journals and textbooks using key words "neuroanaesthesiology," "traumatic brain injury," "aneurysmal subarachnoid haemorrhage," "carotid artery disease," "brain protection," "glycemic management" and "neurocritical care." In head injured patients, administration of colloid and pre-hospital hypertonic saline resuscitation have not been found beneficial while use of multimodality monitoring, individualized optimal cerebral perfusion pressure therapy, tranexamic acid and decompressive craniectomy needs further evaluation. Studies are underway for establishing cerebroprotective potential of therapeutic hypothermia. Local anaesthesia provides better neurocognitive outcome in patients undergoing carotid endarterectomy compared with general anaesthesia. In patients with aneurysmal subarachnoid haemorrhage, induced hypertension alone is currently recommended for treating suspected cerebral vasospasm in place of triple H therapy. Till date, nimodipine is the only drug with proven efficacy in preventing cerebral vasospasm. In neurocritically ill patients, intensive insulin therapy results in substantial increase in hypoglycemic episodes and mortality rate, with current emphasis on minimizing glucose variability. Results of ongoing multicentric trials are likely to further improvise our practice.

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Background: There is limited data to predict the course of sub-arachnoid block in poliomyelitis patients with scoliotic spine. So we intended to study the course of intrathecal anaesthesia in these patients in comparison to patients with normal spine using 0.5% bupivacaine (heavy). Methods: In this prospective observational study, 41 poliomyelitic patients scheduled for lower limb corrective surgeries under spinal anaesthesia were enrolled. Patients were studied in two groups (Scolotic spine, n=20; Normal spine, n=21). All patients were injected 2 ml of 0.5% bupivacaine heavy intrathecally in the sitting position. The extent of block, bilateral spread, regression of sensory block and motor block were recorded. Demographic data were analysed using the unpaired t test or the chi square test as applicable. Block characteristics were analysed using the Mann Whitney U test. Results: There was statistically significant difference in bilateral spread of sensory block in between the groups. However, there was no significant difference in the maximum extent of the sensory block and the time taken for two segment regression of sensory block. There was no significant difference in time taken to reach complete motor block and for complete recovery from motor block to its preoperative value. Conclusions: Bilateral symmetrical spread of local anaesthetics through intrathecal route cannot be predicted accurately in patients with scoliotic spine. Spinal anaesthesia can be safely administered in poliomyelitis patients with scoliosis with less adverse effects.

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Background: Perfusion index (PI) is a non-invasive numerical value of peripheral perfusion obtained from a pulse oximeter. In this study, we evaluated the efficacy of PI for detecting haemodynamic stress responses to insertion of i-gel, laryngeal mask airway (LMA) and endotracheal tube and compare, its reliability with the conventional haemodynamic criteria in adults during general anaesthesia. Methods: Sixty patients scheduled for elective general surgery under general anaesthesia were randomised to three groups. (i-gel, LMA and ET groups ( n=20/group). Heart rate (HR) (positive if ≥10 bpm), systolic blood pressure (SBP), diastolic blood pressure (DBP) (positive if ≥15 mm Hg) and PI (positive if ≤10%) were monitored for 5 min after insertion. Main outcome measures: SBP, DBP, HR and PI were measured before induction of anaesthesia and before and after insertion of the airway device. Results: Insertion of airway devices produced significant increases in HR, SBP and DBP in LMA and ET groups. Moreover, PI was decreased significantly by 40%, 100% and 100% in the three groups. Using the PI criterion, the sensitivity was 100% (CI 82.4-100.0%). Regarding the SBP and DBP criterions, the sensitivity was 44.4% (CI 24.6-66.3%), 55.6% (CI 33.7-75.4%) respectively. Also, significant change in the mean PI over time (from pre-insertion value to the 1 ^st min, 3 ^rd min, until the 4 ^th min after insertion without regard the device type), ( P<0.001). Conclusion: PI is a reliable and easier alternative to conventional haemodynamic criteria for detection of stress response to insertion of i-gel, LMA and ET during propofol fentanyl isoflurane anaesthesia in adult patients.

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Background: Ineffective face mask seal is the most common cause for suboptimal pre-oxygenation. Room air entrainment can be more with vital capacity (VC) breaths when the mask is not a tight fit. Aims: This study was designed to compare 5 min tidal volume (TV) breathing and eight VC breaths in patients with ineffective face mask seal. Methods: Twenty eight ASA I adults with ineffective face mask seal were randomized to breathe 100% oxygen at normal TV for 5 min (Group TV) and eight VC breaths (Group VC) in a cross over manner through circle system at 10 L/min. End tidal oxygen concentration (EtO ₂ ) and arterial blood gas analysis was performed to evaluate oxygenation with each technique. Statistical Analysis: Data were analysed using SPSS statistical software, version 16. Friedman's two-way analysis of variance by ranks was used for non-parametric data. Results: Significant increase in EtO ₂ (median 90) and PaO ₂ (228.85) was seen in group TV when compared to group VC (EtO ₂ median 85, PaO ₂ 147.65), P<0.05. Mean total ventilation volume in 1 min in group VC was 9.4±3.3 L/min and more than fresh gas flow (10 L/min) in seven patients. In group TV, the fresh gas flow (50 L/5 min) was sufficient at normal TV (mean total ventilation in 5 min 36.7±6.3 L/min). Conclusions: TV breathing for 5 min provides better pre-oxygenation in patients with ineffective mask seal with fresh gas flow of 10 L/min delivered through a circle system.

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Background: Cocaine is often used topically to provide the profound vasoconstriction required for nasal surgery; however, it has been associated with intraoperative cardiac adverse effects. We compared cocaine with phenylephrine as an alternative to ascertain their relative efficacy as vasoconstrictors in nasal septoplasty. Methods: Adult patients, presenting for elective nasal septoplasty, of American Society of Anaesthesiologists physical status I-III, were randomised to either 0.5% phenylephrine or 4% cocaine. The primary outcome was quality of vasoconstriction on a 5-point scale (1=unacceptable, 5=excellent), rated by the surgeon at the end of the procedure. Results: Twenty-nine patients received phenylephrine and 26 received cocaine. The median rating for quality of the vasoconstriction was 4.0 (good) in both the phenylephrine and cocaine groups ( P=0.84). Median blood loss was 50 ml in the phenylephrine group and 62.5 ml in the cocaine group ( P=0.49). In secondary analyses, phenylephrine was shown to be non-inferior to cocaine on both quality of vasoconstriction (non-inferiority delta of 1 point, P=0.009) and estimated blood loss (non-inferiority delta of 25 ml, P=0.028). The frequency of ventricular ectopy, ST segment changes or blood pressure changes after nasal packing was not significantly different between the two groups. Conclusion: Phenylephrine in a concentration of 0.5% is not different from 4% cocaine on the quality of vasoconstriction in septoplasty. Given the abuse potential of cocaine and the added administrative burden associated with its handling, phenylephrine might serve as an alternative.

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Negative pressure pulmonary oedema (NPPO) is a life threatening condition, manifested due to upper airway obstruction in a spontaneously breathing patient. Upper airway obstruction caused by classic laryngeal mask airway (cLMA) and ProSeal laryngeal mask airway (PLMA) has been reported, and NPPO has also been reported following the use of cLMA. Search of literature did not confirm NPPO following the use of PLMA. We encountered a female patient of NPPO scheduled for incision and drainage of an abscess who had signs of airway obstruction following PLMA insertion. Multiple attempts were made to get patent airway without success. PLMA was replaced with endotracheal tube following which pink frothy secretion appeared in breathing circuit. Patient was managed successfully with ICU care.

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Background: The peripheral nerve endings carrying pain contains opiod receptors. Blocking these receptors during haematoma block or periosteal block may provide better analgesia. Aim: Evaluation of effectiveness and safety of butorphanol as an adjuvant to lidocaine for haematoma block. Settings and Design: This is a two centre, prospective, individually randomised, two group, parallel, double-blind clinical trial. Methods: In this study, 115 American society of anaesthesiologist grade I and II adult patients scheduled for closed reduction of fractures were randomly allocated into two groups; Group A received 1% lidocaine (2 mg/kg) where as Group B received 1% lidocaine (2 mg/kg) with butorphanol (0.02 mg/kg) during haematoma block. Pain was assessed before, during and after manipulation of fracture by using visual analogue scale (VAS 0-10). Onset time of block, time for first rescue analgesic, 24 hour analgesic requirement and sedation levels were noted. Statistical Analysis: Data analysed with the unpaired t-test with Welch correction assuming unequal variances and Fisher's exact test using Graph pad Prism 5.02 version. Results: Onset time of haematoma block was significantly less in the butorphanol group compared to the lidocaine group ( P=0.0003). The mean time for first rescue analgesic was significantly higher and total analgesic requirement was significantly lower in the butorphanol group ( P<0.0001). Mean VAS scores were lower and sedation scores were higher in the butorphanol group. Conclusions: Addition of butorphanol to lidocaine quickens onset of haematoma block, provides excellent post manipulation analgesia and decreases 24 hour total analgesic requirement without excessive sedation.

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Doxorubicin (Dox) is an antineoplastic agent used in a wide variety of malignancies. Its use is limited because of a cumulative, dose-dependent irreversible cardiomyopathy. We report a case of Dox induced cardiomyopathy, posted for modified radical mastectomy. The patient had poor LV function along with moderate pulmonary hypertension. Regional anaesthesia was planned as the risk associated with general anaesthesia was more. A cervical epidural was placed and a block adequate for surgery could be achived. The haemodynamic parameters as measured by esophageal doppler showed a stable trend. The surgery could be managed well under cervical epidural and also provided a good postoperative pain relief.

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Postoperative diaphragmatic hernia following transhiatal oesophagectomy is a rare but potentially life threatening complication. We describe a case of a 65 year old patient who developed diaphragmatic hernia following oesophagectomy and presented with cardio pulmonary compromise. During surgery, haemodynamic instability continued despite fluid resuscitation and noradrenaline infusion. An immediate improvement in the haemodynamics and reduction in airway pressure occurred on reduction of the herniated colon from the thoracic cavity. This can be explained by tension colothorax causing collapse of the underlying lung and cardiac tamponade. It is a surgical emergency requiring urgent decompression for resuscitation. The etiology, clinical presentation, pathophysiology and preventive measures are discussed.

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