Anaesthesiology is a speciality that delivers most prompt and positive results in medical field. This naturally leads to high expectations among the general public. In the past, patients used to subject themselves to surgery after signing a simple willingness form. But in the present scenario, if any catastrophe occurs, it grabs news headlines, negligence is suspected by laymen in such cases, and these cases land up in a court of law. In the courts, decisions are left to judiciary, which can be potentially influenced by the opinon of general public. This leaves a lot of subjectivity in these decisions. There has been a rising trend in medical negligence cases registered in consumer courts after the decision of the Supreme Court, that the services provided by an anaesthesiologist come under the word "service" of Consumer Protection Act (1986). So the apprehension amongst the anaesthesiologists regarding the legal issues is rising. This article underlines the standard of care, protocols by which anaesthesiologists should abide to avoid legal consequences. Doctors should have legal awareness so that they can defend their cases in courts properly. There is a need to maintain healthy doctor-patient relationship, good record keeping, and to provide a reasonable standard of care. Doctors should keep abreast with the latest development in the medical field.

Background and Aims: At equal minimum alveolar concentration (MAC), volatile agents may produce different bispectral index (BIS) values especially at low BIS levels when the effect is volatile agent specific. The present study was performed to compare the BIS values produced by sevoflurane and isoflurane at equal MAC and thereby assessing which is a better hypnotic agent. Methods: Sixty American Society of Anaesthesiologists I and II patients undergoing elective mastoidectomy were divided into groups receiving either isoflurane or sevoflurane, and at equi-MAC. BIS value was measured during both wash in and wash out phase, keeping other parameters same. Statistical analysis was performed using the Friedman two-way analysis and Mann-Whitney U-test. A P < 0.05 was considered significant. Results: BIS value was significantly lower with sevoflurane at all MAC values as compared to isoflurane, except in the beginning and at MAC awake. However, both the drugs proved to be cardiostable. Conclusion: At equi-MAC sevoflurane produces lower BIS values during wash in as well as wash out phase as compared to isoflurane, reflecting probably an agent specific effect and a deficiency in BIS algorithm for certain agents and their interplay.

Background and Aims: Traditionally, uncuffed endotracheal tubes have been used in children. Cuffed tubes may be useful in special situations like laparoscopy. Microcuff ^® endotracheal tube is a specifically designed cuffed endotracheal tube for the paediatric airway. We studied the appropriateness of Microcuff ^® tube size selection, efficacy of ventilation, and complications, in children undergoing laparoscopy. Methods: In a prospective, observational study, 100 children undergoing elective laparoscopy were intubated with Microcuff ^® tube as per recommended size. We studied appropriateness of size selection, sealing pressure, ability to ventilate with low flow, quality of capnography and post-extubation laryngospasm or stridor. Results: Mean age of the patients was 5.44 years (range 8 months 5 days-9 years 11 months). There was no resistance for tube passage during intubation in any patient. Leak on intermittent positive pressure ventilation at airway pressure ≤20 cm H ₂ O was present in all patients. Mean sealing pressure was 11.72 (1.9 standard deviation [SD]) cm H ₂ O. With the creation of pnemoperitoneum, mean intracuff pressure increased to 12.48 (3.12 SD) cm H ₂ O. With head low positioning, mean cuff pressure recorded was 13.32 (2.92 SD). Ventilation at low flow (mean flow 1 L/min), plateau-type capnography was noted in all patients. Mean duration of intubation was 83.50 min. Coughing at extubation occurred in 6 patients. Partial laryngospasm occurred in 4 patients, which responded to continuous positive airway pressure via face mask. Severe laryngospasm or stridor was not seen in any patient. Conclusion: Microcuff ^® tubes can be safely used in children if size selection recommendations are followed and cuff pressure is strictly monitored. Advantages are better airway seal and effective ventilation, permitting use of low flows.

Background and Aims: The effect of perineural dexmedetomidine on the time to onset, quality and duration of motor block with ropivacaine has been equivocal and its interaction with general anaesthesia (GA) has not been reported. We assessed the influence of dexmedetomidine added to 0.5% ropivacaine on the characteristics of supraclavicular brachial plexus block and its interaction with GA. Methods: In a randomised, double blind study, 36 patients scheduled for orthopaedic surgery on the upper limb under supraclavicular block and GA were divided into either R group (35 ml of 0.5% ropivacaine with 0.5 ml of normal saline [n - 18]) or RD group (35 mL of 0.5% ropivacaine with 50 μg dexmedetomidine [n - 18]). The onset time and duration of motor and sensory blockade were noted. The requirement of general anaesthetics was recorded. Results: Both the groups were comparable in demographic characteristics. The time of onset of sensory block was not significantly different. The proportion of patients who achieved complete motor blockade was more in the RD group. The onset of motor block was earlier in group RD than group R (P < 0.05). The durations of analgesia, sensory and motor blockade were significantly prolonged in group RD (P < 0.00). The requirement of entropy guided anaesthetic agents was not different in both groups. Conclusions: The addition of dexmedetomidine to 0.5% ropivacaine improved the time of onset, quality and duration of supraclavicular brachial plexus block but did not decrease the requirement of anaesthetic agents during GA.

Background and Aims: Evidence for the predictive value of the cuff leak test (CLT) for post-extubation stridor (PES) is conflicting. We evaluated the association and accuracy of CLT alone or combined with other laryngeal parameters with PES. Methods: Fifty-one mechanically ventilated adult patients in a medical-surgical intensive care unit were tested prior to extubation using; CLT, laryngeal ultrasound and indirect laryngoscopy. Biometric, laryngeal and endotracheal tube (ETT) parameters were recorded. Results: PES incidence was 4%. CLT demonstrated 'no leak' in 20% of patients. Laryngeal oedema was present in 10% of the patients on indirect laryngoscopy, and 71% of the patients had a Grades 1-3 indirect laryngoscopic view. Mean air column width on laryngeal ultrasound was 0.66 ± 0.15 cm (cuff deflated), mean ratio of ETT to laryngeal diameter was 0.48 ± 0.07, and the calculated CLT and laryngeal survey composite was 0.86 ± 1.25 (range 0-5). CLT and the CLT and Laryngeal survey composite measure were not associated with or predict PES. Age, sex, peri-extubation steroid use, intubation duration and body mass index were not associated with PES. Conclusion: Even including ultrasonographic and indirect laryngoscopic examination of the airway, no single aspect of the CLT or combination with laryngeal parameters accurately predicts PES.

Background and Aims: The anaesthesiologists' understanding and knowledge of law has an important bearing on issues, related to anaesthesia practice. Lack of such knowledge could also lead to misperceptions affecting both patient care and professional practices. The aim of the study was to find out exact nature of apprehension of the anaesthesia providers towards the implementation of the law related to anaesthesia practice. Methods: A prospective survey of 875 anaesthesia specialists was conducted during informal meetings personally by the investigator and the responses to a standard set of queries were noted. Also included were the remarks and suggestions related to each query. Three different set of practitioners depending on the place of work (teaching hospital, corporate hospital and small establishments) were queried. Results: The opinions of all three groups of anaesthesiologists did not differ materially. The opinions and views were similar in many aspects and controversy existed in few areas. Major confusion was about how much information should be provided to patients before anaesthesia to obtain informed consent. Opinions were offered for prevention of litigations and how to face litigations but there was the lack of clarity on these issues. Conclusions: The anaesthesiologists are invariably confused about how exactly they should prevent litigations or respond to them. The majority expressed need for intervention by Indian Society of Anaesthesiologists (ISA) to prepare protocols and set up medico-legal cells.

Trends in selection of a career in medicine vary from country to country. To plan future recruitment strategies and to balance distribution of physicians among medical specialties, each country needs to examine these reasons as part of educational research. The aim of this study was to explore the Anaesthesiology postgraduate students' knowledge about anaesthesia as a speciality, their attitude towards anaesthesia as a career choice, stress levels during the period of postgraduation, views regarding Diploma in Anaesthesiology and undergraduate exposure to the subject. Eight hundred pretested questionnaires were provided to the anaesthesia postgraduate students attending various national level conferences in India. The collected data were statistically analysed using SPSS version 20. Only 31.6% of the students were aware of scope of anaesthesiology and 42.3% of students joined the speciality out of the interest to learn the subject, whereas 55.7% joined for other reasons, including non-availability of other specialties during medical postgraduate counselling. About 70% of students were stressed out during postgraduation, 31.6% found difficulty in accommodating the demands of challenging job and 3.8% went into depression. Majority of anaesthesiology postgraduate students were unaware of the scope of Anaesthesiology at the time of medical postgraduate counselling; only two-fifth of the students joined the speciality out of interest to learn the subject and most of them felt stressed out during the period of postgraduation. Majority of the students were of the opinion that Diploma in Anaesthesia was not a viable career option and should be scrapped.

Epidural analgesia, though the gold standard of post-operative pain management for laparotomies, is associated with limitations and is contraindicated in many patients. Opioid-based pain management, which is an alternative to epidural, has been implicated in post-operative nausea, vomiting, and ileus. We report successful management of post operative pain with ultrasound guided rectus sheath (RS) catheters. RS block is a promising alternative in scenarios were epidural is contraindicated, has failed or in case of unexpected change in the surgical plan.