The brain-dead organ donation programme is slowly gathering momentum in India. There is a long way to go before our cadaver donor numbers, currently at 0.35 per million reaches 35 per million as is the case in countries like Spain. Each donor, therefore, has to be managed immaculately. The anaesthesiologists will be well served by familiarising themselves with the challenges during the crucial period preceding and during the actual harvest of organs in a brain-dead donor. There are significant opportunities for anaesthesiologists to make great contributions in this cause due to their unique skill sets and perspective. A robust brain-dead cadaver programme will go a long way in saving numerous lives as well as reduce the requirements of the living donor programme. A well-managed harvest will ensure good quality organs and an overall superior outcome in the recipients.

Background and Aims: Brain death is defined as irreversible and complete cessation of all brain function including that of the brainstem. The aim of this study was to assess the level of knowledge and awareness about brain-death declaration among resident doctors. Methods: This was an observational questionnaire-based study conducted in single institute in which 112 junior residents and 46 senior resident doctors in various medical specialities were included by universal sampling method. A prevalidated questionnaire consisting of questions related to knowledge, attitude and performance of brain-death declaration were distributed among residents as per the inclusion criteria to fill in the time limit of 30 min. Statistical tools used were mean and standard deviation, proportion and Chi-square test. Results: A total 87 resident doctors consisting of 71.26% males and 28.73% females responded to the questionnaire. About 91.95% correctly defined it as complete cessation of brain activity including brainstem reflexes. Most of the resident doctors (80.45%) knew about the documentation of absence of brainstem reflexes at 6 h intervals and 64.36% were aware about positive apnoea test. When asked about whether there is legal sanction for disconnecting life support in India, 56.32% said no, and 43.67% said yes. Only 12.64% of resident doctors were aware about a panel of 4 physicians are mandatory to declare brain death in India. Conclusion: Awareness and attitude towards the identification of brain death and possible deceased donor organ transplantation were lacking amongst resident doctors.

Background and Aims: Post-operative vomiting (POV) in children remains a significant clinical problem. This prospective study aims to investigate the applicability of well-established adult early post-operative nausea and vomiting (PONV) risk factors on paediatric POV after adenotonsillectomies under regulated anaesthetic conditions. Methods: After Institutional Review Board approval, 213 children aged 3–10-year-old were enrolled. The participants had pre-operative questionnaires completed, followed protocolised anaesthetic plans and had saliva analysed for cotinine. The primary outcomes were POV as correlated with age, gender, family or personal history of PONV, motion sickness history, opioid use, surgical time, anaesthetic time and environmental tobacco smoke (ETS) exposure, as assessed by cotinine levels and questionnaire reports. Data on analgesics, antiemetics and POV incidence before post-anaesthesia care unit discharge were collected. Statistical analysis was done through multiple logistic regression. Results: A total of 200 patients finalised the study. Early POV occurred in 32%. Family history of PONV (odds ratio [OR] = 5.3, P < 0.01) and motion sickness history (OR = 4.4, P = 0.02) were highly significant risk factors. Age reached borderline statistical significance (OR = 1.4, P = 0.05). None of the other factors reached statistical significance. Conclusion: Early POV occurs frequently in paediatric patients undergoing adenotonsillectomies. In this paediatric-aged group, the incidence of POV was affected by the family history of PONV, and history of motion sickness. Age, female gender, opioid use, surgical and anaesthetic times did not affect the incidence of POV. ETS exposure, as assessed by cotinine levels and questionnaire reports, had no protective effect on early paediatric POV.

Background and Aims: The ProSeal™ laryngeal mask airway (PLMA), i-gel™ and Laryngeal Tube Suction-D (LTS-D™) have previously been evaluated alone or in pair-wise comparisons but differing study designs make it difficult to compare the results. The aim of this study was to compare the clinical performance of these three devices in terms of efficacy and safety in patients receiving mechanical ventilation during elective surgical procedures. Methods: This prospective, randomised, double-blind study was conducted on 150 American Society of Anesthesiologists physical status I–II patients, randomly allocated into 3 groups, undergoing elective surgical procedures under general anaesthesia. PLMA, i-gel™ or LTS-D™ appropriate for weight or/and height was inserted. Primary outcome measured was airway sealing pressure. Insertion time, ease of insertion, number of attempts, overall success rate and the incidence of airway trauma and complications were also recorded. Intergroup differences were compared using one-way analysis of variance with post hoc correction for continuous data and Chi-square test for categorical variables. Results: Overall success rate was comparable between the three devices (i-gel™ 100%, LTS-D™ 94%, PLMA 96%). Airway sealing pressure was lower with i-gel™ (23.38 ± 2.06 cm H₂O) compared to LTS-D™ (26.06 ± 2.11 cm H₂O) and PLMA (28.5 ± 2.8 cm H₂O; P < 0.0005). The mean insertion time was significantly more in PLMA (38.77 ± 3.2 s) compared to i-gel™ (27.9 ± 2.53 s) and LTS-D™ (21.66 ± 2.31 s; P < 0.0005). Conclusion: Airway sealing pressure and insertion time were significantly higher in PLMA compared to i-gel™ and LTS-D™.

Background and Aims: Post-operative nausea and vomiting (PONV) is highly distressing and unpleasant symptom. Dexamethasone and palonosetron are effective antiemetics with minimal side effect profile. This study compares the efficacy of palonosetron or dexamethasone alone and their combination (palonosetron plus dexamethasone) for prevention of PONV after laparoscopic cholecystectomy. Methods: This prospective, randomised, double-blind trial was done on 187 adults, American Society of Anesthesiologists Grade I and II patients, aged 18–75 years undergoing laparoscopic cholecystectomy. They were allocated to three groups which were to receive either of the three treatment regimens: dexamethasone 8 mg (Group D, n = 57), palonosetron 0.075 mg (Group P, n = 66) or dexamethasone 8 mg plus palonosetron 0.075 mg (Group PD, n = 64). The primary outcome was incidence of PONV in 24 h and the secondary outcome was a number of rescue antiemetic required. One-way ANOVA test was used to compare the means amongst three groups. To compare the proportions in the groups, Chi-square test/Fisher's exact test/Two proportions Z-test was applied as appropriate. Results: Overall incidences of PONV in the study 24 h postoperatively were 23.4% in PD, 27.2% in P group and 56.14% in D group (P < 0.001). Requirement of rescue antiemetic was more in dexamethasone group than other two groups (PD = 1 time, P = 1.38 times and D = 1.5 times). Conclusion: Palonosetron alone and palonosetron-dexamethasone combination were equally effective in the prevention of PONV. Dexamethasone alone was least effective amongst the three groups. There is no difference between palonosetron and palonosetron-dexamethasone for PONV prevention.

Background and Aims: The external jugular vein (EJV), often used for resuscitation, has been underutilised for central venous catheterisation (CVC) in view of an unpredictable success rate. There is an encouraging literature on the improved success rate of CVC through EJV with the inclusion of certain body manoeuvres. This prospective randomised controlled study was conducted with the aim of evaluating the efficacy of body manoeuvres in improving the success rate of CVC through EJV. Methods: One hundred patients aged 18–50 years, scheduled for elective surgery requiring CVC, were randomly assigned to either undergo CVC using Seldinger technique with body manoeuvres or a control group undergoing CVC without body manoeuvres. The primary outcome was the success rate of CVC, as observed in the post-procedure chest radiograph. Secondary outcomes included quality of central venous pressure waveform, catheterisation attempts, total time for CVC, complications. Results: CVC was achieved in 98% (49/50) of patients in study group and 80% (40/50) of patients in control group (P = 0.008). Mean catheterisation time was significantly lower in the study group (151.06 ± 40.50 s) compared to control group (173.50 ± 50.66 s) (P = 0.023). The incidence of catheter misplacement and failure to cannulate were lower in the study group (0%, 2% vs. 20%, 12.5%, respectively). Groups did not differ in a number of catheterisation attempts and incidence of haematoma. Conclusion: Inclusion of various body manoeuvres to Seldinger technique significantly improves the success rate of CVC through EJV.

Background and Aims: Hypotension during propofol induction is a common problem. Perfusion index (PI), an indicator of systemic vascular resistance, is said to be predictive of hypotension following subarachnoid block. We hypothesised that PI can predict hypotension following propofol induction and a cut-off value beyond which hypotension is more common can be determined. Methods: Fifty adults belonging to the American Society of Anesthesiologists' physical status I/II undergoing elective surgery under general anaesthesia were enrolled for this prospective, observational study. PI, heart rate, blood pressure (BP) and oxygen saturation were recorded every minute from baseline to 10 min following induction of anaesthesia with a titrated dose of propofol, and after endotracheal intubation. Hypotension was defined as fall in systolic BP (SBP) by >30% of baseline or mean arterial pressure (MAP) to <60 mm Hg. Severe hypotension (MAP of <55 mm Hg) was treated. Results: Within first 5-min after induction, the incidence of hypotension with SBP and MAP criteria was 30% and 42%, respectively, and that of severe hypotension, 22%. Baseline PI <1.05 predicted incidence of hypotension at 5 min with sensitivity 93%, specificity 71%, positive predictive value (PPV) 68% and negative predictive value (NPV) 98%. The area under the ROC curve (AUC) was 0.816, 95% confidence interval (0.699–0.933), P < 0.001 Conclusion: Perfusion index could predict hypotension following propofol induction, especially before endotracheal intubation, and had a very high negative predictive value.

Background and Aims: Hyponatraemia is frequent in post-operative patients and may be corrected with hypertonic saline (HTS). Oral tolvaptan is used to treat hypervolaemic or euvolaemic hyponatraemia. This study was performed to assess the efficacy of oral tolvaptan in correcting postoperative hyponatraemia compared to HTS. Methods: This prospective, randomised study was conducted in 40 symptomatic patients with serum sodium level ≤130 mEq/L. In Group H (n = 20), 3% HTS was infused at 20–30 mL/h aiming for correction of 6 mEq/L/day. Group T received oral tolvaptan 15 mg on the 1^st day. If daily correction was <4 mEq/L, the dose was increased by 15 mg/day to a maximum of 45 mg. The primary outcome was serum sodium concentration 48 hours after starting treatment. Paired t-test was used to compare changes in sodium levels. Results: Baseline sodium and values at 12, 24 and 48 h were comparable in both groups. At 72 h, Group T had significantly higher sodium levels as compared to Group H (133.4 ± 1.9 vs. 131.3 ± 2.4 mEq/L). Intragroup analysis had shown a significant increase in sodium levels from baseline values in both groups at 12, 24, 48 and 72 h. Group H had a significantly lower potassium level and lower negative fluid balance on day 3. Conclusion: Oral tolvaptan and 3% HTS were equally effective in correcting hyponatraemia at 48 hours, but serum sodium levels were higher at 72 hours after oral tolvaptan.

Background and Aims: In patients undergoing transurethral resection of prostate (TURP), it is vital to restrict the level of block to T₁₀dermatome during spinal anaesthesia. Low-dose bupivacaine causes minimum haemodynamic alterations, but may provide insufficient surgical anaesthesia. Dexmedetomidine, a selective α₂-adrenoreceptor agonist, is a potent anti-nociceptive agent when given intrathecally. The aim of this study was to compare the adjuvant effects of intrathecal dexmedetomidine with low-dose bupivacaine spinal anaesthesia versus a higher dose of bupivacaine in patients undergoing TURP. Methods: The study was designed as a prospective, double-blind, randomised trial that included sixty patients of American Society of Anesthesiologists Grade I–III scheduled for TURP. They were allocated into two groups: Group I receiving only hyperbaric bupivacaine intrathecally and Group II receiving dexmedetomidine with low dose bupivacaine. The time to regression of two dermatomes from the peak sensory block level was the primary outcome of the study. Results: With comparable baseline and demographic attributes, both groups had similar peak sensory block levels (T₉). Patients in Group II had quicker onset with the time to reach T₁₀being faster (10.72 ± 3.50 vs. 12.72 ± 3.90 min, P = 0.041), longer duration of motor block (200 ± 18.23 vs. 190 ± 10.15 min, P = 0.011) and increased time to first analgesic requirement (300 ± 25.30 vs. 220 ± 15.12 min, P = 0.0001). Conclusion: Intrathecal dexmedetomidine with low-dose bupivacaine provides faster onset, prolonged sensory and motor block and reduced rescue analgesic requirement in patients undergoing TURP.

The introduction of new chemotherapeutic agents for the treatment of multiple myeloma (MM) has improved the life expectancy and quality of life for these patients in the last decade. Therefore, more patients with MM are being treated for repeated pathological fractures. The anaesthesiologist should continue the optimum supportive care received by these patients in the perioperative period also, by understanding the pathophysiology of the disease, the adverse effects of the chemotherapeutic agents and the guidelines for their supportive care. We report the perioperative management of a patient with MM and discuss the perioperative anaesthetic considerations.