Background and Aims: Current multi-disciplinary management of children with spinal muscular atrophy (SMA) often requires the surgical management of spinal deformities. We present the outcomes of our peri-operative experience around the time of their spinal surgery and share our neuromuscular perioperative protocol. Methods: A single-centre retrospective chart review was performed to evaluate all children with SMA types I and II that underwent thoracolumbar spinal deformity correction (posterior spinal fusion or growing rod insertion) from 1990 to 2015. Electronic medical records were reviewed to assess pre-operative, intraoperative, and postoperative variables. T-tests, Wilcoxon Rank Sum, Fisher's Exact tests were performed as appropriate. Results: Twelve SMA I and twenty-two SMA II patients were included. Type I patients tended to be smaller and had a higher percentage (36.4% vs 4.5%) of American Society of Anesthesiologists (ASA) class 4 patients. Preoperative total parenteral nutrition (TPN) was utilised in 75.0% of type I and 18.2% type II patients. A difficult intubation was experienced in around 25% of the patients (20.0% SMA I, 27.3% SMA II). Approximately two hours of anaesthetic time was required in addition to the actual surgical time in both types. The intensive care unit (ICU) length of stay averaged 6 (4.0-7.5) days for type I and 3 (3-5) days for type II (p = 0.144). Average post-operative length of stay was (8 (7-9) vs. 7 (6-8)) P = 1.0. Conclusion: Children with type I and II SMA have similar hospital courses. The surgical and anaesthesia team should consider perioperative TPN and NIPPV (non-invasive positive-pressure ventilation), anticipate difficult intubations, longer than usual anaesthetic times, and potentially longer ICU stays in both SMA type I and II.

Background and Aims: In adults, video laryngoscopy is recommended for supraglottic airway device (SGAD) placement as it results in better device position and higher oropharyngeal leak pressures. In children, there is a paucity of studies evaluating the impact of visually guided techniques on SGAD placement. Aim of the study was to evaluate the usefulness of visual-guided techniques of SGAD placement in children. Methods: Totally, 75 children, scheduled for elective surgery, were randomly allocated into three groups, that is, standard (S), direct laryngoscopy (DL), and video laryngoscopy (VL). Ambu AuraGain was placed blindly in group S, and under visual guidance with video laryngoscopy and direct laryngoscopy in groups VL and DL, respectively. Ambu AuraGain position was determined by flexible videoendoscope. First attempt success rate, time for successful insertion, oropharyngeal leak and any complications were studied. Results: Incidence of malposition was not significantly different in group S (44%), DL (48%), and VL (64%); P = 0.32. The first attempt success rate was 100% in DL and 92% each in S and VL. Time to insert (seconds) was significantly higher in VL (37.9 ± 21.6), compared to S (18.4 ± 7.9) and DL (27.4 ± 14.5); P <0.001. Incidence of oropharyngeal leak, impact on ventilation, and complications were similar in all three groups. Conclusion: In this study, there was no advantage of visually guided techniques for Ambu AuraGain placement in children.

Background and Aims: Paediatric airway, because of its consistent anatomical differences from that of an adult, often encounters difficulty in aligning the line of sight with the laryngeal inlet during intubation. Paediatric videolaryngoscopes (VLs), by obviating the need for aligning the line of sight with the glottis, offer several advantages over direct laryngoscopy. Therefore, this study aimed to compare the recently introduced paediatric King Vision™ VL (KVL) and the direct laryngoscope with Macintosh blade for elective tracheal intubation in infants of age <1 year. Methods: Seventy-eight infants of American Society of Anesthesiologists physical status 1 and 2, scheduled for elective surgery, were enrolled for this prospective randomised clinical trial and randomised into either of the two groups – Group K and Group C, where the infants were intubated using size 1 King Vision or direct laryngoscope with Macintosh blade. The primary objective of this study was the time taken for intubation and the first-attempt intubation success rate. Results: Time to intubate (25.90 ± 2.34 s vs. 25.03 ± 1.42 s, P = 0.05) and first-attempt intubation success rate (100% vs. 100%, P = 1) were similar between the groups, whereas glottic visualisation (P = 0.01), alternate techniques used to assist intubation (P < 0.001), the ease of intubation (P = 0.02) and intubation difficulty score (P = 0.01) were better in Group K than that in Group C. Conclusion: The outcome of KVL and Macintosh laryngoscope was similar in terms of time taken for intubation and first-attempt intubation success rate with KVL having superior glottic visualisation, better ease of intubation and lower intubation difficulty score for elective intubations in children of age <1 year.

Background and Aims: Ultrasound guided rhomboid intercostal plane block (RIB) is a relatively new regional anaesthesia technique that has shown to provide dermatomal coverage from T2-9 on the whole anterior and posterior hemithorax. It has proved effective in providing preemptive analgesia in various surgeries like mastectomy and thoracotomy. The aim of the study was to study the efficacy of RIB in paediatric patients: 7 to 12 years undergoing thoracoscopic surgeries in terms of analgesic requirement, pain scores and adverse effects. Methods: In this randomised, prospective double-blind study, 40 American Society of Anesthesiologists I/II patients, of the age group 7-12 years scheduled for Video-assisted thoracoscopy (VATS) surgery were recruited. The patients were allocated to one of the two groups: group R: general anaesthesia + RIB (RIB group) and group F: general anaesthesia (FENT group). Perioperative opioid consumption and postoperative pain scores were recorded. Adverse effects like respiratory depression and nausea were also noted. Results: Patients in group R required less intraoperative fentanyl dose (1.45 ± 0.65 vs 2.90 ± 0.45) (P < 0.05). Postoperative opioid consumption was also less in this group R (2.90 ± 0.91 vs 5.56 ± 1.08) (P < 0.05). Less number of patients experienced nausea (2 vs 6) and respiratory depression (2 vs 7) in group R. Conclusion: Ultrasound guided RIB reduces perioperative opioid consumption in patients undergoing VATS surgery with lesser postoperative pain scores.

Background and Aims: Spinal anaesthesia is currently the most common method used for managing patients undergoing elective caesarean sections. Recent meta-analyses have been supporting the use of 5-HT3 antagonists, like ondansetron, to attenuate hypotension induced by spinal block. Various doses of ondansetron were given intravenously five minutes before spinal block. However, a consensus on definitive dose and timing for maximal benefit is yet to be agreed upon. Methods: Our prospective randomised clinical trial investigated a new approach by administrating intravenous ondansetron 20 minutes before spinal anaesthesia. This work investigated ondansetron effect on both haemodynamic changes and vasopressors use by dividing patients into three groups. The first group O4 (n = 51) received 4 mg ondansetron, the second group O6 (n = 51) received 6 mg ondansetron, and the control group C (n = 50) received normal saline. We recorded systolic blood pressure (SBP), diastolic blood pressure (DBP) and the mean blood pressure (MBP) at different time intervals. Results: There was no significant difference in blood pressure measurements among the study groups (P > 0.05). The consumption of ephedrine in the control group is higher than both of the ondansetron groups (P > 0.001), with a mean dose of 27.2 ± 20.5 mg of ephedrine for group C, compared to 17.8 ± 14.9 and 14.7 ± 11.3 in O4 and O6 groups, respectively. Episodes of hypotension and number of patients with hypotension were not significantly different among the studied groups (P = 0.07; P = 0.96, respectively). Conclusions: Prophylactic 4 and 6 mg ondansetron given 20 minutes before spinal anaesthesia in caesarean section does not reduce the incidence of hypotension.

Background: Oxytocin administration regimens are arbitrary and highly subjective. Hence, it is essential to reinvestigate the appropriate dose for effective uterine contraction with minimal bleeding and adverse effects. Aim: To determine the optimal dose of bolus oxytocin for uterine contractions for elective caesarean section under spinal anaesthesia. Methods: Ninety term mothers (37 to 41 weeks) undergoing caesarean section electively under spinal anaesthesia were considered for the trial and divided into three groups to receive oxytocin bolus of one, two or three units. The uterine tone was assessed at 2 min after oxytocin administration. Intraoperative blood loss, mean arterial pressure, heart rate and possible side effects were also compared. Paired t-test, Kruskal-Wallis test, Chi-square test and analysis of variance (ANOVA) test with Scheffe multiple comparisons were used as inferential statistics. Results: Adequate uterine contraction was seen in 66% of participants who received one unit of oxytocin, and in 83.3% of participants who received two units of oxytocin. All those who received three units of oxytocin had an adequate uterine contraction. Blood loss was inversely related to the bolus dose of oxytocin. Conclusions: Lower bolus oxytocin doses of one and two units were inadequate for uterine contraction at elective caeserean section, while three units appeared to be effective in terms of adequate uterine contraction, reduced blood loss and stable haemodynamic system and absent side effects.

Background and Aims: Postdural puncture headache (PDPH) is a side effect of spinal anaesthesia (SA). This study was conducted to investigate the effect of intrathecal fentanyl on the incidence, severity, and duration of PDPH. Methods: This was a prospective randomised controlled study including 220 parturients, who underwent Caesarean section (CS). They were divided into two groups for administration of SA with bupivacaine (bupivacaine group [B0], n = 111) or bupivacaine with fentanyl (bupivacaine fentanyl group [BF], n = 109). Haemodynamics, quality of anaesthesia, maternal side effects, and postoperative analgesia were noted. The neonatal Apgar score was recorded. The patients were followed up for 14 days after CS for the occurrence of PDPH, and its severity and duration. The collected data were statistically analysed, using the Statistical Package for the Social Sciences software version 25. Results: Regarding haemodynamics, heart rate increased at 5 min post-induction and blood pressure decreased at 2min post-induction in both groups. Excellent intraoperative anaesthesia was obtained in 91.7% and 79.3% of cases in groups BF and B0, respectively (P < 0.01). Longer duration of postoperative analgesia was present in the BF group as compared to the B0 group (P < 0.001). The incidence of PDPH decreased in the BF group in a non-significant manner, whereas its severity and duration increased significantly in the B0 group. Conclusion: Although the addition of intrathecal fentanyl to bupivacaine for SA in CS patients did not reduce the incidence of PDPH significantly, its severity and duration decreased significantly.

Background and Aims: Post dural puncture headache (PDPH) following caesarean delivery (CD) is a cause for concern for anaesthesiologists. We aimed to study the effect of reinsertion of the stylet after spinal anaesthesia procedure, prior to spinal needle removal, on the incidence of PDPH in women undergoing CD. We also evaluated the risk factors associated with PDPH. Methods: In this randomised, double-blind study in a tertiary care hospital, 870 American Society of Anesthesiologists (ASA) II/III women undergoing CD under spinal anaesthesia were randomly divided into-GroupA (n = 435): stylet reinsertion before spinal needle removal and Group B (n = 435): spinal needle removal without stylet reinsertion. All patients were questioned for occurrence of PDPH at various time-points. Statistical calculations were done using Statistical Package for the Social Sciences (SPSS) 17 version program for Windows. Results: Sixty-two (7.1%) patients developed PDPH; 27 (6.2%) patients with stylet reinsertion and 35 (8.0%) patients in those with no stylet reinsertion; P = 0.389. The onset of headache was significantly delayed in patients with stylet reinsertion (16.2 ± 6.7 and 13.2 ± 4.3 h, respectively); P = 0.041 and they had greater severity of PDPH compared with those with no stylet reinsertion; P = 0.002. Factors significantly associated with PDPH were hypothyroidism, tea habituation, number of skin punctures and needle redirections, first pass success rate, occurrence of paraesthesia and contact with bone, intraoperative hypotension and time to ambulation. Conclusions: Reinsertion of the stylet before spinal needle removal did not influence the incidence of PDPH. The onset of PDPH was delayed and the severity of headache was greater in women in whom reinsertion of the stylet was done.