Background: Propofol is often used in Total Intravenous Anesthesia (TIVA). Studies found that adding clonidine and ketamine can increase the potential to achieve an adequate level of anesthesia while reducing inflammation and post-operative pain. The goal of this study is to see if the combination of Target Controlled Infusion (TCI) propofol plus clonidine and ketamine is more effective in reducing the IL-6 level, maintaining intraoperative stability, and reducing postoperative pain and morphine consumption. Methods: Forty patients planned for major oncology surgery were divided into two groups. The treatment group (Group T) received pre-medication with clonidine, induction with TCI propofol, and intraoperative ketamine. The control group (Group C) received normal saline solution. Results: The difference of IL-6 level increase between the two groups was not statistically significant (13.6 vs. 16.6 pg/mL, p>0.05). Mean systolic blood pressure (SBP) and mean arterial pressure (MAP) in group T were higher in 5 and 10 minutes after incision, but lower in minutes 30, 60, and 120 (p<0.05). Heart rate in group T was higher in minutes 5, 10, 15, 30, 60, and 120. Visual analog scale (VAS) in 4, 8, 12, and 24 hours post-surgery were lower in group T compared to group C. And post-operative morphine consumptions in group T were also lower. (3.6±1.5 vs 9.9 ± 3.3, p<0.05). Conclusion: TIVA using TCI propofol combined with preoperative clonidine and intraoperative ketamine is effective in maintaining hemodynamic stability, reducing post-operative and reducing morphine consumption compared to TCI propofol alone.

Liposuction or lipoplasty is one of the most popular treatment modalities in aesthetic surgery which brings the certain unique anesthesia considerations. The patient should be assessed by the same standards as anyone else who is undergoing any surgery including a complete preoperative history and physical examination. The patients undergoing major liposuction procedure have a greater associated comorbid condition with the incidence of obesity. Moreover, intraoperative fluid management in liposuction procedure is also different from other surgeries where this procedure has the higher risk for fluid overload. Some complications related to liposuction are pulmonary complications. This case report describes an obese class I (BMI >30.3 kg/m²) patient who was undergoing an elective tumescent liposuction surgery under general anesthesia. During surgery, this patient received total subcutaneous infiltration of 1,200 mL tumescent solution and the total lipoaspirate was 3,300 mL. The surgery was uneventful without any certain complication. The anesthetic management of liposuction includes the preoperative evaluation, with particular attention to anything that might predispose the patient to complications, being essential to avoid unwanted occurrences.

Background: Fracture of the femur is a common, but extremely painful bone injury. Anaesthesiologists face the common problem of improper positioning of the patient while giving sitting spinal due to their extreme pain. Methods: After Institutional Ethical Committee (IEC) clearance, 60 of American Society of Anaesthesiologists (ASA) I/II patients age 18 to 80 years with fracture femur were recruited. Patients in Femoral Nerve Block (FNB) group received ultrasound-guided FNB was given with 15 mL of 1% lignocaine after visualizing the femoral nerve. Patients in the fentanyl group received injection fentanyl 1μg/kg IV. The target was to reduce the Visual Analog Scale (VAS) score less than 4. If despite the intervention, VAS was more than 4, a repeat fentanyl dose (0.5μg/kg) was given. Results: Mean VAS during positioning was 1.57 in FNB versus 2.93 in the fentanyl group (p<0.001). An additional dose of fentanyl required was less in FNB group and was more in fentanyl group (p<0.001). Performer rated quality of patient position was more in FNB group (mean±SD) 2.73 + 0.450 while1.47 + .507 in fentanyl group. This difference was statistically more significant (p<0.001). Patients satisfaction was more in the FNB group than fentanyl group (p<0.001) which was highly significant. Conclusion: Ultrasound-guided FNB provides better analgesia, patient satisfaction, less time for anesthesia and satisfactory positioning than IV fentanyl for a central neuraxial block in patients undergoing surgeries for femur fractures.

Background: Caudal epidural block is the most popular regional anesthesia technique in pediatrics. Several agents are required as an adjuvant with a local anesthetic to prolong the duration of caudal analgesia by single shot technique in children. The aim of this study was to compare the efficacy of clonidine with ropivacaine versus ropivacaine alone for caudal analgesia in children undergoing infraumbilical surgeries under general anesthesia. Methods: Sixty patients of ASA grade I – II between the ages of 1-12 years, of either sex, undergoing infraumbilical surgeries under general anesthesia were included randomly into two groups: Control group (Group A) ropivacaine 0.2% (1ml/kg) with maximum volume 12 ml and clonidine group (Group B) ropivacaine 0.2% (1ml/kg) with clonidine 1μg/kg with maximum volume 12 ml. The changes of hemodynamic parameters were recorded intraoperatively. The FLACC pain score, sedation score, duration of analgesia and requirement of analgesic were recorded in the recovery room. Results: The demographic characteristic were comparable in both the groups. The mean duration of analgesia was significantly prolonged (707.3 ± 59.56 minutes) in group B compared to (411.83 ± 14.82 minutes) in group A. The requirement of first rescue analgesic medication was significantly prolonged in group B compared to group A (P < 0.05). Total analgesic consumption was significantly higher in group A (180 ± 70 mg) compared to group B (90 ± 70 mg) (P < 0.05) Conclusion: Addition of clonidine 1μg/kg to ropivacaine 0.2 % in caudal analgesia significantly increases the duration of postoperative analgesia compared to plain ropivacaine 0.2% without any significant sedation.

Burn injury is one of the challenging cases in medical practice, which need comprehensive and multidiscipline management. Pain management is one of an important factors in caring for the burn patient. Pain management in burn injury is challenging and the patient may be at risk for undertreatment. Undertreated severe acute pain can lead to adverse consequences of many organ systems, delay recovery and discharge process, and potentially lead to chronic pain. Reports of inadequate pain relief persist, although there are advances in the acute pain management in recent years. An understanding of pain pathway can achieve effective burn injury pain management, types of pain in burn injury, analgesics selection, continuous and accurate assessment of the pain and the response to therapy, dose adjustment to achieve maximum effect and minimal side effect, and role of nonpharmacological treatment as a complement to medication. Acute pain service plays an important role in providing effective burn injury pain management for reducing morbidity and mortality.

Pulmonary disease is a known risk factor for perioperative respiratory complications. So anesthesiologists are expected to experience these postpneumonectomy patients coming for elective or emergency surgeries. But there is little data to anesthesia management for cesarean delivery of postpneumonectomy parturient. On reviewing the literature, there is only one reported case of the trial of vaginal delivery followed by cesarean section done under epidural anesthesia, a 41 years-old parturient having preoperative respiratory failure and pneumonia in the antenatal period which was managed on continuous positive airway pressure (CPAP) simultaneously. Our case presented a 24 years-old primigravida of 34 weeks gestation with placenta previa and complaints of two days per vaginal bleeding was posted for the emergency cesarean section. She had past history of left lung lobectomy 10 years back, video bronchoscopy 3 years back and history of admission for treatment of an episode of pneumonia at 32 weeks of present gestation. Emergency cesarean section was managed successfully under spinal anesthesia. This case report highlights that spinal anesthesia may remain a good option in anesthesia management for cesarean section in a primigravida with postpneumonectomy.

Ventilator-associated pneumonia (VAP) is a pulmonary infection that occurs as a mechanical ventilator-related disease which accounts for almost 80% of hospital-acquired pneumonia with of high mortality rate, lengthens the hospital-stay rate and increases health costs. To provide a description of the likelihood of the patient's life expectancy, mortality, and prognosis of patients in ICU, a scoring system should be utilized in order to assess the severity of the disease and estimate mortality during hospital treatment. The PIRO scoring system is a comprehensive concept that provides good validity and derivation in predicting mortality risk in a wide range severity of the disease so that it is very useful in the selection or categorization of patients, especially those admitted to the ICU with VAP. A conjunction or integration with a simple biomarker such as Neutrophil-to-lymphocyte ratio (NLR) provides a better performance of the tool in regards to the predictive value in VAP mortality risk estimation. Since the NLR has a strong predictive value, is simple, low-cost, and easily available compared to other biomarkers, therefore it is practical and useful for prognostic indications for VAP with conjunction with the PIRO score where medical facilities are lacking.

Introduction: The installation of an epidural catheter can be perform by median or paramedian techniques with the aim of position the epidural catheter tip being posterior to the epidural space. The goal of this study was to compare the location and position of the epidural catheter tip placed by the median technique compared to the paramedian technique by using fluoroscopy method. Patients and Methods: Fifty patients aged 18- 65 years who underwent lower abdominal surgery and lower extremities surgery are classified into two groups by consecutive sampling. The first group consists of those who were inserted epidural catheter by median technique approach, and the second group by paramedian technique approach. From the fluoroscopy imaging, the catheter position was classified into one the the following: anterior, posterior, and lateral. Result: In median approach, the epidural catheter tip were placed 16% anteriorly, 20% posteriorly, and 64% laterally. In the paramedian approach, the epidural catheter tip were placed 4% anteriorly and 96% posteriorly. The paramedian approach is more superior to median technique in terms of expected epidural catheter tip position (p <0.001, RR 4.8, CI95%=2.183-10.556). Conclusion: Placement of the catheter tip in the epidural space using paramedian technique is a better option than the median technique.

Introduction: Spine surgery presents a number of challenges to the anesthesiologist. The a₂ adrenergic agonist drugs are commonly used in such cases to provide hemodynamic and sympathoadrenal stability. Dexmedetomidine (DEX) is one of the most potent and highly selective a₂-adrenergic receptor agonists. Another a₂ adrenergic agonist drug that is used widely is clonidine. The study aims to compare both drugs in terms of hemodynamic stability in spine surgeries. Patients and Methods: 30 patients underwent spinal surgery were classified into one of the following group: DEX group (received DEX 1 mcg/kg in 10 minutes followed by 0.5 mcg/kg/hour during the course of the surgery) or CLO group (received clonidine 1 mcg/kg in 10 minutes followed by 1 mcg/kg/hour during surgery), by consecutive sampling. All other treatments and medications were similar in both groups. The systolic and diastolic blood pressure, mean arterial pressure, and heart rate were recorded every 5 minutes. Data was then analyzed by SPSS. Result: The patients in the DEX group had a better mean arterial pressure (p=0.002) and heart rate (p=0.018) stability compared to those in the CLO group. Conclusion: The administration of dexmedetomidine provides a better hemodynamic stability compared to clonidine in patients underwent spinal surgery.

Anesthetic challenges arises in securing airway due to difficult mask ventilation because of obstructed nasal passage and unanticipated intraoral extension by a tumour mass leading to difficult intubation also. This sometime lead to the dreaded path of “Cannot Intubate & Cannot Ventilate”. We are describing a successfully managed case of ossifying fibroma arising from the maxilla causing difficulty in ventilation with the help of pediatric circular facemask and airway.

Background: The emergence of antibiotic resistance is a complicated problem due to many factors, especially its use and abuse. Inappropriate use of antibiotics is very common in both developed and developing countries. The goal of this study was to see the knowledge of the surgeons toward prophylaxis antibiotic at Sanglah Hospital. Methods: This is a descriptive study of 55 surgeons who performed elective surgery at Sanglah Hospital. A questionnaire was filled by the surgeons randomly without prior notice about the study. The information about their behavior toward prophylaxis antibiotics was gathered from medical record of the day. Result: Out of the 55 surgeons participated in this study, 85.5% have followed a training on rational antibiotic use. The level of knowledge about factors that can increase surgical wound infections is quite good (94.4%), while the knowledge regarding factors that can reduce surgical wound infections very low (16.4%). Almost all (92.7%) clean-surgery patients were given prophylactic antibiotics. The most given antibiotic was ceftriaxone (72.7%), the third generation of cephalosporins. Conclusion: The mean knowledge of the surgeons toward antibiotic prophylaxis was 59.8%. The most used antibiotic as pre-surgical prophylaxis was ceftriaxone. And the time of administration for prophylaxis antibiotic was 16-60 minutes prior to surgical incision.

Extrahepatic portal venous obstruction (EHPVO) is the commonest cause of portal hypertension and variceal bleeding in children. Major concerns are growth retardation, decrease lean body mass and loss of muscle that may lead to postoperative respiratory failure. Upper abdominal surgery with severe pain may compound the problem of pulmonary atelectasis. Poor preoperative nutritional status and anemia may lead to delayed wound healing, delayed ambulation, and respiratory complications. To avoid postoperative respiratory complications and surgical site infection we inserted epidural catheter despite the possibility of intraepidural space bleed due to low platelet counts. The patient had an excellent recovery profile in term of analgesia, decrease postoperative nausea and vomiting due to decrease consumption of opioids, increase sedation-free period, early ambulation and parent's satisfaction. The intraoperative epidural also provides better abdominal muscle relaxation, wider surgical bloodless field and optimal pressure in anastomosis vessels. Regional techniques are avoided in thrombocytopenia, but risk and benefits must be assessed in each case.

Background: Inadequate acute postoperative pain management is the main risk factor for chronic pain after breast surgery. Pectoralis blocks I and II (pecs block I and II) are novels peripheral nerves block techniques introduced since 2011 by Blanco et al. Methods: Ten patients diagnosed with breast cancer planned for modified radical mastectomy (MRM), from preoperative evaluation patients with a physical status of American Society of Anesthesiologist (ASA) I and II. Anesthesia management under general anesthesia with an endotracheal tube and we performed PECS block II after general anesthesia. We recorded the systolic blood pressure, mean arterial pressure (MAP), and heart rate intraoperatively, and the pain scale at 4th, 6th, 12th, and 24th hours postoperatively. Results: The pain scale at 4th and 6th hours postoperatively were 0.3±0.5 and 0.6±0.5 respectively. The pain scale at resting starts to increase at the 12th and 24th hours (1.2±0.4 and 1.1±0.6). The mean total use of morphine recorded on PCA was 3.3 ± 0.9 (mg). No pecs block II complications were recorded in this study. Conclusion: Pecs block II is a relatively easy, safe, and effective for MRM surgeries. Further larger and double-blinded studies are needed to know its effectiveness compared to other techniques available.