Noninvasive ventilation (NIV) is one of the alternative therapies for patients with respiratory failure or acute respiratory distress syndrome to avoid endotracheal intubation and its adverse effects. COVID-19 is a disease attacking respiratory system, inducing hypoxic-type respiratory failure. This case report describes that NIV application is somewhat useful in a number of patients with COVID-19 pneumonia suffering from respiratory failure. Nevertheless, in some cases, endotracheal intubation was done. Meticulous observation on deteriorating clinical and laboratory signs is required to make an immediate decision to switch into invasive ventilator to avoid further worsening.

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The current COVID-19 pandemic has affected the health-care system worldwide. While there is a plenty of literature in recent times regarding the anesthetic management of COVID-positive patients for various surgeries, there is a paucity of publications on the concerns and anesthetic implications of COVID-19 recovered patients, posted for major oncology surgery. We, hereby, present a geriatric case of post-COVID-19 recovered patient posted for radical cystectomy following chemotherapy. These patients are immunosuppressed due to cancer per se as well as because of concurrent chemotherapy, and hence, they may have a stormy course of COVID-19 infection. Since, COVID-19 affects multiple organs, preoperative evaluation must thoroughly investigate all the systems. Anesthetic management and operating theatre preparedness for such cases is discussed in brief.

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Background: The laryngeal mask airway (LMA) is widely used as an effective and safe airway adjunct in the routine practice of anesthesia. There are various methods to assess the correct placement, the gold standard being fiberoptic visualization through the LMA. Ultrasound (USG) is a noninvasive, readily available diagnostic tool and has been used with increased frequency for airway examination. The aim of our study was comparison of fiberoptic and USG evaluation for the confirmation of placement of LMA. Patients and Methods: This was a cross-sectional observational study conducted on 250 patients of American Society of Anesthesiologists Grade 1 and 2, in the age group of 18–65 years undergoing elective surgery under general anesthesia with LMA. The position of the LMA cuff was confirmed by USG and reconfirmed with fiberoptic laryngoscopy (FOL). Results: We observed that the USG Grade 1 was seen in 76.8% of patients as compared to FOL Grade 1 seen in 81.6%. The frequency of LMA misplacement (i.e., Grades 2–4) noted with USG was 23.2% and with FOL was 18.4%. The Bland–Altman scatter plot showed insignificant differences between the two grading systems (near-zero mean: 0.05), with small limits of agreement (−0.509 to +0.609). Conclusion: USG can replace fiberoptic examination for confirmation of the correct placement of an LMA. USG can further give insight into the grading of LMA placement and the cause of airway and ventilation events, which can be corrected and prevented.

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Background: Tracheal extubation is always linked with hypertension, tachycardia, and high-plasma catecholamine levels. These hemodynamic fluctuations are seen more often in hypertensive patients than in normotensives. The present study evaluates the effects of three different doses of dexmedetomidine in hypertensive patients relative to each other in attenuating extubation response. Patients and Methods: In this randomized, controlled, triple-blinded study, 105 controlled hypertensive patients of either sex on antihypertensive drugs in the age group of 30–70 years, scheduled for laparoscopic cholecystectomy were included. They were randomized into Groups A, B, and C receiving 0.5 μg/kg, 0.75 μg/kg, and 1 μg/kg of dexmedetomidine 10 ml infusion 10 min before extubation. Hemodynamic parameters in form of pulse rate, systolic and diastolic blood pressure, mean arterial pressure (MAP), oxygen saturation, and bispectral index (BIS) were noted. Extubation time, quality, and sedation were evaluated. Any side effects in form of postoperative nausea, vomiting, and bradycardia were noted. Results: There was significant attenuation of rise in heart rate, systolic, diastolic, and MAPs after 4 min of starting infusion between the three groups. At extubation, the values of hemodynamic parameters and BIS were significant between the three groups (P < 0.001). While the quality of extubation improved and the sedation scores increased with the increase in the dose of dexmedetomidine, the incidence of bradycardia was more with dose of 1 μg/kg as compared to 0.75 μg/kg and 0.5 μg/kg. Conclusion: It was found that 0.75 μg/kg was the optimal dose for extubation as it facilitated smooth extubation and maintained hemodynamic stability in patients without causing undue sedation.

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Background: Neuromuscular-blocking drugs block neuromuscular transmission, causing paralysis of the affected skeletal muscles. In clinical use, neuromuscular block is used adjunctively to anesthesia to produce paralysis, first to paralyze the vocal cords, and permit intubation of the trachea, and second to optimize the surgical field by inhibiting spontaneous ventilation, and causing relaxation of skeletal muscles. Patients and Methods: This was a prospective, randomized study registered in Clinical Trials Registry of India (CTRI/2019/04/018580). We included 100 patients divided into two groups of 50 each. Group A received atracurium (0.5 mg/kg), whereas Group B received cisatracurium (0.15 mg/kg). Efficacy of both the drugs was compared in terms of onset of action, duration of action, duration of recovery, hemodynamic conditions during and after intubation, and signs of histamine release in both the drugs. Results: Mean duration of 25% recovery from the reversal in the atracurium group was 32.4 ± 1.90 min which was significantly less as compared to 49.46 ± 1.86 min of cisatracurium group (P < 0.001). The mean duration of recovery from the reversal in cisatracurium group was 2.18 ± 0.82 min which was significantly more as compared to 1.8 ± 0.75 min of atracurium group (P = 0.02). Conclusion: Cisatracurium in a dose of 0.15 mg/kg had a faster onset and duration of action than atracurium 0.5 mg/kg. At this dose, cisatracurium provides optimal intubating condition, rapid neuromuscular blocking with longer duration of action, stable hemodynamic status, no signs of histamine release clinically, and without any residual muscle paralysis compared to atracurium.

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Background: Health-care system reform in Indonesia is challenging for anesthesiologists in determining the minimum cost of anesthesia and maintaining inflammation and pain to a minimum. This study is aimed to analyze the effectiveness of general anesthesia techniques between target-controlled inhalational anesthesia (TCIA) sevoflurane and target-controlled infusion (TCI) propofol in mastectomy surgery from the perspective of cost, C-reactive protein (CRP) levels, postoperative pain level, postoperative opioid consumption, and side effects. Patients and Methods: This was a randomized controlled trial with permuted block randomization of 60 subjects allocated into TCIA sevoflurane (Group S) and TCI propofol (Group P). In Group S, we used sevoflurane 8 vol% for induction and maintained with sevoflurane 1–1.5 vol%, compressed air, and oxygen. In Group P, we used TCI propofol with target effect 4 mcg/mL and maintained with TCI propofol (target effect of 1–3 mcg/ml), compressed air, and oxygen. Results: The cost in Group S was US$ 36.33 compared to US$ 29.69 in Group P (P = 0.002). The CRP level was comparable between the two groups (38.39 [42.13] vs. 23.88 [45.26]. P = 0.487). There is neither difference in pain score, total morphine consumption, and side effects between both groups in the first 24-h postoperative period, nor morphine consumption in 24 h postoperative. Conclusion: The cost of anesthesia-related expense in TCI propofol is lower than TCIA sevoflurane in mastectomy surgery underwent general anesthesia. There is no significant difference in terms of CRP levels, postoperative pain, postoperative morphine consumption, and incidence of side effects.

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Background: Knowledge regarding labor analgesia is poor among the pregnant women. This hinders them from utilizing the services in centers where it is available. In this study, we tried to analyze the awareness and knowledge of the antenatal women and their beliefs regarding labor analgesia. Patients and Methods: This prospective, observational study done in antenatal clinic for 1 month. Antenatal women who attended the clinic voluntarily filled the semi-structured questionnaire after the written and informed consent. Results: A total of 170 women filled the questionnaire out of 1099 antenatal visits. 68.8% were multipara and 50.58% had previous vaginal delivery. 63.3% study population had prior information of labor analgesia; while only 42.6% had information that labor analgesia services are available in our hospital (P = 0.002). Age, education, and parity were considered as predictors; however, parity is the only predictor for knowledge of labor analgesia odds ratio = 2.368 (95% CI–1.24, 4.51; P = 0.009). Majority (60.23%) of the study sample believe that there is no effective method of pain relief during labor. Binary logistic regression and Chi-square test used for the statistical analysis. Conclusion: Antenatal women still believe that there is no effective method of labor analgesia. Women prefer obstetrician advice for getting information regarding labor analgesia. In our study, the level of education has no impact on awareness of labor analgesia. Only parity is a predictive factor for knowledge of labor analgesia.

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Background: The application of head fixation device and tightening of the pins on the scalp acts as an intense noxious stimulus with an increased hemodynamic response. We aimed at comparing the efficacy of scalp nerve block (SNB) using levobupivacaine against intravenous fentanyl bolus dose followed by continuous intravenous infusion for attenuation of pain and hemodynamic response to pin fixation. Methods: One hundred and eight patients undergoing elective supratentorial craniotomy under general anesthesia were randomly allocated to two groups: Group F received a bolus of intravenous fentanyl (2 μg/kg) followed by continuous maintenance infusion and Group S, in which a bilateral SNB was performed with 20 ml of 0.5% levobupivacaine. Hemodynamic variables and pain scores were the primary outcomes noted. Intraoperative isoflurane and additional fentanyl requirements, emergence time and any side effects were also recorded. Results: The variation in hemodynamics in terms of heart rate (per minute) at pin fixation (Group F [95.88 ± 7.79] and Group S [89.02 ± 5.42]) was significant (P < 0.001). There was a significant change in mean arterial blood pressure (mm Hg) between the groups at pin fixation Group F (104.70 ± 9.18) and Group S (92.88 ± 6.92) (P < 0.001). A significant reduction in pain and intraoperative fentanyl requirements was also seen. Emergence from anesthesia was significantly longer in Group F as compared to Group S (P < 0.001). No group had any significant complication. Conclusion: SNB is a reasonably safe and effective means for smooth control over hemodynamics and lesser intraoperative analgesic requirements compared to the fentanyl infusion in adult patients undergoing supratentorial craniotomies.

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Endocrine emergencies can occur during pregnancy and are associated with the thyroid gland and diabetes. Thyrotoxicosis is a hypermetabolic condition associated with an increase in thyroid hormone in the blood. The manifestations of thyrotoxicosis can range from those without symptoms to a life-threatening condition such as thyroid storm. The diagnosis of thyroid storm can be made based on a history of previous thyroid gland disorders; current signs and symptoms; and laboratory tests of thyroid-stimulating hormone, free thyroxine, and triiodothyronine. The thyroid storm is a rare condition, but the mortality rate on these patients is high. Characteristics of thyroid storms are altered consciousness, hyperpyrexia, tachycardia, and gastrointestinal disturbances. Thyroid storm management focuses on the prevention of thyroid hormone synthesis and its conversion in the periphery, identification, and intervention of the thyroid storm causes and the management of systemic disorders that present during thyroid storm. We present a 24-year-old female who presented with a very high suspicion of thyroid storm based on her Burch and Wartofsky's score criteria had a total score with a very high suspicion of thyroid storm. While pregnancy itself can increase the risk of developing severe thyrotoxicosis, the main management is determined by the presence of emergency manifestations. Our concern was not only for the safety of the mother but also for the fetus. Some drugs need special attention because they cross the blood–placental barrier. Previous patient comorbidities should also receive attention in the management of thyroid storm. The patient was being treated in the intensive care unit and managed to move to a regular ward after 3 days.

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Hypotension event in intraoperative settings may cause postoperative morbidity in surgical correction of scoliosis. Most often complications of intraoperative hypotension are postoperative ischemic optic neuropathy and postoperative ischemic stroke due to global hypoperfusion. Hypovolemic shock due to bleeding or blood loss is the most common cause of intraoperative hypotension in surgical correction of scoliosis. However, bleeding is not only the main cause of hypotension. A young female underwent surgical correction of scoliosis, during the operation she had a sudden and rapid decrease of blood pressure (BP) but then rapidly improved after the surgeon stopped the surgery which was a de-rotational procedure. Neurogenic shock is one of the complications that may occur during the manipulation of the spinal cord which is marked by a sudden and rapid decrease of BP and usually accompanied by bradycardia due to sudden and rapid loss of autonomic tone. Hypotension in neurogenic shock usually is refractory hypotension which cannot be treated only with fluid resuscitation but also needs vasopressor, thus this neurogenic shock should get immediate and prompt treatment to avoid further complications.

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Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by vascular thrombosis or pregnancy complications with the presence of antiphospholipid antibodies. It is a rare disease affecting 40–50/100,000 population yet responsible for 10%–15% of recurrent pregnancy loss. Diagnosis requires at least one clinical and one laboratory criteria to be met. Perioperative management in obstetric APS underwent cesarean section stressed on the management of anticoagulation and proper choice of anesthesia technique. We report the case of a 21-years-old woman, 39 weeks pregnant, diagnosed with APS since the 8^th week of gestation. She had two previous miscarriages and an elevated level of anticardiolipin antibody (aCL IgG: 21 GPL U/ml) with normal aCL IgM and lupus anticoagulant. She was treated with a prophylactic dose of low-molecular-weight heparin (0.4 IU subcutaneous enoxaparin) and oral aspirin 80 mg daily. She presented to the obstetric department and scheduled for an urgent cesarean section. Enoxaparin was held, and the surgery was done with spinal anesthesia. Anticoagulation resumed 12 h after surgery. No complications on the mother and baby were found after 3 days of observation.

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Background: We conducted a survey among anesthesiologists in a Singapore Anesthesiology Academic Clinical Program to investigate the rate of successful publications following conference abstract submissions, the reasons for not submitting manuscripts, and unsuccessful publications. Materials and Methods: Anonymous online survey enquired about respondents' publication records, the number of abstracts submitted and accepted, the number of manuscripts written and their status in the past 3 years, the reasons for not submitting manuscripts following abstract submission, unsuccessful publications, and the types of published articles. Statistical analyses included the descriptive statistics and comparisons between two subgroups of clinician (Senior Resident/Associate Consultant [SRAC], Consultant [C]). Results: There were 68 responses to the survey. A total of 175 local and international conferences abstract submissions were accepted from May 2016 to May 2019. Of these, 67 (38.3%) were written into full-length manuscripts and 64 (36.5%) were published. The top reasons for the lack of manuscripts were “the low likelihood to be accepted for the publication due to methodological reasons,” “no intention to write the abstracts to manuscripts,” and “lack of time to prepare manuscripts.” The most common categories of published articles were case report/case series, retrospective, and prospective studies. The SRAC group (n = 41) reported higher number of retrospective studies than the C group (n = 27): 14 versus 3 studies, P = 0.045. Clinical research and medical education were the main successful publication domains. Conclusion: A minority of 36.5% (N = 65) of the abstracts submitted to conferences were published. This study identified potential areas where support can be given to anesthesiologists to improve publication success.

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An arterial tourniquet is a pneumatic device consisting of an inflated cuff connected to a supply of compressed gas. The most common use for these tourniquets is in surgical procedures on the extremities, where the tourniquet is very useful in optimizing the operating conditions by creating a bloodless surgical field. However, the exsanguination process followed by ischemia will result in physiological problems with local and systemic consequences. The patient in the case to be discussed is a 54-year-old woman with a diagnosis of implant loosening et causa nonunion left Montegia fracture who was scheduled for implant revision surgery. From these cases, it is possible that the patient experienced tourniquet-induced hypertension, which is one of the systemic complications that can arise due to the use of the tourniquet. It is said that tourniquet-induced hypertension is often difficult to control and is resistant so it is difficult to lower it. Emerging hypertension may not present a significant problem in young, noncomorbid patients, but in these patients with comorbid of hypertensive heart disease (HHD), elevated blood pressure can be very detrimental. Preoperative ketamine, clonidine, or lidocaine has been used to prevent tourniquet pain, which can lead to increased arterial pressure that is difficult to control. The anesthetist is also obliged to monitor the duration and pressure applied by the tourniquet so that it is not excessive so that detrimental complications can be prevented.

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Background: The severe acute respiratory syndrome coronavirus-2-2019 pandemic has posed significant challenges and barrier devices such as aerosol/intubation box, intubation tent, and intubation screen have been widely used during endotracheal intubation by the clinicians without any definite proven benefit. The initial experience at our institute with the intubation box posed some difficulties leading to failed intubations. Hence, as an alternative, we switched to a transparent plastic intubation screen that is likely to provide better vision and space during intubation. We evaluated the impact of intubation box and plastic screen on intubations in this simulation-based crossover study. Materials and Methods: Ten anesthesiologists performed 90 intubations in an operating room on a Laerdal^® adult airway management trainer. Each participant performed 9 intubations, 3 without any barrier and 3 each with intubation box and plastic screen. The primary outcome was intubation time; secondary outcomes included first-pass success and breaches to personal protective equipment. Results: Intubation time with no barrier was significantly shorter than with the intubation box (median interquartile range [IQR]: 25 [22–28] vs. 40 [30–51] s, P < 0.001) and with the screen (median [IQR] 29 [25–35] s, P = 0.015). The intubation time was significantly lesser with the screen compared to the box (P = 0.023). The first-pass success was 86.66%, 96.66%, and 100% in the box, screen, and no barrier groups, respectively. Conclusion: In comparison to an intubation box, the transparent plastic screen decreases intubation times and has greater operator comfort. These devices require further evaluation for patient safety.

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Esophageal atresia/tracheoesophageal fistula (TEF) is a congenital defect that often presents with respiratory distress in neonates. The anatomical defect in the form of connection between the esophagus and the trachea often affects respiratory function. Gastric distention often occurs due to large air leak into the stomach and may lead to respiratory distress. Surgical correction of the anatomical defect will improve the outcome in these patients. Preoperative preparation and intraoperative management is an essential point. Suboptimal preparation may lead to a life-threatening situation intraoperative. Focusing on airway and ventilatory management may help in reducing morbidity and mortality. We report a case of anesthesia management of TEF repair in a premature neonate with a complication during airway and ventilatory management.

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Cephalocele refers to defects in the skull and dura with extensions from intracranial to extracranial structures. Cephalocele is divided into four types which are meningoencephalocele, meningocele, atretic encephalocele, and gliocele. Encephalocele is a head's contents herniation through a defect in the skull. Meningocele is a herniation sac that contains cerebrospinal fluid and nerve elements. Meningoencephalocele is a prominent herniation of the meningeal part, nerve elements, and brain tissue in a sac that protrudes through a defect in the skull. In Southeast Asia, the incidence of meningoencephalocele is estimated to occur in 1 in 5000 live births. The occipital bone is the most common location of cephalocele. The neurological outcome of malformations that occur depends on the size of the sac formed, the nerve tissue involved, hydrocephalus, related infections, and other pathological conditions involved. Perioperative preparation must be well made by an anesthesiologist based on airway management, fluid balance, and hypothermia prevention. The main challenge of anesthesia in the management of the occipital meningoencephalocele is securing the airway. Pediatric patients have low functional reserve volume, and failure of tracheal intubation can cause hypoxemia, bradycardia, and even heart attacks. Improper positioning and limited neck extension can complicate endotracheal intubation.

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Background: Both surgery and anesthesia can cause an inflammatory response, rise in C-reactive protein (CRP) levels in response to the acute phase, as well as the activation and increased number of neutrophils. Ketamine with the right time of administration is expected to control the inflammatory response so that it can reduce the risk of postoperative complications such as pain and reduce the use of opioids. Patients and Methods: A total of 68 patients with physical status American Society of Anesthesiologists (ASA) I–II who underwent elective laparotomy were collected by consecutive sampling. The samples were divided into 2 groups; Group A received a low dose of ketamine at the end of the surgery, and Group B received a low dose of ketamine at the time of anesthesia induction. We measured CRP level, neutrophil count, visual analog scale (VAS), as well as total morphine consumption at 24 h postoperatively. Results: The increase in CRP levels in Group A was significantly lower compared to Group B (70.8 ± 42.7 vs. 115.0 ± 44.0 mg/L, P = 0.001). Group A has a significantly lower increase in CRP levels, VAS, and the total consumption of morphine 24 h postoperatively (P < 0.05). There was a strong positive between CRP and VAS (R = 0.702, P = 0.001). Conclusion: Administration of low doses of ketamine at the end of surgery was more effective in suppressing CRP levels, resulting in lower VAS score, and lower total morphine consumption in the 24-h postoperative period compared to low-dose ketamine given at the time of induction.

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Caudal block technique remains as the most popular regional anesthetic choice for the pediatric population since its first description in 1933 for pediatric urological interventions. This technique could provide exquisite analgesia during surgery, likewise in the postoperative period after infraumbilical surgeries. Caudal continues to essentially reduce systemic anesthetic and analgesic requirements, thus conceive a better postoperative outcome. Ropivacaine is a safe and effective local anesthetic agent which provides prolonged postoperative analgesia with significantly minor motor blockade following caudal block in pediatric patients undergoing infraumbilical surgeries.

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Moyamoya disease (MMD) is chronic cerebrovascular disease with progressive stenosis in various vessels of cerebral circulation leading to the development of collateral vessels. Patients may exhibit ischemic or hemorrhagic complications. Surgical management is usually complicated by impairment in cerebral blood flow and metabolism. The goal of anesthetic management of such patients is to maintain adequate oxygen demand supply balance. We present a case of MMD in a 6-year-old male child and discuss anesthetic management of such patients undergoing indirect vascularization procedures.

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