The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic has become a matter of concern all over the world. This virus caused acute respiratory distress syndrome(ARDS) in almost 67% of patients, with 71% of total patients requiring mechanical ventilation. Oxygen therapy is prudent for patients suffering fromSARS-CoV-2 at different stages of the disease. The choice of different oxygen delivery devices depends on the patient's status and its availability. In this review we will discuss the pros and cons of several oxygen delivery devices, as well as the safety precautions and personal protective equipments.

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C5 palsy is a well-known complication following cervical spine surgery. We describe a case of a 68-year-old male who underwent C3 to C6 posterior instrumentation and fusion with laminectomy and C7 hemilaminectomy for severe multilevel cervical stenosis. This is complicated by severe bilateral C5 palsy and neuropathic symptoms postoperatively, which improved with conservative management and acupuncture. This is the first described case of acupuncture being used in the treatment of C5 palsy. Further studies are needed to determine the efficacy of acupuncture in the management of neuropathic symptoms in patients with C5 palsy.

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Kidneys play an essential role in the regulation of water homeostasis, electrolyte balance, and acid–base balance. Anesthesiologists are frequently involved in the perioperative care of patients with kidney disease in elective and emergency scenarios. Fluid therapy is a main component of resuscitation to improve cardiac output, blood pressure, and perfusion pressure. This sometimes comes at a cost of increased risk of tissue edema due to fluid overload. Both during the transplant and nontransplant surgeries, the use or choice of fluid may influence the biochemical environment or homeostasis of human body and clinical outcomes. In this narrative review, we address the electrolyte and acid–base changes in renal disease, pharmacology of fluids, hemodynamic monitoring, and their applications.

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In anesthetized patient, aspiration occurs because of insufficient airway protective reflex and subsequent aspiration of gastric contents. It is rare but potentially fatal, depending on its severity. Symptoms may vary from hypoxia to respiratory failure and acute respiratory distress syndrome, even collapsed lung and death. A 30-year-old woman who had a hysterectomy with intra-abdominal packing was scheduled for pack removal. She vomited during induction and ended up with aspiration pneumonitis (Mendelson's syndrome). She was admitted to the intensive care unit after surgery and was extubated on the 4^th day. She was then moved to the ward 6 days after the surgery. Awareness and skills to minimize the risk of aspiration anesthetic practice are developing well, but it still causes more than 50% of deaths related to the airway during anesthesia. Recognizing risks and its management is essential to prevent morbidity and mortality.

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Congenital diaphragmatic hernia (CDH) is an emergency case in neonates. The prevalence of CDH is 1 in 2500 births and occurs 4–8 times more commonly on left side than right side. CDH is usually worsened by pulmonary hypoplasia and pulmonary hypertension. It is characterized by respiratory failure and bowel sound in the chest area and mostly requires surgical procedure. This case report discusses a neonate with congenital left diaphragmatic hernia who underwent surgical procedure to close the defect. Patients present with cyanosis and shortness of breath, are early intubated, and are mechanically ventilated in neonatal intensive care unit (NICU). In the present case, the surgical procedure lasted approximately 2 h with general anesthesia, with hemodynamic stability during the surgery. The patient was thereafter intubated and treated at the NICU for close monitoring.

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Introduction: Hypotension after spinal anesthesia is a frequent complication in patients undergoing cesarean section; the incidence of maternal hypotension is 60%–70%. One way to overcome or prevent hypotension due to spinal anesthesia is by administering intravenous fluid boluses. This study was conducted with the aim of comparing the effectiveness of crystalloid fluid preloading and coloading against the incidence of hypotension after spinal anesthesia in cesarean section. Methods: This research is a single-blind clinical trial. The number of subjects who participated in this study were 51 subjects. Subjects selected by consecutive sampling with inclusion criteria gravida patients aged 16 years to 40 years with ASA 1 or ASA 2 physical status who would undergo elective cesarean section with spinal anesthesia and there were no contraindications for spinal anesthesia. Participants were divided into three groups, namely preloading group, coloading group, and control group. Systolic blood pressure, diastolic blood pressure, mean arterial pressure (MAP), and pulse rates are measured in basal conditions and 1, 2, 4, 6, 8, 10, 15, 20, 25, and 30 min after spinal anesthesia. Statistical analysis for the differences in hemodynamic parameters among the three groups of subjects were analyzed by the Repeated Measured Multivariate Analysis of Variance (MANOVA) test. Whereas Bonferonni post hoc test was used to compare the differences in hemodynamic parameters between each group. Results: Bonferroni post hoc test results showed that there were significant differences in the decrease of systolic, diastolic, and MAP blood pressure differences between the coloading group with the preloading group and the control group (P < 0.001); the lowest decrease was in the coloading group. Conclusion: Crystalloid fluid coloading was significantly better in reducing hypotension incidence after spinal anesthesia in cesarean section compared with the preloading and control groups.

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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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Background: Regional anesthesia is usually preferred over general anesthesia for transurethral resection of the prostate (TURP). Spinal anesthesia increases the risk of hypotension. Saddle block provides a block that is dense in lumbosacral and lower thoracic dermatomes; hence, hemodynamic derangement will be less. In this study, we aimed at comparing the hemodynamic stability and anesthetic efficacy of subarachnoid block versus saddle block in patients undergoing TURP. Patients and Methods: After obtaining written informed consent, a prospective randomized comparative study was conducted in 90 patients, 50–70 years, of ASA physical status 1–2 scheduled for TURP. They were randomly allocated into two groups of 45 each. Group SA received spinal and Group SB received saddle block using the same volume (2.5 ml) of hyperbaric bupivacaine. Hemodynamic parameters such as heart rate (HR), systolic, diastolic, and mean arterial blood pressure (BP), and height of block were recorded in both groups. If hypotension was present, ephedrine bolus intravenously was administered, and the total requirement of vasopressor was noted. Results: Maximum decrease in HR from baseline was low in Group SB (P = 0.008). Maximum fall in systolic, diastolic, and mean BP was also found to be low (P = 0.005), (P = 0.001), and (P = 0.001), respectively, in Group SB. In Group SB, time to achieve T10 sensory level was delayed, whereas the level of motor blockade was low according to the modified Bromage score. Ephedrine consumption was also low in Group SB (P = 0.001) versus Group SA. Conclusion: Saddle block can be safely administered in TURP for elderly patients, with the reduced hemodynamic imbalance and vasopressor requirement.

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Background: Pregnant women and neonates are susceptible populations in many infections. Health-care workers are facing a new challenge as only few data are available on the effect of coronavirus disease 2019 (COVID-19) on pregnancy. The aim of this review was to see the current recommendations regarding the perioperative management of the cesarean section in COVID-19 patients. Methods: We used the keywords of (((((coronavirus [Title/Abstract]) OR (covid-19 [Title/Abstract])) OR (ncov-19 [Title/Abstract])) OR (SARS-cov-2 [Title/Abstract]))) AND (Cesarean [Title/Abstract] or Pregnancy [Title/Abstract]) in the PubMed database to find eligible reports. We studied all titles and abstracts from the search results and removed irrelevant studies that did not comply with our research question. Two authors were assigned to assess the validity and reliability of the studies using the Joanna Briggs Institute's critical appraisal tool. The cutoff point for inclusion was 50% of the total checkmarks in each critical appraisal checklist. Results: We found 16 articles from the PubMed database based on keywords described earlier. After eligibility screening, we found seven eligible articles describing perioperative management of the cesarean section during the COVID-19 pandemic. Conclusion: There is no solid evidence that the cesarean section is protective against the transmission of COVID-19. The use of an appropriate biosafety level-3 protective suits is imperative in managing patients presenting for cesarean section with COVID-19 in an operating room. A negative-pressure environment, both in the operating room and incubator, should be prepared for such cases. Regional anesthesia is the recommended technique, but general anesthesia is preferable in specific maternity conditions.

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Introduction: Anxiety is a common phenomenon among hospitalized patients awaiting any surgical procedure and causes acute psychological distress in the perioperative period. It activates the sympathetic nervous system, adversely affecting the induction and maintenance of anesthesia and postoperative recovery, leading to a lower level of satisfaction with the treatment. The current study aims to explore the effect of music on preoperative anxiety. Patients and Methods: In this randomized controlled study, 104 patients posted for laparoscopic cholecystectomy were randomly divided into two groups. Patients in both groups received oral alprazolam 0.25 mg on the night before surgery. In addition, patients in Group II were also exposed to 30 min of soft, soothing music, 1 h before the surgery. Vitals of patients, including heart rate (HR), blood pressure, and respiratory rate, in both the groups along with the general anxiety – visual analog scale (GA-VAS), were recorded and compared. Results: On comparing T30 vitals between the two groups, a statistically significant difference was seen in all the monitored parameters, with vitals in Group II being lower than in Group I. T60 vitals in Group II were found to be lower than Group I in all the monitored parameters, except for HR (P = 0.051). The GA-VAS scores in Group II were lower compared to Group I (P = 0.008). Conclusion: Exposure to music, as an addition to alprazolam 0.25 mg, in the preoperative period for patients who underwent laparoscopic cholecystectomy reduces the patient's anxiety compared to alprazolam alone.

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Background: Intubation is crucial in the management of anesthesia because it is related to the maintenance of oxygenation and ventilation during general anesthesia. Clinical markers for predicting difficult airway have limitations, including requiring coordination with patients. The use of ultrasonography (USG) to measure the distance of the skin to epiglottis is expected to estimate the difficulty level of intubation. Patients and Methods: This was a cross-sectional study of 128 patients who underwent surgery under general anesthesia. We examined the skin-to-epiglottis distance using US prior to surgery. We then assessed the Cormack–Lehane scores during direct laryngoscopy for intubation. The unpaired t-test was used to assess differences in the skin-to-epiglottis distance between patients with easy intubation (Cormack–Lehane I and IIa) and difficult intubation (Cormack–Lehane IIb, III, and IV). Results: The cutoff value of skin-to-epiglottis distance between easy and difficult intubation was 26.05 mm. The sensitivity and specificity of this method to predict difficult airway were 69.4% and 93.5%, respectively. The positive and negative predictive values were 80.6% and 88.7%, respectively. Conclusion: The skin-to-epiglottis distance of >26.05 is a risk factor for difficult intubation.

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The most frequent patients’ complaints of spinal anesthesia are post-spinal headache and post-spinal backache. As many as 13.4% of the patients have backache as the major reason for refusing spinal anesthesia. This systematic review was conducted using keywords: “post spinal backache,” “post spinal backpain,” “caesarean section,” “caesarean delivery,” and “obstetric,” which were combined using Boolean operator “OR” and “AND.” The time filter was set from 2000 until 2020. We included six studies that included a total of 2721 subjects who underwent elective cesarean delivery under spinal anesthesia, of which 675 subjects or about 24% of them experienced backache. Many factors were thought to be responsible for the incidence of post-spinal backache. Trauma due to needle injection, hematoma, and excessive stretching of ligaments until infection which leads to abscess are possibly being the main causes of post-spinal backache. There are several efforts that can be made to reduce the risk of post-spinal backache, such as using a small needle without an introducer, performing spinal anesthesia with a paramedian approach, and reducing the number of attempts.

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Esophageal atresia (EA) is a congenital anomaly commonly found with tracheoesophageal fistula (TEF) of neonates in the first week of life. This anomaly can cause several complications including aspiration, reduction in respiration, and complication from other concomitant congenital anomalies, mostly from the heart origin. The treatment for this anomaly is a surgery. Intraoperatively, the patient may develop hypoxia due to lung retraction and hemodynamic instability from bleeding or hypothermia. Anaesthesiologists play an important role in the management of EA during the perioperative period. Careful examination of the preoperative period must be done to discover any other concomitant anomaly and complication. Good anticipation of any complication during surgery and continuous monitoring post surgery can elevate the prognosis of the patient.

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Background: Difficult laryngoscopy (DL) is challenging when difficult ventilation occurs during standard laryngoscopy. For airway assessment, the common clinical airway predictors have low sensitivity (Sn) and specificity (Sp) with a limited predictive value. Ultrasound can be a useful tool for predicting such difficulties. We aimed to evaluate the usefulness of several sonographic airway parameters in predicting DL in adults. Patients and Methods: This prospective observational study included 120 patients who underwent elective surgery requiring general anesthesia with direct laryngoscopy (Macintosh blade) and endotracheal intubation. Ultrasonography (USG) assessment included preepiglottic space (PES), hyomental distance (HMD), distance from skin to the hyoid bone-skin (DSHB), and distance from skin-to-epiglottis midway between the hyoid bone and thyroid cartilage distance from skin to epiglottis midway (DSEM). Demographic variables and Cormack-Lehane (CL) grading for laryngoscopy (CL grade 1, 2-easy; 3, 4-difficult). Receiver operating characteristic (ROC) analysis was done, and area under the curve (AUC) was calculated to determine the best predictor of DL. Results: DL was present in 22.50% of patients. Compared to those with easy laryngoscopy, patients with DL had lesser HMD (4.55 vs. 4.96, P = 0.002), and comparable DSHB, DSEM, and PES. Among the various US parameters for predicting DL, we found the highest Sn of DSHB (74.07%); highest Sp of HMD (86.02%); highest positive predictive value of HMD (50%); and highest negative predictive value of HMD (85.1%). ROC curve analysis showed HMD to be the best predictor for DL with the highest AUC of 0.684. Conclusion: DL is common, present in 22.5% patients. US is a novel modality for predicting the DL, especially HMD, which showed the highest AUC among DSHB, DSEM, and PES.

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Background: Postoperative pain is an essential consequence of lower limb surgeries that can affect early ambulation, range of motion, and duration of stay in the hospital. This study aimed to evaluate the effect of the adductor canal block in the postoperative pain control and analgesic consumption in the lower limb surgeries done under spinal anesthesia. The adductor canal block is a compartment block of the saphenous nerve (branch of femoral nerve), which can provide adequate analgesia with the preservation of motor function. Patients and Methods: Sixty patients aged 18–70 years scheduled for lower limb surgeries under spinal anesthesia were included in this prospective, placebo-controlled randomized study. The patients were randomly divided into two equal groups of 30 each. At the end of the surgery, single-shot ultrasound-guided adductor canal blockade was given with 30 ml of 0.5% ropivacaine (Group A) or 30 ml of 0.9% saline (Group C). The pain was assessed for 24 h postoperatively by a visual analog scale (VAS). Postoperative analgesia consumption was also studied. Motor function was assessed with a straight leg raise test. Results: Analgesic consumption was lesser in the ropivacaine group as compared to the control group. VAS was favorable in the ropivacaine group. There was no prolonged loss of motor function in either group. Conclusions: The adductor canal block significantly reduces pain and analgesic consumption. It also does not affect motor function. Hence, it can be effectively used as an adjuvant to spinal anesthesia for lower limb surgeries.

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Background: This study aimed to get optimal sniffing position for successful intubation rate and measuring intubation time. The classical rationale for the sniffing position is that the alignment of the mandibular axis, pharyngeal axis, and laryngeal axis is facilitated, permitting successful direct laryngoscopy. Patients and Methods: A total of 100 patients without any anticipated difficult airway were enrolled after informed consent is given. After induction of anesthesia, patients were randomly divided into two groups. In Group PB, a deflated pressure infusion bag was put under the nape of the neck and occiput. The anesthetist performed laryngoscopy with the left hand while inflating the bag with the right hand up to the best glottic view without external pressure is achieved. The height of the bag was measured. In Group PI, 10-cm fixed-height noncompressible pillow was placed behind the head up to the shoulder. The best glottic view of the entire glottis without external pressure was noticed. Grading of glottic opening grade, SPO₂, intubation time, and intubation trials were also noted. Results: Failure to intubate was noted in one patient in Group PB and two in Group PI. Intubations successful in 45 (90%) patients in Group PB as compared to 38 (76%) patients in Group PI (P < 0.05). Laryngoscopic view in Group PB was superior to that with Group PI (P < 0.05), with mean pressure bag height of 4.86 cm. Conclusion: The use of pressure infusion bag for adjustable-pillow height provides more success in intubation condition by head elevated position than the fixed height of 10 cm.

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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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Introduction: Coronavirus disease 2019 (Covid-19) has become a pandemic all over the world. Despite our familiarity with various protection devices, the high incidence among medical personnel is still worrisome. In this review, we provide several perioperative strategies regarding the management of daily cases in the Covid-19 pandemic setting. Methods: We used keywords (((((coronavirus[Title/Abstract]) OR (covid-19[Title/Abstract])) OR (ncov-19[Title/Abstract])) OR (SARS-cov-2[Title/Abstract]))) AND (perioperative[Title/Abstract]) in the National Library of Medicine (NLM) database to find eligible reports. Results: We found 32 articles from the NLM database. After eligibility screening, we found 25 eligible articles describing perioperative management during the Covid-19 pandemic that relates to the staff's safety. All eligible articles stress the importance of the negative-pressurized environment to deal with perioperative care of Covid-19 patients. In general, the use of personal protective equipment (PPE) and video laryngoscopy is also essential. Conclusion: The best protective suit to avoid health-care personnel from getting Covid-19 infection is proper training and self-discipline. This combined with cooperative, honest patients and proper PPE supply is vital in efforts to reduce the spread of the disease. Negative-pressure chambers, both in operating rooms and intensive care units, are essential in this pandemic. Unfortunately, they are not easily available in underdeveloped and developing countries.

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Background: This systematic review aimed to summarize the evidence base on randomized controlled trials (RCTs) comparing the continuous adductor canal block (CACB) and continuous epidural analgesia (CEA) in total knee arthroplasty (TKA) surgery. Methods: We searched the Cochrane Library, PubMed, and EMBASE database from the beginning of 2016 until 2020 to find RCTs published in English language, which have investigated pain score, length of stay (LOS), ambulation distance, and total opioid consumption in TKA. Results: Three RCTs were included in the final analysis. All of them employed similar argument that CACB is better than CEA in pain score, but only two of three studies investigated the other parameters such as LOS, ambulation distance, and opioid consumption, with the result that CACB is better than CEA. Conclusion: It was found that CACB was better in pain control compared to CEA, but there are very few similar studies. Future research is required to establish the therapeutic efficiency of CACB than CEA in TKA surgery.

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Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a lengthy diagnostic/therapeutic procedure performed for various pancreatic-biliary disorders often involving high-risk patients. The aim of our study is to compare the ketamine hydrochloride and fentanyl citrate with propofol for patients undergoing ERCP. Patients and Methods: In this prospective randomized study, 100 consenting patients undergoing ERCP were randomly allocated into two groups of 50 each: Group PK received ketamine 1 mg/kg and Group PF received fentanyl 1 mcg/kg. Sedation (based on the Ramsay Sedation Score), blood pressure (BP), heart rate (HR), peripheral oxygen saturation (SpO₂), recovery time, total propofol consumed, quality of analgesia, endoscopist and patient's satisfaction score, and various complications were recorded. Results: The sedative and analgesic effects did not differ among both the groups. The mean HR in the PK Group was higher than Group PF. The decrease in the mean arterial BP was much more in the PF Group. SpO₂did not differ in both the groups. Total propofol consumption was higher in PF Group than PK. Moreover, the recovery time was longer in the PK Group compared to Group PF. Patients' and endoscopists' satisfaction score showed no significant difference between the two groups. Conclusion: We concluded that ketamine and fentanyl are equally efficacious with propofol for sedation in patients undergoing ERCP. Recovery time was shorter in the propofol-fentanyl regimen compared to the propofol-ketamine regimen.

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Background: Pregnant women are at high risk of experiencing gastric fluid aspiration, which is known as Mendelson's syndrome. The possibility of aspiration increases in an emergency condition. Low pH and high volume of aspirate increase the severity of aspiration. Ranitidine and antacids can increase gastric pH. This study aimed to compare gastric pH after receiving ranitidine, antacids, and ranitidine-antacids combination as premedication in patients undergoing an emergency cesarean section (C-section). Patients and Methods: This study is a true-experimental design on 27 participants who underwent a C-section at Dr. Saiful Anwar Hospital. The R group received ranitidine 50 mg, the A group received 10 ml of antacids, and the C group received the combination of both. The measurement of gastric pH was carried out on 0, 5, 15, 30, 45, and 60 min after premedication. The data were analyzed using the one-way ANOVA test. Results: The average change in gastric pH is better seen in the antacids group. The gastric pH increases from 3.19 ± 1.04 to 4.64 ± 1.20 at 60 min after premedication (P > 0.05). Ranitidine administration showed better results at 5, 15, and 30 min after premedication (P > 0.05). The combination of ranitidine and antacids showed better results at 45 and 60 min after premedication (P > 0.05). Conclusion: There is no significant difference in gastric pH after receiving premedication in patients undergoing a C-section. However, all groups show an increase in gastric pH after receiving premedication. The administration of ranitidine and antacids combination is not better than a single dose of ranitidine or antacids.

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