Aim: Pediatric patients have unique anatomical, physiological and pharmacological characteristics. The process of administering anesthesia for pediatric surgeries is quite challenging. Such cases are usually performed under general anesthesia using face masks, endotracheal tubes (ETT) or supraglottic airways (SGA) depending upon type and duration of surgery. Use of SGA has various advantages over the other two and their use is increasing day by day. We carried out an audit retrospectively to extract data of surgeries where SGA were used over a duration of six months. Primary objective was to delineate percentage of usage of SGA and secondary were to study associated complications and identify areas of improvement, if any. Materials and methods: Subsequent to International Electrotechnical Commission (IEC) approval, all perioperative details related to patients and surgeries were collected from anesthesia records. A number of other parameters were also recorded. Results: Number of patients managed under SGA during 6 months duration were 120 as compared to total of 400. Thus, the usage was 30%. There was no difficult SGA placement. Neuromuscular blockers were used in 10% cases. Dislodgement of device was noted in 12.5% patients and laryngospasm in 10%. Change of size of device was required in seven patients weighing 10 kg. Conclusion: The practice of use of these devices has revolutionized the field of pediatric anesthesia with advantages like avoidance of use of muscle relaxant. They are very tachydidactic and freindly to use. Some vigilance is required to prevent and treat complications associated with their use. Clinical siginficance: The implications of SGAs are becoming wider day by day and in near future with more advance devices, they might still have wider applications than endotracheal tubes.

Context: Bleeding is of utmost concern in major orthopedic operations like total knee replacement, total hip replacement, and spine surgeries. Strategies to reduce blood loss must be employed to reduce allogeneic blood transfusion. Tranexamic acid (TAX) is an inexpensive synthetic derivative of the amino acid lysine. By attaching to lysine binding sites on plasminogen molecules it forms tranexamic acid–plasmin complex which has weaker fibrinolytic properties than plasmin alone. It also exhibits clot stabilizing and anti-inflammatory properties. When administered to surgical patients it can reduce blood loss and thus decrease transfusion requirements. Aim: This is a study to evaluate the efficacy and safety of tranexamic acid in reducing blood loss and need of postoperative blood transfusions following unilateral total knee replacement surgery in a tertiary care teaching hospital. Materials and methods: Sixty patients,18–70 years, American Society of Anesthesiology (ASA) statuses I and II undergoing unilateral total knee replacement under combined spinal-epidural anesthesia were enrolled in this prospective, randomized, double-blind study. Thirty patients each were randomly assigned to group T (TAX) and group C (control). Group T received intravenous tranexamic acid 10 mg/kg before tourniquet inflation followed by its infusion at 1 mg/kg/hour till skin closure. Group C received a similar amount of normal saline and served as the control group. The demographic data, duration of surgery, intraoperative vital parameters, intraoperative and postoperative blood loss, postoperative hemoglobin levels, quantity of blood transfusion required and a number of patients requiring blood transfusions and risk of the thromboembolic phenomenon were studied. Results: The mean (±SD) total blood loss was lower in the group receiving tranexamic acid (306.96 ± 75.23 mL) than in control group (543 ± 163.36 mL) which amounted to 43.47% less blood loss in the group receiving tranexamic acid. On an average control group required six times more blood transfusion than tranexamic acid group. Conclusion: Use of intravenous tranexamic acid is an effective and safe method to decrease blood loss in surgeries on the bone like total knee replacement.

Introduction: Desflurane due to its favorable quality of quick wash in and wash out has gained popularity as a preferred inhalational anesthetic agent for low flow anesthesia (LFA) which can be costeffective, minimizing the operation theatre pollution. This study was conducted to assess the pharmacokinetic effects and safety of desflurane in lower flow rates. Aim: To compare the pharmacokinetics of desflurane by assessing its inspired and end tidal concentrations at fresh gas flow (FGF) of 1 and 1.5 L/min. To compare the inspired and end tidal concentrations of oxygen, nitrous oxide at 1 and 1.5 L/min FGF, to assess the safety as per adequate oxygenation and depth of anesthesia, haemodynamic stability, consumption of gases, MAC values and incidence of awareness. Materials and methods: One hundred patients were included and divided into two groups of 50 each of ASA grades I and II undergoing general anesthesia for laparoscopic abdominal surgeries. They were maintained with FGF of group A–1 L/min, group B–1.5 L/min All patients were monitored for hemodynamics, entropy, inspired and expired concentration of desflurane, oxygen, nitrous oxide, MAC values at FGF depending on the group with O₂:N₂O 50:50 and 5% desflurane. The recovery parameters, side effects and awareness were noted. Results: We found that Inspired and end tidal concentrations of desflurane were significantly different for both groups, but the difference between inspired and end tidal concentrations and ratio of end tidal to vaporizer setting were comparable as the duration of anesthesia increases suggesting saturation being achieved. The inspired and end tidal concentrations of oxygen were significantly different but were maintained at adequately safe levels. Hemodynamics were maintained and comparable in both the groups. The MAC values and requirements of desflurane, oxygen and nitrous oxide were higher in group B and recovery took significantly longer time. The incidence of side effects were comparable and none of the patients experienced awareness. Conclusion: The pharmacokinetics of desflurane favour the use of LFA. Conducting anaesthesia at a FGF 1 L/min was equally safe and there was no added advantage of using 1.5 L/min FGF. In today's modern era low flow anesthesia can be safely practiced and reduces the cost and environmental pollution. Clinical significance: Desflurane can be used efficiently at lower rates with the advantage of reducing the cost and not jeopardising the safety as per the oxygenation, hemodynamic stability and depth of anesthesia.

Aim: The utility of fiberoptic bronchoscopy to formulate the best airway management plan in a child with giant hydatid lung cyst Background: Management of hydatid cyst of lungs is a challenge for the anesthesiologist due to problems associated with airway and one lung ventilation, the potential for rupture of the cyst, dissemination, and anaphylaxis. Case description: We report an 11-year-old boy who was posted for video-assisted thoracoscopic removal (VATS) of a giant hydatid cyst of the left lung. Conclusion and clinical significance: Flexible fiberoptic bronchoscopy provides a quick real-time visual assessment of the airway with minimal discomfort and risk to the patient and is a valuable tool in formulating the best and safest plan for securing the airway.

Fat embolism syndrome (FES) is known to be relatively common in cases of multiple traumatic fractures; it is rare in cases of total knee arthroplasty. We describe a case of a 61-year-old female who underwent unilateral total knee arthroplasty, 5 hours later she developed slurring of speech, disorientation subsequently desaturated, requiring intubation. The clinical diagnosis of fat embolism syndrome was made by criteria of exclusion. Fat embolism syndrome can occur unexpectedly in elective reconstructive orthopedic procedures. One should have a high degree of clinical suspicion of fat embolism syndrome when a patient deteriorates perioperatively. The treatment is primarily supportive.

Disease of the thyroid gland in the general population is well defined. Hyperthyroidism is characterized by increased thyroid hormone synthesis and secretion from the thyroid gland, whereas thyrotoxicosis refers to the clinical syndrome of excess circulating thyroid hormones, irrespective of the source. The signs and symptoms of hyperthyroidism if subtle, can be missed during the preoperative period. This case report highlights the importance of vigilant monitoring to diagnose and manage cases of thyrotoxicosis in the intraoperative period.

The incidence of complete atrioventricular block first time during pregnancy is rare. Majority of cases remain asymptomatic and do not require any active intervention. Symptomatic ones can present with syncope, dyspnea, arrhythmia, heart failure or sudden cardiac death. The risk of syncope and sudden cardiac death is increased in patients with heart rate less than 50/ minute. The goal in the perioperative anesthetic management of this case is to preserve the heart rate and maintain hemodynamic stability. We present a case of 26 years old parturient with pregnancy-induced hypertension (PIH), complete heart block (CHB), intrauterine growth retardation (IUGR), and Rh incompatibility managed under spinal anesthesia.

With changing cohort of cardiac patients, elderly patients with comorbidities like a patient with a pacemaker may be encountered in clinical practice. In patients with a pacemaker undergoing noncardiac surgery, electromagnetic interference can alter the function of a permanent pacemaker. Additional concerns during open heart surgery in a patient with a permanent pacemaker are lead displacement with venous cannulation, electrical activity during cardioplegia and damage to the device by defibrillation. Management of a patient with a pacemaker for a surgery calls for a multidisciplinary approach with involvement of cardiologist, electrophysiologist, device manufacturer, anesthesiologist, and cardiac surgeon. To the best of our knowledge, there are no case reports or guidelines about a patient with a pacemaker coming for cardiac surgery, and we report the perioperative management of a pacemaker dependent patient undergoing aortic valve replacement for severe aortic stenosis.

Central venous cannulations in pediatric patients require procedural sedation. Chances of desaturation are increased with anesthesia and maneuvers reducing functional residual capacity, especially in critically ill patients. Airvo™ is a device which can provide oxygen at very high flows with accurate and titratable FiO2. We present a case with where Airvo™ was instituted while securing central venous access in a patient with nephrotic syndrome with ascites.