Background General anaesthesia (GA) is predominantly important for conducting tracheal intubation; it should be quick and precise, having a prudent performance. It is preferable to use a neuromuscular blocking drug, which ideally should be highly potent, with a rapid onset and a short duration clinical effect in order to prevent the development of hypoxia during laryngoscopy and tracheal intubation and also avoid any changes in haemodynamics caused by the release of histamine, ganglion block, and anti-muscarinic actions. The non-depolarizing muscle relaxants rocuronium and cisatracurium don\'t have any noticeable independent side effects when used within the recommended dosage levels. Aim The aim was to compare the clinical efficacy of rocuronium bromide and cisatracurium besylate with respect to their property as muscle relaxants in producing favourable intubating conditions and to assess their haemodynamic stability. The objectives of the study were to evaluate the onset of action and any undesirable effects. Methods Between the ages of 20 to 60 years, 60 patients of either gender, divided randomly into groups of 30 each, of American Society of Anesthesiologists (ASA) physical status classification I and II, were put for elective surgical procedures to be done under general anaesthesia. Patients were given 0.6 mg kg-1 IV of rocuronium in Group R and 0.15 mg kg-1 IV of cisatracurium in Group C. After injecting the muscle relaxants, parameters were measured 60, 90, 120, 150, 180, 240, and 300 seconds later. Result Demographical variables like age, gender, and ASA physical status of the two groups were analogous. Group R had good to excellent/favourable intubating conditions by 90 seconds, and Group C by 240 seconds with comparable haemodynamic stability. The onset of action was significantly faster in Group R (92 ± 7.61 seconds) than in Group C (188 ± 40.88 seconds). Conclusion Rocuronium produced favourable intubating conditions having good haemodynamic stability and a statistically significant (p < 0.00001) faster onset of action in comparison to cisatracurium.

Elderly patients coming for orthopaedic surgeries usually have many comorbidities. This makes them potentially vulnerable to haemodynamic instability with a conventional bolus dose of spinal anaesthetic. Fractionating the spinal dose was reported to have haemodynamic stability with a longer duration. Here, we present five cases of high-risk elderly patients with multiple comorbidities who presented for orthopaedic surgeries and were successfully managed with fractional spinal anaesthesia.

Transpulmonary thermodilution is often used to measure extravascular lung water during liver transplantation. Here, the case of new onset atrial fibrillation during orthotopic liver transplantation, which may have been induced by iced saline injection for transpulmonary thermodilution measurement, is described. A 52-year-old male patient underwent orthotopic liver transplantation due to alcoholic cirrhosis combined with portal hypertension. During dissection of the recipient liver, transpulmonary thermodilution was performed. At 3 minutes following iced saline injected, atrial fibrillation occurred, the ventricular rate increased to more than 120 beats per min, and blood pressure dropped to 75/50 mmHg. Massive haemorrhage, inferior vena cava clamping, electrolyte disorder, acid-base balance disorder, and hypothermia were all ruled out, and iced saline injection was suspended. Hemodynamic stability was maintained with phenylephrine and lanatocide C (cedilanid), and chemical cardioversion was performed using amiodarone. During the reperfusion phase, transient hemodynamic instability was managed by norepinephrine. The neohepatic phase was uneventful. Atrial fibrillation lasted for 5 days and reversed to sinus rhythm automatically. The patient was hemodynamically stable during this period, and recovery was smooth with no thromboembolic events. In conclusion, atrial fibrillation may be induced by iced saline injection for transpulmonary thermodilution measurement during orthotopic liver transplantation.

Spontaneous pneumothorax (SP) is defined as the presence of air in the pleural cavity and remains a significant health problem. Secondary SP (SSP) is associated with underlying lung diseases, such as cystic fibrosis, chronic obstructive pulmonary disease (COPD), and interstitial lung disease (ILD), and is associated with poor outcomes. The current guidelines in the management of SSP have not been updated since the last decade; therefore, new protocols focused on the management of SSP should be evaluated. We present two cases of patients admitted with SSP who were treated conservatively due to haemodynamic stability. In both cases, the pneumothoraces resolved without further complications.

We presented a rare case of traumatic mitral annular avulsion and interventricular septum dissection after an unintentional falling injury in a 5-year-old female child. A successful surgical repair of mitral annulus and interventricular septum was performed to restore the haemodynamic stability.

Renal dysfunction following intraoperative arterial hypotension is mainly caused by an insufficient renal blood flow. It is associated with higher mortality and morbidity rates. We hypothesised that the intraoperative haemodynamics are more stable during xenon anaesthesia than during isoflurane anaesthesia in patients undergoing partial nephrectomy.
We performed a secondary analysis of the haemodynamic variables collected during the randomised, single-blinded, single-centre PaNeX study, which analysed the postoperative renal function in 46 patients who underwent partial nephrectomy. The patients received either xenon or isoflurane anaesthesia with 1:1 allocation ratio. We analysed the duration of the intraoperative systolic blood pressure decrease by > 40% from baseline values and the cumulative duration of a mean arterial blood pressure (MAP) of < 65 mmHg as primary outcomes. The secondary outcomes were related to other blood pressure thresholds, the amount of administered norepinephrine, and the analysis of confounding factors on the haemodynamic stability.
The periods of an MAP of < 65 mmHg were significantly shorter in the xenon group than in the isoflurane group. The medians [interquartile range] were 0 [0-10.0] and 25.0 [10.0-47.5] minutes, for the xenon and isoflurane group, respectively (P = 0.002). However, the cumulative duration of a systolic blood pressure decrease by > 40% did not significantly differ between the groups (P = 0.51). The periods with a systolic blood pressure decrease by 20% from baseline, MAP decrease to values < 60 mmHg, and the need for norepinephrine, as well as the cumulative dose of norepinephrine were significantly shorter and lower, respectively, in the xenon group. The confounding factors, such as demographic data, surgical technique, or anaesthesia data, were similar in the two groups.
The patients undergoing xenon anaesthesia showed a better haemodynamic stability, which might be attributed to the xenon properties. The indirect effect of xenon anaesthesia might be of importance for the preservation of renal function during renal surgery and needs further elaboration.
ClinicalTrials.gov : NCT01839084. Registered 24 April 2013.

UNASSIGNED: Continuous spinal anaesthesia (CSA) is an underutilised anaesthetic technique. Our objectives were to evaluate the use of CSA in our institution, its efficacy, ease to use and safety.
UNASSIGNED: This was a retrospective analysis conducted in a tertiary centre. Records of all patients who underwent surgery and received CSA between December 2008 and July 2017 were reviewed. Their demographic profiles, type and duration of surgery were analysed. The outcomes measured were the success of CSA, technical evaluation and difficulties encountered, intraoperative haemodynamics, usage of vasopressors and any reported complications. Statistical analysis was done using Chi-square test.
UNASSIGNED: Three hundred and eighteen patients (94%) successfully underwent surgery using CSA. Twenty cases (6%) had failed CSA, of which five of them had CSA insertion failure, while the rest failed to complete the operation under CSA, thus requiring conversion to general anaesthesia. Patients who have had an initial intrathecal local anaesthetic (LA) volume ≥1.5 ml had higher odds (odds ratio (OR) 2.78; 95% confidence interval [CI], 1.70-4.57) of developing hypotension compared to those who had <1.5 ml (P < 0.001). There were no reported post-dural puncture headache, neurological sequelae or infection.
UNASSIGNED: CSA is a useful anaesthetic technique with low failure rate. The key to achieving haemodynamic stability is by giving a small initial bolus, then titrating the block up to required height using aliquots of 0.5 ml of intrathecal LA through the catheter.

BACKGROUND: The neuroanaesthesia ensures stable perioperative cerebral haemodynamics, avoids sudden rise in intracranial pressure and prevents acute brain swelling. The clinical characteristics of dexmeditomidine make this intravenous agent a potentially attractive adjunct for neuroanaesthesia and in the neurological intensive care unit.
OBJECTIVE: This study aimed to assess the effect of dexmedetomidine on intraoperative haemodynamic stability and to assess the intraoperative requirements of analgesic and other anaesthetic agents, and also to assess postoperative sedation, respiratory depression and any other side effects of dexmedetomidine as compared to placebo.
METHODS: This prospective randomized study was done in 60 patients of either sex, age between 18 to 60 years and American Society of Anaesthesiologist (ASA) Grade I and II undergoing elective craniotomies under General Anaesthesia (GA) for intracranial Space Occupying Lesion (SOL). These 60 patients underwent thorough history, clinical examination and laboratory investigations. They were randomly divided into two groups, Group D (received Inj. Dexmedetomidine) and Group P (received Inj. Placebo). During bolus and infusion Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP), Peripheral oxygen saturation (SPO2) was recorded at every five minutes interval for first 20 minute.
RESULTS: The mean age in Group D was 39.5 years and in Group P was 40 years. The sex distribution in two groups was in Group D, 12 patients (40%) were females and 18 (60%) patients were males. While in Group P 10 (33.3%) were females and 20 (66.7%) patients were males. The two groups were comparable with respect to diagnosis and type of surgery of patients and difference was not statistically significant. The mean HR, the mean DBP and the mean MAP was lower in Group D as compared to Group P and the difference was statistically significant.
CONCLUSIONS: Dexmedetomidine provided intraoperative haemodynamic stability. It attenuates the haemodynamic responses to laryngoscopy, intubation, at pin fixation and the emergence from anaesthesia.

BACKGROUND: Various adjuvants like morphine, buprenorphine and fentanyl, clonidine, ketamine are being used in anaesthetic practice since long for improvement of peri-operative analgesia following spinal anaesthesia. Such adjuvants have been helpful in induction of early ambulation but at the cost of their associated adverse effects. Therefore search for an effective adjuvant is still going on. Currently Dexmedetomidine, a highly selective α2-adrenoreceptor agonist is being studied for its adjuvant action in spinal anaesthesia.
OBJECTIVE: The present study aims to evaluate the efficacy of intrathecal Dexmedetomidine as an adjuvant to Bupivacaine in spinal anaesthesia in patients undergoing infra-umbilical surgeries.
METHODS: It was a prospective, double blind study among 60 patients undergoing infraumbilical surgeries under spinal anaesthesia. The patients were randomly allocated to 2 groups (Group I and Group II) of 30 each. Group I received hyperbaric bupivacaine (15 mg) alone and Group II received hyperbaric bupivacaine (15 mg) with Dexmedetomidine (5mcg). The onset time of sensory and motor block, regression time of sensory and motor block, duration of analgesia, haemodynamic parameters were recorded both intra and postoperatively. The primary efficacy parameters were to determine the onset and duration of sensory block, motor block and duration of postoperative analgesia. Secondarily any associated haemodynamic changes and adverse effects of Dexmedetomidine were also recorded.
METHODS: Continuous data were analysed using the Student\'s t-test and categorical variables by two-tailed Fisher-exact test or Chi-square test.
RESULTS: Onset of sensory block was 129.33±14.8 seconds in Group II as compared to 208.33±19.18 seconds in Group I with total duration of sensory block as 317.70±16.16 minutes in Group II and 188±11.86 minutes in Group I. Similarly, onset of motor block was 226.33±31.86 minutes and 320.33±29.81 minutes, with total duration of motor block as 286.33±15.15 minutes and 166.5±12.11 minutes in Group II and in Group I respectively. Duration of analgesia was 333.6±20.67 minutes with Dexmedetomidine but 193.67±7.06 minutes in bupivacaine alone group.
CONCLUSIONS: Dexmedetomidine as an adjuvant had shown early onset of sensory and motor block with longer duration of analgesia and haemodynamic stability in the present study as compared to bupivacaine alone.

BACKGROUND: The two most commonly used uterotonic drugs in caesarean section are oxytocin and carbetocin, a synthetic oxytocin analogue. Carbetocin has a longer half-life when compared to oxytocin, resulting in a reduced use of additional uterotonics. Oxytocin is known to cause fewer cardiovascular side effects when administered as a short-infusion compared to as an intravenous bolus. Based on these findings, we aim at comparing carbetocin 100 mcg given as a slow intravenous bolus with carbetocin 100 mcg applied as a short-infusion in 100 ml 0.9 % sodium chloride in women undergoing a planned or unplanned caesarean delivery. We hypothesise uterine contraction not to be inferior to a bolus application (primary efficacy endpoint) and greater haemodynamic stability to be achieved after a short-infusion than after a bolus administration, as measured by heart rate and mean arterial blood pressure (primary safety endpoint).
METHODS: This is a prospective, double-blind, randomised controlled, investigator-initiated, non-inferiority trial taking place at the University Hospital Basel, Switzerland. Uterine tone is quantified by manual palpation by the obstetrician using a linear analogue scale from 0 to 100 at 2, 3, 5 and 10 minutes after cord clamping. We will evaluate whether the lower limit of the confidence interval for the difference of the maximal uterine tone within the first 5 minutes after cord clamping between both groups does not include the pre-specified non-inferiority limit of -10. Both haemodynamic secondary endpoints will be analysed using a linear regression model, adjusting for the baseline value and the dosage of vasoactive drug given between cord clamping and 1 minute thereafter, in order to investigate superiority of a short-infusion as compared to a bolus application. We will follow the extension of CONSORT guidelines for reporting the results of non-inferiority trials.
CONCLUSIONS: Haemodynamic stability and adequate uterine tone are important outcomes in caesarean sections. The results of this trial may be used to optimise these factors and thereby increase patient safety due to a reduction in cardiovascular side effects.
BACKGROUND: Clinicaltrials.gov NCT02221531 on 19 August 2014 and www.kofam.ch SNCTP000001197 on 15 November 2014.