A 98 years old male patient, diagnosed as intertrochanteric fracture femur, was posted for fixation by dynamic hip screw. His weight was 70 Kg, height 160 cm, blood pressure of 130/90 mm of Hg and a pulse of 56 per minute. He was conscious and oriented in time, place and person. There was no history of chest pain or dyspnoea. His investigations revealed haemoglobin, creatinine, TLC, DLC, with in normal range. Serum sodium 132 mEq/litre. His random blood sugar was 94 mg%. Chest x-ray was showing mild emphysematous changes. Electrocardiogram showed ST segment depression of 1 mm and T wave inversion in chest leads V 1& V2. Echocardiography was normal with LVEF 42%. In view of extreme old age and low ejection fraction, epidural anaesthesia was planned. Procedure was explained to the patient and he was kept nil by mouth for 8 hours. Patient was premedicated with inj. Metoclopramide 10 mg half an hour before surgery. Intravenous access was secured with 18G cannula and monitor was attached. ECG, blood pressure, SpO2, respiratory rate and temperature was monitored. Patient was placed in sitting position with legs hanging by the side of the operation table & supported on a footrest and 18G Tuohy needle was inserted by a paramedian approach into L4-L5 interspace using loss of resistance technique. Epidural catheter was introduced through needle up to 5 cm in cephalad direction. 3 Test dose of 2 ml of lidocaine with adrenaline was given, after that drug solution 8 ml lidocaine 2% +6ml of 0.5% Bupivacaine + 50 mg Tramadol) was slowly injected through catheter after negative aspiration. T8 sensory level was achieved and procedure lasted for one and half hour. Intravascular volumes were maintained by giving Ringer lactate and normal saline solutions. Patient remained hemodynamically stable throughout the procedure except two initial episodes of hypotension which were managed by inj. Mephentermine 3 mg. There was no significant blood loss during the surgery. 4 No untoward complication occurred throughout the course of operation. Patient was shifted to intensive therapy unit for postoperative care. Eight hourly supplementations of Inj. Tramadol 100 mg was done through epidural catheter for 3 days for postoperative analgesia. Patient did well postoperatively and was discharged from hospital after one week.

Acute myeloid leukemia (AML) patients encounter complications mainly due to their underlying disease or chemotherapy. Although they are at high risk for both hemorrhagic and thrombotic complications, thrombotic vascular complication as an initial manifestation is less common and rarely reported, especially in non-acute promyelocytic leukemia (non-APML). A 58-year-old female with no co-morbidity presented with fever, decreased appetite, headache, and weakness in her left upper and lower limbs. Laboratory findings showed hyperleukocytosis with 90% blast cells and thrombocytopenia (50,000/dl). While investigated and conservatively managed, she developed a seizure and loss of consciousness on the same day and was admitted to the intensive care unit. Computed tomography showed a massive right infarct in the middle cerebral artery territory with a significant midline shift. Flow cytometry indicated the diagnosis of non-APML; chemotherapy, platelet transfusion, unfractionated heparin, mechanical ventilation, and other supportive treatments were started. While managing this case, we faced challenges in decision-making on thrombolysis, craniotomy, and chemotherapy. The case highlights the salient points and dilemmas in managing such an acutely ill patient in critical care.

A 40-year-old man reported to the emergency with sudden pain in abdomen early morning. Pain was generalized and increasing in severity. His personal and past history was insignificant with no history of Upper respiratory tract infection, asthma and chronic obstructive pulmonary disease. All routine investigations were within normal range. Quick pre anaesthetic examination was not significant. His vitals were B.P 130/88 mmHg, Pulse rate 98/min, Respiratory rate 20 min, SpO 2 96% on air, without any significant auscultatory findings. Patient was taken in emergency operation theatre for exploratory laparotomy.After securing two large bore 18G peripheral intravenous cannula and placement of nasogastric tube, routine premedication was given as per institutional protocol. General anaesthesia was then induced and maintained throughout the course. During exploration a small perforation (0.5 × 0.5 cm 2 ) was found in the first part of the duodenum A live adult round worm [Table/ Fig-1] came out through the perforation, which was stored in sample collection bottle and sent for microbiology department. Perforation was repaired and skin sutures were secured. After achieving adequate muscle power and respiration, patient was successfully extubated. While patient was still on O.T table, he developed sudden respiratory distress with RR 28/min, fall in saturation gradually till 80% with added expiratory wheeze. Bag and mask ventilation was done with 100% FiO 2 but SpO 2 further decreased to 60% with RR 40 per min, B.P 140/90 mmHg and PR 100/min. Patient was reintubated after giving propofol and supplemented with deriphyllin, hydrocortisone, dexamethasone intravenously. After ventilating with Bain's circuit with 100% FiO 2 gradually SpO 2 increased till 90% and then patient was shifted to Surgical intensive care unit where he was given oxygen (FiO 2 100%) through T piece. After half an hour he was able to maintain SpO 2 to 98% (FiO 2 40%), RR 16/ min, B.P 120/76 mmHg, PR 78/min and bilateral equal air entry ABSTRACTOne of the most prevalent parasitic infestation is ascariasis which poses a great challenge to both the person being infested with and the treating medical team. We present here a case of round worm (Ascaris lumbricoides) infestation. A 40-year-old male, weighing 60 kg, diagnosed as perforation peritonitis, was scheduled for emergency exploratory laparotomy. The round worm was crawling out from duodenal perforation vent during laparotomy confirming the infestation. Patient later developed bronchospasm in postextubation period and was managed accordingly. Surprisingly the patient expelled an adult worm in the next morning. This report highlights the importance of anticipating complications (i.e., airway obstruction, bronchospasm, etc.,) in an undiagnosed case of round worm infestation, especially if routine investigations were within normal limits.on auscultation with no added sounds. He was then extubated and watched for any other complications. In the morning next day patient expelled an adult Ascaris worm [Table/ F...