Background: Over concerns of vasoconstriction leading to free flap failure, it has been a common practice to avoid vasopressors for the maintenance of blood pressure during reconstructive microvascular surgeries. Aims: The aim of this study was to assess the impact of use of noradrenaline in the perioperative period on outcome of free flaps in patients who underwent reconstructive surgeries as compared to those who did not receive noradrenaline. Settings and Design: Retrospective analysis was conducted at a tertiary care institute. Materials and Methods: A total of 120 patients who underwent free flap surgeries were included in the study, of which 102 patients who did not require noradrenaline perioperatively formed the control group (Group C), whereas those who required noradrenaline infusion constituted the study group (Group N). Data regarding flap outcome at discharge, intraoperative hemodynamics and temperature were documented. Statistical Test Used: Chi-square test, Mann–Whitney test, Independent sample t -test, and paired t -test were used for statistical analysis. Results: Out of 120 patients, 15% ( n = 18) patients required noradrenaline (Group N). In Group N, 27.78% ( n = 5) patients and in Group C, 22.55% ( n = 23) were re-explored. Four patients in Group C and none in Group N had a poor flap outcome (3.92% vs. 0%). There was no significant difference in surgical duration and the volume of crystalloids received in both groups. Preoperative hemoglobin levels were lower in Group N; intraoperatively, they were more hypothermic and needed more colloids, blood, and plasma. Conclusion: Perioperative use of noradrenaline did not adversely affect free flap survival in patients who underwent microvascular reconstructive surgeries. Although re-exploration rate was marginally increased with use of noradrenaline, the final flap outcome was unaffected.

The prevalence of perioperative anaphylaxis is 1 in 1250–20,000 anesthetics. Inhalational anesthesia is considered safe in patients with multiple drug allergies, as there have been no reports of anaphylaxis to volatile inhalational agents. Anesthetic management of six patients with documented allergy to all commonly used anesthetic drugs who underwent major surgeries under general anesthesia is described as a case series. The plan of anesthesia in these patients was an anesthetic gas-based general anesthesia without using muscle relaxants but with the use of intravenous fentanyl if patient was not allergic to it. Sevoflurane 8% in oxygen was used for induction. Following cessation of breathing and on attaining an end-tidal concentration of >4% sevoflurane, direct laryngoscopy and intubation were performed. Anesthesia was maintained with sevoflurane in nitrous oxide and oxygen mixture maintaining a lower end-tidal carbon dioxide. Hypotension and/or bradycardia were managed with intermittent intravenous boluses of adrenaline 20 μg. At the end of surgery, all anesthetic gases were cutoff, and patients were extubated when awake. No muscle relaxant was used in any of the cases. Two patients received fentanyl before induction, whereas others were given oral paracetamol 2 h before induction. Postoperative analgesia was provided with oral paracetamol which was given 2–4 h after surgery. Intraoperative period was uneventful for these patients. In patients with multiple drug allergies, inhalational agent-based general anesthesia can be considered as a safe alternative to regular anesthetic practice involving polypharmacy, with a reduced risk of perioperative adverse events.

Background and Aims: Auscultation to verify Ryle’s tube position is difficult in obese patients. We compared the usefulness of ultrasonography (USG) versus auscultation in confirming the correct Ryle’s tube placement in normal versus overweight or obese patients, time taken for confirmation, and incidence of reinsertion. Material and Methods: A prospective, observational study was carried out on 80 patients. Patients with a body mass index (BMI)>25 kg/m2 formed group O and those with BMI <25 kg/m2 constituted group N. After Ryle’s tube insertion correct placement was first confirmed by auscultation. The presence of a gurgling sound over the epigastrium was graded (definite/doubtful/absent). During USG evaluation, if Ryle’s tube was not visualized at the subxiphoid region, 20mL of air was injected, looking for dynamic fogging in the stomach. If auscultation yielded doubtful or absent results and USG also failed to confirm, Ryle’s tube was repositioned and confirmed. Results: Group O had a significantly higher BMI. Auscultation time and the time taken for USG confirmation were significantly longer in group O. The percentage of patients with definite auscultatory signs was significantly higher in group N. Significantly higher number of patients in group O had doubtful/absent auscultatory signs. Ryle’s tube and fogging visualization with USG and the requirement of reinsertion were comparable in both groups. The percentage of patients with definite auscultatory confirmation and definite USG confirmation were comparable in group N. However, in group O, significantly lesser patients had definite auscultatory confirmation compared to definite USG signs. Conclusion: Confirmation of the correct placement of Ryle’s tube using ultrasound is easier than auscultation in overweight and obese patients. In normal patients, both techniques are equally useful.