Background and Aims: Airway ultrasound is an emerging tool to predict difficult laryngoscopy. This study aimed to determine the utility of ultrasound measurement of the anterior soft tissue neck thickness at the level of hyoid, thyrohyoid membrane and thickness of tongue to predict difficult laryngoscopy and compare them with clinical parameters for airway assessment. Methods: The distance from skin to hyoid bone, skin to the thyrohyoid membrane in neutral and sniffing position and maximum tongue thickness was measured by ultrasound and correlated with Cormack Lehane (CL) laryngoscope view in 310 adult surgical patients. Receiver operating characteristic curve was plotted and the area under the curve was calculated for each parameter. The sensitivity and specificity of ultrasound-guided parameters were compared with clinical parameters like the inter-incisor gap, modified Mallampatti classification, thyromental, sternomental distance and neck circumference. Results: Incidence of difficult laryngoscopy (CL grade-III and IV) was 11.3%. A significant difference was observed in the ultrasound parameters between the easy and difficult laryngoscopy ( P -value = 0.001). Sensitivity and specificity to predict difficult airway was 69.6% and 77% for tongue thickness, 68% and 73% for the skin to hyoid bone distance in a neutral position and found to be higher than clinical parameters. Conclusion: The ultrasound measurements of soft tissue thickness of the anterior neck and tongue thickness along with the clinical assessment of airway can be useful in predicting difficult laryngoscopy.

Background: The main aim of emergency medical services (EMS) should be to provide universal emergency medical care which is EMS system available to all those who need it. Most of the developed countries have an integrated EMS system that is accessible by a single dial number in the whole country. Nepal does not have a proper EMS system. We conducted a literature review regarding methods of developing an integrated EMS system in Nepal. Result: The fragmented system, high demand-low supply, inequity with the service, and inadequately trained responders are major problems associated with EMS in Nepal. Nepal too should develop an integrated single dial number EMS system to meet the current demand of EMS. Having a paramedic in ambulances as the first responders will prevent chaos and save critical time. Funding models have to be considered while developing an EMS considering the capital as well as operational cost. Conclusion: Nepal can develop a public private partnership model of EMS where capital cost is provided by the government and operational cost by other methods. Community-based insurance system looks more feasible in a country like Nepal for generating operational cost.

Intraoperative penile tumescence during urological procedure can occur after regional or general anesthesia. It is a rare event but can cause delay or defer of the surgery. Pathophysiology of intraoperative erection is mainly due to autonomic imbalance during anesthesia. Various physical and pharmacological management of tumescence have been tried with variable success and complication. We injected ephedrine 15 mg intracavernous resulting immediate de-tumescence and minimum complication.

Background: Direct Laryngoscopy and endotracheal intubation are essential components of administration of general anaesthesia but trigger major stress response, in the form of in­creased catecholamines leading to tachycardia and hypertension. This study is designed to compare the haemodynamic stress response with the Macintosh, McCoy and Miller blades. Methods: This prospective comparative study was conducted in 150 ASA grade I and II pa­tients, undergoing laparoscopic cholecystectomy under general anaesthesia from March 2017, were randomly divided into three groups using Macintosh, McCoy and Miller blade for endotracheal intubation respectively. Results: The groups were also comparable in respect to gender, mean age, ASA grade, Cor­mack and Lehane grade, Laryngoscopic intubation time, baseline heart rate, heart rate before laryngoscopy, baseline mean arterial pressure and Mean Arterial Pressure before laryngos­copy. The mean heart rates at end of 1, 3 and 5 minute were 93.58±13.11, 88.28±11.57 and 83.64±10.94 bpm with Macintosh blade; 93.08±12.09, 94.54±11.87 and 87.50±10.72 bpm with McCoy blades; 108.20±13.94, 95.18±12.75 and 93.22±12.32 bpm with Miller blades. Rise in heart rate as well as mean arterial pressure following intubation was greatest with Miller blade, followed by Macintosh blade and least with McCoy blade and was statistically significant (P< 0.01). Conclusions: Miller blade produced maximum haemodynamic stress response, followed by Macintosh blade and McCoy blade produced the least haemodynamic response, hence the latter is preferable when less haemodynamic response is desired.