Aim: Epidural anaesthesia which is preferred in most of the prolonged and painful procedures can be dreadful when the catheter breaks inside. In this case report we report accidental breakage of epidural catheter and its successful management. Presentation of Case: 47 year old male patient was posted for arthroscopic Anterior cruciate ligament (ACL) and Posterior Cruciate Ligament (PCL) repair under spinal and epidural anesthesia. Epidural catheter got sheared while securing it. It was managed by surgical removal to avoid further complications. Discussion: There are different causes for epidural catheter breakage including technical error and manufacture error. Catheter should be checked for any manufacturing defect or kinking. If there is resistant while inserting the catheter careful removal of catheter along with the needle should be performed to avoid breakage of catheter. Conclusion: Epidural catheter breakage can be disastrous for any anaesthesiologist, so it is important to be vigilant while securing epidural catheter. If accidentally epidural catheter is retained it should be discussed with the patient and surgeons, and it is either removed since it is a foreign body or if left in situ. Serial follow-up for any neurological symptoms should be done.

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Background: Tramadol is routinely used analgesic postoperatively in ICU patients, it is known to cause nausea and vomiting. Pharmacologically it has analgesic action, centrally as it blocks the reuptake of serotonin at spinal pathway. Ondansetron is a serotonin receptor antagonist used in postoperative time, cancer chemotherapy, radiation therapy, as an anti-emetic. In-spite of known pharmacological antagonism centrally, these two drugs are routinely used together postoperatively. The purpose of this study was to assess tramadol's analgesic efficacy when given alone versus when given along with ondansetron. Requirement of rescue analgesic and side effects like sedation, nausea and vomiting amongst two groups were also evaluated. Methods: This prospective randomized study was conducted at surgical ICU enrolling 60 patients. We have separated patients into two groups of 30 each. Group A was given 100milligram of injection tramadol intravenously slowly over ten minutes and after 12mg/hour tramadol plus ondansetron in the dose of 0.8mg/hour. Group B was given 100milligram of injection tramadol slowly over ten minutes followed by infusion of tramadol 12mg/hour. In both A and B groups, hemodynamic parameters were evaluated at 0, 3, 6, 12, and 24 hours along with pain assessment using the Visual Analog Scale (VAS) in the range of 0 to 10. Rescue analgesia was administered in the form of paracetamol 1 gram IV at any time if VAS > 4. A four point ordinal scale was used to measure side effects such as nausea, vomiting, and the degree of sedation. Results: In group A, postoperative VAS scores were higher up to 24 hours compared to group B, suggesting greater analgesia in the tramadol infusion group only. There was a significant difference when both the groups were compared with respect to requirement of rescue analgesia with 4 patients in group A and no patient in group B requiring rescue analgesia. No significant difference was found with respect to nausea and vomiting and the degree of sedation in both classes. Conclusion: In ICU patients administration of tramadol along with ondansetron should not be practiced as ondansetron decreases the analgesic efficacy of tramadol.

During radial head plating or replacement it has been observed that the end to end repair of annular ligament was impossible especially when torn. It may cause radial head instability later on. Use of Bell Tawse technique and its modification has been elaborated in literature for the management of chronic radial head instability using Triceps tendon autograft, but its application for prevention of instability in the first place has not been elaborated. This case series will explain prevention of instability of radial head in those cases.During radial head plating or replacement, torn or resected annular ligament was augmented with a strip of autologous triceps tendon sheath graft. During subsequent follow-ups no patient had any instability in the elbow. The mean of Mayo elbow performance score (MEPS) was 90 in 6 month follow-up.Radial head instability can be prevented in first place by simply augmenting annular ligament with triceps tendon sheath graft.