Coagulation is a dynamic process and the understanding of the blood coagulation system has evolved over the recent years in anaesthetic practice. Although the traditional classification of the coagulation system into extrinsic and intrinsic pathway is still valid, the newer insights into coagulation provide more authentic description of the same. Normal coagulation pathway represents a balance between the pro coagulant pathway that is responsible for clot formation and the mechanisms that inhibit the same beyond the injury site. Imbalance of the coagulation system may occur in the perioperative period or during critical illness, which may be secondary to numerous factors leading to a tendency of either thrombosis or bleeding. A systematic search of literature on PubMed with MeSH terms ‘coagulation system, haemostasis and anaesthesia revealed twenty eight related clinical trials and review articles in last 10 years. Since the balance of the coagulation system may tilt towards bleeding and thrombosis in many situations, it is mandatory for the clinicians to understand physiologic basis of haemostasis in order to diagnose and manage the abnormalities of the coagulation process and to interpret the diagnostic tests done for the same.

Background and Aims:Transversus abdominis plane (TAP) block is a popular technique for post-operative analgesia in abdominal surgeries. The aim of the study was to evaluate the relative efficacy of bupivacaine versus ropivacaine for post-operative analgesia using ultrasound-guided TAP block in laparoscopic cholecystectomies.Methods:Sixty adults undergoing elective laparoscopic cholecystectomy were randomised to receive ultrasound-guided TAP block at the end of the surgical procedure with either 0.25% bupivacaine (Group I, n = 30) or 0.375% ropivacaine (Group II, n = 30). All patients were assessed for post-operative pain and rescue analgesic consumption at 10 min, 30 min, 1 h, 4 h, 8 h, 12 h and 24 h time points. Means for normally distributed data were compared using Student's t-test, and proportions were compared using Chi-square or Fisher's exact test whichever was applicable.Results:Patients receiving ultrasound-guided TAP block with ropivacaine (Group II) had significantly lower pain scores when compared to patients who received the block with bupivacaine (Group I) at 10 min, 30 min and 1 h. However, both the drugs were equivalent for post-operative analgesia and 24 h cumulative rescue analgesic requirement (median [interquartile range]) (75.00 [75.00–75.00] in Group I vs. 75.00 [75.00–93.75] in Group II, P = 0.366).Conclusion:Ultrasound-guided TAP block with ropivacaine provides effective analgesia in the immediate post-operative period up to 1 h as compared to bupivacaine. However, both the drugs are similar in terms of 24 h cumulative rescue analgesic requirement.

Background:Use of opioids for perioperative analgesia is associated with sedation, respiratory depression and postoperative nausea and vomiting. N-methyl-D-aspartate receptor antagonist such as ketamine has both analgesic and antihyperalgesic properties. We studied the effect of intraoperative infusion of low-dose ketamine on postoperative analgesia and its management with opioids.Materials and Methods:A total of 80 patients scheduled for open cholecystectomy under general anesthesia were randomly allocated into two equal groups in a randomized double-blinded way. The general anesthetic technique was standardized in both groups. Group K patients (n = 40) received bolus of ketamine 0.2 mg/kg intravenously followed by an infusion of 0.1 mg/kg/h before skin incision, which was continued up to the end of surgery. Similar volume of saline was infused in Group C (n = 40). The pain score at different intervals and cumulative morphine consumption over 24 h was observed. Secondary outcomes such as hemodynamic parameters, patient satisfaction score and incidences of side effects were also recorded.Results:Intraoperative infusion of low-dose ketamine resulted in effective analgesia in first 6 h of the postoperative period, which was evident from reduced pain scores and reduced opioid requirements (P = 0.001). The incidence of side effects and patient satisfaction were similar in both groups.Conclusion:Intraoperative low-dose ketamine infusion provides good postoperative analgesia while reducing need of opioid analgesics, which must be considered for better management of postoperative analgesia.

Background and Aims:The objective was to determine the accuracy of sequential organ failure assessment (SOFA) score in predicting outcome of patients in Intensive Care Unit (ICU).Material and Methods:Forty-four consecutive patients between 15 and 80 years admitted to ICU over 8 weeks period were studied prospectively. Three patients were excluded. SOFA score was determined 24 h postadmission to ICU and subsequently every 48 h for the first 10 days. Patients were followed till discharge/death/transfer from the ICU. Initial SOFA score, highest and mean SOFA scores were calculated and correlated with mortality and duration of stay in ICU.Results:The mortality rate was 39% and the mean duration of stay in the ICU was 9 days. The maximum score in survivors (3.92 ± 2.17) was significantly lower than nonsurvivors (8.9 ± 3.45). The initial SOFA score had a strong statistical correlation with mortality. Cardiovascular score on day 1 and 3, respiratory score on day 7, and coagulation profile on day 3 correlated significantly with the outcome. Duration of the stay did not correlate with the survival (P = 0.461).Conclusion:SOFA score is a simple, but effective prognostic indicator and evaluator for patient progress in ICU. Day 1 SOFA can triage the patients into risk categories. For further management, mean and maximum score help determine the severity of illness and can act as a guide for the intensity of therapy required for each patient.