BackgroundWe report the management of two patents from the Indian subcontinent with extrahepatic portal vein obstruction presenting with anticipated difficult airway. A Macintosh blade was used to secure the airway after using various instruments designed for difficult airway. To the best of our knowledge, no case has previously been reported in which a Macintosh blade was used successfully in patients with extrahepatic portal vein obstruction with a difficult airway.Case presentationTwo women (case 1 and case 2) of South Asian ethnicity with extrahepatic portal vein obstruction presented for an elective splenorenal shunt. They both had micrognathia and restricted mouth openings. They had similar airway profiles with mouth openings of just 2 cm, Mallampati class IV, a thyromental distance <4 cm, a hyomental distance <2.5 cm, and a sternomental distance of 10 cm. Awake intubation was attempted in both patients after standard airway preparation in the form of preoperative 4 % lignocaine nebulization and 2 % viscous lignocaine gargle along with an on-table supralaryngeal nerve block using 2 % lignocaine and transtracheal infiltration with 4 % lignocaine.The patient in case 1 tolerated the procedure well whereas the patient in case 2 had to be given propofol 60 mg. Endotracheal intubation with a 6.5 mm polyvinyl chloride endotracheal tube was attempted using a Truview EVO2, an Airtraq, and a Miller blade no. 3 but was unsuccessful. Finally, a trial intubation was performed successfully with a Macintosh blade with a stubby handle assisted by a Frova Intubating Introducer in case 1 and a gum elastic bougie in case 2.ConclusionsAlthough many instruments have been introduced to manage difficult airways, our experience in these cases suggests that the Macintosh blade can be used first when attempting endotracheal intubation before using other instruments. Patients from the Indian subcontinent with extrahepatic portal vein obstruction are often found to have associated temporomandibular joint ankyloses (hence difficult airways). We hypothesize that a difficult intubation should be anticipated in these patients. Such an association has not been made before.

Transplantation provides a near normal life and excellent rehabilitation compared to dialysis and is preferred method of treatment for end stage renal disease patients. After ethics committee approval, a retrospective analysis of recipients of renal transplantation was done at our hospital from January 2010 to December 2014. Preoperative patient status, fluid management, hemodynamic parameters, anesthesia management, and perioperative complications were recorded and analyzed.Total 100 patients were recorded, 92% living and 8% were cadaveric related transplant. 92% were done electively. Most common co-morbidity recorded was hypertension in 49% patients. Predominant cause of end stage renal disease was chronic glomerulonephritis (41%). General anesthesia was technique of choice in all patients, 27 also received epidural. Invasive blood pressure monitoring was done in 3 patients with cardiac co-morbidities. 15% patients required blood transfusion. CVP maintained &#62; 12 mmHg and maximum at de-clamping. Mean arterial pressure maintained above 95 mmHg. Ionotropic support required in 2 patients. 76% patients were transfused with only crystalloid (NS and/or RL) while 24 patients received a combination of both crystalloid and colloid. 97% patients were extubated postoperatively while 3% required ventilator support. Recovery time with desflurane was significantly less as compared to other inhalational agents. One patient died postoperatively. Recent advances in surgical techniques, anesthesia management and immunosuppressive drugs have made renal transplantation safe and predictable. Preoperative patient optimization, intraoperative physiological stability and postoperative care of renal transplant patients have contributed to the success of renal transplant program in our hospital.

We present a case of unusually prolonged motor and sensory block for 30 hours after a successful single injection of ultrasound-guided interscalene block with 0.5% plain bupivacaine. All safety measures such as negative aspiration of blood injection at every 3 mL of drug with usual resistance, slow rate of injection and ultrasound documentation of spread of drug around C 5 and C 6 were followed. There was no evidence of neurological injury, but we should always be prepared to consider the possibility of nerve injury and take appropriate measures to prevent them.

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Congenital complete heart block in pregnancy is rare. Fetal distress permits no time for neuraxial blockade. Twenty-two years antenatal clinic diagnosed atrioventricular dissociation and complete heart block at 6 months of pregnancy, presented with fetal distress at 36 weeks. General anesthesia was given with transcutaneous pacemaker standby. Healthy baby was delivered. One episode of bradycardia occurred which responded to Inj atropine 0.6 mg IV however blood pressure was stable. We managed lower segment cesarean section (LSCS) in complete hearth block with fetal distress uneventfully with general anesthesia.