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Background Dexmedetomidine is a widely used alpha-2 adrenoreceptor agonist in perioperative patient care. Its postsynaptic activation of the receptors in the central nervous system is responsible for reduced neuronal firing with resultant sedation, anxiolysis, analgesia, hypotension and bradycardia leading to effective stress response attenuation seen during laryngoscopy and orotracheal intubation. Major head and neck surgeries demand nasotracheal intubation which is more stressful than orotracheal as it traverses through the nasopharynx which is very pain-sensitive. This is to protect the airway in the immediate postoperative period from oedema or haematoma in the oral cavity or neck. Though its stress response attenuation, haemodynamic stability during the intraoperative period following orotracheal intubation has been well studied, its role in the prevention of emergence delirium and tube tolerance following nasotracheal intubation in major head and neck surgery is not found in the literature. Our aim was to evaluate whether dexmedetomidine effectively attenuates the stress response following nasotracheal intubation, perioperative haemodynamic fluctuations and quality of emergence in patients undergoing head and neck oncosurgeries. Methods A total of 150 patients were randomly assigned to one of the two groups; group D (dexmedetomidine group) and group S (control group with saline). Group D patients received a bolus dose of dexmedetomidine 1 μg/kg in 10 ml saline over 10 mts before induction of GA followed by an infusion at 0.4 μ/kg/h during surgery. Statistical analysis was done using SPSS version 11.0 (SPSS Ltd., Chicago, IL). Categorical data were represented using frequencies and percentages. Continuous variables were represented using mean and standard deviation. The association between categorical variables was assessed using the chi-square or Fisher’s exact test, and continuous variables following normality assumption with respect to the two groups were assessed using an independent sample t-test. P value < 0.05 was considered to be statistically significant. Results Patients in the D group showed statistically significant attenuation of heart rate (P < 0.05) and blood pressure (P < 0.05) throughout the surgical period compared to saline. Also, there was a significant reduction in blood loss (P = 0.042), cough score (P = 0.001) and sedation score (P = 0.001) in the D group. Conclusions We conclude that a bolus dose of dexmedetomidine 1 μg/kg given 10 min before induction of anaesthesia followed by an infusion at 0.4 μg/kg/h during surgery effectively attenuates the haemodynamic responses during nasotracheal intubation and provides smooth emergence as evidenced by reduced coughing, agitation and arousable sedation without respiratory depression which facilitates tube tolerance following major head and neck oncosurgeries. Blood loss was also found to be significantly reduced.

: Difficult tracheal intubation still contributes significantly to anaesthesia related morbidity and mortality. Poor visualisation of laryngeal structures and multiple attempts at intubation are the leading causes with the conventional laryngoscopes. Though the recently introduced video assisted devices have significantly improved the ease of intubation by their superior laryngeal visualisation, the duration of intubation may vary. Here we compared the ease of tracheal intubation using Macintosh conventional direct laryngoscope (DL) and C- MAC videolaryngoscope (VL) in patients with expected difficult tracheal intubation. A total of 140 patients undergoing elective surgery under general anaesthesia with Modified Mallampati Class 3 and 4 found during the preoperative airway assessment were equally recruited to either of the groups. We compared the duration of tracheal intubation, visualisation of the laryngeal inlet, additional optimising manoeuvres required, and number of attempts at intubation and incidence of oral trauma assessed at extubation between the two groups.: Analysis done using Statistical Packages for the Social Sciences (SPSS) software; Windows version 11.0 (SPSS Inc., Chicago, IL, USA). Intubation time was significantly longer in patients with VL than DL (P 0.0001) whereas visualisation of laryngeal inlet was significantly better with VL (P 0.001). Additional optimising manoeuvres (P 0.001) and incidence of oral trauma (P 0.012) were significantly less with VL whereas intubation attempts were found comparable (P 0.586).: Though VL provided significantly better laryngeal view with less need for optimising manoeuvres and less oral trauma compared to DL, the duration of intubation was significantly more with the former.

Pheochromocytoma is a rare tumor of adrenal gland, treatable, curable cause of hypertension and may lead to premature death if not treated early. Medical management by multidisciplinary team is essential for hemodynamic stability during the perioperative period. General anaesthesia with thoracic epidural block offers adequate stress control as hemodynamic fluctuations are quite common and significant during induction, peritoneal insufflation and tumor manipulation. Newer modalities of diagnosis, short acting drugs to control hypertension, vigilant anaesthetic management with beat to beat monitoring of hemodynamics significantly improves patient's safety. Laparoscopic mobilisation of the adrenal helps in minimal manipulation of the tumour and thus minimising the resultant catecholamine surge. However, hypotension upon ligation of adrenal vein is inevitable. Noradrenaline (NA) remains the vasopressor of choice which has to be continued post operatively. A thorough pre-anaesthetic evaluation, preparation and execution with a multimodal analgesic pain management in a high dependency unit aid in early ambulation and discharge of the patient.

Background Methaemoglobinemia (MetHb) is a rare entity in clinical practice which often goes undiagnosed and keeps both the anaesthesiologist and attending surgeon under tension during surgery on seeing dark or chocolate-coloured blood in the surgical field. A low oxygen saturation (SpO2) will further panic us to search for a cause but may end futile. To add further, SpO2 may not rise significantly with adequate oxygenation and may not reach 100 with a fraction of inspired oxygen (FiO2) of 1 which keeps us searching further for a cause. An arterial blood gas (ABG) finally clinches our diagnosis. It is often missed in the pre-anaesthetic evaluation due to its rarity and the patient being asymptomatic most of the time. Case presentation We present a case of a 61-year-old man, a reformed smoker and hypertensive on regular medication was evaluated for laparoscopic partial nephrectomy for right renal cell carcinoma. MetHb was diagnosed preoperatively in the midst of the COVID pandemic when we had all our patients’ room air SpO2 recorded and thus helped us in the smooth and hassle-free management with vitamin C preoperatively for 5 days and an uneventful perioperative period. Conclusions MetHb is an uncommon and potentially reversible cause of hypoxia. A simple bedside SpO2 evaluation may give a hint to the diagnosis along with a high haematocrit which urges us to order for an ABG when no other cause is attributable. A preoperative diagnosis can lead to an effective and simple management with vitamin C which often reduces methaemoglobin to significantly low levels and to have a favourable outcome. According to the literature, any level of less than 20% does not have much clinical significance in asymptomatic patients and surgery need not be deferred.