Multimodal opioid sparing onco-anesthesia: A consensus practice guideline from Society of Onco-Anesthesia and Perioperative Care (SOAPC).

Opioids are an indispensable part of perioperative pain management of cancer surgeries. Opioids do have some side effects and abuse potential, and some laboratory data suggest a possible association of cancer recurrence with perioperative opioid use. Opioid-free anesthesia and opioid-sparing anesthesia are emerging new concepts worldwide to safeguard patients from adverse effects of opioids and potential abuse. Opioid-free anesthesia could lead to ineffective pain management, leaving the perioperative physician with limited options, while opioid-sparing anesthesia may be a rational approach. This consensus guideline includes general considerations of the safe use of perioperative opioids along with concomitant use of central neuraxial or regional blockade and systematic nonopioid analgesics. Region-specific onco-surgeries with their specific recommendations and consensus statements for judicious use of opioids are suggested. Use of epidural analgesia or regional catheter during thoracic, abdominal, pelvic, and lower limb surgeries and use of regional nerve blocks/catheter in head neck, neuro, and upper limb onco-surgeries, wherever possible along with nonopioids analgesics, are suggested. Short-acting opioids in small aliquots may be allowed to control breakthrough pain for expedient control of pain. The purpose of this consensus practice guideline is to provide the practicing anesthesiologists with best practice evidence and consensus recommendations by the expert committee of the Society of Onco-Anesthesia and Perioperative Care for safe opioid use in onco-surgeries.

Opioid free onco-anesthesia: Is it time to convict opioids? A systematic review of literature.

The epidemic of opioid crisis started getting recognised as a public health emergency in view of increasing opioid-related deaths occurring due to undetected respiratory depression. Prescribing opioids at discharge has become an independent risk factor for chronic opioid use, following which, prescription practices have undergone a radical change. A call to action has been voiced recently to end the opioid epidemic although with the pain practitioners still struggling to make opioids readily available. American Society of Anesthesiologist (ASA) has called for reducing patient exposure to opioids in the surgical setting. Opioid sparing strategies have emerged embracing loco-regional techniques and non-opioid based multimodal pain management whereas opioid free anesthesia is the combination of various opioid sparing strategies culminating in complete elimination of opioid usage. The movement away from opioid usage perioperatively is a massive but necessary shift in anesthesia which has rationalised perioperative opioid usage. Ideal way moving forward would be to adapt selective low opioid effective dosing which is both procedure and patient specific while reserving it as rescue analgesia, postoperatively. Many unknowns persist in the domain of immunologic effects of opioids, as complex interplay of factors gets associated during real time surgery towards outcome. At present it would be too premature to conclude upon opioid-induced immunosuppression from the existing evidence. Till evidence is established, there are no recommendations to change current clinical practice. At the same time, consideration for multimodal opioid sparing strategies should be initiated in each patient undergoing surgery.

Anesthesia management of a morbidly obese patient in prone position for lumbar spine surgery.

A morbidly obese, 45-year-old woman with a body mass index of 47 kg/m(2) , presented with a prolapsed intervertebral disc of the lumbar spine for decompression and fixation. Anesthesia and surgical positioning of morbidly obese patient carries 3 main hazards, namely, morbid obesity, prone position, and airway preservation problems. Morbid obesity has its own hazards of deep vein thrombosis and pulmonary embolus. Here we describe anesthetic management, successfully dealing with the specific problems of this patient due to obesity.

Diffuse idiopathic skeletal hyperostosis of cervical spine - An unusual cause of difficult flexible fiber optic intubation.

This is a report of anterior osteophytes on the cervical vertebra resulting in distortion of the airway and leading to difficulty during intubation. The osteophytes associated with the syndrome of diffuse idiopathic skeletal hyperostosis were at the C2-3 and C6-7, T1 level and resulted in anterior displacement of the pharynx and the trachea respectively.

Anaesthesia for renal transplantation: an update.

SUMMARY: Attempts at organ transplantation have been made since the 19(th) century. Renal transplantation is the preferred treatment for end stage renal disease. Renal transplant anaesthesia requires a thorough understanding of the metabolic and systemic abnormalities in end stage renal disease, familiarity with transplant medicine and expertise in managing and optimizing these patients for the best possible outcome. Also, the associated co-morbid conditions increase the complexity of anaesthesia, pain management and perioperative morbidity and mortality. Hence, a good perioperative management of these patients includes a multidisciplinary collaboration with well-planned anaesthetic strategies.

Fiberoptic Intubation Using LMA as A Conduit and Cook Airway Catheter as An Exchanger in A Case of Tessier 7 Facial Cleft Syndrome.

SUMMARY: Any anaesthesiologist handling a paediatric airway must have a detailed understanding of the differences in airway anatomy, signs and symptoms of airway compromise and common paediatric airway abnormalities. In addition to various equipments needed to manage a difficult airway, there should be a clear plan for evaluation, preparation and management of life threatening complications. We share our experience of successfully managing a difficult airway of a 5 year old child with Tessier 7 facial cleft syndrome. We emphasize the importance of preoperative evaluation, preparation and use of various airway adjuncts.

Renal transplantation-anaesthetic experience of 350 cases.

SUMMARY: Transplantation provides a near normal life and excellent rehabilitation compared to dialysis and is the preferred method of treatment for end stage renal disease patients. We describe our experiences through a retrospective analysis of anaesthesia management of 350 cases of both living related and cadaveric renal transplantation conducted between Jan 2004 - April 2008 at Jaslok Hospital And Research Center. Areas of our interest include preoperative patient status, fluid management, hemodynamic stability, anaesthesia management, and perioperative complications. Recent advances in surgical techniques; anaesthesia management and immunosuppressive drugs have made renal transplantation sale and predictable. Preoperative patient optimization, intraoperative physiological stability and postoperative care of renal transplant patients have contributed to the success of renal transplant programme in our hospital.