Evaluation of two doses (20 mL and 15 mL) of 0.25% bupivacaine in pericapsular nerve group block for patient positioning for sub-arachnoid block during hip fracture surgery: A single-centre, randomised comparative trial.

Background and Aims: Peri-capsular nerve group (PENG) block is a novel ultrasound (US)-guided technique to achieve regional analgesia in hip fractures. We compared the effectiveness of two doses of 0.25% bupivacaine (20 mL and 15 mL) in the US-guided PENG block for positioning patients for sub-arachnoid block (SAB) during hip fracture surgery. Methods: The randomised trial included 60 patients aged 40-90 years undergoing hip fracture surgery under SAB. PENG block was given by a US-guided approach with the patient in a supine position 20 minutes before SAB, and a total of 20 mL and 15 mL of bupivacaine (0.25%) were given in groups A and B, respectively. The primary outcome was to measure and compare the ease of positioning (EOP) of patients for the conduct of SAB. The secondary outcome was the pain assessment at rest and 15° leg raise position at baseline and 10 and 20 minutes post block using the verbal analogue scale (VAS). Continuous variables were compared using the t-test, and categorical variables were analysed using Pearson's Chi-square test or Fisher's exact test. Results: The mean (standard deviation) grade of EOP for SAB was significantly better in group A (2.47 (0.73) (95% confidence interval [CI]: 2.19-2.69)) than in group B (1.86 (0.62) (95% CI: 1.65-2.1)) (P = 0.001). The decrease in VAS scores was significantly higher in group A compared to group B at resting and 15° leg raise position at all-time points (P < 0.05). Conclusion: A dose of 20 mL of 0.25% bupivacaine shows better outcomes than 15 mL regarding the patient's positioning during the SAB.

Dexmedetomidine-Ketamine or Dexmedetomidine-Midazolam Nebulised Drug Combination as a Premedicant in Children: A Randomised Clinical Trial.

OBJECTIVE: This study was designed to evaluate the clinical efficacy of 2 low-dose nebulised drug combinations of dexmedetomidine-ketamine and dexmedetomidine-midazolam as a premedication in children scheduled for surgery under general anaesthesia. METHODS: Sixty children classified as American Society of Anesthesiologists physical status I, aged between 3 and 10, listed to undergo elective surgeries under general anaesthesia were enrolled in this prospective, randomised, and double-blind trial. Patients were randomly allocated to receive nebulised premedication approximately 30 minutes before the induction of anaesthesia. Group DK (n=30) received combined nebulised dexmedetomidine and ketamine (1 µg kg-1+1 mg kg-1 ) and the dexmedetomidine-midazolam (DM) group (n=30) received combined nebulised dexmedetomidine and midazolam (1 µg kg-1+0.1 mg kg-1 ). All children were anaesthetised with a protocolised anaesthesia technique. The primary end point was the level of sedation when the child was first seen in the operating room 30 minutes after nebulisation. The secondary end points were parental separation and ease of induction, ease of acceptance of IV cannula, mask acceptance, postoperative analgesia, and wake-up behaviour. RESULTS: Studied groups were comparable in demographic data (age, weight, and sex) and duration of anaesthesia. Level of sedation at 30 minutes was significantly greater in the DM group than in the DK group (P =.013) while the two were comparable in parental separation and ease of induction (P =.808). Group DK exhibited superior ease of acceptance of IV cannula (P =.001), mask acceptance score (P =.001), and postoperative analgesia (P =.021). Hemodynamic parameters and oxygen saturation remained comparable at all time intervals as also the wake-up behaviour. CONCLUSIONS: The nebulised combination of low-dose ketamine and dexmedetomidine was a superior combination producing acceptable sedation with enhanced ease of IV acceptance, mask acceptance, and postoperative analgesia in children.

Comparative evaluation of three techniques for paramedian subarachnoid block: Point-of-care preprocedural ultrasound assisted, real-time ultrasound guided and landmark based.

Background and Aims: Preprocedural ultrasound (US) assisted and real-time US-guided subarachnoid block (SAB) are useful adjuncts for successful SAB. This study compared the feasibility and efficacy of real-time US-guided SAB with preprocedural US-assisted and landmark-based SAB using paramedian approach. Methods: The study enroled 150 American Society of Anesthesiologists I and II patients, aged 20-65 years, scheduled for lower limb orthopaedic surgery under SAB. In group L (n = 50), the patients underwent landmark-guided SAB utilising paramedian approach. In group P (n = 50), preprocedural US-assisted SAB was instituted and in group M (n = 50) real-time US-guided SAB was administered. The number of needle attempts for a successful SAB was the primary outcome. The secondary outcomes included successful SAB in first attempt, time taken to perform SAB and patients' satisfaction. Results: The number of attempts for SAB were (mean ± standard deviation = 1.05 ± 0.35, 1.00 ± 0.28, 1.03 ± 0.26) in groups L, P and M, respectively (P = 0.436). The SAB was successful in the first attempt in 82%, 82% and 80% in groups L, P and M, respectively (P = 0.207). The time taken for the successful SAB was more in group M as compared to groups L and P (groups L and M, P = 0.045 and groups P and M, P = 0.004). The patients' satisfaction score was comparable. Conclusion: Real-time US guidance for spinal anaesthesia resulted in needle attempts comparable to landmark and preprocedural US-assisted SAB in patients with a normal spine. The time required for the completion of the block was more in real-time US-guided SAB.

Comparative evaluation of airway dynamics in patients undergoing laparoscopic cholecystectomy under general anaesthesia with controlled ventilation using ProSeal laryngeal mask airway, I-Gel™ and Baska mask.

Background and Aims: TheProSeal™ laryngeal mask airway (PLMA) and I-Gel™ are second-generation supraglottic airway devices (SADs). The Baska mask is a SAD having a non-inflatable cuff with a tendency to increase the perilaryngeal seal with an increase in airway pressures. This study compared the efficacy of I-Gel™, PLMA and Baska mask with respect to airway dynamics in patients scheduled for laparoscopic surgeries under general anaesthesia (GA). Methods: Ninety patients, of American Society of Anesthesiologists physical status I and II, aged 20-65 years scheduled for laparoscopic cholecystectomy under GA were enroled. The patients were randomised into three groups: Group P (n = 30): airway secured using PLMA, Group I (n = 30): airway secured using I-Gel™ and Group B (n = 30): airway secured using Baska mask. The primary outcome was the change in dynamic compliance, and the secondary outcomes included insertion time, changes in peak inspiratory pressure (PIP) and oropharyngeal leak pressure (OLP) at different time intervals. Results: After insertion of the SADs, the dynamic compliance was highest in group B and least in the group I (p = 0.01). The maximum decrease in dynamic compliance was observed in group I. The insertion time for SAD placement was more in group P. The group B had least PIP as compared to groups P, I at insertion. After carboperitonium, groups P and B had comparable PIP, and group I had highest PIP (p = 0.001). OLP was highest in group B, whereas group I had least OLP. Conclusion: The airway dynamics are better maintained with Baska mask as compared to the PLMA and I-Gel™.

Correlation of preprocedural ultrasound estimated epidural depths in transverse median and posterior sagittal oblique view and body mass index with procedural epidural depths in patients scheduled for surgery under lumbar epidural anaesthesia.

BACKGROUND AND AIMS: Preprocedural lumbar ultrasound (US) is employed for the estimation of epidural depth (ED). This study observed the correlation of preprocedural ED in transverse median (TM), parasagittal oblique (PSO) view, and body mass index (BMI) with procedural ED. METHODS: In a prospective study, 100 female patients, aged 40-65 years, with American Society of Anesthesiologists physical status I/II, BMI 18.5-30 kg m-2 scheduled for surgeries under lumbar epidural blocks were included. In the TM group, preprocedural ultrasonography (USG) was performed in TM view and ED was calculated, whereas in the PSO group, the paramedian sagittal view was used and corresponding markings were done for epidural needle insertion in the midline and paramedian planes, respectively. The primary outcome was the correlation of procedural ED and preprocedural ED in TM and PSO views, respectively. The secondary outcomes included correlation of procedural ED with BMI, comparability of preprocedural, and procedural ED in TM and PSO views. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) v19.0 (International Business Machines, USA). RESULTS: The preprocedural and procedural ED was less in the TM group (4.43 ± 0.75 and 4.44 ± 0.75 cm) in comparison to those in the PSO group (4.86 ± 0.53, 4.90 ± 0.54; P = 0.001). Strong correlation was observed in preprocedural and procedural ED [r2 = 0.996 and 0.995]. The procedural ED had strong correlation with BMI [r2 = 0.600, P = 0.001] in the TM group, and weak correlation [r2 = 0.367] in the PSO group [P = 0.01]. The procedural ED was comparable to preprocedural ED in TM and PSO groups. CONCLUSION: Preprocedural US scanning provides an accurate estimate of actual EDs in TM and PSO view.

Comparative analgesic efficacy of intravenous vs intrathecal dexmedetomidine as an adjuvant to hyperbaric bupivacaine in subarachnoid block for below knee orthopaedic surgery.

BACKGROUND AND AIM: Intrathecal and intravenous dexmedetomidine has been used as adjuvant in subarachnoid block [SAB]. The aim of this study was to compare the analgesic efficacy of intravenous vs intrathecal dexmedetomidine as adjuvant to intrathecal bupivacaine. METHODS: Ninety patients, aged 20-60 years belonging to American Society of Anaesthesiologists (ASA) physical status I and II, scheduled for below knee orthopaedic surgeries under SAB were enrolled. In group I (n = 45) patients received intravenous dexmedetomidine 0.5 µg/kg in 100 mL 0.9% normal saline [NS] intravenous over a period of 15 minutes given 20 minutes before SAB. Subarachnoid block was given with intrathecal (IT) 0.5% bupivacaine (H) 12.5 mg (2.5 mL) with 0.3 mL of NS. Patients in group II (n = 45) received 100 mL of 0.9% NS over a period of 15 minutes given 20 minutes before subarachnoid block. SAB was given with intrathecal 0.5% heavy bupivacaine 12.5 mg with 3 µg of dexmedetomidine (0.3 mL). The primary outcome was duration of analgesia and rescue analgesic requirement, whereas secondary outcome included pain scores. RESULTS: The duration of analgesia was prolonged in group II (median [IQR]: 5 (6-7.5) h than in group I (median[IQR]: 4[2-4.5] h, P = 0.000). Median dose of rescue analgesics over period of 24 hours was less in group II as compared to group I (median [IQR]:150 (75-150) mg vs 195 (150-225) mg, P = 0.000). VAS score was lower in group II till 12 h in the postoperative period (P = 0.00). CONCLUSION: Intrathecal dexmedetomidine is more efficacious as compared to intravenous dexmedetomidine, due to favourable outcomes in terms of increased duration of postoperative analgesia and reduced rescue analgesic requirement.

Ultrasound-assisted subarachnoid block in obese parturient: Need of the hour.

Subarachnoid block is commonly used for caesarean deliveries, by virtue of its simplicity in terms of performance and safety for the parturients when compared with general anesthesia. The landmark technique involves palpating the interspinous space at the level of Tuffier's line to ensure the interspace level and direct the spinal needle through optimally selected puncture site for performing the subarachnoid block. However, spinal block is sometimes not easy to perform in obese parturients primarily because of poorly palpable surface landmarks and challenges related to positioning for the block. Recently, ultrasound (USG) is being used for facilitating central neuraxial block, using low-frequency curvilinear probe with encouraging results. We report a case of a 28-year-old, 95-kg parturient, with body mass index of 39.1 kg/m2 scheduled for elective lower segment caesarean section under subarachnoid block, the indication being previous caesarean section. As the landmarks were not appreciable on palpation, we performed USG-assisted preprocedural landmark-based subarachnoid block successfully.

The usefulness of point of care ultrasound (POCUS) in preanaesthetic airway assessment.

BACKGROUND AND AIMS: Point of care ultrasound has the potential to become reliable airway assessment tool by accurate prediction of difficult laryngoscopy. We aimed to determine the feasibility of ultrasound in preoperative airway assessment. METHODS: This prospective, observational study was conducted on 200 patients requiring general anaesthesia and tracheal intubation. The thickness of anterior soft tissue neck at the level of hyoid bone (DSHB), epiglottis (DSEM), and Pre-E/E-VC[depth of the pre-epiglottic space (Pre-E)/distance from the epiglottis to the midpoint of the distance between the vocal cords (E-VC)] were measured sonographically. The hyomental distance ratio (HMDR) was measured utilising distances with head in neutral and extended position. The primary outcome was the efficacy of the parameters in predicting difficult laryngoscopy[Cormack Lehane 3,4]. The secondary outcome was to correlate the parameters to CL grading. RESULTS: Utilising receiver operating curves, cutoff value of HMDR for predicting difficult laryngoscopy was ≤1.0870 with sensitivity of 65%, specificity of 77%. The cutoff value, sensitivity andspecificity for Pre-E/E-VC were ≥1.785, 82.8% and 83.8%., respectively. The cutoff value of DSHB was ≥0.99 with sensitivity of 48% and specificity of 82%. The cutoff, sensitivity and specificity for DSEM were ≥1.615, 89.7%, and 64.8%, respectively. There was moderate positive correlations of DSHB, DSEM, and Pre-E/E-VC (r = 0.551 and 0.701, 0.787: P = 0.00), whereas moderate negative correlation observed with HMDR (r = -.0671: P = 0.00). CONCLUSION: The strong positive correlation of Pre-E/E-VC, DSEM, and moderate negative correlation of HMDR makes these ultrasound parameters reliable predictors for difficult laryngoscopy.

Point-of-care ultrasound in the airway assessment: A correlation of ultrasonography-guided parameters to the Cormack-Lehane Classification.

BACKGROUND AND AIM: The sonographic assessment of airway in the preoperative period has encouraging results in predicting difficult laryngoscopy. MATERIALS AND METHODS: The prospective, observational study was conducted on 120 patients scheduled for elective surgery requiring general anesthesia and tracheal intubation. The depth of the pre-epiglottic space (Pre-E), the distance from the epiglottis to the midpoint of the distance between the vocal cords (E-VC) was measured sonographically. Similarly, hyomental distance ratio (HMDR) was sonographically measured with head in neutral and extended positions. The primary outcome was the efficacy of Pre E/E-VC, HMDR for predicting difficult laryngoscopy (Cormack-Lehane [CL] Grade 3, 4). The secondary outcome was to correlate these parameters to CL grading. RESULTS: Difficult intubation was observed in 12.5% of patients. The mean ± standard deviation (SD) of Pre E/E-VC ratio was 1.33±0.335, 1.62±0.264 and 1.87±.243, 2.22±.29 for CL Grade 1, 2, 3, and 4, respectively (P = 0.00). The mean ± SD of HMDR was 1.11±.35, 1.12±.29, and 1.07±.39, 1.04 ± 0.01 for CL Grade 1, 2, 3, and 4, respectively (P = 0.00). Pre E/E-VC ratio of more than 1.77 cm had 82% sensitivity, specificity 80%, whereas HMDR less than1.085 had sensitivity 75% and specificity 85.3%, in predicting difficult laryngoscopy (P = 0.00). CONCLUSION: The sonographic measurement of the Pre E/E-VC ratio is a better predictor of CL grading as compared to HMDR. The noninvasive prediction of CL grading can be precisely done by Pre-E/E-VC ratio (range: 0-1.425 corresponds to CL Grade 1; 1.425-1.77 ≈ CL Grade 2; 1.77-1.865 ≈ CL Grade 3, more than 1.865 corresponds to CL Grade 4).

Efficacy of Dexmedetomidine in two Different Doses as an Adjuvant to Lignocaine in Patients Scheduled for Surgeries under Axillary Block.

INTRODUCTION: The effect of adding dexmedetomidine (α2-adrenoceptor agonist) to local anaesthetics in brachial plexus blocks has been evaluated, however there has been no consensus regarding the ideal dose of dexmedetomidine. Without ultrasound axillary block has been considered as the safest approach for brachial block. AIM: To evaluate the efficacy of two doses of dexmedetomidine (0.5 µg/kg and 1 µg/kg) as an adjuvant to lignocaine in patients undergoing forearm surgeries under axillary brachial plexus block. MATERIALS AND METHODS: This prospective randomized controlled study was conducted on 104 adult patients, American Society of Anaesthesiologists (ASA) physical status 1 or 2. They were randomized and given following drug formulations, Group L (n=35) received 23 ml of 2% lignocaine with adrenaline + 7 ml of saline, Group LD0.5 (n=34) received 23 ml of 2% lignocaine with adrenaline + 0.5 µg/kg of dexmedetomidine diluted in saline to make a volume of 7 ml, Group LD1 (n=35) was given 23 ml of 2% lignocaine with adrenaline + 1 µg/kg of dexmedetomidine diluted in saline to make volume of 7 ml, the total volume of drug being 30 ml in each group and concentration of lignocaine 1.5%. The duration of postoperative analgesia and demand for rescue analgesia were the primary outcomes and block characteristics taken as secondary outcome. RESULTS: Sensory and motor block onset times were shorter in Group L than in group LD0.5, LD1 (p < 0.05). Sensory and motor blockade durations were longer in Group LD1, LD0.5 than Group L (p<0.01). Duration of analgesia was longer in Group LD1 than in group LD0.5 and least in Group L (p<0.05). CONCLUSION: Dexmedetomidine (0.5 µg/kg and 1 µg/kg) as an adjuvant in axillary brachial plexus increases the duration of postoperative analgesia and delays the requirement of first dose of analgesic in a dose dependent manner and 1 µg/kg seems to be the near ideal dose of dexmedetomidine as an adjuvant in axillary block.

A dose-finding randomised controlled trial of magnesium sulphate as an adjuvant in ultrasound-guided supraclavicular brachial plexus block.

BACKGROUND AND AIM: Magnesium sulphate (MgSO4) has been used as an adjuvant in brachial plexus block with encouraging results; however, there is no consensus regarding its optimal dose. Thereby, we compared the efficacy of two doses of MgSO4 as an adjuvant in ultrasound (USG) guided supraclavicular brachial plexus block. METHODS: Ninety patients, aged 20-60 years, belonging to American Society of Anesthesiologists physical status 1 or 2, were given USG-guided supraclavicular block. Group B (n = 30) received 20 ml of 0.5%bupivacaine + 5 ml normal saline (NS), Group BM0.5(n = 30) received 20 ml of 0.5%bupivacaine + 3.75 ml NS and 125 mg MgSO4 (1.25 ml) and Group BM1(n = 30) received 20 ml of 0.5%bupivacaine + 2.5 ml NS and 250 mg MgSO4 (2.5 ml). The primary outcome of study was the duration of post-operative analgesia. The normally distributed data were analysed using analysis of variance and categorical data analysed using Chi-square test. RESULTS: Duration of post-operative analgesia was prolonged in Groups BM1 and BM0.5 (665.13 ± 97.874, 475.10 ± 53.294) min respectively as compared to Group B (272.03 ± 40.404 min: P = 0.00). The onset times of sensory and motor block were shorter in Group BM1 (5.17 ± 2.2 min) as compared to Groups BM0.5 and B (8.9 ± 2.3 and 17.7 ± 5.1 min: P = 0.00) respectively. Sensory and motor block durations were prolonged in Group BM1 as compared to BM0.5 and B (P = 0.00). CONCLUSIONS: MgSO4 as adjuvant in brachial plexus block increases the duration of post-operative analgesia. MgSO4 in the dose of 250mg has greater efficacy as compared to 125 mg.

Ultrasound-guided femoro-sciatic nerve block for post-operative analgesia after below knee orthopaedic surgeries under subarachnoid block: Comparison between clonidine and dexmedetomidine as adjuvants to levobupivacaine.

BACKGROUND AND AIMS: The advent of ultrasonographic-guided techniques has led to increased interest in femoro-sciatic nerve block (FSNB) for lower limb surgeries. α2-agonists have been used recently as adjuvants to local anaesthetics in nerve blocks. We aimed to compare equal doses of clonidine or dexmedetomidine as an adjuvant to levobupivacaine in FSNB for post-operative analgesia. METHODS: Ninety patients scheduled to undergo below knee orthopaedic surgeries under subarachnoid block were divided into three groups: Group LL (n = 30) patients received 38 mL of 0.125% levobupivacaine with 2 mL normal saline, Group LD (n = 30) patients received 38 mL of 0.125% levobupivacaine with 0.5 µg/kg dexmedetomidine and Group LC (n = 30) received 38 mL of 0.125% levobupivacaine with 0.5 µg/kg clonidine in saline to make total drug volume of 40 mL. The primary and secondary outcome variables were duration of analgesia and rescue analgesic requirement, verbal rating score respectively. Continuous variables were analysed with analysis of variance or the Kruskal-Wallis test on the basis of data distribution. Categorical variables were analysed with the contingency table analysis and the Fisher's exact test. RESULTS: Duration of analgesia was prolonged with dexmedetomidine (10.17 ± 2.40 h) and clonidine (7.31 ± 1.76 h) as compared to control (4.16 ± 1.04 h, P = 0.00). Significantly lower pain scores were observed in dexmedetomidine group as compared to clonidine up to 8 h post-operatively. CONCLUSION: Equal doses of clonidine or dexmedetomidine added to levobupivacaine prolonged the duration of analgesia, decreased requirement of rescue analgesia. Dexmedetomidine delays the requirement of rescue analgesics with better pain scores as compared to clonidine.

Magnesium sulphate as an adjuvant to bupivacaine in ultrasound-guided transversus abdominis plane block in patients scheduled for total abdominal hysterectomy under subarachnoid block.

BACKGROUND AND AIMS: Transversus abdominis plane (TAP) block has proven to be an effective component of multimodal analgesic regimens for a variety of abdominal procedures. Magnesium sulphate (MgSO4) N-methyl-D-aspartate receptor antagonist has the potential to be an ideal adjuvant in TAP block. We studied the efficacy of MgSO4 as an adjuvant to bupivacaine in TAP block in patients scheduled for total abdominal hysterectomy (TAH) under subarachnoid block (SAB). METHODS: Sixty-five women belonging to American Society of Anesthesiologists physical status 1 or 2, aged between 35 and 70 years, scheduled for TAH under SAB were recruited. Patients in Group B (n = 32) received 18 mL 0.25% bupivacaine (45 mg) with 2 mL normal saline (NS), whereas those in Group BM (n = 33) received 18 mL 0.25% bupivacaine (45 mg) with 1.5 mL (150 mg) MgSO4 and 0.5 mL NS in the ultrasound (USG)-guided TAP block performed on each side after the completion of the surgery under SAB. They were evaluated for pain at 0, 2, 4, 6, 12 and 24 h, time to first rescue analgesic and duration of postoperative analgesia were noted. RESULTS: The post-operative visual analogue scale (VAS) scores were lower in Group BM at 4, 6 and 12 h (P < 0.05). Mean duration of analgesia was significantly prolonged in Group BM with lesser requirement of rescue analgesic (P < 0.05) up to 12 h. CONCLUSION: MgSO4 (150 mg) as an adjuvant to bupivacaine in USG-guided TAP block reduces post-operative pain scores, prolongs the duration of analgesia and decreases demands for rescue analgesics.

Comparative study of systemically and perineurally administered tramadol as an adjunct for supraclavicular brachial plexus block.

BACKGROUND AND AIMS: The study was designed to compare the effects of tramadol administered as an adjunct to bupivacaine in supraclavicular block to that of systemic administration, on postoperative analgesia and rescue analgesic requirement following upper limb surgeries. MATERIAL AND METHODS: A prospective, randomized, controlled, double-blind study was undertaken in patients scheduled for upper limb surgeries under supraclavicular block. All the three group patients received either of the following drugs mixtures: Group A - bupivacaine 0.5%-18 ml + normal saline-7 ml for block and normal saline-10 ml intravenously. Group B - bupivacaine 0.5%-18 ml + normal saline-7 ml mixture for block and tramadol (100 mg) diluted to 10 ml - intravenously. Group C - bupivacaine 0.5%-18 ml + tramadol (100 mg) + normal saline-5 ml mixture and normal saline 10 ml intravenously. The patients were observed for sensory, motor onset along with the duration of sensory and motor block. Patients were monitored for sedation and hemodynamic parameters during intra-operative and postoperative period. Pain-free period and demand for rescue analgesia was noted in all the patients. RESULTS: The study demonstrates that the mixture of tramadol and bupivacaine injected perineurally for supraclavicular brachial plexus block hastens the onset of sensory block, motor block and provides a longer duration of motor blockade and demand for rescue analgesia as compared to other two groups. CONCLUSIONS: In conclusion, the addition of tramadol to bupivacaine mixtures as an adjunct for supraclavicular brachial plexus block provide better postoperative analgesia for orthopedic upper extremity surgery in comparison to control or systemic tramadol group without any side effects.

Single-stage management of large pulmonary and hepatic hydatid cysts in pediatric age group: Report of two cases.

Two patients presented to us with very similar clinical and radiological presentation of huge hydatid cysts in the lung and liver. The first patient was an 11-year-old female child and the second one was a 9-year-old male child. The clinical features in both were breathlessness on exertion, pain abdomen, and abdominal distension. Chest Roentgenogram along with computed tomogram of the chest and abdomen revealed presence of thin-walled homogenous large cysts, one in the right lung and two in the liver, in both the cases. Although the liver cysts were of larger size and occupying most of the right lobe of the liver and part of the left lobe, liver function tests were normal. All three cysts were enucleated in the same sitting by a combined thoracic and abdominal approach (thoracotomy followed by laparotomy). After enucleation of the cyst, capitonnage of the cavity in the lung was done and the liver cavities were filled with omentum to prevent collection of fluid and abscess formation. Both patients recovered well, although the second patient required abdominal drain for a long period of 1 month for bile leakage which decreased gradually and eventually stopped.

Ruptured ectopic pregnancy in caesarean section scar: a case report.

Pregnancy implantation within previous caesarean scar is one of the rarest locations for an ectopic pregnancy. Incidence of caesarean section is increasing worldwide and with more liberal use of transvaginal sonography, more cases of caesarean scar pregnancy are being diagnosed in early pregnancy thus allowing preservation of uterus and fertility. However, a delay in either diagnosis or treatment can lead to uterine rupture, hysterectomy, and significant maternal morbidity. We are reporting a rare case of first trimester caesarean scar pregnancy with viable fetus in the process of rupture, where uterine repair could be done, thus preserving the future fertility.