Competency-based postgraduate training: Mentoring and monitoring using entrustable professional activities with descriptive rubrics for objectivity- A step beyond Dreyfus

Background At Sri Balaji Vidyapeeth, a competency-based learning and training (CoBaLT©) model for postgraduate (PG) curriculum, within the regulatory norms, was implemented in 2016 after adequate faculty development programmes. This focused on well-defined outcomes. Methods A review of the outcomes was undertaken in 2018 as part of internal quality assurance receiving feedback from all stakeholders, viz. students, alumni and faculty. Recent publications were also reviewed. A major problem identified was lack of clarity in definition of levels leading to subjectivity in assessment while grading. It was also noted that the process needed to be aligned with the programme outcomes. Further refinements were, therefore, made to align and objectivize formative assessment using entrustable professional activities (EPA) with the aid of descriptive rubrics of sub-competencies and milestones. Addition of detailed rubrics for objectivity takes assessment a step beyond the Dreyfus model, aligning overall to the programme outcomes. Results Achievement of appropriate grades in EPAs by individual candidates ensures entrustability in professional activities by the time of completion of the PG programme. The modification was found more transparent and objective with reference to grading by the teachers and more conducive to reflections by the residents on their performance and how to improve it. Conclusions The use of descriptive rubrics along with EPAs brings transparency and plays a key role as an objective assessment tool, which can lend direction to individual resident learning and entrustability. This is an important component of outcome-based education.

Efficacy of Dexmedetomidine Infusion for Procedural Comfort and Intraoperative Sedation in Patients Undergoing Surgeries with Subarachnoid Block: A Randomized Double-blind Clinical Trial

INTRODUCTION

There is increasing evidence to include sedation as an integral part of regional anesthesia to ensure patient comfort. This may compromise patient cooperation, an important component of regional anesthesia. We decided to determine the efficacy of dexmedetomidine (0.3 μg/kg/h and 0.5 μg/kg/h) for allaying procedural discomfort and ensuring their cooperation in patients undergoing surgery with subarachnoid block.

SETTING

Tertiary care center.

MATERIALS AND METHODS

Sixty patients with the American Society of Anesthesiologists physical status Class I and II posted for surgeries under subarachnoid block were randomized into two groups of 30 each to receive dexmedetomidine in a loading dose of 1 μg/kg in both groups followed by continuous infusion of 0.3 μg/kg/h in Group D 0.3 and 0.5 μg/kg/h in Group D 0.5. Observer assessment sedation score, ease of positioning score, response to spinal needle insertion, hemodynamic parameters, patient satisfaction (PS) score, and surgeon satisfaction (SS) score were evaluated.

RESULTS

Median observer Assessment Sedation Score ranged between four and three at all times during dexmedetomidine infusion in Group D 0.3. In Group D 0.5, median Observer assessment of alertness/sedation scale ranged between three and two. Ease of positioning (P = 1.000) and response to spinal needle insertion (P = 0.521) were comparable in both groups. PS was higher in Group D 0.5 as compared to Group D 0.3. SS score was comparable in both the groups.

CONCLUSION

Intravenous dexmedetomidine infusion 0.3 μg/kg/h produces effective sedation in patients undergoing surgery with spinal anesthesia while ensuring patient cooperation for positioning and without any recall of the procedure in postoperative period.

Quality of Labor Epidural Analgesia and Maternal Outcome With Levobupivacaine and Ropivacaine: A Double-Blinded Randomized Trial

Background:

Quality of labor analgesia plays a vital role in the maternal outcome. Very few literature are available analyzing the quality of epidural labor analgesia.

Aim:

The aim of this study was to compare the effectiveness of 0.1% levobupivacaine and 0.1% ropivacaine with fentanyl as an adjuvant for epidural labor analgesia in terms of onset, duration, quality of analgesia, and degree of motor blockade.

Methodology:

Sixty nulliparous parturients, with singleton uncomplicated pregnancy, were recruited by continuous sampling. Parturients were randomized to receive either levobupivacaine 0.1% or ropivacaine 0.1% with 2 μg/ml fentanyl as an intermittent epidural bolus. The epidural analgesia was initiated with 12 ml of study drug solution in the active stage of labor (cervix 3 cm dilated). Demand bolus was given whenever the visual analog scale (VAS) score >3. Onset, duration, and quality of analgesia and degree of motor blockade were analyzed. Maternal outcome was evaluated in terms of mode of delivery, duration of labor, and assisted vaginal delivery.

Statistical Analysis:

All the data were recorded in Microsoft Office Excel. Statistical analysis was carried out using SPSS version 19.0 (IBM SPSS, USA) software with Regression Modules installed. Descriptive analyses were reported as mean and standard deviation of continuous variables.

Results:

The mean onset of analgesia was shorter in ropivacaine (21.43 ± 2 min) than in levobupivacaine group (23.57 ± 1.71 min) (P = 0.000). Duration of analgesia was shorter in ropivacaine (60 ± 14 min) than levobupivacaine (68 ± 11 min) (P = 0.027). Levobupivacaine produced a better quality of analgesia in terms of not perceiving pain and uterine contraction during labor analgesia but was associated with 37% incidence of instrumental delivery. Duration of labor and rate of cesarean section were comparable between the groups.

Conclusion:

Quality of analgesia in labor epidural was superior to levobupivacaine but was associated with higher incidence of instrumental vaginal delivery.

Comparison of King Vision and Truview Laryngoscope for Postextubation Visualization of Vocal Cord Mobility in Patients Undergoing Thyroid and Major Neck Surgeries: A Randomized Clinical Trial

Background:

Visualization of vocal cords following extubation after thyroid and major neck surgeries is highly desirable for the surgeon as well as the anaesthesiologist to rule out vocal cord palsy or oedema. As the patient is emerging from general anaesthesia, it may be challenging for the anaesthesiologist to optimally visualise and grade vocal cord movement following extubation.

Setting:

Randomized clinical trial at a tertiary care centre.

Methodology:

After obtaining institutional ethics committee approval, 60 patients posted for thyroid and major neck surgeries under American Society of Anesthesiologists (ASA) grade I and II were recruited for the study. Written informed consent was obtained. Pre-operatively indirect laryngoscopy was performed in all the patients to assess baseline vocal cord function. All patients were premedicated and induced and maintained as per standardized anaesthesia protocol. Patients were randomized using a sealed envelope technique to either Group K where intubation was performed using Kings vision laryngoscope or Group T where intubation was performed using True view laryngoscope. Glottis visualization was graded in all patients and intubated. Ten minutes prior to extubation injection. dexmedetomidine 1 μg/kg was administered. Once patients satisfied extubation criteria, laryngoscopy was performed using respective video-laryngoscope in each group, patient extubated under vision and assessed for vocal cord visualization and mobility grade (VMG) and patient reactivity score (PRS). Heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure was also noted. Total intraoperative morphine consumption was recorded. Vocal cord function was assessed again before the day of discharge by indirect laryngoscopy.

Results:

Age (P = 0.27), sex (P = 0.08), body mass index (P = 0.70), ASA (P = 0.39), mallampati class (P = 0.72) and morphine used (P = 0.39) were comparable in both groups. There was no statistically significant difference among the two groups with respect to VMG (P = 0.18). There was no statistical difference in the PRS (P = 0.06) in both groups. Increase in heart rate or mean arterial pressure from baseline was not significant statistically in both groups. Time taken for laryngoscopy during extubation was significantly less with group T as compared to group K (P = 0.000).

Conclusion:

Both Kings Vision and Truview Video-laryngoscopes provide comparable laryngoscopic view with similar patient comfort, although clinically Truview may be a better choice due to less time consumed for visualisation and rating vocal cord movement during extubation.

Relative Efficacy of Ultrasound-guided Ilioinguinal-iliohypogastric Nerve Block versus Transverse Abdominis Plane Block for Postoperative Analgesia following Lower Segment Cesarean Section: A Prospective, Randomized Observer-blinded Trial

BACKGROUND

Quality of postoperative analgesia after cesarean section makes difference to mother in child bonding, early ambulation, and discharge. Ilioinguinal iliohypogastric (ILIH) and transverse abdominis plane (TAP) block had been tried to reduce the opioid analgesics, but the relative efficacy is unknown. Hence, this study was designed to compare the efficacy of these two regional analgesic techniques in sparing postoperative rescue analgesic requirement following lower segment cesarean section (LSCS).

METHODS

Sixty patients who underwent LSCS were randomly allocated into two groups to receive either US-guided TAP block or ILIH nerve block using sealed envelope technique at the end of the surgery. In the postoperative ward, whenever patient complained of pain, pain nurse in-charge administered the rescue analgesics as per the study protocol. A blinded observer visited the patient at 0, 2, 4, 6, 8, 10, 12, and 24 h postoperative intervals and recorded the quality of pain relief and the amount of rescue analgesic consumed.

RESULTS

All patients in both the study groups required one dose of rescue analgesics in the form of injection diclofenac sodium 50 mg intravenously but subsequently 57% of patients did not require any further analgesics till 24 h in the TAP block group whereas in ILIH group, only 13% did not require further analgesics (P = 0.00), correspondingly the cumulative tramadol dose was significantly higher at all the time interval in the ILIH group when compared to the TAP group.

CONCLUSION

Quality of postoperative analgesia provided by TAP block was superior to ILIH block following LSCS.

Perioperative communication practices of anesthesiologists: A need to introspect and change

Background:

We conducted an audit of various communication practices during perioperative care among anesthesiology resident (R), faculties (F), and private practitioners (PP) in South India. We also documented the level of psycho-social support given to the patient and patient relatives and communication with the surgical colleagues during perioperative care.

Methodology:

A 15-point questionnaire based on communication practices was distributed in three major anesthesiology conferences requesting anesthesiologists to answer and drop the forms in the drop box provided. Resident and consultant level anesthesiologists of various Medical Schools in South India and private practitioners were involved in the study. The answers were analyzed to find out the various communication practices in perioperative care.

Results:

The freelancing private practitioners (PP) were more communicative to patient and relatives especially in complicated cases (Q1 - 45.6%, Q2 - 97.8%, Q4 - 94.4%, Q8 - 98.9%, respectively) in comparison with institutionalized practitioners. The choice of anesthesia and discussion related to the advantages of one mode of anesthesia over other was the most neglected part of communication (R - 14.2%, F - 17.6%, and PP - 5.6%). The PP's (95.6%) are more concerned about intraoperative communication (R - 27.6%, F - 39.2%). The discussion of postoperative pain management plan with the surgeon is not given priority in the communication by postgraduates (7.9%) and teaching faculties (8.8%).

Conclusion:

There is an urgent need to introspect and change the communication practices. We strongly recommend that communications skills should be introduced in anesthesiology resident curriculum.

Assessment of suitability of i-gel and laryngeal mask airway-supreme for controlled ventilation in anesthetized paralyzed patients: A prospective randomized trial

CONTEXT

Laryngeal mask airway supreme (LMA-S) has an inflatable cuff while i-gel has a noninflatable cuff made of thermoplastic elastomer.

AIMS

To study the efficacy of ventilation and the laryngeal seal pressures (LSPs) with either device. Our secondary objectives were to compare the ease of insertion, adequacy of positioning the device, hemodynamic response to device insertion, and any postoperative oropharyngeal morbidity.

SETTINGS AND DESIGN

A prospective, randomized, single-blinded study at Teaching Medical School in South India.

MATERIALS AND METHODS

Forty-two patients posted for surgery under general anesthesia were randomly divided into two groups - LMA-S and i-gel. After a standardized premedication and anesthesia induction sequence, the supra-glottic devices were introduced. Ease of insertion was assessed from the number of attempts taken to insert, insertion time, and any maneuvers required to insert the device. Position of the device was assessed by the ease of gastric catheter placement and the fibreoptic grading of laryngeal visualization. Efficacy of ventilation was determined from the LSP, peak inspiratory pressure (PIP), and end-tidal carbon dioxide (EtCO2)values. Any postoperative oropharyngeal morbidity was also recorded.

STATISTICAL ANALYSIS

Descriptive analysis was reported as a mean and standard deviation, median, and range of continuous variables. Demographics were analyzed using a unpaired t-test for parametric data and Chi-square test for nonparametric data. Respiratory and hemodynamic data was analyzed using one-way ANOVA to find statistical difference within and between the two groups.

RESULTS

LMA-S was successfully inserted in 95% of patients and i-gel in 85.5% of patients. There was a significant difference (P = 0.021) in the LSPs between the two groups (18.15 cmH2O in LMA-S and 21.28 cmH2O in the i-gel group). There was no significant difference in the PIPs, leak fraction, and the EtCO2values.

CONCLUSION

Both devices are suitable for positive pressure ventilation (PPV) in anesthetized paralyzed patients. However, i-gel gives a better laryngeal seal when compared to LMA-S and may be chosen preferentially for PPV.

Anaesthesia practice and reproductive outcomes: Facts unveiled

Background and Aims:

Anaesthetic practice is associated with a risk of chronic exposure to anaesthetic agents. With the advent of newer inhalational agents and changing anaesthetic practices, the risks for anaesthesiologists with regard to adverse reproductive outcomes is unknown. Hence, a nationwide online survey was conducted to study the anaesthetic practices prevalent in India and their association, if any, with poor reproductive outcomes.

Methods:

The online survey involved 9974 anaesthesiologists. A questionnaire soliciting information regarding anaesthetic practice techniques, reproductive outcomes and perinatal outcomes was designed. All the anaesthesiologists in the ISA National database were mailed a link to the above questionnaire.

Results:

Female anaesthesiologists and spouses of male anaesthesiologists had a higher incidence of first trimester spontaneous abortions than the general population. Female anaesthesiologists when compared with spouses of male anaesthesiologists faced more difficulty with conception (P = 0.015). Female anaesthesiologists who worked in the operating room (OR) in their first trimester of gestation had a higher incidence of spontaneous abortions than those who did not work in the OR (P = 0.05). Longer hours of general anaesthesia conducted in the first trimester of pregnancy was associated with a higher risk of birth defects in their progeny (P = 0.05).

Conclusion:

Spontaneous abortions and birth defects were higher in female anaesthesiologists who worked in the OR in the first trimester of gestation. Both female anaesthesiologists and spouses of male anaesthesiologists had a greater risk for a first trimester miscarriage than the general population.

Rapid and reliable smooth extubation - Comparison of fentanyl with dexmedetomidine: A randomized, double-blind clinical trial

BACKGROUND

Fentanyl and dexmedetomidine have been tried to attenuate airway and circulatory reflexes during emergence and extubation individually but have not been compared with respect to the level of sedation to evolve a reliable technique for rapid and smooth extubation.

AIM

To compare the effects of fentanyl and dexmedetomidine in attenuating airway and circulatory reflexes during emergence and extubation of the endotracheal tube.

SETTING AND DESIGN

This double-blind, randomized, controlled study was done in patients undergoing surgery under general anesthesia belonging to the American Society of Anesthesiologists physical status 1 or 2.

METHODOLOGY

All patients received a standardized anesthetic protocol. Patients were randomized to receive either fentanyl 1 μg/kg or dexmedetomidine 0.75 μg/kg. Fifteen minutes before expected last surgical suture, isoflurane was cutoff and equal amount of test solution was given when train-of-four ratio was 0.3. The degree of sedation, airway, and circulatory responses at the time of suction and extubation were analyzed.

STATISTICAL ANALYSIS USED

Chi-square test for nonparametric data and t-test for parametric data.

RESULTS

Heart rate (HR) was comparable in both the groups until endotracheal extubation. Later, there was rise in HR in fentanyl group. There was stastisticaly significant drop in blood pressure at 5 min after test drug administration in both the groups. Airway response for suctioning and extubation was better in dexmedetomidine group and it was associated with better sedation score than fentanyl group.

CONCLUSION

Single dose of 0.75 μg/kg dexmedetomidine given 15 min before extubation provides smooth extubation when compared to fentanyl.

Role of temporary pacing at the right ventricular outflow tract in anesthetic management of a patient with asymptomatic sick sinus syndrome

A 60-year-old woman posted for percutaneous nephrolithotomy with ureterolithotripsy was found to have a history of hypertension and ischemic heart disease from past 6 months on regular treatment. Pulse rate was irregularly irregular in a range of 56–60/min, unresponsive to atropine, with a sinus pause on the electrocardiogram. Although the patient was asymptomatic, anticipating unmasking of the sick sinus syndrome during general anesthesia in the prone position, a temporary pacemaker was implanted at right ventricular outflow tract (RVOT) septum before the scheduled surgery. A balanced anesthesia technique with endotracheal intubation was administered. There were several episodes of continuous pacing by the temporary pacemaker intraoperatively, which may be attributed to unmasking of the sinus node dysfunction due to general anesthesia. At the end of surgery, patient was extubated after adequate reversal from neuromuscular blockade. Postoperative period remained uneventful, and the pacemaker wires were removed on the 2^nd postoperative day. With this case report, we highlight the importance of inserting a temporary pacemaker prior to anesthesia even in an asymptomatic patient if a sinus node dysfunction is suspected preoperatively and if intraoperative access to transvenous pacing is difficult such as in prone position. Pacing at RVOT septum minimizes ventricular dyssynchrony and improves hemodynamic parameters.

Comparison of dexmedetomidine and clonidine as an adjuvant to ropivacaine for epidural anesthesia in lower abdominal and lower limb surgeries

BACKGROUND

The quality and duration of analgesia is improved when a local anesthetic is combined with alpha 2 adrenergic agonist. Though, the effects of clonidine on local anesthetics have been extensively studied, there are limited studies demonstrating the effects of epidural dexmedetomidine on local anesthetics. The aim of our study is to compare the effect of clonidine and dexmedetomidine when used as an adjuvant to epidural ropivacaine in lower abdominal and lower limb surgeries.

MATERIALS AND METHODS

Patients were randomized into two groups-group ropivacaine with clonidine (RC) received 15 ml of 0.75% ropivacaine with 1 μg/kg clonidine and group ropivacaine with dexmedetomidine (RD) received 15 ml of 0.75% ropivacaine with 1 μg/kg dexmedetomidine epidurally. Onset of sensory analgesia using cold swab, onset of motor blockade using Bromage scale, time to 2 dermatome regression of sensory level, time to first demand for analgesia, sedation using Ramsay sedation scale, intra operative hemodynamic parameters and complications were assessed.

RESULTS

The onset (RD-8.53 ± 1.81, RC-11.93 ± 1.96) and duration of sensory blockade (RD-316 ± 31.5, RC-281 ± 37, sedation were found to be significantly better in the dexmedetomidine group. No significant difference was found in terms of onset of motor blockade and hemodynamic changes.

CONCLUSION

Dexmedetomidine at doses of 1 μg/kg is an effective adjuvant to ropivacaine for epidural anesthesia, which is comparable to clonidine.

Submental intubation with intubating laryngeal mask airway as conduit: An airway option for oral submucous fibrosis release

The main anesthetic concern with oral submucous fibrosis is progressive restriction of mouth opening due to fibrosis producing difficult airway. Securing airway by nasotracheal intubation and tracheostomy are associated with potential complications. Flexible fiberoscope is not available in all the institutes. Submental intubation using intubating laryngeal mask airway is an acceptable alternative technique in such situations. It also provides an unobstructed surgical field.

Anesthetic management of a patient presenting with eclampsia

Eclampsia is one of the most common emergencies encountered by anesthesiologists which involve a safe journey of two lives. The definition, etiology, pathophysiology, treatment guidelines along with a special reference to management of labour pain and caesarean section are discussed. Eclampsia is commonly faced challenging case in our day to day anaesthesia practice,but less is discussed in our anaesthesia text books. Lot of controversies with regard to fluid management and monitoring still remain unanswered

Bilateral vocal cord edema following anterior cervical discectomy-usefulness of bonfils retromolar fiberscope

We present a case of a 40-year-old male patient who presented to us with radicular pain in arm for anterior cervical discectomy with fusion. The preanesthetic checkup including indirect laryngoscopy was normal with routine investigations within normal limits. The patient was induced and intubated with the established routine technique without any obvious airway problems. Prophylactic dexamethasone was administered, and the intraoperative course was uneventful. Immediately after extubation, it was noticed that the patient had inspiratory stridor and whispered voice on the operation theater table itself. Assessment by Bonfils retromolar fiberscope under fentanyl sedation revealed bilateral vocal cord edema. The patient was re intubated and put on T piece with humidified O2. After 72-h, patient was extubated after confirming normal vocal cord movement under flexible fiberscope guidance. This case is presented to alert anesthesiologist about the possibility of vocal cord edema even though other potential airway complications are possible. We would also highlight the importance of Bonfils retromolar fiberscope in awake vocal cord examination and flexible fiberscope use in managing patients presenting with airway problems during extubation.

A comparative study between Truview(PCD) laryngoscope and Macintosh laryngoscope in viewing glottic opening and ease of intubation: A crossover study

Background:

Truview^PCD laryngoscope is specially designed to aid positioning of the endotracheal tube as well as to record entry of the tube into glottis. Aim of the study is to compare the view of glottic opening and ease of intubation between Truview^PCD laryngoscope and Macintosh laryngoscope in patients undergoing general anesthesia (GA).

Methodology:

Two hundred patients undergoing elective surgery, under GA were randomized into two groups, Group TV and Group ML. In Group TV, Trueview^PCD laryngoscope was used initially to visualize the vocal cords for Cormack and Lehane grading (CLG) and to spray the vocal cords with 10% lignocaine. Then the patient was ventilated for 1 min and Macintosh laryngoscope was used to visualize the vocal cords for CLG and proceed with intubation. In Group ML, Macintosh laryngoscope was used initially and later Truview^PCD laryngoscope. Time to intubation, CLG, number of attempts and hemodynamic parameters were recorded.

Results:

Ninety-six and 89 patients had CLG1 visualization when Truview^PCD laryngoscope was used as 1^st and 2^nd device respectively compared to 41 and 68 with Macintosh laryngoscope (P = 0.00). Four patients had CLG 4 visualization with Macintosh laryngoscope that turned out to be grade II visualization with Truview^PCD laryngoscope (P = 0.00). Mean time taken for intubation with Truview^PCD and Macintosh laryngoscope was 21.10 ± 5.64 s and 15.79 ± 2.76 s respectively (P = 0.00).

Conclusion:

Better visualization with lesser CLG was found with Truview^PCD laryngoscope but it took longer time for intubation than Macintosh laryngoscope. The hemodynamic response to intubation was significantly less with the use of Truview^PCD laryngoscope when compared to that of Macintosh laryngoscope.

Improved prophylaxis of postoperative nausea vomiting: Palonosetron a novel antiemetic

Many anti-emetics are used in clinical practice. Palonosetron hydrochloride is one of them. It is a novel, centrally acting antiemetic, and anti-nausea agent. This drug is an antagonist of serotonin receptor subtype 3 (5-HT3). This drug has longer duration of action which makes it useful in the prevention and treatment of acute and delayed onset of nausea and vomiting. This drug was initially used for chemotherapy induced nausea and vomiting. Federal drug agency (FDA) has approved it for prevention and treatment of post-operative nausea and vomiting. The literature search for this article was done using Google scholar and Pubmed using the terms "Palonosetron," "longer duration of action," "nausea," "vomiting," and "postoperative".

Comparison of efficacy of three subanesthetic doses of ketamine in allaying procedural discomfort during establishment of subarachnoid block: A randomized double-blind trial

Background:

Procedural discomfort is experienced by patients during the establishment of subarachnoid block even after good preoperative counseling and adequate premedication. To enhance comfort, procedural sedation that would provide good analgesia, faster recovery, and amnesia is necessary.

Materials and Methods:

Patients with American Society of Anesthesiologists Status I and II posted for elective surgeries under subarachnoid block were premedicated with injection midazolam 0.05 mg/kg and preloaded with 10 ml/kg ringer lactate solution. They were randomized into three groups of 30 each. Group K0.3 received ketamine 0.3 mg/kg, Group K0.4 received ketamine 0.4 mg/kg and Group K0.5 received ketamine 0.5 mg/kg intravenously. University of Michigan sedation score, ease of positioning, prick response, verbal response, hallucinations, recall of procedure, and patient satisfaction were evaluated.

Results:

There was statistically significant difference in sedation among the three groups. Increased dose necessitated help of two persons to position the patient, which showed statistically significant difference. Verbal response was seen early in Group K0.3 (4.67 ± 2.84 min). There was no recall of experience of subarachnoid block procedure in any of the groups in spite of back muscle contraction or patient movement. Hence, all patients in all three groups were satisfied and were willing to undergo subarachnoid block, if the situation arises.

Conclusion:

Ketamine in the dose of 0.3 mg/kg provided sufficient sedation for allaying procedural discomfort due to less sedation, less positional difficulty, early verbal response, no hallucinations, no recall of performance of procedure, and good patient satisfaction.

Intraoperative anaphylaxis to ranitidine during cesarean section

Ranitidine, a widely used drug, is known to be well tolerated. This case report illustrates a severe anaphylactic reaction after a single intravenous dose of 50 mg ranitidine during the emergency cesarean section under spinal anesthesia. Anaphylaxis was successfully managed with Inj. adrenaline, Inj. hydrocortisone, ventilatory, and inotropic support following which she had a full recovery. Awareness of this rare but fatal adverse reaction to this commonly used drug could help in early recognition of the event if faced suddenly.