Ascaris Lumbricoides induced intestinal perforation in Paediatric patient: Anaesthetic challenges and managementAuthors: Dr. Shweta singh, Dr. Sonal khatavkar, Dr. Veda sumiSir,The presence of Ascaris Lumbricoides in gastrointestinal tract can lead to mechanical obstruction and intestinal perforation, necessitating surgical intervention is a rare but serious condition, especially in paediatric condition. The perioperative phase can be influenced by the developmental stage of Ascaris lumbricoides, leading to potential complications such as respiratory blockage, bronchospasm, and inflammation of the lungs [1].A 2-year-old, 9 kgs toddler was brought to the emergency department by father, presenting with on-and-off abdominal pain and increasing abdomen tightness for the past 6 days. Additionally, there was one instance of vomiting (non-bilious or no forceful ejection) a day before admission. Alongside these symptoms, history of noticeable loss of appetite with frequent cough was given. The parents also mentioned a history of pica.Vitally child was tachycardic (150/minute) and normotensive (90/58mmHg). Blood investigations showed anemia, leucocytosis, and eosinophilia of 500 cells per microliter of blood, consistent with an inflammatory response. Erect X-Ray abdomen, USG findings confirmed intestinal obstruction.Given the kid’s condition, was taken up from emergency exploratory laparotomy following fasting protocol.Anaesthesia was induced using modified RSI technique with fentanyl 2 mcg/kg, Propofol 3 mg/kg and Microcuff endotracheal tube 4.5 was introduced by Succinylcholine 2mg/kg and maintained with cis-atracurrium 0.03mg/kg, sevoflurane 1.0% in Oxygen and air. Epidural analgesia was employed maintained intra-operative and post-operative period with Ropivacaine 0.2% at 2ml/hr. Dexamethasone 0.1 mg/kg and hydrocortisone 2 mg/kg were given.12Fr Ryles tube was secured and confirmed.On exploratory laparotomy, roundworms were seen loaded from pylorus to the colon. Gangrenous ileal segment and perforation was present approximately 15 cm from ileocecal junction. Round worms were removed by bowel wall milking distally and resection of ileum with double barrel ileostomy was done.After completion of procedure, Patient was reversed using Glycopyrrolate 8mcg/kg and neostigmine 50 mcg/kg and extubated uneventfully and shifted to intensive care unit for monitoring and management.Postoperatively, anti-helminthic drugs were initiated once the eosinophil count returned to within normal limits. Follow up stool examination revealed no eggs or worms.Airway obstruction and anaphylaxis intraoperatively is not very uncommon due to ascaris. In the present case, as pica history was probed into, we suspected intestinal obstruction might be due to worms. Erratic ascariasis seen in conditions like fever, illness, sub-therapeutic antihelminthic drugs. During anaesthesia migration can occur due to sensitivity to anaesthetics[2], supine position, decreased gastric pH, reduced pepsin and absent swallowing reflex during anaesthesia[3]. Using a micro-cuff tube using modified RSI technique night hekp in preventing worms migrate from the esophagus to the trachea post-relaxation of the cardio-esophageal sphincter during anesthesia with a gastric tube in place[4], also reducing risks like upper airway obstruction, re-expansion pulmonary edema, bronchospasm due to anaphylaxis.Intra-venous steroids and inhaled bronchodilators were administered for Loeffler’s syndrome considering high eosinophil count and cough history.In patients from or residing in areas with parasitic infestation, consider the rare but possible risk of acute intestinal or airway obstruction due to Ascaris worms. Be prepared for managing unexpected complications like hypersensitivity, airway blockage, bronchospasm, or respiratory arrest post-extubation also[5].REFERENCES:Bharati SJ, Chowdhury T, Goyal K, Anandani J. Airway obstruction by round worm in mechanically ventilated patient: An unusual cause Indian J Anaesth. 2011;55:637–8.Goldsmith RS. Infectious diseases. Protozoal and Helminthic infections. In: McPhee SJ, Papadakis MA, Turney LM Jr, editors. Current Medical Diagnosis Treatment.  46th ed. McGraw Hill (Medical); 2007.Christopher F, James CF. Pulmonary aspiration of gastric contents. In: Gravenstein N, Kirby RR, editors. Complications in Anesthesiology.  2nd ed. 1996. p. 184.Prakash, Smita; Sitalakshmi, Narayanan; Singh, Jasmeet; Dayal, Madhu; Gogia, Anoop R. Ascaris: An unusual cause of airway obstruction during general anesthesia with ProSeal laryngeal mask airway. Journal of Anaesthesiology Clinical Pharmacology 30(2):p 298-300, Apr–Jun 2014. | DOI: 10.4103/0970-9185.130129Gehlot R, Saxena SS, Kumari I, Verma V, Bidwaikar A. Post Extubation Bronchospasm in an Undiagnosed Case of Ascariasis: Anaesthetic Challenges. J Clin Diagn Res. 2017 Feb;11(2):UD01-UD02. doi: 10.7860/JCDR/2017/22744.9415. Epub 2017 Feb 1. PMID: 28384964; PMCID: PMC5376854.