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   Table of Contents - Current issue
January-June 2020
Volume 21 | Issue 1
Page Nos. 1-80

Online since Thursday, February 13, 2020

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Pericapsular nerve group block: Innovation or just a fad? p. 1
Anand M Sardesai, Ghansham Biyani
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Peripartum cardiomyopathy – An insight p. 4
Namita Saraswat, Pooja Virmani, Aanchal Kakkar, Akhilesh Gupta, Mohandeep Kaur
Peripartum cardiomyopathy (PPCM) is a potentially life-threatening disease. However, timely intervention and early detection can save lives. It presents in peripartum period as left ventricular dysfunction and heart failure. Although the disease is relatively rare, its incidence is rising. Previous research states vascular dysfunction, triggered by late-gestational maternal hormones such as abnormal prolactin and many other causes may lead to the development of PPCM. We have reviewed here the known epidemiology, pathophysiology, clinical presentation, management, and anesthesia concerns of PPCM.
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A comparative study of ultrasound-guided caudal block versus anatomical landmark-based caudal block in pediatric surgical cases p. 10
Nethra H Nanjundaswamy, Saraswathi Nagappa, Raghavendra Biligiri Shridhara, Sandya Kalappa
Background: Caudal block is a popular regional anesthesia technique in pediatrics for anesthesia and perioperative analgesia. Conventional landmark-based technique is a simple technique with good success rate but associated with complications such as dural puncture and venous injection. Ultrasound-guided caudal block is known to improve the success rate and reduce the complications noted with the landmark technique. We aimed to compare the success rates of caudal block in landmark- and ultrasound-guided techniques. Methods: One hundred and twenty-four children under 10 years admitted for infraumbilical surgeries were randomly allocated to Group L and Group U caudal block was administered based on landmarks in Group L and by using ultrasound in Group U. In both the groups, observations noted were success of caudal block, visibility and palpability of sacral cornu; identification of hiatus; first attempt success; number of attempts; block performance time; and complications. In Group U, ultrasound visualization of sacral hiatus, needle, and distension of sacral canal with injection was also noted. Results: Success rates were 81.8% and 92.1% in Group L and Group U, respectively (P = 0.045). Complications noted in Group L were blood tap (23.8%), subcutaneous swelling (15.2%), dural puncture (1.5%), and rectal perforation (1.5%). In Group U, only blood tap (3%) was the complication noted. Block performance was faster in Group L than Group U. There was no significant difference in the first attempt success rate and number of attempts. Conclusion: Ultrasound-guided caudal block improves the success rate, reduces complications, and ensures safety.
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Comparing the efficacy of different doses of intrathecal dexmedetomidine on hemodynamic parameters and block characteristics with ropivacaine spinal anesthesia for cesarean section: A double-blind, randomized clinical trial p. 16
Hesameddin Modir, Bijan Yazdi, Maryam Shokrpour, Rasoul Hesamamini, Arghavan Modir, Abolfazl Mohammadbeigi
Aims: This study aimed to assess the dose-related efficacy of intrathecal dexmedetomidine (DEX) on hemodynamic parameters and block characteristics following ropivacaine (ROP) spinal anesthesia (SA) for cesarean section (CS). Methods: This was a double-blind trial conducted on four groups namely D2.5, D5, D7.5, and placebo. One hundred and twenty patients scheduled for nonemergency CS under SA were recruited and randomized into four groups. The first to fourth groups received 2.5 μg, 5 μg, and 7.5 μg of intrathecal DEX and 1.5 mL normal saline, respectively, in addition to ROP for SA. Blood pressure (BP), heart rate (HR), arterial blood saturation, sensory motor block, and pain score were recorded. Results: The lowest BP/HR was observed in D7.5 group (P < 0.05). Moreover, the onset and duration of sensory motor block were shorter (P = 0.0001) and showed the lowest level of pain (P = 0.0001) in D7.5 group. Decrease in BP, HR, and pain score was observed with increasing dose of DEX, whereas the onset of sensory motor block and the time to achieve sensory motor block to ≥T6 declined with increasing the dose of DEX. Conclusion: The 7.5-μg intrathecal DEX is recommended to use for stabling the hemodynamic parameters and block characteristics following ROP SA for CS. However, likely complications such as fall in both HR and BP should be taken into account simultaneously.
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Intraoperative lidocaine infusion reduces analgesic and anesthetic requirements in patients with high body mass index undergoing laparoscopic cholecystectomy p. 23
Praveen Benjamin Dennis, Kirubakaran Davis, Balaji Kuppuswamy, Raj Sahajanandan
Background: Intravenous (IV) lidocaine has analgesic, antihyperalgesic, and anti-inflammatory properties. Intraoperative use of lidocaine infusion reduces the analgesic and anesthetic requirement during laparoscopic cholecystectomy surgeries. Aims: Our study was designed to analyze the effect of intraoperative infusion of lidocaine, on perioperative opioid, anesthetic and neuromuscular agent requirements, and the incidence of side effects in patients with high body mass index undergoing laparoscopy cholecystectomy. Methods: This is a randomized double-blinded prospective study conducted at a tertiary hospital. Of the 38 patients enrolled in the study, due to cancellation and conversion to open surgery, only 33 patients completed the study (16 in the control group [C] and 17 in the lidocaine group [L]). Patients from both the groups received the test drug (lidocaine or normal saline) as 2 mg/kg bolus during induction and continued as an infusion at a rate of 2 mg/kg/h throughout the surgery which was terminated 30 min after extubation. The patients were analyzed for perioperative analgesic, anesthetic, muscle relaxant requirement, and adverse effects. Results: The mean visual analog scale (VAS) score in 1st and 2nd hour after surgery was less in the group receiving IV lidocaine infusion (7.5 ± 7.8* vs. 10.5 ± 11.8; 12.5 ± 8.1* vs. 23 ± 24.6 [* denotes lidocaine group]); compared to the control group the intraoperative opioid requirement decreased by 43% in the lidocaine group. There was a reduction of 13%–21% in the minimum alveolar concentration of isoflurane in the lidocaine group. The cumulative dose of rocuronium was found to be 53% lesser in the lidocaine group. There was no difference in the sedation scores and there were no adverse effects in either of the groups. Conclusions: The study demonstrates the usefulness of IV lidocaine infusion as an adjunct to provide anesthesia with decreased requirements of opioid, inhalation, and neuromuscular-blocking agents.
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A comparative study of acromio-axillo-suprasternal notch index with upper lip bite test and modified Mallampati score to predict difficult laryngoscopy p. 33
Rupesh Sunkam, Vinayak Seenappa Pujari, Balakrishna Kailasnatha Shenoy, Yatish Bevinaguddaiah, Leena Harshad Parate
Background: The current bedside predictors of the difficult airway are not perfect. A new test, the acromio-axillo-suprasternal notch index (AASI), has been found to be superior to conventional predictors. In this study, we have compared the accuracy of AASI with upper lip bite test (ULBT) and modified Mallampati (MMP) test to predict difficult laryngoscopy and the time taken to complete each test. Methods: Institutional ethical committee clearance was obtained, and written informed consent was taken from 150 patients posted for elective surgery under general anesthesia with endotracheal intubation. Preoperative airway examination was carried out with AASI, ULBT, and MMP score. AASI ≥0.49, ULBT Class III, and MMP score III/IV were considered as predictive of difficult visualization of larynx (DVL). After the induction of anesthesia, the laryngeal view was recorded according to Cormack–Lehane (CL) grade. Sensitivity, specificity, predictive values, and accuracy were calculated for all the three tests. Results: DVL (CL Grades 3/4) was observed in 18 (12%) patients. AASI was found to have higher specificity (93.2%), positive predictive value (PPV) (55%), and accuracy (89.3%) when compared to MMP and ULBT. MMP was found to have the highest sensitivity (77.8%), and ULBT was found to have least sensitivity (50%). Time taken for AASI was higher (13.01 ± 1.03 s) when compared to ULBT (7.49 ± 1.95 s) and MMP (3.97 ± 0.49 s). Conclusion: We conclude that the MMP is the most sensitive and fastest test to predict DVL when compared to AASI and ULBT. AASI is a better predictor for DVL as it has higher specificity, PPV, accuracy, and odds ratio when compared to standard tests such as MMP and ULBT.
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The efficacy of dexmedetomidine and propofol for sedation in endoscopic ultrasonography: A comparative study p. 38
Apurva Jumle, Vaibhav Mahajan, Deepak Phalgune, Ganesh Ghongate, Nachiket Dubale
Background: Efficacy and safety of dexmedetomidine as a sedative agent has not been studied in a procedure such as endoscopic ultrasound (EUS) where propofol is being used extensively to provide a deep level of sedation. The present study was conducted to compare the efficacy of dexmedetomidine and propofol to achieve adequate sedation levels in patients undergoing EUS. Methods: Sixty patients scheduled for EUS under sedation for the diagnostic and therapeutic purpose were randomly divided into two groups. Thirty patients in Group D received dexmedetomidine while 30 Group P patients received propofol. The recovery from sedation was assessed using the modified Aldrete's score. Once the modified Aldrete's score of 10/10 was achieved, the patients' perception regarding the pain was assessed using the Visual Analog Scale (VAS) score. Primary outcome measures were VAS score and vital parameters, whereas secondary outcome measures were gag reflex and recovery from sedation using the modified Aldrete's score. Comparison of quantitative and qualitative variables between the groups was done using unpaired Student's t-test and Chi-square test or Fisher's exact test, respectively. Results: The absence of gag reflex was significantly higher in patients who received dexmedetomidine. Dexmedetomidine was found to have greater hemodynamic stability compared with propofol-treated patients. Dexmedetomidine achieved similar levels of sedation to propofol, although with a slower onset of sedation. Conclusions: The use of dexmedetomidine was associated with greater hemodynamic stability and absence of gag reflex.
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Survey on knowledge of acute trauma care among trainee anesthesiologists p. 44
Malavika Kulkarni, Laxmi Shenoy, N Anitha, TK Sushma, Shwetha Sinha, K Rama Rani
Background: Trauma is a major cause of morbidity and mortality in India. A trauma-related death occurs every 1.9 min, and the mortality in serious injuries is six times worse compared to a developed country. Methods: The postgraduates were given a questionnaire with three sections. The first and second sections had questions pertaining to the participants' demographic data, their training, and their perceptions on training in trauma care. The third section contained ten multiple-choice questions designed to check their factual knowledge on basic trauma care. Their scores were rated as follows: poor (0–6), satisfactory (7–8), and excellent (9–10). Results: All 146 participants were postgraduates. Fifty-five (37.7%) of them claimed to have undergone a formal training in the initial trauma management. The scores obtained by both trained and untrained respondents were very low. Only 30.9% of the trained postgraduates managed a score of ≥7. 87%, whereas the untrained ones had a score of <7. While nearly 19% of the specifically trained postgraduates scored 9–10, only 2.63% of the untrained ones did so. Two trained students and no untrained student got a score of 10. Conclusion: The knowledge of trauma care among postgraduates is grossly inadequate to provide trauma care in acute trauma scenarios. Since training has shown to have better outcomes, such programs need to be incorporated in the postgraduate curriculum.
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The preventive effects of oral caffeine and melatonin on headache after spinal anesthesia for lower limb surgery: A double-blinded, randomized clinical trial p. 50
Hesameddin Modir, Esmail Moshiri, Amirreza Modir, Arghavan Modir, Abolfazl Mohammadbeigi
Background: Postdural puncture headache (PDPH) is a common complication after spinal anesthesia, mainly due to the loss of cerebrospinal fluid. This study was aimed to compare the preventive effect of oral caffeine (CAF) and melatonin (MEL) on headache after the spinal anesthesia for lower limb surgery (LLS). Methods: A double-blinded, randomized clinical trial enrolled on 150 patients undergoing LLS were randomly divided into three groups (n = 50 in each). CAF, MEL, and placebo (PBO) (control group) receiving a capsule containing 300 mg CAF, MEL 3 mg tablet, and a placebo 1 h before the spinal anesthesia. While recording the variables (SaO2, heart rate, mean blood pressure, and the dose of analgesic drug consumption), the pain score was measured using the visual analog scale at 12 and 24 h, as well as 2, 3, 5, and 7 days after surgery, afterward followed by SPSS-based data analysis. Results: Significant differences were found in headache pain score among the three groups (P < 0.001). The lowest pain score was seen with the CAF until 3 days after the surgery and in the MEL on day 5 and 7 days after the surgery. The incidence of PDPH in CAF, MEL, and PBO groups was 18%, 22%, and 36%, respectively (P = 0.006). Conclusion: CAF and MEL reduced the incidence of PDPH after spinal anesthesia for LLS with no hemodynamic changes. Based on the study results, the preventive effects of CAF on PDPH have been confirmed, and MEL can be suggested to be used for its prevention. However, further studies, with larger sample sizes, will be needed to completely prove these findings.
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The effect of insulin resistance on mortality in critically ill patients in the intensive care unit p. 56
Ayse Gülcan Bakkal, Murat Büyükşekerci, Işın Gençay, Gülçin Aydın, Osman Çağlayan, Ünase Büyükkoçak
Background and Aims: Insulin resistance can be described as a subnormal biological response to a specific insulin concentration or deterioration of an accepted response to insulin in glucose homeostasis and deficiency of insulin response. The aim of this study is to evaluate the effect of insulin resistance on mortality in critically ill patients. Methods: Over 18-year-old and nondiabetic 150 patients that had been hospitalized in an intensive care unit (ICU) between September 2013 and October 2014 were enrolled in this study. The Acute Physiology and Chronic Health Enquiry II (APACHE II), Glasgow Coma Scale, and Richmond Agitation and Sedation Scale were calculated on the day of admission to the ICU, and following 4th day and 1st, 2nd, 3rd, and 4th weeks. Insulin resistance was calculated using the HOMA formula. Infection and other complications during ICU stay, the requirement of mechanical ventilation (MV), nutritional status (parenteral and/or enteral), vasopressor, steroid, and insulin treatment were also recorded. Patients followed in the ICU were recorded as survivors and nonsurvivors. Results: Glucose levels were found to be higher in nonsurvivor group at the 1st week and there was a significant positive relationship between APACHE II score and insulin resistance at the 3rd week. There was a significant relationship between mortality and requirement of MV, vasopressor medication, complications, and infection. Conclusion: We conclude that the effect of insulin resistance seems to affect the mortality in critically ill patients after at least a 3 weeks long follow-up time.
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Anesthetic management of bilateral pulmonary alveolar proteinosis for whole lung lavage p. 62
Nilesh M Solanki, Shailesh K Shah, Rashmita H Jasoliya
Pulmonary alveolar proteinosis (PAP) is a rare lung diseases in which there is abnormal accumulation of lung surfactant in alveoli by lipoproteinaceous material. The standard method for management of such cases is whole lung lavage (WLL). We report a PAP patient for WLL under general anesthesia and discuss the anesthetic challenges and management strategies to maintain adequate lung isolation and oxygenation, implementation of lateral positions of the patient with prolonged procedure and hypothermia during the lung lavage.
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An adolescent with large extradural hematoma and undiagnosed congenital cyanotic heart disease at wee hours: An anesthetist's nightmare p. 66
Priyanka Gupta, JS Rahul, Amiya Kumar Barik, Gaurav Gupta
Extradural hematoma (EDH) is a life-threatening emergency, which needs emergent evacuation to prevent mortality and morbidity. We report a case of an adolescent, who had large fronto-temporo-parietal EDH, with significant midline shift, and was incidentally diagnosed to have congenital cyanotic heart disease with deranged coagulation profile in the preoperative area using point-of-care ultrasound.
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Pediatric airway management in undiagnosed congenital subglottic stenosis patients p. 70
Deepak Dwivedi, Gunjan Dwivedi, Vikas Gupta, Shreyas Kate
Pediatric unanticipated difficult airway in cases of subglottic stenosis (SGS) is always a challenge. We present two cases of SGS which were managed according to the pediatric difficult intubation protocols where supraglottic device was used as secondary intubation plan successfully. Airway management in these cases depends on the urgency of the surgery; if the surgery is nonemergent, the case can be postponed and both surgical and nonsurgical modalities of treatment can be offered; however, in wake of emergency surgery, surgical airway is indicated. Strategies of the pediatric airway management have evolved over the years, but the risk and morbidity associated with the adverse airway events loom larger.
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Endotracheal intubation in a case of huge parotid tumor–A Challenge p. 74
Rajnish Kumar, Priyesh Kumar, Mumtaz Hussain, Rajesh Kumar
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Pulmonary embolization of high-flow massive peripheral arteriovenous malformation with isobutyl-2-cyanoacrylate glue p. 75
S Jayaprakash, KB Nalini, Preeti Kandasamy, Mungasuvalli Chanappa Nagaraj
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A rare case of dengue hemorrhagic fever in the postoperative period p. 77
Shalendra Singh, KC Pradip, Saurabh Sud, Munish Sood
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Electrocardiographic changes or artifacts? A dilemma p. 78
Rakesh Kumar, Mritunjay Kumar, Pradeep Bhatia, Manoj Kamal, Sadik Mohammad, Rashmi Syal
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