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LETTER TO EDITOR
“Zero” diastolic blood pressure
Deepak Choudhary, Om Prakash Suthar, Pradeep Kumar Bhatia, Ghansham Biyani
January-June 2016, 17(1):32-33
DOI:10.4103/0973-0311.183572  
  6,040 279 -
REVIEW ARTICLE
Preoperative anxiety-an important but neglected issue: A narrative review
Teena Bansal, Akanksha Joon
July-December 2016, 17(2):37-42
DOI:10.4103/0973-0311.195955  
Anxiety is an emotional state characterized by apprehension and fear resulting from the anticipation of a threatening event. The incidence of preoperative anxiety ranges from 11% to 80% in adult patients and also varies among different surgical groups. Preoperative anxiety may lead to various problems and a wide range of physiological and psychological responses. A variety of objective and subjective methods are available for measuring preoperative anxiety. Every patient scheduled for surgery should be assessed for the presence of anxiety in their routine preoperative anesthesia assessment, and counseling should be done by anesthesiologist in patients with a high level of anxiety. Surgery information reduces anxiety in the preoperative period.
  5,323 425 2
GUEST EDITORIAL
On starting a new medical journal: Problems, challenges, and remedies
Anjan Trikha
January-June 2016, 17(1):3-5
DOI:10.4103/0973-0311.183576  
  2,629 328 -
REVIEW ARTICLES
Anesthetic considerations for a parturient with pulmonary hypertension
Bhavna Gupta, Kamna Kakkar, Lalit Gupta, Anish Gupta
July-December 2017, 18(2):39-45
DOI:10.4103/TheIAForum.TheIAForum_28_17  
Pulmonary hypertension is defined as persistent rise in mean pulmonary artery pressure of 25 mmHg or more with pulmonary occlusion pressure <15 mmHg. Most of the symptoms encountered in pulmonary hypertension overlap with that of normal pregnancy such as shortness of breath, weakness, fatigue, chest pain, syncope, and abdominal discomfort. Pulmonary hypertension in pregnant patients carries high mortality rates between 30% and 56% and is also the important cause of increased perioperative morbidity and mortality. Basic principles of management include maintaining right ventricular function and reducing pulmonary vascular resistance. Preoperative risk assessment and successful management of patients with pulmonary hypertension undergoing surgery are crucial and important and involve an understanding of the pathophysiology of the disease, analysis of preoperative and operative risk factors, thorough multidisciplinary planning, meticulous intraoperative management, and early recognition and treatment of postoperative complications. We searched PubMed and Google Scholar databases with the following key words: pulmonary hypertension, anesthesia concerns, and parturient female for literature search.
  2,525 219 -
EDITORIAL
Hybrid operating room: Clinical applications
Ajmer Singh
July-December 2016, 17(2):35-36
DOI:10.4103/0973-0311.195950  
  2,386 292 1
CASE REPORTS
Anesthetic management of a child with autistic spectrum disorder and homocysteinemia
Deepak Choudhary, Ghansham Biyani, Pradeep Kumar Bhatia, Nikhil Kothari
January-June 2016, 17(1):29-31
DOI:10.4103/0973-0311.183573  
Autistic spectrum disorder (ASD) is a developmental disability of the central nervous system with rapid worsening. A subset of patients also has mitochondrial dysfunction leading to increased sensitivity to various anesthetic agents. Rarely, gene mutation in these patients results in homocysteinemia which causes higher incidences of thromboembolism, hypoglycemia, and seizures. Anesthetic management of ASD with homocysteinemia and refractory seizures has not been previously reported.
  2,437 204 -
ORIGINAL ARTICLE
Anesthetic management of a patient with heart failure and reduced ejection fraction for radical cholecystectomy with liver resection surgery
Amit Kumar Mittal, Itee Chowdhury, Manisha Arora, Chamound Rai Jain
January-June 2017, 18(1):19-22
DOI:10.4103/TheIAForum.TheIAForum_5_17  
We report a case focusing on achieving an optimum cardiac output (CO) in a patient with heart failure with severely reduced ejection fraction using EV1000 monitor to obtain various dynamic parameters such as stroke volume (SV), SV variation (SVV), systemic vascular resistance (SVR), and CO. We optimized preload by SVV-guided intraoperative goal-directed fluid transfusion and modulated SVR using multipronged anesthetic techniques to decrease afterload and increase forward flow to improve CO in a patient undergoing radical cholecystectomy with wedge liver resection.
  2,434 195 -
CASE REPORTS
Takayasu's arteritis: An anesthetic challenge
Geetanjali S Verma
July-December 2016, 17(2):52-54
DOI:10.4103/0973-0311.194266  
Takayasu's arteritis (TA) is found commonly in young women presenting for cesarean section. A 24-year-old woman with a history of cerebrovascular disease and known case of Type I TA was managed successfully without perioperative complications under general anesthesia.
  2,336 248 -
REVIEW ARTICLES
Volume capnography: A narrative review
Shubhangi Singh, Bhavani Shankar Kodali
July-December 2017, 18(2):33-38
DOI:10.4103/TheIAForum.TheIAForum_27_17  
Volume capnography is the graph of expired carbon dioxide concentration against the expired volume. It often requires special and bulky equipment to be recorded. It can be used to estimate the dead space with fair amount of precision. Various formulae and equations have been described to estimate the dead space. While the Bohr formula is likely the most accurate for measurement of dead space, the Enghoff's equation is likely the most popular and convenient to use. Volume capnography has found uses in both the operating room (OR) and the Intensive Care Unit setting. It can be used to identify the optimal level of positive end-expiratory pressure in patients suffering from the acute respiratory distress syndrome as well as to identify its effect on the ventilation. In the OR, it can be invaluable to monitor ventilation and alveolar recruitment in the obese population. It is also a useful diagnostic adjunct in medical emergencies like pulmonary embolism. In the pediatric population, it finds uses in the monitoring of infants suffering from bronchiolitis. In spite of its multiple and diverse uses, it remains an underutilized technology; the main reasons for this being lack of experience of the providers with volume capnography and the expensive and bulky equipment that is often required. However, volume capnography has a great deal of potential and with further advances in technology, is likely to gain popularity.
  2,252 331 -
CASE REPORTS
Anesthetic management of lower segment cesarean section with postpartum hemorrhage in two patients with tetralogy of Fallot
Jayashree Patki, Nareshkumar Reddy
January-June 2016, 17(1):10-13
DOI:10.4103/0973-0311.183577  
Pregnant patient with heart disease is a unique challenge to the obstetrician and anesthesiologist, and requires a thorough understanding of the impact of pregnancy on the haemodynamic response in view of existing cardiac lesion. Among the congenital heart diseases causing right to left shunt, Tetralogy of Fallot (TOF) is commonest congenital heart disease. Symptoms of TOF may get worsened during pregnancy and if neglected, it causes significant morbidity and mortality to the patient as well as to fetus. Uncorrecrected TOF parturient posted for LSCS poses an unique challenge to the anesthesiologist. We present 2 case reports of patients of TOF with BT shunt who underwent caesarean section under general anaesthesia. Both the patients had post partum hemorrhage (PPH) which was treated successfully without further complications
  2,281 289 -
ORIGINAL ARTICLE
Accuracy of tension and saturation-based oxygen indices in the assessment of disease severity and its progress in adults with acute respiratory distress syndrome
Ghada F El-Baradey, Nagat S El-Shmaa
July-December 2016, 17(2):43-47
DOI:10.4103/0973-0311.193103  
Objective: The goal of this study was to assess the reliability of different tension and saturation-based oxygen indices with traditional oxygenation index (OI) in the assessment of disease severity and its progress in adult patients with acute respiratory distress syndrome (ARDS) when compared to the standard arterial oxygen tension (PaO2)/inspired fraction of oxygen (FiO2) (PF) ratio included in the Berlin definition of ARDS; the primary objective was assessed by the correlation of different OIs to the standard PF index. Design: This was a prospective, observational study. Setting: This study was carried out in Intensive Care Unit (ICU) in a university hospital. Patients and Methods: Sixty adult patients with different grades of ARDS severity according to Berlin definition were enrolled in this study. Measurements: The following indices were measured: (1) PF, (2) OI = FiO2 × mean airway pressure [MAP] × 100/PaO2 , (3) oxygen saturation index (OSI) = FiO2 × MAP × 100/oxygen saturation by pulse oximeter. The primary outcome measurement was the correlation of different OIs to the standard PF index. The secondary outcome measurements were sensitivity and specificity of each index. Results: There were a strong significant negative correlation between OI and OSI with the PF (r = −0.9 and −0.91, respectively) and a significant positive correlation between OI and OSI (r = 0.93). Total mortality rate was 36% (22 patients). The PF, OI, and OSI were sensitive and specific (sensitivity: 0.63, 0.77, and 0.81, respectively, and specificity: 0.76, 0.86, and 0.78, respectively). Conclusion: OSI can be used as a noninvasive index for the assessment of ARDS severity in adults as it correlates significantly with PF ratio and OI with high sensitivity and specificity to predict ICU mortality.
  2,293 274 -
CASE REPORTS
Central neuraxial blockade in chronic immune thrombocytopenic purpura: Platelet count or function and the concept of rebalanced hemostasis
Tasneem Dhansura, Nabila Shaikh, Tarana Shaikh, Mohtasib Madaoo
July-December 2016, 17(2):48-51
DOI:10.4103/0973-0311.195961  
Anesthetic management of patients having immune thrombocytopenic purpura (ITP) remains a challenge for the anesthesiologist. Surgeries such as knee arthroplasty are associated with significant bleeding. Neuraxial anesthesia is often preferred for knee arthroplasty. However, in patients with bleeding diathesis such as ITP, neuraxial anesthetic management remains controversial as there are no specific guidelines, and there is a risk of spinal hematoma. There are numerous case reports of safe regional anesthesia administered in parturients suffering from thrombocytopenia, but no explanation has been given. A new emerging concept of "rebalanced hemostasis" is now being used to explain the discrepancies observed in the laboratory reports versus the actual bleeding. In our case report, we have reviewed the literature and described the anesthetic management of a patient having chronic ITP and chronic obstructive pulmonary disease undergoing knee arthroplasty under neuraxial technique.
  2,292 249 -
REVIEW ARTICLE
Recent advances in anesthetic management in repair of tracheoesophageal fistula repair
Bhavna Gupta, Munisha Agarwal, Shandip Kumar Sinha
July-December 2018, 19(2):39-44
DOI:10.4103/TheIAForum.TheIAForum_43_18  
Thoracosopic repair of tracheoesophageal fistula and esophageal atresia (TREAT) is an advanced endoscopic procedure which requires a skilled approach in minimally invasive surgeries. TREAT is considered as a superior technique in achieving cosmesis and avoiding complications when compared to open thoracotomy. It requires a team of surgeons, anesthesiologists, and assistants and neonatal intensivists to look after the neonate in the perioperative period. Recent meta-analysis has shown no significant difference in outcome and functional evaluation in open thoracotomy and thoracoscopic approach to TEF repair. Anesthesiologists should be well versed with knowledge and ability to anticipate challenges in managing neonates under thoracoscopic TEF repair which plays an important role in the management and survival of these kids. We searched PubMed and Google Scholar databases with the following keywords anesthetic management, tracheoesophageal repair, surgical repair, non-intubated video-assisted thoracoscopic surgery, video-assisted thoracoscopic surgery, video-assisted thoracoscopic surgery, pediatric one-lung ventilation, and pediatric regional anesthesia. The last search was made on July 31, 2018.
  2,209 256 -
CASE REPORTS
Posterior reversible encephalopathy syndrome: An atypical postpartum complication
Debashish Paul, Sachin Narayan Kulkarni, Mili Das Choudhury, GD Maity
January-June 2016, 17(1):17-20
DOI:10.4103/0973-0311.183579  
Posterior reversible encephalopathy syndrome (PRES) is presented by headache, altered mental status, blurring of vision, vomiting and seizure in conjunction with radiological finding of posterior cerebral white matter edema. Data suggest that most cases occur in young middle-aged with marked female preponderance, hypertension being the most common cause. In this case, it was diagnosed in a normotensive patient in the postnatal period that underwent cesarean section. The initial symptoms had misled toward a diagnosis of postdural puncture headache. Symptomatic treatment was started immediately in the ICU. This is an interesting case as the patient was a normotensive one without any other contributory factors and there was unanticipated delay in diagnosing the case until the time we could get a magnetic resonance imaging report.
  2,216 230 -
Combined spinal–epidural anesthesia for an elderly patient with proportionate dwarfism for laparotomy
Teena Bansal, Rajmala Jaiswal, Arnab Banerjee
January-June 2016, 17(1):14-16
DOI:10.4103/0973-0311.183578  
Anesthesia in a dwarf patient may be challenging as various anatomical anomalies make both general and regional anesthesia difficult. These patients may have atlantoaxial instability, potential for airway obstruction, and associated respiratory problems that may pose problems for general anesthesia. Spinal stenosis, osteophytes, short pedicles, or a small epidural space could complicate regional anesthesia in dwarfs which could lead to difficulties in locating the epidural space and increase the risk of dural puncture. Spinal stenosis may impair cerebrospinal fluid flow such that identification of dural puncture is difficult. This elderly dwarf patient had history of bronchial asthma with restriction of neck extension, managed successfully using combined spinal–epidural anesthesia.
  2,075 305 -
Ondansetron-induced atrial fibrillation?
Abhijit S Nair, Veena G Enagandula, MS Shyam Prasad, Basanth Kumar Rayani
July-December 2016, 17(2):55-57
DOI:10.4103/0973-0311.193101  
Drug-induced dysrhythmias are frequently encountered with several drugs that are routinely used in the practice of medicine. However, it is difficult to predict in which group of patients the rhythm disturbances can happen. The clinician should try to identify the cause of the new onset rhythm disturbance (electrolyte imbalance, ongoing cardiac insult, hypoxia, hemodynamic disturbance, cerebrovascular event, etc.). Once a drug is suspected, it should be documented on medical case record and everyone involved in the patients care should be informed.
  2,138 177 -
EDITORIAL
The journal in a new avatar
Pradeep Kumar Bhatia
January-June 2016, 17(1):1-2
DOI:10.4103/0973-0311.183574  
  1,949 298 -
CASE REPORTS
Clinical pearls of anesthesia for radio-guided, robot-assisted retroauricular parathyroidectomy
Soumi Pathak, Itee Chowdhury, Nitesh Goel, Col A. K. Bhargava
January-June 2016, 17(1):6-9
DOI:10.4103/0973-0311.183575  
Robot assisted transaxillary and retroauricular parathyroidectomy provides a safe, precise, 3-dimensional (3D) magnified dissection for parathyroid surgery without the need for CO2insufflation, and with a better cosmetic outcome due to an invisible scar in the axillary or retroauricular region. Robotic surgery requires innovations with regard to patient positioning and the overall arrangement of operative equipment and personnel. Anaesthesiologists should become familiar with these changes by learning the basic features of robotic surgical systems to provide good anaesthetic care.
  1,921 269 -
ORIGINAL ARTICLES
Outbreak of Burkholderia cepacia catheter-related bloodstream infection in cancer patients with long-term central venous devices at a tertiary cancer centre in India
Pushplata Gupta, Vinita Jain, Manisha Hemrajani, Anju Gupta, Upendra Sharma
January-June 2018, 19(1):1-5
DOI:10.4103/TheIAForum.TheIAForum_38_17  
Background: Different central venous devices are required in cancer patients for long duration, especially in hematological malignancies. In this new era of highly developed long-term central venous devices such as port and peripherally inserted central catheter line, incidence of catheter-related bloodstream infection (CRBSI) is low. However, immunocompromised cancer patients may acquire catheter-related opportunistic infections frequently including Burkholderia cepacia. B.cepacia can cause various bloodstream infections, pneumonias, and wound infections etc. Methodology and Result: We analyzed an outbreak of 14 cases of B. cepacia infection in patients with long-term central venous lines at a tertiary oncology care center. Febrile neutropenia was the only clinical presentation at the time of detection of infection in almost all patients, and the catheter had to be removed in 10 patients owing to partial response to susceptible antibiotic therapy. The source of infection that led to the outbreak could not be identified. Nevertheless, all possible measures to prevent cross-contamination including training of the staff to maintain hand hygiene and aseptic precautions were taken. Although resecuring central venous access is difficult in these patients due to bleeding diathesis, timely decision to remove the catheter based on standard guidelines can prevent complications. To the best of our knowledge, this is the first outbreak of B. cepacia-positive CRBSI reported in this specific subgroup of patients in North India. Conclusion: The opportunistic infection (B. cepacia) of central venous devices during chemotherapy being resistant to commonly used antibiotics could be an important factor in increasing morbidity and mortality in cancer patients.
  1,921 238 -
Prophylactic administration of ondansetron for prevention of shivering during spinal anesthesia
SP Sharma, K Raghu, N Nikhil, G Rajaram, Shishir Kumar, Seema Singh
January-June 2018, 19(1):11-14
DOI:10.4103/TheIAForum.TheIAForum_8_18  
Background and Aims: Shivering is one of the causes of discomfort in patients undergoing surgeries under spinal anesthesia. A variety of drugs and physical methods are used to control shivering. Among pharmacological interventions ondansetron, a 5-hydroxytryptamine3 antagonist has been found effective in controlling shivering. The aim of this study is to evaluate the effect of prophylactic administration of ondansetron for prevention of shivering during spinal anesthesia. Methods: A prospective, randomized, and double-blind study was conducted on 70 patients, from either gender, aged 20–60 years, of the American Society of Anesthesiologists Grade I or II, scheduled for various surgeries under spinal anesthesia. The patients were randomly divided into two groups of 35 each to receive either saline (Group S) or ondansetron 8 mg, (Group O) as slow intravenous infusion before spinal anesthesia. The primary outcome of the study was intraoperative incidence of shivering. Secondary outcomes, such as hemodynamic parameters and adverse reactions, were recorded. Results: A total of 16 patients in Group S (45.7%) and 4 (11.3%) patients in Group O experienced shivering (P = 0.014). A total of 14 patients in Group S (40%) and five patients in Group O (14.3%) had nausea (P = 0.155). A total of 11 patients in Group S (31%) and three patients in Group O (8%) had hypotension (P = 0.168). No patients in either group experienced bradycardia. Conclusion: Prophylactic administration of ondansetron significantly reduced shivering in patients undergoing spinal anesthesia without significant side effects.
  1,872 217 -
Comparison of validity of airway assessment tests for predicting difficult intubation
Chitra Srinivasan, Balaji Kuppuswamy
July-December 2017, 18(2):63-68
DOI:10.4103/TheIAForum.TheIAForum_31_17  
Aim and Objective of the Study: This prospective study was undertaken at Christian Medical College and Hospital Vellore, India. In this study we evaluated the sensitivity and specificity of airway examination tests including: modified Mallampati test (MMT) Thyromental Distance (TMD), ULBT (Upper Lip Bite Test). BMI (Body Mass Index) was also included as one of the predictors. The tests were evaluated individually and in combination. Methods: Total of 354 patients was recruited. Preoperative airway assessments of patients by Mallampati test, Thyromental Distance measurement, ULBT were done. The BMI was also calculated. The tests were done by the investigator and Laryngoscopic grading done by another experienced Anaesthetist according to modified Cormack and Lehane classification. The sensitivity, specificity, positive predictive and negative predictive values were analyzed for the individual tests and in combination. Statistical analysis was performed using SPSS version 11.0. Results: The modified Mallampati had the highest sensitivity of 70% which was statistically significant with a P = 0.001. Conclusion: From this study we conclude that the modified Mallampati test was a better predictor of difficult intubation than the upper lip bite test and Thyromental Distance.
  1,811 183 -
CASE REPORTS
A child of Williams-Beuren syndrome for inguinal hernia repair: Perioperative management concerns
Sangeeta Deka, Jyotirmoy Das, Sangeeta Khanna, Yatin Mehta, Meera Luthra
July-December 2016, 17(2):62-64
DOI:10.4103/0973-0311.194268  
Williams-Beuren syndrome, commonly known as Williams syndrome (WS), is a multi-organ disorder. The principal anomalies of the syndrome are developmental delay, unusual craniofacial dysmorphic features, and cardiovascular anomalies such as valvular or supravalvular aortic stenosis, pulmonary artery stenosis, and coronary insufficiency. Sudden cardiac death during minor procedures even in the absence of gross cardiovascular pathology is the most dreaded complication in these patients. A 7-year-old child with WS was posted for left-sided inguinal hernia repair under general anesthesia. Our article describes the uneventful perioperative course of the patient and highlights the concerns and complications that may be an integral part with the syndrome.
  1,734 178 -
Anesthetic concern during cesarean delivery in patient with ruptured cerebral arteriovenous malformation
Rakesh Karnawat, Sadik Mohammed, Snehil Gupta, Naveen Paliwal, Meenal Agarwal
January-June 2016, 17(1):25-28
DOI:10.4103/0973-0311.183571  
Vascular malformations of the brain are a rare cause of intracranial hemorrhage during pregnancy. The presentation of arteriovenous malformations during pregnancy is usually a result of hemorrhage following rupture. Once hemorrhage occurs, it accounts for 5–12% of all the maternal deaths and remains the third most common nonobstetric cause of maternal morbidity. Successful anesthetic management during cesarean delivery requires close monitoring to address both the varying maternal and fetal needs. The fundamental aims are to maintain oxygenation and stable systemic, cerebral, and placental hemodynamics and to avoid increase in intracranial pressure.
  1,691 215 -
ORIGINAL ARTICLES
Comparative study of supraclavicular brachial plexus block with or without dexamethasone
Nilesh M Solanki, Ankur Garg, Shradha D Kavad, Ajay Rathod
July-December 2017, 18(2):56-62
DOI:10.4103/TheIAForum.TheIAForum_29_17  
Background: Local anesthetics with various adjuvants are used to increase the duration of postoperative analgesia in supraclavicular brachial plexus block. Perineural injection of steroid is known to influence postoperative analgesia. Materials and Methods: A total of fifty patients of the American Society of Anaesthesiologist Grade I–II undergoing various upper limb surgeries under supraclavicular brachial plexus block were randomly divided into two groups. In Group C, patients received 32 ml of mixture of 1.5% lignocaine–adrenaline 10 ml, 0.5% bupivacaine 20 ml and normal saline 2 ml, whereas in Group D, patients received the same amount of local anesthetics with dexamethasone 2 ml (8 mg). Sensory and motor block were recorded at the regular intervals. Postoperative analgesia was assessed using visual analog scale (VAS) score. Statistical analysis was performed using Student's unpaired t-test. Results: The mean onset time of sensory and motor block was 3.24 ± 1.09 min and 6.2 ± 1.44 min in Group D and 4.24 ± 1.42 min and 7.52 ± 1.50 min in Group C, respectively. There was markedly prolonged duration of analgesia in Group D (12–16 h) compared to Group C (4–5 h). The mean VAS score was 4.16 ± 1.39 at the end of 6 h in Group C, whereas it was 0 (zero) in Group D at the same time. The difference was statistically significant (P < 0.05). Conclusion: Addition of dexamethasone as an adjuvant to local anesthetics in brachial plexus block provides in significantly early-onset and markedly prolonged duration of analgesia without hemodynamic disturbances.
  1,744 161 -
CASE REPORTS
Severe intraoperative hypercarbia undetected by continuous end-tidal CO2 monitoring in a chronic smoker undergoing one-lung ventilation
Shagun Bhatia Shah, Binod Kumar Naithani, Vani Bhageria, Ajay Kumar Bhargava
January-June 2016, 17(1):21-24
DOI:10.4103/0973-0311.183580  
One-lung ventilation is known to alter the physiology and result in a discrepancy between end-tidal CO2 (ETCO2) and arterial blood CO2partial pressure despite protective mechanisms like hypoxic pulmonary vasoconstriction. Shunts in an emphysematous patient, lateral positioning and capnothorax may aggravate the discrepancy. We present here an incredible discrepancy of 40 mmHg which led us to question the very utility of ETCO2monitoring in this subset of patients and consider alternative techniques.
  1,678 221 -