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   Table of Contents - Current issue
Coverpage
July-December 2020
Volume 21 | Issue 2
Page Nos. 81-171

Online since Saturday, September 19, 2020

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SPECIAL ARTICLE  

Impact of COVID-19 pandemic on education and learning of trainee anesthesiologists, and measures to combat the losses p. 81
Pradeep Bhatia, Ghansham Biyani, Sadik Mohammed, Parvez Lala
DOI:10.4103/TheIAForum.TheIAForum_132_20  
The COVID-19 pandemic has affected every facet of medicine, including anesthesiology. The purpose of this article is to enumerate the possible effects of global lockdown on the education, research, and training of postgraduates of different grades, and to discuss the measures which need to be enacted on to mitigate the impact. This includes innovating and adapting to newer modalities of teaching and training, modifications in research and conduct of examination, and other resources required in rebuilding the losses trainees had in their medical education.
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REVIEW ARTICLE Top

Practical tips on making regional anesthesia safer p. 85
Ashwani Gupta, Rohit Garkoti
DOI:10.4103/TheIAForum.TheIAForum_97_20  
There have been many advances in regional anesthesia to make it safer since its inception. The purpose of the review is to make the readers aware of the latest developments in the approach to patient safety and its application to regional anesthesia. We have emphasized particularly the importance of human factors in addition to the technical expertise. Besides the conventional topics of local anesthetic toxicity and nerve injuries, we have also touched on novel developments such as point-of-care ultrasound. Anesthetists should bear in mind that guidelines are designed to encourage safe and quality patient care, but they cannot guarantee a specific outcome. So where possible safety protocols like pre-procedure dedicated checklist, vigilance and enhancements in monitoring, early evaluation and intervention, engagement with simulation based team training, advancements in technology, learning from safety incidents and positive patient pathways should be used to re-enforce safety. Regional anesthesia-based nontechnical skills (cognitive, social, and personal resource skills that complement technical skills) contribute to safe and efficient task performance and are also important in improving patient experience. The most practical safety approach is multidisciplinary, which keeps clinical judgment and patient-centric decision-making at its core. A literature search was done using the library search engine called discovery, which accesses Ovid, open access, evidence-based medicine, and nursing databases. Individual complications were also searched, and appropriate secondary citations were used accordingly.
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ORIGINAL ARTICLES Top

An educational tool to improve patient perceptions on the roles of an anesthesiologist and the importance of pre-anesthetic evaluation: A quality initiative study p. 92
Smitha Elizabeth George, Grace Rebekah, Anita Shirley Joselyn
DOI:10.4103/TheIAForum.TheIAForum_14_20  
Background: There is a huge deficit in patient knowledge about roles played by an anesthesiologist and about the relevance of a proper preanesthetic evaluation. This study attempted to evaluate if quality improvement strategies could improve it during the preanesthesia clinic (PAC) visit. Materials and Methods: The Plan, Do, Study, Act cycle model of quality control projects was implemented by a prospective audit using a questionnaire, conducted in 170 patients scheduled for elective surgeries in the PAC of a tertiary care hospital, to assess knowledge levels about the relevance of PAC and roles of the anesthesiologist. Educational tools consisting of posters and information on a screen displayed in the PAC waiting area were designed. Another audit in consecutive 170 patients was conducted to assess if educational tools improved the patient's knowledge, and if factors such as patient's gender, language, educational level, and previous anesthetic exposure had any impact on knowledge levels. Results: The initial audit demonstrated a knowledge deficit about preanesthesia checkups and about the roles of the anesthesiologist. Quality improvement steps were taken, and educational tools implemented. Knowledge scores improved from 44.54 ± 17.45 to 52.12 ± 18.8 (P < 0.001, confidence interval −11.45–−3.69). Male gender, higher educational levels, and knowledge of the English language were associated with higher knowledge levels after the intervention. Conclusion: Waiting time at PAC can be utilized to educate patients about the relevance of preanesthesia checkup and about various roles of the anesthesiologist by means of posters and information on a display screen.
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Single-shot lumbar epidural and sedation during endoscopic lumbar discectomy: A Case series p. 100
Delma DCunha, PS Balakrishna Achar, Mrinal Shetty
DOI:10.4103/TheIAForum.TheIAForum_13_20  
Endoscopic discectomy is a painful surgery yet preferably done under moderate sedation and analgesia as the surgeon requires cooperation and inputs from the patient during the procedure. While prone positioning poses a problem for airway management, light sedation poses a problem for securing the airway if the need arises. Therefore, adequate sedation and analgesia is a challenge for the anesthesiologist. Here, we report the management of four patients who successfully underwent endoscopic discectomy under single-shot lumbar epidural and mild-to-moderate sedation.
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Comparison of intranasal midazolam versus intranasal ketamine for preoperative anesthetic sedation in pediatric patients p. 104
Nandini Chouhan, Janhavi Thatte, Deepak Phalgune, Charushila Patkar
DOI:10.4103/TheIAForum.TheIAForum_3_20  
Introduction: During induction of anesthesia anxiety of children may be reduced more effectively by sedative medication than parental presence. Keeping in view, the necessity of reducing preoperative anxiety and postoperative psychological problem in pediatric patients, this study was conducted to compare the efficacy and safety of intranasal midazolam versus intranasal ketamine for preanesthetic sedation in pediatric patients. Methods: Ninety patients scheduled for the surgery lasting between 30 min and 120 min under general anesthesia were randomly divided into two groups: Group A patients received intranasal midazolam 0.2 mg/kg as premedication (5 mg/mL ampoule), whereas Group B patients received intranasal ketamine 5 mg/kg as premedication (50 mg/mL vial). The primary outcome measures were the comparison of degree of sedation of intranasal midazolam versus intranasal ketamine for preanesthetic sedation in pediatric patients by accessing parental separation, acceptance of face mask, venipuncture score, and postoperative sedation, whereas the secondary outcome measures were the comparison of side effects. The comparison of quantitative and qualitative variables between the groups was done using the unpaired student's “t”-test and Chi-square test or Fisher's exact test, respectively. Results: The percentage of patients in the ketamine group with parental separation score more than 2 was significantly higher as compared to the midazolam group. Acceptance of face mask, response to venipuncture, postoperative sedation, and postoperative side effects were comparable between the two groups. Both groups have minimal side effects. Conclusions: Both midazolam and ketamine nasally are an effective pediatric premedication for sedation with minimal side effects. Parental separation was better in the ketamine group as compared to the midazolam group.
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Comparative study of bupivacaine with dexmedetomidine as an adjuvant versus bupivacaine alone in ultrasound-guided supraclavicular brachial plexus block p. 109
Chandrashekar Manjunatha, Curpod G Srinivas Prasad, Rashmi
DOI:10.4103/TheIAForum.TheIAForum_23_20  
Background: Skillful usage of adjuvants in peripheral nerve blocks can resolve the key issue of postoperative pain. This study was conducted to compare the effects of dexmedetomidine as an adjuvant with bupivacaine in terms of the duration of analgesia (DOA), onset and duration of sensory and motor block. Materials and Methods: This prospective, randomized, double-blind trial consists of total 72 patients undergoing elective upper limb elective procedures, divided into two groups, 36 in each. Group-C received ultrasound-guided (USG) supraclavicular brachial plexus block using injection 0.25% bupivacaine 20 ml + 0.9% normal saline diluted to total 22 ml and Group D received USG supraclavicular brachial plexus block using injection 0.25% bupivacaine 20 ml + dexmedetomidine 1 μg/kg diluted to total of 22 ml with 0.9% normal saline. The parameters recorded were onset and duration of sensory and motor block, DOA, and side effects. Results: In both the groups, demographic data were similar. Sensory and motor block onset was significantly shorter (P < 0.05) in Group D than Group C, while the duration of blocks and DOA was prolonged in Group D (P < 0.05). Intraoperative hemodynamics were significantly lower in Group D except in two patients, who had bradycardia and were treated. Conclusion: Dexmedetomidine as an adjuvant to bupivacaine in USG supraclavicular plexus block shortens the onset and prolongs the duration of sensory and motor block and DOA.
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A comparative study of desflurane/fentanyl with sevoflurane/fentanyl on time of awakening and airway morbidity in ambulatory surgery using a supraglottic airway device: A randomized, single-blind study p. 114
Sansaya Mahapatra, Raj Tobin, Alok Gupta, Nitin Choudhary, Soumya Dash
DOI:10.4103/TheIAForum.TheIAForum_22_20  
Background and Aims: The goal of anesthesia for ambulatory surgeries is rapid recovery with decreased hospital stay for rapid turnover of patients. We aim to compare desflurane and sevoflurane with regard to their recovery profile and incidence of airway morbidity and to study the effect of opioid (fentanyl) on these study parameters. Methods: We randomized seventy American Society of Anesthesiologists physical status I and II patients, aged 18–60 years of either sex undergoing elective surgery of less than an hour duration into two groups: Group D (desflurane + fentanyl) and Group S (sevoflurane + fentanyl). After standard induction of anesthesia, Proseal laryngeal mask airway was inserted. Intravenous fentanyl was administered based on entropy values. Anesthesia was maintained on a group-specific inhalational agent. We recorded the time taken for eye opening, follow commands, vocalize, attain modified Aldrete score ≥9 in postanesthesia care unit (PACU), incidence of airway morbidity, rescue analgesic requirement in 1st h postoperatively, and any other complication. Results: The mean time to awakening was significantly faster in Group D (P < 0.001) with shorter stay in PACU (P < 0.001). Incidence of airway morbidity was higher in Group D than Group S, but was not statistically significant (P = 0.710). Conclusion: Desflurane provides faster recovery with shorter PACU stay compared to sevoflurane with comparable incidence of airway morbidity. Opioids may affect airway morbidity, but must be used judiciously to avoid its unwanted effect on recovery.
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Efficacy of dexmedetomidine used as an adjuvant to 0.5% ropivacaine in ultrasound-guided supraclavicular brachial plexus block for upper limb surgeries p. 121
Kavita Jain, Surendra Kumar Sethi, Vikas Gupta, Deepak Kumar Garg
DOI:10.4103/TheIAForum.TheIAForum_62_19  
Background: Supraclavicular brachial plexus block (SCBPB) has gained popularity with the addition of various adjuncts to local anesthetics. This study aimed to evaluate the efficacy of dexmedetomidine as an adjuvant to 0.5% ropivacaine in ultrasound-guided (USG) SCBPB. Materials and Methods: One hundred patients of either sex, belonging to the American Society of Anesthesiologists physical status I or II, aged between 15 and 65 years and scheduled for elective upper arm surgery under USG SCBPB were enrolled. Patients were randomly allocated into two groups (n = 50). Both groups received 16 ml (120 mg) 0.75% ropivacaine with 1 μg/kg dexmedetomidine diluted in 8 ml normal saline (NS) (Group Ropivacaine Dexmedetomidine [RD]) or with 8 ml NS only (Group R). The primary outcome measure was the duration of analgesia, whereas secondary outcome measures were onset and duration of sensory and motor block, quality of anesthesia, sedation score, hemodynamic changes, and side effects. Statistical analysis was performed using unpaired Student's t-test or nonparametric Mann–Whitney test and Chi-square test. Results: The duration of analgesia was significantly prolonged in Group RD (730.70 ± 51.62 min) compared to Group R (388.30 ± 41.66 min), (P < 0.0001). The onset time of sensory and motor block was significantly shorter in Group RD in comparison to Group R (P < 0.001). The duration of sensory and motor block was significantly prolonged in Group RD compared to Group R, (P < 0.0001). The quality of anesthesia was significantly better in Group RD (P < 0.05). Sedation scores were significantly higher in Group RD (P < 0.05). No significant hemodynamic changes and side effects were observed in both groups (P > 0.05). Conclusion: Dexmedetomidine provides the prolonged duration of analgesia along with faster onset as well as prolonged duration of both sensory and motor block without any significant hemodynamic changes and side effects.
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The study of intranasal dexmedetomidine during total intravenous anesthesia for endoscopic retrograde cholangiopancreatography p. 129
Darshan Prakash, Leena Harshad Parate, MC Nagaraj, Vinayak S Pujari, Bhavish Reddy, Nithya Dinesh
DOI:10.4103/TheIAForum.TheIAForum_98_19  
Background: Anesthesia for endoscopic retrograde cholangiopancreatography poses many challenges. The level of sedation is highly unpredictable and can shift from conscious to deep sedation with the loss of protective reflexes. Propofol, which is a popular drug, has a narrow therapeutic index. We study the effect of intranasal dexmedetomidine on propofol and fentanyl consumption. Materials and Methods: Ninety patients were randomly divided into two groups to receive either intranasal 1.5 μg/kg dexmedetomidine or saline. After 1 h, the procedure was commenced. Propofol and fentanyl were used to conduct anesthesia. The primary outcome was intraoperative propofol and fentanyl consumption. The secondary outcome was preprocedural hemodynamic parameter and sedation score. Results: There was no statistically significant difference found in terms of demographic data (age, sex, height, weight, or BMI), duration of procedure, basal hemodynamic parameters, and sedation scale. There was a significant reduction in propofol (227.11 ± 61.27 mg vs. 146.89 ± 31.25 mg) and fentanyl (98.11 ± 13.95 μg vs. 82.44 ± 13.34 μg) consumption in the dexmedetomidine group. There was a significant reduction in pulse rate (95.13 ± 11.00 vs. 82.89 ± 9.45) and mean arterial pressure (98.27 ± 6.40 vs. 91.44 ± 8.02) at 60 min in the dexmedetomidine group. The preprocedural sedation score was statistically significantly reduced in the dexmedetomidine group (4.80 ± 0.40 vs. 3.67 ± 0.48). Conclusion: Intranasal administration of 1.5 μg/kg dexmedetomidine can reduce perioperative anesthetic drug requirements. It provides better preprocedural sedation score and hemodynamic profile.
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Do clinical signs of recovery from neuromuscular blockade compare reliably with objective parameters of train-of-four and double burst stimulation: An observational single-center study p. 134
Bhavna Hooda, Rijesh R Unnithan, Saurabh Sud, Deepak Dwivedi, Puja Dudeja
DOI:10.4103/TheIAForum.TheIAForum_17_20  
Background: Recovery from neuromuscular blockade is commonly assessed by clinical signs. There exists wide disparity in what is recommended to monitor neuromuscular blockade and routine clinical practice by anesthesiologists. The objective signs of train-of-four (TOF) ratio of >0.9 and double burst stimulation (DBS) ratio of 1.0 indicate adequate neuromuscular function. This study was planned at a tertiary care hospital to evaluate the ongoing practice of assessing neuromuscular recovery employing clinical signs and comparing with simultaneous TOF and DBS values. Design: A cross-sectional analytical study. Methodology: A total of 100 consecutive patients undergoing surgical procedures lasting more than 1-h duration under general anesthesia with intermediate acting muscle relaxant were enrolled and data of 60 patients analyzed. After extubation, an independent observer recorded simultaneous TOF and DBS ratio using acceleromyography as the clinical signs of neuromuscular recovery (eye opening, tongue protrusion, head lift, sustained bite, hand grip strength, and ability to cough) were attained. Statistical Analysis: Statistical analysis was done utilizing SPSS version 20 (SPSS Inc., Chicago IL, USA) software. Continuous variables are expressed as mean (standard deviation) and Pearson's correlation coefficient was applied to study the correlation between the clinical parameters and quantitative measures of neuromuscular recovery. Results: There was a significant association between ability to retain tongue depressor (sustained bite), absent double vision and ability to cough effectively and TOF and DBS ratios (P < 0.05). None of the clinical signs correlated with TOF ratio >0.9 or DBS ratio of 1.0. Conclusion: Clinical signs of recovery fail to reliably predict postoperative residual paralysis compared to objective neuromuscular monitoring.
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A close look at anesthetists personality construct: Cloninger's personality dimensions in a sample of specialist anesthetists, trainee anesthetists, and nurse anesthetists p. 140
Haluk Ozdemir, Gokcen Basaranoglu, Kerem Erkalp, Nalan Muhammedoglu, Mevlut Comlekci, Yesim Abut, Mustafa Suren, Asiye Merter Demirel, Leyla Saitoglu
DOI:10.4103/TheIAForum.TheIAForum_77_19  
Background: Anesthesiology is one of the most distressing specialities of medicine. Personality construct plays a crucial role in how one copes with profession-related stress. In this current study, the personality profiles of specialist anesthetists, trainee anesthetists, and nurse anesthetists were examined using the Turkish version of the temperament and character inventory (TCI). Materials and Methods: This study included 135 specialist anesthetists, trainee anesthetists, and nurse anesthetists. They were administered the Turkish TCI, Beck's depression inventory, and the Beck anxiety inventory. Results: Harm avoidance (HA), exploratory excitability, disorderliness, anticipatory worry, and fatigability scores of the three kinds of anesthesia providers were significantly lower than Turkish normative values for the general population, yet congruent second nature scores were significantly higher. Self-directedness (SD), reward dependence (RD), and persistence (P) scores were significantly lower than American normative values; however, HA scores were significantly higher. Between-group analysis showed statistically significant differences in five areas: novelty Seeking, HA, SD, RD, and persistence. On the other hand, no significant differences were found between depression and anxiety scores, although both were higher for trainee anesthetists in their first 2 years of training and for nurse anesthetists who had been working in the field for >10 years. Conclusion: This pioneering study using Cloninger's TCI provides a comprehensive personality assessment that may have implications for recruitment, crisis management, and professional development during anesthesiology residency training and also within the anaesthesiology practice.
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A comparative study on the effects of intrathecal chloroprocaine alone and with fentanyl or clonidine for infraumbilical surgeries p. 147
Arvind Khare, Kavita Jain, Mukut Kanwar, Beena Thada, Veena Mathur, Maina Singh
DOI:10.4103/TheIAForum.TheIAForum_25_20  
Background and Aims: Antioxidant- and preservative-free form of 2-chloroprocaine (1%) has been re-emerged as a short-acting local anesthetic for use in spinal anesthesia. This study aimed to compare the effects of intrathecal 2-chloroprocaine (1%) alone or with fentanyl or clonidine used as an adjuvant for infraumbilical surgeries. Materials and Methods: Ninety patients of either sex aged between 18 and 60 years with American Society of Anesthesiologists Grade I or II scheduled for infraumbilical surgeries were randomly allocated into three groups (n = 30). Group C received intrathecal 1% 2-chloroprocaine 5 ml (50 mg) + 0.5 ml normal saline, Group CF received intrathecal 1% 2-chloroprocaine 5 ml (50 mg) + 0.5 ml fentanyl (25 μg), and Group CC received intrathecal 1% 2-chloroprocaine 5 ml (50 mg) + 0.5 ml clonidine (15 μg) diluted in normal saline. The onset and duration of sensory and motor blocks, time for demand of rescue analgesia, hemodynamics, and side effects were observed. Results: The onset of sensory and motor blocks was significantly earlier, and the duration of sensory and blocks and time to demand of rescue analgesia were significantly prolonged in both Group CF and Group CC as compared to Group C. Among Groups CF and CC, the duration of sensory and blocks and time to demand of rescue analgesia were significantly prolonged in Group CC. Conclusion: Intrathecal clonidine (15 μg) proved to be a better alternative to fentanyl (25 μg) used as an adjuvant to 1% 2-chloroprocaine for infraumbilical surgeries.
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CASE REPORT Top

Dexmedetomidine in a patient with unrepaired congenital cyanotic heart disease p. 153
Kumar Parag, Nishith Govil, Vinay Rai, Abullais Raheeq Gowda
DOI:10.4103/TheIAForum.TheIAForum_27_20  
The challenges in a patient with unrepaired congenital cyanotic heart disease (CCHD) requiring controlled hypotension are to prevent a further increase in the right-to-left (R-L) shunt by maintaining systemic vascular resistance, controlling pulmonary vascular resistance (PVR), decreasing oxygen consumption, and preventing arrhythmia and hypovolemia. To the best of our knowledge, combination of ketamine and dexmedetomidine has not been used in a patient with unrepaired CCHD to keep hemodynamic stable, preventing reversal of shunt and arrhythmias while providing controlled hypotension. The rationale of using combination of intravenous ketamine and dexmedetomidine is to counteract sympathoinhibitory effects of dexmedetomidine with the cardiostimulatory effects of ketamine, thus maintaining a stable hemodynamic in cases with R-L shunt. Another benefit in CCHD is that dexmedetomidine decreases the incidence of arrhythmia intraoperatively and decreases dynamic response of the right ventricular outflow tract induced by pain, thus decreasing R-L shunt. Dexmedetomidine encourages protective mechanisms during hypoxia as in patients with CCHD by lowering anti-ischemic responses such as lactate production and a modest decrease in the PVR. Dexmedetomidine provides controlled hypotension and uneventful recovery due to its lowering of stress response of surgery and opioid sparing effect and decreases the incidence of emergence agitation and postoperative nausea and vomiting.
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LETTERS TO EDITOR Top

Hearing the unsaid – “Pravara sign language” for COVID-19 intensive care unit p. 156
Akshaya N Shetti, Bhavika Singla, Bhakti Bhandari, Katyayani P Gurav
DOI:10.4103/TheIAForum.TheIAForum_55_20  
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A unique use of endotracheal tube as a cuffed nasopharyngeal airway as an interface for noninvasive ventilation during weaning from mechanical ventilator p. 157
Deependra Kamble, Nimisha Mahesh Parkar, Shashaank Pandey
DOI:10.4103/TheIAForum.TheIAForum_51_20  
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A modified technique of conventional arterial catheterization to increase success rate while reducing the complications p. 159
Ramalingam Hariprasad, Garima Choudhary, Manoj Kamal, Pradeep Bhatia
DOI:10.4103/TheIAForum.TheIAForum_53_20  
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Spring cranioplasty in a patient of Apert syndrome: Anesthetic challenges p. 160
Shipra Tandon, Sanjay Agarwal, Revanth Challa
DOI:10.4103/TheIAForum.TheIAForum_97_19  
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Surgical emphysema leading to respiratory distress following partial cricotracheal resection for subglottic stenosis in a paediatric patient p. 162
Deepak Dwivedi, Vikas Gupta, Gunjan Dwivedi, Shalendra Singh
DOI:10.4103/TheIAForum.TheIAForum_15_20  
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Delayed recognition of complex staphylococcal infection in pyrexia of unknown origin p. 163
Vanita Ahuja, Kavita Ramakrishna Bhagwat, Pawanpreet Kaur, Karanjot Gill
DOI:10.4103/TheIAForum.TheIAForum_19_20  
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Iatrogenic tracheoesophageal fistula after button-battery ingestion p. 165
BD Vaishnavi, Pooja Bihani, Rakesh Kumar, Pradeep Bhatia, Rashmi Sayal, Rishabh Jaju
DOI:10.4103/TheIAForum.TheIAForum_16_20  
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“MOKA ICE-CUBES”: A novel mixture for paediatric oral premedication p. 166
Tushar Chokshi, Bhavna Gupta
DOI:10.4103/TheIAForum.TheIAForum_79_20  
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Anesthesia management of a patient with advanced juvenile Paget's disease p. 168
Prasanna Vadhanan, Nikhilesh Bokka, Cheran Kalyanasundaram, Saravanan Kasirajan
DOI:10.4103/TheIAForum.TheIAForum_77_20  
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Sustaining academics during the COVID-19 pandemic p. 170
Swati Chhabra, Manoj Kamal, Deepak Chhabra, Mussavvir Agha
DOI:10.4103/TheIAForum.TheIAForum_131_20  
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