Indian Journal of Anaesthesia  
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   Table of Contents - Current issue
January 2020
Volume 64 | Issue 1
Page Nos. 1-85

Online since Tuesday, January 7, 2020

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Vision, mission and formulation of newer approaches and goals at IJA: The scientific journey will continue Highly accessed article p. 1
Lalit Mehdiratta, Sukhminder Jit Singh Bajwa
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VISION 2020 p. 4
Muralidhar Joshi
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The President's Inaugural Address during ISACON 2019, on 26th Nov. 2019 at Bengaluru - 'From history, to the Future' p. 6
S Bala Bhaskar
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ISA academics – A new era p. 9
Naveen Malhotra
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Supraglottic jet oxygenation and ventilation – A novel ventilation technique p. 11
Sushan Gupta
Supraglottic jet oxygenation and ventilation (SJOV) is a novel minimally invasive supraglottic technique of jet ventilation which has shown superior results in maintaining oxygenation without any major complications. Theoretically, it could maintain PaO2and PaCO2 within physiological limits for as long as required, the maximum duration reported till now is 45 min. The distinct advantage of SJOV over techniques of nasal oxygenation is its ability to record EtCO2during the periods of ventilation. In addition, it also provides reliable airway access by the blind passage of the endotracheal tube into the trachea with a high success rate even in Cormack-Lehane-III (CLIII) grading patients. Potential complications seen with SJOV include nasal bleed and sore throat. No studies have shown to cause severe barotrauma. In this article, we review the evidence regarding oxygenation, ventilation, indications, airway patency and complications of SJOV in comparison to other more commonly used supraglottic oxygenation and ventilation devices.
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Relationship between intra-operative hypotension and post-operative complications in traumatic hip surgery p. 18
Subhi M Alghanem, Islam M Massad, Mahmoud M Almustafa, Luma H Al-Shwiat, Mohammad K El-Masri, Omar Q Samarah, Osama A Khalil, Muayyad Ahmad
Background and Aims: The relationship between intra-operative hypotension and post-operative complications has been recently studied in non-cardiac surgery. Little is known about this relationship in traumatic hip surgery. Our study aimed to investigate this relationship. Methods: A retrospective study was conducted on patients who underwent surgical correction of traumatic hip fracture between 2010 and 2015. We reviewed the perioperative blood pressure readings and the episodes of intra-operative hypotension. Hypotension was defined as ≥30% decrease in the pre-induction systolic blood pressure sustained for ≥10 min. The relationship between intra-operative hypotension and post-operative complications was evaluated. Post-operative complications were defined as new events or diseases that required post-operative treatment for 48 h. Factors studied included type of anaesthesia, blood transfusion rate, pre-operative comorbidities and delay in surgery. We used the Statistical Package for Social Sciences (SPSS, IBM 25) to perform descriptive and non-parametric statistics. Results: A total of 502 patients underwent various types of traumatic hip surgery during the study period. Intra-operative hypotension developed in 91 patients (18.1%) and 42 patients (8.4%) developed post-operative complications. Significantly more patients with hypotension developed post-operative complications compared to patients with stable vitals (18.7% vs. 6.1; P < 0.001). There was no statistically significant difference in the incidence of post-operative complication in patients receiving general or spinal anaesthesia. Pre-operative comorbidities had no significant relationship with post-operative complications. Intra-operative blood transfusion was related to both intra-operative hypotension and post-operative complications. Conclusion: There was an association between intra-operative hypotension and post-operative complications in patients undergoing traumatic hip surgery.
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Controlled hypotension for FESS: A randomised double-blinded comparison of magnesium sulphate and dexmedetomidine p. 24
Alka Chhabra, Preeti Saini, Karuna Sharma, Neelam Chaudhary, Abhineet Singh, Sunanda Gupta
Background and Aims: Intense bleeding during general anaesthesia (GA) is the major limitation during functional endoscopic sinus surgery (FESS). This study was aimed to compare the efficacy of dexmedetomidine and magnesium sulphate (MgSO4)for controlled hypotension in FESS. Methods: Sixty eight patients undergoing FESS were randomised to receive either dexmedetomidine 1 μg/kg over 10 min followed by infusion at 0.2 to 0.7 μg/kg/h (Group D) or MgSO440 mg/kg over 10 min followed by an infusion at 10 to 15 mg/kg/h (Group M). Anaesthesia and infusion rates for study drugs were maintained with sevoflurane to keep MAP between 60–70 mmHg throughout the surgery. The time to reach the target MAP, the number of patients requiring a minimum and maximum infusion doses of study drugs were noted. Results: The mean time to achieve target mean arterial pressure (MAP) was less in group D (10.59 ± 2.04) as compared with (21.32 ± 4.65 min) group M (P < 0.001). The target MAP was achieved between 5–15 min in 73.52% patients (Group D) with an infusion dose of 0.2–0.4 μg/kg/h of dexmedetomidine without the use of sevoflurane, while 82.35% patients in group M required 4% sevoflurane along with >12–15 mg/kg/hr infusion of MgSO4to achieve target MAP in 10–20 min. Conclusion: Dexmedetomidine is superior to MgSO4in achieving target MAP in lesser time with minimum infusion dose.
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Systemic lidocaine versus ultrasound-guided transversus abdominis plane block for postoperative analgesia: A comparative randomised study in bariatric surgical patients p. 31
Chandan Gupta, Umesh Kumar Valecha, Shri Prakash Singh, Manu Varshney
Background and Aims: The multimodal analgesia strategies to minimise opioid-related side effects are highly desirable in bariatric surgical procedures. We evaluated the efficacy of ultrasound-guided transversus abdominis plane (USG-TAP) block and intravenous lidocaine for postoperative analgesia in obese patients undergoing laparoscopic bariatric surgery. Methods: We studied 56 patients with body mass index >35 kg/m2. They were randomly allocated to Lidocaine group (Group A) and USG-TAP group (Group B). Group A patients were given intravenous Lidocaine (1.5 mg/kg) bolus followed by (1.5 mg/kg/h) infusion. Group B patients were given ultrasound-guided bilateral TAP block using 20 cc of 0.375% ropivacaine each side. Postoperative numeric rating pain scale score (NRS) hours were compared. Other parameters compared were total fentanyl requirement, sedation score, postoperative nausea vomiting (PONV) score and patient satisfaction score. A P value < 0.05 was considered statistically significant. Results: The patient in the Group A had lower resting NRS score (P < 0.05) postoperatively and less fentanyl consumption (P < 0.001) than in Group B. The difference in the sedation scores (P = 0.161) and PONV (P = 0.293) score was found to be statistically insignificant between Group A and B. The difference between the two groups was statistically significant with respect to patient satisfaction score with majority of patients having an excellent patient satisfaction score in Group A as compared to Group B. Conclusion: Intravenous Lidocaine as part of multimodal analgesic technique in obese patients undergoing laparoscopic bariatric surgery improves pain score and reduces opioid requirement as compared to USG-TAP Block.
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Comparison of ultrasound-guided intermediate vs subcutaneous cervical plexus block for postoperative analgesia in patients undergoing total thyroidectomy: A randomised double-blind trial p. 37
Kartik Syal, Ankita Chandel, Avinash Goyal, Arunima Sharma
Background and Aims: Intermediate cervical plexus block (CPB) is a new procedure whose analgesic efficacy compared to superficial cervical plexus block is yet to be established. We compared the analgesic efficacy of superficial vs intermediate CPB for post-operative analgesia after thyroid surgery. Methods: Forty-five patients with American Society of Anaesthesiologists' physical status 1 or 2 undergoing total thyroidectomy were recruited. Forty-four patients in superficial/subcutaneous CPB group (n = 22) and intermediate CPB (n = 22) received 20 mL 0.25% bupivacaine with adrenaline 100 μg bilaterally in ultrasound-guided superficial and intermediate cervical plexus block before induction of general anaesthesia., respectively. The primary outcome measure was the postoperative visual analogue scale (VAS) scores at 0, 2, 4, 6, 12 and 24. Secondary outcome measures included the total dose of rescue analgesic required, duration of postoperative analgesia and patient's satisfaction score. Statistical analysis was with the Mann-Whitney U test and independent t-test. Results: The post-operative VAS scores were lower in intermediate CPB group compared to superficial CPB group at 2, 4, 6, 12, 18 and 24 h [P < 0.05]. Time to first rescue analgesic demand was prolonged 10.06 ± 3.62 h in intermediate group compared to 7.94 ± 3.62 h in superficial group [P = 0.017] and total analgesic consumption were lower in intermediate group (71.25 ± 16.70 μg) than the superficial group (101.25 ± 50.31 μg) [P = 0.011]. Conclusion: Ultrasound-guided intermediate CPB reduces post-operative pain scores, prolongs duration of analgesia and decreases demands for rescue analgesia compared to superficial CPB.
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Post-operative analgesic effect of intraperitoneal ropivacaine with or without tramadol in laparoscopic cholecystectomy p. 43
Anshu Kumari, Binita Acharya, Bikal Ghimire, Anil Shrestha
Background and Aims: Intraperitoneal instillation of local anaesthetics has been shown to minimise post-operative pain after laparoscopic surgery. This study was aimed to evaluate the post-operative effect of intraperitoneal ropivacaine with and without tramadol in patients undergoing laparoscopic cholecystectomy. Methods: Eighty patients undergoing laparoscopic cholecystectomy were randomised into two groups. Group R received 0.5% ropivacaine 18 mL with normal saline (NS) 2 mL and Group RT received 0.5% ropivacaine 18 mL with tramadol (100 mg, 2 mL) at the end of surgery intraperitoneally through the port. The pain score was monitored using a numerical rating scale (NRS) every 30 min till 4 h post-operatively and then at 6 h, 12 h and 24 h. The primary objective of the study was to compare the severity of pain between the groups. The secondary objectives were to compare the total dose of rescue analgesic and the time to first rescue analgesia between the groups Statistical analysis was performed using statistical package for the social sciences. Chi-square test and Mann Whitney U test were used for analysis. Results: The pain score in Group RT was significantly lower than Group R at 2.5 h to 24 h (P = 0.005). Only 42.5% in Group RT demanded rescue analgesia as compared to 75% in Group R (P = 0.003). Total analgesic consumption of fentanyl was also reduced in the tramadol group (785 μg vs 1800 μg). No significant adverse effects were found. Conclusion: Intraperitoneal instillation of ropivacaine with tramadol reduces the post-operative pain and analgesic requirement in laparoscopic cholecystectomy as compared to ropivacaine alone.
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Erector spinae versus paravertebral plane blocks in modified radical mastectomy: Randomised comparative study of the technique success rate among novice anaesthesiologists p. 49
Moustafa A Moustafa, Ahmad S Alabd, Aly M M Ahmed, Ehsan A Deghidy
Background and Aims: Regional analgesia may play a role in pain management during breast surgery. Ultrasound approach to paravertebral block may be challenging. This study compared success rates of ultrasound-guided erector spinae plane block (ESPB) versus parasagittal in-plane thoracic paravertebral block among senior anaesthesia residents in modified radical mastectomy. Methods: One hundred and two female patients undergoing modified radical mastectomy were randomly categorized into PARA group receiving sagittal in-plane paravertebral block and ESPB group receiving erector spinae plane block. The block in the 1st six cases in each group was done by an experienced consultant as a demonstration for three anaesthesia residents not experienced in either block. Primary endpoint was assessing success rate of the blocks. Secondary endpoint was the haemodynamic response to skin incision and postoperative analgesia. Results: All patients were females undergoing modified radical mastectomy. Success rate among residents was 100% in ESPB versus 77.8% in PARA group (P = 0.002). Duration to perform the block was less in ESPB group (4.39 ± 1.2 min) than PARA group (8.18 ± 2.42 min) (P< 0.0001). Guidance frequency by consultants was significantly higher in PARA than ESPB group. Time to 1st analgesic requirement and morphine consumption postoperatively were insignificant between the groups. There was no significant difference regarding haemodynamics. Conclusion: ESPB may be a simple and safe alternative to parasagittal in-plane paravertebral block to provide postoperative analgesia in modified radical mastectomy especially in novice practitioners. It provides equivalent profile of postoperative analgesia with less time to perform the block.
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Performance in 6-min walk test in prediction of post-operative pulmonary complication in major oncosurgeries: A prospective observational study p. 55
Sethu Lekshmi Sathyaprasad, Mary Thomas, Frenny Ann Philip, K M Jagathnath Krishna
Background and Aims: Post-operative pulmonary complications (PPC) contribute to increased morbidity and mortality, necessitating pre-operative functional assessment. Six-minute walk test (6MWT) is a simple option for functional assessment. Methods: This is a prospective observational study conducted in 75 patients who underwent elective abdominal or thoracic oncosurgery under general anaesthesia with either age above 60 years or with cardiopulmonary diseases or obstructive sleep apnoea or low serum albumin or smoking. Patients with history of acute coronary syndrome in past 6 months, dyspnoea at rest, severe pain, inability to walk or interpret instructions and haemodynamic instability were excluded. Preoperatively 6MWT was conducted according to the American Thoracic Society guidelines and patients were observed for PPC. Patients were divided into two groups: group 1–no PPC and group 2–developed PPC. Statistical analysis was done using SPSS software (version 11.0.1). Categorical variables were assessed using Chi-square/Fisher's exact test and continuous variables using student's t-test/Mann-Whitney U test. Association was tested using logistic regression. Results: Out of the 75 patients, 40 patients had no PPC (group 1) and 35 patients had PPC (group 2) including a death. The 6MWD of group with PPCs was significantly less (344 ± 61.927 m) compared to the group without PPCs (442.28 ± 83.194 m, P value = 0.001). The cut-off 6MWD obtained was 390 m, which correlated with longer duration of hospital stay and ICU stay (P = 0.001). Conclusion: Six-minute walk test is a reliable predictor of post-operative pulmonary complications with a cut-off 6MWD of 390 m in the studied oncosurgery patients.
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A case of post-operative posterior reversible encephalopathy syndrome in children: A preventable neurological catastrophe p. 62
Amit Rastogi, Jaspreet Kaur, Rehman Hyder, Bhanuprakash Bhaskar, Vijay Upadhyaya, Anmol Singh Rai
Posterior reversible encephalopathy syndrome (PRES) is a clinic-radiological syndrome that is generally reversible and may lead to permanent neurological damage if left untreated. PRES has been commonly linked with hypertension along with associated vasogenic oedema. Children are more susceptible to these perturbations due to the narrow range of cerebral autoregulation. PRES must be considered in differentials of any neurological dysfunction which is associated with hypertension in the immediate post-operative period. Inadequate pain control in the post-operative period may cause hypertension that may lead to subsequent PRES. We report a case of postoperative PRES in a 12-year-old previously normotensive child posted for splenectomy with an acute rise in blood pressure in the post-operative period.
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Enhanced recovery after surgery with intrathecal opioid in a patient of Gilbert's syndrome undergoing mitral valve replacement p. 66
Banashree Mandal, Srinath Damodaran, Harkant S Baryah, Gayathri Warrier
Gilbert's syndrome, an inherited autosomal dominant disorder, is the most common cause of congenital unconjugated hyperbilirubinaemia. We report the anaesthetic management of a 46-year-old female with Gilbert's syndrome operated for mitral valve replacement (MVR), with a special focus on the role of intrathecal opioids.
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Onco-anaesthesiology as an emerging sub-speciality domain: Need of the hour! p. 69
Raghu Sudarshan Thota, Rakesh Garg, Seshadri Ramkiran, Jigeeshu V Divatia
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Cough projectile during emergence p. 72
Deepak Gupta
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How to mend a broken heart: A case of right ventricular stab injury p. 73
Anil G Kumar, P Parashuraman, Ashwini Kumar Pasarad, KS Kishore
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Airway management in a patient with corrosive poisoning: New tools aid an old problem p. 75
Gauri R Gangakhedkar, Nisha Gowani, Anjali Rajan, Ravindra Kamble, Prerana Shah
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Erector spinae plane block as a sole anaesthetic technique for simple mastectomy in a cardiorespiratory crippled female p. 77
Monisha Sundararajan, Parthasarathy Srinivasan
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Unilateral erector spinae plane block for managing acute pain arising from multiple unilateral injuries: A case report p. 79
Sandeep Diwan, Abhijit Nair
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Bilateral erector spinae catheter placement for bilateral nephrectomy in a paediatric patient p. 81
Megan A Wellbeloved, Ellen Kemp
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Need to replace codeine for management of paediatric post operative pain p. 83
Aditi Jain, Neerja Bhardwaj
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Supplement information of fasting time for obese children p. 84
Binbin Zhu, Yu Gui
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Operative fasting guidelines and postoperative feeding – Current concepts p. 85
Ann S Toms, Ekta Rai
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