Indian Journal of Anaesthesia  
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   Table of Contents - Current issue
September 2019
Volume 63 | Issue 9
Page Nos. 687-779

Online since Thursday, September 12, 2019

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IJA postgraduate special issue on current concepts in paediatric anaesthesia p. 687
Jigeeshu V Divatia
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The IJA postgraduate educational issue on current concepts in paediatric anaesthesia p. 688
Jeson R Doctor, Anila Malde, Sandhya Yaddanapudi
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Cardiovascular and respiratory physiology in children p. 690
Diganta Saikia, Bandana Mahanta
Children are at increased risk of perioperative respiratory and cardiovascular complications because of their unique respiratory and cardiovascular physiology compared to adults. Anaesthesia can exaggerate respiratory deterioration in young children because of their inability to control respiration and inherent susceptibility to rapid desaturation, airway obstruction, early respiratory fatigue and lung atelectasis. Premature infants (less than 60 weeks of postconceptional age) can be exposed to the danger of prolonged apnoea and consequent worsening of respiratory function. The transitional phase of circulation is vulnerable to revert to persistent foetal circulation in neonates. Myocardium and autonomic control of the heart is immature and different in neonates and infants compared to older children and adults and are predisposed to inadvertent life-threatening haemodynamic changes during the perioperative period. In this review article, we discuss respiratory and cardiovascular physiology in neonates, infants and younger children and their differences with older children and adults. We mainly focus on transitional physiology of both respiratory and cardiovascular system in newborns and infants and the deleterious changes that may occur during anaesthesia or perioperatively.
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Pharmacology related to paediatric anaesthesia p. 698
Meghna Maheshwari, Sadhana Sanwatsarkar, Milind Katakwar
A child is not a mini adult. They differ from adults in terms of weight, shape, anatomical size and major body systems such as cardiovascular and respiratory as well as psychologically. Each organ system is immature in paediatric age group and their growth and development can dramatically affect the pharmacokinetics of different drugs. Children differ in every way from an adult thus mandating to have a basic knowledge of the pharmacokinetic and pharmacodynamic principles in paediatric population to prevent under dosing or toxicity of drugs. This review article aims to simplify the basic principles of pharmacokinetics and pharmacodynamics in paediatric population. It also highlights physiological and pharmacological differences between adults and paediatric age. We performed a PUBMED search for English language articles using keywords including pharmacology, child, paediatric anaesthesia. We also hand searched references from relevant review articles and text book chapters. We have also discussed drug interaction in anaesthesia, pharmacology pertaining to neuromuscular junction and effects of anaesthesia over the developing brain.
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Operative fasting guidelines and postoperative feeding in paediatric anaesthesia-current concepts p. 707
Ann Sumin Toms, Ekta Rai
Preoperative fasting period is the prescribed time prior to any procedure done either under general anaesthesia, regional anaesthesia or sedation, when oral intake of liquids or solids are not allowed. This mandatory fasting is a safety precaution that helps to protect from pulmonary aspiration of gastric contents which may occur any time during anaesthesia. We searched PUBMED for English language articles using keywords including child, paediatric, anaesthesia, fasting, preoperative, gastric emptying. We also hand searched references from relevant review articles and major society guidelines. Association of Paediatric Anaesthesiologists of Great Britain and Ireland (APAGBI), the French Language Society of Paediatric Anaesthesiologists and the European Society of Paediatric Anesthetists recommends clear fluid intake upto one hour prior to elective surgery unless specific contraindications exists. Current guidelines recommend fasting duration of 4 hours for breastmilk, 6 hours for milk and light meals and 8 hours for fatty meals. The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines recommend that oral intake can be initiated within hours of surgery in most patients. While fluids can be started almost immediately, the introduction of solids should be done more cautiously.
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Premedication and induction of anaesthesia in paediatric patients p. 713
Nandini Malay Dave
Perioperative anxiety has been associated with adverse clinical outcomes such as emergence delirium, increased analgesic requirements and negative postoperative behavioural changes such as sleep disturbance, separation anxiety, eating problems and new-onset enuresis. Predictors of preoperative anxiety have been identified, and these include, among other factors, the age and temperament of the child. Any plan for anaesthetic induction in a child must take into account these factors. The anaesthetic plan must be individualised for special situations, for example, the child with behavioural disorder or at risk of aspiration. This article details the pharmacological and nonpharmacological methods to minimise preoperative anxiety and the techniques of anaesthetic induction in infants and children undergoing surgery. The benefits and limitations of inhalational and intravenous induction and the current status of rapid sequence induction in children are discussed. MEDLINE database was searched for this narrative review using the keywords including preoperative anxiety, child, premedication, paediatric and anaesthetic induction. Search was restricted to articles in English, but without any publication date restrictions.
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Airway devices in paediatric anaesthesia p. 721
Sarbari Swaika, Sujata Ghosh, Chiranjib Bhattacharyya
Airway devices were first used in children since 1940 and thereafter an increasingly large number of paediatric airway devices have come into our armamentarium. To control and protect the airway in children during anaesthesia, in intensive care unit or in emergency department either tracheal intubation is performed under direct or indirect visualization of vocal cords with the help of laryngoscopes or video-laryngoscopes respectively or it can be done blindly or by using special instruments such as fiberoptic laryngoscope, lighted stylet or Bullard laryngoscope to name a few. Airway also can be maintained with the help of Laryngeal mask airways, oropharyngeal and nasopharyngeal airways. Updating our information and knowledge regarding these developments is pivotal to our practice of paediatric anaesthesia. With a thorough search of books, MEDLINE, MEDNET, clinical, this article aims at focusing and understanding a brief basis of paediatric devices and their use.
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Perioperative fluid therapy and intraoperative blood loss in children p. 729
Neerja Bhardwaj
Fluid and blood administration are required during surgery in children. The type, amount and tonicity of the intravenous fluids is an important aspect to be considered during anaesthesia management. The physiological differences between adults and children regarding the body water and blood volume needs to be understood. We performed a PUBMED search for English language articles using keywords including 'children', 'intravenous fluid therapy', 'crystalloids', 'colloids', 'fluid homeostasis', 'Starling equation', 'Donnan effect', 'blood loss', 'estimation of blood loss', 'blood management program'. This review discusses the physiological basis, historical background, risk of hyponatraemia, need of glucose in the intravenous fluids as well as the recent concepts in blood transfusion as related to children.
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Vascular access in children p. 737
Vibhavari M Naik, S Shyam Prasad Mantha, Basanth Kumar Rayani
Securing stable vascular access is an important clinical skill for the anaesthesiologist. Sick children, complex surgeries, chronic illnesses, multiple hospitalisations, and prolonged treatments can make vascular access challenging. A search was done in the English language literature using the keywords “paediatric,” “vascular access,” “venous access,” and “techniques” or “complications” in Pubmed, Embase, and Google scholar databases. Articles were screened and appropriate content was included. Intraosseous access is a lifesaving technique that can be performed even in hypovolaemic patients rapidly. Transillumination and near-infrared light improve visualisation of superficial veins in difficult access. Ultrasonography has become the standard of care in selecting the vessel, size of catheter, guide placement, and prevent complications. Fluoroscopy is used during insertion of long-term vascular access devices. This article reviews the various routes of access, their indications, most appropriate site, securing techniques, advantages, disadvantages, and complications associated with vascular access in children.
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Recent trends in paediatric regional anaesthesia p. 746
Vrushali Ponde
Paediatric regional anaesthesia today is one of the fastest growing and exciting aspects of paediatric anaesthesia, which requires an ongoing fervour to learn. Application of paediatric regional anaesthesia in neonates, infants, toddlers and children is undertaken to treat perioperative pain without disturbing the physiological milieu with additional advantages elaborated in the review. The available choices, traditional methods and the most recently described methods are discussed with emphasis on their advantages and disadvantages. Clear pointers for selection of the blocks are also discussed. To present a holistic overview of this rapidly growing subject, a comprehensive literature search was performed in May 2019 in MEDLINE, PubMed and Google Scholar to retrieve articles pertaining to all the above topics. The keywords used in various combinations included 'Central neuraxial, blocks, Paediatric(s)', 'Peripheral Nerve blocks', 'Safety, controversies, regional, anaesthesia'.
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Non-operating room anaesthesia in children p. 754
Subrahmanyam Maddirala, Annu Theagrajan
Administration of sedation and/or anaesthesia to patients undergoing painful or uncomfortable procedures at off-site locations is referred to as non-operating room anaesthesia (NORA). Sedating/anaesthetising children in an unfamiliar environment, with the lack of support staff, nonavailability of choice of medication and equipment is often challenging. Studies have shown an increased risk of airway-related adverse events, complications, and even death outside the operating room locations. It is crucial to be familiar with the anatomical and physiological variations in children, well versed with the difficult airway algorithm and call for help early. The most common event in NORA claims was inadequate oxygenation/ventilation, which are preventable with vigilant monitoring. English language articles were searched in Pubmed, Google Scholar, and Academic using 'sedation in children', 'remote location anaesthesia', 'peadiatric sedation', and 'nonoperating room anaesthesia' as the mesh words. Full text of the relevant articles was obtained and this review article was synthesised. The article outlines various safety guidelines, sedation techniques, drugs used for sedation, environmental concerns, procedure-specific risks, and complications associated with NORA in children.
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Postoperative anaesthetic concerns in children: Postoperative pain, emergence delirium and postoperative nausea and vomiting p. 763
Shikha Mehrotra
The incidence of anaesthetic complications in children is much more than in adults and sometimes with a severe outcome. Patients under one year of age, those with co-morbidities and posted for emergency surgery are at increased risk for morbidities. Sources of information on the risk involved come from institutional audit, closed claim analysis, and large-scale studies of cardiac arrest. A strategy for preventing postoperative nausea and vomiting (PONV), emergence delirium (ED) and postoperative pain should be a part of every anaesthetic plan. A planned multimodal approach should be opted consisting of nonpharmacologic and pharmacologic prophylaxis along with interventions to reduce the baseline risks. The literature in this subject is reviewed extensively to give comprehensive information to postgraduate students about the current understanding of postoperative anaesthetic concerns. Relevant articles from Pub med, review articles, meta-analysis, and editorials were the primary source of information for this article.
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Anaesthetic concerns in preterm and term neonates p. 771
Rajeshwari Subramaniam
Anaesthesia for neonates is a composite of good knowledge of neonatal and transitional physiology combined with skill in airway maintenance and vascular access. When the newborn is a preterm, the complexities of management increase due to the small size and accompanying issues such as bronchopulmonary dysplasia and apnoea. World over, the number of survivors of preterm birth is on the increase. We searched Pubmed for “Anesthesia, apnea, neonatal, neonates, physiology, preterm, spinal anesthesia”, as well as cross references from review articles. These babies have a high incidence of conditions warranting surgery (e.g., tracheoesophaeal fistula, congenital diaphragmatic hernia, anorectal malformations, incarcerated hernia, necrotising enterocolitis). The possibility of neurodevelopmental harm by anaesthetics is currently the topic of active research. In parallel, advances in paediatric anaesthesia equipment, use of regional and neuraxial anaesthesia and availability of monitoring have steadily increased the safety of anaesthesia in these tiny patients.
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