Indian Journal of Anaesthesia  
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   Table of Contents - Current issue
February 2019
Volume 63 | Issue 2
Page Nos. 81-165

Online since Monday, February 11, 2019

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Intraoperative neurophysiologic monitoring and anaesthetic implications Highly accessed article p. 81
Zulfiqar Ali
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Perioperative anaesthetic concerns in transgender patients: Indian perspective Highly accessed article p. 84
Shagun Bhatia Shah, Puneet Khanna, Rashmi Bhatt, Priyanka Goyal, Rakesh Garg, Rajiv Chawla
Medical care of transgender patients is not only legally bound but also ethically required. Globally, 0.5%–0.9% of the adult population exhibits a gender different from their birth sex, but there is a dearth of transgender-friendly hospitals stemming from ignorance to disdain for this marginalised community. With gradually increasing acceptance of the transgender patients in the society, healthcare professionals must gear up to deal with issues specific and unique to this group of population. These concerns remain important to understand for an optimal perioperative care. The medical concerns transcend international boundaries, whereas legal, social, economic and psychological concerns vary from place to place. There is a need for modification of curriculum and training for healthcare personnel to foster sensitivity and empathy in patient dealing, to allow for an unbiased optimal healthcare. Such patients require a thorough assessment in a comfortable environment considering their specific needs. A plan for perioperative care needs to be done and discussed with the patient and the perioperative care team as well. There is scarce literature with regard to perioperative care in the transgender patients and hence requires more research.
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The effects of propofol and isoflurane on intraoperative motor evoked potentials during spinal cord tumour removal surgery - A prospective randomised trial p. 92
Parthiban Velayutham, Verghese T Cherian, Vedantam Rajshekhar, Krothapalli S Babu
Background and Aims: Transcranial electrical stimulation (TES) elicited intraoperative motor evoked potentials (iMEPs), are suppressed by most anaesthetic agents. This prospective randomised study was carried out to compare the effects of Isoflurane and Propofol on iMEPs during surgery for spinal cord tumours. Methods: A total of 110 patients were randomly divided into two groups. In group P, anaesthesia was maintained with intravenous propofol (6.6 ± 1.5 mg/kg/hr) and in group I anaesthesia was maintained with isoflurane (0.8 ± 0.1% minimal alveolar concentration (MAC). An Oxygen- air mixture (FiO2-0.3) was used in both groups. TES-iMEPs were recorded from tibialis anterior, quadriceps, soleus and external anal sphincter muscles in 60 of 90 patients. Statistical analysis was performed with Pearson correlation and Paired 't' tests. Results: Successful baseline iMEPs were recorded in 74% of patients in Group P and in 50% of patients in Group I. Age and duration of symptoms influenced the elicitation of baseline iMEPs under isoflurane (r = −0.71, −0.66 respectively, P < 0.01) as compared to propofol (r = −0.60, −0.50 respectively, P < 0.01). The mean stimulus strength required to elicit the baseline iMEPs were lesser in propofol (205 ± 55Volts) as compared to isoflurane (274 ± 60 Volts). Suppression of the iMEP responses was less under propofol (7.3%) as compared to isoflurane anaesthesia (11.3%) in patients with no preoperative neurological deficits. Conclusion: iMEPs are better maintained under propofol anaesthesia (6-8 mg/kg/hr) when compared with isoflurane (0.7-0.9 MAC). in patients undergoing surgery for excision of spinal cord tumours.
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Analgesia nociception index and systemic haemodynamics during anaesthetic induction and tracheal intubation: A secondary analysis of a randomised controlled trial p. 100
Kamath Sriganesh, Kaushic A Theerth, Madhusudan Reddy, Dhritiman Chakrabarti, Ganne Sesha Umamaheswara Rao
Background and Aims: Direct laryngoscopy and tracheal intubation is a noxious stimulation that induces significant stress response. Currently, this nociceptive response is assessed mainly by haemodynamic changes. Recently, analgesia nociception index (ANI) is introduced into anaesthesia practice and provides objective information about parasympathetic (low nociceptive stress) and sympathetic (high nociceptive stress) balance, which reflects the degree of intraoperative nociception/analgesia. This study evaluated the changes in ANI and haemodynamics during anaesthetic induction and intubation, and their correlation during tracheal intubation. Methods: Sixty adult patients scheduled for elective brain tumour surgery under general anaesthesia were studied for changes in ANI, heart rate (HR) and mean blood pressure (MBP) during anaesthetic induction and intubation. This was a secondary analysis of a previously published trial. Linear mixed effects model was used to evaluate changes in ANI, HR and MBP and to test correlation between ANI and haemodynamics. Results: Anaesthetic induction reduced ANI (but not below the critical threshold of nociception of 50) and MBP, and increased the HR (P < 0.001). Direct laryngoscopy and tracheal intubation resulted in increase in HR and MBP with decrease in ANI below the threshold of 50 (P < 0.001). A linear negative correlation was observed between ANI and HR; r = −0.405, P < 0.001, and ANI and MBP; r = −0.415, P= 0.001. Conclusion: Significant changes are observed in ANI during anaesthetic induction and intubation. There is a negative linear correlation between ANI and systemic haemodynamics during intubation.
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Comparison of postoperative analgesic efficacy of low-dose bolus intravenous dexmedetomidine and intraperitoneal dexmedetomidine with bupivacaine in patients undergoing laparoscopic cholecystectomy: A randomised, controlled trial p. 106
Geetanjali Tolia Chilkoti, Manish Kumar, Medha Mohta, Ashok Kumar Saxena, Naveen Sharma, Jitender Singh
Background and Aims: Recently, low-dose intravenous (IV) dexmedetomidine has been evaluated for obtunding the pneumoperitoneum-induced haemodynamic changes and its analgesic efficacy in laparoscopic cholecystectomy. The aim was to determine the postoperative analgesic efficacy of low-dose bolus of 0.5 μg/kg dexmedetomidine via IV and intraperitoneal (IP) route in laparoscopic cholecystectomy. Methods: Seventy-five patients, aged 18–60 years of ASA physical status I and II, undergoing laparoscopic cholecystectomy under general anaesthesia were included. Patients in Group C received IP bupivacaine. Patients in Group IV received 0.5 μg/kg dexmedetomidine infusion IV after removal of gall bladder along with IP bupivacaine and Group IP received 0.5 μg/kg dexmedetomidine in 40 mL of 0.25% bupivacaine IP. The primary outcome was 'time to first request of analgesia' and the secondary outcomes were 'total consumption of tramadol in 24 hours,' visual analogue scale (VAS) pain score. Results: In total, 75 patients with 25 in each group were included. Time to first request of analgesia was found to be significantly lower in IV (59.68 ± 71.05 min, P= 0.00) and IP group (90.80 ± 80.46 min, P = 0.001) compared tp Group C (59.68 ± 71.05 min). Mean tramadol consumption in 24 hours (152.40 ± 60.958 vs 137.64 ± 52.40 mg) and mean VAS pain score were comparable in both IV and IP groups in the initial 12 h. Conclusion: Low bolus dose of IP dexmedetomidine is as efficacious as IV dexmedetomidine (0.5 μg/kg) along with IP bupivacaine in laparoscopic cholecystectomy.
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Ultrasonographic assessment of altered anatomical relationship between internal jugular vein and common carotid artery with supraglottic airway in children: LMA vs i-gel™ p. 114
Rakhi Khemka, Sonal Rastogi, Arunangshu Chakraborty, Subir Sinha
Background and Aims: Use of ultrasound (US) during internal jugular vein (IJV) cannulation reduces the risk of associated complications in children under general anaesthesia. We studied the effect of two varieties of supraglottic airway device (SGAD), the Ambu AuraOnce™ LMA (Ambu LMA), and i-gel™ on the anatomical relationship between IJV and common carotid artery (CCA). Both these SGAD are known to have similar safety profile in paediatric age group. Methods: A total of 62 children were randomly allocated into 2 groups. In group L: Ambu AuraOnce™ LMA (Ambu LMA) and in group I: i-gel™ was inserted. After induction of GA, US images were taken with head in neutral and 30 degrees rotated to the opposite side both before and after insertion of SGAD. The relationship between IJV and CCA was noted as lateral, anterolateral, and anterior. Degree of overlap between the two vessels was also noted. Results: Lateral rotation of the head significantly alters the relationship between the IJV and CCA and also increases the degree of overlap between them. Though these changes were noted to be similar with both varieties of SGAD, but between the two varieties of SGAD, these changes were significantly higher in group I. Conclusion: Higher oesophageal sealing pressure exerted by i-gel™ as compared to other SGAD might cause increased distortion of the surrounding soft tissue leading to altered anatomical relationship between IJV and CCA, which makes the CCA vulnerable to puncture during IJV cannulation using landmark technique.
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Predicting packed red blood cell transfusion in living donor liver transplantation: A retrospective analysis p. 119
Shweta A Singh, Kelika Prakash, Sandeep Sharma, An Anil, Viniyendra Pamecha, Guresh Kumar, Ajeet Bhadoria
Background and Aims: Blood transfusion is unpredictable in liver transplantation and is associated with increased patient morbidity, mortality and cost. This retrospective analysis was conducted to detect factors which could predict intraoperative transfusion of more than four units of packed red blood cells (PRBCs) during elective living donor liver transplantation (LDLT). Methods: This was a single-centre retrospective study. Demographic, clinical and intraoperative data of 258 adult patients who underwent LDLT from March 2009 to January 2015 were analysed. Univariate and multivariate regression model was used to identify factors responsible for transfusion of more than four PRBCs (defined as massive transfusion [MT]). Results: On univariate regression analysis, preoperative factors like aetiology of liver disease, hypertension, history of spontaneous bacterial peritonitis, low haemoglobin and fibrinogen, high serum bilirubin, high blood urea and creatinine, high model for end-stage liver disease score, portal venous thrombosis, increased duration of surgery and anhepatic phase as well as increased use of other blood products were found to be significantly associated with MT. Multivariate logistic regression analysis revealed that the only independent factor associated with MT was the number of units of fresh frozen plasma transfused (odds ratio = 1.54 [95% CI (1.12–2.12)]). Conclusion: Many factors are responsible for the need for transfusion during LDLT. Preoperative factors alone do not accurately and consistently predict the need for MT as in our study. It is important to be prepared for need for MT during each transplant.
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Low-dose S+ ketamine in target-controlled intravenous anaesthesia with remifentanil and propofol for open gynaecological surgery: A randomised controlled trial p. 126
Farida Binte Ithnin, Daryl Jian An Tan, Xue Lian Xu, Chin How Tan, Rehena Sultana, Ban Leong Sng
Background and Aims: Using remifentanil–propofol target-controlled infusion (TCI) in open gynaecological surgeries could be associated with opioid-induced hyperalgesia postoperatively. This study's aim was to investigate the effect of low-dose S-ketamine compared with control on cumulative morphine consumption 24 h postoperatively in women undergoing open abdominal hysterectomy with remifentanil–propofol TCI technique. Methods: Ninety female patients above 21 years old who underwent elective open abdominal hysterectomy under general anaesthesia with remifentanil–propofol TCI were recruited. They were randomised to receive either normal saline as control (n = 44) or 0.25 mg/kg intravenous boluses of S-ketamine before skin incision and after complete removal of uterus (n = 45). The primary outcome measure was cumulative morphine consumption measured over 24 h postoperatively. The secondary outcome measures were incidences of opioid-related and psychotomimetic side effects, pain and level of sedation scores. Results: The cumulative 24-h morphine consumption postoperatively (P = 0.0547) did not differ between both the groups. S-ketamine group had slower emergence from general anaesthesia (P = 0.0308) and lower pain scores (P = 0.0359) 15 min postoperatively. Sedation level, common opioid-related side effects (nausea, vomiting, pruritus), respiratory depression and psychotomimetic side effects were similar between both the study groups. Conclusion: Low-dose S-ketamine did not reduce the total cumulative morphine consumption in patients undergoing major open gynaecological surgeries with remifentanil–propofol TCI.
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Perioperative management of cytoreductive surgery and hyperthermic intraoperative thoraco-abdominal chemotherapy (HITAC) for pseudomyxoma peritonei p. 134
Sohan Lal Solanki, Jhanvi S Bajaj, Febin Rahman, Avanish P Saklani
Peritoneal carcinomatosis is intraperitoneal spread of gastrointestinal and gynaecological cancers. Cytoreductive surgeries and hyperthermic intraperitoneal chemotherapy offers survival benefits in these cases. Spread of peritoneal carcinomatosis to thorax pose challenges to surgeon and anaesthesiologist. Haemodynamic, temperature and coagulopathy monitoring as well as intraoperative airway pressure, pre- and postoperative pulmonary function test monitoring is required in these cases where diaphragm excision is done and intraoperative intra peritoneal as well as pleural chemotherapy is given. We are reporting a case of pseudomyxoma peritonei involving the abdomen and left side of pleura and lung, posted for cytoreductive surgery and hyperthemic chemotherapy to abdomen and thorax, i.e., hyperthemic intraoperative thoraco-abdominal chemotherapy.
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Optic nerve sheath diameter-guided extubation plan in obese patients undergoing robotic pelvic surgery in steep Trendelenburg position: A report of three cases p. 138

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Monitoring intraoperative motor-evoked potentials in a pregnant patient p. 142
Nitin Manohar, Astha Palan, Ravi Kumar Manchala, ST Manjunath
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Correlation between skin-epidural space diatance with weight, age, and height in paediatric patients p. 143
Apeksha Parekh, Raylene Dias, Nandini Dave
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Laryngoscopic view in a child with previous difficult tracheal intubation and a history of growth hormone therapy p. 147
Shinichiro Kira, Chiharu Arai, Keisuke Shiihara, Kentaro Okuda
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Anaesthetic management of bilateral temporomandibular joint ankylosis with cervical spine fusion for total alloplastic joint replacement in a patient with ankylosing spondylitis p. 148
Saurav , Shalendra Singh, S Kiran, Alok Jaiswal
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Unseen complication of the exhausted soda lime Highly accessed article p. 150
Deepak Dwivedi, Saurabh Sud, Sadhan Sawhney, Shyam P Panjiyar
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Anaesthesia for tracheal reconstruction – Neither a dilemma nor a catastrophe p. 152
Vaijayanti Nitin Gadre, Deoshree Bal Ramteke, Sushila Ramkishan Yadav, Esmat Gulamraza Mundrawala
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Recurrent transient episodes of left bundle branch block immediately following surgery – A rare phenomenon p. 153
Siddharth Chavali, Gyaninder P Singh, Hemanshu Prabhakar, Arvind Chaturvedi
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Robotic pyeloplasty in an infant: Minimal access surgery with minimal ‘access’ to the patient p. 155
Mridul Dhar, T Mageshwaran, Yashwant S Payal, Ankit Agarwal
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Displaced paediatric central venous catheter causing extravasation of intravenous fluid due to relatively longer gap between the distal and proximal lumens p. 157
Nishith Govil, Mridul Dhar, Kesari Masaipeta, Intezar Ahmed
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Gastric ultrasound as an aspiration risk assessment tool p. 160
P Van de Putte, L Vernieuwe, L Bouvet
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Gastric ultrasound as a point of care tool p. 162
Garima Sharma, Subramanyam Mahankali
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Effectiveness of standard fasting guidelines as assessed by gastric ultrasound examination: A clinical audit p. 164
Sadhvi Sharma, Alka S Deo, Padmalatha Raman
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Erratum: Optic nerve sheath diameter-guided extubation plan in obese patients undergoing robotic pelvic surgery in steep Trendelenburg position: A report of three cases p. 165

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