Indian Journal of Anaesthesia  
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   Table of Contents - Current issue
July 2020
Volume 64 | Issue 7
Page Nos. 551-648

Online since Wednesday, July 1, 2020

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The ten essential “T's” imparting impetus to research in anaesthesiology Highly accessed article p. 551
Sukhminder Jit Singh Bajwa, Nishant Kumar, Lalit Mehdiratta
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Perioperative fasting and feeding in adults, obstetric, paediatric and bariatric population: Practice Guidelines from the Indian Society of Anaesthesiologists Highly accessed article p. 556
Pradeep A Dongare, S Bala Bhaskar, SS Harsoor, Rakesh Garg, Sudheesh Kannan, Umesh Goneppanavar, Zulfiqar Ali, Ramachandran Gopinath, Jayashree Sood, Kalaivani Mani, Pradeep Bhatia, Priyanka Rohatgi, Rekha Das, Santu Ghosh, Subramanyam S Mahankali, Sukhminder Jit Singh Bajwa, Sunanda Gupta, Sunil T Pandya, Venkatesh H Keshavan, Muralidhar Joshi, Naveen Malhotra
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Retrospective analysis of patients with severe maternal morbidity receiving anaesthesia services using 'WHO near miss approach' and the applicability of maternal severity score as a predictor of maternal outcome p. 585
Jyoti Sandeep Magar, Preeti Sachin Rustagi, Anila D Malde
Background and Aims: Risk stratification of severely morbid obstetric patients receiving anaesthesia services can be helpful in improving maternal outcomes. This study was undertaken to analyse these patients using the WHO near-miss (NM) approach and to assess the applicability of maternal severity score (MSS) to predict maternal mortality. Methodology: This is a one-year retrospective cohort analysis at a tertiary care centre. Of all the obstetric patients receiving anaesthesia, those with 'potentially life-threatening conditions' (PLTC) were identified. Amongst women with PLTC, those fulfilling the WHO NM criteria were grouped into either maternal near miss (MNM) or maternal death (MD) depending on final survival outcome. The MSS was assessed upon admission to post-anaesthesia ICU. The cases of “near miss” were compared to maternal death to determine the factors and WHO NM criteria significantly associated with mortality. Area under ROC curve (AUROC) was used to assess the accuracy of MSS to predict maternal mortality. Results: Of the 4351 anaesthetised obstetric patients, 301 were PLTC, 59 MNM and 11 MD. Obstetric haemorrhage was the commonest PLTC with the highest risk for MNM and MD. Preoperative organ dysfunction, referral from other centres, intra-uterine fetal death (IUFD) and WHO cardiovascular and respiratory NM criteria were significantly associated with mortality. MSS had excellent accuracy for the prediction of mortality (AUROC was 0.986 and 95% CI 0.966–0.996). Conclusion: Haemorrhage is the leading cause of MNM and MD. MSS is reliable in stratifying the severity of maternal morbidity and in predicting maternal mortality. Thus it can be used as an effective prognostic tool.
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Thoracolumbar curve and Cobb angle in determining spread of spinal anesthesia in Scoliosis. An observational prospective pilot study p. 594
Girija K Ballarapu, Srinivasa R Nallam, Aloka Samantaray, V A Kiran Kumar, Aditya P Reddy
Background and Aims: Disparity in spread of spinal anesthesia is a known complication in scoliosis patients. Our primary aim was to compare this disparity based on Cobb Angle and thorocolumbar spine curvature. Secondary aim was to calculate the appropriate lateral angulation of the spinal needle from midline for successful lumbar puncture. Materials and Methods: All poliomyelitis patients with scoliosis posted for lower limb orthopedic contracture release surgeries were enrolled into Group A (Cobb Angle <50°), Group B (Cobb Angle >50°), and on thoracolumbar curve into Group R (Right), Group L (Left). Group A, B, R, and L were studied for bilateral spread of spinal anaesthesia. Lateral angle of the spinal needle from midline was noted with Goniometer in groups A and B. Statistical analysis was done using unpaired t test and Chi-square test. Results: Failures in subarachnoid block (SAB) (unilateral anaesthesia/inadequate/patchy block) was significant in Group B (P = 0.033). Segmental disparity in bilateral spread of spinal anaesthesia was significant in Group R with P value of 0.042. Approximate lateral angle for needle in Group A was (4.1 ± 2.45) and in Group B was (9.14 ± 2.45). Conclusions: The study showed that there was a strong correlation between right-sided thoracolumbar curve and the spread of spinal anesthesia
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Effect of liberal versus restrictive fluid therapy on intraoperative lactate levels in robot- assisted colorectal surgery p. 599
Lakshmi Kumar, Kalyan Kumar, Sai Sandhya, Deepa M Koshy, Kruthika P Ramamurthi, Sunil Rajan
Background and Aims: Minimally invasive and robotic surgeries need lesser fluid replacement but the role of restricted fluids in robotic surgeries other than prostatic surgeries has not been clearly defined. Our primary aim was to evaluate the effects of a restrictive fluid regimen versus a liberal policy on intra-operative lactate in robotic colorectal surgery. Secondary outcomes were need for vasopressors, extubation on table, post-operative renal functions and length of ICU (LOICU) stay. Methods: American society of anaesthesiologists (ASA) physical status I–II patients scheduled for robot-assisted colorectal surgery were randomised into one of two groups, receiving either 2 mL/kg/h (Group R) or 4mL/kg/h, (group L). Fluid boluses of 250 ml were administered if mean arterial pressure (MAP) <65 mmHg or urine output <0.5 ml/kg/h. Norepinephrine was added for the blood pressure after 2 fluid boluses. Surgical field was assessed by modified Boezaart's scale and surgeon satisfaction by Likert scale. Results: Demographics and baseline renal functions were comparable. Adjusted intra-operative lactate at 2 h, 4 h, and 6 h and need for noradrenaline and post-operative creatinine were similar. One patient in the group L was ventilated due to hypothermia. The field was better at the 4 h in group R and comparable at other time points. The LOICU stay was longer in Group L. Conclusion: The use of restrictive fluid strategy of 2 mL/kg/h (group R) does not increase lactate levels or creatinine, improves surgical field at 4 h and shortens ICU stay in comparison to a liberal 4 mL/kg/h (group L) in robotic colorectal surgery.
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Efficacy of ultrasound guided quadratus lumborum block as postoperative analgesia in renal transplantation recipients: A randomised double blind clinical study p. 605
Gaurav Sindwani, Sandeep Sahu, Aditi Suri, Sanjoy Sureka, Manu Thomas
Background and Aims: Postoperative pain following renal transplantation is moderate to severe. Quadratus lumborum block (QLB) is a new block that can provide effective analgesia following abdominal and retroperitoneal surgeries. This study aimed to evaluate the analgesic efficacy of QLB for postoperative analgesia in patients undergoing renal transplantation. Methods: Patients were randomised into two groups of 30 each. In group A (block group), 20 mL of 0.25% bupivacaine and group B (placebo group), 20 mLof normal saline were injected. In the postoperative room, an intravenous patient controlled analgesia (IVPCA) pump with fentanyl was started in both the group. The postoperatively recorded parameters were numerical rating scale (NRS) pain score at rest and on movement and coughing, total fentanyl consumption, sedation score, postoperative nausea vomiting, limb weakness, paralytic ileus, and any other block-related complication. Data were analysed using SPSS software version 22.0. Categorical data were analysed using the Chi-square method. Student t test or Mann–Whitney U test was applied for the continuous data. Numerical data with normal distribution were displayed as mean (standard deviation), abnormal distribution was displayed in the median (interquartile range) values, and as a percentage for categorical variables. Results: Fentanyl consumption, numerical rating score, and sedation score were significantly less in group A when compared to group B at 1, 4, 8, 12, and 24 h (P < 0.001). Conclusion: Type-1 QLB significantly reduces fentanyl consumption and NRS pain score at 1,4,8,12, and 24 h in the postoperative period in renal transplant recipients.
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Total intravenous anaesthesia with tumescent infiltration anaesthesia without definitive airway for early excision and skin grafting in a major burn - A prospective observational study p. 611
Sweta V Salgaonkar, Nisha M Jain, Sachin P Pawar
Background and Aims: Patients with major burns posted for early tangential excision and skin grafting pose peculiar challenges for anaesthesiologists. The purpose of the study was to assess safety and efficacy of total intravenous anaesthesia (TIVA) with tumescent infiltration anaesthesia (TIA) for these burn procedures. Methods: This observational single-arm study was conducted on 48 cases of a tertiary centre burn unit, requiring early tangential excision and skin grafting between third and fifth days of burn injury. TIVA was administered using a combination of intravenous (iv) infusion of injection dexmedetomidine and iv boluses of fentanyl, ketamine, propofol, midazolam and paracetamol. TIA was administered in burn wounds after aseptic preparation. Spontaneous breathing was maintained with oxygen supplementation. Haemodynamic and respiratory monitoring was done intraoperatively every 15 minutes and for 6 hours postoperatively. Modified Aldrete's score was calculated at 10 minutes after completion of surgery. Statistical analysis was done using statistical package for the social science software (version 16). Descriptive statistics were used for quantitative variables. Results: Baseline mean HR was 106.95 ± 11.17 bpm (beats per minute). HR settled at 73.17 ± 6.97 bpm during the intraoperative period. The baseline mean arterial pressure (MAP) of 82.42 ± 10.04 mmHg was maintained at 81 ± 7.32 mmHg during the intraoperative period. In all, 95.8% achieved early recovery with mean modified Aldrete's score of ≥9 at 10 minutes post-surgery. There was no episode of apnoea or desaturation. Conclusion: TIVA in combination with TIA minimally interferes with homeostasis and promotes early recovery in patients undergoing early excision and grafting in major burns.
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A prospective randomised trial to compare three insertion techniques for i-gel™ placement: Standard, reverse, and rotation p. 618
Mamta Bhardwaj, Suresh K Singhal, Rashmi , Amit Dahiya
Background and Aims: This prospective randomised study was done to compare standard, reverse, and rotation techniques of i-gel™ placement in terms of insertion characteristics and success rate. Material and Methods: After institutional ethics committee approval, 135 patients aged 18-50 years, ASA I and II undergoing elective surgery under general anesthesia were included. After induction of anesthesia, i-gel™ was inserted by standard, reverse, and rotation technique in Groups I, II, and III, respectively. The primary objective was mean time of insertion. Secondary variables included ease of insertion, first attempt success rate, manoeuvres required, fiberoptic view of placement, oropharyngeal leak pressure, ease of placement of nasogastric tube, and complications if any. Results: Mean time of insertion was 18.04 ± 5.65 s, 15.00 ± 5.72 s and 16.12 ± 5.84 s for groups I, II, and III, respectively. Time taken for insertion was shortest and significantly lower (P = 0.048) for group II compared to group I. Insertion time was comparable between rest of groups. The overall success rate in groups I, II, and III were 91.1%, 95.6%, and 93.3% respectively (P = 0.7). The first attempt success rate was 82.2%, 89%, and 84.4% in groups I, II and III, respectively (P = 0.07). Manoeuvres were required in five (12.19%) patients in group I, four (9.30%) patients in group II, and three (7.14%) patients in group III (P = 0.602). Complications occurred in eight, three, and three patients in groups I, II, and III, respectively. Conclusion: All techniques of i-gel insertion are equally good and choice of technique depends upon the experience and comfort of the investigator with the particular technique.
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A cadaver study of four approaches of ultrasound-guided infraclavicular brachial plexus block p. 624
Vijayalakshmi Sivapurapu, Ravindra R Bhat, N Isai Vani, Joseph I Raajesh, S Aruna, Deepak T Paulose
Background and Aims: The ultrasound-guided infraclavicular brachial plexus block (USG ICBPB) is a popular technique for forearm surgeries distal to the elbow. Our study details the ultrasound (US) characteristics of this block and the structures encountered by the needle in four approaches to the infraclavicular area – lateral infraclavicular (LICF), costoclavicular medial to lateral (CML) and lateral to medial (CLM) and retroclavicular (R) by anatomical dissection. Methods: USG ICBPB was performed in 10 cadavers—5 on the right side and 5 on the left side by each of four approaches and with an 18 gauge Tuohy needle kept in situ, and US characteristics were noted. Anatomical dissection was done and important structures were described in detail. Results: Needle tip and shaft visibility were least with LICF approach and best in R approach. Needle angle correlated with chest and neck circumference in LICF and CML groups. During dissection, in all approaches, neurovascular structures have been observed in the near vicinity of the needle, especially the thoracoacromial artery (TAA) or its branches. In the R approach, the 'blind spot' behind the clavicle is an area where neurovascular structures were present. Conclusion: The R approach gives better visibility of needle shaft beyond the clavicle, but the clavicle acts as a 'blind-spot' for the US beam obliterating important neurovascular structures. The various neurovascular structures the needle traverses or in its immediate vicinity, do not necessarily make the CML, CLM or R approach any better than the LICF approach.
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Measurement of non-invasive blood pressure in lateral decubitus position under general anaesthesia — Which arm gives more accurate BP in relation to invasive BP - dependent or non-dependent arm? p. 631
Anju S Thomas, Ranjith K Moorthy, Krishnaprabhu Raju, Jeyaseelan Lakshmanan, Melvin Joy, Ramamani Mariappan
Background and Aims: Non-invasive blood pressure (NiBP) varies with the arm and body position. In the lateral decubitus position (LDP), the non-dependent arm reads lower, and the dependent arm reads higher pressure. We aimed to study the correlation between the NiBP and invasive arterial blood pressure (ABP) as anaesthesia progressed and its correlation in different BP ranges. Methods: American Society of Anesthesiologists (ASA I–III) patients, between 18–70 years undergoing neurosurgical procedures in the LDP were studied. All were anaesthetised using a standard protocol, positioned in the LDP. NiBP was measured every 15 min in both dependent and non-dependent arms and correlated with the ABP. Results: Intra-class correlation (ICC) done between the dependent arm NiBP and ABP showed good correlation for mean and systolic BP and moderate correlation for diastolic BP. ICC was 0.800, 0.846 and 0.818 for mean and 0.771, 0.782, 0.792 for systolic BP at 15 min, 1 h, and 2 h, respectively. The ICC between the non-dependent arm NiBP and the invasive ABP showed poor correlation for all BP (systolic, diastolic and mean). As anaesthesia progressed, the mean difference between the NiBP and the ABP decreased in the dependent arm and increased in the non-dependent arm. The strength of agreement between the NiBP and the ABP in various BP ranges showed moderate correlation for the dependent arm NiBP (0.45–0.54) and poor correlation (0.21–0.38) for the non-dependent arm. Conclusion: The NiBP of the dependent arm correlated well with ABP in LDP under general anaesthesia (GA). It is better to defer measuring NiBP in the non-dependent arm as the correlation with ABP is poor.
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Ultrasound-guided continuous costoclavicular brachial plexus block p. 637
Poonam Kumari, Amarjeet Kumar, Chandni Sinha, Ajeet Kumar
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Combined pericapsular nerve group and lateral femoral cutaneous nerve blocks for surgical anaesthesia in hip arthroscopy p. 638
Praveen Talawar, Shipra Tandon, DK Tripathy, Ashutosh Kaushal
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Systemic amyloidosis: A challenge to the anaesthesiologists p. 640
Kalyani M Rapeti, Manoj Kamal, Bharat Paliwal, Deepak Modi
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Flavoured hookah and perioperative risk: Evil goes global p. 642
Amit Goyal, Sriganesh Kamath, Kumari Pallavi, Mathangi Krishnakumar
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Commentary regarding 'Looped suction catheter in an i-gel™; something to worry about or much ado about nothing?' p. 645
Manbir Kaur, Rakesh Kumar
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ERAS approach and perioperative patient comfort: A closer look! p. 647
Brajesh Kaushal, Rohan Magoon
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