Indian Journal of Anaesthesia  
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   Table of Contents - Current issue
April 2020
Volume 64 | Issue 4
Page Nos. 259-351

Online since Saturday, March 28, 2020

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Indian society of anaesthesiologists (ISA national) advisory and position statement regarding COVID-19 Highly accessed article p. 259
Naveen Malhotra, Muralidhar Joshi, Rashmi Datta, Sukhminder Jit Singh Bajwa, Lalit Mehdiratta
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Ensuring practical feasibility and sustainability of research work: Need of the hour p. 264
Sukhminder Jit Singh Bajwa, Lalit Mehdiratta
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Peri-operative and critical care concerns in coronavirus pandemic Highly accessed article p. 267
Sukhminder Jit Singh Bajwa, Rashi Sarna, Chashamjot Bawa, Lalit Mehdiratta
World Health Organization (WHO) declared novel coronavirus outbreak a “pandemic” on March 11th, 2020. India has already reached Stage 2 (local transmission) and the Indian Government, in collaboration with the Indian Council of Medical Research (ICMR), is taking all necessary steps to halt the community transmission(Stage 3). Anaesthesiologists and intensivists around the globe are making untiring efforts akin to soldiers at the final frontier during war. All efforts pertaining to adequate staffing, Personal Protective Equipment (PPE) and strict adherence to hand hygiene measures are being stressed upon to prevent in-hospital transmission. In this article, all outbreak response measures including triaging, preparation of isolation rooms, decontamination and disinfection protocols as well as fundamental principles of critical care and anaesthetic management in Covid-19 cases is being discussed. All the recommendations have been derived from the past experiences of SARS (Severe Acute Respiratory Syndrome) and MERS (Middle East Respiratory Syndrome) outbreak as well as upcoming guidelines from the international health fraternity and Indian Health Services.
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Critical language during an airway emergency: Time to rethink terminology? p. 275
Sheila Nainan Myatra, Apeksh Patwa, Jigeeshu Vasishtha Divatia
Clear language should be used during emergency airway management to aid communication and understand the nature of the emergency. Unfortunately, during emergency airway management, there is no uniform language used for communication. Various difficult airway guidelines use different terminologies. Terminologies like “can't intubate, can't oxygenate” (CICO) and “can't intubate, can't ventilate” (CICV) have certain limitations. Though terminology like “Front of Neck Access” (FONA) is dominant in the literature,”emergency cricothyroidotomy” is used more often in clinical practice, suggesting a disconnect between the dominant terminology in the literature and in clinical practice. Terminology should not be used merely because it is catchy, simple and advocated by a few. It must accurately reflect the nature of the situation, convey a sense of urgency, and suggest an action sequence. An initiative to achieve consensus among existing terminologies is much needed. Leaders in the field should work towards refining airway terminology and replace poor phrases with ones that are more concise, precise and can be used universally in an airway emergency.
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A randomised evaluation of intercostal block as an adjunct to epidural analgesia for post-thoracotomy pain p. 280
Priya Ranganathan, Asharab Tadvi, Sabita Jiwnani, George Karimundackal, CS Pramesh
Background and Aims: Post-thoracotomy pain can be severe and disabling. The aim of this study was to examine the efficacy of intercostal nerve block when used as adjunct to thoracic epidural analgesia in patients undergoing posterolateral thoracotomy. Methods: This was a parallel-group randomised patient and assessor-blinded study carried out at a tertiary-referral cancer center. We included 60 adult patients undergoing elective lung resection under general anaesthesia with thoracic epidural analgesia. In addition, the intervention arm received single-shot intercostal blocks with 10 ml of 0.25% bupivacaine at the level of and two levels above and below the thoracotomy. We assessed post-operative pain scores at 2 to 4 hours and 18 to 24 hours after surgery, peri-operative fentanyl requirement, percentage of patients who needed fentanyl PCA and maximum volume achieved on bedside spirometry 18 to 24 hours after surgery. Groups were compared using the unpaired t-test for continuous data and the chi square test for categorical data at a 5% level of significance. Results: 2 to 4 hours post-operatively, mean pain scores at rest were 3.0 in both groups (difference 0.04, 95% CI -1.1 to + 1.1) and on coughing were 4.6 (ICB group) and 4.9 (C group) (difference 0.32, 95% CI -1.0 to + 1.6). There were no differences between the groups for any of the other outcomes. Conclusion: Addition of intercostal block to epidural analgesia does not confer any benefit in terms of post-operative pain, fentanyl requirements or volume achieved on spirometry.
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Correlation between thromboelastography and rotational thromboelastometry values in adult liver transplant recipients p. 286
Shweta A Singh, Gopi Krishnan, Hashir Ashraf, Rajkumar Subramanian, Vijaykant Pandey, Vaibhav K Nasa, Sumit Goyal, Subhash Gupta
Background and Aims: Viscoelastic haemostatic assays (VHA) namely Thromboelastogram (TEG) and Rotational thromboelastometry (ROTEM) are used for global assessment of coagulopathy and guiding transfusion during living donor liver transplant (LDLT).We conducted a study to compare the interchangeability of the values obtained from these devices in patients with End stage liver disease (ESLD) undergoing LDLT. Methods: In 76 patients undergoing LDLT, ROTEM and TEG were performed and assessed for interchangeability using Spearman Correlation. The direction and strength of correlation between equivalent parameters was calculated using Inter Class Correlation (ICC) and Bland Altman analysis. Results: The correlation ρ between CT (clotting time) of ROTEM and R of TEG was 0.16 (P = 0.19).The ICC was 0.15, with 95% confidence interval (CI) of -0.38-0.48 (P = 0.25).The ρ of CFT (ROTEM) with K (TEG) was 0.425 (P=<0.001).The ICC was0.49 with 95% CI of 0.17-0.69, P = 0.003.Alpha of ROTEM correlated with Angle of TEG with ρ of 0.475 (P=<0.001). The ICC was 0.61, with 95% CI of 0.36-0.76, P=<0.001.Maximum Clot firmness (MCF) correlated with maximum amplitude (MA) with ρ=0.76 (P=<0.001).The ICC was 0.86, with 95% CI of 0.77-0.92, P=<0.001. Lysis index (L30) of ROTEM correlated clot lysis (CL30) of TEG with ρ of 0.16 (P = 0.18).However, the ICC was 0.45, with 95% CI of 0.11-0.66, P = 0.08.The correlation between CT of ROTEM and R of TEG as well as L30 of ROTEM and CL30 of TEG was not significant.The strongest correlation was found between MCF and MA (P < 0.001).However the MCF/MA showed an agreement of only 86% (ICC = 0.86). Conclusion: Values from ROTEM and TEG were not found to be interchangeable.
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Supraclavicular or infraclavicular subclavian vein: Which way to go- A prospective randomized controlled trial comparing catheterization dynamics using ultrasound guidance p. 292
Ram Prasad, Shikha Soni, Sarita Janweja, Jogendra S Rajpurohit, Ram Nivas, Jagdish Kumar
Background and Aims: Subclavian vein (SCV) catheterization via the supraclavicular (SSV) or infraclavicular (ISV) approaches under real time ultrasonographic (USG) guidance is being performed routinely in critically ill patients in ICU.The aim of this study is comparative evaluation of SSV and ISV approaches in terms of success rate, time taken and incidence of complications. Settings and Design: In this prospective study, 110 critically ill patients were randomly divided into two groups of 55 each. Right SCV catheterization was performed using real time USG by single experienced operator. Methods: Success rate, first attempt success rate, time taken for venous visualization, puncture, catheterization, total procedure, incidence of mechanical, and infectious complications were variables used for comparison among groups. Statistical Analysis Used: Normality tests were performed using the Kolmogorov-Smirnov test. All data are expressed as the mean (SD), number (%), or median [interquartile range (IQR)] as indicated. Data were compared using the ρ2 test, the Mann–Whitney U-test, Fisher's exact test and Student's t-test as appropriate. Results: Total procedural time was significantly lesser in SSV group than ISV group (P < 0.0001). Time for visualization, puncture and catheterization were significantly higher in ISV group (P < 0.001). Success rate was 100% in both groups. First attempt success rate was more in SSV (P = 0.171).Two incidence of malposition was found in ISV group. Infectious complications were comparable in both groups. Conclusions: Real time USG-guided supraclavicular subclavian approach is a viable and preferable alternative with significantly lesser total procedural time, similar success rate, fewer attempts, faster and lesser complication rates as compared with infraclavicular approach.
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Development, validation and evaluation of a novel self-instructional module in patients with chronic non-specific low back pain p. 299
Babita Ghai, Kapil Gudala, Mir M Asrar, Neha Chanana, Raju Kanukula, Dipika Bansal
Background: Low back pain (LBP) is ranked highest in terms of disability-adjusted life-years lived. Patient education and self-management have shown to play a crucial role in the overall pain management. However, the literature on the same with respect to Indian context is still lacking. The study was aimed to develop, validate and assess the acceptability and effectiveness of self-instructional educational module among Indian chronic LBP (CLBP) patients. Methods: A prospective single-arm open-label study was conducted in a pain clinic of a tertiary care public hospital in North India with 'Backcare booklet-self-instructional module (SIM)' as an intervention in patients with CLBP. SIM was developed with the intent to provide up-to-date evidence-based information in an easy understanding way to patients with CLBP. 132 patients were administered SIM with a single session of verbal explanation. Pain intensity (numeric rating scale [NRS]), disability, fear-avoidance belief Questionnaire (FABQ), quality of life (EQ5D) and knowledge level were assessed at baseline and after 3 months of intervention. Student's paired t-test and Chi-square test were used. Data were analysed using SPSS version 15.0. Results: 120 patients successfully completed the 3 months' follow-up. Significant reductions were observed in pain intensity (76[12] vs 55 [15, P < 0.01); disability (51[14] vs 43 [10], P < 0.01); FABQ (46[12] vs 41 [10], P < 0.01); EQ5D (0.35 [0.27] vs 0.18 [0.26], P < 0.01). Conclusion: Backcare booklet as an intervention, along with usual pharmacological care is a cost-effective educational medium to promote self-management of CLBP in the clinical outpatient settings.
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Awareness of safety protocols for prevention of needle stick injuries in anaesthesiologists from Maharashtra: A survey study p. 306
Shilpi Yadav, Varsha Vyas, Shruti Hazari, RP Gehdoo, Surekha Patil
Background and Aim: Needle stick injury (NSI) has a serious risk of transmission of various blood borne pathogens amongst healthcare personnel and more so in anaesthesiologists. This survey assessed the prevalence of NSI and awareness of safety protocols for its prevention amongst the anaesthesiologists from Maharashtra, India. Methods: This self-administered survey was completed by 403 anaesthesiologists across Maharashtra from August 2019 to October 2019. The pre-validated and pretested 18-item questionnaire was administered using Google forms and the link was circulated amongst anaesthesiologists electronically. The questionnaire items included information on the awareness of safety protocols and immediate measure after NSI, knowledge of immunisation and safety practices followed in routine practice. Data were collected, tabulated and coded in Microsoft Excel. Descriptives are presented for the different items and prevalence of NSI. Comparison of prevalence of NSI in subgroups based on gender, period of experience and type of practice were analysed using Chi-square test. Results: The prevalence of NSI was 73.7% (n = 403) in anaesthesiologists with 71.1% (n = 235) in males and 77.4% (n = 168) in females. The anaesthesiologists from the medical schools had a prevalence of 75.0% (n = 148), those in private practice had a prevalence of 72.7% (n = 216), whereas those working in both medical school and private practice had a prevalence of 74.4% (n = 39). A greater prevalence was observed in those working for longer periods. Conclusion: The prevalence of NSI's is alarmingly high amongst anaesthesiologists and there is an immediate need of creating awareness and practice safety protocols in routine practice. Training and education are required in the formative years of healthcare curriculum.
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Evaluation of magnesium as an adjuvant to ropivacaine-induced axillary brachial plexus block: A prospective, randomised, double-blind study p. 310
Jyoti P Deshpande, Kalyani N Patil
Background and Aims: Axillary brachial plexus block is commonly performed for surgeries on the hand and forearm. However, there are very few studies on the use of magnesium sulphate in axillary brachial plexus block and, hence, the study was designed to evaluate magnesium as an adjuvant to ropivacaine-induced axillary block with respect to onset and duration of sensorimotor block and postoperative analgesia. Methods: Sixty patients of the American Society of Anesthesiologists (ASA) physical status I and II, undergoing surgeries on the hand and forearm were randomly recruited to receive ultrasound-guided axillary block with either 150 mg magnesium sulphate or 1 mL normal saline added to 0.5% ropivacaine. The primary outcome measure was to compare block characteristics including postoperative analgesia and the secondary outcome was to compare the use of rescue analgesia and the side-effect profile. Data were statistically analysed using Statistical Package for Social Sciences (SPSS version 21.0). Categorical variables were compared using the Chi-square test or Fisher's exact probability test; continuous variables compared using unpaired t-test or Mann-Whitney U test. Results: Onset of sensory (9.93 ± 1.31 vs 8.83 ± 1.12 min) as well as motor block (13.37 ± 1.63 vs 11.57 ± 1.30 min) was significantly hastened with addition of magnesium to ropivacaine (p < 0.001) and so was the duration (sensory 386.60 ± 18.26 vs 526.37 ± 27.43, motor 323.73 ± 15.17 vs 436.97 ± 18.99 min) (p < 0.001) and postoperative analgesia (425 ± 21.39 vs 572.83 ± 32.04 min) (p < 0.001) which reflected in decreased requirement of rescue analgesic and total postoperative analgesic dosage. Conclusions: Magnesium is an effective and safe adjuvant to local anaesthetics and improves all characteristics of axillary brachial plexus block along with postoperative analgesia.
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Comparison of perioperative patient comfort with 'enhanced recovery after surgery (ERAS) approach' versus 'traditional approach' for elective laparoscopic cholecystectomy p. 316
Madhumita Udayasankar, Sandesh Udupi, Anitha Shenoy
Background: Perioperative anxiety, hunger, thirst, fatigue, pain along with nausea and vomiting can influence a patient's recovery after surgery. We aimed to compare 'enhanced recovery after surgery' (ERAS) protocol with a traditional perioperative approach to evaluate a patient's recovery after elective laparoscopic cholecystectomy. Methods: A prospective randomised controlled study was conducted after institutional ethical clearance on 50 patients undergoing elective laparoscopic cholecystectomy, and divided equally into two groups. In group 1 (traditional); standard fasting guidelines and routine perioperative management was implemented. In group 2 (ERAS); patients received appropriate multimedia information about surgery and anaesthesia besidecarbohydrate loading with tender coconut water on the previous night and on the morning of surgery. Standard guidelines of fasting for solids were followed. Intraoperatively, goal-directed fluid therapy and an inspired oxygen concentration of 60% were administered. Postoperatively, early diet and mobilisation were initiated. The primary outcome was the assessment of perioperative anxiety. Hunger, thirst, fatigue, pain, nausea, vomiting and overall perioperative experience were also evaluated. Results: ERAS group had reduced anxiety prior to surgery: median (interquartile range) 3 (3–4) vs 2 (2–3) (P = 0.003), and at 6 h postoperatively: 4 (3–6) vs 3 (1–4) (P = 0.001). Hunger, thirst and fatigue (P < 0.01) were also decreased with better overall perioperative experience (5 [4–5] vs 6 [5–7], P = 0.004). Pain, nausea, vomiting and blood glucose were similar between the groups. Conclusion:'ERAS approach reduces anxiety in addition to hunger, thirst and fatigue with enhanced overall perioperative comfort in patients undergoing laparoscopic cholecystectomy.
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Anaesthesia concerns and perioperative management in a child with DiGeorge syndrome with corrected tetralogy of Fallot with pulmonary atresia posted for laparoscopic orchidopexy: Case report p. 322
Natasha Kale, Sandip Katkade, Hemant Mehta, Shivaprakash Krishnanaik
DiGeorge syndrome is afflicted with multiple congenital anomalies such as conotruncal and craniofacial anomaly, immune system dysfunction and hypoplasia/aplasia of parathyroid glands. Laparoscopy is a preferred surgical approach over open orchidopexy due to better visualisation of impalpable testis avoiding long incision, minimal tissue damage and a faster recovery. We report a case of DiGeorge syndrome with corrected tetralogy of Fallot with pulmonary atresia in a 1-year-old male child posted for laparoscopic orchidopexy. The anaesthesiologists face unique challenges due to the multisystem involvement and the effects of laparoscopic surgery on multiple organs. Thorough understanding of DiGeorge syndrome is essential for a good perioperative outcome.
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Dental procedure under opioid-free balanced anaesthesia in a child with Rett syndrome who convulsed on every attempt to feed: Case report p. 325
Vrushali Ponde, Ankit Desai, Karthic Ekambaram, Selabh Thakur
Rett syndrome is a genetic neurodevelopmental disorder which occurs in females and includes autism, spasticity, hypotonia, microcephaly, scoliosis, stereotyping, abnormal respiratory control and seizures. They are at an increased predisposition for QT interval prolongation and cardiac arrhythmias. An 8-year-old severely intellectually impaired girl with Rett syndrome was referred to us for anaesthesia for multiple dental abscess drainage and rehabilitation. Her frequency of convulsions had increased and she convulsed every time an attempt was made to feed her. The pain of chewing exacerbated the convulsions. The cornerstone of our management was to provide adequate pain relief, anaesthesia without muscle relaxant and opioids, and judicious use of local anaesthetics. We discuss the anaesthetic management and its advantages and limitations in this case report.
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Erector spinae plane block for breast oncological procedure as a surrogate to general anaesthesia: A retrospective study p. 328
Aman Malawat, Durga Jethava, Sudhir Sachdev, Dharam Das Jethava
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Air pollution: A new challenge for anaesthesiologists! p. 333
Soumya Sarkar, Puneet Khanna, Rakesh Garg
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Anaesthetic management and considerations in a patient with chronic dicyclomine addiction p. 338
P Prabakaran, Megha Gupta, Praveen Talawar, Mridul Dhar
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Post traumatic recurrent ventricular tachycardia in intensive care unit: It's time not to give up p. 339
Mohit Mittal, Shalvi Mahajan
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Venous air embolism during air arthrogram of hip in an infant with arthrogryposes multiplex congenita p. 341
Chetan Mehra, Balaji Pallapotu
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Non-operating room anaesthesia and difficult airway management in a case of ectopic lingual thyroid planned for magnetic resonance imaging p. 343
Rishabh Agarwal, Atif Khan, Mridul Dhar
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Medical adhesive-related skin injuries caused by taping of the eye using acrylic-based adhesive tapes in prone surgery: A case report p. 345
Summit Bloria, Rajeev Chauhan, Ankur Luthra, Pallavi Bloria
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Use of a pre-injection technique to identify neural elements in the costoclavicular space for brachial plexus block for upper limb orthopaedic surgery p. 347
Srinivasan Parthasarathy, Ratnasamy Surya
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”Neurogenic stunned myocardium”: A rare but real possibility in a paediatric patient p. 348
M Sindhupriya, Prashanth A Menon, M Radhakrishnan, K Mathangi
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Comments on published article p. 351
Nandini Dave, Kiran Kranappu
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