Indian Journal of Anaesthesia  
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   Table of Contents - Current issue
November 2019
Volume 63 | Issue 11
Page Nos. 875-960

Online since Friday, November 8, 2019

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If Oscar the cat could, can't we? – A commentary on intraoperative hypotension – Role of artificial intelligence p. 875
Murali Chakravarthy
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Intraoperative hypotension and its prediction Highly accessed article p. 877
Jaap J Vos, Thomas W L Scheeren
Intraoperative hypotension (IOH) very commonly accompanies general anaesthesia in patients undergoing major surgical procedures. The development of IOH is unwanted, since it is associated with adverse outcomes such as acute kidney injury and myocardial injury, stroke and mortality. Although the definition of IOH is variable, harm starts to occur below a mean arterial pressure (MAP) threshold of 65 mmHg. The odds of adverse outcome increase for increasing duration and/or magnitude of IOH below this threshold, and even short periods of IOH seem to be associated with adverse outcomes. Therefore, reducing the hypotensive burden by predicting and preventing IOH through proactive appropriate treatment may potentially improve patient outcome. In this review article, we summarise the current state of the prediction of IOH by the use of so-called machine-learning algorithms. Machine-learning algorithms that use high-fidelity data from the arterial pressure waveform, may be used to reveal 'traits' that are unseen by the human eye and are associated with the later development of IOH. These algorithms can use large datasets for 'training', and can subsequently be used by clinicians for haemodynamic monitoring and guiding therapy. A first clinically available application, the hypotension prediction index (HPI), is aimed to predict an impending hypotensive event, and additionally, to guide appropriate treatment by calculated secondary variables to asses preload (dynamic preload variables), contractility (dP/dtmax), and afterload (dynamic arterial elastance, Eadyn). In this narrative review, we summarise the current state of the prediction of hypotension using such novel, automated algorithms and we will highlight HPI and the secondary variables provided to identify the probable origin of the (impending) hypotensive event.
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Scalp block for analgesia after craniotomy: A meta-analysis p. 886
Ardyan Wardhana, Sudadi Sudadi
Background and Aims: A previous meta-analysis reported that scalp block had limited benefits (low-quality evidence) compared to no-scalp block modalities for analgesia after craniotomy. However, it included studies using two different pain intensity measurement scales. Therefore, we performed another meta-analysis using a single scale. Methods: We conducted the search for all randomised controlled trials evaluating the effect of scalp block on postcraniotomy pain compared to no-scalp block in Cochrane Central Register of Controlled Trials and PubMed database. We assessed the quality of included studies employing GRADE approach. We performed random-effects inverse-variance weighted meta-analysis of outcomes including pain intensity assessed by a 0--10 visual analog scale and opioid consumption during the first 24 h postoperative period using RevMan 5.3. Results: A total of 10 studies (551 patients) were included. It revealed a statistically significant mean pain intensity reduction in scalp block group when compared to no-scalp block at very early and early 24 h period (seven trials, very low-quality evidence, mean difference (MD) = −1.37, 95% confidence interval (CI): −2.23 to -0.05, I2 = 70%; nine trials, very low-quality evidence, MD = −1.16, 95% CI: −2.09 to −0.24, I2 = 57%, respectively). There was also reduction in the opioid requirements over the first 24 h postoperatively. Conclusion: Scalp block might be useful at <6 h postcraniotomy with very-low quality evidence. Additionally, it had uncertain but moderate effect on reducing total 24 h opioid consumption. Therefore, more studies are needed to reach optimal information size.
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Pre-emptive multimodal analgesic regimen reduces post-operative epidural demand boluses in traumatic shaft of femur fracture - A randomised controlled trial p. 895
Jeetinder K Makkar, Kajal Jain, Aswini Kuberan, Mukilan Balasubramanian, Nidhi Bhatia, Preet M Singh
Background and Aims: The efficacy of preemptive multimodal analgesia in post-traumatic patients has not been elucidated. Our aim was to evaluate the efficacy of preemptive MMA regimen in reducing the epidural demand boluses in the first 48 hours following the traumatic shaft of femur fractures. Methods: Patients scheduled for traumatic femur fracture surgery were randomised (n = 135) into two groups in this double blind, placebo controlled trial. Patients received either (Preemptive multimodal group) intravenous acetaminophen 1 gm, diclofenac 75 mg, morphine 3 mg, 75 mg Pregabalin (per oral) or a placebo 30 minutes pre-operatively. Intra-operatively, all patients were managed with spinal and epidural anaesthesia. Post-operatively, patients received patient-controlled epidural analgesia (PCEA) programmed to deliver a bolus of 5 ml of 0.2% Ropivacaine with 2 μg/ml of Fentanyl with lockout interval time of 15 min. Primary outcome was number of PCEA boluses received post-operatively over 48 h. Secondary outcomes measures were time to receive first epidural bolus, postoperative VAS scores and episodes of post-operative nausea, vomiting and sedation. Total number of PCEA bolus doses over 48 hours and VAS scores were analysed using Mann-Whitney test. Results: Significant reduction in median number of demand boluses were observed in preemptive multimodal group (3 [2-4]) compared to placebo group (5 [4-7]); P = 0.00. Time to first rescue epidural bolus was significantly greater in preemptive multimodal group than placebo group. Conclusion: The use of preemptive MMA regimen reduced the requirement of demand epidural bolus doses.
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Comparative evaluation of i-gel® insertion conditions using dexmedetomidine-propofol versus fentanyl-propofol - A randomised double-blind study p. 900
Preeti Sachin Rustagi, Shalaka Sandeep Nellore, Amala Guru Kudalkar, Rashmi Sawant
Background and Aims: i-gel® insertion necessitates adequate depth of anaesthesia to prevent laryngospasm, gagging or limb movements. We aimed to compare i-gel® insertion conditions with propofol induction after pre-treatment with dexmedetomidine or fentanyl. Methods: Eighty ASAI/II patients undergoing general anaesthesia were randomised into Groups D (n = 40) and F (n = 40). Group D received 1 μg/kg dexmedetomidine over 10 minutes followed by 5ml of 0.9%normal saline (NS) over 2 minutes. Group F received 10 ml of 0.9%NS over 10 minutes followed by fentanyl 1 μg/kg over 2 minutes. Thirty seconds after study drugs, propofol 2 mg/kg was given. Ninety seconds after propofol, i-gel® was inserted. Overall insertion conditions were assessed by Modified Scheme of Lund and Stovener. Heart-rate (HR) and mean arterial pressure (MAP) were noted at baseline, after study drug, propofol induction and 1,3,5,10 minutes after i-gel® insertion. Respiratory rate and apnoea times were recorded. Results: Insertion conditions were comparable between both groups. Moderately relaxed jaw, coughing and movement was observed in more patients of Group F. Incidence of apnoea was significantly higher (P < 0.0001) in group F (18/40) than group D (3/40).Mean duration of apnoea in group F (284.5 ± 11.19 sec) was significantly higher than group D (217.17 ± 16.48 sec). Percentage drop in MAP from baseline after propofol was more in group F (10.3%) than group D (5.6%). MAP after induction was significantly lower in group F compared to group D (P = 0.002), but similar after i-gel® insertion, 1,3,5 and 10 minutes after insertion. After propofol (P = 0.003) and i-gel® insertion (P < 0.001), HR was significantly lower with dexmedetomidine. Conclusion: Dexmedetomidine and fentanyl provide comparable conditions for i-gel® insertion with propofol.
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Evaluation of resident satisfaction and change in knowledge following use of high-fidelity simulation teaching for anaesthesia residents p. 908
S Shailaja, SS Hilda, Prajna A Pinto, Rithesh J D'Cunha, Lulu S Mahmood, Radhesh B Hegde
Background and Aims: Anaesthesia practice demands medical knowledge and skills as essential components for patient management in peri-operative emergencies. Since all residents are not exposed to such situations during their residency, training them using simulation technology could bridge this knowledge and skill gap. The aim of this study was to train and evaluate residents to manage anaesthesia emergencies on high fidelity simulators. Methods: Kirkpatrick model of program evaluation was carried out. Resident reaction was captured using a satisfaction questionnaire and the change in knowledge was assessed using pre-test and post-test Multiple Choice Questions (MCQs). Six scenarios were created and executed on a human patient simulator (HPS). All 22 residents participated in this teaching learning method. The steps of simulation teaching included pre-test, pre-briefing, orientation to manikins, performing/scribe, debriefing, feedback questionnaire, and post-test. The satisfaction questionnaire was administered following the second and fourth scenario. Results: 95% residents agreed on overall satisfaction, that it helps in building team dynamics and clinical reasoning. All students agreed that this teaching had positive professional impact. 14% residents felt they were anxious during the class. The items in the questionnaire had a Cronbach's α value of 0.9. The mean score for pre-test was 24.22 ± 7 (Mean ± SD) and the post-test was 47.18 ± 5.6, the difference between the scores were statistically significant (P = 0.007). Conclusion: The use of high-fidelity simulation to train anaesthesia residents resulted in greater satisfaction scores and improved the residents' reasoning skills.
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Attenuation of haemodynamic responses to laryngoscopy and endotracheal intubation with dexmedetomidine: A comparison between intravenous and intranasal route p. 915
Saikat Niyogi, Asit Biswas, Indrani Chakraborty, Soumya Chakraborty, Amita Acharjee
Background and Aims: Haemodynamic changes during endotracheal intubation are major concerns in general anaesthesia This study compared the efficacy of intranasal and intravenous dexmedetomidine (DEX) to attenuate the stress response of laryngoscopy and endotracheal intubation. Methods: In this prospective, randomised, double-blinded study, 70 adults were divided into two groups [Group DIV (n=35) and Group DIN (n=35)]. DIV group received intravenous dexmedetomidine (DEX) infusion (0.5 μg/kg) over 40 min and DIN group received intranasal dexmedetomidine (1 μg/kg) 40 min before induction. The primary objective was the comparison the mean arterial pressure (MAP) between two groups from 40 min before induction at every 10 min intervals till induction of anaesthesia, at the time of intubation, thereafter every 1 min interval till 5 min, at 7 min and 10 min after intubation. The secondary outcomes were comparison of heart rate, systolic and diastolic blood pressure along with sedation and other adverse effects. Statistical analysis was with Statistica 6.0 and Graph Pad prism version 5. Results: In both the groups, all the haemodynamic parameters were maintained within (20% of baseline values) throughout the study period. There was no statistically significant difference in MAP between two groups (P>0.05). Preoperative sedation score was significantly higher in the DIV group than the DIN group (P = 0.014). Conclusion: Like IV DEX, intranasal DEX can also attenuate the haemodynamic stress responses of laryngoscopy and endotracheal intubation without significant differences in MAP between two groups.
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Preprocedural ultrasound as an adjunct to blind conventional technique for epidural neuraxial blockade in patients undergoing hip or knee joint replacement surgery: A randomised controlled trial p. 924
Kompal Jain, Arun Puri, Rajeev Taneja, Vikky Jaiswal, Anant Jain
Background and Aims: The patients undergoing total knee and hip replacement surgeries are mostly obese, more than 50 years of age with osteophytic spine and spine deformities making the blind conventional technique of regional anaesthesia more difficult. The aim of the study was to compare the role of preprocedural ultrasound scan to conventional blind technique in obese patients with osteophytic spines undergoing total knee or hip replacement surgeries in terms of technical difficulty, clinical efficacy, safety and patient comfort. Methods: A prospective, randomised controlled trial was conducted in which 210 consenting American Society of Anesthesiologists (ASA) grade III patients, age >50 years, Body Mass Index (BMI) ≥30 kg/m2 with osteophytic spines including abnormalities undergoing joint replacement surgeries were randomised in two groups. Ultrasound group (“B”) received Combined Spinal Epidural Anaesthesia (CSEA) after preprocedural lumbar ultrasound scan. In control group (“A”), CSEA was given by blind conventional technique. The primary objective was to compare the rate of successful epidural block on 1st needle insertion attempts in both the groups. The secondary objectives were to compare both groups in terms of ease, success, comfort and safety of epidural block. Results: Ultrasound improved success of CSEA at 1st attempt from 74.3% in control group (“A”) to 85.7% in Ultrasound group (“B”) (P = 0.038). Fewer needle insertion attempts, passes and anaesthesiologist were required in ultrasound group. Pearson correlation coefficient was 0.976 using both views. Conclusion: Preprocedural ultrasound scan is a useful adjunct to lumbar epidural blocks in obese patients with osteophytic abnormal spines.
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Fascia iliaca compartment block: How far does the local anaesthetic spread and is a real time continuous technique feasible in children? p. 932
Vrushali C Ponde, Anuya A Gursale, Dilip N Chavan, Ashok N Johari, Maryrose O Osazuwa, Tripti Nagdev
Background and Aims: The fascia iliaca compartment block (FICB) is commonly administered in children for anterolateral thigh surgery. The actual spread of the local anaesthetic (LA) beneath the fascial layers in children is not known. We hypothesised that in children there could be a possibility of the LA to reach lumbar plexus with the dose we used. Methods: This study included 25 children, aged 1-15 years for lower limb surgeries after standardised general anesthesia, the FICB was done with ultrasonography. Radio-opaque dye was tagged to LA and the fluoroscopic study was performed. The catheter was placed under ultrasonography. The primary objective was to investigate the fluoroscopic demonstration of the extent of LA spread by our technique and drug volume which is not known in children. The secondary objectives were to evaluate the intraoperative and postoperative analgesic efficacy, complications if any, of the continuous FICB catheters placed by our method. Results: In all patients, the visualisation of ilium and iliacus muscle, the fascia iliaca and needle tip was possible. The fluoroscopic imaging showed that the LA did not spread till the lumbar plexus in 20 patients. In 5 patients, delineated the psoas muscle and reached the L4 vertebral level. The analgesia was adequate. In the postoperative period, 92% had sufficient pain relief. Mild soakage was an issue with catheters. Conclusion: Although single shot fascia iliaca compartment block has limited spread of local anaesthetic in children, it is efficacious. Continuous fascia iliaca compartment block is feasible and effective in this age group.
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Anaesthetic management of pacemaker implantation in a child with dilated cardiomyopathy and acquired complete atrioventricular heart block p. 938
Garima Choudhary, Rashmi Syal, Rakesh Kumar, Manoj Kamal
We report a case of an 8-year-old girl who presented with syncopal attacks and a history of viral illness a month ago. On examination, she was conscious, oriented but had a heart rate of 42/min which was unresponsive to atropine. She was started on dobutamine and isoproterenol. Electrocardiography and echocardiography revealed complete heart block with moderate tricuspid regurgitation, dilated cardiomyopathy and low ejection fraction. Patient was planned for urgent permanent pacemaker insertion. General anaesthesia was administered with endotracheal tube and controlled ventilation using fentanyl, ketamine and pancuronium. For patient safety, invasive arterial monitoring was instituted and external pacing was kept standby. Transvenous pacemaker leads were implanted onto the right ventricular wall through the left subclavian vein.
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SponTaneous Respiration using IntraVEnous anaesthesia and Hi-flow nasal oxygen (STRIVE Hi) in tracheal stenting: Experience of ten cases in a regional cancer center p. 941
Sayandeep Mandal, Suparna M Barman, Anshuman Sarkar, Jyotsna Goswami
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Device for centralisation during fibrescope-guided orotracheal intubation. An i-gel® innovation p. 945
Nishant Sahay, Umesh Kumar Bhadani, Ravi Singh
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Knotty Catheter! - An unusual complication of rectus sheath block p. 947
Jeson R Doctor, Sohan Lal Solanki, Sumitra Bakshi
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Anaesthetic management of a child with Varadi–Papp (orofacial digital syndrome type VI) syndrome p. 948
Ramya Ravi, Sandeep Kumar Mishra, Prasanna Udupi Bidkar, Ranjithkumar Sivakumar
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Bypassing trachea-oesophageal fistula during endotracheal intubation for surgical correction: Time to rethink! p. 950
Anju Gupta, KK Girdhar
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Chewing gum, the anaesthesiologist and perioperative checklists p. 951
Tasneem Dhansura, Dhanwanti Rajwade
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Anaesthetic management of a child with Farber's lipogranulomatosis posted for exploratory laparotomy p. 953
Nitin Choudhary, Sonia Wadhawan, Rahil Singh, Poonam Bhadoria
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Scientometrics in medical journals: Indices, their pros and cons p. 955
Abhijit S Nair
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Ultrasound guided bi-level thoracic and lumbar erector spinae plane block as surgical anaesthesia method for inguinal hernia repair in a high-risk patient: Case report p. 957
Tayfun Aydin, Miray Turgut, Onur Balaban
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Fatal pulmonary haemorrhage following repeated intercostal drain insertions: Think before you re-do p. 959
Amit Rastogi, Shantanu Pandey, Ankita Singh, Shashank Tripathi
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