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   Table of Contents - Current issue
September 2020
Volume 64 | Issue 9
Page Nos. 739-829

Online since Tuesday, September 1, 2020

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Striding towards the pinnacles of professional growth, scientific epitome, and leadership: India's women anaesthesiologists Highly accessed article p. 739
Madhuri S Kurdi, Manisha D Katikar, Vanita Ahuja, Ridhima Sharma
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Intraoperative factors contributory to myocardial injury in high-risk patients undergoing abdominal surgery in a South Indian population Highly accessed article p. 743
G Gopan, Lakshmi Kumar, Anjana Rajan Babu, Abish Sudhakar, Rubin George, Vidya P Menon
Background and Aims: Myocardial injury after non-cardiac surgery (MINS) is associated with high postoperative mortality. We sought to examine the intraoperative variables associated with MINS among high-risk patients undergoing abdominal surgery at a South Indian Centre. Methods: A retrospective analysis of patients who underwent abdominal surgery, aged >45 years with one of five factors: hypertension, diabetes mellitus, previous coronary artery disease (CAD), stroke, or peripheral vascular disease or all patients >65 years of age was undertaken. Forty-six patients with raised troponin Group P (Trop I > 0.03 ng/d) were compared with 125 troponin-negative patients Group N (Trop I < 0.012 ng/dL) as well as 51 with intermediate levels Group I (Trop I > 0.012 and < 0.03 ng/dL). We evaluated the association of pre and intraoperative factors on MINS using logistic regression to identify the explanatory variables. Results: Demographics were similar among the three groups. In-hospital mortality was significantly higher in group P (P = 0.005).The use of vasopressors (OR 2.6; 95% CI 1.2–5.5), female gender, (OR 2.3; 95%CI 1.1–4.7), associated CAD (OR 2.8;95% CI 1.1–7.4), and fresh frozen plasma (FFP) transfusion (OR 12.1;95% CI 1.3–11.7) were associated with MINS in regression analysis between group P versus group N. Female gender (OR2.3; 95% CI 1.2–4.5), postoperative mechanical ventilation (OR 3.5; 95% CI 1.2–10.4), and perioperative hypothermia (OR 4.5; 95% CI 1.3–14.9) were significant between Group P and Group I with Group N. Conclusions: Female patients with CAD undergoing abdominal surgery, needing vasopressors and transfusion of plasma are at high risk for MINS with higher hospital mortality and merit vigilant monitoring postoperatively.
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Comparison of postoperative analgesia and opioid requirement with thoracic epidural vs. continuous rectus sheath infusion in midline incision laparotomies under general anaesthesia – A prospective randomised controlled study p. 750
Nandita Gupta, Amit Kumar, Rajesh K Harish, Deepak Jain, Adarsh C Swami
Background and Aims: To assess and compare the effect of bilateral continuous rectus sheath infusion (CRSB) for postoperative analgesia with continuous thoracic epidural infusion (TEA) in patients undergoing midline incision laparotomies. Methods: A prospective, randomised study involving sixty patients with Indian Society of Anesthesiologists (ASA) grade I to III, planned for elective laparotomy were enrolled for the study. Patients were randomly allocated into two groups. In the TEA group, an epidural was sited before induction of general anaesthesia (GA), whereas in the CRSB group, bilateral ultrasound-guided RSB catheters were placed at the end of the surgical procedure, before extubation. Both groups received continuous 0.2% Ropivacaine infusion for postoperative analgesia. They were followed for two post-operative days (POD), for the opioid requirement and post-operative pain at rest, coughing, and moving. Age and body mass index (BMI) were compared using independent t-test and visual analogue scale (VAS) scores were compared by the Mann–Whitney test between the two groups. Opioid consumption, gender, and type of surgery were compared using the Chi-Square test. Statistical analysis was done using Statistical Package for Social Sciences (SPSS 21.0). Results: Opioid consumption in both groups was comparable, for the first two post-operative days with no statistically significant difference. Pain scores were comparable among the groups at all times except postoperative day (POD) 0 (4 h and 12 h postop) and POD 2 (8 AM and 12 PM), where lower pain scores were observed in CRSB Group. Conclusions: As a part of the multimodal analgesia technique, CRSB offers a reliable, safe, and effective alternative to TEA.
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Comparison of recovery characteristics with two different washout techniques of desflurane anaesthesia: A randomised controlled trial p. 756
R Sripriya, Charulatha Ravindran, Ravishankar Murugesan
Background: Rapid emergence with low soluble inhalational agents (IA) is offset by a significant association with emergence agitation (EA). Research on the influence of elimination methods of IA on recovery characteristics is very few. We conducted this study to compare the recovery characteristics of slow elimination (SE) of desflurane with purging technique. Methodology: Forty-five participants, 18–60 years, undergoing elective laparoscopic surgeries were randomised either into Group-P (n = 23) or Group-SE (n = 22). A standardised induction-maintenance protocol including desflurane and fresh gas flow (FGF) of 0.8 l/min was followed. During recovery, the FGF was increased in Group-P to 10 L/min and in Group-SE it was continued at 0.8 L/min. The decrement in end-tidal concentration of desflurane, time for emergence and extubation, EA and time for psychomotor recovery were noted. Results: Time for emergence (Group-SE: 22.8 ± 9 vs. Group-P: 5.6 ± 1.5 min; P = 0.000) and emergence to extubation duration (Group-SE: 128 ± 36 s vs. Group-P: 11.5 ± 1.7 s; P = 0.000) were longer in the Group-SE than in Group-P. EA occurred in 22.7% patients in Group-SE and in 4.3% patients in Group-P (P = 0.07). Psychomotor recovery to baseline values was seen in more number of patients in Group-SE than Group-P at 30 min. There was no difference between the groups at 60 min post-extubation. Conclusions: Slow elimination using FGF of 0.8 L/min significantly prolongs emergence even with low soluble agent like desflurane. SE is not beneficial in decreasing the incidence of EA or hastening psychomotor recovery. Purging technique is, therefore, a better-suited technique with fewer complications for eliminating desflurane.
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The analgesic effect of bilateral ultrasound-guided erector spinae plane block in paediatric lower abdominal surgeries: A randomised, prospective trial p. 762
Swati Singh, Raushan Kumar Jha, Manisha Sharma
Background and Aims: This study aims to evaluate the analgesic effect of ultrasound-guided erector spinae plane block (ESPB) in paediatric lower abdominal surgeries. Methods: Randomised, prospective trial. Forty patients, aged 2–10 years with the American Society of Anesthesiologists Score of I and II scheduled for elective lower abdominal surgery were included in the study. Interventions: Patients were randomised into two groups as control group and ESPB group. Ultrasound-guided erector spinae plane block at L1 vertebral level was performed preoperatively using 0.5 ml/kg 0.25% bupivacaine (max 20 ml) for the patients in ESPB group. Analgesic requirements and time to first analgesic requirement were recorded and Face, Legs, Activity, Cry and Consolability (FLACC) scores for pain were recorded at 0, 1, 2, 3, 6, 12 and 24 h postoperatively. Results: Forty patients were included in the final analyses. Significant difference was determined between the groups on post-operative morphine requirement and FLACC scores at 3 h and 6 h postoperatively (P < 0.05). Significant difference was also determined in time to first dose of rescue analgesia between the groups (P < 0.05). Conclusions: This study shows that the ESPB provides adequate post-operative analgesia in paediatric patients undergoing lower abdominal surgery.
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To compare the analgesic efficacy of two different doses of epidural ketamine in chronic low back-pain patients: A randomised double-blind study p. 768
Ruchi Gupta, Harmandeep Kaur, Shubhdeep Kaur, Lakshmi Mahajan, Tavleen Kaur
Background and Aims: Ketamine, an adjunct to epidural steroid injections (ESI) for chronic back-pain provides better quality and prolonged duration of analgesia. The present study aims to evaluate the analgesic efficacy in terms of pain scores, duration of pain-free period, patient satisfaction score (PSS) and number of repeat injections with 25 mg versus 50 mg ketamine as adjuvants to ESI. Methods: In a prospective, randomised, double-blind trial at a tertiary care hospital, 60 patients of chronic low back-pain of either sex, aged 18–65 years, received preservative free 25 mg ketamine in Group I and 50 mg ketamine in Group II as adjunct to 40 mg triamcinolone in total 6 ml volume given epidurally. Baseline data along with follow-ups at 2, 4, 8 and 12 weeks post-procedure included assessment of pain using Visual Analogue Scale (VAS), duration, number of repeat blocks using PSS, Quality of Life (QoL) and side-effects. Categorical data analysed using the Chi-Square test, and continuous data using paired t-test. Results: Pain evaluation within the groups over time showed significant improvement from baseline (P = 0.000), and between the groups showed comparable VAS scores at 12 weeks (P = 0.392). The PSS, pain-free duration and number of repeat injections were also statistically comparable. However, the QoL improved more in Group II vs Group I (P = 0.024). The short-lasting side effects were more in Group II, but no features of neurotoxicity were observed in any patient. Conclusion: The analgesic efficacy of adjuvant therapy with 50 mg ketamine appeared comparable to 25 mg ketamine. Although, there was a better quality of life and longer pain-free interval with 50 mg ketamine, the side effects were more.
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COVID-19 pandemic: Psychological impact on anaesthesiologists p. 774
Ayushi Jain, Geeta Singariya, Manoj Kamal, Mritunjay Kumar, Ayush Jain, Rajendra Kumar Solanki
Background and Aim: The anaesthesiologists are at the highest risk of contracting infection of coronavirus disease 2019 (COVID-19) in emergency room, operation theatres and intensive care units. This overwhelming situation can make them prone for psychological stress leading to anxiety and insomnia. Materials and Methods We did an online self-administered questionnaire-based observational cross-sectional study amongst anaesthesiologists across India. The objectives were to find out the main causes for anxiety and insomnia in COVID-19 pandemic. Generalised Anxiety Disorder-7 (GAD-7) scale and Insomnia Severity Index (ISI) were used for assessing anxiety and insomnia. Results: Of 512 participants, 74.2% suffered from anxiety and 60.5% suffered from insomnia. The age <35 years, female sex, being married, resident doctors, fear of infection to self or family, fear of salary deductions, increase in working hours, loneliness due to isolation, food and accommodation issues and posting in COVID-19 duty were risk factors for anxiety. ISI scores ≥8 was observed in <35 years, unmarried, those with stress because of COVID-19, fear of loneliness, issues of food and accommodation, increased working hours and with GAD-7 score ≥5. Adjusted odd's ratio of insomnia in participants having GAD-7 score ≥5 was 10.499 (95% confidence interval 6.097–18.080; P < 0.001). Conclusion: The majority of anaesthesiologists on COVID-19 duty suffer from anxiety and insomnia. Addressing risk factors identified during this study with targeted interventions and psychosocial support will help them to cope better with the stress.
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A randomised controlled trial to evaluate the peri-operative role of intraoperative dexmedetomidine infusion in robotic-assisted laparoscopic oncosurgeries p. 784
Sumitra G Bakshi, Susan V Paulin, Pranay Bhawalkar
Background: Robotic and minimal invasive surgeries pose challenges to the anaesthesiologists. Dexmedetomidine (dexmed), with distinct properties of sedation and analgesia has emerged as a promising drug. Our primary aim, in this double-blinded study, was to evaluate reduction in the intraoperative opioid requirement with the use of intravenous dexmed infusion. Secondary objectives included effect on intraoperative anaesthetic and postoperative analgesic requirement. Methodology: After approval from Ethics board and registration of the trial, 46 eligible patients planned for robotic oncosurgeries (abdomen) were included. As per computer generated randomisation chart, patients were randomised into either dexmed or saline group. Five minutes after insufflation of the abdomen, the study drug bolus—saline or dexmed (1 μg/kg) was given over 10 min and was followed by maintenance infusion (0.2 μg/kg/h) until release of pneumoperitoneum. Study drug titration, fentanyl boluses, and changes in minimum alveolar concentration (MAC) of inhalational agent were protocolised. Results: The mean intraoperative fentanyl requirement was significantly lower in the dexmed group 192.6 μg (±66.4) versus the saline group 260.7 μg (±88.6), P = 0.013. The MAC requirement of inhalational agent was significantly lower in the dexmed group. Intraoperative episodes of hypotension and bradycardia were similar in both groups. First analgesic request, 24 h postoperative pain scores and side effects profile were comparable in both groups. Conclusion: Intraoperative dexmed (bolus of 1 μg/kg followed by 0.2 μg/kg/h infusion) has an opioid and inhalational anaesthetic sparing role during robotic oncosurgeries. However, no benefit of the infusion is seen in the postoperative period.
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Evaluation of segmental epidural blockade following standard test dose versus test dose with addition of saline in abdominal surgeries p. 790
Nandhini Joseph, Lakshmi Kumar, P Shyamsundar, Sindhu Balakrishnan, Rajesh Kesavan, Sunil Rajan
Background and Aims: Epidural analgesia is widely used for pain relief but confirmation of accurate epidural placement is poorly understood. We proposed that sensory blockade to cold sensation would predict the accurate placement of epidural. The primary outcome was the assessment of sensory blockade at 5 and 10 min with a standard epidural test dose versus test dose with additional saline. We looked at haemodynamic changes following administration as secondary outcomes. Methods: Following Ethics Committee approval, 161 patients presenting for elective abdominal surgery needing epidural analgesia with general anaesthesia were randomly allocated into Group 1 receiving standard test dose (3 ml of 2% lignocaine with 1:2,00,000 adrenaline) or Group 2 (standard test dose with 6 ml of saline) epidurally. The blockade to cold sensation was assessed at 5 and 10 min. The heart rate (HR), systolic blood pressure (SBP), and mean arterial pressure (MAP) were recorded at baseline, 1, 5, and 10 min following epidural dosing. Statistical analysis was performed with Chi-square test for categorical and Student's t-test for continuous variables. Results: The sensory blockade at 5 min was 69.5% versus 82.3% (P = 0.059), and at 10 min 85.4% versus 97.5% (P = 0.01) in Groups 1 and 2, respectively. The MAP at 5 min (P = 0.032) and the HR and MAP at 10 min (P = 0.015, 0.04) were significantly lower in Group 2. Conclusion: An epidural test dose of 3 ml followed by additional 6 ml saline accurately predicted sensory blockade to cold at 10 min in comparison to the standard dose of 3 ml but was associated with a decrease in the HR and MAP.
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Preparedness to combat COVID-19 via structured online training program regarding specific airway management: A prospective observational study p. 796
Bhavna Gupta, Gaurav Jain, Priyanka Mishra, Sharmishtha Pathak
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The troublesome triumvirate: Temporomandibular joint ankylosis, Pierre Robin syndrome and severe obstructive sleep apnoea p. 800
Akhil Goel, Nandini Dave, Harick Shah, Priyanka Muneshwar
Managing the paediatric airway with a multitude of issues, poses a unique anaesthetic challenge. Thorough understanding of implications of the associated co-morbidities, meticulous planning to counter the anticipated difficulties with back-up plans and optimal utilisation of modern anaesthesia techniques are the cornerstones in ensuring success in such tricky situations.
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Paediatric lumbar paravertebral sonoanatomy: More like a “Dragon fly” than a “Shamrock” p. 804
Nita J Dsouza, Kirthi Priya Mara, Pranita Patil, Sandeep Diwan
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COVID-19: Early detection and timely diagnosis in a neurological setup p. 805
Manisha D Katikar
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Operative procedures performed during SARS-Cov-2 pandemic: Safe for patients and health care workers under appropriate guidelines p. 807
Mona S Jadhav
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Frova saved the day!! p. 809
Priyanka P Karnik, Nandini M Dave, Arpita Ganguly
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Unconventional positioning in severely kyphotic patient for retinal detachment surgery p. 810
Shilpi Sethi, Abhishek Dixit
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Role of percutaneous left stellate ganglion blockade (LSGB) as a rescue therapy in refractory ventricular tachycardia p. 812
Vijitha Burra, Parimala Prasanna Simha, N Manjunath
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Surgeries in asymptomatic carriers during SARS-COV-2 pandemic: Challenges and future p. 814
Snigdha Bellapukonda, Chitta Ranjan Mohanty
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Prolonged relief of chronic pelvic pain by pulsed radiofrequency ablation of superior hypogastric plexus performed under ultrasound guidance: A case report p. 816
Jyotsna Punj, Mesha Srivastava
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A game plan for the safe resumption of preanaesthetic clinic during the coronavirus disease 2019 pandemic p. 818
Vanitha Rajagopalan, Mayank K Tyagi, Surya Kumar Dube, Girija Prasad Rath
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Hypocalcaemia-induced acute exacerbation of bronchial asthma: An unusual cause of a common disorder p. 820
Nidhi Jain, Kamlesh Kumari, Shipra Roy, Rashmi Syal
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Severe metabolic acidosis secondary to iatrogenic hyperglycaemia in secondary cytoreduction and hyperthermic intraperitoneal chemotherapy (HiPEC) p. 821
Sachin Sogal, Priyanka Mishra, Nishith Govil
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Post radiotherapy isolated absence of uvula – Yet another case of indeterminate Mallampati classification? p. 823
Bhavna Gupta, Jyoti Rawat, Kamna Kakkar
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Anaesthetic management of a patient with Montgomery T-tube in situ for T-tube removal p. 825
J Lakshmi, SM Senthil Nathan
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A comment on “Indian Resuscitation Council suggested guidelines for Comprehensive Cardiopulmonary Life Support for suspected or confirmed coronavirus disease patient” p. 827
Paul O Raphael
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Reply to comments on prone CPR for COVID-19 patients p. 828
Baljit Singh, Rakesh Garg, S S C Chakra Rao, Syed Moied Ahmed, JV Divatia, TV Ramakrishnan, Lalit Mehdiratta, Muralidhar Joshi, Naveen Malhotra, Sukhminder Jit Singh Bajwa
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