Indian Journal of Anaesthesia  
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   Table of Contents - Current issue
April 2017
Volume 61 | Issue 4
Page Nos. 285-365

Online since Tuesday, April 11, 2017

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'Advances in understanding and management in obstetric anaesthesia': The great myth of our times Highly accessed article p. 285
Edward Johnson
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The parturient in the interventional radiology suite: New frontier in obstetric anaesthesia p. 289
Tasneem Dhansura, Nabila Shaikh
The anaesthesiologist's presence during interventional radiology (IR) is increasing due to increasingly ill patients and intricate procedures. The management of a parturient in IR suite is complex in terms of logistics of an unfamiliar procedure in an unfamiliar area. The literature available is largely written by radiologists with little attention paid to anaesthetic details and considerations. In the Indian scenario, in the absence of hybrid operating rooms (ORs), logistics involve transport of a parturient back and forth between the IR suite and the OR. As members of a multidisciplinary team, anaesthesiologists should utilise their expertise in fluid management, transfusion therapy and critical care to prevent and treat catastrophic events that may accompany severe peri-partum bleeding. Ensuring familiarity with the variety of IR procedures and the peri-procedure requirements can help the anaesthesiologist provide optimum care in the IR suite.
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Changes in cardiac index during labour analgesia: A double-blind randomised controlled trial of epidural versus combined spinal epidural analgesia - A preliminary study p. 295
Stephanie Yacoubian, Corrina M Oxford, Bhavani Shankar Kodali
Background and Aims: Combined spinal-epidural (CSE) analgesia for labour and delivery is occasionally associated with foetal bradycardia. Decreases in cardiac index (CI) and/or uterine hypertonia are implicated as possible aetiological factors. No study has evaluated CI changes following combined spinal analgesia for labour and delivery. This prospective, double-blind, randomised controlled trial evaluates haemodynamic trends during CSE and epidural analgesia for labour. Methods: Twenty-six parturients at term requesting labour analgesia were randomised to receive either epidural (E) or CSE analgesia. The Electrical Cardiometry Monitor ICON® was used to continuously determine maternal CI non-invasively, heart rate (HR) and stroke volume at baseline and up to 60 min after initiation of either intrathecal or epidural analgesia. In addition, maternal systolic blood pressure (SBP) and diastolic blood pressure (DBP) were recorded. Results: Both SBP and DBP had a similar, significant decrease following initiation of either epidural or CSE analgesia. However, parturients in the CSE group (n = 10) demonstrated a significant decrease in HR and CI compared to the baseline measurements. On the other hand, the parturients in the E (n = 13) group showed no decreases in either maternal HR or CI. Foetal heart changes were observed in four patients following CSE and one patient following an epidural. Conclusion: Labour analgesia with CSE is associated with a significant decrease in HR and CI when compared to labour analgesia with epidural analgesia. Further studies are necessary to determine whether a decrease in CI diminishes placental blood flow.
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A clinical comparison between 0.5% levobupivacaine and 0.5% levobupivacaine with dexamethasone 8 mg combination in brachial plexus block by the supraclavicular approach p. 302
Nibedita Pani, Sidharth Sraban Routray, Debasis Mishra, Basant Kumar Pradhan, Bishnu Prasad Mohapatra, Deepti Swain
Background and Aims: Dexamethasone as an adjuvant to bupivacaine for supraclavicular brachial plexus (SCBP) block prolongs motor and sensory blockade. However, the effect of dexamethasone (8 mg) when added to levobupivacaine has not been well studied. This study was conducted to find out analgesic efficacy of dexamethasone as adjuvant to levobupivacaine in SCBP block. Methods: Ultrasound- guided SCBP block was given to sixty patients, randomly assigned into two groups. Group S (thirty patients) received 2 mL normal saline with 25 mL levobupivacaine (0.5%) and Group D (thirty patients) received 2 mL of dexamethasone (8 mg) with 25 mL of levobupivacaine (0.5%), respectively. Time for the first rescue analgesia, number of rescue analgesics required in 24 h and different block characteristics was assessed. Chi-square test and Student's t-test were used for statistical analysis. Results: Time for request of the first rescue analgesia was 396.13 ± 109.42 min in Group S and 705.80 ± 121.46 min in Group D (P < 0.001). The requirement for rescue analgesics was more in Group S when compared to Group D. The onset of sensory and motor block was faster in Group D when compared to Group S. The mean duration of sensory and motor block was significantly longer in Group D than Group S. Conclusion: The addition of dexamethasone to levobupivacaine in SCBP blockade prolonged time for first rescue analgesia and reduced the requirement of rescue analgesics with faster onset and prolonged duration of sensory and motor block.
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Is segmental epidural anaesthesia an optimal technique for patients undergoing percutaneous nephrolithotomy? p. 308
Devangi A Parikh, Geeta A Patkar, Mayur S Ganvir, Ajit Sawant, Bharati A Tendolkar
Background and Aims: Neuraxial anaesthesia has recently become popular for percutaneous nephrolithotomy (PCNL). We conducted a study comparing general anaesthesia (GA) with segmental (T6–T12) epidural anaesthesia (SEA) for PCNL with respect to anaesthesia and surgical characteristics. Methods: Ninety American Society of Anesthesiologists Physical Status-I and II patients undergoing PCNL randomly received either GA or SEA. Overall patient satisfaction was the primary end point. Intraoperative haemodynamics, epidural block characteristics, post-operative pain, time to rescue analgesic, total analgesic consumption, discharge times from post-anaesthesia care unit, surgeon satisfaction scores and stone clearance were secondary end points. Parametric data were analysed by Student's t-test while non-parametric data were compared with Mann–Whitney U-test. Results: Group SEA reported better patient satisfaction (P = 0.005). Patients in group GA had significantly higher heart rates (P = 0.0001) and comparable mean arterial pressures (P = 0.24). Postoperatively, time to first rescue analgesic and total tramadol consumption was higher in Group GA (P = 0.001). Group SEA had lower pain scores (P = 0.001). Time to reach Aldrete's score of 9 was shorter in group SEA (P = 0.0001). The incidence of nausea was higher in group GA (P = 0.001); vomiting rates were comparable (P = 0.15). One patient in group SEA developed bradycardia which was successfully treated. Eight patients (18%) had hypertensive episodes in group GA versus none in group SEA (P = 0.0001). One patient in GA group had pleural injury and was managed with intercostal drain. Stone clearance and post-operative haemoglobin levels were comparable in both groups. Conclusion: PCNL under SEA has a role in selected patients, for short duration surgery and in expert hands.
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Desflurane for ambulatory anaesthesia: A comparison with sevoflurane for recovery profile and airway responses p. 315
Kajal Sachin Dalal, Meghana Vijay Choudhary, Adit Jagdish Palsania, Pratibha Vinayak Toal
Background and Aims: Desflurane and sevoflurane have low blood gas solubility co-efficients, allowing a rapid awakening from anaesthesia. However, desfluraneis pungent and may cause airway irritability. We compared desflurane and sevoflurane with respect to recovery and occurrence of adverse airway responses in spontaneously breathing patients while using the ProSeal™ laryngeal mask airway (LMA). Methods: Ninety-four adult patients undergoing hysteroscopic procedures were divided into sevoflurane (S) group or desflurane (D) group. Patients were premedicated with midazolam 0.03 mg/kg and fentanyl 1μg/kg. Anaesthesia was induced with propofol 2.0–2.5 mg/kg, followed by insertion of a ProSeal™ LMA. Adverse airway responses such as cough, hiccups, laryngospasm and breathholding were recorded. In the post-operative period: time to awakening, response to verbal commands, orientation, ability to sit with support and the recovery room Aldrete score were recorded. Results: Three patients in group S (6.4%) and six patients (13.3%) in Group D had adverse airway events. The mean time to eye opening (Group S-10.75 ± 7.54 min, Group D-4.94 ± 1.74 min), obeying verbal commands (Group S-13.13 ± 8.75 min, Group D-6.55 ± 1.75 min), orientation (Group S-15.42 ± 8.46 min, Group D-6.23 ± 2.4 min) and to sit with support (Group S-36.09 ± 12.68 min, Group D-14.35 ± 3.75 min) were found to be lesser with desflurane than with sevoflurane (P < 0.001). The mean time to recovery was delayed in Group S-46.00 ± 12.86 min compared to Group D-26.44 ± 5.33 min (P < 0.001). Conclusion: Desflurane has faster awakening properties than sevoflurane without an increase in adverse airway events when used during spontaneous ventilation through a ProSeal™ LMA along with propofol and fentanyl.
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A comparative evaluation of Video Stylet and flexible fibre-optic bronchoscope in the performance of intubation in adult patients p. 321
Syed Hussain Amir, Qazi Ehsan Ali, Sonali Bansal
Background and Aims: Video Stylet (VS) is a new intubating modality that provides real-time video of endotracheal intubation (ETI). This device does not need alignment of the oral, pharyngeal and tracheal axes to view glottis and can be used in patients with limited mouth opening. The aim of this study was to compare flexible fibre-optic (FO) bronchoscope with VS in elective surgical patients in apparently normal airway patients requiring oral ETI. Methods: Sixty patients undergoing elective surgery under general anaesthesia of age group 20–60 years, weight 40–70 kg, American Society of Anesthesiologist 1 and 2 and modified Mallampatti I and II were included in the study. Patients in group FO (n = 30) were intubated by flexible FO bronchoscope, whereas patients in group VS (n = 30) were intubated by VS. Primary outcome measure was time taken for intubation (TTI). Secondary outcome measures were successful intubation, haemodynamic response and post-operative complications if any. Results: Average TTI in cases of FO group was 38.2 s (95% confidence interval [CI] 36–41) and in VS group was 19.7 s (95% CI 19–21; P = 0.0001). Three patients required a second attempt for successful intubation in FO group compared to eight in VS group (P = 0.2), with no failures in any group. Haemodynamic response and complications rate were greater in VS group; however, the differences were not statistically significant. Conclusion: VS takes lesser time to intubate than flexible FO bronchoscope.
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Comparative evaluation of Airtraq™ optical Laryngoscope and Miller's blade in paediatric patients undergoing elective surgery requiring tracheal intubation: A randomized, controlled trial p. 326
Bikramjit Das, Arijit Samanta, Subhro Mitra, Shahin Nikhat Jamil
Background and Aims: The Airtraq™ optical laryngoscope is the only marketed videolaryngoscope for paediatric patients besides the fibre-optic bronchoscope. We hypothesized that intubation would be easier with Airtraq™ compared to Miller blade. Hence, we compared Airtraq™ with the Miller laryngoscope as intubation devices in paediatric patients. Methods: This prospective, randomized study was conducted in a tertiary care teaching hospital. Sixty children belonging to American Society of Anesthesiologists' Grade I–II, aged 2–10 years, posted for routine surgery requiring tracheal intubation were randomly allocated to undergo intubation using a Miller (n = 30) or Airtraq™ (n = 30) laryngoscope. The primary outcome measure was time of intubation. We also measured ease of intubation, number of attempts, percentage of glottic opening score (POGO), haemodynamic changes and airway trauma. Student t test was used to analyse parametric data. Results: Intubation time was comparable between Miller's laryngoscope (15.13 ± 1.33s) compared to Airtraq™ (11.53 ± 0.49 s) (P = 0.29) The number of first and second attempts at intubation were 25 and 5 for the Miller laryngoscope and 29 and 1 for the Airtraq™. Median visual analogue score (VAS) for ease of intubation was 5 in Miller group compared to 3 in Airtraq™ group. The median POGO score was 75 in the Miller group and 100 in the Airtraq™ group (P = 0.01). Haemodynamic changes were maximum and most significant immediately and 1 min after intubation. Airway trauma occurred in three patients (9.09%) in Miller group and one patient (3.33%) in Airtraq™ group. Conclusion: The Airtraq™ reduced the difficulty of tracheal intubation and degree of haemodynamic stimulation compared to the Miller laryngoscope in paediatric patients.
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Comparison of Airtraq™, McCoy™ and Macintosh laryngoscopes for endotracheal intubation in patients with cervical spine immobilisation: A randomised clinical trial p. 332
Vinod Hosalli, BK Arjun, Uday Ambi, Shivanand Hulakund
Background and Aims: The study aimed at comparing the performance of the novel optical Airtraq™ laryngoscope with the McCoy™ and conventional Macintosh laryngoscopes for ease of endotracheal intubation in patients with neck immobilisation using manual inline axial cervical spine stabilisation (MIAS) technique. Methods: Ninety consenting American Society of Anaesthesiologist's physical status I–II patients, aged 18–60 years, scheduled for various surgeries requiring tracheal intubation were randomly assigned into three groups of thirty each to undergo intubation with Macintosh, Airtraq™, or McCoy™ laryngoscope with neck immobilisation by MIAS technique. The ease of intubation based on Intubation difficulty scale (IDS) score, Cormack-Lehane grade of glottic view, optimisation manoeuvres and impact on haemodynamic parameters were recorded. Statistical analysis was performed with ANOVA and Bonferroni correction for post hoc tests. Results: All patients in three groups had a comparable demographic profile and were successfully intubated. The Airtraq™ laryngoscope significantly reduced the IDS (mean − 0.43 ± 0.81) as compared with both McCoy™ (mean − 1.63 ± 1.49, P = 0.001) and Macintosh laryngoscope (mean −2.23 ± 1.92, P < 0.001) and improved the Cormack-Lehane glottic view (77% grade 1 view and no patients with grade 3 or 4 view). There were less haemodynamic variations during laryngoscopy with the Airtraq™ compared to the Macintosh laryngoscope, but there was not between the Airtraq™ and McCoy™ laryngoscope groups. Conclusion: In patients undergoing endotracheal intubation with cervical immobilisation, Airtraq™ laryngoscope was superior to the McCoy™ and Macintosh laryngoscopes, with greater ease of intubation and lower impact on haemodynamic variables.
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Comparison of endotracheal intubation time in neutral position between C-Mac® and Airtraq® laryngoscopes: A prospective randomised study p. 338
Syed Moied Ahmed, Kashmiri Doley, Manazir Athar, Nadeem Raza, Obaid Ahmad Siddiqi, Shahna Ali
Background and Aims: In the recent past, many novel devices such as AirTraq®and C-MAC®video laryngoscope (VL) have been introduced in an attempt to reduce anaesthetic morbidity and mortality associated with difficult intubation. In this study, we aimed to evaluate and compare C-MAC®VL with a standard Macintosh blade and the AirTraq®optical laryngoscope as a intubating devices with the patient's head in neutral position. Methods: Sixty American Society of Anesthesiologist Physical Status I–II patients were randomly assigned to be intubated with C-MAC®VL (Group CM; n = 30) or AirTraq® (Group AT; n = 30) in the neutral position, with or without the application of optimization manoeuvres. The primary outcomes of this study were the success rate and the time taken to intubate. Glottic view, ease of tracheal intubation and haemodynamic responses were considered as secondary end points. Results: The incidence of successful intubation was similar in both the groups (P = 1.00). However, the time for intubation was significantly less with C-MAC®VL (Group CM = 14.9 ± 12.89 s, Group AT = 26.3 ± 13.34 s; P = 0.0014). There was no significant difference between the two groups in terms of ease of intubation and glottic view. However, the haemodynamic perturbations were much less with C-MAC®VL. Conclusion: We conclude that both the devices were similar in visualising larynx in the neutral position with similar success rates of intubation. However, the C-MAC®VL was better with respect to intubation time and haemodynamic stability.
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Spinal anaesthesia for a caesarean section in a patient with paraneoplastic cerebellar ataxia p. 344
Ayca Tas Tuna, Fatih Sahin, Dilcan Kotan, Ali Fuat Erdem, Meltem Baykara, Tuba Duzcan
Paraneoplastic cerebellar ataxia (PCA) is most frequently observed in gynaecological cancers, small cell lung cancer, breast cancer, Hodgkin's lymphoma, cancer testis or malignant thymoma. In the literature, there is no data related to the effects of PCA during pregnancy or reports on the effects of anaesthesia in patients with PCA. We present management of a pregnant woman with PCA who was suddenly unable to walk with PCA and for whom effective spinal anaesthesia was performed for an elective caesarean section with no complications.
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Management of an intraoperatively damaged endotracheal tube in a case of difficult airway using fibre-optic bronchoscope with minimal apnoea period p. 347
Jayachandran Himarani, S Mary Nancy, VB Krishna Kumar Raja, S Shanmuga Sundaram
Damage to the endotracheal tube (ETT) is common in head and neck surgeries, especially in maxillary osteotomy. Airway management in such a crisis is crucial as there is risk of aspiration of blood into lungs, hypoxia and apnoea. This case illustrates a patient with an anticipated difficult airway who had an intraoperative damage to the ETT and was successfully managed by re-intubation with fiberoptic bronchoscope in a minimal apnoea period of <15 s using a new technique.
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Fentanyl or ketamine pre-treatment to prevent withdrawal response to rocuronium p. 350
Suchita S Kosare, Nandini M Dave, Madhu Garasia
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Can fluid resuscitation be a risk factor for laryngeal oedema in severe dengue? p. 353
Sai Saran, Afzal Azim
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Perioperative management of a patient with haemophilia-A for major abdominal surgery p. 354
Mamta Sethi, Pavan Gurha
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Failing to learn from the past: Report of a patient with twice failed central venous cannulation p. 356
Udismita Baruah, KK Giridhar
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Maternal patent ductus arteriosus with bidirectional shunt: Obstetric anaesthesia and its challenges p. 357
Karima Karam Khan, Sobia Khan, Mohammad Hamid
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Anaesthetic management of a pregnant woman with preeclampsia and Eisenmenger's syndrome: Role of advanced haemodynamic monitoring p. 359
Muthapillai Senthilnathan, Savitri Velayudhan, Anusha Cherian, Pankaj Kundra
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Asystole during rigid bronchoscopic stenting under general anaesthesia in a patient with tracheo-oesophageal fistula p. 360
Vinod Kumar, Rakesh Garg, Shilpi Agarwal, Karan Madan
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Bilateral quadratus lumborum block for post-caesarean analgesia p. 362
Abhijit Nair
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Quadratus lumborum block for post-caesarean analgesia p. 364
Sukhyanti Kerai, Kirti Nath Saxena
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Lighter Planes p. 365
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