Indian Journal of Anaesthesia  
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   Table of Contents - Current issue
Coverpage
Dec 2018
Volume 62 | Issue 12
Page Nos. 927-1010

Online since Monday, December 10, 2018

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EDITORIAL  

Does my septic patient have scurvy? p. 927
Subhash Kumar Todi
DOI:10.4103/ija.IJA_795_18  
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SPECIAL ARTICLE Top

The Pre-Conception and Pre-Natal Diagnostic Techniques Act and its implication on advancement of ultrasound in anaesthesiology; time to change mindsets rather than laws p. 930
Mridul Dhar, Yashwant S Payal, Vamshi Krishna
DOI:10.4103/ija.IJA_518_18  
Ultrasonography (USG) has a continuously expanding role in anaesthesiology, critical care and pain management and has enhanced and refined patient care. The Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act was established to counter the persistent problem of female foeticide in India. This unique problem which seems to be rooted in our social structure has indirectly impeded the evolution of USG as a widespread tool in medicine in our country. This brief review is aimed at highlighting the expanding role of USG in anaesthesia practice and training, nuances of the PCPNDT act and its implications on the growth and management of ultrasound technology in anaesthesia, in India.
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ORIGINAL ARTICLES Top

Hydrocortisone, Vitamin C and thiamine for the treatment of sepsis and septic shock following cardiac surgery p. 934
Mahesh Balakrishnan, Hemang Gandhi, Komal Shah, Himani Pandya, Ramesh Patel, Sunny Keshwani, Nikhil Yadav
DOI:10.4103/ija.IJA_361_18  
Background and Aims: The effect of vitamin C on vasopressor requirement in critically ill patients have been evaluated previously. We aimed to evaluate the effect of vitamin C, hydrocortisone and thiamine on vasopressor requirement and mortality in post-operative adult cardiac surgical patients with septic shock. Methods: About 24 patients with septic shock were randomised into Group 1 (receiving matching placebo per day for 4 days) and Group 2 (receiving 6 g vitamin C, 400 mg thiamine and 200 mg hydrocortisone per day for 4 days). Vasopressor dose over 4 days of therapy was the primary endpoint, whereas in-hospital mortality was the secondary endpoint. Results: APACHE IV and EUROSCORE II scores were similar between both the groups. Significant reductions in the requirement of vasopressin (difference from day 1 – 0.0008 ± 0.00289 vs 0.0033 ± 0.00492 units/kg/min; P = 0.019) and noradrenaline (difference from day 1 – 0.0283 ± 0.040 vs 0.023 ± 0.035 μg/kg/min; P = 0.006) were observed with vitamin C treatment as compared to control group. PCT levels on Day 3 (68.11 ± 33.64 vs 33.2 ± 27.55 ng/mL; P = 0.0161) and Day 4 (70.03 ± 29.74 vs 26.3 ± 23.08 ng/mL; P = 0.0009) were significantly lower in treatment group as compared to control. However, there was no difference in the Sepsis-Related Organ Failure Assessment (SOFA) score and mortality between the studied groups. Conclusion: Combination of vitamin C, thiamine and hydrocortisone reduces vasopressor requirement in adult cardiac surgical patients with septic shock.
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Obstetric admissions to tertiary level intensive care unit – Prevalence, clinical characteristics and outcomes p. 940
Chris Maria Joseph, Gaurav Bhatia, Valsamma Abraham, Tapasya Dhar
DOI:10.4103/ija.IJA_537_18  
Background and Aims: Obstetric admissions to the intensive care unit (ICU) are a subject of increasing interest, as it is an indirect indicator of maternal morbidity and mortality. The studies from areas reported to have a higher maternal mortality rate are lacking. Thus, we undertook this study to determine the prevalence pattern, clinical characteristics and outcome of obstetric patients admitted to the ICU of a tertiary care hospital. Methods: All obstetric patients (up till 42 days of delivery) admitted to the ICU from 1st October 2015 to 30th September 2016 and from 1st October 2010 to 30th September 2015 were included. Data collected for our study included demographic characteristics, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score at the time of admission, obstetric and medical history, provisional diagnosis, the reason for ICU admission, interventions required in ICU and the outcome. Results: The third trimester (46.79%) and postpartum period (40.37%) were the most common time of admission with conditions such as severe pre-eclampsia, eclampsia, HELLP syndrome (Haemolysis, elevated liver enzymes, low platelet count), antepartum haemorrhage, postpartum haemorrhage and anaemia. The mean APACHE II score was 16.89 ± 7.48 with a mortality rate of 17.76%. The mean length of stay in ICU was 3.47 ± 3.16 days, and mean length of stay in our hospital was 8.78 ± 6.76 days Conclusion: Obstetric patients recover well if treated early. A good ICU care with monitoring can save a young productive life.
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An observational prospective study of performance of acromioaxillosuprasternal notch index in predicting difficult visualisation of the larynx p. 945
Tejwant Rajkhowa, Priyam Saikia, Deepjyoti Das
DOI:10.4103/ija.IJA_480_18  
Background and Aims: Bedside screening test for predicting difficult intubation is an accepted practice, even though its clinical value remains limited. This study aimed to study the predicting value of acromioaxillosuprasternal notch index (AASI) for difficult visualisation of the larynx (DVL). Methods: After Hospital Ethical Committee approval, 440 consecutive consenting adult non-obstetric patients were included in this study. AASI, modified Mallampati class (MMT), sternomental distance (SMD), thyromental distance (TMD) and inter incisor distance (IID) were evaluated preoperatively by trained personnel. Visualisation of larynx was graded according to Cormack–Lehane grading, with grade III and IV being considered as DVL. The cut-off values for prediction of DVL were defined a priori. Direct laryngoscopy was carried out by qualified anaesthesiologists blinded to the results of the airway predictors under evaluation. Primary outcome variable was AASI as a predictor of DVL. Comparing DVL with MMT, SMD, TMD and IID were secondary objectives. Results: DVL was observed in 3.6% [95% confidence interval (1.9–5.4%)] patients. We observed that sensitivity, specificity and Area Under Curve i.e., AUC (95% confidence interval) of ROC of AASI was 81.25 (53.69-95.03), 96.7 (94.39-98.11) and 0.890 (0.777-1.000) respectively. AUC of AASI was found to better than MMT, SMD, TMD and IID. Conclusion: AASI (≥0.5) is a good predictor of difficult visualisation of the larynx at direct laryngoscopy.
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Endovascular treatment of acute ischaemic stroke under conscious sedation: Predictors of poor outcomes p. 951
Umeshkumar Athiraman, Arbi Ben Abdallah, Akash Kansagra, Rene Tempelhoff
DOI:10.4103/ija.IJA_487_18  
Background and Aims: Though, many practitioners prefer conscious sedation (CS), it is unclear which factors most influence neurological outcome following mechanical thrombectomy under CS. The aim of this retrospective study is to identify these factors. Methods: After institutional review board approval, data were collected for the patients >18 years of age who underwent endovascular treatment of AIS under CS at our comprehensive stroke centre between January 2009 and June 2015. The primary outcome measure was the modified Rankin Scale (mRS) at discharge. A good outcome was defined as mRS 0–3 and poor outcome as mRS 4–6. Univariate and logistic regression analysis were performed to identify the independent predictors of poor outcomes at discharge. A P < 0.05 was considered statistically significant. Results: One hundred two patients, aged 67 ± 16 years were included. The anterior cerebral circulation was affected in 88 patients (86%), and the median National Institute of Health Stroke Scale (NIHSS) score at presentation was 17.5 (range: 1–36). Overall, 21 (21%) patients had good outcome and 81 (79%) had poor outcome. Logistic regression identified the modified treatment in cerebral ischaemia (mTICI) score [odds ratio (OR): 0.443, confidence interval (CI): 0.244–0.805], NIHSS score (OR: 1.290, CI: 1.125–1.481) and previous transient ischaemic attack (TIA) (OR: 6.988, CI: 1.342–36.380) as significant independent predictors of poor outcome at discharge. Conclusion: The outcome of patients who underwent endovascular treatment of AIS under CS depends on the mTICI score, NIHSS score and history of previous TIA.
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Effect of premedication with oral midazolam on preoperative anxiety in children with history of previous surgery – A prospective study p. 958
Pulak Priyadarshi Padhi, Neerja Bhardwaj, Sandhya Yaddanapudi
DOI:10.4103/ija.IJA_529_18  
Background and Aims: History of previous surgery may be a risk factor for high preoperative anxiety. The most commonly used technique to reduce preoperative anxiety is oral midazolam premedication because of its safety profile. The aim of this study was to compare the anxiety after premedication in children with a history of previous surgery and those without a history of previous surgery. Methods: A prospective study was conducted in children aged 4–10 years scheduled for surgery under general anaesthesia. Thirty-five children with a history of previous surgery and 35 children without any history of previous surgery were enrolled. Anxiety was assessed using modified Yale Preoperative Anxiety Scale (mYPAS) before and 20 min after premedication with oral midazolam. Anxiety during parental separation and mask acceptance during induction of anaesthesia was assessed using 4-point scale. mYPAS scores were compared using Mann–Whitney U-test, and the incidence of satisfactory parental separation and mask acceptance was compared using χ2 test. Results: The median (interquartile range) anxiety scores after premedication were statistically similar (P = 0.74) in children without a history of previous surgery [31.7 (23.3–40.8)] and in those with a history of previous surgery [33.3 (28.3–47.5)]. Baseline anxiety scores were comparable in the two groups. A high percentage of children in both the groups had a satisfactory parental separation and mask acceptance score. Conclusion: Anxiety scores after premedication with midazolam were similar in children with history of previous anaesthesia exposure and those experiencing anaesthesia for the first time.
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Impact of preoperative pulmonary arterial hypertension on early and late outcomes in patients undergoing valve surgery for rheumatic heart disease p. 963
Deepak Prakash Borde, Balaji Asegaonkar, Sujit Khade, Manish Puranik, Antony George, Shreedhar Joshi
DOI:10.4103/ija.IJA_374_18  
Background and Aims: There is conflicting evidence on adverse effect of Pulmonary Arterial Hypertension (PAH) on outcomes after cardiac surgery for rheumatic heart disease (RHD). The authors studied Indian patients with RHD and preoperative PAH, who undergo cardiac surgery with a hypothesis that they have poor short and long-term outcomes. Methods: This was a retrospective observational study of 407 patients. The patients were divided in three groups based on PAH estimated on echocardiograph as; no or mild PAH (pulmonary artery systolic pressure (PASP) <30 mm of Hg); moderate PAH (PASP 31-55 mm of Hg) and severe PAH (PASP >55 mm of Hg). The primary endpoint was in-hospital mortality and major morbidities; while secondary endpoint was long-term survival. Results: In-hospital mortality was 24 (5.9%); and was not different in patients with severe, (9.1%), moderate (4.5%) or mild PAH (2.8%) (P = 0.09). Patients with severe PAH had higher incidence of prolonged ventilation (P = 0.007). Factors independently associated with mortality were; >2-packed cell transfusion, prolonged ventilation and acute kidney injury but not moderate and severe PAH. Patients with mitral stenosis (MS) and severe PAH had significantly higher mortality as compared to no or mild PAH (P = 0.03) on long-term follow-up [81.37% (mean duration 19.40 ± 14.10 months)], mortality was 8% and not statistically different (P = 0.25) across PAH categories. Conclusion: Moderate and severe PAH does not affect short and long term outcomes of patients undergoing valve surgery for RHD. Patients with MS with severe PAH had higher mortality compared to those with no PAH.
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Sphenopalatine ganglion block for treatment of post-dural puncture headache in obstetric patients: An observational study p. 972
Nitu Puthenveettil, Sunil Rajan, Anish Mohan, Jerry Paul, Lakshmi Kumar
DOI:10.4103/ija.IJA_443_18  
Background and Aims: Post-dural puncture headache (PDPH) is a consequence of spinal and epidural anaesthesia in approximately 1% of obstetric patients. The gold standard for its treatment is epidural blood patch. Sphenopalatine ganglion block (SPGB) has been proposed as a non-invasive intervention with minimal adverse effect. The primary objective of this study was to assess the efficacy of SPGB for treatment of PDPH. Secondary objectives were to assess onset of analgesia, duration of block and adverse effects. Methods: Twenty parturients diagnosed to have PDPH, resistant to standard treatment modalities such as intravenous fluids, abdominal binder, bed rest and caffeine, were recruited into this prospective observational study. Patients were allocated to either of the two groups. Group A patients received paracetamol 1 g 8 hourly intravenously for a day. If adequate pain relief was not achieved, diclofenac 75 mg 12 hourly was added. Patients in group B received SPGB with 2% lignocaine. Fisher's exact test, Mann–Whitney test and independent sample t-test were used for statistical analysis. Results: About 88.89% patients in group B had adequate pain relief within 5 min of block (P < 0.001). Pain was significantly lower in Group B for up to 8 h, with no adverse effects. Conclusion: SPGB is an effective initial modality for managing severe headache in patients with PDPH.
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Correlation between ultrasound-guided subglottic diameter and little finger breadth with the outer diameter of the endotracheal tube in paediatric patients – A prospective observational study p. 978
MAN Rajasekhar, Srilata Moningi, Sujatha Patnaik, Prasad Rao
DOI:10.4103/ija.IJA_545_18  
Background and Aims: Selection of an appropriate endotracheal tube (ETT) in paediatric patients is a challenging situation. The purpose of this study was to compare whether measurement of subglottic diameter with ultrasound or the age-old little finger width correlates better with the outer diameter (OD) of the ETT used for intubation. Methods: Following approval from the Institutional Ethics board and a written informed consent from parent or guardian, this prospective observational study was carried out on 60 American Society of Anesthesiologists physical status I and II patients aged 6 months–8 years, scheduled for elective surgery under general anaesthesia requiring oral endotracheal intubation. Preoperatively ultrasound-guided subglottic diameter (USGD) and little finger breadth (LFB) measurements were taken. On the day of surgery, intubation was done with an uncuffed ETT, whose OD was noted. The concordance and agreeability between two techniques for estimation of the OD of the ETT were measured by Lin's concordance correlation coefficient. Further, the bias and precision between the techniques and the inter-changeability of the techniques were assessed by using Bland and Altman and Mountain plotting, respectively. Results: Lin's concordance correlation coefficient between USGD and LFB with the OD of the ETT was found to be 0.29 (0.13–0.41) and 0.46 (0.29–0.6), respectively. Conclusion: Overall, neither USGD nor LFB can be used as a reliable tool to predict the OD of the ETT. Registered in Clinical Trial Registry of India. REF/2016/08/011955.
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CASE REPORTS Top

Intractable brain swelling during cerebral arteriovenous malformation surgery due to contralateral acute subdural haematoma p. 984
Ankur Khandelwal, Arvind Chaturvedi, Gyaninder Pal Singh, Rajeeb Kumar Mishra
DOI:10.4103/ija.IJA_491_18  
Severe brain swelling during routine neurosurgery can herald serious consequences. Failure to control brain swelling despite adequate measures warns of a surgical cause and should be dealt efficiently. We report a case of an adult female who developed intraoperative acute subdural haematoma (SDH) and consequent intractable brain swelling during surgery of supratentorial arteriovenous malformation (AVM). Such a manifestation of contralateral acute SDH during supratentorial AVM surgery has not been reported earlier.
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Reverse stress cardiomyopathy post-liver transplant needing mechanical circulatory support p. 988
Rakesh V Reddy, Sanjay Agarwal, Vinod Choudhary, Amit K Singhal
DOI:10.4103/ija.IJA_402_18  
A 39-year-old female patient with hepatitis B-related decompensated chronic liver disease underwent living donor liver transplantation. Preoperatively, she had a normal electrocardiogram (ECG) and echocardiography, and also a negative dobutamine stress echocardiography test. Intraoperative course went uneventful. Two hours postoperatively, she developed hypotension. Initially, hypotension was treated with fluids and blood products after confirming normal echocardiography, but with time, patient's haemodynamics worsened. Repeat echocardiography showed postero-inferior regional wall motion abnormality. Troponin I was significantly elevated, but ECG was normal. Suspecting myocardial infarction coronary angiography was done which was normal. Based on Mayo's criteria, patient was diagnosed with reverse Takotsubo cardiomyopathy since postero-inferior wall was involved. Inotropic support failed to maintain haemodynamics and intra-aortic balloon pump (IABP) was placed. Inotropes were gradually tapered and IABP was removed at day 4. Twenty days later, repeat echocardiography was normal and patient was subsequently discharged.
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BRIEF COMMUNICATIONS Top

Survey of change in practice following simulation-based training in crisis management p. 991
Priyanka Pavithran, MC Rajesh, K Rekha, Binu Sajid
DOI:10.4103/ija.IJA_121_18  
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Publications in high impact journals from India in the last two years–A reality check p. 994
Summit Dev Bloria, Ketan Kataria, Ankur Luthra, Pallavi Bloria
DOI:10.4103/ija.IJA_494_18  
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LETTERS TO EDITOR Top

Aberrant femoral nerve anatomy: No longer a cause of block failure when using ultrasound guidance p. 997
R Sripriya, T Sivashanmugam
DOI:10.4103/ija.IJA_433_18  
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Intraoperative anaphylaxis due to rupture of ascaris lumbricoides p. 998
Rajnish Kumar, Abhyuday Kumar, Umesh Kumar Bhadani, Utpal Anand
DOI:10.4103/ija.IJA_435_18  
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Leucocytosis before liver transplant, source could be hiding in heart: Case report p. 1000
M Tandon, P Kumaraswamy, AK Sood, V Pamecha
DOI:10.4103/ija.IJA_473_18  
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Venous air embolism following application of Mayfield head clamp: A word of caution p. 1002
Ankur Khandelwal, Shruti Gupta, Hemanshu Prabhakar, Sourav Burman
DOI:10.4103/ija.IJA_477_18  
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Atypical prolonged spinal anaesthesia p. 1004
Sukhman Shergill, Ursula Galway
DOI:10.4103/ija.IJA_527_18  
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Polyuria during endonasal endoscopic surgery: An atypical effect of intraoperative dexmedetomidine administration p. 1005
Rudrashish Haldar, Jagriti Shukla, Devendra Gupta, Sapna Yadav
DOI:10.4103/ija.IJA_532_18  
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Perioperative concerns of a patient with Escobar syndrome for ocular surgery p. 1007
Sana Yasmin Hussain, Manpreet Kaur
DOI:10.4103/ija.IJA_585_18  
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Epidural catheter displacement – A report of delayed diagnosis p. 1009
Rishabh Jaju, Bharat Paliwal, Priyanka Sethi, Pradeep Bhatia
DOI:10.4103/ija.IJA_593_18  
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