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2010| September-October | Volume 54 | Issue 5
Online since
October 9, 2010
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REVIEW ARTICLES
Labour analgesia: Recent advances
Sunil T Pandya
September-October 2010, 54(5):400-408
DOI
:10.4103/0019-5049.71033
PMID
:21189877
Advances in the field of labour analgesia have tread a long journey from the days of ether and chloroform in 1847 to the present day practice of comprehensive programme of labour pain management using evidence-based medicine. Newer advances include introduction of newer techniques like combined spinal epidurals, low-dose epidurals facilitating ambulation, pharmacological advances like introduction of remifentanil for patient-controlled intravenous analgesia, introduction of newer local anaesthetics and adjuvants like ropivacaine, levobupivacaine, sufentanil, clonidine and neostigmine, use of inhalational agents like sevoflourane for patient-controlled inhalational analgesia using special vaporizers, all have revolutionized the practice of pain management in labouring parturients. Technological advances like use of ultrasound to localize epidural space in difficult cases minimizes failed epidurals and introduction of novel drug delivery modalities like patient-controlled epidural analgesia (PCEA) pumps and computer-integrated drug delivery pumps have improved the overall maternal satisfaction rate and have enabled us to customize a suitable analgesic regimen for each parturient. Recent randomized controlled trials and Cochrane studies have concluded that the association of epidurals with increased caesarean section and long-term backache remains only a myth. Studies have also shown that the newer, low-dose regimes do not have a statistically significant impact on the duration of labour and breast feeding and also that these reduce the instrumental delivery rates thus improving maternal and foetal safety. Advances in medical technology like use of ultrasound for localizing epidural space have helped the clinicians to minimize the failure rates, and many novel drug delivery modalities like PCEA and computer-integrated PCEA have contributed to the overall maternal satisfaction and safety.
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Anaemia and pregnancy: Anaesthetic implications
Anju Grewal
September-October 2010, 54(5):380-386
DOI
:10.4103/0019-5049.71026
PMID
:21189874
Anaemia in pregnancy defined as haemoglobin (Hb) level of < 10 gm/dL, is a qualitative or quantitative deficiency of Hb or red blood cells in circulation resulting in reduced oxygen (O
2
)-carrying capacity of the blood. Compensatory mechanisms in the form of increase in cardiac output (CO), PaO
2
, 2,3 diphosphoglycerate levels, rightward shift in the oxygen dissociation curve (ODC), decrease in blood viscosity and release of renal erythropoietin, get activated to variable degrees to maintain tissue oxygenation and offset the decreases in arterial O
2
content. Parturients with concomitant medical diseases or those with acute ongoing blood losses may get decompensated, leading to serious consequences like right heart failure, angina or tissue hypoxemia in severe anaemia. Preoperative evaluation is aimed at assessing the severity and cause of anaemia. The concept of an acceptable Hb level varies with the underlying medical condition, extent of physiological compensation, the threat of bleeding and ongoing blood losses. The main anaesthetic considerations are to minimize factors interfering with O
2
delivery, prevent any increase in oxygen consumption and to optimize the partial pressure of O
2
in the arterial blood. Both general anaesthesia and regional anaesthesia can be employed judiciously. Monitoring should focus mainly on the adequacy of perfusion and oxygenation of vital organs. Hypoxia, hyperventilation, hypothermia, acidosis and other conditions that shift the ODC to left should be avoided. Any decrease in CO should be averted and aggressively treated.
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Mitral stenosis and pregnancy: Current concepts in anaesthetic practice
M Kannan, G Vijayanand
September-October 2010, 54(5):439-444
DOI
:10.4103/0019-5049.71043
PMID
:21189882
The incidence of rheumatic mitral stenosis is grossly reduced in India. Still, among heart disease complicating pregnancy, rheumatic mitral stenosis occupies a greater segment. The unique physiological changes in pregnancy and the pathological impact of mitral stenosis over pregnancy and labour are discussed in detail. A multidisciplinary approach in the diagnosis and management reduces the mortality and morbidity during peripartum. The labour analgesia technique and the evidence-based regional and general anaesthesia techniques are discussed at length in this article.
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Neonatal resuscitation: Current issues
Indu A Chadha
September-October 2010, 54(5):428-438
DOI
:10.4103/0019-5049.71042
PMID
:21189881
The following guidelines are intended for practitioners responsible for resuscitating neonates. They apply primarily to neonates undergoing transition from intrauterine to extrauterine life. The updated guidelines on Neonatal Resuscitation have assimilated the latest evidence in neonatal resuscitation. Important changes with regard to the old guidelines and recommendations for daily practice are provided. Current controversial issues concerning neonatal resuscitation are reviewed and argued in the context of the ILCOR 2005 consensus.
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CLINICAL INVESTIGATIONS
Efficacy of clonidine as an adjuvant to bupivacaine for caudal analgesia in children undergoing sub-umbilical surgery
Aruna Parameswari, Anand M Dhev, Mahesh Vakamudi
September-October 2010, 54(5):458-463
DOI
:10.4103/0019-5049.71047
PMID
:21189886
Caudal epidural analgesia with bupivacaine is very popular in paediatric anaesthesia for providing intra- and postoperative analgesia. Several adjuvants have been used to prolong the action of bupivacaine. We evaluated the efficacy of clonidine added to bupivacaine in prolonging the analgesia produced by caudal bupivacaine in children undergoing sub-umbilical surgery. One hundred children, age one to three years, undergoing sub-umbilical surgery, were prospectively randomized to one of two groups: caudal analgesia with 1 ml/kg of 0.25% bupivacaine in normal saline (Group A) or caudal analgesia with 1 ml/kg of 0.25% bupivacaine with 1 μg/kg of clonidine in normal saline (Group B). Post-operative pain was assessed for 24 hours using the FLACC scale. The mean duration of analgesia was significantly longer in Group B (593.4 ± 423.3 min) than in Group A (288.7 ± 259.1 min);
P
< 0.05. The pain score assessed using FLACC scale was compared between the two groups, and children in Group B had lower pain scores, which was statistically significant. The requirement of rescue medicine was lesser in Group B. Clonidine in a dose of 1 μg/kg added to 0.25% bupivacaine for caudal analgesia, during sub-umbilical surgeries, prolongs the duration of analgesia of bupivacaine, without any side effects.
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REVIEW ARTICLES
Complications of regional and general anaesthesia in obstetric practice
Ashok Jadon
September-October 2010, 54(5):415-420
DOI
:10.4103/0019-5049.71039
PMID
:21189879
Any anaesthetic technique, either regional or general, has potential for complications. Moreover, it has been seen that in obstetric patients, the complications are potentiated due to pregnancy-related changes in physiology and due to various other factors. Increasing trend of caesarean section in the setting of increasing maternal age, obesity and other concomitant diseases will continue to challenge the obstetric anaesthetist in his/her task of providing safe regional and general anaesthesia. This review has highlighted the possible complications of regional and general anaesthesia encountered during the obstetric anaesthesia practice.
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Diabetic parturient - Anaesthetic implications
Nibedita Pani, Shakti Bedanta Mishra, Shovan Kumar Rath
September-October 2010, 54(5):387-393
DOI
:10.4103/0019-5049.71028
PMID
:21189875
Pregnancy induces progressive changes in maternal carbohydrate metabolism. As pregnancy advances insulin resistance and diabetogenic stress due to placental hormones necessitate compensatory increase in insulin secretion. When this compensation is inadequate gestational diabetes develops. 'Gestational diabetes mellitus' (GDM) is defined as carbohydrate intolerance with onset or recognition during pregnancy. Women diagnosed to have GDM are at increased risk of future diabetes predominantly type 2 DM as are their children. Thus GDM offers an important opportunity for the development, testing and implementation of clinical strategies for diabetes prevention. Timely action taken now in screening all pregnant women for glucose intolerance, achieving euglycaemia in them and ensuring adequate nutrition may prevent in all probability, the vicious cycle of transmitting glucose intolerance from one generation to another. Given that diabetic mothers have proportionately larger babies it is likely that vaginal delivery will be more difficult than in the normal population, with a higher rate of instrumentally assisted delivery, episiotomy and conversion to urgent caesarean section. So an indwelling epidural catheter is a better choice for labour analgesia as well to use, should a caesarean delivery become necessary. Diabetes in pregnancy has potential serious adverse effects for both the mother and the neonate. Standardized multidisciplinary care including anaesthetists should be carried out obsessively throughout pregnancy. Diabetes is the most common endocrine disorder of pregnancy. In pregnancy, it has considerable cost and care demands and is associated with increased risks to the health of the mother and the outcome of the pregnancy. However, with careful and appropriate screening, multidisciplinary management and a motivated patient these risks can be minimized.
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Anaesthesia for lower-segment caesarean section: Changing perspectives
Sean Brian Yeoh, Sng Ban Leong, Alex Sia Tiong Heng
September-October 2010, 54(5):409-414
DOI
:10.4103/0019-5049.71037
PMID
:21189878
The number of caesarean sections has increased over the last two decades, especially in the developed countries. Hence, it has increasingly become a greater challenge to provide care for the parturient, but this has given obstetric anaesthetists a greater opportunity to contribute to obstetric services. While caesarean deliveries were historically performed using general anaesthesia, there is a recent significant move towards regional anaesthesia. Unique problems that patients with obesity and pre-eclampsia present will be discussed in the present article. New medications and devices now used in obstetric anaesthesia will change the practice and perspectives of our clinical practice.
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EDITORIAL
Are we using right dose of oxytocin?
D Devikarani, SS Harsoor
September-October 2010, 54(5):371-373
DOI
:10.4103/0019-5049.71020
PMID
:21189871
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REVIEW ARTICLES
The critically ill obstetric patient - Recent concepts
Anjan Trikha, PM Singh
September-October 2010, 54(5):421-427
DOI
:10.4103/0019-5049.71041
PMID
:21189880
Obstetric patients admitted to an Intensive Care Unit (ICU) present a challenge to an intensivist because of normal physiological changes associated with pregnancy and puerperium, the specific medical diseases peculiar to pregnancy and the need to take care of both the mother and the foetus. Most common causes of admission to an ICU for obstetric patients are eclampsia, severe preeclampsia, haemorrhage, congenital and valvular heart disease, septic abortions, severe anemia, cardiomyopathy and non-obstetric sepsis. The purpose of this review is to present the recent concepts in critical care management of obstetric patients with special focus mainly on ventilatory strategies, treatment of shock and nutrition. The details regarding management of individual diseases would not be discussed as these would be beyond the purview of this article. In addition, some specific issues of importance while managing such patients would also be highlighted.
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LETTERS TO EDITOR
Estimation of the dose of hyperbaric bupivacaine for spinal anaesthesia for emergency caesarean section in an achondroplastic dwarf
Tanvir Samra, Sujata Sharma
September-October 2010, 54(5):481-482
DOI
:10.4103/0019-5049.71030
PMID
:21189897
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SPECIAL ARTICLE
"Nil per oral after midnight": Is it necessary for clear fluids?
Kajal S Dalal, Dhanwanti Rajwade, Ragini Suchak
September-October 2010, 54(5):445-447
DOI
:10.4103/0019-5049.71044
PMID
:21189883
Fasting before general anaesthesia aims to reduce the volume and acidity of stomach contents, thus reducing the risk of regurgitation and aspiration. Recent guidelines have recommended a shift in fasting policies from the standard 'nil per oral from midnight' to a more relaxed policy of clear fluid intake a few hours before surgery. The effect of preoperative oral administration of 150 ml of water 2 h prior to surgery was studied prospectively in 100 ASA I and II patients, for elective surgery. Patients were randomly assigned to two groups. Group I (n = 50) was fasting overnight while Group II (n = 50) was given 150 ml of water 2 h prior to surgery. A nasogastric tube was inserted after intubation and gastric aspirate was collected for volume and pH. The gastric fluid volume was found to be lesser in Group II (5.5 ± 3.70 ml) than Group I (17.1 ± 8.2 ml) which was statistically significant. The mean pH values for both groups were similar. Hence, we conclude that patients not at risk for aspiration can be allowed to ingest 150 ml water 2 h prior to surgery.
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CASE REPORTS
A late presenting congenital diaphragmatic hernia misdiagnosed as spontaneous pneumothorax
Chitra Sanjeev Juwarkar, Deependra Suresh Kamble, Vishal Sawant
September-October 2010, 54(5):464-466
DOI
:10.4103/0019-5049.71034
PMID
:21189887
Congenital diaphragmatic hernia (CDH) is described as (1) failure of diaphragmatic closure at development, (2) presence of herniated abdominal contents into chest and (3) pulmonary hypoplasia. Usually, pleural space is drained urgently when there is respiratory distress and radiological appearance of mediastinal shift. We present a case of a 5-month-old baby, diagnosed as tension pneumothorax and treated with chest drain insertion. CDH was the intraoperative diagnosis.
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CLINICAL INVESTIGATIONS
Comparative analgesic efficacy of buprenorphine or clonidine with bupivacaine in the caesarean section
Kiran Agarwal, Navneet Agarwal, Vijender Agrawal, Ashok Agarwal, Mahender Sharma, Kanupriya Agarwal
September-October 2010, 54(5):453-457
DOI
:10.4103/0019-5049.71046
PMID
:21189885
The need for early ambulation for caring of the neonate by mothers makes postoperative pain management after cesarean delivery unique. Favorable results have been observed with buprenorphine, clonidine and bupivacaine as epidural analgesics. This prospective, randomised triple blind control study was carried out among 112 lower segment caesarean segment (LSCS) patients, divided into three groups, to assess the analgesic efficacy and side effects of epidural analgesia, with an intermittent top up of (i) bupivacaine (0.125%) and buprenorphine (0.075 mg) (ii) bupivacaine (0.125%) and clonidine (37.5 microgram) and (iii) bupivacaine (0.125%) alone, in LSCS cases. The demographic characteristics (age, weight and height) of the three groups were comparable and the differences were not statistically significant. The mean duration of the analgesia was significantly longer in the group one patients receiving buprenorphine plus bupivacaine (690 ± 35 minutes) and it was lowest in group three patients receiving bupivacaine (170 ± 31 minutes) alone. The mean highest pain score (VAS scale) was significantly lower (3.4 ± 0.6) in group one patients and it was highest in group three (6.7 ± 0.8) patients. Requirement of continuation of epidural analgesia after 15 hours of operation and requirement of diclonfenac injections as well as incidence of itching and pruritus was significantly lower in group one patients. Incidence of nausea and vomiting was the lowest in group one patients. Incidence of respiratory depression, sedation and hypotension were nil in all three group of patients. Epidural buprenorphine combined with bupivacaine produced significantly longer duration and better quality of analgesia than bupivacaine combined with clonidine or bupivacaine alone, and it was safe in LSCS patients, for post-operative analgesia.
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REVIEW ARTICLES
Management of foetal asphyxia by intrauterine foetal resuscitation
S Velayudhareddy, H Kirankumar
September-October 2010, 54(5):394-399
DOI
:10.4103/0019-5049.71032
PMID
:21189876
Management of foetal distress is a subject of gynaecological interest, but an anaesthesiologist should know about resuscitation, because he should be able to treat the patient, whenever he is directly involved in managing the parturient patient during labour analgesia and before an emergency operative delivery. Progressive asphyxia is known as foetal distress; the foetus does not breathe directly from the atmosphere, but depends on maternal circulation for its oxygen requirement. The oxygen delivery to the foetus depends on the placental (maternal side), placental transfer and foetal circulation. Oxygen transport to the foetus is reduced physiologically during uterine contractions in labour. Significant impairment of oxygen transport to the foetus, either temporary or permanent may cause foetal distress, resulting in progressive hypoxia and acidosis. Intrauterine foetal resuscitation comprises of applying measures to a mother in active labour, with the intention of improving oxygen delivery to the distressed foetus to the base line, if the placenta is functioning normally. These measures include left lateral recumbent position, high flow oxygen administration, tocolysis to reduce uterine contractions, rapid intravenous fluid administration, vasopressors for correction of maternal hypotension and amnioinfusion for improving uterine blood flow. Intrauterine Foetal Resuscitation measures are easy to perform and do not require extensive resources, but the results are encouraging in improving the foetal well-being. The anaesthesiologist plays a major role in the application of intrauterine foetal resuscitation measures.
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LETTERS TO EDITOR
Management of neonatal giant occipital encephalocele: Anaesthetic challenge
Vikash Goel, Neelam Dogra, Mamta Khandelwal, RS Chaudhri
September-October 2010, 54(5):477-478
DOI
:10.4103/0019-5049.71022
PMID
:21189892
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GUEST EDITORIALS
Perioperative fasting: A time to relook
M Subrahmanyam, M Venugopal
September-October 2010, 54(5):374-375
DOI
:10.4103/0019-5049.71021
PMID
:21189872
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Obstetric anaesthesia: Widening horizons?
Sunanda Gupta
September-October 2010, 54(5):376-379
DOI
:10.4103/0019-5049.71023
PMID
:21189873
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CASE REPORTS
An unanticipated cardiac arrest and unusual post-resuscitation psycho-behavioural phenomena/near death experience in a patient with pregnancy induced hypertension and twin pregnancy undergoing elective lower segment caesarean section
Mridul M Panditrao, Chanchal Singh, Minnu M Panditrao
September-October 2010, 54(5):467-469
DOI
:10.4103/0019-5049.71035
PMID
:21189888
A case report of a primigravida, who was admitted with severe pregnancy induced hypertension (BP 160/122 mmHg) and twin pregnancy, is presented here. Antihypertensive therapy was initiated. Elective LSCS under general anaesthesia was planned. After the birth of both the babies, intramyometrial injections of Carboprost and Pitocin were administered. Immediately, she suffered cardiac arrest. Cardio pulmonary resucitation (CPR) was started and within 3 minutes, she was successfully resuscitated. The patient initially showed peculiar psychological changes and with passage of time, certain psycho-behavioural patterns emerged which could be attributed to near death experiences, as described in this case report.
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HISTORY
Sir Thomas Lauder Brunton, F.R.S. (1844-1916) about his visit to Hyderabad - Deccan: His role in the 2
nd
Hyderabad Chloroform Commission (1889 A.D.)
Narayana Ala, A Ramachari, R Krishna Kumar
September-October 2010, 54(5):475-476
DOI
:10.4103/0019-5049.71040
PMID
:21189891
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CLINICAL INVESTIGATIONS
Effect of 6% hydroxyethyl starch-450 and low molecular weight dextran on blood sugar levels during surgery under subarachnoid block: A prospective randomised study
Abhiruchi Patki, VC Shelgaonkar
September-October 2010, 54(5):448-452
DOI
:10.4103/0019-5049.71045
PMID
:21189884
Dextrans and hydroxyethyl starches produce significant levels of free glucose residues following metabolism. The following study was designed to compare 6% hydroxyethyl starch-450 with Dextran 40, both used as preloading fluids, for their potential to raise peri-operative blood glucose levels. After taking an informed consent, 180 non-diabetic adult patients, posted for elective surgery under spinal anaesthesia, were randomly divided into three groups, to receive Ringer's Lactate 20 ml/kg (group 1), Dextran 40,10 ml/kg (group 2) and Hestar 6%-450, 10 ml/kg (group 3), over half an hour, prior to the subarachnoid block, as preloading fluid, and serial capillary blood glucose measurements were taken thereafter at regular intervals up to 240 minutes from the baseline reading. All the three preloading fluids, including Ringer's Lactate used as control, were seen to significantly increase the capillary blood glucose levels intra-operatively (
P
< 0.05), but the rise with Dextran-40 was seen to be sustained and highly significant (
P
< 0.001). We thus conclude that, Dextran40 causes a sustained and significant rise in peri-operative blood glucose levels.
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CASE REPORTS
Subdural haematoma in pregnancy-induced idiopathic thrombocytopenia: Conservative management
Maitree Pandey, Namita Saraswat, Homay Vajifdar, Lalita Chaudhary
September-October 2010, 54(5):470-471
DOI
:10.4103/0019-5049.71036
PMID
:21189889
Conservative management of subdural haematoma with antioedema measures in second gravida with idiopathic thrombocytopenic purpura (ITP) resulted in resolution of haematoma. We present a case of second gravida with ITP who developed subdural haematoma following normal vaginal delivery. She was put on mechanical ventilation and managed conservatively with platelet transfusion, Mannitol 1g/kg, Dexamethasone 1mg/kg and Glycerol 10ml TDS. She regained consciousness and was extubated after 48 hrs. Repeat CT after 10 days showed no mass effect with resolving haematoma which resolved completely after 15 days. Trial of conservative management is safe in pregnant patient with ITP who develops subdural haematoma.
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LETTERS TO EDITOR
Cannot ventilate, Can we intubate?
Sarita Sutrayya Swami, Shubhada Sunil Aphale, Sunil Bapat
September-October 2010, 54(5):479-480
DOI
:10.4103/0019-5049.71025
PMID
:21189894
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2,030
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CASE REPORTS
Facial nerve involvement in critical illness polyneuropathy
Mohan Gurjar, Afzal Azim, Arvind K Baronia, Banani Poddar
September-October 2010, 54(5):472-474
DOI
:10.4103/0019-5049.71038
PMID
:21189890
Although ICU-acquired neuromuscular weakness is a well-known problem, critical illness neuropathy is an under-diagnosed entity in critically ill patients. Facial musculature is typically not involved in critical illness neuropathy. This report highlights an unusual presentation of critical illness polyneuropathy in a patient with involvement of facial musculature.
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LETTERS TO EDITOR
Transcutaneous electrical nerve stimulation to reduce pain in post-op thoracotomy patients: A physical therapists' perspective
Abraham Samuel Babu, Lenny T Vasanthan, Arun G Maiya
September-October 2010, 54(5):478-478
DOI
:10.4103/0019-5049.71024
PMID
:21189893
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Damaged Proseal
TM
LMA inflation line can be repaired
Pankaj Kundra, Bhaskar Nisha
September-October 2010, 54(5):481-481
DOI
:10.4103/0019-5049.71029
PMID
:21189896
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2
Extensive deep vein thrombosis in a young parturient with a brief use of oral contraceptive pills
Jayashree C Patki, Naresh C.K Reddy
September-October 2010, 54(5):482-484
DOI
:10.4103/0019-5049.71031
PMID
:21189898
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1,721
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Locked-in syndrome after stellate ganglion block
Ashok Jadon
September-October 2010, 54(5):480-480
DOI
:10.4103/0019-5049.71027
PMID
:21189895
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