Indian Journal of Anaesthesia  
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Designing an ideal operating room complex
SS Harsoor, S Bala Bhaskar
May-June 2007, 51(3):193-199
Designing of an operation theatre complex is a major exercise and is mainly intended to benefit the patient. The need for safety, convenience and economy will guide the planning of a modern operation theatre complex, whatever the size, number or the speciality. Guidelines based on current and widely accepted recom­mendations as also ones for possible expansion of the operation theatre complex are dealt with in this article.
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Survey of supraglottic airway devices usage in anaesthetic practice in South Indian State
S Mohideen Abdul Kadar, Rachel Koshy
March 2015, 59(3):190-193
DOI:10.4103/0019-5049.153044  PMID:25838594
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Anaesthetic and airway management of a post-burn contracture neck patient with microstomia and distorted nasal anatomy
Rajni Mathur, Pawan K Jain, Pranay Singh Chakotiya, Pratibha Rathore
March-April 2014, 58(2):210-213
DOI:10.4103/0019-5049.130834  PMID:24963193
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All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults
Sheila Nainan Myatra, Amit Shah, Pankaj Kundra, Apeksh Patwa, Venkateswaran Ramkumar, Jigeeshu Vasishtha Divatia, Ubaradka S Raveendra, Sumalatha Radhakrishna Shetty, Syed Moied Ahmed, Jeson Rajan Doctor, Dilip K Pawar, Singaravelu Ramesh, Sabyasachi Das, Rakesh Garg
December 2016, 60(12):885-898
DOI:10.4103/0019-5049.195481  PMID:28003690
The All India Difficult Airway Association (AIDAA) guidelines for management of the unanticipated difficult airway in adults provide a structured, stepwise approach to manage unanticipated difficulty during tracheal intubation in adults. They have been developed based on the available evidence; wherever robust evidence was lacking, or to suit the needs and situation in India, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists. We recommend optimum pre-oxygenation and nasal insufflation of 15 L/min oxygen during apnoea in all patients, and calling for help if the initial attempt at intubation is unsuccessful. Transnasal humidified rapid insufflations of oxygen at 70 L/min (transnasal humidified rapid insufflation ventilatory exchange) should be used when available. We recommend no more than three attempts at tracheal intubation and two attempts at supraglottic airway device (SAD) insertion if intubation fails, provided oxygen saturation remains ≥ 95%. Intubation should be confirmed by capnography. Blind tracheal intubation through the SAD is not recommended. If SAD insertion fails, one final attempt at mask ventilation should be tried after ensuring neuromuscular blockade using the optimal technique for mask ventilation. Failure to intubate the trachea as well as an inability to ventilate the lungs by face mask and SAD constitutes 'complete ventilation failure', and emergency cricothyroidotomy should be performed. Patient counselling, documentation and standard reporting of the airway difficulty using a 'difficult airway alert form' must be done. In addition, the AIDAA provides suggestions for the contents of a difficult airway cart.
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Safety features in anaesthesia machine
M Subrahmanyam, S Mohan
September-October 2013, 57(5):472-480
DOI:10.4103/0019-5049.120143  PMID:24249880
Anaesthesia is one of the few sub-specialties of medicine, which has quickly adapted technology to improve patient safety. This application of technology can be seen in patient monitoring, advances in anaesthesia machines, intubating devices, ultrasound for visualisation of nerves and vessels, etc., Anaesthesia machines have come a long way in the last 100 years, the improvements being driven both by patient safety as well as functionality and economy of use. Incorporation of safety features in anaesthesia machines and ensuring that a proper check of the machine is done before use on a patient ensures patient safety. This review will trace all the present safety features in the machine and their evolution.
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Anaesthetic considerations in cardiac patients undergoing non cardiac surgery
Tej K Kaul, Geeta Tayal
July-August 2007, 51(4):280-280
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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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Paediatric Spinal Anesthesia
Rakhee Goyal, Kavitha Jirtjil, BB Baj, Sunil Singh, Santosh Kumar
May-June 2008, 52(3):264-272
Paediatric spinal anesthesia is not only a safe alternative to general anaesthesia but often the anaesthesia technique of choice in many lower abdominal and lower limb surgeries in children. The misconception regarding its safety and feasibility is broken and is now found to be even more cost-effective. It is a much preferred technique especially for the common daycase surgeries generally performed in the paediatric age group. There is no require­ment of any additional expensive equipment either and this procedure can be easily performed in peripheral centers. However, greater acceptance and experience is yet desired for this technique to become popular.
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Management of perioperative arrhythmias
N Dua, VP Kumra
July-August 2007, 51(4):310-310
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Scoliosis and anaesthetic considerations
Anand H Kulkarni, M Ambareesha
November-December 2007, 51(6):486-495
Scoliosis may be of varied etiology and tends to cause a restrictive ventilatory defect, along with ventilation-perfusion mismatch and hypoxemia. There is also cardiovascular involvement in the form of raised right heart pressures, mitral valve prolapse or congenital heart disease. Thus a careful pre-anaesthetic evaluation and optimization should be done. Intraoperatively temperature and fluid balance, positioning, spinal cord integrity testing and blood conservation techniques are to be kept in mind. Postoperatively, intensive respiratory therapy and pain management are prime concerns.
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The basic anaesthesia machine
CL Gurudatt
September-October 2013, 57(5):438-445
DOI:10.4103/0019-5049.120138  PMID:24249876
After WTG Morton's first public demonstration in 1846 of use of ether as an anaesthetic agent, for many years anaesthesiologists did not require a machine to deliver anaesthesia to the patients. After the introduction of oxygen and nitrous oxide in the form of compressed gases in cylinders, there was a necessity for mounting these cylinders on a metal frame. This stimulated many people to attempt to construct the anaesthesia machine. HEG Boyle in the year 1917 modified the Gwathmey's machine and this became popular as Boyle anaesthesia machine. Though a lot of changes have been made for the original Boyle machine still the basic structure remains the same. All the subsequent changes which have been brought are mainly to improve the safety of the patients. Knowing the details of the basic machine will make the trainee to understand the additional improvements. It is also important for every practicing anaesthesiologist to have a thorough knowledge of the basic anaesthesia machine for safe conduct of anaesthesia.
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Anaesthesia for neurosurgical procedures in paediatric patients
Girija Prasad Rath, Hari H Dash
September-October 2012, 56(5):502-510
DOI:10.4103/0019-5049.103979  PMID:23293391
Recent advances in neurosurgery, neuromonitoring and neurointensive care have dramatically improved the outcome in patients affected by surgical lesions of central nervous system (CNS). Although most of these techniques were applied first in the adult population, paediatric patients present a set of inherent challenges because of their developing and maturing neurological and physiological status, apart from the CNS disease process. To provide optimal neuroanaesthesia care, the anaesthesiologist must have the knowledge of basic neurophysiology of developing brain and effects of various drugs on cerebral haemodynamics apart from the specialised training on paediatric neuroanaesthesia. This article highlights on the perioperative management of paediatric neurosurgical patients.
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Mapleson's breathing systems
Tej K Kaul, Geeta Mittal
September-October 2013, 57(5):507-515
DOI:10.4103/0019-5049.120148  PMID:24249884
Mapleson breathing systems are used for delivering oxygen and anaesthetic agents and to eliminate carbon dioxide during anaesthesia. They consist of different components: Fresh gas flow, reservoir bag, breathing tubes, expiratory valve, and patient connection. There are five basic types of Mapleson system: A, B, C, D and E depending upon the different arrangements of these components. Mapleson F was added later. For adults, Mapleson A is the circuit of choice for spontaneous respiration where as Mapleson D and its Bains modifications are best available circuits for controlled ventilation. For neonates and paediatric patients Mapleson E and F (Jackson Rees modification) are the best circuits. In this review article, we will discuss the structure of the circuits and functional analysis of various types of Mapleson systems and their advantages and disadvantages.
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Anatomy and physiology of respiratory system relevant to anaesthesia
Apeksh Patwa, Amit Shah
September 2015, 59(9):533-541
DOI:10.4103/0019-5049.165849  PMID:26556911
Clinical application of anatomical and physiological knowledge of respiratory system improves patient's safety during anaesthesia. It also optimises patient's ventilatory condition and airway patency. Such knowledge has influence on airway management, lung isolation during anaesthesia, management of cases with respiratory disorders, respiratory endoluminal procedures and optimising ventilator strategies in the perioperative period. Understanding of ventilation, perfusion and their relation with each other is important for understanding respiratory physiology. Ventilation to perfusion ratio alters with anaesthesia, body position and with one-lung anaesthesia. Hypoxic pulmonary vasoconstriction, an important safety mechanism, is inhibited by majority of the anaesthetic drugs. Ventilation perfusion mismatch leads to reduced arterial oxygen concentration mainly because of early closure of airway, thus leading to decreased ventilation and atelectasis during anaesthesia. Various anaesthetic drugs alter neuronal control of the breathing and bronchomotor tone.
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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.
  18,024 6,120 4
Monitoring Devices for Measuring the Depth of Anaesthesia - An Overview
Prabhat Kumar Sinha, Thomas Koshy
September-October 2007, 51(5):365-365
Achieving adequate depth of anaesthesia during surgical procedures is desirable. Therefore, assessment and monitoring/ measurement of the depth of anaesthesia are fundamental to anaesthetic practice. The purpose of this review is to identify the risk factors that may be associated with intraoperative awareness, provide decision tools that may enable the clinician to reduce the frequency of unintended intraoperative awareness, stimulate the pursuit and evaluation of strategies that may prevent or reduce the frequency of intraoperative awareness, different types of tools developed to date to monitor the depth of anaesthesia, provide guidance for the intraoperative use of different monitoring tools as they relate to intraoperative awareness and how to approach a patient when awareness is reported by the patient along with current guidelines in the use of current available monitors.
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Basics of fluid and blood transfusion therapy in paediatric surgical patients
Virendra K Arya
September-October 2012, 56(5):454-462
DOI:10.4103/0019-5049.103960  PMID:23293384
Perioperative fluid, electrolyte and blood transfusion therapy for infants and children can be confusing due the numerous opinions, formulas and clinical applications, which can result in a picture that is not practical and is often misleading. Perioperatively, crystalloids, colloids and blood components are required to meet the ongoing losses and for maintaining cardiovascular stability to sustain adequate tissue perfusion. Recently controversies have been raised regarding historically used formulas and practices of glucose containing hypotonic maintenance crystalloid solutions for perioperative fluid therapy in children. Paediatric intraoperative transfusion therapy, particularly the approach to massive blood transfusion (blood loss ≥ one blood volume) can be quite complex because of the unique relationship between the patient's blood volume and the volume of the individual blood product transfused. A meticulous fluid, electrolyte and blood transfusion management is required in paediatric patients perioperatively because of an extremely limited margin for error. This article reviews the basic concepts in perioperative fluid and blood transfusion therapy for paediatric patients, along with recent recommendations. For this review, Pubmed, Ovid MEDLINE, HINARI and Google scholar were searched without date restrictions. Search terms included the following in various combinations: Perioperative, fluid therapy, paediatrics, blood transfusion, electrolyte disturbances and guidelines. Only articles with English translation were used.
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Ultrasound-guided truncal blocks: A new frontier in regional anaesthesia
Arunangshu Chakraborty, Rakhi Khemka, Taniya Datta
October 2016, 60(10):703-711
DOI:10.4103/0019-5049.191665  PMID:27761032
The practice of regional anaesthesia is rapidly changing with the introduction of ultrasound into the working domain of the anaesthesiologist. New techniques are being pioneered. Among the recent techniques, notable are the truncal blocks, for example, the transversus abdominis plane block, rectus sheath block, hernia block and quadratus lumborum block in the abdomen and the pectoral nerves (Pecs) block 1 and 2, serratus anterior plane block and intercostal nerve block. This narrative review covers the brief anatomical discourse along with technical description of the ultrasound-guided truncal blocks.
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Ultrasound of the airway
Pankaj Kundra, Sandeep Kumar Mishra, Anathakrishnan Ramesh
September-October 2011, 55(5):456-462
DOI:10.4103/0019-5049.89868  PMID:22174461
Currently, the role of ultrasound (US) in anaesthesia-related airway assessment and procedural interventions is encouraging, though it is still ill defined. US can visualise anatomical structures in the supraglottic, glottic and subglottic regions. The floor of the mouth can be visualised by both transcutaneous view of the neck and also by transoral or sublinguial views. However, imaging the epiglottis can be challenging as it is suspended in air. US may detect signs suggestive of difficult intubation, but the data are limited. Other possible applications in airway management include confirmation of correct endotracheal tube placement, prediction of post-extubation stridor, evaluation of soft tissue masses in the neck prior to intubation, assessment of subglottic diameter for determination of paediatric endotracheal tube size and percutaneous dilatational tracheostomy. With development of better probes, high-resolution imaging, real-time picture and clinical experience, US has become the potential first-line noninvasive airway assessment tool in anaesthesia and intensive care practice.
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Tramadol for control of shivering (Comparison with pethidine)
Aditi A Dhimar, Mamta G Patel, VN Swadia
January-February 2007, 51(1):28-31
Shivering is common problem faced by an anaesthesiologist during intraoperative as well as in postoperative period. Shivering occurs during both general anaesthesia and regional anaesthesia, but it is more frequent and troublesome during regional anaesthesia. This randomized, prospective study conducted in 60 ASA grade I, II, or III patients, was designed to explore the efficacy and potency of Tramadol in comparison to Pethidine for control of shivering under regional anaesthesia. Patients received Tramadol or Pethidine in a dose of -1 I.V after the appearance of shivering. Disappearance and recurrence of shivering, as well as haemodynamics were observed at scheduled intervals. Onset of disappearance of shivering was found at 1 minute in Tramadol group (T)( p < 0.05) and at 3 minutes in Pethidine group (P)( p < 0.05 ). The complete disappearance of shivering took 5 minutes in T group while 20 minutes in P group.Reccurence rate of shivering was 10% in T and 50% in P group patients respectively (p < 0.05). None of the patients had any complications except nausea and vomiting (6.6% and 20% in group T and P respectively, p> 0.05). Thus Tramadol and Pethidine were equally efficacious, but Tramadol was more potent with respect to control of shivering and its recurrence .It was concluded that I.V Tramadol is qualitatively superior to Pethidine for control of shivering.
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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.
  14,773 4,938 5
Assessment of Sedation and Analgesia in Mechanically Ventilated Patients in Intensive Care Unit
Udita Naithani, Pramila Bajaj, Sanjay Chhabra
September-October 2008, 52(5):519-519
Post traumatic stress resulting from an intensive care unit(ICU) stay may be prevented by adequate level of sedation and analgesia. Aims of the study were reviewing the current practices of sedation and analgesia in our ICU setup and to assess level of sedation and analgesia to know the requirement of sedative and analgesics in mechani­cally ventilated ICU patients. This prospective observational study was conducted on 50 consecutive mechanically ventilated patients in ICU over a period of 6 months. Patient's sedation level was assessed by Ramsay Sedation Scale (RSS = 1 : Agitated; 2,3 : Comfortable; 4,5,6 : Sedated) and pain intensity by Behavioural Pain Scale (BPS = 3 :No pain, to 16 : Maximum pain). BPS, mean arterial pressure(MAP) and heart rate(HR) were assessed before and after painful stimulus (tracheal suction). Although no patient had received sedative and analgesics, mean Ramsay score was 3.52±1.92 with 30% patients categorized as 'agitated', 12% as 'comfortable' and 58% as 'sedated' because of depressed consciousness level. Mean BPS at rest was 4.30±1.28 revealing background pain that further increased to 6.18±1.88 after painful stimulus. There was significant rise in HR (10.30%), MAP (7.56%) and BPS (40.86%) after painful stimulus, P<0.0001. The correlation between BPS and Ramsay Score was negative and significant (P< 0.01). We conclude that there should be regular definition of the appropriate level of sedation and analgesia as well as monitoring of the desired level, using sedation and pain scales as a part of the total care for mechanically ventilated patients.
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American Society of Anaesthesiologists physical status classification
Mohamed Daabiss
March-April 2011, 55(2):111-115
DOI:10.4103/0019-5049.79879  PMID:21712864
Although the American Society of Anaesthesiologists' (ASA) classification of Physical Health is a widely used grading system for preoperative health of the surgical patients, multiple variations were observed between individual anaesthetist's assessments when describing common clinical problems. This article reviews the current knowledge and evaluation regarding ASA Classification of Physical Health as well as trials for possible modification.
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Dexmedetomidine in anaesthesia practice: A wonder drug?
K Sudheesh, SS Harsoor
July-August 2011, 55(4):323-324
DOI:10.4103/0019-5049.84824  PMID:22013245
  15,501 3,725 11
Legal Aspects of Anaesthesia Practice
SC Parakh
May-June 2008, 52(3):247-257
There has been a renewed interest in matters relating to Medical Negligence since the Consumer Protection Act (CPA) was made applicable to the Medical Profession. Cases of medical negligence are now being filed in consumer courts instead of the regular courts. The Supreme Court judgement in Indian Medical Association Vs V. P. Shantha& Ors. has brought a radical change in the interpretation of CPA. This article reviews the situation in the light of cases decided by various courts in India and Abroad including the Consumer Courts.
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