Indian Journal of Anaesthesia  
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   2015| November  | Volume 59 | Issue 11  
    Online since November 20, 2015

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Consent and the Indian medical practitioner
Ajay Kumar, Parul Mullick, Smita Prakash, Aseem Bharadwaj
November 2015, 59(11):695-700
DOI:10.4103/0019-5049.169989  PMID:26755833
Consent is a legal requirement of medical practice and not a procedural formality. Getting a mere signature on a form is no consent. If a patient is rushed into signing consent, without giving sufficient information, the consent may be invalid, despite the signature. Often medical professionals either ignore or are ignorant of the requirements of a valid consent and its legal implications. Instances where either consent was not taken or when an invalid consent was obtained have been a subject matter of judicial scrutiny in several medical malpractice cases. This article highlights the essential principles of consent and the Indian law related to it along with some citations, so that medical practitioners are not only able to safeguard themselves against litigations and unnecessary harassment but can act rightfully.
  16,388 1,763 -
Peri-operative concerns in a patient with thyroid storm secondary to molar pregnancy
Tanvir Samra, Ranvinder Kaur, Neha Sharma, Lalita Chaudhary
November 2015, 59(11):739-742
DOI:10.4103/0019-5049.170035  PMID:26755840
Awareness of the presence of thyroid function abnormalities in patients with molar pregnancy is important for its prompt diagnosis and management. We report the development of thyroid storm in the immediate post-operative period in a 25-year-old female who underwent evacuation of her molar pregnancy under saddle spinal block after being controlled for her thyrotoxicosis with a combination of antithyroid drugs, iodine, steroids and adrenergic blocking agents. We advocate the use of esmolol infusions up to a maximum dose of 200 μg/kg/min for immediate haemodynamic management of the patient. Optimum time needed for stabilisation of the hyper metabolic state after initiation of antithyroid drugs is still not known and evacuation of molar pregnancy remains the only definitive management of the thyrotoxic state.
  3,069 624 -
Drug utilisation and off-label use of medications in anaesthesia in surgical wards of a teaching hospital
Amol E Patil, Yashashri C Shetty, Snehalata V Gajbhiye, Sweta V Salgaonkar
November 2015, 59(11):721-727
DOI:10.4103/0019-5049.170032  PMID:26755837
Background and Aims: When a drug is used in a way that is different from that described in regulatory body approved drug label, it is said to be 'off label use'. Perioperative phase is sensitive from the point of view of patient safety and off-label drug use in this setup can prove to be hazardous to patient. Hence, it was planned to assess the pattern of drug utilisation and off-label use of perioperative medication during anaesthesia. Methods: Preoperatively, demographic details and adverse events check list were filled from a total of 400 patients from general surgery, paediatric surgery and orthopaedics departments scheduled to undergo surgery. The perioperative assessment form was assessed to record all prescriptions followed by refilling of adverse events checklist in case record form. World Health Organization (WHO) prescribing indicators were used for analysis of drug utilisation data. National Formulary of India 2011 was used as reference material to decide off-label drug use in majority instances along with package insert. Results: A total of 3705 drugs were prescribed to the 400 participants and average number of drugs per patient was 9.26 ± 3.33. Prescriptions by generic name were 68.07% whereas 85.3% drugs were prescribed from hospital schedule. Off-label drugs overall formed 20.19% of the drugs prescribed. At least one off-label drug was prescribed to 82.5% of patients. Inappropriate dose was the most common form of off-label use. There was 1.6 times greater risk of occurrence of adverse events associated with the use of off-label drugs. Conclusion: Prescription indicators were WHO compliant. Off-label drug use was practiced in anaesthesia department with questionable clinical justification in some instances.
  2,477 378 -
Comparison of clonidine and dexmedetomidine as adjuncts to intravenous regional anaesthesia
Shalini Pravin Sardesai, Kalyani Nilesh Patil, Adnanali Sarkar
November 2015, 59(11):733-738
DOI:10.4103/0019-5049.170034  PMID:26755839
Background and Aims: Intravenous regional anaesthesia (IVRA) provides reliable and rapid analgesia with good muscular relaxation of the extremity distal to the tourniquet, but tourniquet pain and absence of post-operative analgesia are major drawbacks. α2 agonists, clonidine and dexmedetomidine are known to potentiate peripheral nerve blocks. The aim of this study was to compare clonidine and dexmedetomidine as adjuvants to IVRA with respect to block characteristics, tourniquet pain and post-operative analgesia. Methods: A prospective, randomised, double-blind study was conducted on 60 adult patients of American Society of Anesthesiologists physical status grades I and II, in two groups of 30 each, to receive either clonidine 1 μg/kg or dexmedetomidine 1 μg/kg added to 40 ml 0.5% preservative-free lignocaine. Independent samples t-test was used for analysing demographic data, haemodynamic data and block characteristics and Mann-Whitney U-test for skewed data. Results: Sensorimotor block onset was significantly faster and recovery delayed with dexmedetomidine as compared to clonidine. Intra-operative visual analogue scale (VAS) at 10 min, 15 min and 40 min and post-operative VAS at 30 min and 2 h were significantly higher with clonidine. Fentanyl consumption and sedation were comparable. Duration of analgesia was significantly longer with dexmedetomidine. Haemodynamic parameters were comparable. Conclusions: Dexmedetomidine significantly facilitates onset, prolongs recovery of sensory as well as motor block and also prolongs duration of analgesia as compared to clonidine.   Both decrease tourniquet pain satisfactorily and have comparable intra-operative fentanyl requirement . Patient satisfaction is better with dexmedetomidine.
  2,045 652 -
Anaesthesia practice and reproductive outcomes: Facts unveiled
Amrutha Bindu Nagella, M Ravishankar, VR Hemanth Kumar
November 2015, 59(11):706-714
DOI:10.4103/0019-5049.170028  PMID:26755835
Background and Aims: Anaesthetic practice is associated with a risk of chronic exposure to anaesthetic agents. With the advent of newer inhalational agents and changing anaesthetic practices, the risks for anaesthesiologists with regard to adverse reproductive outcomes is unknown. Hence, a nationwide online survey was conducted to study the anaesthetic practices prevalent in India and their association, if any, with poor reproductive outcomes. Methods: The online survey involved 9974 anaesthesiologists. A questionnaire soliciting information regarding anaesthetic practice techniques, reproductive outcomes and perinatal outcomes was designed. All the anaesthesiologists in the ISA National database were mailed a link to the above questionnaire. Results: Female anaesthesiologists and spouses of male anaesthesiologists had a higher incidence of first trimester spontaneous abortions than the general population. Female anaesthesiologists when compared with spouses of male anaesthesiologists faced more difficulty with conception (P = 0.015). Female anaesthesiologists who worked in the operating room (OR) in their first trimester of gestation had a higher incidence of spontaneous abortions than those who did not work in the OR (P = 0.05). Longer hours of general anaesthesia conducted in the first trimester of pregnancy was associated with a higher risk of birth defects in their progeny (P = 0.05). Conclusion: Spontaneous abortions and birth defects were higher in female anaesthesiologists who worked in the OR in the first trimester of gestation. Both female anaesthesiologists and spouses of male anaesthesiologists had a greater risk for a first trimester miscarriage than the general population.
  2,099 580 1
A retrospective study of clinical profile and outcomes of critically ill patients with heat-related illness
MS Kalaiselvan, MK Renuka, AS Arunkumar
November 2015, 59(11):715-720
DOI:10.4103/0019-5049.170030  PMID:26755836
Background and Aims: Heat-related illness (HRI) due to high ambient temperatures is a common feature during the Indian summer. HRI often results in Intensive Care Unit (ICU) admissions and are associated with significant morbidity and mortality. However, published report on the effects of HRI among the Indian population is lacking. This study was undertaken to identify the profile of patients admitted to ICU with clinical features of HRI and study their clinical outcomes. Methods: This was a retrospective case series of patients admitted with features of HRI during the summer of 2012 in our multidisciplinary ICU. Data on demographics, co-morbid illness, admission severity of illness (Acute Physiology and Chronic Health Evaluation II [APACHE II]), organ failure scores (Sequential Organ Failure Assessment [SOFA]) and neuroimaging studies were collected. Outcome data studied included mortality, ICU length of stay (LOS), ventilator days and hospital LOS. Statistical analysis was performed using Student's t-test, Chi-square test and multivariate analysis. Results: Twenty-six patients met the diagnostic criteria for HRI. Fifteen were males. The mean age was 53.12 ΁ 18.6 years. Mean APACHE II score was 19.6 ΁ 7.7 and mean SOFA score was 7.5 ΁ 2.6. The common presenting symptoms were fever with neurological impairment (100%) and gastrointestinal symptoms (30%). Major organ systems involvement include neurological (100%), renal (57%), hepatic (34%) and coagulation abnormalities (26%). Most common metabolic abnormality noted was hyponatraemia (73%). Magnetic resonance imaging findings suggestive of heat stroke were seen in 5 of 26 patients. Mortality rate was 34%. 8 of 17 survivors had residual neurological impairment. Conclusion: HRI carries a high mortality and significant neurological morbidity.
  1,843 427 2
Transversus abdominis plane block as sole anaesthetic technique for inguinal hernia repair in two patients having complex medical conditions
Sukhyanti Kerai, Namrata Dabas, Lalit Sehrawat, Namrata Gupta
November 2015, 59(11):754-756
DOI:10.4103/0019-5049.170040  PMID:26755845
  1,585 472 -
Comments: New approach to treat an old problem: Mannitol for post dural puncture headache
Tasneem Dhansura, Tarana Shaikh, Mohammed Aslam Shaikh
November 2015, 59(11):762-762
DOI:10.4103/0019-5049.170046  PMID:26755849
  1,476 310 1
Opioid sparing effect of diclofenac sodium when used as an intra-operative analgesic during maxillofacial cancer surgeries
Kalpesh Bhoyar, Vijaya Patil, Madhavi Shetmahajan
November 2015, 59(11):748-752
DOI:10.4103/0019-5049.170038  PMID:26755843
  1,263 330 -
The effect of alfentanil on maternal haemodynamic changes due to tracheal intubation in elective caesarean sections under general anaesthesia
Seyedeh Masoumeh Hosseini Valami, Seyed Abbas Hosseini Jahromi, Niolofar Masoodi
November 2015, 59(11):728-732
DOI:10.4103/0019-5049.170033  PMID:26755838
Background and Aims: Endotracheal intubation can produce severe maternal haemodynamic changes during caesarean sections under general anaesthesia. However, administration of narcotics before endotracheal intubation to prevent these changes may affect the Apgar score in neonates. This study was designed to evaluate the effect of intravenous alfentanil on haemodynamic changes due to endotracheal intubation in elective caesarean sections performed under general anaesthesia. Methods: Fifty parturients were randomly divided into two equal groups. Patients in the first group received alfentanil 10 μg/kg and in the second group received placebo intravenously 1 min before induction of anaesthesia for elective caesarean section. Haemodynamic parameters and bispectral index system (BIS) in mothers, peripheral capillary oxygen saturation (SpO 2 ) and Apgar score in the newborn were assessed. Results: Changes in systolic blood pressure were significant at 1, 5 and 10 min after intubation between two groups. Changes in diastolic blood pressure were significantly less in alfentanil group, 1 min after induction of anaesthesia and 1 min after endotracheal intubation. Mean heart rate at 1 min after induction and at 1 and 5 min after intubation also reduced significantly in this group. Conclusion: Alfentanil use was associated with decreases or minimal increases in maternal systolic and diastolic blood pressures and heart rate after endotracheal intubation.
  1,282 299 -
Effect of 50% enantiomeric excess bupivacaine mixture combined with pancuronium on neuromuscular transmission in rat phrenic nerve-diaphragm preparation; a pilot study
Angelica de Fátima de Assunção Braga, Vanessa Henriques Carvalho, Franklin Sarmento da Silva Braga, Gloria Maria Braga Potério, Filipe Nadir Caparica Santos, Fernando Eduardo Féres Junqueira
November 2015, 59(11):701-705
DOI:10.4103/0019-5049.170019  PMID:26755834
Background and Aims: Local anaesthetics are drugs that are widely used in clinical practice. However, the effects of these drugs on the neuromuscular junction and their influence on the blockade produced by non-depolarising neuromuscular blocking drugs are still under investigation. The aim of this study was to evaluate, in vitro, the influence of a 50% enantiomeric excess bupivacaine mixture on neuromuscular transmission and neuromuscular block produced by pancuronium. Methods: Rats were distributed into three groups (n = 5) according to the drug studied namely, 50% enantiomeric excess bupivacaine mixture (5 μg/mL); pancuronium (2 μg/mL); 50% enantiomeric excess bupivacaine mixture + pancuronium. The following parameters were evaluated: (1) Effects of a 50% enantiomeric excess bupivacaine mixture on membrane potential (MP) and miniature endplate potentials (MEPPs); (2) amplitude of diaphragmatic response before and 60 min after the addition of a 50% enantiomeric excess bupivacaine mixture; the degree of neuromuscular block with pancuronium and pancuronium combined with a 50% enantiomeric excess bupivacaine mixture. Results: A 50% enantiomeric excess bupivacaine mixture did not alter the amplitude of muscle response (MP) but decreased the frequency and amplitude of MEPP. The block produced by pancuronium was potentiated by a 50% enantiomeric excess bupivacaine mixture. Conclusion: A 50% enantiomeric excess bupivacaine mixture used alone did not affect neuromuscular transmission, but potentiated the neuromuscular block produced by pancuronium. No action was shown on the muscle fibre, and alterations on MEPPs demonstrated a presynaptic action.
  1,263 282 1
Repair of late-presenting right Bochdalek hernia in a patient with uncorrected tetralogy of Fallot: Anaesthetic management
Priyam Saikia, Faiza Ahmed Talukdar, Bulen Phukan, Kishalaya Chakraborty
November 2015, 59(11):756-758
DOI:10.4103/0019-5049.170041  PMID:26755846
  1,289 232 -
Anaesthetic management of a patient with tuberous sclerosis for partial nephrectomy
Stalin Vinayagam, Sangeeta Dhanger, Srinivasan Ramachandran
November 2015, 59(11):746-748
DOI:10.4103/0019-5049.170037  PMID:26755842
  1,214 278 -
Temperature and cisatracurium degradation: So what is new?
Vandana Sharma, Shilpi Verma, Ghansham Biyani, Pradeep Kumar Bhatia
November 2015, 59(11):763-763
DOI:10.4103/0019-5049.170048  PMID:26755850
  1,094 271 -
A rare cause of respiratory distress after transthoracic oesophagectomy
Vinod Kumar, Rakesh Garg, Sachidanand Jee Bharati, Nishkarsh Gupta
November 2015, 59(11):743-745
DOI:10.4103/0019-5049.170036  PMID:26755841
Transthoracic oesophagectomy is a standard surgical procedure for oesophageal cancer. Because of thoracotomy and lung handling, perioperative pulmonary complications make such procedures challenging. The issues related to respiratory complications may be predicted and managed accordingly. However, we report two cases of respiratory compromise caused due to a peculiar iatrogenic component.
  1,112 230 -
Air leak with intact cuff inflation system: A case report with brief review of literature
Hemalatha Pasupuleti, Aloka Samantaray, Kasturi Surapneni, Hemanth Natham
November 2015, 59(11):760-761
DOI:10.4103/0019-5049.170044  PMID:26755848
  966 216 -
"No rent is small for migration of epidural catheter into sub-arachnoid space"
Ashok Jadon
November 2015, 59(11):764-764
DOI:10.4103/0019-5049.170049  PMID:26755851
  911 213 1
Superior vena cava syndrome due to catheter related thrombus in a patient with a permanent pacemaker
Swetha Malenahalli Chandrashekarappa, Sudheer Othiyil Vayoth, Murukesh Seetharaman, Lakshmi Kumar
November 2015, 59(11):758-760
DOI:10.4103/0019-5049.170042  PMID:26755847
  866 211 -
In response to comments on: No rent is small for migration of epidural catheter into subarachnoid space
Manish Tandon, Chandra Kant Pandey
November 2015, 59(11):765-765
  883 171 -
Role of transoesophageal echocardiography in peri-operative management of cardiac hydatid cyst
Sathappan Karuppiah, Satishkumar Dharmalingam, Raj Sahajanandan, Gladdy George
November 2015, 59(11):753-754
DOI:10.4103/0019-5049.170039  PMID:26755844
  857 178 -
Erratum: Safety of post-operative epidural analgesia in the paediatric population: A retrospective analysis

November 2015, 59(11):766-766
DOI:10.4103/0019-5049.170051  PMID:26755853
  852 182 1
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