Indian Journal of Anaesthesia  
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   2018| June  | Volume 62 | Issue 6  
    Online since June 11, 2018

 
 
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REVIEW ARTICLE
Intraoperative magnetic resonance imaging for neurosurgery – An anaesthesiologist's challenge
Rajashree U Gandhe, Chinmaya P Bhave
June 2018, 62(6):411-417
DOI:10.4103/ija.IJA_29_18  PMID:29962521
Intraoperative magnetic resonance imaging (MRI)-guided neurosurgery has gained popularity over the years globally. These surgeries require a dedicated operating room and MRI-compatible anaesthesia equipment. The anaesthesiologist providing care in this setup needs to be experienced and vigilant to ensure patient safety. Strict adherence to MRI safety checklists and regular personnel training would avoid potential accidents and life-threatening emergencies. Teamwork, good communication, preprocedure planning, and familiarity with the surroundings are very important for safe care and good outcomes. We performed a literature search in Google Scholar, PubMed and Cochrane databases for original and reviewed articles for the origins, development and applications of intraoperative MRI in neurosurgical procedures. Much of the research has emphasised on the surgical indications than the anaesthetic challenges faced during intraoperative MRI guided surgery. The purpose of this review is to discuss the anaesthetic concerns specific to this unique environment.
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ORIGINAL ARTICLES
A randomised controlled study of the post-operative analgesic efficacy of ultrasound-guided pectoral nerve block in the first 24 h after modified radical mastectomy
Satish Kumar, Deepali Goel, Santosh Kumar Sharma, Shahbaz Ahmad, Priyanka Dwivedi, Narendra Deo, Raka Rani
June 2018, 62(6):436-442
DOI:10.4103/ija.IJA_523_17  PMID:29962525
Background and Aims: Breast cancer has become the most common cancer in women worldwide. Acute post-operative pain following mastectomy remains a challenge for the anaesthesiologist despite a range of treatment options available. The present study aimed to compare the post-operative analgesic efficacy of pectoral nerve (Pecs) block performed under ultrasound with our standard practice of opioids and non-steroidal anti-inflammatory drugs for mastectomy. Methods: This randomised controlled study was conducted at a tertiary care teaching hospital in India, after obtaining ethical clearance. Fifty adult female patients posted for elective unilateral modified radical mastectomy were divided into two groups as follows: Group I (general anaesthesia only) and Group II (general anaesthesia plus ultrasound-guided Pecs block), each comprising 25 patients. Post-randomisation, patients in Group I received general anaesthesia, while Group II patients received ultrasound-guided Pecs block followed by general anaesthesia after 20 min. The primary outcome was measured as patient-reported pain intensity using Visual Analogue Scale (VAS) at rest. Statistical analysis was performed using Student's t-test and Mann–Whitney U-test. Data were entered into MS Excel spreadsheet and analysis was performed using the Statistical Package for the Social Sciences version 23.0. Results: VAS score was significantly lower in Group II at rest and on abduction post-operatively at all time intervals (P < 0.001). The 24-h tramadol consumption was significantly less in Group II compared to Group I (114.4 ± 4.63 mg vs. 402.88 ± 74.22, P < 0.0001). Conclusion: Pecs block provided excellent post-operative analgesia in the first 24 h.
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Comparision of Ambu AuraGain™ and LMA® ProSeal in children under controlled ventilation
Reesha Joshi, Priya Rudingwa, Pankaj Kundra, Sakthirajan Panneerselvam, Sandeep K Mishra
June 2018, 62(6):455-460
DOI:10.4103/ija.IJA_86_18  PMID:29962528
Background and Aims: The LMA ProSeal® is considered a prototype among the second-generation supraglottic airway devices (SAD). The Ambu AuraGain™ is a relatively new, single use, second-generation SAD with a preformed shape. We conducted this study with the aim of comparing the difference in clinical performance between Ambu AuraGain™ and LMA ProSeal® in children receiving controlled ventilation. Methods: Ninety-four children, aged between 6 months to 12 years, weighing 5 to 30 kg, belonging to American Society of Anesthesiologists Physical Status I and II, undergoing elective surgical procedures, were randomized into two groups. The primary end-point was oropharyngeal seal pressure, and the secondary parameters were the number of attempts, time of insertion, ease of placement of the device and gastric tube, and fiberoptic visualization of the laryngeal aperture. Results: The mean oropharyngeal seal pressure with Ambu AuraGain™ was significantly higher than LMA ProSeal® (23.3 ± 4.6 cmH2O vs 20.6 ± 4.8 cmH2O, P = 0.007, respectively). The ease and success rate for device placement, fiberoptic visualization of the larynx, and complications were comparable. However, the time for insertion in Ambu AuraGain™ group was shorter when compared to LMA ProSeal® group, median (IQR [range]); 12 (10–15) s vs 20 (18–23) s (P < 0.001), respectively. The gastric drain was significantly easier to insert in Ambu AuraGain™ compared to LMA® ProSeal (P = 0.01). Conclusion: Our study suggests that Ambu AuraGain™ could be a useful disposable alternative to LMA ProSeal® for securing airway in children.
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Paravertebral block with morphine or dexmedetomidine as adjuvant to bupivacaine for post-operative analgesia in modified radical mastectomy: A prospective, randomised, double-blind study
T Megha, Harihar Vishwanath Hegde, P Raghavendra Rao
June 2018, 62(6):424-430
DOI:10.4103/ija.IJA_79_18  PMID:29962523
Background and Aims: General anaesthesia (GA) is the standard technique and paravertebral block (PVB) is suggested as an ideal analgesic in patients undergoing modified radical mastectomy (MRM). This study assessed post-operative analgesic efficacy of morphine or dexmedetomidine as adjuvant to bupivacaine in PVB. Methods: Forty-five women (18–60 years) undergoing MRM ± axillary clearance received PVB with 20 ml bupivacaine 0.25% with morphine 3 mg (Group BM) or dexmedetomidine 1 μg/kg (Group BD) in this prospective, randomised, double-blind study. After confirming the onset of PVB, standardised GA induction sequence was used. Intra-operative consumption of fentanyl and propofol along with postoperative morphine and diclofenac consumption, numerical rating scores (NRS) for pain at rest and on movement, nausea and vomiting scores, sedation scores and time to rescue analgesic were recorded. Chi-square or Fisher's exact test and Kruskal–Wallis followed by Mann–Whitney U-test were applied as applicable. Results: The number of patients requiring morphine during first 2-h post-operatively was significantly lower (P = 0.006) in Group BM. The mean dose of morphine in Group BM (0.84 [2.41] mg) and Group BD (1.70 [1.84] mg) was comparable (P = 0.187). NRS for pain at rest and on movement was significantly lower in Group BM at 2, 6, 12 and 18 h. The duration of analgesia was significantly prolonged in Group BM (1019.8 [422.9] min) than in Group BD (263.7 [194.9] min) (P < 0.001). Conclusion: Morphine is superior adjuvant to bupivacaine in PVB for modified radical mastectomy than dexmedetomidine.
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Accuracy of skin temperature over carotid artery in estimation of core temperature in infants and young children during general anaesthesia
CK Suhail, Nandini Dave, Raylene Dias, Madhu Garasia
June 2018, 62(6):418-423
DOI:10.4103/ija.IJA_679_17  PMID:29962522
Background and Aims: Core temperature monitoring is essential in children under general anaesthesia as they are more susceptible to hypothermia. We aimed to use skin temperature over the carotid artery (Tsk-carotid) with correction factors (Cf) to estimate core temperature. Primary outcome measure was to assess the sensitivity of Tsk-carotid with Cf for detecting hypothermia. Secondary outcome measure was to assess the specificity of Tsk-carotid with Cf for detecting hypothermia. Methods: First consecutive 50 patients fulfilling the inclusion criteria were included in modelling group and next 60 in the validation group. In the modelling group, average estimation error between Tsk-carotid and Tnaso was calculated and Cf was derived by multiple regression analysis (body surface area to mass ratio, body fat %, room temperature, relative humidity and warm Gamgee). In the validation group, Cf derived was used to predict Tnaso using Tsk-carotid by the formula: Tnaso-predicted = Tsk-carotid + Cf. Bland–Altman plots were used to assess the agreement between Tsk-carotid with Cf and Tnaso in the validation group. Results: The sensitivity for detecting hypothermia with the use of Tsk-carotid and Cf was 100%. The final Cf derived was 0.064 × (room temperature) −2.65. Most of the measurements fell within 95% confidence limit of Bland–Altman plot; 95% confidence interval (0.504–[−0.451]).The specificity of this method was 11%. Conclusion: This method overestimated hypothermia in most cases and cannot be accurately used as a measure of core temperature monitoring perioperatively.
  1,286 288 -
EDITORIAL
Comments on Published Article: A valuable resource
JV Divatia
June 2018, 62(6):409-410
DOI:10.4103/ija.IJA_398_18  PMID:29962520
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ORIGINAL ARTICLES
Anaesthetic management of robotic-assisted gynaecology surgery in the morbidly obese – A case series of 46 patients in a UK university teaching hospital
Jagadish Sadashivaiah, Dabeer Ahmed, Nahid Gul
June 2018, 62(6):443-448
DOI:10.4103/ija.IJA_96_18  PMID:29962526
Background and Aims: The evolution of robotic technology has enhanced the scope of laparoscopic surgery. Morbid obesity [body mass index (BMI) >40 kg/m2] due to significant physiological attributes presents a significant surgical and anaesthetic challenge. Robotic surgery in this subset of patients can present with its own problems due to surgical requirements of prolonged pneumoperitoneum and steep Trendelenburg position. Methods: We reviewed the anaesthetic management of 46 morbidly obese patients undergoing robotic-assisted laparoscopic gynaecology surgery. Patient characteristics, anaesthetic management, length of hospital stay (LOS), complications, and readmissions within 30 days were noted. Mean with standard deviation was used for statistical analysis. Results: The mean [standard deviation (SD)] weight and BMI were 121.2 (18.49) kg and 47.83 (7.89) kg/m2, respectively. The mean (SD) anaesthetic and surgical times were 229 (75.9) and 167.7 (62.7) min, respectively. The mean (SD) LOS was 1.57 (1.03) days. About 70% of patients were discharged on the first day after surgery. Six patients needed critical care support. There were two readmissions within 30 days. Conclusion: Good preparation, teamwork, and multidisciplinary input helped us to conduct complex robotic-assisted and long-duration surgery in morbidly obese patients with minimal complications.
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COMMENTS ON PUBLISHED ARTICLE
Neuromuscular monitoring: An assistant not an alternative
Himani Tak, Prateek
June 2018, 62(6):480-481
DOI:10.4103/ija.IJA_210_18  PMID:29962536
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ORIGINAL ARTICLES
Post-operative bilateral continuous ultrasound-guided transversus abdominis plane block versus continuous local anaesthetic wound infusion in patients undergoing abdominoplasty
Eman Ramadan Salama
June 2018, 62(6):449-454
DOI:10.4103/ija.IJA_221_18  PMID:29962527
Background and Aims: Transversus abdominis plane (TAP) block and continuous local anaesthetic wound infusion are used as part of multimodal analgesia to treat postoperative pain after lower abdominal surgeries. The aim of this randomised controlled study was to assess the efficacy of the two techniques and compare the two in patients undergoing abdominoplasty. Methods: Ninety female patients undergoing abdominoplasty were allocated to receive continuous wound infusion with saline (control group, GC, n = 30), continuous bilateral TAP block with 0.25% levobupivacaine (group GT, n = 30), or continuous wound infusion with 0.25% levobupivacaine (group GW, n = 30). The primary end-point was morphine requirement in the first 48 h. Numerical rating scale (NRS) at rest and during movement, time to first morphine dose and time to first ambulation were recorded. Results: Morphine requirement in the first 48 h was significantly higher in GC than GW and GT (61.9 ± 12.8, 21.5 ± 9.5, and 18.9 ± 8.1 mg, respectively; P = 0.001), but GW and GT were comparable (P = 0.259). NRS was significantly higher in GC during movement in the first 24 h. GW and GT showed significantly longer time to first morphine dose (6.5 ± 1.7 and 8.9 ± 1.4 h, respectively, vs. 1.2 ± 0.3 h in GC) and significantly shorter time to first ambulation (7.8 ± 3.1 and 6.9 ± 3.4 h, respectively, vs. 13.2 ± 4.9 h in GC) (P = 0.001). Conclusion: Continuous bilateral ultrasound-guided TAP block and continuous local anaesthetic wound infusion significantly decreased total morphine consumption in the first 48 h compared to placebo; however, both treatment techniques were comparable.
  1,068 270 -
Multimodal temperature management during donor hepatectomy under combined general anaesthesia and neuraxial analgesia: Retrospective analysis
Manish Tandon, Sunaina Tejpal Karna, Chandra Kant Pandey, Ravindra Chaturvedi, Priyanka Jain
June 2018, 62(6):431-435
DOI:10.4103/ija.IJA_123_18  PMID:29962524
Background and Aims: Unintended hypothermia (UIH) during surgery under general anaesthesia has adverse implications. A retrospective analysis of the perioperative temperature records of healthy voluntary liver donors was done to evaluate the efficacy of a multimodal protocol for temperature management. Methods: Records of 50 American Society of Anesthesiologists physical status Class 1 patients operated for Donor Hepatectomy lasting >2 h under combined general and epidural anaesthesia were analysed. Ambient temperature was maintained 24°C–27°C before induction of GA and during insertion of epidural catheter. Active warming was done using warming mattress set to temperature 38°C, hot air blanket with temperature set to 38°C and fluid warming device (Hotline™) with preset temperature of 41°C. Nasopharyngeal temperature was continuously monitored. After induction of GA and draping of the patient, ambient temperature was decreased and maintained at 21°C–24°C and was again increased to 24°C–27°C at the conclusion of surgery. During surgery, for every 0.1°C above 37°C, one heating device was switched off such that at 37.3°C all the 3 devices were switched off. Irrigation fluid was pre-warmed to 39°C. Results: Baseline temperature was 35.9°C ± 0.4°C. Minimum temperature recorded was 35.7°C ± 0.4°C. Mean decrease in temperature below the baseline temperature was 0.2°C ± 0.2°C. Temperature at the end of surgery was 37.4°C ± 0.5°C. Conclusion: Protocol-based temperature management with simultaneous use of resistive heating mattress, forced-air warming blanket, and fluid warmer along with ambient temperature management is an effective method to prevent unintended perioperative variation in body temperature.
  1,092 203 -
Efficacy and safety of Parecoxib for prevention of catheter-related bladder discomfort in patients undergoing transurethral resection of bladder tumor: Prospective randomised trial
Ali Jendoubi, Wafa Aissi, Ahmed Abbes, Abderrazek Bouzouita, Sami Fourati, Hatem Necib, Salma Ghedira, Mohamed Houissa
June 2018, 62(6):461-465
DOI:10.4103/ija.IJA_137_18  PMID:29962529
Background and Aims: Catheter-related bladder discomfort (CRBD) is the urge to void or discomfort in the suprapubic region secondary to an indwelling urinary catheter. We aimed to evaluate the safety and efficacy of single-dose of intravenous parecoxib in reducing the incidence and severity of CRBD in patients undergoing transurethral resection of bladder tumor (TURBT). Methods: Sixty-one adult patients, American Society of Anesthesiologists physical status I or II, undergoing elective TURBT under spinal anaesthesia, were randomly allocated to receive 40 mg of IV parecoxib (group P; n = 29) or an equal volume of normal saline (control group C; n = 32). CRBD was graded as none, mild, moderate, and severe. Between-group comparisons were made for the incidence and severity of CRBD, postoperative Visual analog scales (VAS), rescue analgesia equirements, and occurrence of adverse events. Statistical analysis done with the Mann–Whitney U-test and Fisher's Exact Test. A P value of ≤ 0.05 was considered statistically significant. Results: Parecoxib significantly reduced the incidence and severity of CRBD at 2, 4, 6, and 12 hours postoperatively compared to placebo (P < 0.05). Median pain VAS scores were lower in the P group at all times except the first hour. Rescue analgesia was given to more patients in group C (16/32, 50%) than in group P (1/29) (P < 0.001). None of the patients who received parecoxib experienced an adverse event. Conclusion: A single intravenous injection of parecoxib is safe and effective in decreasing the incidence and severity of CRBD in patients undergoing TURBT. Trial Registration Identifier: NCT02729935(www.clinicaltrials.gov).
  1,063 207 -
LETTERS TO EDITOR
Difficult intubation: ‘Beyond the vocal cords’
Saurabh Mittal, Anant Mohan, Karan Madan
June 2018, 62(6):476-477
DOI:10.4103/ija.IJA_87_18  PMID:29962534
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CASE REPORT
Delayed emergence from anaesthesia and bilateral mydriasis following bilateral pallidotomy
Ankur Khandelwal, Mihir Prakash Pandia, Ritesh Lamsal
June 2018, 62(6):466-469
DOI:10.4103/ija.IJA_27_18  PMID:29962530
Pallidotomy is a surgical procedure done widely for Parkinson's disease and various dystonias refractory to medical treatment. The technique involves radiofrequency (RF) thermal coagulation of globus pallidus internus, either unilaterally or bilaterally. The technique has been shown to produce good success. However, the involvement of nearby vital structures can result in new post-operative complications. We encountered a case of delayed emergence from anaesthesia associated with bilateral mydriasis and visual field defects in a patient after bilateral RF thermal lesioning.
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LETTERS TO EDITOR
Methaemoglobinaemia: Recognition and realisation at bedside
Subramanian Senthilkumaran, MP Senthilraj, Narendra Nath Jena, Ponniah Thirumalaikolundusubramanian
June 2018, 62(6):475-476
DOI:10.4103/ija.IJA_138_18  PMID:29962533
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COMMENTS ON PUBLISHED ARTICLE
Reversal of neuromuscular block
Anju Romina Bhalotra
June 2018, 62(6):484-485
DOI:10.4103/ija.IJA_253_18  PMID:29962538
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Reversal agent is mandatory even with neuromuscular monitoring!
Sripada Gopalakrishna Mehandale, Ananda Bangera, Smruthi Vallikat Thiyath
June 2018, 62(6):482-483
DOI:10.4103/ija.IJA_280_18  PMID:29962537
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RESPONSE TO COMMENTS
Response to comments on “Reversal agents: Do we need to administer with neuromuscular monitoring”
Shilpa Goyal, Nikhil Kothari, Deepak Chaudhary, Shilpi Verma, Pooja Bihani, Mahaveer S Rodha
June 2018, 62(6):486-487
DOI:10.4103/ija.IJA_237_18  PMID:29962539
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LETTERS TO EDITOR
Oral gastroscope-guided bougie insertion and endotracheal intubation
Gaurav Sindwani, Aditi Suri, Rafat Shamim
June 2018, 62(6):478-479
DOI:10.4103/ija.IJA_64_18  PMID:29962535
  774 165 -
BRIEF COMMUNICATION
Brachytherapy implant insertion in head-and-neck cancer: Results of anaesthetic technique at a tertiary care hospital
Suruchi Ambasta, Satyen Parida, Priya Rudingwa, Sandeep Kumar Mishra
June 2018, 62(6):470-472
DOI:10.4103/ija.IJA_206_18  PMID:29962531
  718 140 -
LETTERS TO EDITOR
Air- Q intubating laryngeal airway guided intubation in Morquio syndrome
Sadik Mohammed, Sunit Kumar Gupta, Pradeep Kumar Bhatia, Swati Chhabra, Priyanka Sethi, Ravindra Singh Chouhan
June 2018, 62(6):473-474
DOI:10.4103/ija.IJA_465_17  PMID:29962532
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