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EDITORIAL |
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Transporting critically Ill patients: Look before you leap! |
p. 449 |
Jigeeshu V Divatia, Suhail S Siddiqui DOI:10.4103/0019-5049.186017 PMID:27512158 |
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REVIEW ARTICLE |
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Inter-hospital and intra-hospital patient transfer: Recent concepts  |
p. 451 |
Ashish Kulshrestha, Jasveer Singh DOI:10.4103/0019-5049.186012 PMID:27512159The intra- and inter-hospital patient transfer is an important aspect of patient care which is often undertaken to improve upon the existing management of the patient. It may involve transfer of patient within the same facility for any diagnostic procedure or transfer to another facility with more advanced care. The main aim in all such transfers is maintaining the continuity of medical care. As the transfer of sick patient may induce various physiological alterations which may adversely affect the prognosis of the patient, it should be initiated systematically and according to the evidence-based guidelines. The key elements of safe transfer involve decision to transfer and communication, pre-transfer stabilisation and preparation, choosing the appropriate mode of transfer, i.e., land transport or air transport, personnel accompanying the patient, equipment and monitoring required during the transfer, and finally, the documentation and handover of the patient at the receiving facility. These key elements should be followed in each transfer to prevent any adverse events which may severely affect the patient prognosis. The existing international guidelines are evidence based from various professional bodies in developed countries. However, in developing countries like India, with limited infrastructure, these guidelines can be modified accordingly. The most important aspect is implementation of these guidelines in Indian scenario with periodical quality assessments to improve the standard of care. |
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ORIGINAL ARTICLES |
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Comparative assessment of ProSeal™ laryngeal mask airway intervention versus standard technique of endotracheal extubation for attenuation of pressor response in controlled hypertensive patients |
p. 458 |
Raj Pal Singh, Michell Gulabani, Mohandeep Kaur, Rajesh Sood DOI:10.4103/0019-5049.186029 PMID:27512160Background and Aims: Swapping of the endotracheal tube with laryngeal mask airway (LMA) before emergence from anaesthesia is one of the methods employed for attenuation of pressor response at extubation. We decided to compare the placement of ProSeal ™ LMA (PLMA) before endotracheal extubation versus conventional endotracheal extubation in controlled hypertensive patients scheduled for elective surgeries under general anaesthesia. Methods: Sixty consenting adult patients were randomly allocated to two groups of thirty each; Group E in whom extubation was performed using standard technique and Group P in whom PLMA was inserted before endotracheal extubation (Bailey manoeuvre). The primary outcome parameter was heart rate (HR). The secondary outcomes were systolic, diastolic and mean blood pressure (MBP), electrocardiogram, oxygen saturation and end-tidal carbon dioxide. Two-tailed paired Student's t-test was used for comparison between the two study groups. The value of P< 0.05 was considered as statistically significant. Results: The patient characteristics, demographic data and surgical procedures were comparable in the two groups. A statistically significant decrease was observed in HR in Group P as compared to Group E. Secondary outcomes such as systolic, diastolic and MBP depicted a statistically insignificant difference. Conclusion: Bailey manoeuvre was not effective method to be completely relied upon during extubation when compared to standard extubation. |
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Post-operative hypertension, a surrogate marker of the graft function and predictor of survival in living donor liver transplant recipients: A retrospective study |
p. 463 |
Manish Tandon, Anshuman Singh, Vandana Saluja, Gaurav Dubey, Vijay Kant Pandey, Chandra Kant Pandey, Sunaina Tejpal Karna, Shweta A Singh DOI:10.4103/0019-5049.186016 PMID:27512161Background and Aims: De novo hypertension (HTN) in liver transplantation recipients is a known entity. We investigated haemodynamic behaviour after a liver transplant to see if it can predict survival to discharge from the hospital. Methods: electronic records of Haemodynamic parameters and laboratory investigations of 95 patients of living donor liver transplant (LDLT) were retrospectively analysed. Results: Twenty-three patients were operated for acute liver failure (ALF) and 72 patients for chronic liver disease (CLD). Eight patients of CLD and four of ALF did not survive. CLD patients had statistically significant rise in systolic blood pressure from the post-operative day (POD) 1 to POD 4 and diastolic blood pressure (DBP) from POD 3 to POD 6. Heart rate (HR) significantly decreased from POD 3 to POD 5. Haemodynamic parameters returned to baseline values within 20 days. Diastolic HTN had a positive predictive value of 100% for survival with 100% sensitivity and specificity. Systolic HTN had a positive predictive value of 100% for survival (sensitivity-89%, specificity-100%). ALF patients had a significant decrease in HR from POD 2 to POD 10. Bradycardia (HR ≤60/min) had a positive predictive value of 100% for survival with a sensitivity of 45% and 58% in CLD and ALF, respectively, with a specificity of 100% in both the groups. Non-survivors had no significant change in haemodynamics. In CLD group, International Normalised Ratio had statistically significant, strong negative correlation with DBP. Conclusion: Haemodynamic pattern of recovery may be used for predicting survival to discharge after LDLT. |
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A comparative study of two techniques (electrocardiogram- and landmark-guided) for correct depth of the central venous catheter placement in paediatric patients undergoing elective cardiovascular surgery |
p. 470 |
Neeraj Kumar Barnwal, Sona T Dave, Raylene Dias DOI:10.4103/0019-5049.186030 PMID:27512162Background and Aims: The complications of central venous catheterisation can be minimized by ensuring catheter tip placement just above the superior vena cava-right atrium junction. We aimed to compare two methods, using an electrocardiogram (ECG) or landmark as guides, for assessing correct depth of central venous catheter (CVC) placement. Methods: In a prospective randomised study of sixty patients of <12 years of age, thirty patients each were allotted randomly to two groups (ECG and landmark). After induction, central venous catheterisation was performed by either of the two techniques and position of CVC tip was compared in post-operative chest X-ray with respect to carina. Unpaired t-test was used for quantitative data and Chi-square test was used for qualitative data. Results: In ECG group, positions of CVC tip were above carina in 12, at carina in 9 and below carina in 9 patients. In landmark group, the positions of CVC tips were above carina in 10, at carina in 4 and below carina in 16 patients. Mean distance of CVC tip in ECG group was 0.34 ± 0.23 cm and 0.66 ± 0.35 cm in landmark group (P = 0.0001). Complications occurred in one patient in ECG group and in nine patients in landmark group (P = 0.0056). Conclusion: Overall, landmark-guided technique was comparable with ECG technique. ECG-guided technique was more precise for CVC tip placement closer to carina. The incidence of complications was more in the landmark group. |
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Anaesthesia and intensive care for simultaneous liver-kidney transplantation: A single-centre experience with 12 recipients |
p. 476 |
Akila Rajakumar, Shiwalika Gupta, Selvakumar Malleeswaran, Joy Varghese, Ilankumaran Kaliamoorthy, Mohamed Rela DOI:10.4103/0019-5049.186025 PMID:27512163Background and Aims: The perioperative management of patients presenting for simultaneous liver and kidney transplantation (SLKT) is a complex process. We analysed SLKTs performed in our institution to identify preoperative,intraoperative and post-operative challenges encountered in the management. Methods: We retrospectively studied the case records of 12 patients who underwent SLKT between 2009 and 2014 and analysed details of pre-operative evaluation and optimisation, intraoperative anaesthetic management and the implications of use of perioperative continuous renal replacement therapy (CRRT) and the post-operative course of these patients. Results: Of the total 12 cases, 4 were under 16 years of age. The indications for SLKT were primary hyperoxaluria (5), congenital hepatic fibrosis with polycystic kidney disease (2), ethanol-related end-stage liver disease (ESLD) with hepatorenal syndrome type 1 (1). Four patients had ESLD with end-stage renal disease due to other causes. Six recipients received live donor grafts and 6 patients received cadaveric grafts. Seven patients received intraoperative CRRT. Mean duration of surgery was 12.5 h. Cardiac output monitors used were trans-oesophageal echocardiogram (2), pulmonary artery catheter (1) and pulse contour cardiac output monitor (3). There was 1 sepsis-related mortality on 7th post-operative day. Conclusion: A thorough pre-operative evaluation and optimisation, knowledge and anticipation of potential problems, and meticulous intraoperative fluid management guided by appropriate monitoring and use of CRRT when needed can help in achieving successful outcomes. |
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Ultrasound-guided femoro-sciatic nerve block for post-operative analgesia after below knee orthopaedic surgeries under subarachnoid block: Comparison between clonidine and dexmedetomidine as adjuvants to levobupivacaine |
p. 484 |
Sudarshan Kumar Chaudhary, Ravinder Kumar Verma, Shelly Rana, Jai Singh, Bhanu Gupta, Yuvraj Singh DOI:10.4103/0019-5049.186027 PMID:27512164Background and Aims: The advent of ultrasonographic-guided techniques has led to increased interest in femoro-sciatic nerve block (FSNB) for lower limb surgeries. α2-agonists have been used recently as adjuvants to local anaesthetics in nerve blocks. We aimed to compare equal doses of clonidine or dexmedetomidine as an adjuvant to levobupivacaine in FSNB for post-operative analgesia. Methods: Ninety patients scheduled to undergo below knee orthopaedic surgeries under subarachnoid block were divided into three groups: Group LL (n = 30) patients received 38 mL of 0.125% levobupivacaine with 2 mL normal saline, Group LD (n = 30) patients received 38 mL of 0.125% levobupivacaine with 0.5 μg/kg dexmedetomidine and Group LC (n = 30) received 38 mL of 0.125% levobupivacaine with 0.5 μg/kg clonidine in saline to make total drug volume of 40 mL. The primary and secondary outcome variables were duration of analgesia and rescue analgesic requirement, verbal rating score respectively. Continuous variables were analysed with analysis of variance or the Kruskal–Wallis test on the basis of data distribution. Categorical variables were analysed with the contingency table analysis and the Fisher's exact test. Results: Duration of analgesia was prolonged with dexmedetomidine (10.17 ± 2.40 h) and clonidine (7.31 ± 1.76 h) as compared to control (4.16 ± 1.04 h, P= 0.00). Significantly lower pain scores were observed in dexmedetomidine group as compared to clonidine up to 8 h post-operatively. Conclusion: Equal doses of clonidine or dexmedetomidine added to levobupivacaine prolonged the duration of analgesia, decreased requirement of rescue analgesia. Dexmedetomidine delays the requirement of rescue analgesics with better pain scores as compared to clonidine. |
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Efficacy of magnesium as an adjuvant to bupivacaine in 3-in-1 nerve block for arthroscopic anterior cruciate ligament repair |
p. 491 |
Thilaka Muthiah, Mahesh K Arora, Anjan Trikha, Rani A Sunder, Ganga Prasad, Preet M Singh DOI:10.4103/0019-5049.186018 PMID:27512165Background and Aims: Three-in-one and femoral nerve blocks are proven modalities for postoperative analgesia following anterior cruciate ligament (ACL) reconstruction. The aim of this study was to evaluate the efficacy of magnesium (Mg) as an adjuvant to bupivacaine in 3-in-1 block for ACL reconstruction. Methods: Sixty patients undergoing arthroscopic ACL reconstruction were randomly allocated to Group I (3-in-1 block with 30 ml of 0.25% bupivacaine preceded by 1.5 ml of intravenous [IV] saline), Group II (3-in-1 block with 30 ml of 0.25% bupivacaine preceded by 1.5 ml of solution containing 150 mg Mg IV) or Group III (3-in-1 block with 30 ml containing 0.25% bupivacaine and 150 mg of Mg as adjuvant preceded by 1.5 ml of IV saline). Post-operatively, patients received morphine when visual analogue scale (VAS) score was ≥4. Quantitative parameters were compared using one-way ANOVA and Kruskal–Wallis test and qualitative data were analysed using Chi-square test. Results: Demographics, haemodynamic parameters, intra-operative fentanyl requirement, post-operative VAS scores and total morphine requirement were comparable between groups. Time to first analgesic requirement was significantly prolonged in Group III (789 ± 436) min compared to Group I (466 ± 290 min) and Group II (519 ± 274 min), (P = 0.02 and 0.05). Significantly less number of patients in Group III (1/20) received morphine in the first 6 h post-operatively, compared to Group I (8/20) and Group II (6/20) (P = 0.008 and 0.03). No side effects were observed. Conclusion: Mg as an adjuvant to bupivacaine in 3-in-1 block for ACL reconstruction significantly prolongs the time to first analgesic requirement and reduces the number of patients requiring morphine in the immediate post-operative period. |
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A comparative study of landmark-based topographic method versus the formula method for estimating depth of insertion of right subclavian central venous catheters |
p. 496 |
Tejesh C Anandaswamy, Vinay Marulasiddappa DOI:10.4103/0019-5049.186021 PMID:27512166Background and Aims: Subclavian central venous catheterisation (CVC) is employed in critically ill patients requiring long-term central venous access. There is no gold standard for estimating their depth of insertion. In this study, we compared the landmark topographic method with the formula technique for estimating depth of insertion of right subclavian CVCs. Methods: Two hundred and sixty patients admitted to Intensive Care Unit requiring subclavian CVC were randomly assigned to either topographic method or formula method (130 in each group). Catheter tip position in relation to the carina was measured on a post-procedure chest X-ray. The primary endpoint was the need for catheter repositioning. Mann–Whitney test and Chi-square test was performed for statistical analysis using SPSS for windows version 18.0 (Armonk, NY: IBM Corp). Results: Nearly, half the catheters positioned by both the methods were situated >1 cm below the carina and required repositioning. Conclusion: Both the techniques were not effective in estimating the approximate depth of insertion of right subclavian CVCs. |
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The comparative evaluation of safety and efficacy of unilateral paravertebral block with conventional spinal anaesthesia for inguinal hernia repair |
p. 499 |
Sunil Kumar Sinha, Yudhyavir Brahmchari, Manpreet Kaur, Aruna Jain DOI:10.4103/0019-5049.186020 PMID:27512167Background and Aims: Unilateral paravertebral block (PVB) as a sole anaesthetic technique is underutilised even in experienced hands. Hence, this study was undertaken regarding the efficacy and safety of PVB and compared with subarachnoid block (SAB) for inguinal hernia repair procedures. Methods: Sixty-three consenting adult male patients scheduled for unilateral inguinal hernia repair were randomly assigned to receive either PVB or SAB (Group P: PVBs at T10–L2 levels, 5 mL of 0.5% bupivacaine at each segment; Group S: SAB at L3–L4 level with 12.5 mg 0.5% of hyperbaric bupivacaine). Primary objective was to compare duration of post-operative analgesia and time to reach discharge criteria (modified Aldrete scores and modified post-anaesthetic discharge scoring [PADS] scores). Secondary objectives were to compare the block characteristics (time required for performing the block, time to surgical anaesthesia, time to ambulation, time to the first analgesic, total rescue analgesic consumption) and adverse effects. Independent Student's t-test was used for continuous data and Pearson Chi-square test for categorical data. P<0.05 was considered as statistically significant. Results: The duration of post-operative analgesia (min) was 384.57 ± 38.67 in Group P and 194.27 ± 20.30 in Group S (P < 0.05). Modified PADS scores were significantly higher at 4 h and 6 h (P < 0.0001) in Group P. Time to reach the discharge criteria was early in Group P than Group S. Conclusion: PVB provides excellent post-operative analgesic conditions with lesser adverse effects and shorter time to reach the discharge criteria compared to SAB. |
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CASE REPORTS |
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Failed fibreoptic intubation: 70° rigid nasendoscope and Frova introducer to the rescue |
p. 506 |
Stalin Vinayagam, MVS Satya Prakash, Pankaj Kundra, Surianarayana Gopalakrishnan DOI:10.4103/0019-5049.186028 PMID:27512168Endotracheal intubation was successfully accomplished with 70° rigid nasendoscope under video guidance in two patients in whom repeated attempts to secure airway with flexible fibreoptic bronchoscope were unsuccessful. Both patients had compromised airway (laryngeal papillomatosis and a huge thyroid swelling) and were uncooperative. Frova intubating introducer was used along with 70° rigid nasendoscope to accomplish tracheal intubation under video guidance. |
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A novel method of airway management in a case of penetrating neck injury |
p. 509 |
Malavika Kulkarni, Manjunath Prabhu, Sagar Maddineni DOI:10.4103/0019-5049.186019 PMID:27512169Direct injury to airway is a rare event and also a challenge to anaesthesiologist and surgeon. We present a case report of open tracheal injury with right pneumothorax in a young male following assault with a sharp weapon. In spite of a chest tube in situ, the patient came with collapse of one lung and tachypnoea which required surgical exploration. Lower airway was evaluated by fibre-optic bronchoscopy through the open tracheal wound while he was awake and tracheal tube was passed over the bronchoscope. There was no vascular or oesophageal injury detected. Although there was a pleural tear, there were no signs of injury to lung parenchyma. After evaluation, end to end anastomosis of the trachea was planned, for which orotracheal tube was passed with surgical assistance. Patient was shifted to post-operative high dependency unit and was electively ventilated for 7 days and was later successfully extubated under fibre-optic bronchoscope guidance. |
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BRIEF COMMUNICATIONS |
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A low cost, customised anaesthesia information management system: An evolving process |
p. 512 |
Mridul Dhar, Deepak Kumar Sreevastava, Navdeep Singh Lamba DOI:10.4103/0019-5049.186026 PMID:27512170 |
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Intraoperative hyperthermia: Can surgery itself be a cause? |
p. 515 |
Ankur Luthra, Surya K Dube, Sandeep Kumar, Keshav Goyal DOI:10.4103/0019-5049.186023 PMID:27512171 |
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LETTERS TO EDITOR |
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Anaesthetic concerns of a pregnant patient with Pott's spine for spine surgery in prone position |
p. 518 |
Geetanjali T Chilkoti, Medha Mohta, Sakshi Duggal, Ashok Kumar Saxena DOI:10.4103/0019-5049.186011 PMID:27512172 |
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Intra-hospital transfer: Human error and safety concerns with improper setting up of a cylinder-based oxygen delivery system |
p. 519 |
Dwivedi Deepak, Jinjil Kavitha, Sheshadri Kiran, Bhatnagar Vidhu DOI:10.4103/0019-5049.186015 PMID:27512173 |
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A novel technique for securing supra-glottic airway device to prevent mal-positioning |
p. 521 |
Arindam Chatterjee, Ashish Kumar Kannaujia DOI:10.4103/0019-5049.186013 PMID:27512174 |
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Intraoperative air embolism during hepatectomy |
p. 522 |
Binu Sajid, Aravinth Perumal DOI:10.4103/0019-5049.186022 PMID:27512175 |
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Difficult epidural in a patient with undiagnosed alkaptonuria |
p. 523 |
Kanchan Bilgi, Satish Jagadeeshan, Prabhakaran Venugopal DOI:10.4103/0019-5049.186010 PMID:27512176 |
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Spinal needle with prefilled syringe to prevent medication error: A proposal |
p. 525 |
Md Rabiul Alam DOI:10.4103/0019-5049.186014 PMID:27512177 |
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Post-operative pneumothorax with subcutaneous emphysema in a pre-eclamptic patient |
p. 527 |
Suresh Kumar, Ankita Kabi, Charu Bamba DOI:10.4103/0019-5049.186024 PMID:27512178 |
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ERRATUM |
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Erratum: Effect of addition of dexmedetomidine to ropivacaine 0.2% for femoral nerve block in patients undergoing unilateral total knee replacement: A randomised double blind study |
p. 529 |
DOI:10.4103/0019-5049.186031 PMID:27512179 |
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