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EDITORIAL |
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Aiming for small is a crime |
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SS Harsoor, D Devikarani DOI:10.4103/0019-5049.60486 PMID:20532062 |
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GUEST EDITORIAL |
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Transgression in scientific communication |
p. 2 |
PF Kotur DOI:10.4103/0019-5049.60487 PMID:20532063 |
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PRESIDENT MESSAGE |
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President's Message |
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J Ranganathan DOI:10.4103/0019-5049.60488 |
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PAST PRESIDENT ADDRESS |
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Past President Address |
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Manjushree Ray DOI:10.4103/0019-5049.60489 PMID:20532064 |
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REVIEW ARTICLE |
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Deep vein thrombosis and pulmonary embolism - Prevention, management, and anaesthetic considerations  |
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Krishan Kumar Narani DOI:10.4103/0019-5049.60490 PMID:20532065There is high incidence of venous thromboembolism, comprising of deep vein thrombosis and pulmonary embolism, in hospitalized patients. The need for systemic thromboprophylaxis is essential, especially in patients with inherited or acquired patient-specific risk factors or in patients undergoing surgeries associated with high incidence of postoperative deep vein thrombosis and pulmonary embolism. These patients, on prophylactic or therapeutic doses of anticoagulants, may present for surgery. General or regional anaesthesia may be considered depending on the type and urgency of surgery and degree of anticoagulation as judged by investigations. The dilemma regarding the type of anaesthesia can be solved if the anaesthesiologist is aware of the pharmacokinetics of drugs affecting haemostasis. The anaesthesiologist must keep abreast with the latest developments of methods and drugs used in the prevention and management of venous thromboembolism and their implications in the conduct of anaesthesia. |
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SPECIAL ARTICLE |
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Obstructive sleep apnoea syndrome in children and anaesthesia |
p. 18 |
A Rudra, Manjushree Ray, S Sengupta, Asif Iqbal, G Maitra, S Chatterjee DOI:10.4103/0019-5049.60491 PMID:20532066Obstructive sleep apnoea syndrome (OSAS) is a common medical disorder among adults, which is increasingly being recognized in children too. It is a breathing disorder characterized by upper airway obstruction with or without intermittent complete obstruction that disrupts normal breathing during sleep. Anatomical and neuromuscular disorders are mainly responsible for this disorder. This disorder leads to a state of chronic hypoxemia, which has significant cardiac, pulmonary and central nervous system implications. Diagnosis of OSAS is based on thorough history and clinical examination along with appropriate sleep studies including polysomnography. The mainstay of treatment of paediatric OSAS is adenotonsillectomy. Good anaesthetic practice in Paediatric patients with OSAS revolves around good and ideal airway management. Early detection of airway obstruction, intense monitoring to warn of impending airway problems and appropriate and early intervention of airway compromise are good anaesthetic practices. Coexisting medical problems should be adequately addressed and safe analgesic techniques in the perioperative period go towards improving outcomes in patients with paediatric OSAS. |
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CLINICAL INVESTIGATIONS |
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Transdermal nitroglycerine enhances postoperative analgesia of intrathecal neostigmine following abdominal hysterectomies |
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Fareed Ahmed, Ashish Garg, Vipul Chawla, Mamta Khandelwal DOI:10.4103/0019-5049.60492 PMID:20532067This study was carried out to assess the effect of nitroglycerine (transdermal) on intrathecal neostigmine with bupivacaine on postoperative analgesia and note the incidence of adverse effects, if any. After taking informed consent, 120 patients of ASA Grade I and II were systematically randomised into four groups of 30 each. Patients were premedicated with midazolam 0.05 mg/kg intravenously and hydration with Ringer's lactate solution 10ml/kg preoperatively in the holding room. Group I patients received Intrathecal injection of 15 mg bupivacaine with 1ml of normal saline and transdermal placebo patch. Group II patients received Intrathecal injection of 15 mg bupivacaine with 5 mcg of neostigmine and transdermal placebo patch. Group III patients received Intrathecal injection of 15 mg bupivacaine with 1ml of normal saline with transdermal nitroglycerine patch (5 mg/24 hours). Group IV patients received Intrathecal injection of 15 mg bupivacaine with 5mcg of neostigmine and transdermal nitroglycerine patch (5 mg/24 hours), applied on a non anaesthetised area after 20 minutes. Groups were demographically similar and did not differ in intraoperative characteristics like sensory block, motor block, haemodynamic parameters and SpO 2 . The mean duration of analgesia was 202.17 minutes, 407.20 minutes, 207.53 minutes and 581.63 minutes in control group (I), neostigmine group (II), nitroglycerine group (III) and nitroglycerine neostigmine group (IV) respectively (P<0.01). To conclude, our results show that transdermal nitroglycerine itself does not show any analgesic potential but it enhances the analgesic potential of intrathecal neostigmine. |
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Tracheal intubation without neuromuscular block in children |
p. 29 |
Safiya I Shaikh, Vijayalaxmi P Bellagali DOI:10.4103/0019-5049.60493 PMID:20532068Endotracheal intubation has been performed during the administration of Propofol anaesthesia without neuromuscular blockade. In the study, we have assessed tracheal intubating conditions and haemodynamic responses in children aged 4 to12 years by using combination of either Fentanyl and Propofol; or Propofol and a neuromuscular blocker, suxamethonium. Intubating conditions were assessed on a 1-4 scale based on ease of laryngoscopy, position of vocal cords, degree of coughing and jaw relaxation. Tracheal intubation was successful in 95% of patients receiving Fentanyl-Propofol and 100% of patients receiving Propofol-suxamethonium. Fentanyl-Propofol provided better haemodynamic stability than Propofol-suxamethonium. We conclude that Propofol-Fentanyl combination could be a useful alternative technique for tracheal intubation when neuromuscular blocking drugs are contraindicated or need to be avoided. |
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Comparison of bougie-guided insertion of Proseal tm laryngeal mask airway with digital technique in adults |
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Anand Kuppusamy, Naheed Azhar DOI:10.4103/0019-5049.60494 PMID:20532069The Proseal TM laryngeal mask airway (PLMA TM , Laryngeal Mask Company, UK) was designed to improve ventilatory characteristics and offer protection against regurgitation and gastric insufflation. The PLMA is a modified laryngeal mask airway with large ventral cuff, dorsal cuff and a drain tube. These modifications improve seal around glottis and enable better ventilatory characteristics. The drain tube prevents gastric distension and offers protection against aspiration. There were occasional problems, like failed insertion and inadequate ventilation, in placing PLMA TM using the classical digital technique. To overcome these problems, newer placement techniques like thumb insertion technique, introducer tool placement and gum elastic bougie (GEB)-aided placement were devised. We compared classical digital placement of PLMA TM with gum elastic bougie-aided technique in 60 anaesthetised adult patients (with 30 patients in each group) with respect to number of attempts to successful placement, effective airway time, airway trauma during insertion, postoperative airway morbidity and haemodynamic response to insertion. The number of attempts to successful placement, airway trauma during insertion and haemodynamic response to insertion were comparable among the two groups, while effective airway time and oropharyngeal leak pressure were significantly higher in bougie- guided insertion of PLMA. Postoperatively, sore throat was more frequent with digital technique while dysphagia was more frequent with bougie-guided technique. Hence gum elastic bougie guided, laryngoscope aided insertion of PLMA is an excellent alternate to classical digital technique. |
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MEDICOLEGAL ARTICLE |
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Medicolegal Article |
p. 39 |
SC Parakh PMID:20532070 |
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CLINICAL INVESTIGATIONS |
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Quantifying the effect of isoflurane and nitrous oxide on somatosensory-evoked potentials |
p. 40 |
Usha Devadoss, S Babu, VT Cherian DOI:10.4103/0019-5049.60496 PMID:20532071Anaesthetic techniques may have a significant effect on intraoperative-evoked potentials (EP). The present study is designed to compare Propofol anaesthesia with Isoflurane (with or without nitrous oxide) during intraoperative somatosensory-evoked potential (SSEP) monitoring in 15 ASA Grade I and II patients undergoing surgery for intracranial tumours. SSEPs in response to median and posterior tibial nerve stimulation were recorded under four different anaesthetic conditions:
1) Propofol infusion and ventilation with air-oxygen, 2) Isoflurane, 1.0 MAC and ventilation with air-oxygen, 3) Isoflurane 1.0 MAC and ventilation with nitrous oxide-oxygen, and 4) Return to Isoflurane, 1.0 MAC and ventilation with air-oxygen. Intraoperative monitoring of somatosensory evoked potentials is best recordable using Propofol. The morphology of the EP is reproducible with Isoflurane. This effect is exaggerated when it is advisable to avoid nitrous oxide.
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Optimal external laryngeal manipulation versus McCoy blade in active position in patients with poor view of glottis on direct laryngoscopy |
p. 45 |
Arumugam Vasudevan, Ranjani Venkat, Ashok Shankar Badhe DOI:10.4103/0019-5049.60497 PMID:20532072Successful endotracheal intubation requires a clear view of glottis. Optimal external laryngeal manipulation may improve the view of glottis on direct laryngoscopy with Macintosh blade, but it requires another trained hand. Alternatively, McCoy laryngoscope with elevated tip may be useful. This study has been designed to compare the two techniques in patients with poor view of glottis. Two hundred patients with 'Grade 2 or more' view of glottis on direct laryngoscopy with Macintosh blade are included in the study. Optimal external laryngeal manipulation was applied, followed by laryngoscopy with McCoy blade in activated position; and the view was noted in both situations. The two interventions were compared using Chi-square test. The overall changes, in the views, were analyzed with Wilcoxon signed rank test. Both the techniques improved the view of glottis significantly (P<0.05). Optimal external laryngeal manipulation was significantly better than McCoy laryngoscope in active position, especially in patients with Grade 3 or 4 baseline view, poor oropharyngeal class, decreased head extension and decreased submandibular space (odds ratio = 2.36, 3.17, 3.22 and 26.48 respectively). To conclude, optimal external laryngeal manipulation is a better technique than McCoy laryngoscope in patients with poor view of glottis on direct laryngoscopy with Macintosh blade. |
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CASE REPORTS |
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Significant air embolism: A possibility even with collapsible intravenous fluid containers when used with rapid infuser system |
p. 49 |
Deepanjali Pant, Krishan Kumar Narani, Jayashree Sood DOI:10.4103/0019-5049.60498 PMID:20532073Significant venous air embolism may develop acutely during the perioperative period due to a number of causes such as during head and neck surgery, spinal surgery, improper central venous and haemodialysis catheter handling, etc. The current trend of using self collapsible intravenous (IV) infusion bags instead of the conventional glass or plastic bottles has several advantages, one of thaem being protection against air embolism. We present a 56-year-old man undergoing kidney transplantation, who developed a near fatal venous air embolism during volume resuscitation with normal saline in collapsible IV bags used with rapid infuser system. To our knowledge, this problem with collapsible infusion bags has not been reported earlier. |
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CASE REPORTS |
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Continuous cervical epidural analgesia for Isshiki type - I thyroplasty |
p. 52 |
Vandana Trivedi DOI:10.4103/0019-5049.60499 PMID:20532074 |
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CASE REPORTS |
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Refractory hypotension due to intraoperative hypothermia during spinal instrumentation |
p. 56 |
Ponniah Vanamoorthy, Mihir P Pandia, Parmod K Bithal, Sebastian S Valiaveedan DOI:10.4103/0019-5049.60500 PMID:20532075We report a case of inadvertent hypothermia leading to severe hypotension resistant to high dose vasopressors, which responded to temperature correction in a patient undergoing spinal instrumentation surgery. A 60-year-old female developed severe hypotension during spinal instrumentation surgery. After review of all factors it was found to be secondary to hypothermia. The patient did not respond to high dose vasopressors. However, when normothermia was restored she recovered uneventfully. Patients undergoing lengthy spinal procedures in prone position are vulnerable to develop hypothermia and consequent cardiovascular depression so adequate measures should be taken to prevent hypothermia. |
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Management of difficult airway in penetrating cervical spine injury |
p. 59 |
Mukesh Kumar Prasad, Ajay Kumar Sinha, Umesh Kumar Bhadani, Balbir Chabra, Kanchan Rani, Bhavana Srivastava DOI:10.4103/0019-5049.60501 PMID:20532076Management of airway in trauma victim with penetrating cervical/thoracic spine injury has always been a challenge to the anaesthesiologist. Stabilisation of spine during airway manipulation, to prevent any further neural damage, is of obvious concern to the anaesthesiologist. Most anaesthesiologists are not exposed to direct laryngoscopy and intubation in lateral position during their training period. Tracheal intubation in the lateral position may be unavoidable in some circumstances. Difficult airway in an uncooperative patient compounds the problem to secure airway in lateral position. We present a 46-year-old alcoholic, hypertensive, morbidly obese person who suffered a sharp instrument (screwdriver) spinal injury with anticipated difficult intubation; the case was managed successfully. |
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Anaesthetic management of closed mitral valvotomy for severe mitral stenosis with traumatic kyphoscoliosis |
p. 62 |
AM Jagadeesh, N Manjunath, Venugopal Ram Rao, Sunitha A Sathyakumari DOI:10.4103/0019-5049.60502 PMID:20532077A 42-year-old male patient with rheumatic mitral stenosis was posted for percutaneous transluminal mitral commissurotomy. He had associated traumatic kyphoscoliosis and osteoarthritis of hip and knee joints, causing severe permanent flexion of these joints. This position caused technical difficulty in approach to the femoral vessels. So he was rescheduled for closed mitral valvotomy. This also posed similar problems, but was successfully managed. |
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Transnasal TOE: An alternate approach in the setting of difficult probe placement for seated spinal surgery |
p. 65 |
Michael G Fitzsimons, Brinda Kamdar, Johnica Eyvazzadeh, B Heidi DOI:10.4103/0019-5049.60503 PMID:20532078Transnasal transoesophageal echocardiography may be an effective alternative approach when difficulty is encountered while placing a probe for patients with severe kyphoscoliosis. We describe a successful approach in a patient presenting for orthopaedic fixation and review the current literature. |
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OBITUARIES |
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Obituaries |
p. 67 |
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LETTERS TO EDITOR |
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Cauda equina syndrome following an uneventful spinal anaesthesia |
p. 68 |
Mamta Jain, Uma Srivastava, S Saxena, Anish K Singh, Aditya Kumar DOI:10.4103/0019-5049.60505 PMID:20532079 |
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Are we reluctant to share our experiences through E-mail and still love postal survey? |
p. 69 |
Ashok Jadon DOI:10.4103/0019-5049.60506 PMID:20532080 |
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Ankylosing spondylitis: A challenge to anaesthesiologists due to difficulties in airway management and systemic involvement of disease |
p. 70 |
Anand T Talikoti, K Dinesh, Anand Kumar, Goolappa DOI:10.4103/0019-5049.60507 PMID:20532081 |
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Succinylcholine relaxant: Anaesthesiologist not relaxed! |
p. 71 |
Sarah Ninan, L Jeslin, PA Saravanan, Kamal Kumar DOI:10.4103/0019-5049.60508 PMID:20532082 |
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Is sterile supply department meant for sterilization or adding more trouble? |
p. 72 |
Kiran Dasari DOI:10.4103/0019-5049.60509 PMID:20532083 |
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Right middle cerebral artery aneurysm posted for clipping on dual anti-platelet therapy |
p. 73 |
Satyen Parida, Sandeep Kumar Mishra, K Sudeeep, Ashok Shankar Badhe DOI:10.4103/0019-5049.60510 PMID:20532084 |
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Prevention of aspiration of nasopharyngeal airway |
p. 74 |
Paul J Grube, Dapeng Fan, Vijayasimha R Pothula, Charles T Vonfrolio, David Tsang, David Hoffman DOI:10.4103/0019-5049.60511 PMID:20532085 |
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Anaesthetic considerations in metabolic syndrome X |
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Nitesh Goel, Kapil Gupta, Poonam Bhadoria, Raktima Anand DOI:10.4103/0019-5049.60512 PMID:20532086 |
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Use of paediatric face mask for adult ventilation in a patient with nasal tumour |
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Sameer Sethi, Vikramjeet Arora, Hemant Bhagat, Arun Sharma DOI:10.4103/0019-5049.60513 PMID:20532087 |
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