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EDITORIAL |
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Probing the future - Can gastric ultrasound herald a change in perioperative fasting guidelines? |
p. 735 |
Goneppanavar Umesh, CA Tejesh DOI:10.4103/ija.IJA_669_18 PMID:30443053 |
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REVIEW ARTICLE |
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Perioperative stroke – Prediction, Prevention, and Protection |
p. 738 |
Amarja S Nagre DOI:10.4103/ija.IJA_292_18 PMID:30443054
Stroke culminates into 6.2 million deaths annually and is thereby a leading cause of disability and death worldwide. In patients undergoing noncardiac, nonneurological surgery, perioperative stroke can eventuate into a catastropic aftermath with almost eight-fold rise in mortality. In cardiac, neurological, and carotid surgery, stroke rate accounts to be high (2.2%–5.2%) and is a significant instigator of morbidity and mortality as well. These facts kindle interest to review the predictive parameters, preventive measures, and all the possibilities in the management and protection against perioperative stroke.
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SPECIAL ARTICLE |
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Anaesthesiologist and social media: Walking the fine line |
p. 743 |
S Kiran, Navdeep Sethi DOI:10.4103/ija.IJA_449_18 PMID:30443055
Social media use is pervasive in society and has been rapidly amalgamated into the lives of anaesthesiologists. Using social media as an educational resource and ensuring an appropriate online presence is essential for professional growth. However, there are huge lacunae in editorial responsibility, peer review, and accountability of educational content on social media networks. The anaesthesiologist needs to be aware of the numerous shortcomings and must use social media responsibly. Following etiquettes, adopting a code of conduct and a high sense of professionalism is expected from the anaesthesiologist while posting on social media. Anaesthesiologists need to decide on their social media goals, like interaction with colleagues, continuing medical education or patient education, and then register for social media accounts accordingly. The need of the hour is comprehensive social media guidelines for anaesthesiologists, endorsed by institutions, societies, and professional health-care associations in India.
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ORIGINAL ARTICLES |
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Effectiveness of standard fasting guidelines as assessed by gastric ultrasound examination: A clinical audit |
p. 747 |
Sadhvi Sharma, Alka Sachin Deo, Padmalatha Raman DOI:10.4103/ija.IJA_54_18 PMID:30443056
Background and Aims: An audit was conducted between July 2017 and November 2017 to assess the adequacy of American Society of Anesthesiologists (ASA) fasting guidelines on 246 patients by means of gastric ultrasonography (USG). The relevance of this audit is that many of our patients have one or more risk factors for aspiration such as diabetes mellitus, chronic kidney disease (CKD), gastro-oesophageal reflux disease (GERD), and obesity. Methods: This audit was a prospective observational study which included all patients posted for surgery within the audit period. Patients were fasted according to ASA fasting guidelines. Their gastric content was assessed preoperatively using USG. The residual gastric volume was calculated using a validated formula. Statistical correlation between gastric volumes and the risk factors were analysed. Results: Of 246 patients, 69 (28.04%) had high residual gastric volume. We found no correlation between hours of fasting and residual gastric volume (P = 0.47). We found a linear correlation between rising body mass index and residual gastric volume (P < 0.0001). Patients with GERD had 2.3 times higher risk. The CKD patient subgroup had 24 patients (30%) with high residual gastric volume. No incidents of aspiration were noted. Conclusion: In our audit, we found that risk factor association has a greater effect on residual gastric volume than hours of fasting. While the current fasting guidelines are adequate for healthy individuals, they are not conclusive in patients with risk factors. Ultrasound assessment of preoperative gastric volume is an effective screening tool in patients with risk factors.
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Preoperative assessment of gastric contents and volume using bedside ultrasound in adult patients: A prospective, observational, correlation study  |
p. 753 |
Garima Sharma, Rebecca Jacob, Subramanyam Mahankali, MN Ravindra DOI:10.4103/ija.IJA_147_18 PMID:30443057
Background and Aims: Pulmonary aspiration of gastric contents is a serious complication of anaesthesia. The aim of this study was to determine, with the help of ultrasound, the gastric volume and content in fasted patients presenting for elective surgeries and correlate the results with fasting times and co-morbidities of the patients. Methods: The study was conducted in 100 adult patients presenting for elective surgery. A preoperative bedside gastric ultrasound scan was done in supine and right lateral position. Gastric contents were noted, and gastric volume was calculated at the level of the gastric antrum. Gastric volume was estimated by measuring antral cross-sectional area (CSA) and using a mathematical model. Gastric volume in the right lateral decubitus (RLD) position was taken as the final reading. Analysis of variance and Student's t-test were done for statistical significance and P < 0.05 was considered statistically significant. Results: Six out of 100 patients had solid gastric contents and 16 had >1.5 ml/kg clear liquids, although they had been fasting between 10 and 15 hours. Patients suffering from diabetes and chronic kidney disease had statistically significant increase in CSA in both supine and RLD. We also found increase in estimated gastric volume as the BMI of the patients increased. Conclusion: Our study showed that fasting for more than 6–10 hours does not guarantee an empty stomach. Those with co-morbidities like diabetes mellitus, obesity and chronic kidney disease (CKD) appear more prone to have unsafe gastric contents.
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Comparing epidural and wound infiltration analgesia for total abdominal hysterectomy: A randomised controlled study |
p. 759 |
Pooja Lal Ammianickal, Chitra Rajeswari Thangaswamy, Hemavathi Balachander, Murali Subbaiah, N C Pankaj Kumar DOI:10.4103/ija.IJA_124_18 PMID:30443058
Background and Aims: Continuous wound infiltration (CWI) is emerging as an alternative to continuous epidural infusion (CEI). This study compared postoperative pain scores of CEI with CWI in patients undergoing total abdominal hysterectomy (TAH). Methods: This prospective randomised controlled trial included 102 patients planned for TAH who were randomised into either Group E (CEI) or Group L (CWI). The catheter (epidural/wound infiltration) was inserted in Group E before induction) and Group L at the end of surgery. General anaesthesia was administered according to standard protocol. At the end of surgery, both groups received 10 mL bolus of 0.2% ropivacaine followed by infusion at 6 mL/h through the respective catheters. They also received intravenous patient-controlled analgesia with morphine. The primary outcome was the visual analogue score at rest (VASR) and at deep breathing (VASDB) post-operatively. Secondary outcomes were post-operative morphine consumption, side effects and patient satisfaction. Results: The mean VASR between two groups were comparable up to 8 h. Group E showed significantly reduced VASR compared to Group L at 12 h (2.32 ± 0.59 vs 2.62 ± 0.67, P = 0.019) and 24 h (2.30 ± 0.58 vs 2.62 ± 0.57, P = 0.006). Group E showed significantly reduced VASDB compared to Group L at 5 min and from 4 to 24 h. Total morphine consumption, side effects and patient satisfaction were comparable. Conclusion: We conclude that CEI is a superior analgesic technique compared to CWI in total abdominal hysterectomy in terms of reduced pain scores.
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Continuous spinal anaesthesia: A retrospective analysis of 318 cases |
p. 765 |
Zhi Yuen Beh, Phui Sze Au Yong, Siyu Lye, Sneha Elizabeth Eapen, Chee Seng Yoong, Kwee Lian Woon, Jimmy Guan Cheng Lim DOI:10.4103/ija.IJA_387_18 PMID:30443059
Background and Aims: Continuous spinal anaesthesia (CSA) is an underutilised anaesthetic technique. Our objectives were to evaluate the use of CSA in our institution, its efficacy, ease to use and safety. Methods: This was a retrospective analysis conducted in a tertiary centre. Records of all patients who underwent surgery and received CSA between December 2008 and July 2017 were reviewed. Their demographic profiles, type and duration of surgery were analysed. The outcomes measured were the success of CSA, technical evaluation and difficulties encountered, intraoperative haemodynamics, usage of vasopressors and any reported complications. Statistical analysis was done using Chi-square test. Results: Three hundred and eighteen patients (94%) successfully underwent surgery using CSA. Twenty cases (6%) had failed CSA, of which five of them had CSA insertion failure, while the rest failed to complete the operation under CSA, thus requiring conversion to general anaesthesia. Patients who have had an initial intrathecal local anaesthetic (LA) volume ≥1.5 ml had higher odds (odds ratio (OR) 2.78; 95% confidence interval [CI], 1.70–4.57) of developing hypotension compared to those who had <1.5 ml (P < 0.001). There were no reported post-dural puncture headache, neurological sequelae or infection. Conclusion: CSA is a useful anaesthetic technique with low failure rate. The key to achieving haemodynamic stability is by giving a small initial bolus, then titrating the block up to required height using aliquots of 0.5 ml of intrathecal LA through the catheter.
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Comparison of palonosetron and dexamethasone with ondansetron and dexamethasone for postoperative nausea and vomiting in postchemotherapy ovarian cancer surgeries requiring opioid-based patient-controlled analgesia: A randomised, double-blind, active controlled study |
p. 773 |
Amit Kumar, Sohan Lal Solanki, Gauri Raman Gangakhedkar, TS Shylasree, Kailash S Sharma DOI:10.4103/ija.IJA_437_18 PMID:30443060
Background and Aims: Patients undergoing ovarian cancer surgery after chemotherapy and requiring opioid-based patient-controlled analgesia (PCA) are at high-risk of postoperative nausea and vomiting (PONV). We aimed to assess the effect of palonosetron and dexamethasone combination for these patients for prevention of PONV. Methods: This study included 2 groups and 150 patients. At the time of wound closure, patients in group A received ondansetron 8 mg intravenous (IV) + dexamethasone 4 mg IV and group B received palonosetron 0.075 mg IV + dexamethasone 4 mg IV. Postoperatively for 48 hours, group A patients received ondansetron 4 mg 8 hourly IV, group B patients received normal saline 8 hourly IV in 2 cc syringe. The primary objective was the overall incidence of PONV. Independent t-test, Chi-square test, and Fisher's exact test were used and multivariate regression analysis was done. Results: Vomiting was significantly higher in group A (37.3%) as compared with group B (21.3%) at 0–48 hours (P = 0.031). Significantly more patients in Group A had nausea as compared with group B at 90–120 minutes (30.66% vs 18.66%, P = 0.043) and 6–24 hours (32.0% vs 22.66%, P = 0.029). PCA opioid usage in microgram was significantly higher in group A at 0–24 hours (690.53 ± 332.57 vs 576.85 ± 250.79, P = 0.024) and 0–48 hours (1126.10 ± 512.18 vs 952.13 ± 353.85, P = 0.030). Conclusion: Palonosetron with dexamethasone is more effective than ondasetron with dexamethasone for prevention of PONV in post-chemotherapy ovarian cancer surgeries receiving opioid-based patient controlled analgesia.
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EO technique provides better mask seal than the EC clamp technique during single handed mask holding by novices in anaesthetised and paralysed patients |
p. 780 |
Goneppanavar Umesh, Gopal V Gotur, Amrut Krishnananda Rao, Tim Thomas Joseph DOI:10.4103/ija.IJA_228_18 PMID:30443061
Background and Aims: Bag mask ventilation (BMV) allows for oxygenation and ventilation of patients until a definitive airway is secured and when definitive airway is difficult/impossible. This study hypothesised that the EO (thumb and index finger form a O shape around the mask) technique of mask holding provides better mask seal with the novices compared to the classic EC clamp technique (thumb and index finger form a C shape around the mask). Methods: Sixty patients participated in this double blinded, prospective, crossover study. The patients were randomly allocated to either EC or EO group. After adequate anaesthesia and neuromuscular blockade, a novice (experience of less than five attempts at BMV) held the mask with preferred hand with the allotted technique, while the ventilator provided five breaths at set pressure control of 15 cm H2O with one second each for inspiration and expiration. After recording the exhaled tidal volume (primary objective) for each breath for five consecutive breaths, the study was repeated with the other technique. Secondary outcome variables were minute ventilation, audible mask and epigastric leak. Results: The tidal volume and minute ventilation were significantly better with EO technique compared with the EC technique (P = 0.001, a tidal volume difference of 46 mL and P = 0.001, a minute volume difference of 0.51 L). Conclusion: The EO technique provides better mask seal (superior tidal volumes) than the conventional EC technique during single-handed mask holding performed by novices in the absence of other factors contributing to difficulty in mask ventilation.
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Pattern of anaesthetic equipment contamination and infection prevention in anaesthesia practice at university hospitals |
p. 786 |
Rehab M Elsaid Tash, Ahmed A Wegdan, Fatma A Amer, Rasha H A Bassyouni, Joseph M Botros DOI:10.4103/ija.IJA_41_18 PMID:30443062
Background and Aims: Infection control is essential in anaesthetic practice for both personnel and equipment used. This study aims to evaluate knowledge of anaesthesiologists about infection control practices and to detect the pattern of anaesthetic devices contamination. Methods: Cross-sectional observational study at two university hospitals was done. Self-administered questionnaires were distributed to 80 anaesthesiologists and 90 nursing staff. Forty-four samples were taken from rigid laryngoscopes (22 pairs from handle and blade) for detection of bacterial or fungal contamination. Same laryngoscopes were tested for occult blood. Results: The response rate among the physicians was 72% while for nurses 94.4%. The responses were variable reflecting lack of adequate knowledge and unsatisfactory compliance to infection control practices. Tested samples showed no fungal growth. Fourteen (31.8%) samples were negative for bacteriological contamination and 5/44 (11.4%) showed gram-positive bacilli; gram-positive cocci were isolated from 12 samples (27.3%) where Staphylococcus epidermidis and Staphylococcus aureus, respectively, shared 18.2% and 9.1% of the total samples. Gram-negative bacilli were isolated from 13 samples (29.5%), of which Klebsiella spp. were most frequent (11.4%). Both Pseudomonas aeruginosa and Acinetobacter baumannii were isolated from 6.8% each. Citerobacter spp. was isolated from 4.5%. Occult blood was found in 45.5% of samples. Conclusion: The current study showed contamination of ready-to-use laryngoscopes in operative theatres and ICUs.
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Sevoflurane versus isoflurane in shoulder arthroscopy in beach chair position in patients with prior interscalene brachial plexus block: A prospective randomised equivalency-based haemodynamic evaluation trial |
p. 793 |
Thrivikrama Padur Tantry, Harish Karanth, Sunil P Shenoy, Pramal K Shetty, Sudarshan Bhandary, Karunakara K Adappa DOI:10.4103/ija.IJA_376_18 PMID:30443063
Background and Aims: There is a paucity of literature on comparative effects of different inhalational anaesthetics in beach chair position (BCP) for shoulder arthroscopy. We aimed to investigate and compare the haemodynamic effects, anaesthetic and surgical outcomes between two inhalational agents. Methods: In this randomised study, patients of age 18–60 years, were allotted to two groups (29, sevoflurane and 28, isoflurane) and received protocol-based anaesthesia. Intraoperatively, different haemodynamic and other data were recorded. Results: All mean of averages of individual subject's vitals were comparable between the groups [P = 0.681, 0.325, 0.803, and 0.051, respectively for systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP) and heart rate (HR)]. Higher mean HR was recorded for maximum readings of isoflurane (P = 0.028). Equivalency was observed for SBP, MBP, and DBP (P = 0.000, 002, and 0.027, respectively). Process capability indices indicated that sevoflurane had better values (Pp: 0.55 versus 0.41, Ppk: 0.35 versus 0.22) for SBP as with MBP (Pp: 0.62 versus 0.51, Ppk: 0.36 versus 0.33). For achieving optimal vision, higher pump pressures (PPs) were demanded by surgeon (P = 0.025) and higher differences observed between initial and highest PPs (P = 0.027), in isoflurane subjects. Multivariable analysis revealed that no continuous predictor was able to predict the quality of vision except additional pump flow factor, for both groups. Conclusion: Both inhalational agents demonstrated equivalent haemodynamic effects. Increased arthroscopic PP requirements were observed with isoflurane anaesthesia. Sevoflurane may be superior to isoflurane during BCP arthroscopy.
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CASE REPORTS |
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Combination of lumbar erector spinae plane block and transmuscular quadratus lumborum block for surgical anaesthesia in hemiarthroplasty for femoral neck fracture |
p. 802 |
Serkan Tulgar, Mehmet Nurullah Ermis, Zeliha Ozer DOI:10.4103/ija.IJA_230_18 PMID:30443064
Femur neck fractures may occur in elderly patients with multiple co-morbidities. Spinal or general anaesthesia may not be safe in such patients, leading to a search for other safer alternatives. Herein, we report a case in which a never previously reported combination of quadratus lumborum block (QLB) and erector spinae plane block (ESPB) was successfully used as the main anaesthetic method for hemiarthroplasty. An 86-year-old female patient with severe aortic stenosis was scheduled for internal fixation or hemiarthroplasty due to right femoral neck fracture. Following sedoanalgesia, the patient was placed in lateral decubitis position and ESPB and transmuscular QLB were performed from the fourth lumbar vertebra level. Adequate and effective surgical anaesthesia was achieved and hemiarthroplasty was performed. The combination of lumbar ESPB and QLB can be used for the anaesthesia management in high-risk patients undergoing hemiarthroplasty.
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Fluoroscopic-guided erector spinae plane block: A feasible option |
p. 806 |
Ashok Jadon, Chintala Pavana Swarupa, Mohammad Amir DOI:10.4103/ija.IJA_411_18 PMID:30443065
Erector spinae plane block (ESPB) is a new truncal block which has been used successfully to manage many acute and painful conditions including multiple fractured ribs. This block is primarily an ultrasound-guided block. We have evaluated the feasibility of fluoroscopic guidance for this block. We have reported two cases of severe chest pain due to multiple fractured ribs managed successfully with ESPB given under fluoroscopic guidance.
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Erector spinae plane block: Relatively new block on horizon with a wide spectrum of application – A case series  |
p. 809 |
Kompal Jain, Vikky Jaiswal, Arun Puri DOI:10.4103/ija.IJA_263_18 PMID:30443066
Erector spinae plane (ESP) block is an interfascial plane block where a local anaesthetic is injected in a plane preferably below the erector spinae muscle. It is supposed to work at the origin of spinal nerves based on cadaveric and contrast study. It has emerged as an effective and safe analgesic regional technique. It has a wide variety of applications ranging from control of acute postoperative pain to chronic pain. In this series, we report a series of six cases, which include postoperative pain management in breast, thoracic, and abdominal surgeries along with management of two chronic pain cases to illustrate the potential uses of continuous and single-shot ESP block.
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BRIEF COMMUNICATIONS |
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Extubation success can be better predicted by diaphragmatic excursion using ultrasound compared to rapid shallow breathing index |
p. 814 |
Priya Ramakrishnan, Shahla Siddiqui DOI:10.4103/ija.IJA_428_18 PMID:30443067 |
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Anaesthetic management of tracheal restenosis in operated cases of tracheal resection and anastomosis: A retrospective review |
p. 815 |
Devangi A Parikh, Ruchi A Jain, Smita S Lele, Renuka A Bradoo DOI:10.4103/ija.IJA_213_18 PMID:30443068 |
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LETTERS TO EDITOR |
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A fatal and deceiving case of copper sulphate poisoning |
p. 819 |
Divya Gupta, Sukhyanti Kerai, Mohd S Budoo DOI:10.4103/ija.IJA_71_18 PMID:30443069 |
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Perioperative management of living donor related liver transplantation in an infant for Maple syrup urine disease |
p. 820 |
Atish Pal, Chitra Chatterji, Dileep S Rana, Subhash Gupta DOI:10.4103/ija.IJA_285_18 PMID:30443070 |
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Intraoperative error in estimation of blood loss due to change in the size of abdominal swab |
p. 822 |
Saurabh Sud, Deepak Dwivedi, Sadhan Sawhney, Shyam P Panjiyar DOI:10.4103/ija.IJA_205_18 PMID:30443071 |
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Implications of accessory pectoral muscles for ultrasound-guided thoracic wall blocks |
p. 824 |
Abhijit S Nair, Prashant Vanzar, Basanth Kumar Rayani DOI:10.4103/ija.IJA_260_18 PMID:30443072 |
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Bifid epiglottis, high-arched palate, and mental disorder in a patient with Pallister–Hall syndrome |
p. 825 |
Masanori Tsukamoto, Takashi Hitosugi, Hitoshi Yamanaka, Takeshi Yokoyama DOI:10.4103/ija.IJA_317_18 PMID:30443073 |
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Perioperative management of a neonate with Cantrell's pentalogy |
p. 827 |
Mohammed Rizwan, Kanil R Kumar, Christopher Dass, Magesh Parthiban DOI:10.4103/ija.IJA_341_18 PMID:30443074 |
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COMMENTS ON PUBLISHED ARTICLE |
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Caution: Intravenous cannula should not be used for arterial cannulation |
p. 830 |
Vandana Agarwal DOI:10.4103/ija.IJA_498_18 PMID:30443075 |
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RESPONSE TO COMMENTS |
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Response to comments: Modification of intravenous cannula for arterial line insertion: Simple yet effective technique |
p. 831 |
Ashutosh Kaushal, Ashish Bindra, Shalendra Singh DOI:10.4103/ija.IJA_568_18 PMID:30443076 |
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COMMENTS ON PUBLISHED ARTICLE |
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Concerns while monitoring patients during awake craniotomy with intraoperative magnetic resonance imaging |
p. 832 |
Kotoe Kamata, Makoto Ozaki DOI:10.4103/ija.IJA_521_18 PMID:30443077 |
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