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EDITORIAL |
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Category I caesarean delivery and preferred mode of anaesthesia: Dilemma persists |
p. 835 |
Sunanda Gupta, Alka Chhabra DOI:10.4103/ija.IJA_730_18 PMID:30532317 |
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REVIEW ARTICLE |
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Obstetric anaesthesia practice: Dashboard as a dynamic audit tool |
p. 838 |
Sunil T Pandya, Kausalya Chakravarthy, Aparna Vemareddy DOI:10.4103/ija.IJA_346_18 PMID:30532318
Rapid advances and improved networking abilities have led to the widespread adoption of technology in healthcare, especially focused on diagnostics, documentation and evaluation, or mining of data to improve outcomes. Current technology allows for rapid and accurate decision-making in clinical care decisions for individual patients, collation and analysis at different levels for administrative and financial purposes, and the ability to visualise, analyse, and share data in real time for departmental needs. The adoption of technology may help to improve efficiency and efficacy of healthcare services. Obstetric anaesthesia is a specialised area that has to address the well-being of the pregnant woman and the unborn baby simultaneously. A shift toward caesarean sections as the major mode of childbirth has led to an increased involvement of anaesthesiologists with childbirth. Decisions are often made in high pressure, time intense situations to protect maternal and foetal health. Furthermore, labour analgesia using various neuraxial and non-neuraxial techniques is being demanded by parturients frequently, and for the materno-foetal safety, risk management is the core issue. Hence, it is essential that obstetric anaesthesia teams regularly audit their outcomes to improve services and to identify potential trouble spots earlier. It may be helpful to have audit parameters displayed as visual data, rather than complex tabular and numerical data, for ease of sharing, analysis, and redressal of problem areas. We describe the design and use of an obstetric anaesthesia dashboard that we have used in our department for the past 5 years.
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ORIGINAL ARTICLES |
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Influence of anaesthetic technique on maternal and foetal outcome in category 1 caesarean sections – A prospective single-centre observational study |
p. 844 |
Chitra Rajeswari Thangaswamy, Pankaj Kundra, Savitri Velayudhan, Lakshmi Narasimhan Aswini, P Veena DOI:10.4103/ija.IJA_406_18 PMID:30532319
Background and Aims: In category 1 caesarean section (CS), there is limited evidence regarding superior anaesthetic technique. Hence, this study was designed to study the influence of anaesthetic technique on the maternal and foetal outcome. Methods: Patient characteristics, indication for CS, decision-to-delivery interval (DDI), uterine incision-to-delivery time (UIDT), cord blood pH, Apgar scores and neonatal and maternal outcome were noted. Composite endpoint (Apgar score <7, umbilical cord blood pH <7.2, neonatal intensive care unit admission or death) was created for adverse neonatal outcome. Logistic regression was done to assess the influence of confounding factors on the occurrence of adverse neonatal outcome. Results: Of 123 patients who underwent category 1 cesarean section, 114 patients were included for analysis. The DDI and UIDT were comparable. One and 5-min Apgar scores were significantly lower in the group general anaesthesia (GA) than in the group spinal anaesthesia (SA). The umbilical cord blood pH was comparable (7.21 ± 0.15 vs 7.25 ± 0.11 in groups GA and SA, respectively). Neonatal intensive care admission and maternal outcome were comparable in both the groups. Subgroup analysis of patients with foetal heart rate of less than 100 showed that group GA had significantly lower 1-min Apgar scores and umbilical cord blood pH and significantly more neonatal admission and mortality. Binominal logistic regression showed that group GA (odds ratio 2.9, 95% confidence intervals 1.27-6.41) and gestational age were independently associated with adverse neonatal outcome. Conclusion: GA for category 1 CS was associated with increased incidence of adverse neonatal outcome.
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Perineural vs. intravenous dexmedetomidine as an adjunct to bupivacaine in ultrasound guided fascia iliaca compartment block for femur surgeries: A randomised control trial |
p. 851 |
Ranjith K Sivakumar, Sakthirajan Panneerselvam, Anusha Cherian, Priya Rudingwa, Jagdish Menon DOI:10.4103/ija.IJA_397_18 PMID:30532320
Background and Aims: Perineural and intravenous dexmedetomidine as a local anaesthetic adjunct has not been compared previously in fascia iliaca compartment block (FICB). The aim of this study was to compare the efficacy and side effect profile of dexmedetomidine as an adjunct to bupivacaine in single dose FICB for femur surgeries in two different routes i.e., perineural and intravenous route. Methods: Eighty American Society of Anesthesiologists physical status 1, 2 or 3 patients posted for femur surgeries were randomised to receive ultrasound guided FICB. Intravenous group(ID) received 40 mL of 0.25% bupivacaine with 2 mL of 0.9% saline for FICB along with 1 μg/kg dexmedetomidine intravenous infusion over 30 min as loading dose followed by 0.5 μg/kg/h as maintenance dose till the end of surgery. Perineural group (LD) received 40 mL of 0.25% bupivacaine with 2 mL of 1 μg/kg dexmedetomidine for FICB. M ean duration of postoperative analgesia and 24 h postoperative morphine consumption as primary and secondary outcome respectively, has been compared. Results: The duration of postoperative analgesia was 8 h 36 min ± 1 h 36 min and 10 h 42 min ± 1 h 36 min for the ID and LD groups, respectively (P = 0.001). A 24 h postoperative morphine consumption in Group ID was 19.7 ± 1.9 mg compared to 17.5 ± 2.2 mg in LD groups (P = 0.001). Conclusion: Perineural dexmedetomidine effectively prolongs the USG guided FICB analgesic duration and reduces the 24 h postoperative morphine consumption when compared to intravenous dexmedetomidine as a local anaesthetic adjuvant for femur surgeries.
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A comparative evaluation of ProSeal laryngeal mask airway, I-gel and Supreme laryngeal mask airway in adult patients undergoing elective surgery: A randomised trial |
p. 858 |
Anisha Singh, Anju R Bhalotra, Raktima Anand DOI:10.4103/ija.IJA_153_18 PMID:30532321
Background and Aims: Second-generation supraglottic airway devices are widely used in current anaesthesia practice. This randomised study was undertaken to evaluate and compare laryngeal mask airway: ProSeal laryngeal mask airway (PLMA), Supreme laryngeal mask airway (SLMA) and I-gel. Methods: Eighty-four adult patients undergoing elective surgery were randomly allocated to three groups: group P (PLMA), group I (I-gel) and group S (SLMA) of 28 patients each. Insertion times, number of insertion attempts, haemodynamic response to insertion, ease of insertion of airway device and gastric tube, oropharyngeal leak pressure (OLP) and pharyngolaryngeal morbidity were assessed. The primary outcome measure was the OLP after successful device insertion. Statistical analysis was performed using Statistical Package for the Social Sciences version 18.0 software using Chi-squared/Fisher's exact test (categorical data) and analysis of variance (continuous data) tests. P < 0.05 was considered statistically significant. Results: The demographic profile of patients was comparable. OLP measured after insertion, 30 minutes later and at the end of surgery differed significantly between the three groups (P < 0.001). The mean OLP was 32.64 ± 4.14 cm·H2O in group P and 29.79 ± 3.70 cm·H2O in group S. In group I, the mean OLP after insertion was 26.71 ± 3.45 cm H2O, which increased to 27.36 ± 3.22 cm H2O at 30 minutes and to 27.50 ± 3.24 cm H2O towards the end of surgery. However, these increases were not statistically significant (P = 0.641). Device insertion time was longest for group P (P = 0.001) and gastric tube insertion time was longest for group I (P = 0.001). Haemodynamic response to insertion and pharyngolaryngeal morbidity were similar with all three devices. Conclusion: PLMA provides better sealing pressure but takes longer to insert. I-gel and SLMA have similar sealing pressures. I-gel insertion time is quicker.
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Effect of different doses of intrathecal nalbuphine as adjuvant to ropivacaine in elective lower limb surgeries: A dose finding study |
p. 865 |
Tridip Jyoti Borah, Samarjit Dey, Md Yunus, Priyanka Dev, Habib Md Reazaul Karim, Prithwis Bhattacharyya DOI:10.4103/ija.IJA_278_18 PMID:30532322
Background and Aim: Nalbuphine as an adjuvant intrathecally can produce significant analgesia with minimal side effects. However, no research has been done with isobaric ropivacaine. We, therefore, in this prospective, randomised double-blind study tried to find the optimal dose of intrathecal nalbuphine with isobaric 0.75% ropivacaine for elective lower limb surgeries. Materials and Methods: One hundred American Society of Anaesthesiologists I and II patients undergoing elective lower limb surgery were divided into four groups randomly: groups A, B, C and D, who received 0.5 mL normal saline or 0.4, 0.8 and 1.6 mg nalbuphine made up to 0.5 mL normal saline added to 22.5 mg (total volume 3.5 mL) isobaric 0.75% ropivacaine, respectively. The onset of sensory and motor block, two-segment regression time, duration of sensory and motor block, Visual Analogue Scale (VAS) and the incidence of adverse effects were compared between the groups. Results: The onset of both sensory and motor blockade was faster with addition of 0.4, 0.8 and 1.6 mg of nalbuphine when compared with ropivacaine alone; however, it was not statistically significant (P > 0.05). Two-segment regression time and duration of analgesia and motor blockade were highest with 1.6 mg of nalbuphine followed by 0.8, 0.4 and plain 0.75% ropivacaine (P < 0.05). The duration of sensory blockade in all four groups was slightly more than the duration of motor blockade. VAS readings were comparable in all nalbuphine groups when compared with ropivacaine group. Haemodynamic variability among the four groups was comparable. Incidence of adverse effects was highest in the 1.6-mg group when compared with others, although it was statistically insignificant (P > 0.05). Conclusion: Nalbuphine can be a good alternative to other opioids as an adjuvant intrathecally to prolong postoperative analgesia with a minimal side effect profile. Addition of nalbuphine to isobaric 0.75% ropivacaine gives the added advantage of significant analgesia with early motor recovery. We infer from our study that when compared with 1.6 mg of nalbuphine, both 0.4 and 0.8 mg nalbuphine are equally good as adjuvants to isobaric 0.75% ropivacaine in elective lower limb surgeries with prolonged analgesia, a reliable block with equal efficacy but with lesser side effects.
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Ultrasound-guided trigeminal nerve block and its comparison with conventional analgesics in patients undergoing faciomaxillary surgery: Randomised control trial |
p. 871 |
Amarjeet Kumar, Chandni Sinha, Ajeet Kumar, Poonam Kumari, Sailesh Kumar Mukul DOI:10.4103/ija.IJA_256_18 PMID:30532323
Background and Aims: Ultrasound (USG)-guided injection in pterygopalatine fossa is an indirect approach to block the trigeminal nerve. Trigeminal nerve block for maxillofacial surgeries may provide preemptive analgesia, reduce opioid consumption and opioid-related adverse effects. Methods: In this randomised, prospective double-blind study, 60 American Society of Anesthesiologists I/II patients, within the age group of 18–60 years scheduled for faciomaxillary surgery (fracture/pathological lesion of maxilla or mandible and cleft lip), were recruited. The patients were allocated in either of the two groups: group I: general anaesthesia (FENT group) and group II: general anaesthesia + trigeminal nerve (TNB group). Perioperative opioid consumption and postoperative pain scores were recorded. Any adverse effects like respiratory depression and nausea were also looked for. Results: Patients in group II required less intraoperative fentanyl top ups (1.17 ± 0.53 vs 2.70 ± 0.53) (P < 0.05). Postoperative opioid consumption was also less in this group (0.93 ± 0.69 vs 3.53 ± 0.68) (P < 0.05). Conclusion: USG-guided TNB reduces perioperative opioid consumption in patients undergoing faciomaxillary surgery with better patient pain scores.
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Comparative evaluation of monopolar and bipolar radiofrequency ablation of genicular nerves in chronic knee pain due to osteoarthritis |
p. 876 |
Ashok Jadon, Priyanka Jain, Mayur Motaka, Chintala Pavana Swarupa, Mohammad Amir DOI:10.4103/ija.IJA_528_18 PMID:30532324
Background and Aims: Monopolar radiofrequency ablation (MRFA) of the genicular nerve is effective in managing chronic knee pain from osteoarthritis (OA); however, the procedure itself is associated with significant pain due to manipulation of electrode to localise tiny genicular nerves. We hypothesised that inserting two electrodes to target the genicular nerves [bipolar radiofrequency ablation (BRFA)] without sensory localisation can decrease the procedural pain with equal analgesic efficacy in treating knee pain. Methods: Thirty patients with chronic knee pain due to OA were randomised to receive either MRFA (n = 15) or BRFA (n = 15), after having 50% pain relief with diagnostic genicular nerve block. Pain during the procedure (assessed by the Numeric Rating Scale [NRS]), time taken to do the procedure and complications were recorded. Knee pain was assessed by the Oxford Knee Score at baseline, 1 week, 1 month, 3 months and 6 months following the procedure. Results: Patients in both groups had good pain relief, and no difference in pain relief and the duration of pain relief was seen between the two groups. The median (range) NRS for procedural pain was significantly lower in the bipolar group [3 (3–5)] than in the monopolar group [5 (3–7), P = 0.013]. There was no significant difference in procedure time and no complications were seen in either group. Conclusion: BRFA is an effective alternative for ablation of genicular nerves in patients with knee pain due to OA. It causes less procedural pain compared with MRFA.
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Incidence and management of post-dural puncture headache following spinal anaesthesia and accidental dural puncture from a non-obstetric hospital: A retrospective analysis  |
p. 881 |
Sumitra G Bakshi, Raghuveer Singh P Gehdoo DOI:10.4103/ija.IJA_354_18 PMID:30532325
Background and Aims: Post-dural puncture headache (PDPH) is one of the complications following spinal anaesthesia (SA) and accidental dural puncture (ADP). In our institute, we routinely practice epidural analgesia (EA) for supra-major surgeries. Our previous audit on EA revealed 4% incidence of ADP. This lead us to a clinical initiative to follow-up patients with dural puncture (DP) to note the incidence, presentation, associated symptoms and treatment of PDPH. Herewith, we present the retrospective analysis over a 2-year period. Methods: Following institutional review board approval, the follow-up notes of patients who had DP from May 2011 to April 2013 were analysed retrospectively (using SPSS 20 version) with respect to the needle size, level of DP, reinsertion of epidural catheter, details of ongoing analgesics, incidence and severity of PDPH and treatment received. Results: In 2 years, we found that the incidence of PDPH in the patients who received SA was 3.9% and 25% in the ADP group. There was a positive association between needle size, type and PDPH, and it was seen more in the 20–40 age group. The commonest presentation of PDPH was occipital/frontal headache within 96 h and lasted for a mean of 3 days. All patients received pharmacological treatment. Seventy-one per cent of patients (25) were either on coffee or caffeine tablets. One case of intractable PDPH responded well to oral pregabalin 75 mg. Conclusion: PDPH severity and incidence following ADP in our centre is lower than the reported incidence from obstetric centres and can be effectively controlled with drug treatment only.
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Incidence and risk factors for development of atrial fibrillation after cardiac surgery under cardiopulmonary bypass |
p. 887 |
Sona Dave, Anand Nirgude, Pinakin Gujjar, Ritika Sharma DOI:10.4103/ija.IJA_6_18 PMID:30532326
Background and Aims: Atrial fibrillation (AF) is a common postoperative complication after cardiac surgery due to multifactorial causes. The aim of this study was to evaluate the incidence and risk factors of postoperative atrial fibrillation (POAF) after cardiac surgery under cardiopulmonary bypass (CPB). Methods: A total of 150 adult patients undergoing coronary artery bypass graft (CABG) surgery and valvular surgeries were included. They were evaluated with respect to preoperative risk factors [age, use of β-blockers, left ventricular ejection fraction (LVEF), previous myocardial infarction (MI) and diabetes], intraoperative factors (CABG or valvular surgery, duration of CPB and aortic cross clamp time) and postoperative factors (duration of inotropic support and ventilatory support). Outcome measure was POAF after cardiac surgery under CPB. Postoperative intensive care unit and hospital stay and mortality were also studied. Results: Of the patients who developed POAF, 50% were less than 60 years, 50.6% were diabetics, 50.7% had prior MI,19.7% had LVEF <40%, 82.6%were not on β-blockers, 66.7% had aortic cross clamp time >60 min and 60% had surgery with CPB time >100 min. About 38.8% underwent CABG and 43.1%underwent valvular surgery. There was a positive association with LVEF <40%, prior MI, post-bypass inotropic support greater than 10 min and ventilatory support more than 24 h with the development of POAF. Conclusion: The incidence of POAF after cardiac surgery was 40.7%. Preoperative LVEF <0.4, prior MI, CPB time >100 minand extended ventilation for >24 h were significantly associated with POAF.
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CASE REPORTS |
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Perioperative monitoring of intracranial pressure using optic nerve sheath diameter in paediatric liver transplantation |
p. 892 |
Atish Pal, Purnima Dhar, Neerav Goyal DOI:10.4103/ija.IJA_104_18 PMID:30532327
An elevation of intracranial pressure (ICP) secondary to cerebral oedema is a major contributor to morbidity and mortality in acute liver failure (ALF). We present a case of ICP monitoring with ocular ultrasonography in a 2-year-old child with ALF for liver transplantation. Since invasive ICP monitoring was risky considering the level of coagulopathy, optic nerve sheath diameter (ONSD) monitoring was done by ultrasound. A value of 4.5 mm was chosen as the cut-off for an ICP >20 mmHg in this child and was checked at regular intervals during the surgery. Ultrasonographic ONSD assessment can be a useful modality in liver transplant recipients, with severe coagulopathy and high ICP. In our specific patient scenario, ocular ultrasound proved to be a valuable safe and noninvasive monitoring tool in this paediatric patient.
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Optic nerve sheath diameter-guided extubation plan in obese patients undergoing robotic pelvic surgery in steep Trendelenburg position: A report of three cases |
p. 896 |
Nambiath Sujata, Raj Tobin, Punit Mehta, Gautam Girotra DOI:10.4103/ija.IJA_370_18 PMID:30532328
Robotic pelvic surgery requires steep Trendelenburg positioning with pneumoperitoneum which causes raised thoracic and intracranial pressures. In obese patients, the basal thoracic pressures are high. Increased intrathoracic pressure can decrease the cranial venous flow leading to deficient intracranial absorption of cerebrospinal fluid and a further increase in intracranial pressure. Operating times are also longer due to unfavorable anatomy. Such patients frequently have a delayed awakening from anaesthesia due to a combination of factors such as hypercapnoea, acidosis, and raised intracranial pressures. Normocapnoea can be achieved in a ventilated patient towards the end of surgery. In cases where the anaesthetic agents have been washed out and normocapnoea has been achieved, the intracranial pressure may be an important factor causing delayed emergence. The sonographically measured optic nerve sheath diameter correlates with the intracranial pressure. We report three cases of robot-assisted pelvic surgery in obese patients where we used the optic nerve sheath diameter as a guide for the timing of extubation.
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Anesthetic challenges in a child with Lowe's and Fanconi syndrome |
p. 900 |
Shital Digambar Chaudhari, Manpreet Kaur DOI:10.4103/ija.IJA_294_18 PMID:30532329
Oculocerebrorenal syndrome of Lowe is a rare X-linked metabolic disorder complicated by Fanconi's syndrome. Anaesthetic management of Lowe syndrome with Fanconi's syndrome is challenging to the anaesthesiologists in view of difficult airway due to microcephaly, metabolic abnormalities, and risk of peri-operative seizures. We report a successful anaesthetic management of a case of 2-year-old child scheduled for evaluation under anaesthesia following bilateral lens aspiration surgery.
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BRIEF COMMUNICATIONS |
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Organophosphate–pyrethroid combined poisoning may be associated with prolonged cholinergic symptoms compared to either poison alone  |
p. 903 |
Bhavna Gupta, Sukhyanti Kerai, Izan Khan DOI:10.4103/ija.IJA_338_18 PMID:30532330 |
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A mysterious case of unusual computed radiographic imaging artefacts: A clinician's dilemma |
p. 905 |
Harihar Vishwanath Hegde, IK Annie, Shyamsundar K Joshi, Swathy S Iyengar DOI:10.4103/ija.IJA_255_18 PMID:30532331 |
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LETTERS TO EDITOR |
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Liver transplantation for acute liver failure due to hepatitis E in a pregnant patient |
p. 908 |
Rakesh Babu, Kishore Kanianchalil, Sajeesh Sahadevan, Rajesh Nambiar, Anish Kumar DOI:10.4103/ija.IJA_149_18 PMID:30532332 |
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Awake fibreoptic bronchoscopy guided intubation – significance of sitting position |
p. 910 |
Kanil Ranjith Kumar, Sathish Raja Selvam, Banu Priya DOI:10.4103/ija.IJA_300_18 PMID:30532333 |
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Internal jaw thrust for nasogastric tube insertion |
p. 911 |
Satyajeet Misra, Bikram Kishore Behera, Alok Kumar Sahoo DOI:10.4103/ija.IJA_400_18 PMID:30532334 |
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Infraclavicular catheter as an aid to physiotherapy in postoperative patients of elbow ankylosis |
p. 913 |
Harsha H Narkhede, Viral Parekh, Deepa Kane DOI:10.4103/ija.IJA_424_18 PMID:30532335 |
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Anaesthetic management of emergency lower segment caesarean section in a patient with Ebstein's anomaly |
p. 915 |
Jayshree V Gite, Gauri R Gangakhedkar, Manali Nadkarni DOI:10.4103/ija.IJA_426_18 PMID:30532336 |
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C-MAC® D-BLADE for awake oro-tracheal intubation with minimal mouth opening – A safe alternative to fibreoptic bronchoscope |
p. 916 |
Kanil R Kumar, Renu Sinha, Pranita Mandal, Apala R Chowdhury DOI:10.4103/ija.IJA_431_18 PMID:30532337 |
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COMMENTS ON PUBLISHED ARTICLES |
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Implementation of Indian Society of Anesthesiologists' cardiopulmonary resuscitation guidelines: A bumpy road ahead? |
p. 919 |
Akhilesh Pahade, Rajiv Chawla, Shagun B Shah, AK Bhargava DOI:10.4103/ija.IJA_142_18 PMID:30532338 |
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Compression-only life support: A turning-point for Indian public health |
p. 922 |
Gauri R Gangakhedkar DOI:10.4103/ija.IJA_634_18 PMID:30532339 |
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RESPONSE TO COMMENTS |
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Indian resuscitation council cardiopulmonary resuscitation guidelines: The way ahead! |
p. 924 |
Mukul C Kapoor, Syed Moied Ahmed, Rakesh Garg DOI:10.4103/ija.IJA_646_18 PMID:30532340 |
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