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   2016| November  | Volume 60 | Issue 11  
    Online since November 9, 2016

 
 
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ORIGINAL ARTICLES
Ultrasonography - A viable tool for airway assessment
Preethi B Reddy, Pankaj Punetha, Kolli S Chalam
November 2016, 60(11):807-813
DOI:10.4103/0019-5049.193660  PMID:27942053
Background and Aims: Accurate prediction of the Cormack-Lehane (CL) grade preoperatively can help in better airway management of the patient during induction of anaesthesia. Our aim was to determine the utility of ultrasonography in predicting CL grade. Methods: We studied 100 patients undergoing general endotracheal anaesthesia. Mallampati (MP) class, thyromental distance (TMD) and sternomental distance (SMD) were noted. Ultrasound measurements of the anterior neck soft tissue thickness at the level of the hyoid (ANS-Hyoid), anterior neck soft tissue thickness at the level of the vocal cords (ANS-VC) and ratio of the depth of the pre-epiglottic space (Pre-E) to the  distance from the epiglottis to the mid-point of the distance between the vocal cords (E-VC) were obtained. CL grade was noted during intubation. Chi-square test was employed to determine if there was any statistical difference in the measurements of patients with different CL grades. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were calculated for the various parameters. Results: The incidence of difficult intubation was 14%. An ANS-VC >0.23 cm had a sensitivity of 85.7% in predicting a CL Grade of 3 or 4, which was higher than that of MP class, TMD and SMD. However, the specificity, PPV and accuracy were lower than the physical parameters. The NPV was comparable. Conclusion: Ultrasound is a useful tool in airway assessment. ANS-VC >0.23 cm is a potential predictor of difficult intubation. ANS-Hyoid is not indicative of difficult intubation. The ratio Pre-E/E-VC has a low to moderate predictive value.
  37,362 2,084 5
Critical incidents in paediatric anaesthesia: A prospective analysis over a 1 year period
Raylene Dias, Nandini Dave, Swapna Chiluveru, Madhu Garasia
November 2016, 60(11):801-806
DOI:10.4103/0019-5049.193658  PMID:27942052
Background and Aims: Critical incident reporting helps to identify errors and formulate preventive strategies. Many countries have existing national reporting systems. Such a system is yet to be established in India. We aimed to study the incidence of critical events in the paediatric operation theatre (OT) of our institute. Methods: We conducted a prospective observational study of all children receiving anaesthesia in paediatric OT over a period of 1 year. They were monitored intraoperatively as well as postoperatively, and critical incidents were noted in terms of date and time of incident, location (OT/post-anaesthesia care unit, clinical category, age of patient, degree of patient harm resulting from the incident, description of what happened and duration of surgery. Percentage incidence of critical events was calculated. Results: A total of 1206 children received an anaesthetic during the study. Incidence of critical events was 8.9% (108). Airway and respiratory events were the maximum recorded accounting for 60 (55%) incidents. There were 43 cases of oxygen desaturation out of which 21 were attributable to laryngospasm. Cardiovascular events were 12 (11.1%). Medication-related incidents were 4 (3.8%). Severe harm was reported in ten incidents, and 1 death was reported. A few uncommon incidents like change in voice following use of a cuffed endotracheal tube and post-operative acute renal failure requiring haemodialysis were noted. Conclusion: Incidence of critical incidents was almost one for every ten patients, and the audit helped us establish policy guidelines in our institution.
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EDITORIAL
The mandatory regulations from the Medical Council of India: Facts, opinions and prejudices
S Bala Bhaskar
November 2016, 60(11):793-795
DOI:10.4103/0019-5049.193656  PMID:27942050
  5,140 526 -
SPECIAL ARTICLE
Faculty promotions in medical institutions in India: Can we improve the criteria?
Vithal Krishna Dhulkhed, Madhuri S Kurdi, Pavan V Dhulkhed, Ashwini H Ramaswamy
November 2016, 60(11):796-800
DOI:10.4103/0019-5049.193657  PMID:27942051
Research publications are desirable for academic promotion in medical colleges as per the current rules of the Medical Council of India (MCI). These rules reflect an endeavour to improve the academic standards. We strongly believe that every medical college teacher should conduct true research and contribute to good peer-reviewed publications. However, it is felt that the MCI rule has the potential to lead to undesirable consequences, and the quality of teaching and learning could take a back-seat. There is an urgent need to adopt more objective criteria and better guidelines as followed by well-known global institutes. In our own country, the University Grants Commission has formulated specific guidelines for this purpose in the form of Academic Performance Indicators which, it appears, are not taken into consideration by the MCI. This article discusses the adverse impact of the rule and suggests ways for the adoption of a more scientific assessment system for faculty appointment and promotion.
  4,870 528 2
HISTORY
The isolation of morphine by Serturner
Chandrasekhar Krishnamurti, SSC Chakra Rao
November 2016, 60(11):861-862
DOI:10.4103/0019-5049.193696  PMID:27942064
  2,898 474 -
ORIGINAL ARTICLES
Pre-operative laboratory testing: A prospective study on comparison and cost analysis
Venkatesh H Keshavan, Chidananda MN Swamy
November 2016, 60(11):838-842
DOI:10.4103/0019-5049.193678  PMID:27942058
Background and Aims : Pre-operative investigations are performed before any surgical intervention under anaesthesia. Many are considered as routine. However, there are no clear guidelines regarding these in India. We aim to look at the relevance of the laboratory investigations ordered routinely and their cost implications compared with the National Institute of Clinical Excellence (NICE) guidelines. Methods: This prospective study was carried out at a tertiary care hospital. A total of 163 patients scheduled for elective surgical procedures were included in this study. Neither the surgeons nor anaesthesiologists involved in the case were aware of the study. The laboratory investigations of the patients who underwent surgery were noted. All values were categorised as normal or abnormal and they were assessed as indicated or unindicated based on NICE guidelines. Results: One hundred and sixty-three patients were subjected to a total of 984 tests. Forty three patients (26%) were subjected to tests as per NICE guidelines. Of the 984 tests, 515 tests were unindicated (52%). Out of the 515 unindicated tests, 7 (1.3%) were abnormal. None of these seven tests required any intervention or change of anaesthetic plan. The most common unindicated tests done were cardiac echocardiography and chest X-ray (92.5% and 93% respectively). The additional cost incurred towards unindicated tests was 63% of the total cost for the tests. Conclusion: Pre-operative laboratory investigations add to cost significantly. Patient premorbid conditions and surgical grade should guide the clinician to request for the relevant laboratory tests.
  2,781 452 -
Role of pre-operative multimedia video information in allaying anxiety related to spinal anaesthesia: A randomised controlled trial
Raylene Dias, Lipika Baliarsing, Neeraj Kumar Barnwal, Shweta Mogal, Pinakin Gujjar
November 2016, 60(11):843-847
DOI:10.4103/0019-5049.193681  PMID:27942059
Background and Aims: A high incidence of anxiety has been reported in patients in the operation theatre set up. We developed a short visual clip of 206 s duration depicting the procedure of spinal anaesthesia (SAB) and aimed to compare the effect of this video on perioperative anxiety in patients undergoing procedures under SAB. Methods: A prospective randomised study of 200 patients undergoing surgery under SAB was conducted. Patients were allotted to either the nonvideo group (Group NV - those who were not shown the video) or the video group (Group V - those who were shown the video). Anxiety was assessed using the Spielberger State-Trait Anxiety Inventory during the pre-anaesthetic check-up and before surgery. Haemodynamic parameters such as heart rate (HR) and mean arterial pressure (MAP) were also noted. Student's t-test was used for normally distributed and Mann-Whitney U-test for nonnormally distributed quantitative data. Chi-square test was used for categorical data. Results: Both groups were comparable with respect to baseline anxiety scores and haemodynamic parameters. The nonvideo group showed a significant increase in state anxiety scores before administration of SAB (P < 0.001). Patients in the video group had significantly lower HR and MAP preoperatively (P < 0.001). The prevalence of 'high anxiety' for SAB was 81% in our study which decreased to 66% in the video group before surgery. Conclusion: Multimedia information in the form of a short audiovisual clip is an effective and feasible method to reduce perioperative anxiety related to SAB.
  2,505 486 2
A comparison of ropivacaine, ropivacaine with tramadol and ropivacaine with midazolam for post-operative caudal epidural analgesia
A Krishnadas, K Suvarna, VR Hema, M Taznim
November 2016, 60(11):827-832
DOI:10.4103/0019-5049.193672  PMID:27942056
Background and Aims : Caudal epidural analgesia is the most commonly used method of post-operative analgesia in children undergoing subumbilical surgeries. Many additive drugs have been used to prolong the post-operative analgesia. The aim of this study was to compare the efficacy of tramadol or midazolam addition to caudal ropivacaine for post-operative analgesia in children undergoing subumbilical surgeries. Methods: In this prospective, randomised, double-blinded comparative study, sixty children of either gender, in the age group of 1-5 years and scheduled for elective subumbilical surgeries were randomly divided into three groups of twenty each. Children in Group R received an epidural injection of 1 mL/kg of 0.2% plain ropivacaine whereas children in Group RT received an epidural injection of 2 mg/kg of tramadol plus 1 mL/kg of 0.2% ropivacaine and Group RM received an epidural injection of 50 μg/kg midazolam plus 1 mL/kg of 0.2% ropivacaine. The primary outcome variable was the duration of time to rescue analgesia. The secondary outcome variables were motor block, sedation score and urinary retention. Statistical comparison among the three groups was performed using one-way ANOVA with post hoc analysis using Bonferroni. For qualitative variables, Chi-square test was used. Statistical significance was defined as P < 0.05. Results: The mean duration of time to rescue analgesia was significantly longer (P < 0.001) in Group RT (913 ± 315.5 min) and Group RM (769.2 ± 331.9 min) compared to Group R (437.75 ± 75.68 min). However, there was no significant difference in the duration of time to rescue analgesia between RT and RM groups. Motor block and sedation scores were comparable between groups. Conclusions: The addition of tramadol or midazolam to caudal epidural ropivacaine prolongs the duration of analgesia without causing significant side effects.
  2,370 609 -
CASE REPORT
Anaesthetic challenges in conjoined twins' separation surgery
Suvarna Kaniyil, Priyanka Pavithran, KK Mubarak, Taznim Mohamed
November 2016, 60(11):852-855
DOI:10.4103/0019-5049.193685  PMID:27942061
Conjoined twins are a rare congenital anomaly of unknown aetiology. We report the successful anaesthetic management of separation of ischiopagus tetrapus conjoined twins. The importance of a multidisciplinary approach, thorough pre-operative evaluation and planning, vigilant monitoring and anticipation of complications such as massive blood and fluid loss, haemodynamic instability, hypothermia and intensive, post-operative care are emphasised.
  2,471 496 -
LETTERS TO EDITOR
Pectus carinatum repair in an adolescent with hyperhomocysteinaemia: Anaesthetic implications
Prachi Kar, Suresh Kumar Chintha, Padmaja Durga, Ramachandran Gopinath
November 2016, 60(11):873-875
DOI:10.4103/0019-5049.193711  PMID:27942072
  2,677 201 -
ORIGINAL ARTICLES
Effect of melatonin on duration of delirium in organophosphorus compound poisoning patients: A double-blind randomised placebo controlled trial
HN Vijayakumar, K Ramya, Devika Rani Duggappa, KM Veeranna Gowda, K Sudheesh, SS Nethra, RS Raghavendra Rao
November 2016, 60(11):814-820
DOI:10.4103/0019-5049.193664  PMID:27942054
Background and Aims: Organophosphate compound poisoning (OPCP) is associated with high incidence of delirium. Melatonin has been tried in the treatment of delirium and has shown a beneficial effect in OPCP. This study was conducted to know the effect of melatonin on duration of delirium and recovery profile in OPCP patients. Methods: Double-blind randomised placebo control trial in which 56 patients of OPCP confirmed by history and syndrome of OPCP with low plasma pseudocholinesterase, aged >18 years and weighing between 50 and 100 kg, and Acute Physiology and Chronic Health Evaluation II score of <20 were studied. Group M (n = 26) received tablet melatonin 3 mg and Group C (n = 30) received placebo tablet at 9 PM, every night throughout the Intensive Care Unit (ICU) stay. Delirium was assessed using the Confusion Assessment Method for ICU, thrice a day. Sedation was provided with injection midazolam, fentanyl and lorazepam. Duration of mechanical ventilation, vital parameters, ICU stay, sedative and atropine requirement, were recorded. Results: The time taken to be delirium free was significantly lower in Group M (6 ± 2.92 days) compared to Group C (9.05 ± 2.75 days) (P = 0.001) and prevalence of delirium was significantly decreased in Group M compared to Group C from day 3 onwards. The requirement of midazolam (Group M - 2.98 ± 4.99 mg/day, Group C - 9.68 ± 9.17 mg/day, P < 0.001) and fentanyl (Group M - 94.09 ± 170.05 μg/day, Group C - 189.33 ± 156.38 μg/day, P = 0.03) decreased significantly in Group M. There was no significant difference in the average atropine consumption (P = 0.27), duration of mechanical ventilation (P = 0.26), ICU stay (P = 0.21) and the number of patients requiring mechanical ventilation (P = 0.50). Conclusion: Orally given melatonin in organophosphate compound poisoning patients reduces the duration of delirium and the requirement of sedation and analgesia.
  2,304 492 -
LETTERS TO EDITOR
A failure of pre-anaesthetic check-up leading to unsuspected difficult intubation
Shweta A Singh, Vijay Kant Pandey, Kelika Prakash, Vinod Choudhary
November 2016, 60(11):863-864
DOI:10.4103/0019-5049.193697  PMID:27942065
  2,444 335 -
The significance (or the insignificance) of wide pulse pressure
Ying Hui Low, Charles S Brudney, Srinivas Pyati
November 2016, 60(11):864-866
DOI:10.4103/0019-5049.193699  PMID:27942066
  2,034 332 -
ORIGINAL ARTICLES
Efficacy of methylprednisolone and lignocaine on propofol injection pain: A randomised, double-blind, prospective study in adult cardiac surgical patients
Shivaprakash Shivanna, Shio Priye, Dipali Singh, Sathyanarayan Jagannath, Syed Mudassar, Durga Prasad Reddy
November 2016, 60(11):848-851
DOI:10.4103/0019-5049.193683  PMID:27942060
Background and Aims: Propofol (2, 6-di-isopropylphenol) used for the induction of anaesthesia often causes mild to severe pain or discomfort on injection. We designed this double-blind study to compare the efficacy of methylprednisolone and lignocaine in reducing the pain of propofol injection in patients scheduled for cardiac surgery. Methods: A total of 165 adult patients, scheduled for elective cardiac surgery, were divided into three groups: saline (group S, n = 55), lignocaine 20 mg (Group L, n = 55) and methylprednisolone 125 mg diluted into 2 ml of distilled water (Group MP, n = 55). Drugs were administered after tourniquet application and occlusion was released after 1 min and 1/4 th of the total dose of propofol (2 mg/kg) was administered at the rate of 0.5 ml/s. Pain on propofol injection was evaluated by four-point verbal rating scale. Statistical methods used included Student's t-test and Chi-square test/Fisher's exact test. Results: The overall incidence of pain was 70.9% in the saline group, 30.9% in the lignocaine group and 36.4% in the methylprednisolone group. The intensity of pain was significantly less in patients receiving methylprednisolone and lignocaine than those receiving saline (P < 0.012). Conclusion: Pre-treatment with intravenous methylprednisolone was found to be as effective as lignocaine in reducing propofol injection-induced pain.
  1,820 503 -
BOOK REVIEW
Manual of ICU procedures
S Bala Bhaskar
November 2016, 60(11):877-878
DOI:10.4103/0019-5049.193716  
  1,646 518 -
ORIGINAL ARTICLES
Students' satisfaction to hybrid problem-based learning format for basic life support/advanced cardiac life support teaching
Geetanjali Chilkoti, Medha Mohta, Rachna Wadhwa, Ashok Kumar Saxena, Chhavi Sarabpreet Sharma, Neelima Shankar
November 2016, 60(11):821-825
DOI:10.4103/0019-5049.193669  PMID:27942055
Background and Aims: Students are exposed to basic life support (BLS) and advanced cardiac life support (ACLS) training in the first semester in some medical colleges. The aim of this study was to compare students' satisfaction between lecture-based traditional method and hybrid problem-based learning (PBL) in BLS/ACLS teaching to undergraduate medical students. Methods: We conducted a questionnaire-based, cross-sectional survey among 118 1 st -year medical students from a university medical college in the city of New Delhi, India. We aimed to assess the students' satisfaction between lecture-based and hybrid-PBL method in BLS/ACLS teaching. Likert 5-point scale was used to assess students' satisfaction levels between the two teaching methods. Data were collected and scores regarding the students' satisfaction levels between these two teaching methods were analysed using a two-sided paired t-test. Results: Most students preferred hybrid-PBL format over traditional lecture-based method in the following four aspects; learning and understanding, interest and motivation, training of personal abilities and being confident and satisfied with the teaching method (P < 0.05). Conclusion: Implementation of hybrid-PBL format along with the lecture-based method in BLS/ACLS teaching provided high satisfaction among undergraduate medical students.
  1,661 303 -
A nested case-control study to determine the incidence and factors associated with unanticipated admissions following day care surgery
Madhurita Singh, Manickam Ponniah, KS Jacob
November 2016, 60(11):833-837
DOI:10.4103/0019-5049.193676  PMID:27942057
Background and Aims: Day care surgery offers respite from hospitalisation for specific surgical procedures and has many advantages. However, occasionally patients who undergo such surgery require hospitalisation for unanticipated complications. We aimed to determine their incidence and to identify factors associated with unanticipated admissions in a tertiary care hospital in South India. Methods: During the 3-month study, 63 cases requiring admission and 126 randomly selected controls were taken from the 776 procedures that were performed were compared. The variables studied were patients' demographic characteristics, pre-operative medical illness, personal habits, American Society of Anesthesiologists status, the diagnosis and surgical procedures, time since last meal, duration of anaesthesia and surgery, experience of the surgeon and anaesthetist, and intraoperative management (techniques, drugs, monitoring, etc.). Univariate and bivariate statistics were used to determine factors associated with unanticipated admissions. Results: The incidence of unanticipated admissions following day care surgery was 8.11%. The reasons for admission were anaesthetic (33.33%), surgical (15.87%), medical (6.34%) and social (44.44%). The factors significantly associated with unanticipated admissions included duration of anaesthesia more than 50 min (odds ratio [OR]: 3.179; 95% confidence interval [CI]: 1.503-6.722), and starting the last case after 3 pm (OR: 10.095; 95% CI: 2.418-42.148). Conclusion: Unanticipated admissions following day care surgery occur mainly due to anaesthetic, surgical, medical and social reasons.
  1,686 255 -
BRIEF COMMUNICATIONS
Management of chronic shoulder pain with restricted mobility - a case series
Deepak Thapa, Vanita Ahuja, Deepanshu Dhiman
November 2016, 60(11):858-860
DOI:10.4103/0019-5049.193692  PMID:27942063
  1,614 281 -
Role of dexmedetomidine for sedation in a patient with schizophrenia for strabismus surgery
Ram Kumar, Renu Sinha, Riddhi Kundu, Bikash Ranjan
November 2016, 60(11):856-857
DOI:10.4103/0019-5049.193688  PMID:27942062
  1,341 241 -
LETTERS TO EDITOR
Overcoming airway challenges with the C-MAC® video laryngoscope in a child with Goldenhar syndrome
Wan Fadzlina Wan Muhd Shukeri, Rhendra Hardy Mohamad Zaini, Chong Eu Soon, Mohamad Hasyizan Hassan
November 2016, 60(11):868-869
DOI:10.4103/0019-5049.193704  PMID:27942068
  1,301 216 1
Anaesthetic management of a patient with Huntington's chorea undergoing robot-assisted nephron-sparing surgery
Ankita Batra, Neeru Sahni, Uttam K Mete
November 2016, 60(11):866-867
DOI:10.4103/0019-5049.193702  PMID:27942067
  1,291 199 -
Acquired tracheoesophageal fistula with undiagnosed tracheal stenosis: A simple innovation to avoid tracheostomy!
Vansh Priya, Rameez Riaz, Puneet Goyal, Surendra Singh
November 2016, 60(11):869-870
DOI:10.4103/0019-5049.193706  PMID:27942069
  1,224 259 -
COMMENTS ON PUBLISHED ARTICLE
Incremental epidural anaesthesia for emergency caesarean section in a patient with ostium secundum atrial septal defect and severe pulmonary stenosis with right to left shunt
Sohan Lal Solanki, Swapnil Y Parab
November 2016, 60(11):876-876
DOI:10.4103/0019-5049.193714  PMID:27942073
  1,082 212 -
LETTERS TO EDITOR
Successful Airtraq® use for emergency off-centre glottic intubation in a patient with post-dialysis neck haematoma
Anjana S Wajekar, Nirav Kotak, Rajendra Patel, Rohit Moharir
November 2016, 60(11):872-873
DOI:10.4103/0019-5049.193709  PMID:27942071
  1,103 191 1
A peculiar manufacturing defect in catheter mount
Alpesh Chhaganlal Bhanushali, Harshal Wagh
November 2016, 60(11):871-871
DOI:10.4103/0019-5049.193708  PMID:27942070
  1,075 179 -