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   Table of Contents - Current issue
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April-June 2019
Volume 35 | Issue 2
Page Nos. 145-283

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EDITORIAL  

The unending pursuit for subduing postoperative pain after cesarean section: Current gradation of transversus abdominis plane block Highly accessed article p. 145
Devendra Gupta, Rudrashish Haldar
DOI:10.4103/joacp.JOACP_304_18  
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REVIEW ARTICLES Top

Perioperative “stress dose” of corticosteroid: Pharmacological and clinical perspective p. 147
Geetanjali T Chilkoti, Anshul Singh, Medha Mohta, Ashok Kumar Saxena
DOI:10.4103/joacp.JOACP_242_17  
Various exogenous steroid preparations have been in use for a wide range of indications. We, as an anesthesiologist often encounters a surgical patient receiving chronic steroid therapy. Perioperative use of steroid is associated with major complications such as full-blown adrenal crisis in the perioperative period due to the secondary adrenal insufficiency. Henceforth, comes the role of the perioperative “stress-dose” of steroids to mitigate this rare but potentially fatal complication. There have been opposing views regarding the need and the appropriate dosage of the perioperative steroids. The present review discusses the changing concept of perioperative “stress dose” of corticosteroids, its pharmacokinetics, clinical relevance, and the related controversies such as the need and the appropriate dose.
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Exploring the transversus abdominis plane block in cesarean sections and the subsequent toxicity risk to neonates via breast milk Highly accessed article p. 153
Joshua Junge, Mario A Inchiosa, Jeff L Xu
DOI:10.4103/joacp.JOACP_343_18  
The transversus abdominis plane (TAP) block with its wide application has shown to be an analgesic effective for use in abdominal surgeries, including for cesarean section. However, the bupivacaine delivered in the TAP block comes with the risk of toxicity, both central nerve system (CNS) and cardiovascular system, and has been shown in some instances to reach maximum serum concentrations in excess of the 2 μg/mL associated with the lower end of CNS toxicity. There is a specific concern with cesarean section TAP blocks of the anesthetic passage to the neonate via maternal breast milk and whether this poses a toxicity risk. Bupivacaine has been shown to pass into maternal milk at concentrations 0.34 times the maternal serum concentration. Preliminary statistical analyses suggest that the bupivacaine delivered in breast milk is not in concentrations high enough to cause neonatal toxicity, but further studies would be useful in identifying what the toxicity risk is, if any, to the neonates' breastfeeding after the delivery and TAP block.
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H3 antagonists and postoperative cognitive dysfunction p. 157
Chandrasekhar Krishnamurti
DOI:10.4103/joacp.JOACP_141_18  
Since histamine (HA) was first synthesized in 1907 and isolated as a bacterial contaminant of an extract of ergot in 1910, its role in health and disease and its molecular mechanism of action have been unraveled, leading to the formulation of an array of drugs with immense therapeutic value. HA is produced by decarboxylation of histidine, and its biological actions are mediated through four HA receptors, namely, H1, H2, H3, and H4 based on their sequence, their link to differential intracellular signaling mechanisms, and their unique pharmacological properties. H1 and H2 receptors have been targeted for treating allergic conditions and peptic ulcers, respectively. The discovery of a third HA receptor subtype (H3R) by molecular biologists in 1983, structurally a member of the G-protein-coupled receptor family, has led to the development of many potent and selective H3 receptor antagonists having the potential to treat a wide spectrum of neurological diseases including postoperative cognitive dysfunction.
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ORIGINAL ARTICLES Top

Transversus abdominis plane (TAP) block with levobupivacaine versus levobupivacaine with dexmedetomidine for postoperative analgesia following cesarean delivery p. 161
Aman Varshney, Manjunath Prabhu, Bhavya Periyadka, Divyashri C Nanjundegowda, Amrut Rao
DOI:10.4103/joacp.JOACP_372_17  
Background and Aims: Transverse abdominus plane (TAP) block provides good quality analgesia with minimal side effects. Addition of adjuvant like dexmedetomidine to the local anesthetics has been shown to prolong the action of the block in earlier studies. In this prospective randomised study TAP block with levobupivacane with or without dexmedetomidine was compared with control group for post-operative analgesia following cesarean delivery. Material and Methods: Ninety healthy women undergoing cesarean delivery under spinal anesthesia were randomized into three groups (GroupC, GroupL and Group LD). And following this Group L received ultrasound guided bilateral TAP block with 20 ml 0.25% levobupivacaine on each side, while Group LD received TAP block with same volume of levobupivacaine with 1μg/kg of dexmedetomidine. Group C, the control group did not receive TAP block. Postoperatively, time for first request for rescue analgesia and the number of women requesting analgesia in 6 h, 12 h and 24 h were noted. Pain score was measured with the Visual Analogue Scale (VAS) at rest and on movement for the first 24 h. Patient comfort and satisfaction with analgesia was evaluated at the end of 24 h. Results: Time for first rescue analgesia was significantly longer and patient satisfaction scores were significantly higher in patients who received TAP block (Groups LD and L) as compared to control (Group C). Pain scores were also lower in the TAP block groups compared to control group. Among the women who received TAP block, those with dexmedetomidine group (Group LD) asked for rescue analgesia significantly later compared to group L. Patient satisfaction score was highest in the Group LD compared to Group L which in turn was better than control group. There were no significant differences in the observed side effects. Conclusion: Bilateral TAP block with 0.25% levobupivacaine provides good quality analgesia for early postoperative period. Adding dexmedetomidine further improves pain control and gives higher patient satisfaction without any added side effects.
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Effect of dexamethasone on analgesic efficacy of transverse abdominis plane block in laparoscopic gynecological procedures: A prospective randomized clinical study p. 165
Parasuraman Vetriselvan, Banashree Mandal, Nidhi Bhatia, Vanita Jain
DOI:10.4103/joacp.JOACP_374_17  
Background and Aims: Dexamethasone has been increasingly used as an adjuvant to local anesthetics in peripheral nerve blocks with various studies showing an opioid sparing the effect of intravenous (IV) dexamethasone as well in a multimodal analgesia technique. It is not clear whether this effect of dexamethasone is because of its peripheral action or because of its systemic absorption. In our study, we compared the effectiveness of dexamethasone on duration of analgesia when used as an adjuvant with local anesthetic in transverse abdominis plane block (TAP) versus when given systemically by IV route along with block only, in patients undergoing laparoscopic gynecological procedures under general anesthesia (GA). Material and Methods: This is a prospective, randomized, parallel treatment, double-blinded study. The primary outcome of our study was the time to administration of first rescue analgesia. Forty patients were randomly assigned to perineural (PN) and IV Group using a computer-generated random numbers table and allocated using sealed opaque envelopes technique. After induction of GA, PN group received ultrasound guided TAP block with 15 ml of 0.25% levobupivacaine plus 4 mg (1 ml) dexamethasone on each side. Patients in IV group received TAP block on both sides with 15 ml of 0.25% levobupivacaine and 8 mg IV dexamethasone. Results: Time to request for first rescue analgesia was 6.63 ± 1.5 h in PN group and 5.04 ± 1.7 h in IV group. Pain scores were comparable in both the groups. Conclusion: Dexamethasone administered in either of the routes has comparative effect on quality of analgesia of TAP block with 0.25% levobupivacaine.
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Quality of recovery and analgesia after total abdominal hysterectomy under general anesthesia: A randomized controlled trial of TAP block vs epidural analgesia vs parenteral medications p. 170
Preethy Mathew, Neelam Aggarwal, Kamlesh Kumari, Aakriti Gupta, Nidhi Panda, Rashmi Bagga
DOI:10.4103/joacp.JOACP_206_18  
Background and Aims: Parenteral analgesics and epidural analgesia are two standard options to treat postoperative pain after total abdominal hysterectomy (TAH). Fascial plane blocks such as transversus abdominis plane (TAP) block have gained popularity recently. However, effect of these analgesic regimens on quality of postoperative recovery (QoR) has not been studied. Hence we aimed to assess and compare the QoR with three different postoperative analgesic regimens---parenteral analgesia, epidural analgesia, and TAP block in patients undergoing TAH under general anesthesia. Material and Methods: Sixty female patients undergoing TAH were randomized into three groups of 20 each for postoperative analgesia. Epidural group received boluses of 0.125% bupivacaine for 24 h, parenteral group received injection diclofenac and injection tramadol alternately every 6 h for 24 h, and TAP group received bilateral TAP block with 0.25% bupivacaine at end of operation. QoR was assessed postoperatively by 40-item questionnaire-QOR-40 and pain was assessed by numerical rating scale (NRS). Results: QOR-40 score was comparable across the three groups at 24, 48, and 72 h postoperatively. TAP block prolonged the time to first rescue analgesic (P = 0.02) and reduced the total 24-h postoperative morphine consumption by 2.4 (95% CI: 1.0, 3.8) mg (P = 0.002) and 7.8 (95% CI: 6.4, 9.1) mg (P < 0.001) when compared with epidural and parenteral groups, respectively. Conclusion: The QoR after abdominal hysterectomy is similar with either intravenous analgesics or epidural analgesia or TAP block when used with rescue analgesia to manage postoperative pain. TAP block provides superior analgesia and reduces 24-h morphine consumption when compared with parenteral and epidural analgesia.
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Comparison of IV granisetron and IV palonosetron on hemodynamics and sensory and motor block after spinal anesthesia with hyperbaric bupivacaine in patients undergoing abdominal hysterectomy p. 176
Jasmeen Choudhary, Rajesh Mahajan, Arti Mahajan, Smriti Gulati, Anjali Mehta, Robina Nazir
DOI:10.4103/joacp.JOACP_334_17  
Background and Aims: The present study evaluated the effects of two 5-HT3 serotonin receptor antagonists; granisetron and palonosetron on hemodynamics, sensory, and motor blockade induced by intrathecal bupivacaine in patients undergoing abdominal hysterectomy. Material and Methods: In total, 126 female patients (ASA I and II physical status) undergoing abdominal hysterectomy under spinal anesthesia with intrathecal bupivacaine were randomly divided into three groups out of which 40 patients in each group were evaluated for final outcome. Group G received intravenous 1 mg granisetron, group P received intravenous palonosetron 0.075 mg, and group C received intravenous normal saline. Study drug was given 5 min before the spinal anesthesia. Systolic, diastolic and mean arterial blood pressure, heart rate, sensory and motor blockade were assessed. Results: The systolic blood pressure, diastolic blood pressure, mean arterial pressure, and heart rate showed no significant differences among the three groups. Time to reach peak sensory block and modified Bromage 3 motor block, time to two segmental regression of sensory block, and motor regression to modified Bromage score of 0 were not statistically different among the three groups. Although statistically significant early regression of sensory block to segment S1 was seen in group G as compared to group P and group C, it was of no clinical significance. The incidence of nausea and vomiting was significantly lower in group G and P. Conclusion: Intravenous administration of granisetron and palonosetron before intrathecal bupivacaine does not attenuate the hemodynamic changes in patients undergoing abdominal hysterectomy. Further, both 5-HT3 receptors antagonists do not have clinically significant effects on the spinal blockade produced by hyperbaric bupivacaine.
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A randomized study to compare palonosetron with ondansetron for prevention of postoperative nausea and vomiting following middle ear surgeries p. 182
Shubhangi Sharma, Sangeeta Khanna, Jyotirmoy Das, Yatin Mehta, Kumud Kumar Handa
DOI:10.4103/joacp.JOACP_196_17  
Background and Aims: Postoperative nausea and vomiting (PONV) has multifactorial etiology. It is a commonly encountered morbidity after anesthesia specially following middle ear surgery. Various antiemetic medications have been tried with mixed responses. Palonosetron is a newer 5-hydroxytryptamine (5-HT3) receptor antagonist marketed for PONV prophylaxis. This study was designed to compare the efficacy of palonosetron and ondansetron in preventing PONV after middle ear surgeries. Material and Methods: One hundred patients of ASA class 1 or 2, aged 18 years and above, weighing between 40 and 90 kg scheduled for elective middle ear surgeries were randomly assigned into palonosetron group (n = 50) and ondansetron group (n = 50). Palonosetron was administered in dose of 1 mcg/kg maximum up to 75 mcg and ondansetron in dose of 0.1 mg/kg maximum up to 8 mg. Intraoperative monitoring of QTc interval was also done to see any significant change after the antiemetic administration. The incidence of nausea, vomiting, and side effects were recorded over 2, 12, and 24 hours postoperatively. All parameters were compared between the two groups as mean ± standard deviation and as count (%). Two sided P values of <0.05 were considered significant. Results: The incidence of PONV (P = 0.002), nausea (P = 0.0002) and vomiting (P = 0.006) was significantly lower in palonosetron group than in ondansetron group in 2- to 12-hour period. QTc interval prolongation, a known side effect of ondansetron was not found in palonosetron group intraoperatively. Conclusion: Palonosetron was found to be superior to ondansetron up to 12 hours after the surgery with no significant effect on QTc interval.
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Prospective, double-blind randomized study of comparison of analgesic efficacy of parenteral paracetamol and diclofenac for postoperative pain relief p. 188
Ushma D Shah, Krunal N Dudhwala, Mukesh S Vakil
DOI:10.4103/joacp.JOACP_384_16  
Background and Aims: Injectable paracetamol has analgesic and antipyretic activities, especially used in postoperative period. The aim of this study was to assess the analgesic efficacy and safety of IV paracetamol in comparison with IV diclofenac for postoperative pain relief. Material and Methods: Randomly selected 120 patients who underwent elective surgery under general anesthesia were divided into two groups: group A (paracetamol group): patients received IV paracetamol (15 mg/kg)/100 mL, 30 min before completion of surgery over the period of 15 min (rounded of to 1 g), the selected cases were in range of 60-70 kg body weight. Group B (diclofenac group): patients received IV diclofenac (1 mg/kg) diluted in 100 mL NS, 30 min before completion of surgery over the period of 15 min (rounded of to 75 mg). Pain relief and side effects were observed in postoperative period. Statistical analysis of continuous data was done by unpaired t-test and Chi-square test was applied for discrete data. Results: Both IV paracetamol and IV diclofenac were effective for postoperative pain relief. No significant differences were found between them for any measures of analgesic activity. Only minor and common adverse events were reported, with no overall differences between groups. Conclusion: Both paracetamol and diclofenac drugs are safe to provide analgesia through IV route in postoperative period without any major significant side effects.
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A novel factor influencing perioperative midazolam administration: The effect of presentation dose on administration dose p. 192
Brent D Ershoff, Raymond Y Machi, Sheila Navi, Joe C Hong
DOI:10.4103/joacp.JOACP_156_18  
Background and Aims: Determinants of pharmaceutical unit presentations are not well understood and often appear indiscriminate. However, the dose administered may play a key role in the patient's anesthetic course. A recent change in a pharmaceutical vendor at our institution resulted in a change in midazolam presentation. In this study, we sought to determine whether the dose in which midazolam was dispensed to anesthesiologists was associated with the quantity of midazolam administered perioperatively. Material and Methods: In this retrospective, observational study, we examined 310 adult patients who underwent general anesthesia at a single site, tertiary care, university hospital before and after a change in midazolam presentation from 2 mg to 3 mg. The primary outcome was the quantity of midazolam administered during the anesthetic. Additional clinical variables measured included patient age, weight, gender, and American Society of Anesthesiology (ASA) classification. Results: The mean dose of midazolam administered to the 3 mg presentation cohort was 2.67 mg compared to 1.99 mg to the 2 mg presentation cohort (mean difference: 0.68 mg, 95% CI: 0.46–0.9 mg; P value <0.001). According to a logistic regression model, the odds of receiving a dose of 3 mg or greater in the 3 mg presentation cohort was 22 times greater than the odds of receiving such a dose in the 2 mg presentation cohort (OR: 22.3; 95% CI: 10.6–47.0; P < 0.001). This effect of presentation dose on administration dose was not observed in patients greater than or equal to 65 years of age. Conclusions: Midazolam presentation dose influences the administration dose.
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Bedside prediction of the central venous catheter insertion depth – Comparison of different techniques p. 197
Jayaprakash Jayaraman, Veena Shah
DOI:10.4103/joacp.JOACP_125_16  
Background and Aims: Central venous catheterization is a frequently performed procedure in anesthesia and critical care, and is indispensable in the practice of emergency medicine. Correct positioning of the central venous catheter (CVC) tip is often regarded as a secondary goal and there are various complications that can occur due to abnormal position of the catheter tip. Different methods have been advocated to guide accurate prediction of optimal CVC depth insertion before or during the procedure at the bedside. Material and Methods: A prospective randomized double blinded study was conducted in 180 patients aged between 18 to 65 years requiring central venous catheterization. The optimal depth of insertion of right internal jugular vein (IJV) catheter using three different techniques, Peres' formula method, Landmark technique and Intra atrial Electrocardiography (ECG) guided technique was performed and the three techniques were compared with respect to optimal positioning using carina as a landmark in post procedural chest radiograph. Correct position of the catheter tip was considered upto 1 cm above or below the carina in post procedure X ray. Results: The average final depth of insertion was 15.30 ± 0.62 cms in the Formula group, 12.74 ± 0.77 cms in landmark group and 12.64 ± 0.70 cms in ECG group. The vertical distance from carina was 0.91 ± 0.94 cms in formula group, 0.54 ± 0.67 cms in landmark group and 0.53 ± 0.43 cms in ECG group. The CVC tip was properly positioned within 1 cm above and below the carina in 58.33% patients in the formula group, 93.33% patients in landmark group and 96.67% patients in ECG group. Conclusion: We conclude that both landmark guidance and ECG guidance are comparable with regard to accurate central venous catheter tip positioning when CVCs are placed through right internal jugular vein whereas formula based technique is least accurate and results in over insertion of CVCs.
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A multicenter survey on the use of neuromuscular blockade in Greece. Does the real-world clinical practice indicate the necessity of guidelines? p. 202
Chrysanthi Batistaki, Kyriaki Vagdatli, Adelais Tsiotou, Alexandra Papaioannou, Aggeliki Pandazi, Paraskevi Matsota
DOI:10.4103/joacp.JOACP_195_18  
Background and Aims: The aim of this study was to investigate the current status of clinical practice regarding neuromuscular blocking drugs and their antagonists in Greece. Material and Methods: This is a multicenter survey, including a questionnaire based on previous studies, which was translated and modified by a Task Force of the Hellenic Society of Anaesthesiology. It was completed on a web-based database after invitation via e-mail and was left online for a period of 2 months. Results: A total of 1,100 questionnaires were sent, with a response rate of 7.9%. 13.7% stated that they do not use neuromuscular monitoring. Rocuronium was most commonly used for intubation [“often” stated by 19 (21.8%) and “very often” by 62 (71.2%)], followed by cis-atracurium, atracurium, and succinylcholine. Neostigmine and sugammadex were both used, with reversal not always administered by 23 (26.4%). Both agents were mostly used at fixed doses and not calculated based on TOF monitoring or body weight. Sugammadex was preferred in special patient groups and in operations of short duration. Reversal was most often administered based on clinical signs of neuromuscular recovery rather than objective monitoring. A significant percentage of respondents used an inadequate TOF ratio for extubation [37 (43.2%) used a TOF ratio <90%]. The reported incidence of observed residual neuromuscular blockade (RNMB) was 44.8%. Conclusion: Great variability was observed in Greek clinical practice regarding the use of neuromuscular blockade, which indicates serious issues that must be addressed. The needs for educating anesthesia providers and developing official guidelines are obvious in order to improve patient outcomes.
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Is there an interaction between dexamethasone and sugammadex in real clinical conditions? A randomized controlled trial in patients undergoing laparoscopic cholecystectomy p. 215
Chrysanthi Batistaki, Aggeliki Pandazi, Aikaterini Kyttari, Evangelia Kaminiotis, Georgia Kostopanagiotou
DOI:10.4103/joacp.JOACP_42_17  
Background and Aims: There is evidence that sugammadex can encapsulate other substances except rocuronium, such as dexamethasone. The aim of this study was to investigate the possible clinical interaction between dexamethasone and sugammadex, in patients undergoing laparoscopic cholecystectomy. Material and Methods: This was a randomized, double-blind controlled trial, performed in patients aged 18–75 years, American Society of Anesthesiologists (ASA) I–III, who underwent a laparoscopic cholecystectomy under deep neuromuscular blockade with rocuronium. Patients received 5 mg of dexamethasone or placebo (N/S 0.9%) during induction of anesthesia. Sugammadex 4 mg/kg was administered at the end of surgery at post-tetanic count 1–2. The outcome measures assessed were the time from sugammadex administration until train-of-four (TOF) 0.9, and until patient's extubation, postoperative pain (measured by numeric rating scale 0–10), nausea and vomiting, as well as rescue analgesics and antiemetics required during the first 24 hours postoperatively. The total dose of rocuronium required in both groups was also recorded. Results: Overall, 44 patients were studied. No difference was detected regarding the demographic and surgical characteristics of patients. The time from sugammadex administration until TOF 0.9 and until patients' extubation did not differ significantly between the groups (P = 0.21 and 0.17). Operating conditions, pain scores, nausea/vomiting, and rescue analgesics and antiemetics during the first 24 hours postoperatively, did not differ between the groups. The total dose of rocuronium, however, was significantly more in patients who received dexamethasone (P = 0.01). Conclusion: No significant clinical interaction was revealed between dexamethasone and sugammadex during reversal of deep neuromuscular blockade in patients undergoing laparoscopic cholecystectomy.
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Drug administration errors among anesthesiologists: The burden in India – A questionnaire-based survey p. 220
Sheeba John Annie, Murali Rajagopalan Thirilogasundary, Vadlamudi Reddy Hemanth Kumar
DOI:10.4103/joacp.JOACP_178_18  
Background and Aims: Safe medication is an important part of anesthesia practice. Even though anesthesia practice has become safer with various patient safety initiatives, it is not completely secure from errors which can sometimes lead to devastating complications. Multiple reports on medication errors have been published; yet, there exists a lacuna regarding the quantum of these events occurring in our country or the preventive measures taken. Hence, we conducted a survey to study the occurrence of medication errors, incident reporting, and preventive measures taken by anesthesiologists in our country. Material and Methods: A self-reporting survey questionnaire (24 questions, 4 parts) was mailed to 9000 anesthesiologists registered in Indian Society of Anaesthesiologists via Survey Monkey Website. Results: A total of 978 completed surveys were returned for analysis (response rate = 9.2%). More than two-thirds (75.6%, n = 740) had experienced drug administration error and 7.7% (57) of respondents faced major morbidity and complications. Haste/Hurry (23.4%) was identified as the most common contributor to medication errors in the operation theater. Loading and double-checking of drugs before administration by concerned anesthesiologist were identified as safety measures to reduce drug errors. Conclusion: Majority of our respondents have experienced drug administration error at some point in their career. A small yet important proportion of these errors have caused morbidity/mortality to patients. The critical incident reporting system should be established for regular audits, an effective root cause analysis of critical events, and to propose measures to prevent the same in future.
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Preoperative laboratory testing - Comparison of National Institute of Clinical Excellence guidelines with current practice - An observational study p. 227
Neeraj Guttikonda, Anitha Nileshwar, Madhu Rao, TK Sushma
DOI:10.4103/joacp.JOACP_342_17  
Background and Aims: Preoperative laboratory testing is done to detect abnormalities in the body not detected by clinical examination. Often a battery of tests is advocated as a routine for patients scheduled for low or intermediate risk surgery. This prospective observational study was aimed to assess agreement of the current practice of preoperative laboratory investigations with the National Institute of Clinical Excellence (NICE) guidelines, and the impact of investigations on patient care and costs. Material and Methods: The study was conducted at a tertiary referral center on 385 patients aged 18-70 years of either gender, posted for elective general surgical, gynaecological or otolaryngological surgery. Sixteen investigations were examined: hemogram, blood urea, serum creatinine, serum electrolytes, coagulation profile, urinalysis, thyroid function tests, electrocardiogram, echocardiogram, chest x-ray, pulmonary function tests, blood sugar, glycosylated hemoglobin, liver function tests, treadmill test and coronary angiogram. The history and physical examination were reviewed to examine for indication for these laboratory investigations. These were compared with NICE guidelines. Impact of these investigations on anesthetic decision-making was noted. Results: There was almost no agreement of the current practice with the NICE guidelines. The total cost of all tests obtained was Rs 5,48,755. Total additional cost of unindicated tests was Rs 5,10,730 (93%). Average amount spent on additional investigations per patient was Rs 1326.57. Conclusion: Most investigations are overprescribed and have minimal agreement with NICE guidelines. None of the tests had any impact on clinical care. Nearly a million rupees is incurred per year in one referral hospital alone, when NICE guidelines are not followed.
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A prospective comparative study between prewarming and cowarming to prevent intraoperative hypothermia p. 231
Laxmi Shenoy, Handattu Mahabaleswara Krishna, Nichenametla Kalyan, Kaipu Hari Prasad
DOI:10.4103/joacp.JOACP_353_17  
Background and Aims: Inadvertent perioperative hypothermia defined as the perioperative core temperature of <36°C is a common problem in day-to-day anesthesia practice. It is not clear from the literature whether prewarming, that is, initiation of convective warming of the patient at a time point prior to induction of anesthesia is superior or comparable to cowarming, that is, initiation of convective warming simultaneously with induction of anesthesia. We conducted this study to find whether cowarming is as good as prewarming in preventing the occurrence of intraoperative hypothermia. Material and Methods: Sixty-two adult patients undergoing major abdominal surgery under general anesthesia were randomized to receive either prewarming for 60 min at 40° C or cowarming using the Level 1® Equator ® body warmer. All patients who were prewarmed also received cowarming during induction of anesthesia. In both the groups, convective warming was continued during intraoperative period. Incidence of intraoperative hypothermia, core, and peripheral body temperatures were compared between the two groups. Results: Among 27 patients in each group who completed the study core temperature decreased to <35° C toward the end of surgery in 17 patients in group prewarming [mean (SD) 34.59 (1.17° C)] and 18 patients in group cowarming [mean (SD) 34.31 (1.34° C)]. The incidence of intraoperative hypothermia and the core temperature at the end of surgery were comparable (P = 0.42). Conclusion: Cowarming is as effective as prewarming to prevent intraoperative hypothermia.
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Psychomotor recovery of dexmedetomidine compared with propofol after sedation during spinal anesthesia: A randomized control trial p. 236
Tilak Perika, Suman Lata Gupta, Lenin Babu Elakkumanan, Shivanand Kattimani
DOI:10.4103/joacp.JOACP_390_17  
Background and Aims: Early psychomotor recovery is an essential part of day care surgery which depends on brain integration of motor and sensory co-ordination. Even though dexmedetomidine is commonly used for day care procedures, the recovery profile was not studied. Hence, this study was designed to evaluate the psychomotor recovery of sedation with dexmedetomidine during spinal anesthesia. Material and Methods: Sixty-six patients were included. Group D received dexmedetomidine 0.5 μg/kg (loading dose) followed by 0.2–1 μg/kg/hour. Group P received propofol infusion of 25–100 μg/kg/minute. Psychomotor recovery was assessed by finger-tapping, manual dexterity, visual spatial memory capacity, and pen and paper tests. Psychomotor tasks were given to the patients postoperatively at every 30 minutes for 2 hours followed by every hour up to 4 hours after surgery. Distribution of patients, age, weight, duration of surgery, and the level of sensory blockade was compared using independent t-test. Student's t-test has been used to find the significance of parameters such as heart rate, mean arterial pressure, oxygen saturation (SpO2), psychomotor recovery between two groups. P < 0.05 was considered as significant. Results: The motor recovery using finger tapping test was faster in Group D than Group P (73.94 ± 42.13 vs 101.21 ± 37.98 minutes, P–value = 0.007). Motor recovery using peg board test was faster in Group P than Group D (82.12 ± 40.37 vs 99.39 ± 43.08 minutes, P–value = 0.098). Visual spatial capacity memory test and pen and paper test were unaffected. Conclusions: We conclude that patients who received dexmedetomidine showed earlier recovery with finger tapping test. Hence, we suggest to use dexmedetomidine for complete psychomotor recovery and fast-track discharging of the patient after spinal anesthesia.
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Effect of intravenous versus intraperitoneal magnesium sulfate on hemodynamic parameters and postoperative analgesia during laparoscopic sleeve gastrectomy–A prospective randomized study p. 242
Mona B El Mourad, Sherif K Arafa
DOI:10.4103/joacp.JOACP_208_18  
Background and Aims: Hemodynamic changes to pneumoperitoneum and postoperative pain can be detrimental in obese patients; we investigated whether intravenous (IV) or intraperitoneal (IP) magnesium sulphate (MgSo4) administration could attenuate the hemodynamic stress response to pneumoperitoneum and improve postoperative pain control after laparoscopic sleeve gastrectomy (LSG). Material and Methods: In total, 120 patients scheduled for LSG were randomized to either, control group (Group C, IV and IP saline), Group I (IV 30 mg/kg MgSo4), or Group P (IP 30 mg/kg MgSo4). Outcome variables were mean arterial pressure (MAP), heart rate (HR), postoperative pain score, total analgesic consumption, and incidence of adverse events. Results: MAP and HR were significantly lower in Groups I and P than that in control group. Pain score was better in Groups I and P than in control group up to 2 h postoperative (P = 0.023, 0.010, respectively); it was significantly lower in Group P than other two groups at 4 h postoperative (P <0.001). Significantly, reduced postoperative analgesic consumption with delayed onset to first analgesic request were observed in magnesium groups compared to control (P = 0.001, respectively). Moreover, onset to first analgesic request was longer in Group P than Group I (P = 0.001). No serious side effects were noticed. Conclusion: The IV and IP administration of MgSo4 significantly attenuated the circulatory response to pneumoperitoneum and reduced postoperative pain as well as opioid consumption as compared to controls in obese patients undergoing LSG with no serious adverse effects.
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Effect of a low-dose dexmedetomidine infusion on intraoperative hemodynamics, anesthetic requirements and recovery profile in patients undergoing lumbar spine surgery p. 248
Sandeep Kundra, Sachin Taneja, Ashwani K Choudhary, Sunil Katyal, Isha Garg, Rajat Roy
DOI:10.4103/joacp.JOACP_338_18  
Background and Aims: Dexmedetomidine has been used as an anesthetic adjuvant; however, hypotension is a concern especially in prone patients. The aim of the study was to evaluate the effect of a low-dose dexmedetomidine infusion on intraoperative hemodynamics, blood loss, anesthetic requirements, and recovery profile in patients undergoing lumbar spine surgery in the prone position. Material and Methods: The study was conducted in a randomized double-blinded manner in 60 patients scheduled for one- or two-level lumbar laminectomy. After administration of general anesthesia, patients were placed in prone position and allocated to either of two groups of 30 patients each. Patients in Group A received dexmedetomidine infusion at the rate of 0.3 μg kg-1 hr-1, whereas, group B patients received a saline infusion. The depth of anesthesia was guided by Bispectral index (BIS) monitoring, maintaining BIS between 40 and 60. Results: The demographic profile and duration of surgery in both groups were similar. Mean heart rate was statistically similar in both the groups. Mean blood pressure was lower in group A, though the difference was significant only for the initial 30 min. The mean end-tidal sevoflurane requirement in group A was significantly less than that in group B (P = 0.003). Patients in group A had better recovery profile with mean emergence, extubation, and recovery times of 8.08 ± 3.48 min, 9.37 ± 3.64 min, and 11.65 ± 4.03 min, respectively, as compared with 11.27 ± 3.05 min, 12.24 ± 2.39 min, and 14.90 ± 2.63 min, respectively, in group B (P < 0.001). Mean intraoperative blood loss in group A of 263.47 ± 58.66 mL was significantly lower than 347.67 ± 72.90 ml in group B (P = 0.0001). Conclusion: Group A patients had stable hemodynamic parameters, reduced intraoperative blood loss, less anesthetic requirement, and could be extubated earlier as compared with group B patients.
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Incidence and predictors of postoperative pulmonary complications in patients undergoing craniotomy and excision of posterior fossa tumor p. 254
Bhavna Hooda, Rajendra Singh Chouhan, Girija Prasad Rath, Ritesh Lamsal, Parmod Kumar Bithal
DOI:10.4103/joacp.JOACP_350_17  
Background and Aims: Infratentorial neurosurgical procedures are considered high risk for the development of postoperative pulmonary complications (POPCs), prolonging hospital stay of patients with substantial morbidity and mortality. Material and Methods: Patients between the ages of 18 and 65 years, who underwent elective surgery for posterior fossa tumors over a period of two years, were reviewed. Data including American Society of Anesthesiologists physical status; comorbidities like hypertension, diabetes mellitus and hypothyroidism, history of smoking, obstructive sleep apnea, respiratory symptoms, lower cranial nerve (LCN) palsy; intraoperative complications such as hemodynamic alterations suggestive of brain stem or cranial nerve handling, tight brain as informed by the operating neurosurgeon, blood loss, and transfusion; and postoperative duration of mechanical ventilation, tracheostomy, POPCs, length of ICU and hospital stay, general condition of the patient at discharge, and cause of in-hospital mortality were collected. POPC was defined as the presence of atelectasis, tracheobronchitis, pneumonia, bronchospasm, respiratory failure, reintubation, or weaning failure. Results: Case files of 288 patients fulfilling the study criteria were analyzed; POPCs were observed in 35 patients (12.1%). On multivariate analysis, postoperative blood transfusion, LCN palsy, prolonged ICU stay, and tracheostomy were found to be independent predictors of POPC. Conclusions: The incidence of POPC was 12.1% following infratentorial tumor surgery. The predictors for the occurrence of POPCs were postoperative blood transfusion, LCN palsy, prolonged ICU stay, and tracheostomy.
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Current transfusion practices of anesthesiologists in a major city in South India p. 261
Priyanka Pavithran, MC Rajesh, Suvarna Kaniyil, Kishore Kaniachalil, Bindiya Anoop, TN Jithin
DOI:10.4103/joacp.JOACP_296_18  
Background and Aims: Allogenic blood transfusion is a double edged sword with a delicate balance between benefits and risks. There is heavy use of blood products in the perioperative setting mostly initiated by anesthesiologists. Limited research has been done in evaluating the transfusion practices of anesthesiologists especially in Indian setting. We conducted a survey among the anesthesiologists in our city to assess their blood transfusion practices, to evaluate the level of adherence to principles of Patient Blood Management and to look for innovative strategies to improve the perioperative transfusions. Methods: A validated questionnaire with four sets of questions was distributed among the practitioners in the Indian Society of Anaesthesiologists city branch and the responses were collected and analysed. The first and second parts were structured to assess the current blood transfusion practices. The third part evaluated the keenness of participants in further updating their practices as per the recommended protocols of patient blood management. The last part assessed how the participants would act in a given clinical scenario. Statistical analysis was done using Statistical Package for the Social Sciences version 21. Results are expressed in numbers and percentages. Results: Moderate preoperative anemia was acceptable to majority of the responders. There was a high demand for continuing medical education in transfusion medicine and for formulating Indian guidelines for perioperative transfusion. The clinical scenarios demonstrated the restrictive transfusion strategy of the majority of our anesthesiologists. The lack of institutional protocols and blood transfusion committees was also seen. Conclusion: The restrictive strategy of our practitioners was an encouraging finding. There is lack of uniformity in patient blood management services. Regular educational interventions are needed to update the clinicians. Formulation and implementation of institutional protocols for perioperative blood transfusion is mandatory.
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Misplaced nasogastric tube: A simple test to rule out its intratracheal placement p. 267
Nishkarsh Gupta, Anju Gupta
DOI:10.4103/joacp.JOACP_47_16  
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Kirschner wire in acromoclavicular joint – Should chest X-ray be recommended in preoperative evaluation of the patient? p. 268
Raman Sikka, Rajinder S Kalyan
DOI:10.4103/joacp.JOACP_251_18  
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Atrial fibrillation during anhepatic phase liver transplantation: Now what? p. 269
Kelika Prakash, Sunaina Tejpal Karna, Chandra Kant Pandey
DOI:10.4103/joacp.JOACP_234_17  
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Pulmonary arterio venous malformations - What the anesthesiologist must know p. 271
BK Lakshmi, Supriya Dsouza, Adarsh Kulkarni, Jyoti Kamble, Madhu Garasia
DOI:10.4103/joacp.JOACP_181_18  
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Propriospinal myoclonus following spinal anesthesia: A rare complication p. 273
Vijayanand Budi, Nitin Manohar, Gajanan Fultambkar, Bharath Srinivasaiah
DOI:10.4103/joacp.JOACP_35_17  
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Oxygenated blood from central venous catheter: A case of missed partial anomalous pulmonary venous connection p. 274
Udismita Baruah, Mahesh Chandra, Sushil Guria, Virendra Kumar, AR Gogia
DOI:10.4103/joacp.JOACP_41_18  
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Use of ropivacaine 0.2% with or without clonidine 1 μg/kg for epidural labor analgesia p. 276
Hemlata
DOI:10.4103/joacp.JOACP_122_18  
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Accidental vertebral vein catheterization during internal jugular vein cannulation – A rare complication p. 277
Adarsh Kulkarni, Neha Chandrakar, Suhasinee Deokar, Nikhil Bhasin
DOI:10.4103/joacp.JOACP_132_18  
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Anesthesia for total knee replacement surgery in a patient with positive stress test p. 279
Kompal Jain, Vikky Jaiswal, Arun Puri
DOI:10.4103/joacp.JOACP_23_18  
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Prediction of inadvertent internal mammary (thoracic) vein cannulation by CVP monitoring p. 282
Swayam Tara, Amit Rai, Ashish Chauhan
DOI:10.4103/joacp.JOACP_264_18  
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