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   Table of Contents - Current issue
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October-December 2019
Volume 35 | Issue 4
Page Nos. 431-572

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EDITORIAL  

Hemodynamic effects of alveolar recruitment maneuvres in the operating room: Proceed with caution Highly accessed article p. 431
Sheila N Myatra
DOI:10.4103/joacp.JOACP_223_19  
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REVIEW ARTICLES Top

Anesthetic considerations for stereotactic electroencephalography implantation Highly accessed article p. 434
Chakrabarti Rajkalyan, Anurag Tewari, Shilpa Rao, Rafi Avitsian
DOI:10.4103/joacp.JOACP_342_18  
The refractory seizures have significant impact on the quality of life and increase long term neurologic and non-neurologic complications. Implantation of Stereotactic Electroencephalography (SEEG) leads is one of the newer surgical techniques intended to localize seizure foci with higher accuracy than the conventional methods. Most of the commonly utilized anesthetic agents depress EEG waveforms affecting intra operative monitoring during these surgeries. Hence, the anesthetic goals include a stable induction and maintenance with agents which have minimal effect on EEG. This article discusses the peri-operative considerations of multiple anti-epileptic medications, recent advances in anesthetic management, and important post-operative concerns.
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Opioid free onco-anesthesia: Is it time to convict opioids? A systematic review of literature Highly accessed article p. 441
Raghu S Thota, Seshadri Ramkiran, Rakesh Garg, Jyotsna Goswami, Vaibhavi Baxi, Mary Thomas
DOI:10.4103/joacp.JOACP_128_19  
The epidemic of opioid crisis started getting recognised as a public health emergency in view of increasing opioid-related deaths occurring due to undetected respiratory depression. Prescribing opioids at discharge has become an independent risk factor for chronic opioid use, following which, prescription practices have undergone a radical change. A call to action has been voiced recently to end the opioid epidemic although with the pain practitioners still struggling to make opioids readily available. American Society of Anesthesiologist (ASA) has called for reducing patient exposure to opioids in the surgical setting. Opioid sparing strategies have emerged embracing loco-regional techniques and non-opioid based multimodal pain management whereas opioid free anesthesia is the combination of various opioid sparing strategies culminating in complete elimination of opioid usage.The movement away from opioid usage perioperatively is a massive but necessary shift in anesthesia which has rationalised perioperative opioid usage. Ideal way moving forward would be to adapt selective low opioid effective dosing which is both procedure and patient specific while reserving it as rescue analgesia, postoperatively. Many unknowns persist in the domain of immunologic effects of opioids, as complex interplay of factors gets associated during real time surgery towards outcome. At present it would be too premature to conclude upon opioid-induced immunosuppression from the existing evidence. Till evidence is established, there are no recommendations to change current clinical practice. At the same time, consideration for multimodal opioid sparing strategies should be initiated in each patient undergoing surgery.
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ORIGINAL ARTICLES Top

Changes in stroke volume during an alveolar recruitment maneuvers through a stepwise increase in positive end expiratory pressure and transient continuous positive airway pressure in anesthetized patients. A prospective observational pilot study p. 453
Jean Luc Hanouz, Axel Coquerel, Christophe Persyn, Dorothée Radenac, Jean Louis Gérard, Marc Olivier Fischer
DOI:10.4103/joacp.JOACP_167_18  
Background and Aims: Recruitment maneuvers may be used during anesthesia as part of perioperative protective ventilation strategy. However, the hemodynamic effect of recruitment maneuvers remain poorly documented in this setting. Material and Methods: This was a prospective observational study performed in operating theatre including patients scheduled for major vascular surgery. Patients were monitored with invasive arterial pressure and esophageal doppler. After induction of general anesthesia, before surgery began, preload optimization based on stroke volume (SV) variation following fluid challenge was performed. Then, an alveolar recruitment maneuver (ARM) through stepwise increase in positive end expiratory pressure (PEEP) or continuous positive airway pressure (CPAP) was performed. Hemodynamic data were noted before, during, and after the alveolar recruitment maneuver. Results: ARM through stepwise increase in PEEP and CPAP were applied in 22 and 14 preload independent patients, respectively. Relative changes in SV during ARMs were significantly greater in the ARMCPAPgroup (-39 ± 20%) as compared to the ARMPEEPgroup (-15 ± 22%; P= 0.002). The difference (95% CI) in relative decrease in SV between ARMCPAPand ARMPEEPgroups was -24% (-38 to -9; P= 0.001). Changes in arterial pressure, cardiac index, pulse pressure variation, peak velocity, and corrected flow time measures were not different between groups. Conclusion: During anesthesia, in preload independent patients, ARMs through CPAP resulted in a significantly greater decrease in SV than stepwise increase in PEEP. During anesthesia, ARM should be used cautiously.
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Low tidal volume ventilation strategy and organ functions in patients with pre-existing systemic inflammatory response p. 460
Vanya Chugh, Asha Tyagi, Vandna Arora, Abhay Tyagi, Shukla Das, Gargi Rai, Ashok K Sethi
DOI:10.4103/joacp.JOACP_112_18  
Background and Aims: Ventilation can induce increase in inflammatory mediators that may contribute to systemic organ dysfunction. Ventilation-induced organ dysfunction is likely to be accentuated if there is a pre-existing systemic inflammatory response. Material and Methods: Adult patients suffering from intestinal perforation peritonitis-induced systemic inflammatory response syndrome and scheduled for emergency laparotomy were randomized to receive intraoperative ventilation with 10 ml.kg-1 tidal volume (Group H) versus lower tidal volume of 6 ml.kg-1 along with positive end-expiratory pressure (PEEP) of 10 cmH2O (Group L), (n = 45 each). The primary outcome was postoperative organ dysfunction evaluated using the aggregate Sepsis-related Organ Failure Assessment (SOFA) score. The secondary outcomes were, inflammatory mediators viz. interleukin-6, tumor necrosis factor-α, procalcitonin, and C-reactive protein, assessed prior to (basal) and 1 h after initiation of mechanical ventilation, and 18 h postoperatively. Results: The aggregate SOFA score (3[1–3] vs. 1[1–3]); and that on the first postoperative day (2[1–3] vs. 1[0–3]) were higher for group L as compared to group H (P < 0.05). All inflammatory mediators were statistically similar between both groups at all time intervals (P > 0.05). Conclusions: Mechanical ventilation with low tidal volume of 6 ml/kg-1 along with PEEP of 10 cmH2O is associated with significantly worse postoperative organ functions as compared to high tidal volume of 10 ml.kg-1 in patients of perforation peritonitis-induced systemic inflammation undergoing emergency laparotomy.
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Pressure-controlled ventilation could decrease intraoperative blood loss and improve airway pressure measures during lumbar discectomy in the prone position: A comparison with volume-controlled ventilation mode p. 468
Amir Abouzkry El-Sayed, Sherif Kamal Arafa, Ayman Mohamady El-Demerdash
DOI:10.4103/joacp.JOACP_288_18  
Background and Aims: Prone positioning may induce alterations of hemodynamic and airway pressure parameters that may affect intraoperative (IO) blood loss. Pressure-controlled ventilation (PCV) may modify these alterations. To observe the relation between ventilation mode and hemodynamic, airway pressure changes, and blood loss during lumbar discectomy performed in the prone position. Material and Methods: Volume-controlled ventilation (VCV) patients were using tidal volume (TV) of 8–10 ml/Kg, but for pressure-controlled ventilation (PCV) patients peak inspiratory pressure (PIP) was adjusted to provide the same TV according to ideal body weight. Respiratory and hemodynamic parameters were recorded in supine (T1), on turning to prone (T2), and on returning to the supine position (T3). Primary outcome included amount of IO blood loss; Secondary outcome included need for blood transfusion, IO hemodynamics, and airway pressure changes. Results: IO blood loss and central venous pressure (CVP) were significantly higher with VCV than PCV patients. Heart rate and blood pressure were significantly reduced in the prone position with little impact of ventilation mode. Prone positioning resulted in significant increase of P-peak and non-significant decrease of P-mean pressure with VCV, while with PCV resulted in a significantly increased airway pressures. P-peak pressure was significantly lower with PCV in supine and prone positions than VCV. P-mean pressure was significantly lower in supine but significantly higher in the prone position with PCV than VCV. Conclusions: Prone positioning and VCV were associated with increased CVP and IO blood loss, while PCV could lessen these effects and significantly improve airway pressures.
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Opioid-free anesthesia for breast cancer surgery: A comparison of ultrasound guided paravertebral and pectoral nerve blocks. A randomized controlled trial p. 475
Swagata Tripathy, Indraprava Mandal, Parnandi Bhaskar Rao, Aparajita Panda, Tushar Mishra, Madhabananda Kar
DOI:10.4103/joacp.JOACP_364_18  
Background and Aims: Pectoral block (PECS)-based anesthesia without opioids decreases analgesic requirement, pain scores and post-operative nausea vomiting (PONV) compared to conventional opioid-based general anesthesia in patients undergoing modified radical mastectomy and axillary dissection (MRM-AD). We compared PECS versus Paravertebral Block (PVB) in providing an opioid free, nerve block-based regimen. Outcomes of interest were post-operative analgesic requirement, duration of analgesia, PONV and patient and surgeon satisfaction. Material and Methods: This randomised controlled study involved 58 adult ASA I-III patients posted for MRM-AD. After randomization patients were induced with propofol and maintained on spontaneous ventilation with isoflurane (0.8-1.0 MAC) through i-gel. Ultrasound-guided PECS or PV blocks (30 ml of 0.1% lignocaine + 0.25% bupivacaine + 1 μg/kg dexmedetomidine) were administered. Post-operative pain scores, non-opioid analgesic requirement over 24 hours, PONV, satisfaction of surgeon and patient were measured. Results: Between the two groups, there was no difference in demographics, ASA status, location and volume of breast tumour excised or the duration of surgery. The time from block to incision was significantly longer in the PV group (P = 0.01). There was no difference between the two groups in terms of intra and post-operative parameters, and the median VAS scores for pain at rest or during shoulder abduction were similarly low in both the groups. Conclusion: Both blocks result in equally prolonged analgesia and preclude requirement of opioid analgesics intra and post-operatively. PECS block is associated with lesser time to allow incision. Complications are low in both the groups. Routine use of these blocks to avoid opioids may be studied further. Clinical trial number – Registered in Clinical Trials Registry of India (CTRI/2017/02/007897). http://ctri.nic.in.
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Comparison of opioid-based and opioid-free TIVA for laparoscopic urological procedures in obese patients p. 481
Shaman Bhardwaj, Kamakshi Garg, Sumeet Devgan
DOI:10.4103/joacp.JOACP_382_18  
Background and Aims: Perioperative pain management in an obese patient is challenging. The incidence of respiratory depression is higher in obese patients and is exaggerated with opioids. We evaluated the efficacy of opioid-free anesthesia with propofol, dexmedetomidine, lignocaine, and ketamine in obese patients undergoing urological laparoscopic procedures with reference to postoperative analgesic consumption, hemodynamic stability, and respiratory depression. Material and Methods: In this prospective, randomized, blinded controlled study, patients were randomized to receive either opioid-based (opioid group) or opioid-free (opioid-free group) anesthesia. Postoperative pain was assessed using visual analog score (VAS) 30 min after recovery, hourly for 2 h and every 4 hourly for 24 h. The primary outcomes studied were respiratory depression, mean analgesic consumption and time to rescue analgesia. Intraoperative hemodynamic parameters, mean SpO2, respiratory rate and postanesthesia care unit (PACU) discharge time were secondary objectives. Results: There were no differences in the demographic and intraoperative hemodynamic profile between the groups. Incidence of respiratory depression, defined as fall in saturation, was more in opioid-based group. Postoperative analgesic requirement (225 ± 48.4 vs 63.6 ± 68.5 mg of tramadol with P value of <0.001) and PACU discharge times (18.1 ± 5.4 vs 11.7 ± 4.3 hours with P value of <0.001) were significantly less in the opioid-free group. Conclusions: Opioid-free anesthesia is a safer and better form of anesthesia in obese patients undergoing laparoscopic urological procedures as there is a lower requirement of postoperative analgesia.
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Minimal flow anesthesia can be initiated early with the use of higher fresh gas flow to facilitate desflurane “Wash-in” p. 487
Mukul Chandra Kapoor, Ayalasomayajula Sashank, Ashok Vats, Shaloo Garg, Archana Puri
DOI:10.4103/joacp.JOACP_188_19  
Background and Aims: More than 80% of delivered anesthetic gases get wasted at high fresh gas flows as they are vented out unused. Use of minimal flow anesthesia is associated with less waste anesthetic gas emission and environmental pollution. There is no approved or validated technique to initiate minimal flow anesthesia and simultaneously achieve denitrogenation of the breathing circuit. We studied the wash-in characteristics of desflurane, when delivered with 50% nitrous oxide, to reach a target end-tidal concentration at two different gas flow rates. Material and Methods: Patients were allocated randomly to two groups of 25 adults each. In Group A, with the vaporizer dial fixed at 4 vol %, after an initial fresh gas flow of 4 L/min was administered to wash-in of desflurane using the closed-circuit, with 50% N2O in O2, and in group B, 6 L/min was used. Minimal flow anesthesia, with 0.5 L/min, was initiated in both groups on attaining a target end-tidal desflurane concentration of 3.5 vol %. After initiation of desflurane delivery, the inspired/expired gas concentrations were noted every minute for 15 min. Results: In Group A, the target desflurane end-tidal concentration was reached in 499.2 ± 68.6 s±, and in the Group B (P < 0.001), it was reached significantly faster in 314.4 ± 69.89 s. Denitrogenation of the circuit was adequate in both groups. Conclusion: Minimal flow anesthesia can be initiated, without any gas-volume deficit, in about 5 min with an initial fresh gas flow rate of 6 L/min and the vaporizer set at 4 vol%.
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Comparison of intensive insulin therapy and conventional glucose management in patients undergoing coronary artery bypass grafting p. 493
Vaishali Mohod, Veena Ganeriwal, Juilee Bhange
DOI:10.4103/joacp.JOACP_61_17  
Background and Aims: Hyperglycemia during cardiac surgery is a risk factor for postoperative outcomes. Because incidence of diabetes mellitus is increasing in Indian population, we tried to evaluate the western protocol for strict control of blood sugar perioperatively. The main aim of the study was to evaluate glycemic control during coronary artery bypass grafting and to determine whether intensive insulin therapy (IIT) is better than the conventional one. Material and Methods: A prospective randomized comparative study was conducted to evaluate IIT and conventional management of glucose in 40 patients undergoing on-pump coronary artery bypass grafting. Outcomes measured were incidence of hyperglycemia or hypoglycemia, incidence of hypokalemia, prolonged intubation, wound infections, strokes, acute renal failure, new onset arrhythmias, length of stay in ICU and hospital, cardiac arrest and mortality. The statistical analysis was done by using Chi-square test, and paired and unpaired t test. Results: The diabetic patients had significantly higher mean blood sugar and insulin requirement. The incidence of hyperglycemia was significantly higher in conventional management of blood sugar (P = 0.001), whereas hypoglycemia (P = 0.047) and hypokalemia (P = 0.020) were significantly higher in IIT. There were no significant difference in the incidence of prolonged intubation, wound infection, length of ICU and hospital stay, strokes, acute renal failure, new onset arrhythmias, cardiac arrest, and mortality. Conclusion: The IIT did not improve the morbidity and mortality in our patients undergoing coronary artery bypass grafting.
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Ropivacaine plus lidocaine versus bupivacaine plus lidocaine for peribulbar block in cataract surgery: A prospective, randomized, double-blind, single-center, comparative clinical study p. 498
Venkata Ramanareddy Moolagani, Shanker Rao Burla, Bhaskara Rao Neethipudi, Suryanarayana Murthy Upadhyayula, Anusha Bikkina, Narasimha Rao Arepalli
DOI:10.4103/joacp.JOACP_341_18  
Background and Aims: Cataract surgery in ophthalmology is usually done under peribulbar block with a mixture of 0.5% bupivacaine and 2% lidocaine. Several case reports of fatalities associated with bupivacaine has necessitated a search for alternative safe agents. The aim of this study was to compare peribulbar block characteristics using a mixture of 0.5% bupivacaine and 2% lidocaine with a mixture of 0.5% ropivacaine and 2% lidocaine. Material and Methods: Eighty patients were allocated to two random groups of 40 each. Patients of groups BL and RL were given 4 ml of 0.5% bupivacaine and 4 ml of 0.5% ropivacaine each in a mixture with 4 ml of 2% lidocaine and 100 IU of hyaluronidase respectively. Block characteristics, hemodynamic variables, adverse drug interactions and other complications were recorded. Results: Demographic characteristics were comparable in both the groups. Duration of onset of the block and the side effect profile was comparable in both the groups but the total duration of the block and the time for first rescue analgesia was found to be longer in group BL than in group RL. Conclusions: Ropivacaine 0.5% and lidocaine 2% as a 1:1 mixture in a volume of 8 ml with 100 IU of hyaluronidase is as effective as a 1:1 mixture of bupivacaine 0.5% and lidocaine 2% in a volume of 8 ml with 100 IU of hyaluronidase with regards to onset and total duration of the block and side effects and hemodynamic changes.
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Hemodynamic response to tracheal intubation in postlaryngectomy patients p. 504
Sunil Rajan, Rajvignesh Chandramohan, Jerry Paul, Lakshmi Kumar
DOI:10.4103/joacp.JOACP_207_18  
Background and Aims: Endotracheal intubation in postlaryngectomy patients is usually accomplished by inserting endotracheal tube directly into the laryngectomy stoma. The primary objective of our study was to assess the systolic blood pressure (SBP) response to intubation in postlaryngectomy patients. Secondary objectives included assessment of changes in heart rate (HR), mean arterial pressure (MAP), and to estimate tracheal component of hemodynamic response to intubation in normal patients by finding out the relative reduction in hemodynamic response that might occur in postlaryngectomy patients. Material and Methods: This was a prospective, observational study. Forty postlaryngectomy patients formed group L and 40 normal patients constituted group N. After induction of anesthesia and neuromuscular blockade, direct laryngoscopy and tracheal intubation were performed in group N, whereas an endotracheal tube was passed through the laryngectomy stoma directly into the trachea in group L. Hemodynamic responses were documented. Chi-square test, independent samples t-test, and analysis of covariance (ANCOVA) test were applied. Result: Group L patients were significantly older with significantly lower baseline HR with higher SBP and MAP. As baseline values were not comparable, they were taken as covariates and ANCOVA was applied. Adjusted mean values were then compared. Immediately after induction HR, SBP and MAP were comparable in both groups. Subsequent comparison of adjusted mean values showed significantly higher HR, SBP, and MAP in group N immediately after intubation and 1,3,5, and 10 min later (P < 0.001). At 15 min, HR and SBP were significantly higher in group N with comparable MAP. Conclusion: Hemodynamic stress response to endotracheal intubation is minimal or absent in postlaryngectomy patients. They mostly present with elevated blood pressure and develop hypotension following induction that persists despite intubation.
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Comparison of the C-MAC video laryngoscope size 2 Macintosh blade with size 2 C-MAC D-Blade for laryngoscopy and endotracheal intubation in children with simulated cervical spine injury: A prospective randomized crossover study p. 509
Renu Sinha, Bikash Ranjan Ray, Ankur Sharma, Ravinder Kumar Pandey, Jyotsna Punj, Vanlalnghaka Darlong, Anjan Trikha
DOI:10.4103/joacp.JOACP_106_18  
Background and Aims: CMAC video laryngoscope size 2 D-Blade has been recently introduced for management of pediatric difficult airway. Our primary outcome was to compare glottic view, intubation time, and ease of intubation with the size 2 Macintosh versus D-Blade of C-MAC video laryngoscope in simulated cervical injury in children. Material and Methods: This randomized crossover study was conducted in a tertiary care hospital of Northern India. Forty children of 4–14 years of age were enrolled in this study. After induction of anesthesia, video laryngoscopy was performed either with size 2 CMAC Macintosh (group M) or D-Blade (group D) with manual in-line stabilization. After removal of the first blade, second video laryngoscopy was performed with the alternative blade. Endotracheal intubation was done with the second laryngoscopy. Best glottic view, time for best glottic view, and difficulty in blade insertion were recorded during both the video laryngoscopies. During second video laryngoscopy, difficulty of tube insertion and time for intubation were noted. Results: The glottic view grade was significantly better in group D compared with the group M (P = 0.0002). Insertion of D-Blade was more difficult than Macintosh blade (P = 0.0007). There was no statistical difference in terms of time for best glottic view in group M and group D (13.40 ± 4.90 vs 13.62 ± 5.60 s) and endotracheal tube insertion time (24.80 ± 7.90 vs 27.90 ± 10.90 s), respectively. Number of intubation attempts was similar in both the groups. Conclusions: Size 2 D-Blade of C-MAC video laryngoscope provided a better glottic view in children with simulated cervical spine injury as compared with CMAC Macintosh blade. Success of intubation, intubation time, and ease of intubation were comparable with both the blades.
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Evaluation of anesthesia informed consent in pediatric practice – An observation cohort study p. 515
Ekta Rai, Regina Yu Ying Chen, Chia S Noi, Hwan I Hee
DOI:10.4103/joacp.JOACP_74_18  
Background and Aims: An informed consent requires active participation by both physicians and patients. It is the responsibility of the physician to give the complete disclosure of information in easy language for the parent to understand. An informed consent process can be a challenge especially for the anesthetists when time is a limiting factor for patient-anesthetist interaction especially in same day admission and day surgery. The aim of this study was to subjectively evaluate the understanding and recall of the informed consent by the parents. Material and Methods: The validated survey was conducted over 10 weeks and was limited to one parent per child and to the parent who was directly involved in the consent process. Results: Majority of parents rated positively for adequate disclosure of all items of information. Consent process done on day of surgery was found to be associated with lower parental rating in adequacy of disclosure of pain relief options. Seniority of anesthetists was associated with higher parental rating of adequacy of information regarding post operative plan, specific risk of child and overall consent process. Consent for minor surgeries, on day of surgery, did not significantly affect the parental performance in their recall of disclosed information but was associated with significant lower rating of adequacy of postoperative plan. Postoperative pain is among the areas for improvement especially in day surgery cases. Conclusion: Consent taken on day of surgery was found to be associated with lower parental rating. Postoperative plan for pain required improvement especially in day surgery cases.
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A cohort study of anatomical landmark-guided midline versus pre-procedure ultrasound-guided midline technique of spinal anesthesia in elderly patients undergoing orthopedic surgery p. 522
Harsha Hemraj Narkhede, Deepa Kane, Viral Parekh, Indrani Hemantkumar
DOI:10.4103/joacp.JOACP_396_17  
Background and Aims: The primary objective of the study was to compare the number of attempts and number of passes of spinal needle insertion and secondary objective was to compare complications, bloody tap, and patient discomfort in anatomical landmark-guided versus pre-procedure USG-guided midline technique of spinal anesthesia in elderly patients posted for orthopedic surgery. Material and Methods: In this a prospective observational cohort study, 60 patients of either sex, ASA grades I–III, and aged more than 65 years were randomly allocated to 2 groups of 30 patients each. In group AG (Anatomical landmark guided), standard landmark technique was used. In group UG (Ultrasound guided), pre-procedure ultrasound guided marking for insertion point of a spinal needle was done before giving spinal anesthesia. Patients in both the groups were compared on the basis of number of attempts, number of passes, vascular injury (bloody tap), pain score, complications, and procedure time. Results: Successful dural puncture on the first needle insertion attempt was achieved more in UG group (90%) than in AG group (50%) (P < 0.05). Dural puncture was not achieved in only 3.3% patients in the UG group even after three midline attempts at spinal needle insertion. Mean of the number of passes was more in AG group (1.90) than in UG group (1.07) (P < 0.05). VAS (Visual Analogue Scale) score was 0.4 in AG group and 0.3 in UG group (P > 0.05). Group UG had shorter procedure time (2.25 min) than AG group (4.35 min). Conclusion: Preprocedure ultrasound imaging is a very useful tool to facilitate the performance of central neuraxial blockade in patients with difficult anatomical landmarks, especially in elderly patients.
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Evaluation of lignocaine infusion on recovery profile, quality of recovery, and postoperative analgesia in patients undergoing total abdominal hysterectomy p. 528
Harish S Koshyari, Veena Asthana, Sanjay Agrawal
DOI:10.4103/joacp.JOACP_209_18  
Background and Aims: Multimodal analgesia entrains the use of drugs in perioperative period producing adequate pain relief without affecting the quality of recovery by decreasing drug-related adverse effects. Systemic lignocaine has effective analgesic, anti-inflammatory, and anti-hyperalgesic properties and improves the quality of recovery after surgery. Material and Methods: Ninety women scheduled for elective transabdominal hysterectomy under general anesthesia were randomized to receive infusion of lignocaine (1.5 mg/kg over 15 min followed by a 2 mg/kg/h infusion until the end of surgery) (Group 1) or normal saline (10 mL over 15 min followed by infusion 1 mL/kg/h till end of surgery) (Group 2). Standard anesthesia techniques were used in both the groups. The patients received inj. tramadol for postoperative analgesia. Perioperative hemodynamics, extubation variables, postoperative analgesic requirement, and quality of recovery score were evaluated. Results: Hemodynamics were maintained in both the groups. Time for extubation was also similar. Demand for first postoperative analgesic was after 70.8 ± 70.4 min (Group 1) and 40.7 ± 30.0 min (Group 2) (P = 0.006). Total tramadol usage was 477.0 ± 133.2 mg (Group 1) and 560.0 ± 115.0 mg (Group 2) (P < 0.001). Return of bowel function was faster in Group 2 compared with Group 1 (37.1 ± 5 vs 41.8 ± 7.4 h, P < 0.001). The median (interquartile range) recovery score (QoR-40) was 184 (178–191) in Group 1 and 178 (171–180) in Group 2 (P < 0.001). Conclusion: Perioperative use of intravenous infusion of lignocaine is associated with decreased analgesic requirement postoperatively, and improved quality of recovery score signifying greater patient satisfaction.
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A comparative study on the effect of addition of intrathecal buprenorphine to 2-chloroprocaine spinal anesthesia in short duration surgeries p. 533
Jayaprakash Siddaiah, Vinayak S Pujari, Ashok S Madalu, Yatish Bevinaguddaiah, Leena H Parate
DOI:10.4103/joacp.JOACP_65_19  
Background and Aims: Spinal anesthesia is a safe and reliable technique for surgeries on the lower abdomen and lower limbs. Some of its characteristics like delayed ambulation and pain after block regression may limit its use, especially for short duration surgeries. 2-chloroprocaine is an amino-ester local anesthetic with an approximate duration of action of 40 minutes, which is ideal for short duration surgeries. This study aims to compare the effect of adding intrathecal buprenorphine to 2-chloroprocaine with regard to spinal anesthesia characteristics. Material and Methods: After obtaining the institutional ethical committee clearance and clinical trial registration, informed consent was taken from 90 patients who were undergoing either lower abdominal or lower limb surgeries of less than 60 minutes duration and were then randomized into two groups. Group C received 40 mg of 1% 2-chloroprocaine and Group B received 40 mg of 1% 2-chloroprocaine with 60 mcg of buprenorphine. Sensory/motor block characteristics, first analgesic requirements, time to void, and unassisted ambulation were assessed. Student t test was used to analyze the metric parameters and Fisher's exact test was used to compare the categorical variables. Results: The time of onset of sensory and motor blocks, peak sensory block, readiness for surgery, and complete regression of both sensory and motor blocks were comparable between the groups. Group B showed significantly prolonged duration of postoperative analgesia (855.82 ± 667.09 vs. 359.07 ± 253.3 minutes). 91.1% patients were able to ambulate within 100 minutes in our study. Conclusion: We conclude that addition of buprenorphine to 2-chloroprocaine has a significant synergistic effect on prolonging postoperative analgesia.
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ERRATUM Top

Erratum: Ambu AuraGain versus intubating laryngeal tube suction as a conduit for endotracheal intubation p. 539

DOI:10.4103/0970-9185.189878  
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ORIGINAL ARTICLES Top

The supraglottic airway device as first line of management in anticipated difficult mask ventilation in the morbidly obese p. 540
Aparna Sinha, Lakshmi Jayaraman, Dinesh Punhani
DOI:10.4103/joacp.JOACP_159_19  
Background and Aims: Supraglottic airway devices (SGAs) are used to rescue difficult and failed mask ventilation (DMV). We aimed to use the SGA as first-line device, prior to obtaining a definitive airway and to find any predictors of difficulty for the same, in the morbidly obese patients. Material and Methods: Obese surgical patients [body mass index (BMI) >35 kg/m2] were investigated. Difficulties with bag mask ventilation (MV) was graded using the following scale: MV-1, one anesthesiologist unassisted could achieve MV and maintain SpO2 >90%; MV-2, one additional anesthesiologist was needed to facilitate MV to achieve SpO2> 90%; MV-3, two additional anesthesiologists were needed for this purpose; and MV-3P, when a supraglottic device was required to ventilate and maintain SpO2more than 90%. Parameters studied were age, gender, neck circumference (NC), BMI, STOPBANG score, and safe apnea time (SAT). Results: Logistic regression was performed for predictors of MV-3P; receiver operating characteristic curve was used to locate the best cut-off. Analysis of 834 morbidly obese patients revealed an incidence of MV 1/2/3/3-P as 16%/38%/27%/19%, respectively. DMV was associated with BMI ≥50 kg/m2, NC ≥49.5 cm, and STOPBANG ≥6; P < 0.001. The mean SAT for a population with mean BMI 48 ± 8 kg/m2 was 256 ± 66 s. The SAT showed inverse relation to BMI and NC. As per our results, the NC was the single most important predictor of MV-3P, with sensitivity 0.62 and specificity 0.85 at best cut-off 49.5 cm; P < 0.001. Conclusion: NC ≥49.5 cm is strongly associated with low SAT and need for SGA to achieve MV. SGA may provide safety for initial management following induction of anesthesia in this patient population.
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COMMENTARY Top

Supraglottic airway devices in airway management of obese patients p. 546
Manpreet Singh
DOI:10.4103/joacp.JOACP_271_19  
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ORIGINAL ARTICLES Top

Predictors of difficult epidural placement in pregnant women: A trainees' perspective p. 548
Suman Rajagopalan, Krishna Shah, Danielle Guffey, Connie Tran, Maya Suresh, Ashutosh Wali
DOI:10.4103/joacp.JOACP_340_18  
Background and Aims: Epidural analgesia is believed to be the most difficult technique to learn for a trainee. The reason for this is not only inexperience of the provider and the complexity of the technique but also patient factors like obesity, spinal deformity and others which makes the epidural placement difficult. The aim of this study was to evaluate some of the common risk factors for difficult epidural placement as perceived by the anesthesia providers during training, with varying level of experience. Material and Methods: This prospective observational study includes patients who received epidural placement for labor analgesia. Data recorded on these patients included age, height, weight, body mass index (BMI), ease of palpation of the spinous process, level of epidural placement, number of attempts, time taken for epidural placement and experience of the provider. The association between the variables were assessed using logistic regression for first attempt success and Cox proportional hazard ratio for time to epidural placement. Results: A total of 373 patients received epidural placement for labor analgesia. The mean BMI at the time of placement was 34. The first attempt success rate for the placement of epidural was 67% (n = 273). Women with well palpable spinous process were 3.3 times more likely to have a successful first attempt placement irrespective of the provider experience or BMI [3.39 (1.77-6.51), P < 0.001]. The time to placement was shorter in patients with good anatomical landmarks [1.58 (1.20-2.07), P < 0.001) and when performed by a trainee who had performed a minimum of 20 epidural procedures [1.57 (1.26-1.94), P < 0.001). Conclusion: Inability to palpate the spinous process contributes to multiple attempts at epidural placement when performed by a trainee.
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FORUM Top

Surgically assisted caudal anesthesia in a case of Ankylosing Spondylitis—An innovative approach p. 553
Paria Radhashyam, Chattopadhyay Ipsita
DOI:10.4103/joacp.JOACP_389_17  
Anticipated difficult endotracheal intubation and impossibility of conventional methods of neuraxial blocks in Ankylosing Spondylitis (AS) led to our search for an alternative technique of regional anesthesia for total hip replacement surgery in such a patient. The approach undertaken was, after infiltration of the area with a local anesthetic drug, an orthopedic surgeon drilled the posterior wall of sacral hiatus and surgically created a small opening on it. A nerve stimulator needle was then introduced through this opening to get muscle twitches of the great toe, which helped in identification of the sacral epidural space. 30 ml of 0.5% injection ropivacaine was then deposited in this extradural space. Motor and sensory blocks developed within 10 minutes. The novel approach of surgically assisted drilling of the posterior wall of sacral hiatus may be established as an alternative approach to the classical caudal anesthesia when other alternatives fail.
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LETTERS TO EDITOR Top

Ultrasound-guided bilateral costoclavicular brachial plexus blocks for single-stage bilateral upper limb surgeries: Abstain or indulge p. 556
Tuhin Mistry, Jagannathan Balavenkatasubhramanian, Vivekanandan Natarajan, Elayavendhan Kuppusamy
DOI:10.4103/joacp.JOACP_222_18  
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Malignant hyperthermia: An Indian perspective p. 557
Mukundan Ramanujam, Sweta Gulati, Asha Tyagi
DOI:10.4103/joacp.JOACP_243_18  
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Thyroid storm – A case report p. 559
Rajani Sundar, Mohanraj Ramaswamy
DOI:10.4103/joacp.JOACP_80_18  
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Steroids for adult cardiac surgery: The debate echoes on Highly accessed article p. 560
Rohan Magoon, Arindam Choudhury, Subhajit Sahoo, Vishwas Malik
DOI:10.4103/joacp.JOACP_268_19  
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Preoperative inferior vena cava collapsibility is a poor marker of intraoperative fluid requirements and hypotension: A pilot study p. 562
Jack Louro, Amir Rowshanrad, Richard H Epstein, Roman Dudaryk
DOI:10.4103/joacp.JOACP_136_18  
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An unexpected cause of endotracheal tube obstruction after routine tracheal suctioning p. 564
Ravindra Singh Chouhan, Mritunjay Kumar, Anita Saran, Sadik Mohammed, Sunit Gupta, Komal Chopra
DOI:10.4103/joacp.JOACP_100_18  
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Undiagnosed peripartum cardiomyopathy: Anesthesiologist's nightmare! p. 566
Anuradha Borle, Devalina Goswami, Tanvi Meshram, Manpreet Kaur, Shiv Akshat
DOI:10.4103/joacp.JOACP_221_17  
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Pregnancy with dengue hemorrhagic fever in respiratory distress for cesarean delivery: Anesthetic management p. 568
Shalendra Singh, Saurabh Khurana, Navdeep Sethi, Ankur Khandelwal
DOI:10.4103/joacp.JOACP_260_18  
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Fentanyl can be mitochondrion -toxic depending on dosage and cell type p. 570
Josef Finsterer, Sinda Zarrouk-Mahjoub
DOI:10.4103/joacp.JOACP_262_18  
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Lumbar ultrasound scan: A guide to the epidural space p. 571
Kompal Jain, Vikky Jaiswal, Arun Puri
DOI:10.4103/joacp.JOACP_293_18  
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