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   Table of Contents - Current issue
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July-September 2019
Volume 35 | Issue 3
Page Nos. 287-427

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EDITORIALS  

Acquiring skills of airway management: The grandpa–granddaughter model! Highly accessed article p. 287
Rakesh Kumar
DOI:10.4103/joacp.JOACP_253_19  PMID:31543572
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Optimal position for laryngoscopy – Time for individualization? Highly accessed article p. 289
Sheila Nainan Myatra
DOI:10.4103/joacp.JOACP_254_19  PMID:31543573
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Digital future in perioperative medicine: Are we there yet? p. 292
Umakanth Panchagnula, Mohan Shanmugam, Biyyam Meghna Rao
DOI:10.4103/joacp.JOACP_228_19  PMID:31543574
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REVIEW ARTICLES Top

Beyond the borders: Lessons from various industries adopted in anesthesiology Highly accessed article p. 295
Subramanyam S Mahankali, Priya Nair
DOI:10.4103/joacp.JOACP_375_18  PMID:31543575
Since the first public demonstration of anaesthesia in Boston, USA which happened around 172 years back, the field of anesthesiology has rapidly progressed, with many developments that have improved the quality and safety of anesthesia care. This has enabled tremendous advances in the surgical disciplines and increasing the life expectancy and quality of life of humans. This is a result of learning and constantly evolving. There are several similarities between healthcare and other industries, though there are several distinguishing characteristics that set it apart from other industries. There are a number of safety and quality improvement measures in healthcare which have been influenced by safety practices in other industries. Anaesthesia has been the leader among the medical specialities in adoption of innovative practices from various industries in an effort to advance patient safety, enhance quality of care, reduce waste & inefficiency, and improve customer service and satisfaction. This article emphasises on learnings from other industries in the recent decades, focusing on aviation, high-reliability organizations, car manufacturing, telecommunication, car racing, entertainment, and retail. Learning and implanting the best practices from these industries can bring about a paradigm shift in health care industry. It has a potential to improve efficiency and make anaesthesia safer than ever before in the history of human kind.
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Anesthetic considerations for extracranial injuries in patients with associated brain trauma Highly accessed article p. 302
Ankur Khandelwal, Parmod Kumar Bithal, Girija Prasad Rath
DOI:10.4103/joacp.JOACP_278_18  PMID:31543576
Patients with severe traumatic brain injury often presents with extracranial injuries, which may contribute to fatal outcome. Anesthetic management of such polytrauma patients is extremely challenging that includes prioritizing the organ system to be dealt first, reducing on-going injury, and preventing secondary injuries. Neuroprotective and neurorescue measures should be instituted simultaneously during extracranial surgeries. Selection of anesthetic drugs that minimally interferes with cerebral dynamics, maintenance of hemodynamics and cerebral perfusion pressure, optimal utilization of multimodal monitoring techniques, and aggressive rehabilitation approach are the key factors for improving overall patient outcome.
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ORIGINAL ARTICLES Top

Comparative evaluation of laryngeal view and intubating conditions in two laryngoscopy positions-attained by conventional 7 cm head raise and that attained by horizontal alignment of external auditory meatus - sternal notch line – using an inflatable pillow - A prospective randomised cross-over trial p. 312
Anant V Pachisia, Kavita R Sharma, Jaspal S Dali, Mona Arya, Neha Pangasa, Rakesh Kumar
DOI:10.4103/joacp.JOACP_35_19  PMID:31543577
Background and Aims: We compared the laryngoscopy position attained by a 7-cm-high pillow (Sniffing position-SP) with that attained by horizontal alignment of external auditory meatus-sternal notch (AM-S) line-using variable height inflatable pillow. Material and Methods: This prospective-randomised-cross-over study included 50 patients in each group. Group-AM-S: A 7 cm uncompressible pillow was used for attaining first laryngoscopy position, followed by horizontal alignment of external auditory meatus-sternal notch (AM-S) line-using an inflatable pillow for attaining second laryngoscopy position followed by intubation. Group-SP: Horizontal alignment of external auditory meatus-sternal notch (AM-S) line-was done using an inflatable pillow for attaining first laryngoscopy position, followed by using 7 cm uncompressible pillow for second laryngoscopy position followed by intubation. The CL-grade, Intubation Difficulty Score (IDS) and time to intubation were compared in both positions. The head raise (in cm) required for attaining AM-S alignment was noted. Results: CL-grade-I was obtained in significantly larger number of patients with AM-S alignment position than with 7 cm head raise (P = 0.004). CL-grade-III was obtained in significantly lesser number of patients with AM-S alignment (P = 0.002). Mean IDS with AM-S alignment (1.18 ± 1.69) was significantly less than with 7cm head raise (2 ± 1.59; P = 0.007) and time to intubation with AM-S alignment (17.33 ± 4.52 s) was significantly less than that with 7cm head raise (18.94 ± 4.64 s; P = 0.041). The mean head rise required to achieve AM-S line alignment was 4.920 ± 1.460 cm. Conclusion: External Auditory Meatus-Sternal notch (AM-S) line alignment provides better laryngeal view, better intubating conditions and requires lesser time to intubate as compared to a conventional 7-cm-head raise. The size of pillow used for head raise should be individualised.
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Emergency front of neck airway: What do trainers in the UK teach? A national survey p. 318
Ilyas Qazi, Cyprian Mendonca, Achuthan Sajayan, Adam Boulton, Imran Ahmad
DOI:10.4103/joacp.JOACP_65_18  PMID:31543578
Background and Aims: Front of neck airway (FONA) is the final step to deliver oxygen in the difficult airway management algorithms. The Difficult Airway Society 2015 guidelines have recommended a standardized scalpel cricothyroidotomy technique for an emergency FONA. There is a wide variability in the FONA techniques with disparate approaches and training. We conducted a national postal survey to evaluate current teaching, availability of equipment, experienced surgical help and prevalent attitudes in the face of a can't intubate, can't oxygenate situation. Material and Methods: The postal survey was addressed to airway leads across National Health Service hospitals in the United Kingdom (UK). In the anesthetic departments with no designated airway leads, the survey was addressed to the respective college tutors. A total of 259 survey questionnaires were posted. Results: We received 209 survey replies with an overall response rate of 81%. Although 75% of respondents preferred scalpel cricothyroidotomy, only 28% of the anesthetic departments considered in-house FONA training as mandatory for all grades of anesthetists. Scalpel-bougie-tube kits were available in 95% of the anesthetic departments, either solely or in combination with other FONA devices. Conclusion: The survey has demonstrated that a majority of the airway trainers in the UK would prefer scalpel cricothyroidotomy as emergency FONA. There is a significant variation and deficiency in the current levels of FONA training. Hence, it is important that emergency FONA training is standardized and imparted at a multidisciplinary level.
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COMMENTARY Top

Emergency surgical access in complete ventilation failure or CICO: The right time! p. 324
Rakesh Garg
DOI:10.4103/joacp.JOACP_310_18  PMID:31543579
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ORIGINAL ARTICLES Top

Advanced airway training in the UK: A national survey of senior anesthetic trainees p. 326
Adam J Boulton, Sunita R Balla, Aleksandra Nowicka, Thomas M Loka, Cyprian Mendonca
DOI:10.4103/joacp.JOACP_325_18  PMID:31543580
Background and Aims: High-quality training in advanced airway skills is imperative to ensure safe anesthetic care and develop future airway specialists. Modern airway management skills are continually evolving in response to advancing technology and developing research. Therefore, it is of concern that training provisions and trainee competencies remain current and effective. Material and Methods: A survey questionnaire based on the airway competencies described in the Royal College of Anaesthetists' curriculum and Difficult Airway Society guidelines was posted to all United Kingdom (UK) National Health Service hospitals to be completed by the most senior anesthetic trainee (ST 5–7, resident). Results: A total of 149 responses were analyzed from 237 hospitals with eligible anesthetic trainees (response rate 63%), including 53 (36%) and 39 (26%) respondents who had completed higher and advanced level airway training respectively. Although clinical experience with videolaryngoscopy was satisfactory, poor confidence and familiarity was identified with awake fiberoptic intubation, high frequency jet ventilation, at risk extubation techniques, and airway ultrasound assessment. Only 26 (17%) respondents had access to an airway skills room or had regular airway emergency training with multidisciplinary theater team participation. Reported barriers to training included lack of training lists, dedicated teaching time, experienced trainers, and availability of equipment. Conclusions: This national survey identified numerous deficiencies in airway competencies and training amongst senior anesthetic trainees (residents) in the UK. Restructuring of the airway training program and improvements in access to training facilities are essential to ensure effective airway training and the capability to produce future airway specialists.
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Efficacy of surface landmark palpation for identification of the cricoid cartilage in obstetric patients: A prospective observational study p. 335
Fatemah Qasem, Roy Khalaf, Ilana Sebbag, Ronit Lavi, Philip M Jones, Sudhu Indu Singh
DOI:10.4103/joacp.JOACP_222_17  PMID:31543581
Background and Aims: Rapid sequence induction, with the application of cricoid pressure is an accepted practice during induction of general anesthesia in pregnant patients to prevent pulmonary apiration. We found no prior studies assessing the accuracy of locating the cricoid cartilage by professional caregivers, and therefore conducted an observational study to assess the ability of different caregivers – anesthesia consultants, anesthesia residents, respiratory therapists (RTs), and nurses, in the obstetric care unit, to correctly identify the cricoid cartilage of parturients. We hypothesized that anesthesia consultants would be most accurate. Material and Methods: Institutional REB approval was obtained, as was written informed consent from all participants in the study. The subjects were made up of thirty healthy obstetric patients scheduled for elective cesarean delivery. Their cricoid cartilages were assessed by 53 caregivers (assessors). Localization of the cricoid cartilage by assessors was considered accurate if it was within 5 mm of the sonographically identified mark. The difficulty in localization was reported on a VAS scale and the time taken for localization was recorded. Results: Data from 30 subjects and 53 assessors (13 anesthesia consultants, 12 residents, 13 RTs, and 15 nurses) performing a total of 60 evaluations (some assessors evaluated 2 subjects) were analyzed. About 60% of RTs, 53% of anesthesia residents, 40% of anesthesia consultants, and 13% of nurses correctly identified the cricoid cartilage. No differences in caregivers'perception of difficulty were found, but RTs were the quickest at identification (P < 0.001 vs anesthesia consultants; P = 0.002 vs residents; P = 0.071 vs nurses). Conclusion: RTs were the most successful and accurate in identifying the cricoid cartilage of parturients among the different groups of professional caregivers.
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A comparison between ProSeal laryngeal mask airway and Air-Q Blocker in patients undergoing elective laparoscopic cholecystectomy p. 340
Roshni Gupta, Rajesh Mahajan, Mukta Jatinder, Smriti Gulati, Anjali Mehta, Robina Nazir
DOI:10.4103/joacp.JOACP_397_17  PMID:31543582
Background and Aims: ProSeal laryngeal mask airway (PLMA) is an established device for airway management, while Air-Q Blocker (AQB) is a relatively new supraglottic device. The aim of this study is to compare AQB against PLMA in adults undergoing laparoscopic cholecystectomy under general anesthesia. Material and Methods: Eighty-eight adult patients scheduled for laparoscopic cholecystectomy under general anesthesia were randomly allocated into two groups. A drain tube (gastric tube for PLMA and blocker tube for AQB) was inserted through the drain channel of the respective device. PLMA was inserted in Group P (n = 44) and AQB was inserted in Group A (n = 44) to secure the airway. The primary endpoint was airway seal pressure. Secondarily, we sought to compare overall insertion success, ease of insertion, hemodynamic effects after initial placement, ease of drain tube placement, and perioperative oropharyngolaryngeal morbidity between the devices. Results: Oropharyngeal seal pressures for AQB and PLMA were 31.5 ± 2.41 and 29.41 ± 2.14 cm H2O, respectively (P = 0.01). Insertion time was longer with AQB than PLMA, 25.59 ± 5.71 and 18.66 ± 3.15 seconds, respectively (P = 0.001). Ease and success rate of insertion was better with PLMA compared to AQB. Failure of device insertion was seen in 2 cases of Group A. Gastric distension was seen in 4 patients in Group A, requiring replacement with endotracheal tube in two patients. Ventilation was successful in all 44 patients with PLMA. Both the devices were comparable in providing a patent airway and adequate oxygenation during controlled ventilation. There was an increased trend of airway trauma and complications in the AQB group. Conclusion: Both PLMA and AQB show similar efficacy in maintaining ventilation and oxygenation, during laparoscopic surgery. However, proper positioning and functioning of the blocker tube of AQB is a limiting factor, and needs further evaluation.
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Ambu AuraGain versus intubating laryngeal tube suction as a conduit for endotracheal intubation p. 348
Melanio A Bruceta, Dalal G Priti, Paul McAllister, Jansie Prozesky, Sonia J Vaida, Arne O Budde
DOI:10.4103/joacp.JOACP_214_17  PMID:31543583
Background and Aims: Newly developed supraglottic airway devices (SGAs) are designed to be used both for ventilation and as conduits for endotracheal intubation with standard endotracheal tubes (ETTs). We compared the efficacy of the Ambu AuraGain (AAG) and the newly developed intubating laryngeal tube suction disposable (ILTS-D) as conduits for blind and fiber-optically guided endotracheal intubation in an airway mannequin. Material and Methods: This is a prospective, randomized, crossover study in an airway mannequin, with two arms: blind ETT insertion by medical students and fiber-optically guided ETT insertion by anesthesiologists. The primary outcome variable was the time to achieve an effective airway through an ETT using AAG and ILTS-D as conduits. Secondary outcome variables were the time to achieve effective supraglottic ventilation and successful exchange with an ETT, and the success rates for blind endotracheal intubation and fiber-optically guided intubation techniques for both SGAs. Results: Forty participants were recruited to each group. All participants were able to insert both devices successfully on the first attempt. For blind intubation, the success rate for establishing a definitive airway with an ETT using the SGA as a conduit was significantly higher with ILTS-D (82.5%) compared with AAG (20.0%) (P < 0.001). None of the participants were able to successfully complete the exchange of the SGA for the ETT with the AAG. In the fiber optic guided intubation group, the rate of successful exchange was significantly higher with ILTS-D (84.6%) compared with AAG (61.5%) (P = 0.041). Conclusion: The ILTS-D successfully performs in an airway mannequin with higher success rate and shorter time for blindly establishing an airway with an ETT using the SGA as a conduit, compared with AAG. Further clinical trials are warranted.
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Confirmation of placement of endotracheal tube – A comparative observational pilot study of three ultrasound methods p. 353
Ashok K Sethi, Rashmi Salhotra, Monika Chandra, Medha Mohta, Shuchi Bhatt, Choro A Kayina
DOI:10.4103/joacp.JOACP_317_18  PMID:31543584
Background and Aims: Confirmation of endotracheal tube (ETT) position is necessary to ensure proper ventilation. The present study was conducted with the aim to compare the efficacy of three ultrasonographic (USG) techniques in terms of time taken for confirmation of ETT position. The time taken by each USG technique was also compared with that for auscultation and capnography. The ability of the three USG techniques to identify tracheal placement of ETT was evaluated in all patients. Material and Methods: Ninety adult American Society of Anesthesiologists (ASA) I/II patients requiring general anaesthesia with tracheal intubation were randomised into three groups (n = 30 each) depending upon the initial USG transducer position used to confirm tracheal placement of ETT: group T (tracheal), group P (pleural) and group D (diaphragm). The time taken for confirmation of tracheal placement of ETT by USG, auscultation and capnography was recorded for each of the groups. Subsequently, USG confirmation of ETT placement was performed with the other two USG techniques in all patients. Results: The time taken for USG in group T was significantly less (3.8 ± 0.9 s) compared to group P (12.1 ± 1.6 s) and group D (13.8 ± 1.7 s); P < 0.001. USG was significantly faster than both auscultation and capnography in group T (P < 0.001), whereas in group P and group D, USG took longer time compared to auscultation (P = 0.014 and P < 0.001, respectively) but lesser time than capnography (P < 0.001 in both groups). Conclusion: USG is a rapid technique for identification of ETT placement. All the three USG techniques are reliable in identifying the tracheal placement of ETT.
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Comparison of King Vision video laryngoscope (channeled blade) with Macintosh laryngoscope for tracheal intubation using armored endotracheal tubes p. 359
Reena
DOI:10.4103/joacp.JOACP_43_18  PMID:31543585
Background and Aims: During direct laryngoscopy (DL), intubation using armored endotracheal tubes (ETTs) requires help of bougies, stylets, or Magill's forceps, which leads to unnecessary prolongation in the intubation times. The channeled blade of King Vision (KV) video laryngoscope is likely to obviate the need of these equipments for a successful intubation using armored tubes. Material and Methods: After approval from Institutional Ethics Committee and informed consent, 100 patients were randomized to receive endotracheal intubation using armored ETTs either with KV video laryngoscope (VL) channeled blade or with Macintosh laryngoscope. Time to intubation, success rate, time for best glottis view, number of attempts, optimization maneuvers, or complications if any were recorded. Ease of device use was also assessed in terms of insertion, glottis visualization, and intubation. Continuous variables were tested using unpaired t-test and categorical variables with Pearson's Chi-square test. P ≤ 0.05 was considered significant. Result: First attempt success rate was 92% in group KV and 74% in group DL (P = 0.017). Time for successful intubation was less in group KV as compared with group DL (P < 0.0001). Optimization maneuvers such as “BURP” was needed in three patients of group KV and 11 patients of group DL (P = 0.0218). Bougie was needed in 13 patients of group DL and none from group KV (P = <0.001). Ease of device use was similar in the two groups. Conclusion: KVVL offers faster intubating conditions for tracheal intubation requiring armored ETTs in comparison to DL using Macintosh blade.
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A comparison of King vision video laryngoscope with CMAC D-blade in obese patients with anticipated difficult airway in tertiary hospital in India – Randomized control study p. 363
Raj Sahajanandan, Anity Singh Dhanyee, Arun Kumar Gautam
DOI:10.4103/joacp.JOACP_245_18  PMID:31543586
Background and Aims: This randomized control trial was conducted to compare two video laryngoscopes in obese patients with anticipated difficult airway. Video laryngoscopes have shown to be beneficial in many difficult airway scenarios including obesity. Many studies have shown that even though the glottic view is better, it takes longer to negotiate the endotracheal tube. We proposed to compare CMAC D-blade with King vision-channeled blade for intubating obese patients with anticipated airway difficulty. We hypothesized that channeled scope may be superior as once visualized, tube could be easily negotiated. This would be reflected by time taken for the glottis visualization, time taken for intubation, incidence of complications, and hemodynamic stability. Material and Methods: Sixty-three patients who fulfilled inclusion criteria were enrolled after informed consent. Based on the computer-generated randomization, they were assigned to group 1 (King vision laryngoscope – KVL) and group 2 (CMAC D-blade). All anesthetists who intubated, performed 20 intubations with both video laryngoscopes on manikin before performing the study case. The parameters analyzed were time to visualize the glottis, time to successful intubation, and intubation-related hemodynamic variations and complications. Results: The mean time taken to visualize the glottis with KVL was 12.93 s compared to 10 s with CMAC D-blade (P value 0.12). Time taken to intubate was 50.04 s with KVL compared to CMAC D-blade which took 46.93 s (P value 0.64). KVL had a complication rate of 20.7% compared to 3.1% with CMAC D-blade (P value 0.04). Conclusion: There was no statistically significant difference in time to visualize the glottis and intubation between KVL and CMAC D-blade. But there was a high incidence of complications with KVL.
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Dexmedetomidine with propofol versus fentanyl with propofol for insertion of Proseal laryngeal mask airway: A randomized, double-blinded clinical trial p. 368
Jaya Choudhary, Aaditya Prabhudesai, Chumki Datta
DOI:10.4103/joacp.JOACP_104_18  PMID:31543587
Background and Aims: Successful insertion of the proseal laryngeal mask airway (PLMA) requires much greater doses of propofol as compared to classic laryngeal mask (CLMA). Dexmedetomidine and fentanyl are equally effective adjuvants for CLMA insertion. We designed this study to compare the efficacy of these two drugs as sole adjuvant in PLMA insertion. Material and Methods: Seventy four American Society of Anesthesiologists (ASA) I and II patients were randomly allocated to receive either dexmedetomidine 1 μg/kg [Group PD] or fentanyl 1 μg/kg [Group PF]. Study drugs were diluted in 10 ml NS and administered over 10 min prior to induction of anesthesia with 2.5 mg/kg propofol. PLMA insertion condition was measured according to the Muzi scoring system. Score ≤2 was considered optimal for PLMA insertion. Patient's cardio-respiratory parameters, emergence time, and postoperative pain were also recorded. Results: In our study 83.8% patients in the group PF and 91.9% in the group PD achieved optimal insertion condition (not significant). Hemodynamic stability was maintained in both the groups but the incidence of apnea was significantly higher in the PF group (P = 0.011). We also observed that emergence time was prolonged but postoperative pain scores were significantly lower in the PD group (P < 0.001). Conclusion: We conclude that both dexmedetomidine and fentanyl in a dose of 1 μg/kg when used before induction with propofol provide comparable conditions for successful PLMA insertion. Dexmedetomidine has additional advantage of preserving spontaneous respiration and providing better analgesia.
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Single-point versus double-point injection technique of ultrasound-guided supraclavicular block: A randomized controlled study p. 373
Nitin Choudhary, Abhijit Kumar, Amit Kohli, Sonia Wadhawan, Tabish H Siddiqui, Poonam Bhadoria, Hemlata Kamat
DOI:10.4103/joacp.JOACP_144_18  PMID:31543588
Background and Aims: This study aims to compare the single-point injection and double-point injection technique of ultrasound-guided supraclavicular block with regard to the success rate, time taken to perform the procedure, onset and duration of sensory and motor block, and complications. Material and Methods: A total of 60 American Society of Anesthesiologists physical status I and II patients between 20 and 50 years of age, with body mass index ≤30 kg/m2 posted for forearm surgeries, with anticipated surgical duration more than 1 h were randomly divided into two groups: group S (single-point injection) and group D (double-point injection technique). After locating the brachial plexus with ultrasound, needle was inserted from lateral to medial direction to reach the plexus. In group D, 20 ml of inj. bupivacaine 0.5% was deposited as 10 ml each in superior (in the cluster) and inferior pocket (corner pocket) between the plexus and subclavian artery with the help of hydrodissection while in group S the total 20 ml was deposited in the superior (in the cluster) pocket. The onset of sensory and motor block was assessed using pin prick method and modified Bromage scale. Adequacy of block was ensured by assessing the ulnar, radial, and median nerve distribution. Procedural time was defined from the point of scanning the plexus till the drug was injected completely. Total sensory, motor duration, and complications if any were noted. Results: Group D had higher success rate compared to group S (96.7 vs. 83.3%; P < 0.0001). The total procedural time was significantly more in group D compared to group S (14.6 ± 2.7 vs. 10.1 ± 1.7 min; P < 0.0001). The onset of sensory and motor block was faster and the duration of sensory and motor block was significantly longer in group D. Conclusion: The adequacy of block, sensory, and motor duration was significantly high in newer double-point injection technique. However, it requires longer procedural time compared to single-point injection technique.
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A non-randomized controlled study of total intravenous anesthesia regimens for magnetic resonance imaging studies in children p. 379
Bhuvaneswari Balasubramanian, Anila D Malde, Shantanu B Kulkarni
DOI:10.4103/joacp.JOACP_289_17  PMID:31543589
Background and Aims: We studied the efficacy and safety of different total intravenous anesthesia used for pediatric magnetic resonance imaging (MRI). Material and Methods: Children of 1–7 years age (n = 88), undergoing MRI received a loading dose of dexmedetomidine 1 μg/kg over 10 min, ketamine 1 mg/kg, and propofol 1 mg/kg in sequence. University of Michigan Sedation Scale (UMSS) of 3 was considered an acceptable level for starting the scan. Rescue ketamine 0.25–0.5 mg/kg was given if UMSS remained <3. After the loading dose of drugs, some children attained UMSS = 4 or progressive decline in heart rate, therefore, did not receive any infusion. The rest received either dexmedetomidine (0.7 μg/kg/h) (n = 35) or propofol (3 mg/kg/h) (n = 38) infusion for maintenance. Ketamine 0.25 mg/kg was used as rescue. Sedation failure was considered if either there was inability to complete the scan at the pre-set infusion rate, or there was need for >3 ketamine boluses or serious adverse events occurred. Statistical Package for Social Sciences 20 was used for analysis. Results: Initiation of scan was 100% successful with median induction time of 10 min. Maintenance of sedation was successful in 100% with dexmedetomidine and 97.4% with propofol infusion. Recovery time (25 min v/s 30 min), discharge time (35 min v/s 60 min), and total care duration (80 min v/s 105 min) were significantly less with propofol as compared to dexmedetomidine (P = 0.002, 0.000, and 0.000, respectively). There were no significant adverse events observed. Conclusion: Dexmedetomidine 1μg/kg, ketamine 1 mg/kg, and propofol 1 mg/kg provide good conditions for initiation of MRI. Although dexmedetomidine at 0.7μg/kg/h and propofol at 3 mg/kg/h are safe and effective for maintenance, propofol provides faster recovery.
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A randomized, controlled trial of comparison of a continuous femoral nerve block (CFNB) and continuous epidural infusion (CEI) using 0.2% ropivacaine for postoperative analgesia and knee rehabilitation after total knee arthroplasty (TKA) p. 386
Harshil J Gandhi, Lopa H Trivedi, Deepshikha C Tripathi, Deepika M Dash, Amit M Khare, Mayur U Gupta
DOI:10.4103/joacp.JOACP_134_16  PMID:31543590
Background and Aims: Postoperative pain relief following total knee arthroplasty (TKA) is a major concern as it will help to achieve an effective functional outcome. The present study was conducted to compare continuous femoral nerve block (CFNB) and continuous epidural infusion (CEI) techniques using ropivacaine. Material and Methods: Forty patients were randomly allocated into group F and group E to receive 0.2% ropivacaine through femoral catheter or epidural catheter respectively. An infusion was started @6 ml/h post-operatively when VAS was ≥4. The dose was titrated to keep VAS <4 (with minimum rate 2 ml/h and maximum rate 10 ml/h). If VAS ≥4 occurred despite maximum rate of infusion, a rescue analgesic was given. Primary objectives were to compare visual analogue score (VAS), rehabilitation indices, and rescue analgesic requirement. Secondary objectives were to assess patient and surgeon's satisfaction score, motor blockade, and complications if any. Results: The mean VAS score, rehabilitation goals, rescue analgesic requirement, and patient's and surgeon's mean satisfaction scores were comparable in both the groups. Motor blockade was not seen and though the number of side effects were more in group E, they did not achieve statistical or clinical significance. Conclusion: CFNB can be used as an alternative, effective postoperative analgesic technique for TKA.
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FORUM Top

Comparison of thyromental height test with ratio of height to thyromental distance, thyromental distance, and modified Mallampati test in predicting difficult laryngoscopy: A prospective study p. 390
Pratibha Panjiar, Anjali Kochhar, Kharat M Bhat, Mudassir A Bhat
DOI:10.4103/joacp.JOACP_276_18  PMID:31543591
Background and Aims: Preoperative airway assessment to predict patients with difficult laryngoscopy is always crucial for anesthesiologists. Several predictive tests have been studied by various authors in quest of finding the best airway predictor. Recently, a new airway predictor, thyromental height test (TMHT) has been reported to have good predictive value in assessing difficult airway. We conducted this study with primary aim to evaluate the diagnostic accuracy of TMHT and to compare it with other established airway predictors, such as ratio of height to thyromental distance (RHTMD), thyromental distance (TMD), and modified Mallampati test (MMT) for predicting difficult laryngoscopy. Material and Methods: This prospective, observational study was conducted in 550 patients of either sex aged >18 years scheduled for elective surgery under general anesthesia. The patients' airway was assessed preoperatively by two anesthetists. Standard anesthetic protocol was followed in all the patients. The laryngoscopic view was graded according to Cormack–Lehane scale. The receiver operating characteristic (ROC) curve was used to calculate the ideal cut off values for TMHT and RHTMD. Standard formulae were used to calculate validity indexes. Results: The incidence of difficult laryngoscopy was 10%. The cut-off value for TMHT and RHTMD were 5.1 cm and 19.5, respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of TMHT were 78.18%, 93.94%, 58.90%, and 97.48%, respectively. The highest sensitivity, PPV, and NPV were observed with TMHT as compared with RHTMD, TMD, and MMT (P < 0.0001). Conclusions: TMHT is the best predictive test with highest accuracy and odds ratio for predicting difficult airway out of all predictive tests evaluated.
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CASE REPORT Top

Perioperative anesthetic management of a combined right atrial thrombectomy with living donor liver transplantation p. 396
Rajkumar Subramanian, Shweta A Singh, Subhash Gupta, Sanjoy Kumar Majhi, Rajneesh Malhotra
DOI:10.4103/joacp.JOACP_180_18  PMID:31543592
Hepatocellular carcinoma (HCC) with vascular invasion is usually considered inoperable. We describe a case of HCC with vascular invasion and right atrial thrombus that was successfully down staged. Patient underwent combined right atrial thrombectomy and living donor liver transplantation (LDLT) in the same setting. Perioperative anesthesia management and perioperative concerns of two major combined procedures are discussed.
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LETTERS TO EDITOR Top

Endotracheal tube fixation: Still a dilemma p. 400
Abhishek Nagarajappa, Manpreet Kaur, Anupam Samanta, Abhay Tyagi
DOI:10.4103/joacp.JOACP_92_19  PMID:31543593
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The “critical” link in the transport of critically ill patients; role of the anesthesiologist and challenges in the Indian setup p. 401
Mridul Dhar, Sanjay Agrawal, Ummed Singh, Rishabh Agarwal
DOI:10.4103/joacp.JOACP_6_19  PMID:31543594
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Gluteal compartment syndrome a rare complication of lithotomy position and continuous postoperative epidural analgesia p. 403
Chitta R Mohanty, Alok K Sahoo, Ritesh Panda, Mantu Jain
DOI:10.4103/joacp.JOACP_146_18  PMID:31543595
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Intraoperative brachial plexus injury – Do we need a wake-up call? p. 404
Supriya Dsouza, Preeti Gupta, Manju Butani
DOI:10.4103/joacp.JOACP_173_18  PMID:31543596
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McCoy Laryngoscope: A savior in patient with limited mouth opening p. 406
Teena Bansal, Susheela Taxak, Aruna Yadav, Somesh Singh
DOI:10.4103/joacp.JOACP_210_18  PMID:31543597
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Foley catheter-based inexpensive, indigenous airway device p. 407
GP Deepak, Riniki Sarma, Rakesh Kumar, Sunil Kumar
DOI:10.4103/joacp.JOACP_162_18  PMID:31543598
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Iatrogenic cause of postextubation total airway obstruction caught on camera: A case report p. 409
Rakesh Kumar, Anju Gupta, Sunil Kumar, Divya Kumar
DOI:10.4103/joacp.JOACP_95_17  PMID:31543599
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Ketamine and propofol infusion for therapeutic rigid bronchoscopy in a patient with central airway obstruction p. 410
Nishkarsh Gupta, Kalpajit Dutta, Rakesh Garg, Sachidanand Jee Bharti
DOI:10.4103/joacp.JOACP_259_17  PMID:31543600
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A unique way of securing the tracheostomy tube in a case of facial and neck burns p. 412
Kapil D Soni, Thanigai Arasu, Richa Aggarwal, Vanlal Darlong
DOI:10.4103/joacp.JOACP_278_17  PMID:31543601
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Xanthous vocal cords p. 413
Vijay Adabala, Nishith Govil
DOI:10.4103/joacp.JOACP_287_18  PMID:31543602
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Abdominal surgery in a patient with bullous emphysema: Anesthetic concerns p. 414
Vikas Saini, Shiraz M Assu, Nidhi Bhatia, Sameer Sethi
DOI:10.4103/joacp.JOACP_231_18  PMID:31543603
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Air embolism following hysteroscopy p. 416
Neeru Luthra, Namrata , Anju Grewal
DOI:10.4103/joacp.JOACP_143_18  PMID:31543604
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COMMENTARY Top

Commentary: Venous air embolism during hysteroscopy: A stitch in time saves nine! p. 417
Nishkarsh Gupta, Anju Gupta
DOI:10.4103/joacp.JOACP_352_18  PMID:31543605
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LETTERS TO EDITOR Top

Continuous erector spinae plane block as an anesthetic technique for breast cancer surgery p. 420
Raghu S Thota, Dipannita Mukherjee
DOI:10.4103/joacp.JOACP_192_18  PMID:31543606
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COMMENTARY Top

Continuous erector spinae block as an anesthetic technique in breast surgery: What is the current evidence? p. 422
Nishkarsh Gupta, Rohini Dattatri, Anju Gupta
DOI:10.4103/joacp.JOACP_372_18  PMID:31543607
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LETTERS TO EDITOR Top

Erector spinae plane block provides complete perioperative analgesia for chronic scapulothoracic pain p. 424
Christopher Godlewski
DOI:10.4103/joacp.JOACP_272_18  PMID:31543608
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