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   Table of Contents - Current issue
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April-June 2020
Volume 36 | Issue 2
Page Nos. 145-285

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EDITORIALS  

Understanding data and its analysis for interpretation – Correct interpretation and safety matters! p. 145
Rakesh Garg
DOI:10.4103/joacp.JOACP_438_19  
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The use of sphenopalatine ganglion block for analgesia and attenuation of stress response induced by skull-pin head-holder during neurosurgery p. 147
Shuchita Garg, Harsh Sachdeva
DOI:10.4103/joacp.JOACP_134_20  
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REVIEW ARTICLE Top

Safety of anesthetic exposure on the developing brain – Do we have the answer yet? Highly accessed article p. 149
Anju Gupta, Shruti Gairola, Nishkarsh Gupta
DOI:10.4103/joacp.JOACP_229_19  
During the past two decades, a vast number of studies done on rodents and nonhuman primates have implicated general anesthetic exposure of developing brains in producing neurotoxicity leading to various structural and functional neurological abnormalities with cognitive and behavioral deficits later in life. However, it is still unclear whether these findings translate to children and whether single exposure to anesthesia in childhood can have long-term neuro-developmental risks. Considering the fact that a large number of healthy young children are undergoing elective surgery under general anesthesia globally, any such potential neurocognitive risk of pediatric anesthesia is a serious public health issue and is therefore important to understand. This review aims to assess the current preclinical and clinical evidence related to anesthetic neurotoxicity.
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ORIGINAL ARTICLES Top

Prospective audit of sedation/anesthesia practices for children undergoing computerized tomography in a tertiary care institute p. 156
Aakriti Gupta, Indu Sen, Neerja Bhardwaj, Sandhya Yaddanapudi, Preethy J Mathew, Neeru Sahni, Anmol Bhatia
DOI:10.4103/joacp.JOACP_16_19  
Background and Aims: The aim of the study was to enumerate the sedative drugs used, assess the efficacy of sedative drugs, and determine the incidence of adverse events. Material and Methods: A prospective audit of children sedated for computerized tomography (CT) by anesthesiology team was conducted for a period of 4 months. The data included patient demographic variables, fasting period, medications administered, adequacy of sedation, imaging characteristics, adverse events, and requirement for escalated care. Results: A total of 331 children were enrolled for sedation by the anesthesia team. The drugs used for sedation were propofol, ketamine, and midazolam. Twenty-two percent children received one sedative drug, 60% children were administered two drugs, and 5% children required a combination of all three drugs for successful sedation. Sedation was effective for successful conduct of CT scan in 95.8% patients without the requirement of a repeat scan. Twelve (5%) children experienced adverse events during the study period. However, none of the adverse events necessitated prolonged postprocedural hospitalization or resulted in permanent neurologic injury or death. Conclusions: The current practice of sedation with propofol, ketamine, and midazolam, either single or in combination was efficacious in a high percentage of patients. The incidence of adverse events during the study period was low.
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Is intraoperative supplementation of dextrose essential for infants undergoing facial cleft surgeries? p. 162
Sunil Rajan, Kaushik Barua, Pulak Tosh, Lakshmi Kumar
DOI:10.4103/joacp.JOACP_318_18  
Background and Aims: Dextrose is commonly added to the intraoperative maintenance fluids of pediatric patients. The primary objective was to evaluate the effect of addition of 1% dextrose to Ringer's lactate (RL) on blood glucose levels in infants undergoing facial cleft surgeries. Material and Methods: This prospective, randomized, single blinded study was conducted in forty infants undergoing either cheiloplasty or palatoplasty. Random blood sugar (RBS) was assessed using a glucometer after induction of anaesthesia, and at 1 and 2 hours later. Group R received RL and Group D received RL with 1% dextrose as intraoperative maintenance fluid. Hypoglycemia was defined as RBS <70 mg/dL and hyperglycemia as RBS >150 mg/dL. Results: Baseline RBS levels and those at 60 min and 120 min post-induction were comparable in both groups. The increase in blood sugar levels from baseline to 60 min and to 120 min in each group was significant. Incidence of hyperglycemia was comparable in both groups. There were no episodes of hypoglycemia, intraoperatively. Conclusion: Use of Ringer lactate alone or with addition of 1% dextrose resulted in comparable intraoperative blood sugar levels when used as maintenance fluid in infants undergoing facial cleft surgeries.
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Enhancing cooperation during pediatric ultrasound: Oral midazolam versus conventional techniques p. 166
Rachna Chaurasia, Anshul Jain, Narendra Singh Sengar, Shivali Pandey
DOI:10.4103/joacp.JOACP_343_17  
Background and Aims: Ultrasound is a safe and non-invasive method for detecting numerous pathologies. Pediatric patients are often uncooperative which leads to decreased quality and increased time of scan. We compared the conventional means alone and combination of oral midazolam for the above cited purpose. Material and Methods: This double blind prospective study (CTRI/2016/06/007030) was conducted after obtaining due approval from institutional ethical committee. One hundred Children aged 2-6 years belonging to ASA class 1 or 2, posted for high resolution ultrasonography of abdomen were included in the study. They were randomised to receive midazolam 0.3 mg/kg mixed in 20 mL of apple juice (Group I) or 20 mL of apple juice alone (Group II) 20 minutes prior to the procedure. The parameters assessed were level of cooperation, sonologist's satisfaction, total scan time, heart rate and SpO2. Results: Out of 100 patients, 44 patients of group I and 42 of group II were analysed. The cooperation score was significantly higher in Group I (35%) than Group II (19%). Likert scale revealed very satisfied and satisfied rating in 61.3% (Group I) and 21.4% (Group II). The time taken by sonologist and number of attempts were significantly less in Group I than Group II. There was no difference in discharge time between the groups. There was no reportable adverse event in either group. Conclusion: Oral midazolam is a safe and effective agent to aid routine abdominal ultrasonography in pediatric patients.
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Ultrasound-guided transversus abdominis plane block versus caudal block for postoperative analgesia in children undergoing inguinal hernia surgery: A comparative study p. 172
Amit Kumar, Neelam Dogra, Anupama Gupta, Swati Aggarwal
DOI:10.4103/joacp.JOACP_100_19  
Background and Aims: Ultrasound-guided (USG) transversus abdominis plane (TAP) block has emerged as a safe and effective regional anesthesia technique as it provides adequate postoperative pain relief for lower abdominal surgeries. Caudal block is a gold standard technique in pediatric surgeries. Our aim was to compare the duration of postoperative analgesia between TAP block and caudal block in children undergoing inguinal hernia surgeries. Material and Methods: In a prospective, randomized, controlled study, 112 children of age 2-8 years and ASA grade I and II, undergoing elective inguinal hernia surgery were randomly allocated into two groups: Group T (n = 56) received USG-guided TAP block with 0.5mL/kg of 0.2% ropivacaine and Group C (n = 56) received caudal block with 1mL/kg of 0.2% ropivacaine. The primary outcome variable was the duration of postoperative analgesia and the secondary outcome variables included variation in hemodynamic parameters and adverse effects, if any. Results: There was no significant difference in median of CHEOPS score till 5 postoperative hours, thereafter till 24 postoperative hours, significantly lower CHEOPS score were found in Group T. Mean duration of analgesia was 523.44 ± 61.30 min in Group T, whereas in Group C, it was 352.59 ± 32.54 min. No significant difference was observed in hemodynamic variations and adverse effects. Conclusion: TAP block and caudal block both are effective in providing postoperative analgesia in children undergoing inguinal herniotomy. USG-guided TAP block was found to be superior as it provided longer duration of analgesia and reduced rescue analgesic dose without any significant adverse effects as compared with caudal block after inguinal herniotomy.
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Efficacy of 0.5 mg/kg of propofol at the end of anesthesia to reduce the incidence of emergence agitation in children undergoing general anesthesia with sevoflurane p. 177
Andi Ade Wijaya Ramlan, Dimas K. Bonardo Pardede, Arif H. M. S Marsaban, Jefferson Hidayat, Fildza Sasri Peddyandhari
DOI:10.4103/joacp.JOACP_257_19  
Background and Aims: Emergence agitation (EA) is a common transient behavioral disturbance after inhalational anesthesia and may cause harm to the patient. This study evaluated the efficacy of 0.5 mg/kg of propofol administered at the end of anesthesia to reduce the incidence of EA in children undergoing general inhalational anesthesia. Material and Methods: This double-blind randomized clinical trial was done in children aged 1–5 years undergoing general anesthesia with sevoflurane. One hundred and eight subjects were included using consecutive sampling method and randomized into two equal groups. Propofol in the dose of 0.5 mg/kg was administered at the end of anesthesia to children in the propofol group, while those in the control group did not receive any intervention at the end of anesthesia. Incidence of EA, transfer time, postoperative hypotension, desaturation, and nausea-vomiting were observed. Aono and Pediatric Anesthesia Emergence Delirium scale were used to assess EA. Results: Incidence of EA was 25.9% in the propofol group compared to 51.9% in the control group (RR = 0.500; 95% CI 0.298–0.840; P = 0.006). Mean transfer time in propofol group was longer (9.5 ± 3.9 min) than control group (7.8 ± 3.6 min) (mean difference 1.71 min; 95% CI 0.28–3.14; P = 0.020). Hypotension was found in one patient (1.9%) in propofol group, while in control group there was none. Nausea-vomiting was found in five patients (9.3%) in propofol group and eight patients (14.8%) in control. There was no desaturation in both the groups. Conclusion: Administration of 0.5 mg/kg of propofol at the end of anesthesia effectively reduces the incidence of EA in children undergoing general inhalational anesthesia with sevoflurane.
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Cervical epidural analgesia combined with general anesthesia for head and neck cancer surgery: A randomized study p. 182
Anjali Kochhar, Jahanara Banday, Zainab Ahmad, Pratibha Panjiar, Homay Vajifdar
DOI:10.4103/joacp.JOACP_72_19  
Background and Aims: The role of cervical epidural analgesia in head and neck cancer surgery is not fully explored. The aim of this study was to evaluate cervical epidural analgesia in terms of opioid and anesthetic requirements and stress response in patients undergoing head and neck cancer surgery. Material and Methods: After institutional ethical committee approval and written informed consent, 30 patients undergoing elective head and neck cancer surgery were randomized into two groups: Group E (cervical epidural analgesia with general anesthesia), and group G (general anesthesia alone). In group E, an 18 gauge epidural catheter was placed at cervical (C) 6 – thoracic (T) 1 level. After test dose, a bolus of 10 ml of 0.2% ropivacaine was given followed by continuous infusion. Technique of general anesthesia and post-operative management was standardized in both the groups. Opioid and anesthetic drug requirement was observed. Blood glucose and serum cortisol levels were measured at baseline; post-incision and after surgery. Results: There was significant reduction in the requirement of morphine (P < 0.001), isoflurane (P = 0.004) and vecuronium (P = 0.001) in group E. Post-operative, blood glucose and serum cortisol levels were significantly reduced (P = 0.0153 and 0.0074, respectively). Early post-operative pain was reduced with the lesser requirement of post-operative morphine. Conclusions: The use of combined cervical epidural analgesia with general anesthesia reduces opioid, anesthetic drug requirement and stress response as compared to general anesthesia alone in patients undergoing head and neck cancer surgery.
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Does an acute pain service improve the perception of postoperative pain management in patients undergoing lower limb surgery? A prospective controlled non-randomized study p. 187
Sukanya Mitra, Kompal Jain, Jasveer Singh, Swati Jindal, Puja Saxena, Manpreet Singh, Richa Saroa, Vanita Ahuja, Jannat Kang, Sudhir Garg
DOI:10.4103/joacp.JOACP_104_19  
Background and Aim: An acute pain service (APS) has been running in our institute since April 2013 and is managed by the Department of Anesthesia and Intensive Care. However, it is not clear to what extent the patients feel benefited from the APS. The aim of the study was to compare the perception of postoperative pain management in patients receiving care under APS with those receiving routine postoperative pain relief following lower limb surgery. Material and Methods: This was a prospective, hospital-based, controlled non-randomized study. American Society of Anesthesiologists (ASA) grades I–III patients with age 18–75 years undergoing lower limb orthopedic surgery were prospectively recruited into APS (index group) or routine postoperative care (control group) (n = 55 each). Postoperatively, American Pain Society Patient Outcome Questionnaire-Revised (APS-POQ-R) and Short Form (SF-12) were used to evaluate the outcome of postoperative pain management at 24 h and health-related quality of life after 4 weeks respectively. Results: Both groups were comparable in terms of demographic data. Patients in the index group had statistically significant better perception of care than the control group. Index group scored significantly higher than control group on median patient satisfaction score (9; interquartile range [IQR] [7–10] vs. 5 [3–6]; P < 0.001). In index group, there was significant reduction of worst pain in first 24 h along with decreased frequency of severe pain. Conclusion: Implementation of acute pain service plays an important role in improving the quality of postoperative pain relief, perception of care, and patient satisfaction.
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Continuous preperitoneal infusion of ropivacaine for postoperative analgesia in patients undergoing major abdominal or pelvic surgeries. A prospective controlled randomized study p. 195
Reem Abdelraouf ElSharkawy, Tamer Elmetwally Farahat, Khaled Abdelwahab
DOI:10.4103/joacp.JOACP_333_18  
Background and Aims: This study was conducted to compare continuous preperitoneal infusion (CPI) with continuous epidural infusion (CEI) of ropivacaine for pain relief and effect on pulmonary functions after major abdominal and pelvic surgeries. Material and Methods: One hundred patients were randomized into two equal groups. Patients in CPI group (n = 50) received analgesia by continuous infusion of 0.2% ropivacaine, whereas those in the CEI group (n = 50) received continuous epidural infusion of 0.2% ropivacaine. The primary outcome was the first request of analgesia. The secondary outcome was the influence on the pulmonary functions. Results: The time for the first request of analgesia was longer in the CPI group compared with that in the CEI group (7.3 ± 1.6 vs. 4.1 ± 1.1 h with P value = 0.001). The daily dose of morphine was lesser in CPI versus CEI group (11.3 ± 1 against 17.4 ± 0.9 mg). The pulmonary function tests were comparable except peak expiratory flow rate, which was better in CPI (170 ± 5.4) than CEI group (148.1 ± 5.8; with P value = 0.001). Conclusion: Continuous preperitoneal infusion provides a superior analgesic effect than the continuous epidural infusion as regards delayed first request of analgesia, better pain scores, lesser usage of additional analgesics with better respiratory function.
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Erector spinae plane block and transversus abdominis plane block for postoperative analgesia in cesarean section: A prospective randomized comparative study p. 201
Aman Malawat, Kalpana Verma, Durga Jethava, Dharam Das Jethava
DOI:10.4103/joacp.JOACP_116_19  
Background and Aims: Erector spinae plane (ESP) block is an interfascial plane block given at the paraspinal region and provides effective visceral and somatic analgesia. Transversus abdominis plane (TAP) block is also an interfascial block that provides adequate somatic pain control. We conducted this study to compare the analgesic efficacy of ESP and TAP blocks with ropivacaine for 48 h after the cesarean section. Material and Methods: Sixty patients scheduled for elective cesarean section under spinal anesthesia, randomly divided into ESP block (n = 30) or TAP block (n = 30) groups. After completion of surgery, ultrasound-guided ESP or TAP block was given using 0.2% ropivacaine (0.2 ml/kg on either side). Postoperatively visual analogue scale (VAS) score and analgesic requirement of each patient was assessed at regular interval for 48 h by a blinded investigator. Statistical analysis was done using SPSS version 21. Student's t-test and Chi-square test were used for demographic and other data. Results: ESP block provided prolonged analgesia compared to the TAP block, andthe mean time to first rescue analgesia was 43.53 h and 12.07 h, respectively (P < 0.001). The requirement for total analgesic was also significantly less in the ESP group compared to the TAP group (P < 0.001). Conclusion: ESP block provided prolonged analgesia with a significant decrease in analgesic requirement compared to TAP block and can be used as a standard technique for post-cesarean analgesia.
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Sphenopalatine ganglion block: Intranasal transmucosal approach for anterior scalp blockade - A prospective randomized comparative study p. 207
Narmada Padhy, Srilata Moningi, Dilip K Kulkarni, Rajesh Alugolu, Srikanth Inturi, Gopinath Ramachandran
DOI:10.4103/joacp.JOACP_249_18  
Background and Aims: Peripheral nerve blocks in neurosurgical practice attenuate most stressful responses like pin insertion, skin, and dural incision. Scalp block is conventionally the blockade of choice. Further studies for less invasive techniques are required. Intranasal transmucosal block of the sphenopalatine ganglion has shown promising results in patients with chronic headache and facial pain. The primary objective of our study was to compare the gold standard scalp block and bilateral sphenopalatine ganglion block (nasal approach) for attenuation of hemodynamic response to pin insertion. Secondary objectives included hemodynamic response to skin and dural incision. Material and Methods: After IRB approval and informed consent, a prospective randomized comparative study was carried out on 50 adult patients undergoing elective supratentorial surgery. The hemodynamic response to pin insertion, skin incision, and dural incision was noted in both the groups. The data was analyzed with NCSS version 9.0 statistical software. Results: The HR and MAP were comparable between the groups. Following dural incision MAP was significantly lower at 1,2,3,4,5 and 10 min in group SPG whereas in group S it was significantly lower at 1 and 2min. (P = 0.02 at T1, P = 0.03 at T2). Conclusions: Concomitant use of bilateral SPG block with general anesthesia is an effective and safe alternative technique to scalp blockade for obtundation of hemodynamic responses due to noxious stimulus during craniotomy surgeries.
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Hyperbaric oxygen therapy as an adjuvant to standard therapy in the treatment of diabetic foot ulcers p. 213
Atit Kumar, Usha Shukla, Tallamraju Prabhakar, Dhiraj Srivastava
DOI:10.4103/joacp.JOACP_94_19  
Background and Aims: Chronic diabetic foot ulcers pose a major problem because of associated limb threatening complications. The aim of the present study was to evaluate the efficacy of hyperbaric oxygen therapy (HBOT) as an adjuvant to standard therapy for treatment of diabetic foot ulcers. Material and Methods: A total of 54 patients with diabetic foot ulcer of Wagner grade II–IV were recruited in this prospective, randomized, double blind study. Patients were randomized to receive HBOT along with standard therapy (group H; n = 28) or standard therapy alone (group S; n = 26). Patients were given 6 sessions per week for 6 weeks and followed up for 1 year. Outcomes were measured in terms of healing, and need for amputation, grafting or debridement. Parametric continuous variables were analyzed using Student unpaired t-test and categorical variables were analyzed using Chi square test. Results: The diabetic ulcers in 78% patients in Group H completely healed without any surgical intervention while no patient in group S healed without surgical intervention (P = 0.001). 2 patients in group H required distal amputation while in Group S, three patients underwent proximal amputation. Conclusion: The present study shows that hyperbaric oxygen therapy is a useful adjuvant to standard therapy and is a better treatment modality if combined with standard treatment rather than standard treatment alone for management of diabetic foot ulcers.
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Cost identification analysis of general anesthesia p. 219
Rohit Malhotra, Nishant Kumar, Aruna Jain
DOI:10.4103/joacp.JOACP_77_19  
Background and Aims : Rising health costs are challenging anesthesiologists to search for cost-effective anesthetic techniques. We conducted a study to estimate variable cost per case and cost of drug wastage as percentage of total drug cost associated with different modalities of general anesthesia (GA). Material and Methods: This prospective study was carried out after approval by institutional ethical committee in 258 adult patients aged 18–60 years of either sex, American Society of Anesthesiologists physical status I or II, with a surgical duration of 1–4 hours, posted for elective surgery under GA with endotracheal intubation. At the end of surgery, total utilization of each drug, anesthetic gases, and consumables were noted and remaining drug was regarded as wastage. Cost was recorded as per maximum retail price for that particular brand in the market at start of study and total cost was calculated. For purpose of analysis, cases were divided into low flow sevoflurane, high flow sevoflurane, high flow isoflurane, low flow isoflurane, and total intravenous anesthesia (TIVA). Results: The mean variable cost was highest with TIVA (₹2713.82 ± 509.57) and lowest with low flow isoflurane (₹1981.62 ± 335.03; P < 0.001). Drug wastage was 13.1% overall, with highest in low sevoflurane group and lowest in TIVA. Conclusion: Low flow anesthesia with isoflurane is more cost-effective as compared to high flow techniques and TIVA even for short duration surgeries. Rational use of drugs and consumables and minimizing wastage can further reduce anesthesia costs.
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Comparison of leakage test and ultrasound imaging to validate ProSeal supraglottic airway device placement p. 227
Sachin E Ajithan, Archana Puri, Mukul C Kapoor
DOI:10.4103/joacp.JOACP_332_19  
Background and Aims: To validate the placement of ProSeal supraglottic airway device using ultrasound (USG) with leakage test in adult population of both sexes. Material and Methods: This single-arm observational study was conducted on 80 American Society of Anesthesiology (ASA) I-III patients, undergoing elective surgery under general anesthesia with ProSeal supraglottic airway device. Leakage pressure test was conducted in all cases. The position of the ProSeal laryngeal mask airway (LMA) was assessed by USG in the pharyngeal, laryngeal, and the cranial-caudal axis plane. The fiberoptic examination was done to confirm the position of ProSeal if the seal pressure was <27 cm H2O, to confirm suboptimal placement. The position of the ProSeal in the three USG planes was allocated a predetermined score. This score was compared with the leakage test to determine the strength of the correlation, sensitivity, and specificity for predicting a need for reinsertion. Results: Leakage seal pressure was recorded as <27 cm H2O in 6 (7.5%) patients and fiberoptic bronchoscopy was done in these cases to determine the need for reinsertion. ProSeal was reinserted in 5 (6.25%) cases. Patients with a composite ultrasound score of 0–1 required ProSeal reinsertion while those with a score of 2–3 did not require reinsertion. Seventy-one patients had seal pressure >27 cm H2O and a score of 3. USG examination is comparable with leakage test in predicting the requirement of reinsertion (P = 0.003) and a score of 19 equating 0–1 predicted the need for reinsertion with a sensitivity and specificity of 80% and 100%, respectively. Conclusion: USG is comparable with the leakage test for confirmation of ProSeal placement.
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Evaluation of King's vision videolaryngoscope and glidescope on hemodynamic stress response to laryngoscopy and endotracheal intubation p. 233
Nagat S EL-Shmaa
DOI:10.4103/joacp.JOACP_183_18  
Background and Aims: We hypothesis that the use of novel airway devices would decrease hemodynamic stress response (HDSR) to laryngoscopy and endotracheal (ET) intubation. The aim of our study was to evaluate the hemodynamic stress response (HDSR) to laryngoscopy and tracheal intubation using the King vision video laryngoscope (KVVL) versus glidescope (GLS). Material and Methods: A prospective randomized, comparative study that was conducted on 80 patients of both sexes; American Society of Anesthesiologists physical status I and II with no anticipated difficult airway, aged 20–60 years; who were scheduled for elective surgical procedure under general anesthesia. Patients were randomly allocated into two groups (40 each). Group I: laryngoscopy and tracheal intubation were carried out using KVVL, Group II: laryngoscopy and tracheal intubation were carried out using GLS. The two groups were compared for noninvasive hemodynamic data such as heart rate and mean arterial pressure. Time to successful intubation and number of attempts were recorded. Hemodynamic parameters were recorded at the preinduction, after induction, at intubation, 1 min, 3 min, 5 min, 10 min, and 15 min. Results: There was significant decrease (P < 0.05) in HR and MBP in both groups just before intubation. In comparison with the baseline, HR and MBP in group I and group II increased but this difference was not significant at 3 min and 5 min after intubation and returned to the baseline at 10 min after intubation and below the baseline at 15 min after intubation. Also, there were no significant differences in the hemodynamic response between the studied groups. Conclusion: Novel airway devices either KVVL or GLS are efficient in reducing HDSR to laryngoscopy and ET intubation.
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Dexmedetomidine vs dexamethasone as an adjuvant to 0.5% ropivacaine in ultrasound-guided supraclavicular brachial plexus block p. 238
Nidhi Singh, Shikha Gupta, Suneet Kathuria
DOI:10.4103/joacp.JOACP_176_19  
Background and Aims: Both dexmedetomidine and dexamethasone have individually been shown to be beneficial as an adjuvant to ropivacaine. We compared the efficacy of combination of ropivacaine with dexmedetomidine and ropivacaine with dexamethasone in ultrasound-guided supraclavicular brachial plexus (SCBP) block. Material and Methods: In this prospective randomised double-blind controlled trial, 60 ASA physical status I/II patients undergoing elective upper-limb surgery under ultrasound-guided SCBP block with 30 ml of 0.5% ropivacaine were randomised into three groups. Group 1 (n = 20) received 1 μg/kg of dexmedetomidine, and group 2 (n = 20) received 8 mg of dexamethasone in addition to ropivacaine, while group 3 (n = 20) received only ropivacaine. The primary outcomes studied were onset and duration of sensory and motor block. Secondary outcomes included duration of analgesia, total analgesic consumption in 24 h postoperatively and quality of block. ANOVA and Chi-square test were used to compare results on continuous measurements and categorical measurements, respectively. Results: Onset of sensory and motor block was faster in group 1 (13.5 ± 4.1 and 17.0 ± 4.1 min) and group 2 (15.6 ± 3.6 and 18.5 ± 3.7 min) as compared to group 3 (20.1 ± 5.3 and 24.9 ± 5.6 min; P < 0.001). Block duration was significantly longer in group 1 and group 2 than in group 3. Duration of analgesia was prolonged in group 1 and 2 (1218.0 ± 224.6 and 1128.0 ± 207.5 min, respectively) as compared to group 3 (768.0 ± 273.7 min; P < 0.001). Twenty-four hours analgesic consumption postoperatively was reduced in the two study groups. Conclusion: Both dexmedetomidine and dexamethasone when used as adjuvants to ropivacaine for SCBP block, block onset time, and prolong' block duration.
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Hemodynamic changes under spinal anesthesia after elastic wrapping or pneumatic compression of lower limbs in elective cesarean section: A randomized control trial p. 244
Krishnamoorthy Retnamma Prajith, Gayatri Mishra, M Ravishankar, Vadlamudi Reddy Hemanth Kumar
DOI:10.4103/joacp.JOACP_72_18  
Background and Aims: In spite of adequate fluid loading and left lateral tilt, parturients develop hypotension under spinal anesthesia during cesarean section. Elastic crepe bandage (CB) or pneumatic compression device (PCD) can be utilized to prevent the pooling of blood in lower limbs and thereby it may reduce the incidence of hypotension in these patients. This study was formulated to analyze the hemodynamic effects of leg wrapping with elastic CB and PCD in parturients undergoing for cesarean section under anesthesia. Material and Methods: Ninety term obstetric patients posted for elective cesarean section under spinal anesthesia were randomized into 3 groups: Group 1 (control), Group 2 (CB), and Group 3 (PCD). All the parturients had their legs wrapped with an elastic bandage and pneumatic sleeve applied over it. In Group 1 (Control), patients had their legs wrapped with CB loosely and pneumatic sleeve also applied was switched on. In Group 2, patients the CB was applied by stretching the bandage (15 cm width and 4 m stretched length). The PCD was not switched on in this group. In Group 3, the legs were wrapped with the CB loosely. The pneumatic sleeve was applied over the bandage, and the machine was switched on with a preset pressure of 40–50 mmHg after spinal anesthesia. Incidence of maternal hypotension and ephedrine requirement to maintain systolic blood pressure, neonatal Apgar score were recorded. Results: The incidence of hypotension was significantly lower in Group 2 and 3 than the control group. Similarly, the requirement of ephedrine was significantly high in control group compared to CB and PCD. The incidence of hypotension was lower in group CB than group PCD. Meantime to receive the first dose of ephedrine was significantly low in control (7.37 ± 4.94 min) as compared to CB (10 ± 2.8 min) and PCD (13.88 ± 9.23). Conclusion: Leg-wrapping with CB is cost-effective, non-invasive, non-pharmacological, and effective tool to reduce the incidence of hypotension after spinal anesthesia in a parturient.
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Profile of cerebrovascular accidents in subjects with or without type 2 diabetes mellitus in intensive care units of tertiary care centre p. 251
Dinesh Jain, Mukesh Chawala, Birinder S Paul, Naveen Mittal, Aayush Jain, Sandeep Puri
DOI:10.4103/joacp.JOACP_181_14  
Background and Aims: Diabetes Mellitus (DM) is a modifiable and independent risk factor for stroke. As the clinical features, radiological profile, outcome and prognosis of the stroke in type 2 diabetic and non diabetic patients are significantly variable, we proposed to evaluate these variations of stroke in patients with or without Type 2 DM. Material and Methods: A prospective study was conducted from January, 2011 to June, 2012 on in-hospital admitted diabetic and non diabetic patients presenting with stroke. Data was recorded on a predesigned Performa. Results: A total of 150 cases were enrolled into the study. Out of these, 66% of patients had ischemic stroke and 34% of patients had hemorrhagic stroke. Type 2 diabetes mellitus was present in 52% patients. Ischemic stroke was significantly higher in diabetics than non diabetics (P = 0.007); however, hemorrhagic stroke was more in non diabetics. Mean age was significantly higher in diabetics (P = 0.04). CAD (P = 0.04), recurrent stroke (P = 0.006) had significant association with diabetes. Large vessel stroke was more common than small vessel stroke. Anterior circulation stroke was more common than posterior circulation stroke. There was significant improvement in morbidity and disability of the patients on follow up with treatment. Conclusions: A greater incidence of anterior circulation ischemic stroke, and recurrent strokes occur in patients with DM.
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Effect of dexmedetomidine on attenuation of hemodynamic response to intubation, skin incision, and sternotomy in coronary artery bypass graft patients: A double-blind randomized control trial p. 255
Manoj Kamal, Deepa Agarwal, Geeta Singariya, Kamlesh Kumari, Bharat Paliwal, Shobha Ujwal
DOI:10.4103/joacp.JOACP_353_18  
Background and Aims: Coronary artery bypass grafting (CABG) surgery involves various noxious stimuli resulting in stress response, which in turn increases the risk of perioperative myocardial ischemia. The present study was conducted to evaluate the effect of dexmedetomidine on the attenuation of hemodynamic response to intubation, skin incision, and sternotomy in CABG surgery. Material and Methods: Sixty patients were randomized into two groups of 30 each. Group D patients received dexmedetomidine 1 μg/kg as loading dose over 10 min, followed by continuous infusion of 0.5 μg/kg/h. In group P, normal saline was infused as loading and maintenance dose at similar rate. Hemodynamic parameters, total induction dose of thiopentone, and adverse effects were recorded. Statistical analysis was performed using SPSS version 20.0. Chi-square test and ANNOVA test were used and P < 0.05 was considered significant. Results: The percentage increase in heart rate was significantly lesser in group D than group P after intubation (7.04% v/s 15.08%), skin incision (5.91% v/s 10.11%), and sternotomy (5.33% v/s 11.65%). Similarly increase in systolic, diastolic, and mean blood pressure were significantly lesser in group D than group P after intubation, skin incision, and sternotomy. There was a significant reduction of mean total of thiopentone in group D in comparison to group P. (1.16 mg/kg v/s 2.44 mg/kg) (P<0.001). Conclusion: Dexmedetomidine resulted in significant attenuation of hemodynamic response to intubation, skin incision, and sternotomy in CABG surgery without significant adverse effects. It also significantly reduced the dose of thiopentone required for induction.
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FORUM Top

Total postoperative analgesia for total knee arthroplasty: ultrasound guided single injection modified 4 in 1 block p. 261
Ritesh Roy, Gaurav Agarwal, Chandrasekhar Pradhan, Debasis Kuanar
DOI:10.4103/joacp.JOACP_260_19  
Background and Aims: Total pain free outcome following total knee arthroplasty has led to the evolution of regional blocks. In this series, the authors have revisited and modified Roy et al. 's technique of Ultrasound guided 4 in 1 block for knee and below knee surgeries, to provide a complete comprehensive yet simple single injection technique for postoperative analgesia for Total Knee Arthroplasty (TKA). Material and Methods: After Instituional ethics approval, we performed the modified 4 in 1 block on 10 consenting patients scheduled to undergo total knee arthroplasty. A linear USG-probe was used to identify medial femoral condyle, then vastus and sartorius intersection was identified. The probe was slid till the descending genicular artery branching from superficial femoral artery was visualized proximal to hiatus. At this point the needle with PNS attached, was guided into the Vastus medialis muscle till the stimulation of the nerve to Vastus medialis (0.4-0.5 mA). At this point 5–7 mL of 0.2% Ropivacaine was injected. The needle was guided in plane to perivascular region and after negative aspiration 0.2%ropivacaine 20–25 ml was injected, visualised to push the femoral artery. Results: All ten patients considered in this study had an optimum pain score of <5 and were comfortable along with no quadriceps weakness, except one patient had a pain score of more than 5 after 36 hr post-operatively and required rescue analgesia. Conclusion: The addition of USG and PNS guided Vastus medialis nerve block to USG 4-in-1 block in the technique gives good post-operative analgesia for TKA.
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CASE REPORT Top

Continuous stellate ganglion block in delayed cerebral ischemia: A possible supplementary approach to traditional therapy? p. 265
Andrea Bortolato, Davide Simonato, Paolo Feltracco, Marina Munari
DOI:10.4103/joacp.JOACP_251_19  
Delayed Cerebral Ischemia (DCI) is a major contributor to morbidity and mortality after SAH. Currently the prevention of vasospasm and DCI relies on nimodipine administration and on maintaining an adequate cerebral perfusion pressure. We report a patient with initial DCI after SAH in which stellate ganglion block (SGB) was performed after nimodipine administration. Firstly the procedure was characterized by a iv and intra-arterial nimodipine administration which did not result into a normal perfusion pattern. Therefore a single-shot stellate ganglion block was performed, as suggested in literature. Because of the not sufficient but promising perfusion improvement, we decided to deliver a continuous ganglion block (cSGB) for 5 days. Consequently a further improvement of the cerebral perfusion on CTPerfusion and Real Time Angiographic Perfusion Assessment was registered. In order to treat cerebral vasospasm, SGB is known to be a further valuable treatment, despite its temporary effect. However the continuous use of SGB during initial DCI has never been described before.
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LETTERS TO EDITOR Top

Cardiac arrest after administration of sugammadex as neuromuscular blockade reversal agent and full recovery from anesthesia p. 268
Evangelia Samara, Ioanna Iatrelli, Theofilos Georgakis, Petros Tzimas
DOI:10.4103/joacp.JOACP_345_19  
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Comment on: Assessment of head and neck position for optimal ultrasonographic visualization of the internal jugular vein and its relation to the common carotid artery: A prospective observational study p. 270
Sohan L Solanki, Jeson R Doctor
DOI:10.4103/joacp.JOACP_93_20  
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Is intraoperative low tidal volume ventilation worse in patients with preexisting systemic inflammatory response? Our insights to Chugh et al. study p. 271
Gil Goncalves, Habid M. R. Karim, Antonio M Esquinas
DOI:10.4103/joacp.JOACP_89_20  
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Evolving spectrum of dexmedetomidine preconditioning for Ischemia–reperfusion injury amelioration p. 272
Jasvinder K Kohli, Rohan Magoon, Souvik Dey, Ramesh Kashav
DOI:10.4103/joacp.JOACP_408_19  
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Importance of preanesthetic evaluation in emergency: Are we in haste p. 273
Rajeev Chauhan, Gourav Mittal, Pranshuta Sabharwal, Aditi Jain
DOI:10.4103/joacp.JOACP_216_19  
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An individualized hemodynamic optimization: Tailoring the targets of therapy p. 274
Rohan Magoon, Poonam M Kapoor, Arindam Choudhury, Ameya Karanjkar
DOI:10.4103/joacp.JOACP_299_19  
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Scrambler therapy – A novel treatment approach for chronic postoperative pain p. 276
Komal Kashyap, Saurabh Vig, Swati Bhan, Sushma Bhatnagar
DOI:10.4103/joacp.JOACP_11_19  
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Accidental arterial chemoport catheter insertion p. 278
Pooja Bihani, Narendra Kaloria, Pradeep Bhatia, Sanjeev Kumar, Rishabh Jaju
DOI:10.4103/joacp.JOACP_127_19  
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Undiagnosed hypothyroidism with delayed recovery: A case report p. 279
Shilpa Agarwal, Ashim Banerjee, Nidhi Jain
DOI:10.4103/joacp.JOACP_85_18  
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Permanent dialysis catheter-related right atrial mass: A case report p. 280
Ajmer Singh, Battu K Shrestha, Yatin Mehta, Naresh Trehan
DOI:10.4103/joacp.JOACP_130_19  
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Critical heart rate and left bundle-branch block resolution in anesthesia p. 282
Jeremy Laney, Thang Tran, Arash Motamed
DOI:10.4103/joacp.JOACP_197_18  
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