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   Table of Contents - Current issue
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January-March 2019
Volume 35 | Issue 1
Page Nos. 1-141

Online since Tuesday, April 16, 2019

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EDITORIAL  

Medication errors: They continue Highly accessed article p. 1
Rashmi Salhotra, Asha Tyagi
DOI:10.4103/joacp.JOACP_88_19  
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REVIEW ARTICLES Top

Anesthetic implications in hyperthermic intraperitoneal chemotherapy Highly accessed article p. 3
Nishkarsh Gupta, Vinod Kumar, Rakesh Garg, Sachidanand Jee Bharti, Seema Mishra, Sushma Bhatnagar
DOI:10.4103/joacp.JOACP_93_18  
Patients with peritoneal carcinomatosis were considered incurable with dismal survival rates till hyperthermic intraperitoneal chemotherapy after optimal cytoreductive surgery evolved. Perioperative management for these procedures is complex and involves an optimal cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy. In this article we highlight the perioperative concerns in these patients including anesthetic challenges, such as optimal fluid management, maintaining blood pressure, control of body temperature, coagulation and electrolyte derangement and renal toxicity of chemotherapeutic drugs. We have also discussed the postoperative problems and their management.
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Monitoring cerebral vasospasm: How much can we rely on transcranial Doppler Highly accessed article p. 12
Navneh Samagh, Hemant Bhagat, Kiran Jangra
DOI:10.4103/joacp.JOACP_192_17  
Cerebral vasospasm leading to delayed cerebral ischaemia is one of the major concerns following subarachnoid haemorrhage (SAH). Various modalities are present for evaluation and detection of cerebral vasospasm that occurs following SAH. They include transcranial Doppler (TCD), computed tomographic angiography (CTA), computed tomographic (CT) perfusion and digital subtraction angiography (DSA). The recent guidelines have advocated the use of TCD and have described it as a reasonable technique for monitoring the development of vasospasm. This review describes the functioning of TCD, the cerebral haemodynamic changes during vasospasm and TCD-based detection of vasospasm. The review shall highlight as to how the TCD derived values are relevant in the settings of neurocritical care. The data in the review have been consolidated based on our search of literature from year 1981 till 2016 using various data base.
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Maternal anesthesia for EXIT procedure: A systematic review of literature Highly accessed article p. 19
Kamal Kumar, Cristiana Miron, Sudha Indu Singh
DOI:10.4103/joacp.JOACP_302_17  
The ex utero intrapartum treatment (EXIT) procedure is performed in cases of fetal congenital malformation. The anesthetic management is much more challenging and involves providing profound uterine relaxation, maintenance of Uteroplacental blood flow and fetal anesthesia. The aim of the article is to review the literature and compare the efficacy of both the anesthetic techniques with respect to maternal and fetal outcomes. The literature source for this review was obtained via PubMed, Medline, Google scholar and Cochrane database of systematic reviews until January 2017. In our literature review we found that both GA and Regional anesthesia were successfully described for EXIT procedure but GA was performed in the majority of cases.Consideration for anesthetic technique should be done on a case-by-case basis.
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ORIGINAL ARTICLES Top

Comparative evaluation of Truview evo2 and Macintosh laryngoscope for ease of orotracheal intubation in children – A prospective randomized controlled trial p. 25
Neha Pangasa, Jaspal Singh Dali, Kavita Rani Sharma, Mona Arya, Anant Vikram Pachisia
DOI:10.4103/joacp.JOACP_118_18  
Background and Aims: Truview evo2 has been found to improve the glottic view when compared with the Miller blade in pediatric population. However, there is limited literature comparing it with Macintosh laryngoscope in children. We thus aimed to assess and compare Truview evo2 with the Macintosh laryngoscope for orotracheal intubation in children with regards to time to intubate, laryngoscopic view, ease of intubation, and associated hemodynamic changes. Material and Methods: Fifty ASA I-II children aged 2–8 years for elective surgery requiring general anesthesia with orotracheal intubation participated in this prospective randomized-controlled study. They were randomly allocated to two groups. In group-M (N = 25), laryngoscopy and intubation were performed using Macintosh laryngoscope, and in group-T (N = 25), Truview evo2 laryngoscope was used. Modified Cormack–Lehane grade, time to intubation, intubation difficulty score (IDS), and hemodynamic changes were compared between the groups. Data were analyzed using SPSS statistical software version 17 and P value <0.05 was considered statistically significant. Results: CL grade 1 was found in a larger number of patients of group-T (P = 0.003) and CL grades2a and 2b were found in a larger number of patients of group-M (P = 0.023 and P = 0.037, respectively). The mean time to intubation was significantly longer in group-T (19.0 ± 3.4 seconds) than in group-M (13.1 ± 2.1 seconds), P = 0.00. The over all IDS was lower in group-T than group M [i.e. median (IQR): 0 (0-0) vs 1 (0-2), respectively]. Heart rate, systolic and diastolic blood pressure, and oxygen saturation were comparable between the groups at all times. Conclusion: Truview evo2 provides better laryngeal view and has a lesser IDS, but takes longer for intubation, when compared to the Macintosh laryngoscope in children.
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Comparative evaluation of I-gel vs. endotracheal intubation for adequacy of ventilation in pediatric patients undergoing laparoscopic surgeries p. 30
Megha Kohli, Sonia Wadhawan, Poonam Bhadoria, Simmi K Ratan
DOI:10.4103/joacp.JOACP_249_17  
Background and Aims: The use of newer supraglottic devices has been extended to laparoscopic procedures. We conducted this study to compare and evaluate the efficacy of these two devices in pediatric laparoscopic surgeries. Material and Methods: Eighty children, 2–8 years of age, scheduled for elective short laparoscopic procedures were randomly allocated to the I-gel or endotracheal tube (ETT) group. Standard anesthesia protocol was followed for inhalational induction. I-gel or ETT was inserted according to the manufacturer's recommendations. Ventilation was set with tidal volume 10 ml/kg and a respiratory rate of 16/min. Carboperitoneum was achieved up to an intra-abdominal pressure of 12 mmHg. Statistical Analysis: The primary outcome variable was adequacy of ventilation (peak airway pressure, end-tidal CO2, minute ventilation, and SPO2). These variables were recorded after securing airway, after carboperitoneum and desufflation of the peritoneal cavity. The oropharyngeal leak pressures were also noted. Statistical analysis was done using SPSS software version 17.0. P <0.05 was considered statistically significant. Results: No significant difference was observed in the heart rate or mean arterial pressure. There was a significant increase in the PECO2and peak airway pressure after creation of carboperitoneum. There was significant increase in minute ventilation in both groups after creation of carboperitoneum. Conclusion: To conclude, I-gel is comparable to endotracheal intubation in terms of adequacy of ventilation. The increase in peak airway pressures is less with I-gel. In addition, postoperative complications are fewer with I-gel.
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A comparison of oral dexmedetomidine and oral midazolam as premedicants in children p. 36
Binu Sajid, Taznim Mohamed, M Jumaila
DOI:10.4103/joacp.JOACP_20_18  
Background and Aim: Midazolam has been the most popular oral premedicant in children despite its side effects. Dexmedetomidine with its favorable clinical profile is a suitable alternative, but with limited research. The aim of this study was to compare the effectiveness of dexmedetomidine and midazolam as oral premedicants in children. Material and Methods: Eighty children of the American Society of Anesthesiologist physical status I scheduled for elective herniotomy were included in this prospective randomized double-blind study. Patients were randomly assigned to receive either dexmedetomidine 4 μg/kg (Group A, n = 40) or midazolam 0.5 mg/kg (Group B, n= 40) orally 40 min before induction. Pre-operative sedation, response to parental separation and venepuncture, emergence agitation, recovery nurse satisfaction, and side effects were compared between the two groups. Quantitative data were compared using unpaired Student's t-test and categorical variables with Chi-square test. Results: Pre-operative sedation and response to parental separation and venepuncture were similar between the two groups. Group A had a significantly lower incidence and severity of emergence agitation (P = 0.000). Recovery nurse satisfaction was significantly higher in Group A (P = 0.002). However, incidence of hypotension and bradycardia was found to be more in Group A (P = 0.04). Conclusion: Premedication with oral dexmedetomidine is as effective as oral midazolam in providing sedation and anxiolysis in children. Dexmedetomidine in addition reduces the incidence and severity of emergence agitation.
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The estimation of minimum effective volume of 0.5% ropivacaine in ultrasound-guided interscalene brachial plexus nerve block: A clinical trial p. 41
Kailash Mittal, Sarita Janweja, Prateek , Pushpender Sangwan, Deepa Agarwal, Himani Tak
DOI:10.4103/joacp.JOACP_70_18  
Background and Aims: Interscalene brachial plexus block (ISB) is the most commonly used mode of anesthesia for upper limb surgeries. Higher volume of local anesthetic used in ISB is associated with increased incidence of side effects, particularly phrenic nerve palsy. The aim of this study was to determine the minimum effective volume of 0.5% ropivacaine in 90% patients (MEV90) in ISB. Material and Methods: With target of 45 successful cases, phase 1 clinical trial was conducted based on the principles of biased coin design up-and-down method. After obtaining Ethical Committee's approval and patient's consent, patients with American Society of Anesthesiologist physical status (ASA PS) I and II, aged 18–60 years of either sex, undergoing upper arm surgery were recruited into the study until 45 successful cases. A 7 ml of 0.5% ropivacaine was used as starting dose, with patients receiving a higher or lower dose depending on previous patient's response. R package, SPSS 23, and Microsoft Excel were used for statistical analysis. Results: MEV90 of 0.5% ropivacaine for ISB was determined as 8.64 ml [confidence interval (CI) 95%, 8.28–9.02 ml]. Time for onset of sensory block and motor block was 5 min (5–15 min) and 10 min (5–20 min), respectively, while duration of analgesia was observed as 8.2 (4.8–12.5) h. Conclusions: This study observes that surgical anesthesia can be accomplished with 8.64 ml (95% CI: 8.28–9.02 ml) of 0.5% ropivacaine with ultrasound-guided ISB with multiple injection technique, without clinical deterioration in block onset and duration of analgesia.
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COMMENTARY Top

Challenges to implement minimum effective volume in regional anesthesia p. 47
Sudhakar Subramani, Shuchita Garg
DOI:10.4103/joacp.JOACP_279_18  
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ORIGINAL ARTICLES Top

Effect of intrathecal catheterisation on incidence of postdural puncture headache after accidental dural puncture in non-obstetric patients p. 49
Prateek Ahuja, Ranju Singh, Aruna Jain
DOI:10.4103/joacp.JOACP_158_18  
Background and Aims: After accidental dural puncture (ADP) with large bore epidural needles, postdural puncture headache (PDPH) develops in 16%–86% of patients, which is unpleasant and interferes with activities of daily life of the patient.Hence we aimed to assess the effect of intrathecal catheter insertion after ADP with 18G Tuohy needle on incidence of PDPH. Material and Methods: In all, 173 patients after ADP were enrolled and divided into two groups according to the choice of treating anesthesiologist. Group IC included 74 patients who had intrathecal catheter placed in subarachnoid space. In group NIC, which included 99 patients, one of the following was done: epidural catheter was cited in a different intervertebral space, or the procedure was abandoned and general anesthesia was administered or single-shot spinal anesthesia was administered through the Tuohy needle itself. The catheters were left in situ for 36–48 h. Patients were monitored for the next 7 days after ADP for the incidence of PDPH, its severity and requirement of analgesics, and duration of catheter in situ from the time of ADP. Results: The incidence of PDPH in group IC was 36% in comparison to 59% in group NIC (P = 0.001). The severity of PDPH and requirement of analgesics was significantly less in group IC. Conclusion: Insertion of intrathecal catheter at the site of ADP significantly reduces the incidence and severity of PDPH.
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A prospective randomized double-blind study to compare the early recovery profiles of desflurane and sevoflurane in patients undergoing laparoscopic cholecystectomy p. 53
Gauri R Gangakhedkar, Joseph N Monteiro
DOI:10.4103/joacp.JOACP_375_17  
Background and Aims: General anesthesia using agents like Desflurane or Sevoflurane are beneficial for early recovery especially for ambulatory procedures. The aim of this randomised controlled double-blind study was to compare the early recovery profiles of sevoflurane and desflurane in patients undergoing laparoscopic cholecystectomy. Material and Methods: ASA I, II patients, undergoing laparoscopic cholecystectomy were randomly assigned to receive desflurane (n = 30) or sevoflurane (n = 30), using Bispectral Index System (BIS) to determine the depth of anaesthesia. An independent adjudicator, who was blinded to the agent used, recorded the events during the recovery phase. The time required for extubation, eye opening, verbal response and achievement of a modified Aldrete score of 9 were recorded. Results: The time required for extubation and for eye opening was significantly shorter in the Desflurane group as compared to the Sevoflurane group [9.1 min ± 5.0 versus 12.5 min ± 7.1, P = 0.049 and 10.1 min ± 5.2 versus 6.3 min ± 4.0, P = 0.008]. Verbal Response also occurred significantly faster in the Desflurane group [12.7 min ± 5.4 versus 8.7 min ± 4.7, P = 0.002]. A significantly higher mean modified Aldrete score was seen at extubation [7.1 ± 0.6 vs 6.0 ± 0.8, P < 0.001] in the Desflurane group, which also achieved a modified Aldrete score of ≥9 significantly sooner [11.1 min ± 4.6 versus 17.8 min ± 6.9, P < 0.001] than the Sevoflurane group. The frequency of adverse effects was not significantly different in either of the groups. Conclusion: The time required for early recovery from anaesthesia, was significantly shorter in the Desflurane group compared to the Sevoflurane group.
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Patient-controlled analgesia with and without transverse abdominis plane and rectus sheath space block in cirrhotic patients undergoing liver resection p. 58
Khaled Yassen, Maha Lotfy, Ashraf Miligi, Ahmed Sallam, Eman Abdel Razik Hegazi, Mohamed Afifi
DOI:10.4103/joacp.JOACP_36_17  
Background and Aims: Optimal pain control can be a challenge in cirrhotic patients. The aim was to compare the analgesic efficacy and side effects of intravenous fentanyl patient-controlled analgesia (PCA) with and without bupivacaine boluses in transversus abdominis plane (TAP) and rectus sheath space (RSB) in cirrhotics undergoing liver surgery. Material and Methods: A double-blinded randomized controlled trial (n = 55, child's A) was conducted. Catheters were inserted surgically in TAP and rectal sheath space during surgical closure. Fentanyl PCA + TAP + RSB group (gp) (n = 30): (0.2 ml/kg of 0.25% bupivacaine, 8 hourly) was compared with fentanyl PCA gp (n = 25): [0.2 ml/kg of saline (placebo) injected in catheters 8 hourly] for 48 h postoperatively. Plasma bupivacaine was measured with an enzyme-linked immunosorbent assay at 10 min, 30 min, 1 h, 2 h, and 4 h after each injection and 30 min before next injection. Results: Fentanyl consumption was reduced in (PCA + TAP + RSB) gp compared to PCA gp (Day 1: 325.4 ± 169.1 vs. 1034 ± 231.7, Day 2: 204.44 ± 62.9 vs. 481.6 ± 158.3 μg, P < 0.05). Both groups demonstrated effective pain control at rest [Visual Analog Scales (VAS) <3), but on movement pain control with bupivacaine was better (P < 0.05). Increased demand for rescue opioids was observed prior to next scheduled bupivacaine injection in 10/30 patients on Day 1 and 2/30 on Day 2, in association with a reduced bupivacaine serum levels compared to 10 min after injection (47.6 ± 22.7 vs. 93.6 ± 61.0 ng/ml, respectively, P < 0.05). Bupivacaine did not exceed referred toxic levels. Conclusion: Repeated bupivacaine TAP and RSB with PCA fentanyl improved pain control, reduced opioids demand with no toxicity. Time interval between injections needs to be reduced to avoid breakthrough pain.
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Comparative evaluation of the efficacy of two anesthetic gels (2% lignocaine and 20% benzocaine) in reducing pain during administration of local anesthesia – A randomized controlled trial p. 65
Manisha Nair, Deepa Gurunathan
DOI:10.4103/joacp.JOACP_73_18  
Background and Aims: Topical anesthetic agents are widely used in the field of pediatric dentistry to reduce pain and apprehension during administration of local anesthesia. Various topical anesthetic agents are available, among which the most commonly used ones are lignocaine and benzocaine. Hence we planned this study to compare and evaluate the effectiveness of topical anesthesia on needle insertion pain during administration of inferior alveolar nerve block. Material and Methods: This double blind clinical study included 30 children of 4–8 years of age who were divided equally into two groups: Group A-2% lignocaine hydrochloride gel (Lox 2%) and Group B-20% benzocaine gel (ProGel-B). The intervention involved assessment of pain perception by the child during administration of inferior alveolar nerve block. The child's pain assessment was done using modified Wong–Baker pain rating scale. The ratings were subjected to statistical analysis. Results: In Group A, 6.7% (N = 1) showed slight pain, 66.7% (N = 10) showed moderate pain, and 26.7% (N = 4) showed severe pain. In Group B, 46.7% (N = 7) showed no pain, 46% (N = 7) showed slight pain, and 6.7% (N = 1) showed moderate pain on needle insertion. (P value –0.000). Conclusion: This study demonstrates that there is a highly significant difference between the topical anesthetic effectiveness of 2% lignocaine and 20% benzocaine on needle insertion pain in inferior alveolar nerve block. Twenty percent benzocaine showed better results than 2% lignocaine in reducing the needle insertion pain.
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Comparative evaluation of Ambu Aura-i and Fastrach™ intubating laryngeal mask airway for tracheal intubation: A randomized controlled trial p. 70
Lakesh Anand, Manpreet Singh, Dheeraj Kapoor, Anjali Singh
DOI:10.4103/joacp.JOACP_59_18  
Background and aims: Ambu Aura-i was compared with Fastrach™ (FT)-laryngeal mask airway (LMA) as a conduit for tracheal intubation. Material and Methods: A hundred consenting patients were randomly allocated into two groups of 50 patients each in a prospective randomized study. Standard anesthesia technique was used for all patients and FT-LMA or Ambu Aura-i was selected. After insertion of airway device, the cuff was inflated and ventilation was attempted. Once satisfactory ventilation was achieved, with or without maneuvers, a fiberoptic scoring for glottis view was noted. A polyvinylchloride (PVC) tracheal tube of appropriate size was inserted through the airway device as per procedure. If no resistance was felt while advancing the tracheal tube, it was fully inserted into the device and tracheal tube cuff was inflated. The device was removed and tracheal tube was left in situ. If the first attempt failed during tracheal tube insertion, the recommended maneuvers were used. A maximum of three attempts were allowed for intubation. First attempt for tracheal intubation attempt was a blind, second attempt was made with maneuver. If second attempt of intubation was unsuccessful, fiberoptic-guided intubation was performed as a third attempt. When tracheal intubation was unsuccessful, it was performed by direct laryngoscopy and considered as failed intubation. Rest of the anesthesia management was as per the discretion of attending anesthesiologists. The success rate of device insertion, fiberoptic score of glottis view, tracheal intubation via FT-LMA or Aura-i and time were recorded. Results: Both FT-LMA and Aura-i were successfully placed within two attempts. The success rate of blind intubation was 92% in FT-LMA and 76% in Aura-i (P < 0.01). Time taken for tracheal intubation at first attempt was lesser in group FT-LMA and Aura-i, respectively (P < 0.01). Fiberoptic-guided intubation success rate was higher with Aura-i than with FT-LMA. Conclusions: FT-LMA had a higher success rate in facilitating blind tracheal intubation compared with Ambu Aura-i.
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Investigation of possible aqueous phase formation during vaporization of sevoflurane p. 76
Shane Varughese, Vikram G Kalthod, James P Petzel, Hans Peter Bacher, Arthur W Wallace
DOI:10.4103/joacp.JOACP_53_18  
Background and Aims: Ultane®(sevoflurane; AbbVie Inc., North Chicago, IL, USA) has a dissolved water content of approximately 0.035% weight/weight (w/w). A previous report described formation of an aqueous layer in 4 of 13 sevoflurane vaporizers used in operating rooms. We investigated the conditions under which an aqueous layer could develop during vaporization of sevoflurane–water mixtures. Material and Methods: A temperature-controlled glass reactor was used to simulate a vaporizer. In four experiments, the vaporization of different sevoflurane–water mixtures was monitored over approximately 3–4 days. Samples were removed at regular intervals for analysis of water content. For confirmation, one experiment was replicated in a Tec 7 vaporizer. Results: Saturation of sevoflurane with water occurred at 0.11%–0.13% w/w at an ambient temperature; at greater water concentrations a separate aqueous phase was initially present. The sevoflurane–water azeotrope contained approximately 1.2% w/w water at 25°C. When the initial water content was <1.2% w/w (0.11%–1.03% w/w), vaporization resulted in a single phase of drier sevoflurane (final water concentration 0.02%–0.08% w/w). When the starting water concentration exceeded the azeotropic concentration (5.0% w/w), vaporization increased the water content, reaching 13% w/w at 71 h. Results under the low initial water condition were similar in the Tec 7 vaporizer. Conclusions: An increase in water concentration following vaporization of sevoflurane can only occur when the starting water content is higher than the azeotropic concentration and therefore cannot originate from the dissolved water present in the marketed product because the water concentration in Ultane®is 34 times lower than the azeotropic concentration.
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Choosing anesthesia options for cataract surgery in patients with dementia p. 81
Chandra M Kumar, Lekha Gopal, Edwin Seet
DOI:10.4103/joacp.JOACP_22_18  
Background and Aims: Not all patients with dementia are the same, and Global Deterioration Scale (GDS) helps in staging dementia. Ophthalmologists usually prefer general anesthesia (GA) for cataract surgery in patients with dementia. We evaluated the impact of “Choosing Wisely” initiative on anesthesia options for cataract surgery in patients with dementia undergoing cataract surgery. Material and Methods: A retrospective review of electronic perioperative database was performed over a 4-year period of patients with a specific diagnosis of dementia undergoing cataract surgery, after the introduction of the “Choosing Wisely” based on preoperative GDS assessment. Preferred method by the listing ophthalmologist, changes in anesthesia modality based on GDS, and the occurrence of intraoperative events were analyzed. Results: One hundred and thirty-six patients with dementia underwent cataract surgery over a 4-year period. The mean patient age was 78 years, 73.5% female, and 55% ASA physical status III. GA was administered for GDS stage 6–7, and regional anesthesia (RA) for GDS stages 1–5. Surgery was uneventful under RA in 64% of the patients (87 out of 136), and 2% (3 patients) originally deemed suitable for RA were converted to GA. Conclusions: The authors found a reduced requirement for GA when “Choosing Wisely' initiative was used based on the GDS stage.
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Evaluation of airway care score as a criterion for extubation in patients admitted in neurosurgery intensive care unit p. 85
Gayatri Tanwar, Udeyana Singh, Sandeep Kundra, Ashwani K Chaudhary, Sunil Kaytal, Anju Grewal
DOI:10.4103/joacp.JOACP_362_17  
Background and Aims: Early extubation in neurocritical patients has several potential benefits. Glasgow Coma Scale (GCS) is a crude measure of neurologic function in these patients and a low GCS score does not necessarily mean contraindication for extubation. Data on patients with neurosurgical or neurological pathology undergoing early extubation utilizing the airway score criteria is limited. Hence, this study was conceived to assess the usefulness of modified airway care score (ACS) as a criterion for successful extubation of neurocritical patients whilst comparing various outcomes. Material and Methods: One hundred and twenty four patient who underwent endotracheal intubation in the neurocritical care unit were enrolled in this prospective observational study over a period of 12 months. Patients were randomly enrolled into either the study group patients (S), who were extubated immediately after a successful spontaneous breathing trial (SBT) and an ACS ≤7 or into the control group (N), wherein patients were extubated/tracheostomized at discretion of the attending neurointensivist. Both groups were observed for comparison of preset outcomes and analyzed statistically. Results: Patients of study group experienced a statistically significant shorter extubation delay (3.28 h vs 25.41 h) compared to the control group. Successful extubation rate was significantly higher and reintubation rate was significantly lower in study group (6.6% vs 29.3%). Incidence of nosocomial pneumonia, duration of ICU stay and overall duration of mechanical ventilation were significantly lower in the study group. ACS and GCS had a negative correlation at the time of extubation. Conclusion: ACS can be used as a criterion for successful early extubation of neurocritical patients.
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Effect of dexmedetomidine on recovery profile of patients undergoing anterior cervical discectomy and fusion p. 92
Varun Jain, Arvind Chaturvedi, Mihir P Pandia, Parmod K Bithal
DOI:10.4103/joacp.JOACP_5_18  
Background and Aim: Smooth and rapid emergence and extubation, with minimal coughing, is desirable after cervical spine surgery to facilitate early neurological examination. The present study investigated the effect of dexmedetomidine as an intraoperative anesthetic adjuvant on postoperative extubation and recovery profile in patients undergoing anterior cervical discectomy and fusion (ACDF) surgery. Material and Methods: Sixty-four, American Society of Anesthesiologist I or II adult patients (age 18–60 years) were randomized in this placebo-controlled, double-blind study. In group D, dexmedetomidine was started at 0.2 μg/kg/h after a loading dose of 1 μg/kg before induction and in group P, volume and infusion rate-matched normal saline was used. Perioperative hemodynamics, intraoperative anesthetic consumption, and postoperative recovery profile were observed. Results: Thirty-one patients in each group successfully completed the study. Time to emergence (6.9 min vs 10 min, P < 0.001), time to extubation (8.5 min vs 12.2 min, P = 0.002), and time to achieve modified Aldrete score ≥9 (5 min vs 10 min, P < 0.001) were earlier in group D compared to group P, respectively. Pain score at extubation was lower (0 vs 20) and time for first analgesic was longer (50 min vs 15 min) in group D compared to group P. Coughing at extubation was comparable in both the groups. One patient in group D had severe postextubation bradycardia. Conclusions: Intraoperative use of dexmedetomidine at the lowest recommended dosage in adults undergoing ACDF surgery results in a favorable recovery profile with reduced emergence/extubation time and postoperative pain, but similar incidence of coughing.
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Changes in central venous oxygen saturation, lactates, and ST segment changes in a V lead ECG with changes in hemoglobin in neurosurgical patients undergoing craniotomy and tumor excision: A prospective observational study p. 99
Liby G Pappachan, Aparna Williams, Tunny Sebastian, Grace Korula, Georgene Singh
DOI:10.4103/joacp.JOACP_304_17  
Background and Aims: The aim of the study was to observe the trends in central venous oxygen saturation (ScvO2), lactate, and ST segment changes with change in hemoglobin in patients undergoing acute blood loss during surgery and to assess their role as blood transfusion trigger. Material and Methods: Seventy-seven consecutive patients undergoing craniotomy at a tertiary care institution were recruited for this study after obtaining written, informed consent. After establishing standard monitoring, anesthesia was induced with standard anesthetic protocol. Hemodynamic parameters such as heart rate, blood pressure (mean, systolic, diastolic), pulse pressure variation (PPV), and physiological parameters such as lactate, ScvO2, ST segment changes were checked at baseline, before and after blood transfusion and at the end of the procedure. Statistical Analysis: Comparison of the mean and standard deviation for the hemodynamic parameters was performed between the transfused and nontransfused patient groups. Pearson correlation test was done to assess the correlation between the covariates. Receiver operating characteristic (ROC) curve was constructed for the ScvO2variable, which was used as a transfusion trigger and the cutoff value at 100% sensitivity and 75% specificity was constructed. Linear regression analysis was done between the change in hemoglobin and the change in ScvO2and change in hemoglobin and change in the ST segment. Results: There was a statistically significant positive correlation between the change in ScvO2and change in hemoglobin during acute blood loss with a regression coefficient of 0.8 and also between change in ST segment and hemoglobin with a regression coefficient of –0.132. No significant change was observed with lactate. The ROC showed a ScvO2cutoff of 64.5% with a 100% sensitivity and 75% specificity with area under curve of 0.896 for blood transfusion requirement. Conclusions: We conclude that ScvO2and ST change may be considered as physiological transfusion triggers in patients requiring blood transfusion in the intraoperative period.
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Assessment of knowledge, attitude, and practices regarding biomedical waste management among operation room personnel in a tertiary care center p. 106
Tejesh C Aanandaswamy, Geetha C Rajappa, Narendranath Venkatachala, Ramachandra Kamath
DOI:10.4103/joacp.JOACP_196_16  
Background and Aims: Biomedical waste management is an important issue of concern to all healthcare personnel as inappropriate management has the potential for serious infections and noninfectious injury to patients and care providers. Operation room is a department in the hospital wherein large amounts of waste are generated on a daily basis. This study aims to evaluate the knowledge, attitude, and practice regarding biomedical waste among operation room personnel. Material and Methods: This is a cross-sectional study done among various strata of operation room personnel with a questionnaire to evaluate the knowledge, attitude, and practice with respect to biomedical waste management. Results: This study revealed gaps in knowledge and practices among all strata of operation room personnel regarding biomedical waste management. Conclusion: This study highlights the need for appropriate training of all operation room personnel about appropriate waste management practices.
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Epidural levobupivacaine versus a combination of levobupivacaine and dexamethasone in patients receiving epidural analgesia p. 109
Amr Samir Wahdan, Ahmed Ibrahim El-sakka, Amira Refaie Hassan, Mennatallah Magdi Mohamed, Hassan Mostafa Ismail Gaafar, Nadia Youssef Helmy
DOI:10.4103/joacp.JOACP_87_17  
Background and Aims: The use of dexamethasone as an adjuvant to local anesthetic rarely has been described. Some studies have demonstrated the analgesic effect of local spinal and systemic corticosteroids in combination with bupivacaine. It works by decreasing inflammation and blocking transmission of nociceptive C-fibers and by stopping the ectopic discharge of the nerve. The aim of this randomized controlled trial was to compare the efficacy of epidural levobupivacaine alone versus a combination of levobupivacaine with dexamethasone for labor analgesia. Material and Methods: This prospective double-blind trial included the 60 primigravidas during vaginal delivery with a cervical dilatation ≥4 cm and 50% effacement randomly assigned to one of two groups – Group A (n=30): epidural levobupivacaine 0.125% in normal saline in a total volume of 15 mL and Group B (n=30): epidural levobupivacaine 0.125% in normal saline combined with dexamethasone 4 mg in a total volume of 15 mL. At first request of analgesia, 10 mL of 0.125% levobupivacaine was administrated through epidural catheter. Further analgesia was provided with 8 mL of 0.125% levobupivacaine hourly. Primary outcome measure was the duration of epidural analgesia. Secondary outcome measures include pain score by Visual Analog Scale score before the block and 15 min following it, the total amount of levobupivacaine used, Apgar score and umbilical vein blood gas analysis, maternal satisfaction, and side effects recorded. Results and Conclusion: The duration of epidural analgesia was significantly longer (P < 0.05) upon adding dexamethasone to levobupivacaine. Total epidural levobupivacaine consumption was significantly lower (P = 0.05) in Group B. There were no statistical differences between the two groups regarding hemodynamics, pain score, neonatal outcome, and complications. Epidural dexamethasone plus levobupivacaine prolongs the duration of epidural analgesia during management of labor pain with hemodynamic stability and limited maternal and neonatal adverse effects.
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Effect of infraorbital nerve block on postoperative pain and 30-day morbidity at the donor site in buccal mucosal graft urethroplasty p. 114
Nirmala Jonnavithula, Deepak Bachu, Vidyasagar Sriramoju, Rahul Devraj, Ramachandraiah Gunta, Murthy V. L. N Pisapati
DOI:10.4103/joacp.JOACP_211_17  
Background and Aims: Buccal mucosa harvest for substitution urethroplasty can be painful, and may be associated with long-term complications such as perioral numbness, persistent difficulty with mouth opening, and change in salivary function. This study was designed to evaluate the efficacy of infraorbital nerve block (IOB) in relieving postoperative pain at the donor site of the buccal mucosal graft (BMG) and its associated morbidity at 30 days. Material and Methods: Thirty adults scheduled for BMG urethroplasty were enrolled in this study and were randomized to receive either no block group I (control) and IOB group II intraorally with 1 mL of 0.5% bupivacaine. Pain was assessed by visual analog scale, intraoral morbidity, and patient satisfaction in the immediate postoperative period. All patients were reviewed after 1 month for morbidity such as perioral numbness, pain on mastication, and tightness on mouth opening. Statistical analysis was done using Mann–Whitney's U and Chi-square tests. Results: Median time to pain-free oral intake for liquids (group I: 2–5 days, group II: 1 day, P < 0.001) and solids (group I: 4 days, group II: 2 days, P < 0.001) was earlier in group II. At the follow-up after 1 month, one patient in group II and three patients in group I showed perioral numbness (P = 0.026), and five patients had pain on mastication in group I (P = 0.016). Conclusion: IOB is associated with postoperative analgesia and facilitation of early food intake, mitigating the morbidity of the donor site and provides satisfaction.
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A prospective observational study of predictors of difficult intubation in Indian patients p. 119
Harsha H Narkhede, Rajendra D Patel, Hemraj R Narkhede
DOI:10.4103/joacp.JOACP_269_17  
Background and Aims: During routine preoperative assessment of patients one of the commonest practices is predicting difficulty of intubation. The present study was undertaken to evaluate parameters associated with difficult intubation and to test on new set of patients. At the end, to form simple predictive rule to decreased the number of false alarms. Material and Methods: In initial series of 483 Indian population patients we measured age, sex, weight, height, interincisor gap, mandibular length, neck movement, neck circumference, subluxation of mandible, sternocricoid distance, and identified factors associated with difficult intubation. These were applied on next 480 patients of prospective series and simple predictive rule in form of risk sum score was developed. Results: After analyzing initial series data we found that weight (P = 0.033), height (P = 0.034), interincisor gap (P = 0.005), subluxation (P < 0.001), neck movement (P < 0.001), and sternocricoid distance (P = 0.020) were significantly associated with difficult intubation. These six factors were applied on next set of 480 patients to found accuracy of predicting difficult intubation of weight (51.7%), height (83.8%), interincisor gap (80.2%), subluxation (77.7%), neck movement (82.7%), and sternocricoid distance (79.2). Total score greater than 2 predicted 92.8% of difficult laryngoscopies correctly as against 33.9% would be falsely labeled as difficult. Conclusion: Interincisor gap and sternocricoid distance are the two most sensitive factors predicting difficult intubation in Indian patients. However, risk sum score of more than 6 may lead to better anticipation of truly difficult intubations.
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Effect of preoperative application of buprenorphine transdermal patch on analgesic requirement in postoperative period in hip and knee replacement surgeries p. 124
Monu Yadav, C Lalit Mohan, I Srikanth, E Roop Raj, R Gopinath, P Chandrasekhar
DOI:10.4103/joacp.JOACP_13_17  
Background and Aims: Although no pain control following hip and knee replacement surgeries has attained gold standard, it is clear that patients should have optimum pain control after total knee arthroplasty and total hip arthroplasty for enhanced satisfaction and function. We conducted this study to evaluate the effect of preoperative application of buprenorphine transdermal patch on analgesic requirement in perioperative period after knee and hip replacement surgeries Material and Methods: Following institutional ethical committee approval and written informed consent, a prospective study was conducted in 50 patients of either gender belonging to ASA1 or ASA2 status, requiring either knee or hip replacement. The patients were assessed in preoperative period, and buprenorphine patch of 10 mg (sustained release of 10 μg/h) was applied either on the chest or on outer side of the arm 12 h before surgery. Total knee arthroplasty/total hip arthroplasty was done under combined spinal epidural blockade. Epidural infusion with 0.125% bupivacaine at a rate of 4–5 mL/h was continued in postoperative period. Intravenous opioid analgesics were avoided in postoperative period, and whenever required only iv paracetamol 1g was given. Outcome in terms of requirement of iv analgesic, visual analog pain score, any associated nausea vomiting, itching, and level of somnolence was noted in postoperative period at 1,2,3,4,8,12,16,20,24,48, and 72 h, respectively. Results: None of the patient required rescue analgesia in the first 2 h. During 72 h postoperative period of observation 32% of patients demanded rescue analgesics at 8th hour, followed by 20% at 4th hour and 16% at 12th hour. Conclusion: Preoperative application of transdermal patch significantly reduces the requirement of postoperative intravenous opioid and nonopioid analgesic drugs.
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COMMENTARIES Top

Need of intraoperative laryngeal nerve monitoring in head and neck surgeries p. 129
Nishkarsh Gupta, Abhishek Kumar, Anju Gupta
DOI:10.4103/joacp.JOACP_307_18  
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Intraoperative neural monitoring in head and neck surgeries: Feasibility and concerns p. 131
Manpreet Kaur
DOI:10.4103/joacp.JOACP_301_18  
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LETTERS TO EDITOR Top

Selection of laryngeal electrodes for intraoperative laryngeal nerve monitoring p. 132
Hwan Ing Hee
DOI:10.4103/joacp.JOACP_138_18  
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Anatomical variations in brachial plexus on ultrasound: Reason for failure of supraclavicular block – Nerve stimulator along with ultrasound can play a major role for success p. 135
Teena Bansal, Mamta Jain, Somesh Singh
DOI:10.4103/joacp.JOACP_211_18  
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Inadvertent administration of potassium chloride in the epidural space: How to prevent the inevitable p. 137
Jasmeet Kaur, Adarsh C Swami, Ashwini Sharma, Kanika Arora
DOI:10.4103/joacp.JOACP_19_17  
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Comment on published article: Assessment of awake i-gel™ insertion for fiberoptic-guided intubation in patients with predicted difficult airway: A prospective, observational study p. 138
Sohan Lal Solanki, Jeson R Doctor
DOI:10.4103/joacp.JOACP_12_19  
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Pediatric adverse airway event in gastroenterology suite during assisted ventilation with defective reservoir bag p. 139
Debashish Paul, Deepak Dwivedi, Navdeep Sethi, Saurabh Sud
DOI:10.4103/joacp.JOACP_33_18  
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