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   Table of Contents - Current issue
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January-March 2020
Volume 36 | Issue 1
Page Nos. 1-141

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EDITORIAL  

Are we too focused on blocks, to care, for the patient as an individual who needs holistic care? Highly accessed article p. 1
Vrushali Ponde
DOI:10.4103/joacp.JOACP_441_19  
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REVIEW ARTICLES Top

Ultrasonographic assessment of airway Highly accessed article p. 5
Kinshuki Jain, Mukesh Yadav, Nishkarsh Gupta, Sanjay Thulkar, Sushma Bhatnagar
DOI:10.4103/joacp.JOACP_319_18  
Ultrasound is gaining increasing popularity among anesthesiologists as it is readily available and provides real-time imaging for various procedures. It is considered as a “visual stethoscope” of the anesthesiologist. After establishing its use in regional blocks and central venous catheter insertion, it is now finding increasing use in anticipation of difficult airway and securing and maintaining it. It has challenged the classical approach of clinical assessment of airway and allows more dynamic bedside assessment. This article attempts to briefly outline the role of ultrasound and its applications for airway management in patients.
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New and promising anti-bacterials: Can this promise be sustained? Highly accessed article p. 13
Sai Saran, Namrata S Rao, Afzal Azim
DOI:10.4103/joacp.JOACP_113_19  
The World Health Organization (WHO) announced antimicrobial resistance (AMR) as a major threat to public health which requires that new antimicrobials need to be developed faster than ever before. The rapid development of resistance has rendered many promising antibacterials useless in treating critically ill patients. This article discusses new antibacterials, which got Food and Drug Administration (FDA) approval in the last few years, along with their key pharmacokinetic and pharmacodynamic (PK/PD) advantages, added antimicrobial spectrum, indications, strengths and weaknesses of these drugs from an intensivist point of view. A brief mention has been made on antimicrobial peptides (AMPs), bacteriophages and nanoparticles, which are likely to dominate the future of antibacterials. Finally, it must be understood that the battle against AMR can only be won by a combination of innovative therapies, good infection control practices, strong antibiotic stewardship in the hands of informed healthcare workers.
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A prospective single-center observational study to assess the efficacy of the second-generation supraglottic airway device I-gel in laparoscopic surgeries in children p. 20
Rakhee Goyal, Rajat Chauhan, Rajan Anand, Manoj Goyal
DOI:10.4103/joacp.JOACP_295_19  
Background and Aims: Supraglottic airways used in pediatric surgeries are associated with a lesser number of postanesthesia respiratory complications. However, there is limited literature on the use of i-gel for pediatric laparoscopic surgery. The aim of this study is to assess the adequacy of ventilation of i-gel for pediatric laparoscopic surgery and note any associated adverse event. Material and Methods: This is a single-centered prospective observational study including 119 children, aged 6 months to 18 years, scheduled for laparoscopic surgery, during a 9-month period, in a tertiary care center. I-gel was used for positive pressure ventilation, and if the post-insertion oropharyngeal seal pressure was <25 cm H2O, it was replaced with a tracheal tube. Adequacy of ventilation and adverse events were noted. Results: Data from 102 cases were analyzed (17 cases excluded: tracheal intubation in 11; missing data in 6 cases). The mean oropharyngeal seal pressure was 34.2 ± 5.2 cm H2O and mean airway pressure was 16.1 ± 2.4 cm H2O. The adverse events included transient cough (10.7%), sore throat (4.9%), and desaturation (3.9%). There was no sign of respiratory distress during the recovery and no intervention was required in any child postoperatively. Conclusion: I-gel provided adequate ventilation of the lungs in children undergoing laparoscopic surgery with no major adverse event.
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Predictors of difficult airway in the obese are closely related to safe apnea time! p. 25
Aparna Sinha, Lakshmi Jayaraman, Dinesh Punhani
DOI:10.4103/joacp.JOACP_164_19  
Background and Aims: We aimed to redefine the preoperative factors that may challenge the airway and safe apnea time (SAT) in the obese. Material and Methods: We analyzed 834 patients with body mass index (BMI) >35 kg/m2 for their difficult airway score (DASc). DASc is a consolidation of measures of difficult airway like mask ventilation, difficult intubation, change of device, and number of personnel required. DASc varied from “0” no difficulty to “12” serious difficulty and DASc ≥6 was considered difficult. Preoperative parameters – neck circumference (NC), BMI, STOPBANG score, Mallampati score, obstructive sleep apnea grade, and waist circumference– were assessed. Results: Receiver operating characteristic curve was used to identify risk factors for obese patients at DASc ≥6. The Youden index (for the best threshold, with highest sensitivity and specificity) was BMI 45 kg/m2 and NC 44.5 cm. Their absence had an 81% negative predictive value to include a difficult airway, while their presence had a positive predictive value of 55%. This further has sensitivity of 66% and specificity of 73%. The mean SAT (256 ± 6 s) was inversely related to DASc (P < 0.001). Conclusion: This study demonstrates that BMI and NC have a strong association with difficult airway in obese patients and are inversely related to SAT. Amongst these NC is the single most important predictor of difficult airway in obese and should be used as a screening tool.
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Efficacy of Baska mask and Laryngeal mask airway supreme during positive pressure ventilation – A comparative study p. 31
Sreedevi Jayalekshmi, Cherish Paul, Mariam K Thomas
DOI:10.4103/joacp.JOACP_17_19  
Background and Aims: Supraglottic airway devices have several roles including maintenance of a clear upper airway during general anesthesia. We primarily compared the efficacy of Baska mask (BM) and laryngeal mask airway supreme (LMAS) for the rate of first time successful placement and the seal pressure. The secondary outcome measures included laryngopharyngeal morbidity and the correct positioning of the gastric port. Material and Methods: A sample size of 30 was calculated in each study group. A total of 70 study participants were included in the statistical analysis of which 36 patients were in the BM group and 34 patients were in the LMAS group. Results: The BM was successfully inserted in 28 patients (77.8%), whereas LMAS was successfully inserted in 33 patients (97.1%) in the first attempt (P = 0.028). The mean oropharyngeal seal pressure in the BM group was higher (33.28 ± 6.80 cm H2O) than compared to the LMAS group (27.47 ± 2.34 cm H2O) with a P value <0.001. There was no significant difference between the two groups in the incidence of postoperative laryngopharyngeal morbidity both in the immediate postoperative period (P = 0.479) and that seen 24 hours post operatively (P = 0.660). The nasogastric tube could easily be inserted in the entire study population. Conclusion: From the present study, it is concluded that the BM creates a higher oropharyngeal seal pressure than the LMAS. However, the BM is more difficult to insert. The incidence of postoperative laryngopharyngeal morbidity is similar in both groups.
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Determination of dose and efficacy of atracurium for rapid sequence induction of anesthesia: A randomised prospective study p. 37
Pornpan Chalermkitpanit, Oraluxna Rodanant, Winnie Thaveepunsan, Sireedhorn Assavanop
DOI:10.4103/joacp.JOACP_36_19  
Background and Aims: Succinylcholine and high dose rocuronium are neuromuscular blocking agents commonly used for rapid sequence induction of anesthesia. Their usage is limited or contraindicated in some circumstances. The aim of this study is to determine the dosage and efficacy of atracurium without priming for rapid sequence induction of anesthesia. Material and Methods: One hundred fifteen surgical patients under general anesthesia were randomised into three groups. All patients were given 2-3 mg/kg propofol and 1 μg/kg fentanyl intravenously for the induction of anesthesia followed by different doses of atracurium (0.6 mg/kg, 0.75 mg/kg or 1 mg/kg) without a priming dose. Tracheal intubation was performed within one minute after the administration of the study drugs. The intubating conditions, vocal cord movement and diaphragm movement were graded as the primary endpoints. Statistical analysis was done using one-way analysis of variance (ANOVA) and Post Hoc tests. Results: Atracurium doses of 1 mg/kg, 0.75 mg/kg, and 0.6 mg/kg provided 51.4%, 43.6% and 26.3% success rates of intubation without coughing or bucking, respectively (P = 0.03). The intubating conditions were graded as excellent or good in 86.5% of the 1 mg/kg atracurium group patients and in 84.6% of the 0.75 mg/kg group patients (P < 0.05). An atracurium dose of 1 mg/kg facilitated significant differences in vocal cord and diaphragm paralysis compared with the dose of 0.6 mg/kg (P = 0.03). Conclusion: The administration of a relatively high dose of atracurium without priming can be used as an alternative neuromuscular blocking agent for rapid sequence induction of anesthesia in some circumstances.
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Comparison of conventional with Parker flex-tip tracheal tube for intubation through air-Q intubating laryngeal airway p. 43
Jatin Lal, Teena Bansal, Gaurav Dhawan, Susheela Taxak, Manu Smriti, Jyoti Sharma, Deepali Thaper
DOI:10.4103/joacp.JOACP_227_18  
Background and Aims: The problem of difficult and failed intubation led to increased development of equipment for airway management. A number of supraglottic airways have now been developed to facilitate the passage of tracheal tubes. Conventional PVC tracheal tubes are recommended for intubation through the air-Q ILA. No study has compared different PVC tubes for blind intubation through air-Q ILA. Thus, we undertook this prospective, randomised, single blind study to compare two PVC tracheal tubes with different designs viz. conventional PVC tracheal tube (TT) and Parker flex-tip TT with regards to success rate, ease of intubation and total time required for successful intubation through air-Q ILA. Material and Methods: One hundred patients of either sex, aged 18–60 years, belonging to American Society of Anesthesiologists (ASA) physical status class I and II scheduled for elective surgery under general anesthesia requiring endotracheal intubation were included in the study. Blind intubation using conventional PVC TT and Parker flex-tip tube was done in group A (n = 50) and group B (n = 50), respectively. Results: The first attempt success rate in Parker flex-tip TT was significantly more as compared to conventional PVC TT (P = 0.002). Success rate of intubation was significantly more in Parker flex-tip TT as compared to conventional PVC TT (P = 0.004). The intubation was significantly easy in Parker flex-tip tube as compared to conventional PVC TT (P = 0.002). Total time of intubation was less in Parker flex-tip tube as compared to PVC TT (P = 0.043). Conclusion: Unique design of the Parker Flex-tip TT resulted in increase in success rate, first attempt success rate and ease of intubation in group B in present study.
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Peri-operative management of pheochromocytoma with intravenous urapidil to prevent hemodynamic instability: A 17-year experience p. 49
Patrick Tauzin-Fin, Kévin Barrucand, Musa Sesay, Stéphanie Roullet, Philippe Gosse, Jean-Christophe Bernhard, Gregoire Robert, François Sztark
DOI:10.4103/joacp.JOACP_71_18  
Background and Aims: Surgery for pheochromocytoma (PCC) can cause excessive catecholamine release with severe hypertension. Alpha blockade is the mainstay of preoperative management. The aim of this study was to evaluate the efficacy and tolerance of intra-venous (IV) urapidil, a competitive short acting α1 receptor antagonist, in the prevention of peri-operative hemodynamic instability of patients with PCC. Material and Methods: This retrospective observational study included 75 patients (79 PCC) for PCC removal surgery from 2001 to 2017 at the Bordeaux University Hospital. They received, 3 days before surgery, continuous intravenous infusion of urapidil with stepwise increase to the maximum tolerated dose. Urapidil was maintained during the procedure and stopped after clamping the adrenal vein. Plasma catecholamine concentrations were measured during surgery. Hypertensive peaks (SAP >160 mmHg) and tachycardia >100 beats/min were treated with boluses of nicardipine 2 mg and esmolol 0.5 mg/kg. Results: We recorded 20/79 (25%) cases with systolic arterial pressure (SAP) >180 mmHg. Only 11/79 (14%) had hypotension with SAP <80 mmHg. Peaks of catecholamine secretions were observed preferentially during peritoneal insufflation and tumor dissection (P < 0.05). A correlation was found between tumor size (mm) and the highest norepinephrine levels [r = 0.288, P = 0.015], and between hypertensive peaks (mmHg) and the highest norepinephrine levels [r = 0.45, P = 0.017]. No mortality was reported. The median [range] postoperative hospital stay was 4 [2–9] days. Conclusion: IV urapidil limits hypertensive and hypotensive peaks during PCC surgery, and corresponds to surgical imperatives allowing a short hospital stay, due to its “on–off” effect.
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Urapidil in the Preoperative treatment of pheochromocytoma: How safe is it? p. 55
Abhishek Kumar, Nishkarsh Gupta, Anju Gupta
DOI:10.4103/joacp.JOACP_328_18  
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Comparative evaluation of success of ultrasound-guided internal jugular vein cannulation using needle with guard: A randomized, controlled study p. 57
Vikas Arya, Devendra Gupta, Anil Agarwal, Mekhala Paul, Prabhaker Mishra
DOI:10.4103/joacp.JOACP_305_18  
Background and Aims: We devised a guard which can be slid and fixed over the central venous puncture needle at a desired length (measured through ultrasound) preventing the needle from penetrating deeper into the skin beyond this guard. This randomized, single blinded, controlled study was designed to evaluate the success of ultrasound guided internal jugular vein (IJV) cannulation using measured guided needle with guard in terms of success and occurrence of complications. Material and Methods: After ethical approval and written informed consent from the patients ultrasound-guided right-sided IJV cannulation was done with a conventional puncture needle (length of 6.4 cm) in the control group (n = 210) and with a conventional puncture needle with a guard fixed proximal to the bevel at a distance equal to the distance between the skin entry point and the midpoint of IJV measured with the help of USG in the study group (n = 210). The primary outcome studied was the number of attempts for successful cannulation. The secondary outcomes studied were complications and ease of cannulation. Results: 419 patients were randomized into control (n = 209) and study groups (210). Successful IJV cannulation in the first attempt (primary endpoint) in the study group was significantly higher compared to the control group (98.6 vs. 85.7%, P = 0.007). Posterior venous wall puncture was reduced in the study group, that is, 0.5% (1/210) compared to control group, that is, 8.61% (18/209) (P = 0.001). Common carotid artery puncture was 7.18% (15/209) in control group and 0% (0/210) in study group (P = 0.001). Operators rated better ease in study group (P < 0.001). Conclusions: The use of measured guided needle with guard significantly improved the accuracy, success and ease of USG guided IJV cannulation and decreased complications.
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Assessment of head and neck position for optimal ultrasonographic visualisation of the internal jugular vein and its relation to the common carotid artery: a prospective observational study p. 62
Gaurav Purohit, Rangraj Setlur, Mridul Dhar, Sidharth Bhasin
DOI:10.4103/joacp.JOACP_330_18  
Background and Aims: There is a wide variation in the anatomical relationship of the Internal Jugular Vein (IJV) to the Common Carotid Artery (CCA). This makes landmark based techniques of IJV cannulation and head rotation questionable and may lead to accidental arterial puncture. We conducted this study to determine the anatomical relation of the IJV to the CCA using (USG) in patients undergoing IJV cannulation for central venous access, and to analyse the effect of head rotation on this relationship. Material and Methods: A prospective observational study was conducted on 100 patients requiring central venous access, in the operation theatre or the intensive care unit. Anatomical relationship of the IJV to CCA at the level of the cricoid cartilage was analysed by noting the segment position (1-12) around the CCA using a high frequency linear USG probe on patients in neutral head position, on both sides and also with the head rotated to the contra lateral side by 15° and 45°. Results: Antero-lateral segments 1 and 2 were the most common positions (50% on the right and 73% on the left side). Change in segment causing increase in overlap of IJV and CCA with 15° head rotation was seen in 44% subjects on the right and 39% on the left. Statistically, a higher number of subjects showed overlap with 45° rotation (99% on right and 97% on left, P < 0.05). Conclusion: There is a wide variation in anatomical location of the IJV in relation to the CCA as seen by USG. Excessive head rotation causes overlap of IJV over CCA which may cause inadvertent arterial puncture, even under USG guidance. Thus, it is preferable to cannulate the IJV in neutral or near neutral head and neck position.
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Efficacy of multimodal analgesia with perineural buprenorphine or dexmedetomidine for surgeries performed under ultrasound-guided infraclavicular brachial plexus block p. 66
Prashant A Lomate, Manohar V Mane
DOI:10.4103/joacp.JOACP_30_18  
Background and Aims: Perineural adjuvants when used as a part of multimodal analgesia (MMA) will maximize the quality and duration of analgesia of the nerve blocks. In the present study, we compared the duration of postoperative analgesia and other block characteristics of two groups of MMA comprising either perineural buprenorphine or dexmedetomidine in the upper limb surgeries performed under ultrasound-guided (US-guided) infraclavicular brachial plexus blocks. Material and Methods: A total of 100 adult patients undergoing elective upper limb orthopedic surgery under US-guided infraclavicular brachial plexus block were randomly divided into two groups. Group I received 150 μg buprenorphine and Group II received 50 μg dexmedetomidine, perineurally added to 30 ml of 0.375% bupivacaine. Both groups also received tramadol 50 mg IV, dexamethasone 4 mg IV, and diclofenac 75 mg infusion as part of MMA. Both groups were compared for the duration of postoperative analgesia, block characteristics, and incidence of adverse effects. Results: The duration of postoperative analgesia was significantly prolonged in Group II (937.6 ± 179.1 min vs 1280.4 ± 288.8 min). The onset of sensory and motor blocks was shorter in Group II (P < 0.05). The duration of sensory and motor blocks was significantly prolonged in Group II (P < 0.05). The number of rescue analgesics required in the first 24 hours was less in Group II (1.98 ± 0.62 vs 0.8 ± 0.64). Although heart rate and blood pressure levels were lower in Group II, all patients were hemodynamically stable. Conclusion: For surgeries under brachial plexus block, perineural dexmedetomidine when used as a part of MMA provided a prolonged duration of postoperative analgesia and improved block characteristics than perineural buprenorphine.
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Evaluation of postoperative analgesic efficacy and perioperative hemodynamic changes with low dose intravenous dexmedetomidine infusion in patients undergoing laparoscopic cholecystectomy – A randomised, double-blinded, placebo-controlled trial p. 72
Geetanjali T Chilkoti, Ganeshan Karthik, Rajesh Rautela
DOI:10.4103/joacp.JOACP_184_17  
Background and Aim: Dexmedetomidine is a α2-agonist with sedative, sympatholytic and analgesic properties and hence, it can be a very useful adjuvant in anesthesia as stress response buster, sedative and analgesic. We aimed to evaluate the effects of low dose dexmedetomidine infusion (0.5 mcg/kg/h) on postoperative analgesic efficacy along with the perioperative hemodynamic changes in patients undergoing laparoscopic cholecystectomy. Material and Methods: Eighty patients of American Society of Anesthesiologists (ASA) physical grades I and II undergoing laparoscopic cholecystectomy were randomly allocated into two groups of 40 patients each. Group I (Normal Saline group) patients received normal saline and group II (Dexmedetomidine group) patients received dexmedetomidine infusion at 0.5 mcg/kg/h respectively, starting 15 min before induction and continued till the end of surgery. Parameters noted were heart rate, mean arterial pressure, oxygen saturation, post-operative pain was evaluated using VAS and analgesic requirement. Statistical tests such as ANOVA test for continuous variables, post-hoc test for intergroup comparison, and Chi-square test for discrete values were applied. Results: Post-operative efficacy was found to be limited in the dexmedetomidine group in terms of VAS score. The analgesic requirement in 24-hour was observed to be reduced in dexmedetomidine group when compared to the NS group; however, not statistically significant. In group NS, significant hemodynamic stress response was seen following laryngoscopy, tracheal intubation, creation of pneumoperitoneum and extubation. On intergroup comparison, the hemodynamic response was significantly attenuated in the dexmedetomidine group when compared to the NS group. No significant side effects were noted. Conclusion: Dexmedetomidine IV in an infusion dose of 0.5 μg/kg/hr is effective in providing postoperative analgesia in terms of significant reduction in analgesic consumption in 24 hours and in addition to the effective obtundation of the pneumoperitoneum-induced hemodynamic changes.
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Effects of intravenous dexmedetomidine on spinal anesthesia and sedation – A comparison of two different maintenance infusions p. 78
Pritee H Bhirud, Shrividya Chellam, Mandar N Mote, Pratibha V Toal
DOI:10.4103/joacp.JOACP_129_18  
Background and Aims: Our aim was to study the effects of a low-dose bolus (0.5 mcg/kg) of dexmedetomidine followed by two different infusion doses (0.25, 0.5 mcg/kg/h) on spinal anesthesia, sedation, hemodynamics and side effects. Material and Methods: Eighty consenting patients were randomized into two groups A and B with 40 patients each. Patients in both groups were administered intravenous (IV) dexmedetomidine 0.5 mcg/kg over 10 min prior to SAB followed by IV dexmedetomidine 0.25 mcg/kg/h infusion (A) and 0.5 mcg/kg/h infusion (B) throughout the duration of surgery. Time for onset of sensory and motor block, duration of motor block and analgesia, time for two segment regression, intra operative hemodynamics and sedation were assessed. P value less than 0.05 was taken as significant. Results: Onset of sensory block to T10 was 2.1 ± 0.3 min in group A and group B. Onset of motor block was 4.6 ± 0.9 min in group A and 4.3 ± 0.9 min in group B. Duration of motor block in group A was 235.6 ± 12.4 min compared to group B which was 245.3 ± 9.3 min. Time for 2 segment regression in group A was 139.7 ± 29.7 min compared to group B which was 152.3 ± 18.7 min. Total duration of analgesia was 259.3 ± 92.4 min in group A and 273.8 ± 52.3 min in group B. There was a significant reduction in heart rate and mean blood pressure compared to the baseline within both the groups. Sedation was comparable in both the groups. Conclusion: IV dexmedetomidine bolus of 0.5 mcg/kg prior to subarachnoid block followed by maintenance infusion of 0.5 mcg/kg/h significantly prolonged duration of motor block, time for two segment regression, along with stable hemodynamics and adequate sedation.
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Comparison of the efficacy of two doses of dexmedetomidine in attenuating the hemodynamic response to intubation in patients undergoing elective cardiac surgery: A randomized double-blinded study p. 83
Annedath R Silpa, KA Koshy, Arun Subramanian, Kizakke K Pradeep
DOI:10.4103/joacp.JOACP_235_18  
Background and Aims: Transient tachycardia and hypertension associated with laryngoscopy and intubation may be hazardous to patients presenting for cardiac surgery. The α 2 agonist dexmedetomidine may blunt this stress response, but the optimal dose which will accomplish this without causing hypotension and bradycardia is not well established. The primary objective of this study was to compare the efficacy of two doses of dexmedetomidine (0.5 and 1 μg/kg) as a 15 min infusion in attenuating the hemodynamic stress response to laryngoscopy and endotracheal intubation in elective cardiac surgery. Material and Methods: Seventy six patients scheduled for elective cardiac surgery received a single preoperative dose of dexmedetomidine of either 0.5 μg/kg (low dose) or 1 μg/kg (high dose) as a 15-min infusion prior to induction. The hemodynamic response to laryngoscopy and endotracheal intubation (heart rate, systolic blood pressure, mean arterial pressure, and diastolic blood pressure) were recorded at different times. Independent sample t-test, Chi-square test of association, and repeated measures analysis of variance were used to analyze the collected data. Results: The incidence of hypertension following intubation was significantly more in the low-dose group. Administration of 1 μg/kg dexmedetomidine was not accompanied by hypotension or bradycardia. Conclusion: Dexmedetomidine in a dose of 1 μg/kg is more effective than 0.5 μg/kg for attenuation of hemodynamic stress response to intubation in cardiac surgery. A more graded increase in the dose of dexmedetomidine may lead to an optimum dose in attenuating the hemodynamic response to intubation.
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Perioperative risk factors for pulmonary complications after non-cardiac surgery p. 88
Surbhi Gupta, Roshan Joseph Fernandes, Joseph Sushil Rao, Radhika Dhanpal
DOI:10.4103/joacp.JOACP_54_19  
Background and Aims: Postoperative pulmonary complications (PPCs) lead to increased morbidity, mortality, length of hospital stay, and cost to the patient. This study was conducted to determine the risk factors and assess the incidence of PPC after non-cardiac surgery. Material and Methods: This prospective, observational study was conducted on 1,170 patients undergoing non-cardiac surgery. Details of patient, surgical, and anesthetic factors were collected and patients were followed up for the entire duration of hospital stay for the occurrence of PPC. Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score and the length of hospital stay was noted for all the patients. Regression analysis was used to find the risk factors associated with development of respiratory complications. Results: The incidence of PPC was found to be 59 in 1,170 patients (5%) in our hospital. Multivariate analysis revealed that patients with intermediate and high risk ARISCAT scoring had higher odds of developing PPC. Higher age (>50 years), positive cough test, presence of nasogastric tube, and intraoperative pulmonary complications were identified as independent risk factors associated with the occurrence of PPC. Conclusion: We found 5% incidence of PPC in our study. Recognition of the delineated risk factors and routine use of ARISCAT score for preoperative assessment may help identify patients at a higher risk of developing postoperative pulmonary complications.
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Postoperative urinary retention: A controlled trial of fixed-dose spinal anesthesia using bupivacaine versus ropivacaine p. 94
Shahla Haleem, Ahmad Ozair, Abhishek Singh, Muazzam Hasan, Manazir Athar
DOI:10.4103/joacp.JOACP_221_18  
Background and Aims: Following spinal anesthesia (SA), patient discharge is often delayed due to postoperative urinary retention (POUR), the incidence of which varies widely. The present study of bupivacaine versus ropivacaine in equianalgesic doses was taken to explore the correlation between time to void urine and time for complete functional recovery. Material and Methods: In this double-blinded study fifty adult patients were assigned to two groups (bupivacaine/ropivacaine) according to alternate case allocation for receiving SA for lower abdominal, perineal, and lower limb surgeries, lasting less than 2 h. Statistical analysis was conducted using an intention-to-treat approach, using Mann–Whitney test for nonparametric data. Primary outcome data could not be obtained for 14 out of the 50 patients due to perioperative bladder catheterization. No patients were lost to follow-up. Results: Both the bupivacaine and ropivacaine groups were comparable in terms of ability to void (8.0 ± 2.3 vs. 7.0 ± 1.2 h;P > 0.05), modified Bromage scale after 4 h of SA (1.8 ± 1.3 vs. 2.6 ± 0.9 grade;P > 0.05), time to complete ambulation (6.7 ± 1.4 vs. 6.1 ± 1.0 h;P > 0.05), and time to negative Romberg test (6.1 ± 1.4 vs. 5.6 ± 0.9 h;P > 0.05), respectively. Strong positive correlations (r = 0.7–0.9) were found between time to void urine and time for complete ambulation. Conclusions: Time to void urine and recovery of motor functions were found comparable statistically when bupivacaine and ropivacaine were used in the doses of 12.5 and 18.75 mg, respectively, for SA. However, group ropivacaine required lesser time to void and no patient developed POUR. Time to void urine was more than the time for ambulation. This may indicate a need for “selective spinal anesthesia” or adjuvant combination technique to accelerate the resolution of a block for ambulatory surgery.
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COMMENTARY Top

To sniff or not to sniff: The eternal debate p. 100
Riniki Sarma, Nishkarsh Gupta, Anju Gupta
DOI:10.4103/joacp.JOACP_181_19  
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Hydroxyethyl starch should not be used for cesarean section to prevent maternal hypotension following spinal anesthesia p. 102
Günther Putz, Christian J Wiedermann
DOI:10.4103/joacp.JOACP_59_19  
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CLINICAL PHARMACOLOGY Top

Erenumab: A novel calcitonin gene-related peptide receptor antagonist developed specifically for migraine prevention p. 104
Shuchita Garg, Malti Vij, Neeraj Edward, Brinder Vij
DOI:10.4103/joacp.JOACP_3_19  
Headaches and migraines continue to be a leading cause of suffering and disability. As per the Global Burden of Disease Survey conducted in 2010, the exact magnitude of the disease still is underestimated. Migraine alone continues to rank seventh as a cause of disability. Various therapeutic modalities exist and newer classes of medications are currently being trialed to provide effective treatment to this population of patients. Erenumab, a calcitonin gene-related peptide receptor inhibitor, is a recent addition to this armamentarium and has been approved by the FDA for use in 2018. It has shown modestly improved outcomes according to the current trials. However, long-term outcomes and adverse effects still are under research. The following article elaborates on the current literature and evidence on this novel drug.
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The use of extended release bupivacaine with transversus abdominis plane and subcostal anterior quadratus lumborum catheters: A retrospective analysis of a novel technique p. 110
Hesham Elsharkawy, Wael Saasouh, Yoon Jeong Cho, Loran Mounir Soliman, Jean-Louis Horn
DOI:10.4103/joacp.JOACP_358_18  
Background and Aims: Liposomal bupivacaine (LB) is a formulation of local anesthetic that may exert analgesia over a prolonged period. Anecdotal use of LB suggests benefit and prolonged analgesia when used to supplement infiltration blocks. Our aim was to test the effect of a bolus of LB delivered through a nerve catheter in two types of interfascial plane blocks (transversus abdominis plane and anterior subcostal quadratus lumborum). The effect was evaluated through patient self-reporting of postsurgical pain up to 48 postoperative hours. Material and Methods: Medical records of adult postoperative patients who received LB in a peripheral nerve catheter were followed retrospectively and analysed for pain scores and spread of dermatomal numbness over 48 h following the postoperative dose. A chart review of patients who qualified between June 2015 and March 2017 was performed, and clinical data were obtained from the institutional Perioperative Health Documentation System. Results: Pain scores decreased following LB bolus, and all patients reported efficient block analgesia after bolus injection. Dermatomal numbness decreased gradually and was minimal by 48 h following bolus. Conclusion: LB can be injected through a peripheral nerve catheter to prolong analgesia after catheter removal.
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CASE REPORT Top

Quadratus lumborum block provides significant pain relief after abdominal transplant p. 115
Christopher Adam Godlewski
DOI:10.4103/joacp.JOACP_266_19  
Abdominal organ transplantation - and more specifically small bowel transplant - can be quite painful, generally requiring significant opioid administration with the attendant negative ramifications. We present contrasting experiences with a gentleman who underwent transplantation for Crohn's disease and his retransplantation with the addition of post-operative anterior Quadratus Lumborum (QL) block. After the index procedure, he had significant pain and discomfort. The addition of the QL block lead to substantial improvement in both subjective and objective endpoints. While each case is different, a QL block can be a useful adjunct to achieve pain control, decrease opioid requirements, and potentially facilitate early extubation.
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LETTERS TO EDITOR Top

Is ESP block an answer for upper abdominal surgeries where epidural analgesia can't be used? p. 117
Nidhi Arun, Swati Singh
DOI:10.4103/joacp.JOACP_278_19  
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COMMENTARY Top

Ultrasound-guided truncal/plane blocks: Are they safe in anticoagulated patients? p. 118
Rashmi Salhotra
DOI:10.4103/joacp.JOACP_306_19  
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LETTERS TO EDITOR Top

RACK approach to erector spinae plane block p. 120
Ritesh Roy, Gaurav Agarwal, Chandrasekhar Pradhan, Debasis Kuanar
DOI:10.4103/joacp.JOACP_248_19  
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Solving extubation puzzle with Intubating fibrescope p. 122
Manoj Bhardwaj, Amit Mittal, Nitesh Goel
DOI:10.4103/joacp.JOACP_335_18  
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Use of Arndt bronchial blocker through nasal RAE endotracheal tube in a patient with limited mouth opening p. 123
Vini N K. Depal, Furkan Akhtar Ansari, Souvik Maitra
DOI:10.4103/joacp.JOACP_346_18  
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Oxygen reserve index – A new paradigm in patient safety p. 125
Barkha D Agrawal, Priyanka P Karnik, Nandini M Dave
DOI:10.4103/joacp.JOACP_76_19  
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Laparoscopic cholecystectomy in a patient with distal renal tubular acidosis associated with Sjogren's syndrome: An anesthetic challenge p. 127
Snigdha Bellapukonda, Kiran Jangra, Pranshuta Sabharwal
DOI:10.4103/joacp.JOACP_78_19  
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Retained tracheostomy tube brush tip manifesting as recurrent respiratory tract infection p. 128
Vikas Marwah, Shalendra Singh, Navdeep Sethi, Ankur Khandelwal
DOI:10.4103/joacp.JOACP_271_18  
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Difficult and failed airway in small neonates: Lightwand revisited p. 130
Chitta R Mohanty, Suma R Ahmad, Bikram Kishore Behera, Snigdha Bellapukonda
DOI:10.4103/joacp.JOACP_218_19  
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Airway management using a non-coaxial fibreoptic bronchoscope guided endotracheal intubation in a case of near complete palatoglossal synechiae p. 131
Vaishali Waindeskar, Anuj Jain
DOI:10.4103/joacp.JOACP_250_18  
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Dilemmas in a parturient with intracranial meningioma with raised intracranial pressure and difficult airway for cesarean section p. 133
Neisevilie Nisa, Ishtiyak Hussain, Jyotsna Punj, Magesh Parthiban, Purnima Narasimhan
DOI:10.4103/joacp.JOACP_25_19  
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Thromboembolic complications in patients with septic shock requiring invasive mechanical ventilation: Incidence, risk factors, and outcomes p. 135
Mabrouk Bahloul, Sabrine Bradai, Olfa Turki, Karama Bouchaala, Nadia Khlaf Bouaziz, Hedi Chelly, Sondes Haddar, Mounir Bouaziz
DOI:10.4103/joacp.JOACP_163_18  
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Perioperative metformin: Friend or foe p. 137
Abhijit S Nair
DOI:10.4103/joacp.JOACP_305_17  
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Perioperative management of a giant solitary fibrous tumor of Pleura p. 138
Raghav Gupta, Vinod Kumar, Nishkarsh Gupta, Brajesh K Ratre
DOI:10.4103/joacp.JOACP_232_18  
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Dexmedetomidine and postoperative delirium: Decoding the evidence! p. 140
Rohan Magoon, Ashok K Kumar, Vishwas Malik, Neeti Makhija
DOI:10.4103/joacp.JOACP_237_19  
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