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   Table of Contents - Current issue
Coverpage
October-December 2017
Volume 33 | Issue 4
Page Nos. 427-564

Online since Tuesday, January 9, 2018

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EDITORIAL  

Postoperative nausea and vomiting: The achilles heel of anesthesiologists p. 427
Shuchita Garg, Sudhakar Subramani, Harsh Sachdeva
DOI:10.4103/joacp.JOACP_321_17  
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REVIEW ARTICLES Top

Etomidate derivatives: Novel pharmaceutical agents in anesthesia p. 429
Raymond J Malapero, Michael P Zaccagnino, Ethan Y Brovman, Alan David Kaye, Richard D Urman
DOI:10.4103/0970-9185.222521  
Etomidate is an imidazole derivative that possesses important sedative properties employed in anesthesia practice, however, etomidate has a number of well-know side effects which limit its use in certain subpopulations and over long periods of time, mostly related to dose-dependent adrenal suppression. This review focuses on novel etomidate derivatives with an emphasis on pharmacological properties which afford improved safety profile and potentially desirable clinical effects. The pharmacology and clinical investigation of some of these etomidate derivatives, e.g. cyclopropyl-methoxycarbonyl, carboetomidate metomidate, methoxycarbonyl-etomidate, cyclopropyl-methoxycarbonyl metomidate (CPMM), and dimethyl-methoxycarbonyl metomidate, are discussed in detail. The increased potency and decreased metabolite build-up of CPMM potentially makes it a very favorable drug, particularly in the setting of prolonged infusions. Further, when compared with etomidate, CPMM produces lower plasma cytokine concentration and improved survival in lipopolysaccharide inflammatory sepsis models.
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Anesthesia for intellectually disabled p. 432
Kapil Chaudhary, Preranna Bagharwal, Sonia Wadhawan
DOI:10.4103/joacp.JOACP_357_15  
Anesthetizing an intellectually disabled patient is a challenge due to lack of cognition and communication which makes perioperative evaluation difficult. The presence of associated medical problems and lack of cooperation further complicates the anesthetic technique. An online literature search was performed using keywords anesthesia, intellectually disabled, and mentally retarded and relevant articles were included for review. There is scarcity of literature dealing with intellectually disabled patients. The present review highlights the anesthetic challenges, their relevant evidence-based management, and the role of caretakers in the perioperative period. Proper understanding of the associated problems along with a considerate and unhurried approach are the essentials of anesthetic management of these patients.
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The role of neurokinin-1 (substance P) antagonists in the prevention of postoperative nausea and vomiting p. 441
Dionne Okafor, Alan David Kaye, Rachel J Kaye, Richard D Urman
DOI:10.4103/0970-9185.222511  
Postoperative nausea and vomiting (PONV) can be very debilitating for surgical patients, and effective management reduces potential morbidity, aiding in patient satisfaction, and minimizing the need for unintended hospital stays. Risk factors include female sex, nonsmoker, and having a previous history of motion sickness or PONV. Anesthetic risk factors include receiving opioids, not receiving a total intravenous anesthetic (TIVA), exposure to nitrous oxide, and extended length of anesthetic. Many treatments, including serotonin antagonists, dopamine antagonists, corticosteroids, inhaled isopropyl alcohol, and anticholinergics, as well as techniques such as TIVA, have been utilized over recent decades in an attempt to reduce PONV incidence. However, it remains a problem for a significant number of surgical patients. Aprepitant is a neurokinin-1 (substance P) antagonist, which exerts its effects via a final common pathway of the emetic centers after crossing the blood brain barrier. Aprepitant is commonly used in the cancer population to help prevent cancer chemotherapy-induced nausea and vomiting and has shown great promise in both acute and delayed phase PONV. Published data has shown improved efficacy when compared with ondansetron administered prior to surgery. The use of aprepitant in combination with other antiemetics potentially may help decrease unplanned hospital admissions and potentially, reduce costs associated with PONV.
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COMMENTARIES Top

Video-assisted laryngoscopic devices: Have we found the panacea for difficult airway yet? p. 446
Anju Gupta
DOI:10.4103/joacp.JOACP_250_16  
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Off-label use of drugs in regional anesthesia: A need for setting up policies p. 448
Saru Singh, Pranav Bansal, Jagdish Dureja
DOI:10.4103/joacp.JOACP_341_15  
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ORIGINAL ARTICLES Top

The effect of intravenous infusion of N-acetyl cysteine in cirrhotic patients undergoing liver resection: A randomized controlled trial p. 450
Eman Sayed, Khaled Gaballah, Eman Younis, Khaled Yassen, Abo K El-Einen
DOI:10.4103/joacp.JOACP_70_17  
Background and Aims: Liver resection can lead to hepatocellular dysfunction. The aim was to evaluate the effect of N-acetyl cysteine (NAC) on liver enzymes (alanine aminotransferase [ALT] and aspartate aminotransferase [AST]), international normalized ratio (INR), C-reactive protein (CRP), and intercellular adhesion molecule 1 (ICAM 1) in cirrhotic patients undergoing liver resection. Material and Methods: A randomized controlled trial (RCT), Pan African Clinical Trial registry (PACTR201508001251260). 60 Child A patients were studied. NAC group (n = 30) received intravenous infusion of NAC 10 g/24 h in 250 ml of 5% dextrose during surgery and for 2 days. Controls (C) (n = 30) received a similar volume of 5% dextrose. All above parameter were measured during and after surgery. Results: ALT and AST were significantly elevated after surgery, but to a less extent with NAC versus C (day 3; 118.3 ± 18.6 vs. 145.4 ± 14.0 U/L. P < 0.01) and (121.5 ± 19.5 vs. 146.6 ± 15.1 U/L, P = 0.00), respectively. Lower serum CRP and ICAM 1 with NAC versus C on day 3 (44.2 ± 13.4 vs. 68.7 ± 48.2 mg/l, P = 0.003), (308.8 ± 38.2 vs. 352.8 ± 59.4 ng/ml, P = 0.002), respectively. Hospital stay was shorter with NAC versus C (6.1 ± 0.8 vs. 6.9 ± 1.2 days, P = 0.006). Duration of surgery, INR, and hemodynamics were comparable. Conclusion: Prophylactic NAC in hepatic patients undergoing liver surgery attenuated postoperative increase in transaminases, ICAM 1, and CRP blood levels. The impact of these findings and the cost benefit of reduced hospital stay on enhanced recovery after surgery needs to be evaluated.
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Dexmedetomidine as an adjunctive analgesic to ropivacaine in pectoral nerve block in oncological breast surgery: A randomized double-blind prospective study p. 457
Haramritpal Kaur, Poonam Arora, Gurpreet Singh, Amandeep Singh, Shobha Aggarwal, Mukesh Kumar
DOI:10.4103/joacp.JOACP_298_16  
Background and Aims: Pectoral nerve block (Pecs) using local anesthetic (LA) agent is a newer analgesic technique for breast surgeries. This study further evaluates the effect of addition of dexmedetomidine to LA agent on total duration of analgesia and postoperative morphine consumption. Material and Methods: A total of 60 American Society of Anesthesiologist Grade I and II female patients with age ≥18 years, scheduled for oncological breast surgery, were enrolled in the study. Patients were randomized into two equal groups of 30 each. Group R (n = 30) received ultrasound (US)-guided Pecs block with 30 ml of 0.25% ropivacaine. Group RD (n = 30 patients) received US-guided Pecs block with 30 ml of ropivacaine 0.25% and dexmedetomidine 1 μ/kg body weight. Duration of analgesia and total postoperative morphine consumption was noted in 24 h period. Unpaired t-test and Chi-square test were used for statistical analysis. Results: A statistically highly significant increase in total duration of analgesia (in minutes) was recorded in Group RD as compared to Group R (469.6 ± 81.5 in Group RD and 298.2 ± 42.3 in Group R) (P = 0.000). Total postoperative morphine consumption in mg was also statistically significantly lower in Group RD as compared to Group R (14.8 ± 2.4 in Group RD and 21.6 ± 3.1 in Group R) (P = 0.000). No patient under study reported any adverse effects. Conclusion: Addition of 1 μ/kg dexmedetomidine to 0.25% ropivacaine for Pecs block increases the duration of analgesia and decreases postoperative morphine consumption.
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Front of neck access: A survey among anesthetists and surgeons p. 462
Cyprian Mendonca, Imran Ahmad, Achuthapillai Sajayan, Rathinavel Shanmugam, Manu Sharma, Will Tosh, Emily Pallister, Peter K Kimani
DOI:10.4103/joacp.JOACP_109_17  
Background and Aims: Emergency front of neck access (FONA) is the final step in a Can't Intubate–Can't Oxygenate (CICO) scenario. In view of maintaining simplicity and promoting standardized training, the 2015 Difficult Airway Society guidelines recommend surgical cricothyroidotomy using scalpel, bougie, and tube (SBT) as the preferred technique. Material and Methods: We undertook a survey over a 2-week period to evaluate the knowledge and training, preferred rescue technique, and confidence in performing the SBT technique. Data were collected from both anesthetists and surgeons. Results: One hundred and eighty-nine responses were collected across four hospitals in the United Kingdom. The majority of participants were anesthetists (55%). One hundred and eleven (59%) respondents were aware of the national guidelines (96.2% among anesthetists and 12.9% among surgeons). Only 71 (37.6%) respondents indicated that they had formal FONA training within the last one year. Seventy-five anesthetists (72.8%) knew that SBT equipment was readily available in their department, while most surgeons (81.2%) did not know what equipment available. One hundred and five (55.5%) respondents were confident in performing surgical cricothyroidotomy in a situation where the membrane was palpable and only in 33 (17.5%) where the cricothyroid membrane was not palpable. Conclusion: This survey has demonstrated that despite evidence of good training for anesthetists in FONA, there are still shortfalls in the training and knowledge of our surgical colleagues. In an emergency, surgeons may be required to assist or secure an airway in a CICO situation. Regular multidisciplinary training of all clinicians working with anesthetized patients should be encouraged and supported.
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I-Gel versus laryngeal mask airway (LMA) classic as a conduit for tracheal intubation using ventilating bougie p. 467
Aditi A Dhimar, Bhavika R Sangada, Mahendra R Upadhyay, Sangita H Patel
DOI:10.4103/joacp.JOACP_113_16  
Background and Aims: Supraglottic airways (SGAs) are generally used for airway management; but can also be used as a conduit for tracheal intubation. Our primary aim was to evaluate i-Gel and laryngeal mask airway (LMA) classic as conduits for tracheal intubation using ventilating bougie by assessing number of attempts and time for insertion of SGAs, ventilating bougie and endotracheal tube (ETT), and total intubation time. Material and Methods: A randomized clinical trial was carried out in 58 patients requiring general anesthesia and endotracheal intubation for planned surgery. They were randomly divided into Group I and Group C. After induction of anesthesia, i-Gel was inserted in Group I and LMA Classic in Group C; ventilating bougie was passed through SGA followed by the removal of SGA and railroading of ETT over ventilating bougie. Parameters observed were number of attempts and time taken for device insertion, total intubation time, and hemodynamic variables. Results: Twenty-nine patients were included in each group. First attempt success rate for SGA insertion (86.2% in Group I and 75.9% in Group C (P = 0.5)), ventilating bougie insertion (79.32% in Group I and 82.8% in Group C (P = 0.99)) and ETT insertion (100% in Group I and 96.5% in Group C) was not different in the two groups. Total intubation time was 93.3 ± 9.0 s in Group I and 108. 96 ± 16.5 s in Group C (P < 0.0001). Conclusions: i-Gel and LMA Classic both can be used as a conduit for tracheal intubation using ventilating bougie with stable hemodynamic parameters.
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Tracheal intubation through laryngeal mask airway CTrach™ with polyvinyl chloride tube: Comparison between two orientations of the tracheal tube p. 473
Karri Pavani, Handattu Mahabaleswara Krishna, Joseph Nandhini
DOI:10.4103/0970-9185.222507  
Background and Aims: Higher success rate of intubation is observed with the reverse orientation of polyvinyl chloride (PVC) tracheal tube while intubating through laryngeal mask airway (LMA) Fastrach™. It is not clear whether the same is true during intubation through LMA CTrach™ visualizing the process of intubation. The primary aim of this study was to compare the influence of the PVC tracheal tube orientation on the success rate of intubation while intubating through LMA CTrach™. Material and Methods: One-hundred and fifty patients belonging to American Society of Anesthesiologists status I–II, undergoing elective surgery under general anesthesia were randomized to either group normal orientation or group reverse orientation. A maximum of 3 intubation attempts within a span of 3 min was allowed in each group before the change over to the other group. If intubation failed with the other orientation of the tube also, then intubation through LMA CTrach™ was abandoned and intubation done by direct laryngoscopy. The success of intubation, time, maneuvers, postoperative sore throat, and hoarseness were recorded. Results: Tracheal intubation through LMA CTrach™ with PVC tube was successful in 94.5% of patients in group normal orientation and in 98.6% of patients in group reverse orientation. The first attempt success rate was 75.3% and 86.3% in group normal and group reverse orientation, respectively. The incidence of a sore throat was higher in the group normal orientation than in the reverse orientation (31.8% and 26.5%, respectively). Conclusions: Overall success rate of intubation was comparable between the two groups. Though statistically insignificant, the first attempt success rate was higher in group reverse orientation.
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Intensive Care Unit delirium: A wide gap between actual prevalence and psychiatric referral p. 480
Sandeep Grover, Siddharth Sarkar, Lakshmi Narayana Yaddanapudi, Abhishek Ghosh, Amit Desouza, Debasish Basu
DOI:10.4103/0970-9185.222505  
Background and Aims: The study aimed to assess the rates of delirium in an Intensive Care Unit (ICU) prospectively assessed with a delirium screening instrument and confirmed through psychiatrist evaluation. In addition, the referral rate to psychiatric consultation liaison services from the same ICU was assessed through the rates of psychiatric referral over the previous 10 years. Material and Methods: In the prospective part of the study, consecutive patients aged 16 years or more admitted to the ICU of a tertiary care hospital were assessed daily for delirium using confusion assessment method for the ICU, a validated instrument that can be used for both mechanically ventilated and nonventilated patient by trained heath care personnel. Retrospectively, records of patients referred to psychiatric referral team for delirium from the ICU over the last 10 years were drawn out and the referral rate was calculated. Results: In the prospective study, 109 patients were recruited of which 43 patients remained comatose throughout their ICU stay and could not be assessed for delirium. Of the 66 assessable patients, 45 (68.2% prevalence rate) patients developed delirium. Incidence rate of delirium was 59.6%. In contrast, the retrospective study showed that only 53 cases out of 3094 admissions in ICU over 10 years (1.71%) were referred to psychiatry consultation liaison team for management of delirium. In the prospective study, hypoactive delirium was the most common subtype of delirium. Conclusion: There is a mismatch between the incidence and prevalence of delirium in ICU patients prospectively diagnosed with structured, validated instruments and the diagnosis of delirium in cases referred to psychiatry consultation-liaison services.
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Evidence-based medicine: A survey among perioperative health care professionals in India p. 487
Reshma Ambulkar, Priya Ranganathan, Vasanth Karthik, Jigeeshu Divatia
DOI:10.4103/0970-9185.222508  
Background and Aims: Evidence-based medicine (EBM) is defined as the use of scientifically proven evidence for delivering best possible health care to patients. Despite growing emphasis on the need for EBM-based practice, acceptability, and perceptions toward EBM might differ among health professionals. The objective of this study was to assess the attitude, knowledge, and current practices of EBM among perioperative care health professionals in India. Material and Methods: This was a single point paper-based questionnaire survey carried out in February 2014 among delegates registered for an EBM conference on “perioperative care” held at a Tertiary referral Cancer Centre in India. Participation was voluntary and respondents were given the option of remaining anonymous. Results: Out of 190 questionnaires, 123 (65%) were returned. Most respondents (98%) agreed that practicing EBM improved patient care. The need to follow departmental protocols (22%) worries about the cost of implementing new treatments (20%) and inadequate skills to critically appraise articles (16%) accounted for major barriers in implementing EBM in clinical practice, with only 15% of respondents stating reluctance to change set practice. “Randomized controlled trial” and “number needed to treat” were the best and least understood EBM terms. Regarding awareness of 10 commonly used EBM-based guidelines in perioperative medicine, the percentage of correct responses ranged from 20% to 88%. Conclusion: Although most respondents agreed that practicing EBM improved patient care, many of them showed a low level of awareness regarding fundamental aspects of EBM. In addition to encouraging implementation of EBM, there should be increased focus on training in EBM methods.
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The minimum dose of dexmedetomidine required for cessation of postspinal anesthesia shivering: A prospective observational study p. 493
Tanveer Singh Kundra, Parminder Kaur
DOI:10.4103/joacp.JOACP_115_16  
Background and Aims: Shivering is a common postanesthesia adverse event with multiple etiologies. Dexmedetomidine, a centrally acting alpha-2 adrenergic agonist, is known to reduce the shivering threshold. However, the minimum dose at which dexmedetomidine causes cessation of shivering is unknown. The aim of this prospective observational study was to find the minimum dosage of dexmedetomidine required for abolition of post-spinal anesthesia (SA) shivering. Material and Methods: Thirty patients having shivering after SA were enrolled, who received dexmedetomidine in the dosage of 1 mcg/kg over 10 min. The time-to-cessation of shivering and the dose of dexmedetomidine required were expressed as mean ± standard deviation. Results: The mean time-to-cessation of shivering after starting dexmedetomidine infusion was 155.88 ± 15.16 s for Grade 3 shivering and 177.71 ± 10.87 s for Grade 4 shivering. Till that time, the mean dose of dexmedetomidine which had been infused was 0.258 ± 0.024 mcg/kg in Grade 3 shivering and 0.295 ± 0.018 mcg/kg in Grade 4 shivering. Conclusion: The minimum dose of dexmedetomidine required for abolition of shivering was 0.258 ± 0.024 mcg/kg for patients with Grade 3 shivering and 0.295 ± 0.018 mcg/kg for patients with Grade 4 shivering, which is much less than the commonly administered dose.
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Sevoflurane sparing effect of dexmedetomidine in patients undergoing laparoscopic cholecystectomy: A randomized controlled trial p. 496
Preeti Sharma, Satinder Gombar, Vanita Ahuja, Aditi Jain, Usha Dalal
DOI:10.4103/joacp.JOACP_144_16  
Background and Aims: Sevoflurane is an excellent but expensive anesthetic agent for laparoscopic cholecystectomy. To decrease sevoflurane consumption during surgery adjuvants like dexmedetomidine may be used. Dexmedetomidine is a recently introduced drug which alleviates the stress response of surgery, produces sedation and analgesia. We aimed to evaluate sevoflurane sparing effect of dexmedetomidine in patients undergoing laparoscopic cholecystectomy under entropy-guided general anesthesia (GA). Material and Methods: In this prospective randomized control study, 100 American Society of Anesthesiologists physical status I–II adult surgical patients scheduled to undergo laparoscopic cholecystectomy were enrolled. Patients were randomly divided into two groups (n = 50). In dexmedetomidine group, patients received intravenous (IV) dexmedetomidine 0.5 μg/kg over 10 min before induction followed by 0.5 μg/kg/h infusion while in control group, patients received the same volume of normal saline. Results: Sevoflurane consumption was 41% lower in dexmedetomidine group as compared to control group (7.1 [1.6] vs. 12.1 [1.9] ml, P<0.001). A 40% reduction was observed in induction dose of propofol (83.0 [19.1] vs. 127.6 [24.8] mg, P<0.001). Mean Riker sedation-agitation score, visual analog score for pain and Aldrete's score were significantly lower in dexmedetomidine group as compared to control group. None of the patients experienced any significant side effects. Conclusion: A 41% reduction in sevoflurane consumption was observed in patients receiving IV dexmedetomidine as an adjuvant in patients undergoing laparoscopic cholecystectomy under GA.
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Comparison of maintenance, emergence and recovery characteristics of sevoflurane and desflurane in pediatric ambulatory surgery p. 503
Manish B Kotwani, Anila D Malde
DOI:10.4103/joacp.JOACP_194_16  
Background and Aims: Increasing number of pediatric ambulatory surgeries are being carried out in general anesthesia using supraglottic airways (SGAs). Literature comparing sevoflurane and desflurane for the maintenance of SGA-based anesthesia is limited. Hence, we planned this prospective randomized study to compare the maintenance, emergence and recovery characteristics of sevoflurane and desflurane for pediatric ambulatory surgery. Material and Methods: Sixty children aged 6 months to 6 years posted for short surgical procedures were enrolled into the study. Anesthesia was induced with intravenous propofol (maximum 4 mg/kg), SGA was inserted, and children were randomized to receive sevoflurane or desflurane for the maintenance of anesthesia. No muscle relaxants were administered, and all children received caudal block and rectal paracetamol suppository. Demographic data, perioperative hemodynamics and adverse events, emergence and recovery characteristics, postoperative pain, and emergence agitation (EA) were recorded. Data were analyzed using SPSS (version 16.0, IBM Corporation, Armonk, New York, USA). P < 0.05 was considered statistically significant. Results: Demography, perioperative hemodynamics, and duration of inhalational anesthesia were comparable between two groups. There were no respiratory adverse events in either group during maintenance. Time to awakening and time to removal of SGA were shorter with desflurane (5.3 ± 1.4 and 5.8 ± 1.3 min) than sevoflurane (9.1 ± 2.4 and 10.0 ± 1.6 min) (P < 0.0001). Recovery (steward recovery score = 6) was faster with desflurane (18 ± 8.4 min) than sevoflurane (45.3 ± 9.7 min) (P < 0.001). The incidence of EA was 16.7% with desflurane and 10% with sevoflurane (P = 0.226). Conclusion: Desflurane provides faster emergence and recovery in comparison to sevoflurane when used for the maintenance of anesthesia through SGA in children. Both sevoflurane and desflurane can be safely used in children for lower abdominal surgeries.
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Analgesic efficacy of dexamethasone as an adjuvant to caudal bupivacaine for infraumbilical surgeries in children: A prospective, randomized study p. 509
Aruna Parameswari, Bhavya Krishna, Akilandeswari Manickam, Mahesh Vakamudi
DOI:10.4103/joacp.JOACP_167_17  
Background and Aims: Provision of adequate perioperative analgesia in children is important to attenuate the stress response to surgery. Caudal analgesia using local anesthetics is a traditionally used technique but provides a limited duration of analgesia. Several adjuvants can be added to local anesthetics to increase the duration of action. This study was undertaken to evaluate the efficacy of dexamethasone added to bupivacaine for caudal block in children. Material and Methods: This was a prospective, double-blinded trial on 130 children aged between 6 months and 6 years of age allocated randomly into one of two groups for elective subumbilical surgeries. Children in Group C received caudal bupivacaine and those in Group D received caudal bupivacaine with 0.1 mg/kg of dexamethasone. Results: The mean duration of analgesia when dexamethasone was added to caudal bupivacaine was 1044.92 (±48.66) min, while it was 435.85 (±17.95) min with plain bupivacaine. The number of doses of rescue analgesics required and the mean pain score was also lesser in this group. Conclusion: The addition of 0.1 mg/kg of dexamethasone to caudal bupivacaine increases the duration of analgesia of caudal bupivacaine without any side effects in children undergoing subumbilical surgeries.
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Effect of lactate versus acetate-based intravenous fluids on acid-base balance in patients undergoing free flap reconstructive surgeries p. 514
Sunil Rajan, Soumya Srikumar, Pulak Tosh, Lakshmi Kumar
DOI:10.4103/joacp.JOACP_18_17  
Background and Aims: Use of lactated intravenous fluids during long surgeries could cause lactate accumulation and lactic acidosis. Acetate-based solutions could be advantageous as they are devoid of lactate. The primary aim of the study was to assess the effect of use of an acetated solution or Ringer's lactate (RL) as intraoperative fluid on lactate levels in patients without hepatic dysfunction undergoing prolonged surgeries. Material and Methods: This was a prospective, randomized, controlled trial involving sixty patients belonging to American Society of Anesthesiologists Physical Status I to II undergoing major head and neck surgeries with free flap reconstruction. Patients were randomly allocated into two equal groups, Group sterofundin (SF) and Group RL. Group SF was started on acetate-based crystalloid solution (sterofundin B Braun®) and Group RL received RL intravenously at the rate of 10 ml/kg/h to maintain systolic blood pressure above 90 mmHg. Blood loss >20% was replaced with packed cells. Arterial blood gas analysis was done 2nd hourly till 8 h. Chi-square test was used to compare categorical variables. Independent sample t-test was used to compare means. Results: Intraoperative lactate levels were significantly high in RL group at 2, 4, 6, and 8 h. The pH was comparable between groups except at 8 h where RL group had a significantly lower pH than SF group (7.42 ± 0.1 vs. 7.4 ± 0.1). Sodium, potassium, chloride, bicarbonate, and pCO2did not show any significant difference between the groups. Conclusion: Use of acetate-based intravenous solutions reduced levels of lactate in comparison with RL in patients undergoing free flap reconstructive surgeries.
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Effect of the addition of rocuronium to 2% lignocaine in peribulbar block for cataract surgery p. 520
Vishalakshi Patil, Allauddin Farooqy, Balaraju Thayappa Chaluvadi, Vinayak Rajashekhar, Ashwini Malshetty
DOI:10.4103/joacp.JOACP_383_16  
Background and Aims: Peribulbar anesthesia is associated with delayed orbital akinesia compared with retrobulbar anesthesia. To test the hypothesis that rocuronium added to a mixture of local anesthetics (LAs) could improve speed of onset of akinesia in peribulbar block (PB), we designed this study. This study examined the effects of adding rocuronium 5 mg to 2% lignocaine with adrenaline to note orbital and eyelid akinesia in patients undergoing cataract surgery. Material and Methods: In a prospective, randomized, double-blind study, 100 patients were equally randomized to receive a mixture of 0.5 ml normal saline, 6 ml lidocaine 2% with adrenaline and hyaluronidase 50 IU/ml (Group I), a mixture of rocuronium 0.5 ml (5 mg), 6 ml lidocaine 2% with adrenaline and hyaluronidase 50 IU/ml (Group II). Orbital akinesia was assessed on a 0–8 score (0 = no movement, 8 = normal) at 2 min intervals for 10 min. Time to adequate anesthesia was also recorded. Results are presented as mean ± standard deviation. Results: Rocuronium group demonstrated significantly better akinesia scores than control group at 2 min intervals post-PB (significant P value obtained). No significant complications were recorded. Rocuronium added to a mixture of LA improved the quality of akinesia in PB and reduced the need for supplementary injections. Conclusion: The addition of rocuronium 5 mg to a mixture of lidocaine 2% with adrenaline and hyaluronidase 50 IU/ml shortened the onset time of peribulbar anesthesia in patients undergoing cataract surgery without causing adverse effects.
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A prospective randomized study comparing recovery following anesthesia with a combination of intravenous dexmedetomidine and desflurane or sevoflurane in spinal surgeries p. 524
Yogita Patil, Suyog Bagade, Nilesh Patil, Nalini Jadhav
DOI:10.4103/joacp.JOACP_61_16  
Background and Aims: Desflurane and sevoflurane are inhalational anesthetics which provide stable intraoperative hemodynamics and rapid emergence from anesthesia. Dexmedetomidine is an α2-agonist with sedative and hypnotic effects. We compared recovery following anesthesia with a combination of a continuous intravenous infusion of dexmedetomidine and desflurane or sevoflurane in cases of spine surgeries because no such data are available from India. Material and Methods: It was a single-blind, prospective, randomized study. After institutional ethics committee approval, patients were randomly allocated to one of the two groups of fifty patients each. Group D received desflurane and Group S received sevoflurane, along with dexmedetomidine 0.5 μg/kg/h IV infusion for maintenance of anesthesia. Results and Conclusions: Extubation time (ET) in Group D was shorter by 4.2 min than in Group S (10.1 ± 2.2 and 14.2 ± 1.3; P = 0.004). Postoperative recovery, postoperative analgesic, and antiemetic requirement between the groups were comparable The mean dial setting required to maintain the minimum alveolar concentration of 1 intraoperatively was 3.1 for desflurane and 0.7 for sevoflurane.
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Evaluation of effect of entropy monitoring on isoflurane consumption and recovery from anesthesia p. 529
Kush Ashokkumar Goyal, Anitha Nileshwar, Lokvendra Singh Budania, Yogesh Gaude, Shaji Mathew, Shriram Vaidya
DOI:10.4103/0970-9185.222523  
Background and Aims: Entropy monitoring entails measurement of the effect of anesthetic on its target organ rather than merely the concentration of anesthetic in the brain (indicated by alveolar concentration based on which minimum alveolar concentration [MAC] is displayed). We proposed this prospective randomised study to evaluate the effect of entropy monitoring on isoflurane consumption and anesthesia recovery period. Material and Methods: Sixty patients undergoing total abdominal hysterectomy under general anesthesia using an endotracheal tube were enrolled in either clinical practice (CP) or entropy (E) group. In group CP, isoflurane was titrated as per clinical parameters and MAC values, while in Group E, it was titrated to entropy values between 40 and 60. Data including demographics, vital parameters, alveolar isoflurane concentration, MAC values, entropy values, and recovery profile were recorded in both groups. Results: Demographic data and duration of surgery were comparable. Time to eye opening on command and time to extubation (mean ± standard deviation) were significantly shorter, in Group E (6.6 ± 3.66 and 7.27 ± 4.059 min) as compared to Group CP (9.77 ± 5.88 and 11.63 ± 6.90 min), respectively. Mean isoflurane consumption (ml/h) was 10.81 ± 2.08 in Group E and 11.45 ± 2.24 in Group CP and was not significantly different between the groups. Time to readiness to recovery room discharge and postanesthesia recovery scores were also same in both groups. Conclusion: Use of entropy monitoring does not change the amount of isoflurane consumed during maintenance of anesthesia or result in clinically significant faster recovery.
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A study of the efficacy of stellate ganglion blocks in complex regional pain syndromes of the upper body p. 534
Rashmi Datta, Jyotsna Agrawal, Amit Sharma, Vikram Singh Rathore, Shivesh Datta
DOI:10.4103/joacp.JOACP_326_16  
Background and Aims: The effect of stellate ganglion blocks (SGBs) was examined in complex regional pain syndromes (CRPS) of the upper body. Material and Methods: A total of 287 SGB were given to patients with documented CRPS on medications. Spontaneous and provoked pain assessment was done with numeric pain rating scale (NPRS). The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and range of motion (ROM) was recorded before and after each blockade. Difference between a 15-point “global rating of change” scale determined the minimal clinically important difference of the DASH score. Results: The overall mean pain reduction was 73.2% (r = 0.83, P < 0.001) considering spontaneous and 55.8% (r = 0.77, P < 0.001) on provoked pain. Mean DASH score decreased from 53 (range 36–63; P = 0.14) to 10.4 (range 10–49.2; P = 0.005). The sensitivity to change was 6.9 for spontaneous and 4.9 for provoked pain. Increase in ipsilateral limb temperature has a good correlation with Horner's syndrome (HS) and sympathetic blockade. Minor, self-limiting complications, such as hoarseness, dysphagia, local hematoma, and ipsilateral brachial plexus block occurred in 11.5%. A rare complication of contralateral HS was documented. One patient developed a small pneumothorax, but it did not require intervention. Conclusions: SGB are relatively safe and effective management in patients with neuropathic conditions already on pharmacotherapy. Serial blocks attained an average reduction in pain by >3 NPRS points from the baseline for both spontaneous and provoked pain with a decrease in mean DASH score and improvement in ROM.
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CASE REPORTS Top

Aortic dissection masquerading as a bicuspid aortic valve Highly accessed article p. 541
Harendra Arora, Priya Ajit Kumar
DOI:10.4103/0970-9185.168160  
A 37-year-old male presented to the Emergency Department with acute worsening of back pain and new onset dyspnea. Transthoracic echocardiography revealed moderate left ventricular dysfunction and a bicuspid aortic valve (BAV). In addition, he was noted to have a dilated thoracic aorta concerning for a dissection, severe aortic insufficiency (AI), and both a pericardial and pleural effusion. Magnetic resonance imaging revealed a Type A ascending aortic dissection. He was taken emergently to the operating room for repair. An intraoperative transesophageal echocardiography examination was performed which revealed a normal trileaflet AV with a Type A aortic dissection flap masquerading as a BAV. The dissection flap interfered with both the valve's function, causing severe AI, as well as the valve's appearance, causing it to look bicuspid on echocardiography.
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Perioperative use of transthoracic echocardiography in a patient with congenitally corrected transposition of great arteries, atrial septal defect and severe pulmonary stenosis for lower segment cesarean section Highly accessed article p. 544
Vikas Saini, Tanvir Samra, Gurpreet Kaur
DOI:10.4103/0970-9185.173342  
A 25-year-old female with congenitally corrected transposition of great arteries (CCTGAs), atrial septal defect, and severe pulmonary stenosis underwent lower segment cesarean section at 34 weeks of gestation using combined spinal epidural anesthesia (CSEA). We used transthoracic echocardiography (TTE) for intraoperative monitoring of the cardiovascular system because these patients are reported to have a high prevalence of myocardial perfusion defects, regional wall motion abnormalities, and impaired ventricular contractility. Scanning was done at four different time intervals; preoperatively, after initiation of CSEA, after delivery of child and postoperatively (6 and 24 h postdelivery) to detect regional wall motion and valvular abnormalities, calculate ejection fractions and optimize fluid administration. In this case report, we thus discuss the anatomical defects of CCTGA, physiologic concerns and emphasize on the use of TTE for perioperative management of such cases.
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LETTERS TO EDITOR Top

Anesthetic management of a patient with Takotsubo cardiomyopathy presenting for surgical clipping of intracranial aneurysm p. 547
Nilima Rahael Muthachen, Manikandan Sethuraman
DOI:10.4103/joacp.JOACP_17_16  
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Administration of Syntocinon by anesthetists at the time of uterine evacuation in early pregnancy p. 549
Anne Elad Babarinsa, Isaac Akinbolu Babarinsa
DOI:10.4103/0970-9185.222513  
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Vitamin D resistant rickets: What an anesthesiologist should know p. 550
Priyanka Pradeep Karnik, Nandini Malay Dave, Madhu Garasia
DOI:10.4103/joacp.JOACP_124_16  
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Use of the Magill forceps as an aid for i-gel® removal after endotracheal intubation: A safe and simple technique Highly accessed article p. 551
Julian Arevalo Ludena, Luis Enrique Muñoz Alameda
DOI:10.4103/0970-9185.168162  
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Awake fiber-optic intubation: “Stop and Think” before you act! p. 552
Manoj Bhardwaj, Shagun Bhatia Shah, Ajay Kumar Bhargava
DOI:10.4103/joacp.JOACP_100_17  
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Tramadol-induced hypoglycemia: An unusual adverse effect p. 554
Subramanian Senthilkumaran, Chidambaram Ananth, Ritesh G Menezes, Ponniah Thirumalaikolundusubramanian
DOI:10.4103/0970-9185.222512  
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Desaturation due to dislodgement of inflation line from SACETT™ — Suction Above the Cuff Endotracheal Tube p. 555
Kanil Ranjith Kumar, Rahul Kumar Anand, Hem Kumar, Mahesh Kumar Arora
DOI:10.4103/0970-9185.222518  
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Intravenous dezocine for suppressing fentanyl-induced cough during general anesthesia induction: A potentially effective and clinically feasible method p. 556
Aria Soleimani, Farshad Hasanzadeh Kiabi, Mohammad Reza Habibi, Amir Emami Zeydi, Abdolghader Assarroudi, Hassan Sharifi
DOI:10.4103/0970-9185.222514  
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Rigid bronchoscopic stenting in a patient of tracheobronchial gout - perioperative anesthetic concerns p. 558
Vinod Kumar, Rakesh Garg, Nishkarsh Gupta, Sachidanand Jee Bharati
DOI:10.4103/0970-9185.222517  
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Cannot intubate situation arising out of difficult mouth opening due to jaw thrust Highly accessed article p. 559
Rajnish Kumar, Nitin Kumar, Gunjan Kumar
DOI:10.4103/0970-9185.173398  
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Fiberoptic-guided intubation after awake insertion of the I-gel™ supraglottic device in a patient with predicted difficult airway Highly accessed article p. 560
Julian Arevalo Ludena, Jose Juan Arcas Bellas, Rafael Alvarez-Rementeria, Luis Enrique Munoz
DOI:10.4103/0970-9185.173388  
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Breath-holding in Vitamin D deficiency rickets: A dilemma for the anesthetist Highly accessed article p. 562
Madhu Rao, Deviprasad Shetty, Kush Ashokkumar Goyal, Lokvendra Singh Budania
DOI:10.4103/0970-9185.173387  
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Subarachnoid space needle's eyelet in dural-arachnoid side-wall of lumbar cistern: Whitacre vs. Quincke Highly accessed article p. 563
Deepak Gupta
DOI:10.4103/0970-9185.173361  
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