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   Table of Contents - Current issue
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July-September 2018
Volume 34 | Issue 3
Page Nos. 287-427

Online since Thursday, October 11, 2018

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EDITORIAL  

Surgical safety checklist: Is all good? Highly accessed article p. 287
Nidhi Bhatia, Kajal Jain
DOI:10.4103/joacp.JOACP_303_18  PMID:30386007
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REVIEW ARTICLES Top

Coagulopathy during liver transplantation p. 289
Ayten Saracoglu, Kemal T Saracoglu
DOI:10.4103/joacp.JOACP_390_16  PMID:30386008
In this review article, we aimed to mainly review the principles for the management of hemostasis, changes that occur in the hemostatic system, and the techniques to reduce hemorrhage during liver transplantation. Hemostasis is a defense mechanism that may ensue from vascular damage and hemorrhage and consists of multiple phases which involve cellular and humoral elements of coagulation. In the presence of a cause, such as trauma-induced liver injury or hepatic failure that may trigger coagulopathy, the process becomes more problematic, and moreover, severe coagulation disorders may arise in daily practice unless the situation is intervened correctly and on time. During liver transplantation, the implementation of transfusion and coagulation management algorithms based on the point of care tests may reduce blood loss and transfusion requirement. Moreover, antifibrinolytic therapy and a low central venous pressure with restrictive fluid administration reduce bleeding.
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Preoperative pulmonary evaluation for lung resection Highly accessed article p. 296
Preety Mittal Roy
DOI:10.4103/joacp.JOACP_89_17  PMID:30386009
Preoperative assessment is a very crucial step in anesthesia management. Anatomical resection (lobectomy or pneumonectomy) offers best long-term prognosis to a lung cancer patient. At the same time, surgery cannot be offered to a patient who is expected to become ventilator dependent, postoperatively. Hence, it is very important to have an objective preoperative assessment for risk stratification. This review article provides a systematic approach for the prognostication of patients planned for pulmonary resection.
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ORIGINAL ARTICLES Top

Effect of sodium bicarbonate infusion in off-pump coronary artery bypass grafting in patients with renal dysfunction p. 301
Muralidhar Kanchi, Rudresh Manjunath, Jos Maessen, Lloyd Vincent, Kumar Belani
DOI:10.4103/joacp.JOACP_75_18  PMID:30386010
Background and Aims: Acute kidney injury (AKI) following cardiac surgery is a major complication resulting in increased morbidity, mortality and economic burden. This study was designed to determine the benefit of sodium bicarbonate (NaHCO3) supplementation in patients with stable chronic kidney disease (CKD) undergoing off-pump coronary artery bypass grafting (OP-CABG). Material and Methods: We prospectively studied 60 non-dialysis CKD patients with glomerular filtration rate (GFR) ≤60 ml/min/1.73 m2 requiring elective OP-CABG. They were randomly allocatted to one of the two groups. One group received NaHCO3 infusion at 0.5 mmol/kg first hour followed by 0.2 mmol/kg/h till the end of surgery and the other group received 0.9% NaCl. A third group of 30 patients without renal dysfunction undergoing OP-CABG was included. The serum creatinine was estimated prior to surgery, immediately after surgery and on postoperative days 1, 2, 3 and 4. Results: Ten patients (33.3%) in NaCl and 6 (20%) patients each in NaHCO3 and normal groups developed Stage-1 AKI. None of our study patient required renal replacement therapy and no mortality was observed in any of the groups during the perioperative and hospitalization period. Conclusion: Perioperative infusion of NaHCO3 in OP-CABG reduced the incidence of Stage-1 AKI by about 40% when compared to NaCl. The incidence of Stage-I AKI in NaHCO3 group was similar to that in patients with normal renal function undergoing OP-CABG. A larger group of patients may be required to suggest a significance of renal protective benefit of NaHCO3 in patients undergoing OP-CABG.
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Effect of remifentanil on the recovery profile after head and neck surgeries: A prospective study p. 307
Thangavelautham Suhitharan, Sudhakar Subramani, Ma Thin Mar Win, Widyawaty Binte Sulaiman, Nurain Binte Johar, Ong Biauw Chi
DOI:10.4103/joacp.JOACP_337_16  PMID:30386011
Background and Aims: Development of opioid tolerance in the perioperative period due to remifentanil remains controversial. We evaluated occurrence of opioid tolerance and other adverse effects due to remifentanil in patients undergoing head and neck surgery. Material and Methods: We recruited adult participants with ASA status I to III who received general anesthesia for approximately 2 h for elective head and neck procedures. Remifentanil infusion was used in one group and intermittent boluses of morphine or fentanyl were administered in another group. Postoperative pain was treated with intermittent boluses of morphine and fentanyl in post-anaesthesia care unit (PACU) to achieve a numerical rating scale score of 3. Opioid requirement was assessed as an indicator of opioid tolerance. Patients were also evaluated for time to discharge from PACU. Results: We studied 222 adults aged between 21 and 80 years. One hundred and eleven patients received a combination of remifentanil infusion and morphine boluses, and another 111 patients received only fentanyl and/or morphine boluses intraoperatively. Fifty-one patients in the remifentanil group and 25 in the fentanyl/morphine group required opioids in the PACU. Opioid requirement were significantly more (mean ± SD, 44.98 ± 59.7 Vs 20.23 ± 46.66 mcg.kg−1; P = 0.001) and required longer time to discharge from PACU in the remifentanil group compared to the fentanyl/morphine group (Mean ± SD, 88.6 ± 39.5 min Vs 73.1 ± 38.4 min; P < 0.001). No difference in the incidence of adverse effects in two groups was noted. Conclusion: At clinically relevant doses, intraoperative remifentanil infusion appears to increase opioid consumption in the immediate postoperative period. This can result in delayed discharge from PACU for patients undergoing elective head and neck procedures.
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Ceftriaxone concentration at the surgical site following systemic and isolated upper limb injection p. 314
Pankaj Kundra, Balaji Vaithilingam, Stalin Vinayagam, Chandrasekaran Adithan, Sandeep Nema
DOI:10.4103/joacp.JOACP_28_18  PMID:30386012
Background and Aims: This study was conducted to find out the equipotent dose of isolated upper limb injection of ceftriaxone in the upper limb (IUL) surgeries under tourniquet that would attain a peak bone marrow concentration (Cmax) similar to systemic (ST) 1 g injection. Material and Methods: Patients were allocated into two groups – ST and IUL. ST group (n = 5) received 1 g of ceftriaxone 20 min before tourniquet inflation, and IUL group received calculated dose (n = 5 in each dosage, i.e., 200, 100, 75, and 50 mg) diluted in 50 mL of normal saline distally after tourniquet inflation. Venous and bone marrow samples were collected at various time intervals intra- and post-operatively. Ceftriaxone concentration was analyzed by high-performance liquid chromatography. Results: There was no significant difference between Cmax following ST 1 g injection and IUL injection with 75 mg (155.8 ± 2.1 vs 158.5 ± 3.1 μg/mL, respectively; P = 0.1). There was significant difference in area under curve (AUC) and t½ between ST 1 g injection and IUL injection with 75 mg of ceftriaxone (AUC 1285 ± 67 vs 784.4 ± 28 μg/mL/h, respectively; P < 0.001), (t½ 5.2 ± 0.5 vs 4.7 ± 0.3 h, respectively; P < 0.001). None of the patients in the ST and IUL groups had post-operative infection up to a period of 1 week duration. Conclusion: IUL injection with 75 mg of ceftriaxone can be equipotent and as effective as ST 1 g injection in upper limb orthopedic surgeries under tourniquet.
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Intraoperative pectoral nerve block (Pec) for breast cancer surgery: A randomized controlled trial p. 318
Mary Thomas, Frenny A Philip, Arun P Mathew, KM Jagathnath Krishna
DOI:10.4103/joacp.JOACP_191_17  PMID:30386013
Background and Aims: In centers with high turnover of breast surgeries, pectoral nerve block (Pec II) is time-consuming and requires ultrasound familiarity for administration. We decided to block the same nerves under vision after resection to evaluate postoperative analgesic effects. Material and Methods: Sixty patients scheduled for modified radical mastectomy were enrolled in this prospective, randomized, placebo-controlled, triple-blinded study. All patients received standardized general anesthesia. After surgical resection, infiltration of either ropivacaine (Group A) or saline (Group B) was given under vision at two points: 20 ml in the fascia over serratus anterior and 10 ml in the fascia between pectoralis major and minor at the level of the third rib. The primary outcomes measured were the time to first request for analgesia after extubation and total dose of analgesics needed, and secondary outcome included pain scores using the Numerical Rating Scale over 24 h. Analgesics used postoperatively were fentanyl citrate and paracetamol. We used Student's t-test to analyze quantity of analgesics needed, the nonparametric Mann–Whitney U-test for time to first request of analgesic, and Fisher's exact test for pain scores. Results: No patient in Group A required fentanyl. The mean time to first request for analgesia and mean dose of paracetamol required was 353.93 ± 135.03 min and 2.71 ± 0.462.71 g in Group A and 27.17 ± 18.08 min and 3.53 ± 1.074 g in Group B [P = 0.002]. Significantly more patients in Group A had mild pain scores compared to Group B. Conclusion: Pec II block with ropivacaine delivered under vision reduced analgesic requirement and pain scores significantly.
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Comparison of postoperative analgesic effect of caudal bupivacaine with and without ketamine in Pediatric subumbilical surgeries p. 324
Sharon P Aliena, Chacko Lini, John J Chirayath
DOI:10.4103/joacp.JOACP_60_17  PMID:30386014
Background and Aims: Management and assessment of postoperative pain in children is often a tough task as they cannot effectively communicate their discomfort. Caudal block is an excellent means of providing postoperative analgesia. In this study, we compared the postoperative analgesic effect of bupivacaine with and without ketamine when given caudally in children undergoing subumbilical surgeries. Material and Methods: Fifty-eight American Society of Anesthesiologists grades I and II children of either gender undergoing subumbilical surgeries were randomly allocated into two groups B and BK of 29 each. Group B received 0.75 ml/kg 0.25% bupivacaine and Group BK received 0.75 ml/kg 0.25% bupivacaine plus ketamine 0.5 mg/kg. A standardized anesthetic protocol was used. The duration of postoperative analgesia, motor block, sedation score, and hemodynamic parameters were assessed. Statistical analysis was performed using Mann–Whitney U test, independent-samples t-test, and Chi-square test. Results: The hemodynamic parameters and motor block were comparable between the groups. Duration of analgesia was prolonged in Group BK compared to Group B 11.3 ± 2.2, vs. 7.0 ± 2.3 hours, p < 0.001. However, sedation score was found to be higher in BK group compared to B Group (P < 0.001). Conclusion: Ketamine as an adjuvant to bupivacaine in caudal block is associated with a significant prolongation of postoperative analgesia.
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Analgesic effect of adding magnesium sulfate to epidural levobupivacaine in patients with pre-eclampsia undergoing elective cesarean section p. 328
Reem Abdelraouf Elsharkawy, Tamer Elmetwally Farahat, Mohamed Sayed Abdelhafez
DOI:10.4103/joacp.JOACP_1_18  PMID:30386015
Background and Aims: Magnesium is a physiological antagonist of NMDA receptor and a calcium channel blocker. This study was designed to test the analgesic effect of magnesium sulfate (MgSO4) when added to epidural anesthesia in mild pre-eclampsia. Material and Methods: Sixty parturients with mild pre-eclampsia were allocated randomly to two equal groups. The Placebo group received 20 ml levobupivacaine hydrochloride 0.5% plus 5 ml isotonic saline 0.9% using two separate syringes. The Magnesium group received the same amount of local anesthetic plus 5 ml of 10% MgSO4 (500 mg) using two separate syringes. The primary outcome was pain free period. While, the secondary outcomes were the onset of motor block and the time needed to achieve complete motor block. The analgesic profile was evaluated by visual analog scale (VAS) during rest or motion, the time to first request for analgesia, and the total analgesic consumption. Results: The pain-free period was significantly longer in the Magnesium group (311.3 ± 21.4) compared to placebo group (153.1 ± 22.18). The total postoperative consumption of fentanyl was significantly lower in the Magnesium group (42.4 ± 5.3) than that in the placebo group (94.4 ± 9.9), with a P value 0. 01. Both the onset time of motor block and the time needed to achieve complete motor block were significantly shorter among the Magnesium group (4.4 ± 1.4 and 8.2 ± 0.4, respectively), with a P value of 0. 01. Conclusion: The addition of 500 mg MgSO4 to epidural anesthesia fastens both sensory and motor blockade and improves postoperative analgesic profile.
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Propofol sparing effect of dexmedetomidine and magnesium sulfate during BIS targeted anesthesia: A prospective, randomized, placebo controlled trial p. 335
Chiteshwar Walia, Ruchi Gupta, Manjot Kaur, Lakshmi Mahajan, Gaganjot Kaur, Bhanupreet Kaur
DOI:10.4103/joacp.JOACP_297_17  PMID:30386016
Background and Aims: Maintenance of adequate depth of anesthetic is crucial to prevent awareness and to reduce stress response associated with surgery. Goals of balanced general anesthetic are met by use of adjuvants to facilitate use of lower anesthetic dose, while ensuring adequate anesthetic depth. This study employed BIS monitoring to compare the anesthetic sparing effects of intravenous dexmedetomidine and magnesium sulphate on induction dose of propofol by maintaining a BIS value of 40-50. Material and Methods: One hundred and twenty ASA I and II patients undergoing elective surgery under general anesthetic were included in three groups of forty each. Group D received 1 μg/kg of dexmedetomidine, Group M was given 30 mg/kg of magnesium sulphate in 100 ml saline and Group N received 100 ml saline over 15-20 minutes 15 minutes before induction. Data compared were dose of propofol and vecuronium, Ramsay sedation score, BIS values and hemodynamic parameters intraoperatively. Results: Propofol required in group D was significantly lower 101.3 ± 16.5 than group M and N with dose of 114 ± 15.5 and 160.50 ± 25.08 respectively (p <0.001). Dose requirement of vecuronium was significantly reduced in group M 5.4 ± 0.8 and group D 6.6 ± 1.2 as compared to N 7.9 ± 1.4 (p <0.001). No significant differences were seen regarding baseline hemodynamics, RSS and BIS values in all groups. After study drug infusion, RSS was 4.59 ± 0.75 in dexmedetomidine group compared to 1.9 ± 0.7 and 1.4 ± 0.5 in group M and N (p <0.001). During maintenance, significantly lower HR, MAP and BIS values were seen in group D and M than N (p <0.001). Conclusion: Our study showed that pretreatment with dexmedetomidine and magnesium sulphate significantly reduced the induction dose of propofol by maintaining a constant BIS in value at 40-50. However, both the drugs reduced the time to reach BIS 40-50 but sedation and sparing of propofol was more in dexmedetomidine group.
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Effect of dexmedetomidine on intracranial pressures during laparoscopic surgery: A randomized, placebo-controlled trial p. 341
Nishant Sahay, Umesh K Bhadani, Subhajit Guha, Alok Himanshu, Chandni Sinha, Mamta Bara, Anubha Sahay, Alok Ranjan, Prashant Singh
DOI:10.4103/joacp.JOACP_171_17  PMID:30386017
Background and Aims: Laparoscopic surgeries cause an increase in intracranial pressure (ICP) after creation of pneumoperitoneum. Sonographically measured, optic nerve sheath diameter (ONSD) correlates well with changes in ICP. Dexmedetomidine (Dex), an α2 agonist is extensively used in day-care surgeries, although its effect on ICP during laparoscopy in humans has not been reported in the literature. The aim of this study was to note the effect of dexmedetomidine infusion on changes in ICPs during laparoscopic cholecystectomy. Material and Methods: This was a prospective, randomized, placebo-controlled, double-blind study done on 60 patients scheduled for laparoscopic cholecystectomy. The study drug, dexmedetomidine hydrochloride (Dex) or placebo saline infusion, was started 10 min before induction and continued till extubation. Changes in ICP were assessed sonographically at baseline before pneumoperitoneum, 5 min after establishing pneumoperitoneum, 10 min after positioning the patient 20° head up, and 5 min after desufflation. Results: Demographically, both groups were comparable. The ONSD showed a significant increase after pneumoperitoneum in both groups (P = 0.0001 and 0.0011). Dex group could marginally attenuate this increase (P = 0.075). After changing patient's position to reverse Trendelenburg, ONSD increased further in both groups. Dex group could significantly attenuate the increase (P = 0.001). The ONSD did not return to baseline values till after 5 min of release of pneumoperitoneum in both groups. Conclusion: Dexmedetomidine is effective in attenuating increase in ICP associated with laparoscopic surgeries. The benefit was marked 10 min after placing patient in the reverse Trendelenburg position during laparoscopic cholecystectomy.
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Comparative evaluation of ropivacaine and levobupivacaine for postoperative analgesia after ultrasound-guided paravertebral block in patients undergoing percutaneous nephrolithotomy p. 347
Richa Saroa, Sanjeev Palta, Siddharath Puri, Ravinder Kaur, Vidur Bhalla, Atin Goel
DOI:10.4103/joacp.JOACP_187_17  PMID:30386018
Background and Aims: Percutaneous nephrolithotomy (PCNL), although a minimally invasive procedure, is associated with substantial postoperative pain that is often underestimated. The present study was undertaken to ascertain the relative analgesic efficacy of levobupivacaine (LB) and ropivacaine (RB) when administered in ultrasound-guided paravertebral block (PVB) in patients scheduled to undergo PCNL. Material and Methods: After obtaining the Institutional Ethics Committee approval and written informed consent, 30 patients aged between 18 and 65 years of either sex, with American Society of Anesthesiologist status I/II and body mass index >18.5 to <25, scheduled to undergo PCNL were enrolled for the study. The patients were randomized to receive single shot of 20 ml of either ropivacaine (0.2%) or levobupivacaine (0.2%) in ultrasound-guided PVB using an in-plane technique. Results: The demographic and the preoperative hemodynamic and respiratory parameters were comparable in both the groups. The postoperative hemodynamic variables, respiratory parameters, and pain scores were also comparable in both the groups. Although the time to first analgesic requirement was more in LB group (1.60 ± 3.64 h) as compared to RB group (0.33 ± 1.04 h), it was statistically nonsignificant. No complications attributable to either the procedure or usage of drugs were noted in any group during the entire postoperative period. Conclusions: We conclude that single-shot ultrasound-guided ipsilateral PVB at the end of the surgical procedure provides adequate and effective analgesia in the postoperative period with either of the local anesthetic. Use of ultrasound provides real-time imaging of the anatomical structures and avoids potential complications of the block.
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Comparison of prophylactic use of ketamine, tramadol, and dexmedetomidine for prevention of shivering after spinal anesthesia p. 352
Nihar Ameta, Mathews Jacob, Shahbaz Hasnain, Gaurishankar Ramesh
DOI:10.4103/joacp.JOACP_211_16  PMID:30386019
Background and Aims: Shivering after spinal anesthesia is a common complication and can occur in as many as 40%–70% of patients after regional anesthesia. This shivering, apart from its physiological and hemodynamic effects, has been described as even worse than surgical pain. The aim of the study was to evaluate and compare the effectiveness of prophylactic use of intravenous (IV) ketamine, dexmedetomidine, and tramadol for prevention of shivering after spinal anesthesia. Material and Methods: Two hundred American Society of Anesthesiologists physical status I and II patients subjected to spinal anesthesia were included in the study. The subjects were randomly divided into four groups to receive either ketamine 0.5 mg/kg IV or tramadol 0.5 mg/kg IV or dexmedetomidine 0.5 microgm/kg IV or 10 mL of 0.9% normal saline (NS). All the drugs/NS were administered as IV infusion over 10 min immediately before giving spinal anesthesia. Temperature (core and surface), heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure, peripheral oxygen saturation were assessed before giving the intrathecal injection and thereafter at 5 min intervals. Important side effects related to study drugs were also noted. Results: Shivering after spinal anesthesia was comparatively better controlled in group receiving dexmedetomidine as compared to other groups (P = 0.022). However, the use of dexmedetomidine was associated with significant hypotension which responded to single dose of mephentermine (3 mg IV). Dexmedetomidine is a better agent for prevention of shivering after spinal anesthesia as compared to ketamine and tramadol. It also provides adequate sedation and improves the surgical conditions. Conclusion: Dexmedetomidine is effective and comparably better than tramadol or ketamine in preventing shivering after spinal anesthesia. Dexmedetomidine also provides sedation without respiratory depression and favorable surgical conditions. However, with its use a fall in blood pressure and heart rate is anticipated.
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Effects of dexmedetomidine as an adjuvant to ropivacaine in ultrasound-guided supraclavicular brachial plexus Block: A prospective, randomized, double-blind study Highly accessed article p. 357
Vandana Mangal, Tuhin Mistry, Gaurav Sharma, Md Kazim, Neelmani Ahuja, Amit Kulshrestha
DOI:10.4103/joacp.JOACP_182_17  PMID:30386020
Background and Aims: Various adjuvants have been added to local anesthetics in single shot blocks so as to prolong the duration of postoperative analgesia. The present study was conceived to evaluate the effect of dexmedetomidine as an adjuvant to ropivacaine for institution of supraclavicular brachial plexus block. Material and Methods: Ninety adult patients (ASA physical status I, II) scheduled for elective upper limb surgeries under ultrasound-guided subclavian perivascular brachial plexus block were allocated randomly into two groups; the study was designed in double-blind fashion. All patients received 20 ml 0.75% ropivacaine, in addition, patients in group A (n = 43) received 2 ml 0.9% normal saline and those in group B (n = 44) received dexmedetomidine (1 μg/kg body weight); total volume was made up to 22 ml with sterile 0.9% saline in both groups. The onset and duration of sensory and motor blocks, time to first request of analgesia, total dose of postoperative analgesic administration, and level of sedation were also studied in both the groups. All the data were analyzed by using unpaired t-test. P < 0.05 was considered significant. Results: Sensory and motor block durations (613.34 ± 165.404 min and 572.7 ± 145.709 min) were longer in group B than those in group A (543.7 ± 112.089 min and 503.26 ± 123.628 min; P < 0.01). Duration of analgesia was shorter in group A (593.19 ± 114.44 min) compared to group B (704.8 ± 178.414 min; P < 0.001). Conclusion: Addition of dexmedetomidine to 0.75% ropivacaine in supraclavicular brachial plexus block significantly prolongs the duration of analgesia.
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An observational study to evaluate the effect of different epidural analgesia regimens on dynamic pain scores in patients receiving epidural analgesia for postoperative pain relief after elective gynecological surgery p. 362
Manpreet Singh, Ranju Singh, Aruna Jain
DOI:10.4103/joacp.JOACP_57_18  PMID:30386021
Background and Aims: The primary measure of efficacy of any analgesic regimen is pain relief, but it is important to measure dynamic pain relief rather than pain relief at rest. Epidural analgesia is an effective technique for postoperative analgesia. The drug combinations given therein (local anesthetics with adjuvants such as opioids/alpha-2 agonists), however, remain a personal choice. The aim of this study was to evaluate dynamic pain scores in patients receiving different epidural analgesia regimens for postoperative pain relief after elective gynecological surgery used in our institution. Material and Methods: One hundred eighty-seven patients enrolled in this study received postoperatively either bupivacaine 0.125% + morphine 0.1 mg/mL (group BM) or bupivacaine 0.125% + fentanyl 2 μg/mL (group BF) or bupivacaine 0.125% + clonidine 1 μg/mL (group C1) or bupivacaine 0.125% + clonidine 2 μg/mL (group C2) by continuous epidural infusion @ 5 mL/h. Differences in dynamic pain scores (on coughing and mobilization), pain scores at rest, sensory and motor blockade, sedation scores, dry mouth, pruritus, nausea, and vomiting were recorded. Also duration of postoperative analgesia, epidural top-ups, requirement of rescue analgesic, and patient satisfaction were determined. All observations were carried out at 1, 2, 4, 8, and 12 h after surgery and then at 8 am, 12 noon, 4 pm, 8 pm on subsequent postoperative day till removal of epidural catheter (after 96 h). Results: There was no difference in demographic or hemodynamic profile among the four groups (P > 0.05). There was no statistically significant difference in pain scores at rest among the four groups but dynamic pain scores were found to be better in group C2 as compared to group BM, BF, and C1 at most of the time intervals although not statistically significant (P > 0.05). Requirement of rescue analgesics was lower in group BM and group C2 as compared to group BF and C1 (P < 0.01). Incidence of pruritus was 43.5% in group BM and 19% in group BF, while no patients in group C1 or C2 had pruritus. Mean postoperative nausea and vomiting (PONV) scores were higher in group BM and group BF as compared to group C1 and C2 (P < 0.001). Mean sedation scores were comparable in all four groups. Incidence of dry mouth was 22% in group C2 as compared to 11% in group C1, while no patients in group BM or BF had dry mouth. Patients in group C2 were more satisfied as compared to other three groups. Conclusions: Combination of clonidine 2 μg/mL to 0.125% bupivacaine @ 5 mL/h in combined spinal epidural provides better postoperative analgesia as compared to combination of bupivacaine with opioids with greater patient satisfaction and significantly reduced side effects.
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Transmuscular quadratus lumborum versus lumbar plexus block for total hip arthroplasty: A retrospective propensity score matched cohort study p. 372
Sanjib D Adhikary, Anthony J Short, Kariem El-Boghdadly, Mena J Abdelmalak, Ki Jinn Chin
DOI:10.4103/joacp.JOACP_335_17  PMID:30386022
Background and Aims: Cadaveric studies have shown that injectate from transmuscular quadratus lumborum block (QLB) can spread to the lumbar plexus. Our aim was to compare analgesic efficacy of transmuscular QLB with lumbar plexus block (LPB) for patients undergoing total hip arthroplasty (THA). Material and Methods: Thirty patients receiving transmuscular QLB were propensity score matched with 30 patients receiving LPB for age, sex, ASA score, BMI, operative time, preoperative oxycodone, and intraoperative opioid use. The primary outcome was postoperative opioid consumption during the first 24 postoperative hours. Secondary outcomes included static pain scores at 0–12, 12–24, and 24–48 h intervals, opioid consumption at 0–12, 12–24, and 24–48 h intervals and the length of hospital stay. The incidence of severe adverse events was also compared. Results: Opioid consumption (median [IQR]) in the first 24 h was similar between the transmuscular QLB and LPB patient groups—33.6 mg (22.9–48.5) versus 32.8 mg (24.8–58.3) intravenous morphine equivalents. There was no difference between groups in static pain scores or opioid consumption during any time interval up to 48 h postoperatively. Length of hospital stay (median [IQR]) was similar between the transmuscular QLB and LPB groups—55.6 h (53.7–60.3) versus 57.9 h (54.3–79.1). Conclusions: This study suggests that transmuscular QLB provides similar analgesia to LPB following THA. Prospective studies are needed to confirm this.
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COMMENTARY Top

Total hip arthroplasty and peripheral nerve blocks: Limited but salient role? p. 379
Asha Tyagi, Rashmi Salhotra
DOI:10.4103/joacp.JOACP_114_18  PMID:30386023
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ORIGINAL ARTICLES Top

Ease of intubation and hemodynamic responses to nasotracheal intubation using C-MAC videolaryngoscope with D blade: A comparison with use of traditional Macintosh laryngoscope p. 381
Sunil Rajan, Dilesh Kadapamannil, Kaushik Barua, Pulak Tosh, Jerry Paul, Lakshmi Kumar
DOI:10.4103/joacp.JOACP_296_17  PMID:30386024
Background and Aims: Nasal intubation with traditional Macintosh laryngoscope usually needs the use of Magill's forceps or external laryngeal manipulation. The primary objective of this study was to assess the ease of intubation during C-MAC videolaryngoscope-assisted nasal intubation using D blade and to compare it with traditional Macintosh laryngoscope-aided nasal intubation. The secondary objectives were comparison of intubation time, attempts, trauma, and hemodynamic stress responses. Material and Methods: Sixty patients requiring nasal intubation were randomized into two groups, M and V. Patients in both the groups received general anesthesia as per a standardized protocol. Laryngoscopy was performed using the traditional Macintosh laryngoscope in group M and with Storz® C-Mac videolaryngoscope with D-blade in group V. Chi-square test, Mann–Whitney test, and independent samples t-test were used as applicable for data analysis. Results: Intubation was significantly easy in 70% of the patients in group V compared to only 3.3% in group M. Time to intubate was significantly shorter in group V (24 vs 68 s). Though majority of patients were intubated in the first attempt in both groups, the number was more in group V (96.7 vs 70%). There was no case of esophageal intubation in group V, but 2 patients (6.7%) had esophageal intubation in group M. Mucosal trauma was significantly more frequent in group M. There was no statistically significant difference in hemodynamics in both groups. Conclusion: C MAC videolaryngoscope-aided nasotracheal intubation using D blade is superior in view of easier, quicker, and less traumatic intubation compared to the use of traditional Macintosh laryngoscope.
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Effect of air, anesthetic gas mixture, saline, or 2% lignocaine used for tracheal tube cuff inflation on coughing and laryngotracheal morbidity after tracheal extubation p. 386
Lokvendra S Budania, Vamsidhar Chamala, Madhu Rao, Samarth Virmani, Kush A Goyal, Kanika Nanda
DOI:10.4103/joacp.JOACP_237_17  PMID:30386025
Background and Aims: Coughing and sore throat postoperatively are common clinical problems during general anesthesia which can be avoided by various methods including topicalization of airway with local anesthetics, endotracheal tube cuff (ETT) inflation with local anesthetics, use of intravenous drugs such as dexamethasone, maintaining ETT cuff pressure, intubation by an experienced anethesiologist, etc. The aims of the study were to compare postextubation coughing response, mean number of cuff deflations required intraoperatively, and postoperative airway morbidity in terms of sore throat (2 h and 18–24 h), hoarseness of voice, and dysphagia following inflation of ETT cuff with air, anesthetic gas mixture, saline, and 2% lignocaine during general anesthesia. Material and Methods: One hundred and four patients were randomized into 1 of 4 groups depending on whether air, anesthetic gas mixture, saline, or 2% lignocaine was used to inflate the cuff of ETT using computer-generated randomization table. Results: There was no significant difference in the postextubation cough response among the four groups. The mean number of times the ETT cuff was deflated was significantly in favor of liquid media comapred to gaseous media (P < 0.001). The incidence of sore throat at 2 h and at 18–24 h, hoarseness of voice, and dysphagia were comparable in all groups. Conclusion: ETT cuff inflation with air, anesthetic gas mixture, 2% lignocaine, and saline are comparable in terms of incidence of postextubation cough and postoperative airway morbidity symptoms such as sore throat, hoarseness of voice, and dysphagia.
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The World Health Organization Surgical Safety Checklist: An audit of quality of implementation at a tertiary care high volume cancer institution p. 392
Reshma Ambulkar, Priya Ranganathan, Kirti Salunke, Sukhada Savarkar
DOI:10.4103/joacp.JOACP_328_17  PMID:30386026
Background and Aims: In 2007, the World Health Organization (WHO) implemented the Surgical Safety Checklist (SSC), which has enhanced the communication between the surgical team members, improved outcomes, decreased complications, and improved patient safety. However, for the checklist to be effective, proper implementation and compliance with the checklist are imperative. The aim of this study was to evaluate the quality of implementation of the WHO SSC during elective surgery at a tertiary referral cancer hospital in India. Material and Methods: In this prospective observational study, a trained research nurse passively observed the implementation of selected items from the modified version of the WHO SSC during elective surgeries and evaluated the compliance with the checklist, percentage of items for which the use of the SSC prompted an action, and level of interaction between the key team players during the conduct of the checklist. Results: We studied 200 surgeries for each part of the SSC. Compliance was 200 (100%), 156 (78%), and 153 (76.5%) for the first, second, and third part of the SSC, respectively. All the three parts were mostly initiated by surgeons [197 (98.5%), 92 (59%), and 136 (88.9%), respectively]. Overall, 131/2200 (5.95%) items in the checklist were carried out only after being prompted during the conduct of the checklist. The interaction between all three representatives was found in only 265/509 (52%) cases. Conclusion: The quality of implementation of the SSC was found to be suboptimal, with a definite scope for improvement. Compliance with all items on the checklist and active participation by all team members are crucial for successful implementation of the checklist.
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LETTERS TO EDITOR Top

Cerebral venous thrombosis following spinal anesthesia p. 399
VK Parashar, Pavan Gupta
DOI:10.4103/joacp.JOACP_274_15  PMID:30386027
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Local anesthetic systemic toxicity after endovenous laser therapy p. 401
Thomas R Hickey, Michael Casimir, Natalie F Holt
DOI:10.4103/joacp.JOACP_113_17  PMID:30386028
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Meeting the challenges in HIV patients undergoing robotic oncosurgery p. 402
SB Shah, M Bhardwaj, AK Bhargava, A Kansal
DOI:10.4103/joacp.JOACP_111_17  PMID:30386029
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Kounis syndrome in anesthesia: The coronary arteries as the primary target of anaphylaxis p. 404
Nicholas G Kounis, Ioanna Koniari, Emmanouil Chourdakis, Anastasios Roumeliotis, George Hahalis
DOI:10.4103/joacp.JOACP_217_17  PMID:30386030
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Early postoperative carbamazepine-induced tetany in a patient with trigeminal neuralgia p. 405
Shalendra Singh, Hirok Roy, Gyaninder Pal Singh, Ankur Khandelwal
DOI:10.4103/joacp.JOACP_245_17  PMID:30386031
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Persistent left superior vena cava: What an anesthesiologist needs to know? p. 407
Keerthi P Nandakumar, Souvik Maitra
DOI:10.4103/joacp.JOACP_301_17  PMID:30386032
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Institution of cardiopulmonary bypass in an awake patient for resection of tracheal tumor causing near total luminal obstruction p. 409
Prachi Kar, Amaresh Rao Malempati, Padmaja Durga, Ramachandran Gopinath
DOI:10.4103/joacp.JOACP_352_15  PMID:30386033
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A stitch in time saves life: Massive tumor embolism p. 411
Divya Jain, Komal Gandhi, Seran Reddy, Vasavi Gattupalli, Ravi Mohan
DOI:10.4103/joacp.JOACP_377_16  PMID:30386034
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Epiglottic cyst in von Hippel-Lindau syndrome: Shared pathology or a separate entity? p. 413
Karen Ruby Lionel, Appavoo Arulvelan, Sethuraman Manikandan
DOI:10.4103/joacp.JOACP_360_15  PMID:30386035
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Intra-operative accidental extubation- An unexpected complication of the flexo-metallic tube p. 414
Suma M Thampi, Susan Thomas, Ekta Rai
DOI:10.4103/joacp.JOACP_86_16  PMID:30386036
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Fiberoptic-guided retromolar intubation in an infant with intraoral tumor p. 416
Divya Jain, Tanvir Samra, Pranshuta Sabarwal, Sachin Rai
DOI:10.4103/joacp.JOACP_119_17  PMID:30386037
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An incidental finding of endotracheal tube obstruction at the level where inflation line enters into the tube p. 417
Arvind Kumar, Sangeeta Khanna, Yatin Mehta
DOI:10.4103/joacp.JOACP_207_15  PMID:30386038
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Cervical rib and the risk for undiagnosed thoracic outlet syndrome p. 419
Omar Viswanath, Allan F Simpao, Gerald P Rosen
DOI:10.4103/joacp.JOACP_395_17  PMID:30386039
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Ultrasonography and Seldinger's technique: Using the best of both worlds for difficult radial artery cannulation! p. 420
Rashmi Ramachandran, Sulagna Bhattacharjee, Snehitha Marada, Vimi Rewari
DOI:10.4103/joacp.JOACP_15_18  PMID:30386040
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Gas analyzer aberrancy: Due to disinfectant? p. 421
Barkha Bindu, Hemanshu Prabhakar, Siddharth Chavali
DOI:10.4103/joacp.JOACP_157_17  PMID:30386041
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Subarachnoid hemorrhage in a patient following systemic absorption of phenylephrine eye drops p. 423
Manjula V Ramsali, Ranjan Kumar, PG Koshy, V Sarada Devi
DOI:10.4103/joacp.JOACP_282_17  PMID:30386042
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A recommendation for cost-effective preparation of phenylephrine p. 424
Pradeep Bhatia, Rakesh Kumar, Ankur Sharma, Swati Chhabra, Sadik Mohammed
DOI:10.4103/joacp.JOACP_119_18  PMID:30386043
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BOOK REVIEW Top

“Manual of ICU procedures” edited by Mohan Gurjar p. 426
Nidhi Bhatia
DOI:10.4103/joacp.JOACP_187_18  
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ERRATUM Top

Erratum: Hydroxyeyhyl starch: Controversies revisited p. 427

DOI:10.4103/0970-9185.243181  PMID:30386044
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