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April-June 2017
Volume 33 | Issue 2
Page Nos. 145-283

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EDITORIAL  

Violence against the medical profession p. 145
Mukul Chandra Kapoor
DOI:10.4103/joacp.JOACP_102_17  
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Thoracic epidural block in sepsis: Looking beyond the known p. 148
Asha Tyagi
DOI:10.4103/joacp.JOACP_121_17  
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REVIEW ARTICLES Top

Emerging roles of liposomal bupivacaine in anesthesia practice p. 151
Obaid Malik, Alan D Kaye, Aaron Kaye, Kumar Belani, Richard D Urman
DOI:10.4103/joacp.JOACP_375_15  
Despite advances in drug technology and improvements in technology, including peripheral nerve catheters and ultrasound, postoperative pain is still a significant problem in the clinical setting worldwide. Postoperative pain can have a critical negative impact with regard to physiological consequences to the body and therefore, the role of liposomal bupivacaine as an extended release bupivacaine with approximately 72 h of duration may have far-reaching and significant impact in clinical practice. Liposomal bupivacaine has a DepoFoam multivesicular liposome technology with particle suspension in an isotonic aqueous solution and consists of tiny lipid-based particles, which contain discrete water-filled chambers dispersed through a lipid matrix. Other advantages include a reduction in opioid consumption, while not requiring a catheter or any other device, as well as easy dilution with saline. This review summarizes current research with this novel agent in postsurgical pain, and discusses potential roles in chronic pain states. Further studies are warranted for its use in epidural and intrathecal administration. Moreover, this review will explore the expansion of liposomal bupivacaine's current clinical role.
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Newer drug delivery systems in anesthesia p. 157
Sona Dave, Deepa Shriyan, Pinakin Gujjar
DOI:10.4103/joacp.JOACP_63_16  
A paradigm shift in drug delivery systems have been noted recently.The focus nowadays is to obtain maximum benefit with lower side effects.It is a monetary burden to launch newer molecules hence the industry is concentrating on improving the efficacy of existing molecules. Thus controlled release, target controlled infusion and closed loop infusion have entered the scene. Applying pharmacokinetic principles, instead of mathematically calculating drug dose could improve safety and maintain steady drug levels in the body. When computers are applied to an efficient operating system, it will only magnify the efficiency. Most of these technologies which were earlier limited to research only have entered clinical practice. This has made it mandatory for the practicing clinician to familiarize themselves with these technologies. Our focus in this review has been to discuss newer drug delivery systems available for anesthesiology practice.
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ORIGINAL ARTICLES Top

A prospective observational study of the use of desflurane anesthesia in Indian adult inpatients undergoing surgery: The Registry in India on Suprane Emergence registry p. 164
Mukul Chandra Kapoor, M Radhakrishnan, VJ Ramesh, HS Murthy, Dhirja Sharma, Parameswara Gundappa, Tanmoy Das, Ravi Wankhede, K Bhaskaran, Saiket Sengupta, Rajendrasingh Patil, Sibasish Dey, Kuljinder Singh, Ashok K Moharana
DOI:10.4103/joacp.JOACP_350_16  
Background and Aims: Limited registry studies are available on the use of anesthetic agents. This registry was conducted to evaluate emergence outcomes in Indian adult patients undergoing surgery with desflurane anesthesia. Material and Methods: This multicenter, prospective, non-interventional, observational study (Registry in India on Suprane Emergence [RISE] registry) included adult inpatients who received desflurane as general anesthetic for surgical procedure of ≥2 h. Patients were stratified by age into three groups: ≥18–40 years, ≥41–65 years, and >65 years. Data on patients' demographics, practice, and usage pattern of medications were collected. The primary efficacy outcomes were time to extubation, time to response to verbal command, and time to orientation. Results: Of 236 patients screened, 201 (≥18–40 years, n = 70; ≥41–65 years, n = 65; >65 years, n = 66) were enrolled in the study. Mean time to extubation observed in ≥18–40 years group was 7.2 ± 4.1 min, ≥41–65 years was 11.6 ± 8.99 min, and >65 years was 12.0 ± 10.5 min. Mean time to response to verbal command was 7.4 ± 4.3 min for ≥18–40 years, 10.9 ± 8.5 min for ≥41–65 years, and 10.0 ± 5.4 min for >65 years. Mean time to orientation was 13.0 ± 7.0 min for ≥18–40 years, 16.1 ± 12.0 min for ≥41–65 years, and 17.0 ± 8.6 min for >65 years. Incidence of nausea and retching/vomiting was observed in 8% of patients each in the postoperative period, and these complications were seen more in the >65 years age group. Overall, desflurane treatment maintained hemodynamic stability and no major airway events were reported. Conclusions: The RISE registry data suggest that desflurane-based anesthesia provides early recovery with stable hemodynamics without any airway adverse events, in a wide variety of surgical procedures.
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The effect of esmolol compared to opioids on postoperative nausea and vomiting, postanesthesia care unit discharge time, and analgesia in noncardiac surgery: A meta-analysis p. 172
Venkatesan Thiruvenkatarajan, Richard Watts, Marni Calvert, Graeme Newcombe, Roelof Markus Van Wijk
DOI:10.4103/0970-9185.209747  
Background and Aims: Perioperative esmolol as an opioid alternative has been shown to reduce postoperative nausea vomiting using opioid sparing. The aim of this meta-analysis was to compare esmolol and opioids on postoperative nausea and vomiting (PONV), time spent in recovery, and analgesia in noncardiac surgeries. Material and Methods: OVID Medline (1980–February 2014), OVID EMBASE, EBSCO, CINAHL, and the Cochrane Register of Controlled Trials were searched for randomized controlled trials (RCTs) comparing esmolol and opioids on early postoperative recovery and pain intensity during general anesthesia in noncardiac surgeries. The primary outcomes were related to PONV and postanesthesia care unit (PACU) discharge time, whereas secondary outcomes were related to early postoperative pain. Results: Eight trials were identified involving 439 patients, 228 of whom received esmolol while 211 received opioids. A random-effects meta-analysis showed that in comparison with opioids, esmolol led to a 69% reduction in the incidence of PONV (odds ratio 0.31, 95% confidence interval [CI] 0.13–0.74, P = 0.008, I2 = 44.1%). An increase in the volatile anesthetic requirement was evident in the esmolol group compared with opioid (MD + 0.67% desflurane equivalent, 95% CI 0.27–1.08, P = 0.001, I2 =23.5%). There was no statistically significant difference between the esmolol and opioid groups in relation to PACU discharge time, early postoperative pain scores, opioid requirement, and cumulative opioid consumption. Significant heterogeneity was noted between studies. No significant adverse effects were noted. Conclusion: Compared with opioids, perioperative esmolol may reduce the incidence of postoperative nausea vomiting and increase the volatile anesthetic requirement. Esmolol administration may not improve the early postoperaive pain intensity. Nonetheless, these findings are limited by the absence of high-quality RCTs and the heterogeneity among studies. Further, large-scale studies are needed to explore these results.
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Deep vein thrombosis in medical and surgical Intensive Care Unit patients in a Tertiary Care Centre in North India: Incidence and risk factors p. 181
Ashish Kumar, Yatin Mehta, Tariq Ali, Mukesh Kumar Gupta, Joby V George
DOI:10.4103/0970-9185.209760  
Background and Aims: Deep venous thrombosis (DVT) prophylaxis is underutilized, and there is a paucity of data reflecting the incidence of DVT in Indian Intensive Care Unit (ICU) population. We sought to evaluate the incidence and risk factors for DVT in medical and surgical ICU patients with DVT prophylaxis. Material and Methods: The ICU patients more than 18 years old, expected to be in the ICU for more than 48 h were enrolled and DVT prophylaxis were given as per risk and were observed for clinical signs of DVT along with duplex ultrasound until in ICU. The patients receiving anticoagulant for some other reasons were excluded along with those with pregnancy, congenital coagulation disorders and terminal illness. Results: The incidence of DVT was 0.8% (95% confidence interval: 0.78-0.81) in mixed populations (1.6% in medical and 0.5% in surgical). The higher DVT score (DVT (+) 10.75 ± 2.06/DVT (−) 8.75 ± 1.7 P = 0. 0264), Acute physiology and chronic health evaluation (APACHE) IV score (DVT positive patient - DVT (+) 59.25 ± 15.06/DVT negative patients - DVT (−) 44.01 ± 13.74) P = 0. 0292), length of ICU stay ([DVT (+) 26.75 ± 12.87 days/DVT (−) 5.19 ± 6.18] P < 0.010), and inotropes (DVT (+) 50%/DVT (−) 12.3% P = 0. 023) were associated with DVT. Conclusion: The incidence of DVT was 0.8% with prophylaxis. High DVT and APACHE IV score were associated with DVT. Prolonged ICU stay and vasopressors were the risk factors.
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Feasibility of dexmedetomidine as sole analgesic agent during robotic urological surgery: A pilot study p. 187
Bright Jebaraj, Rashmi Ramachandran, Vimi Rewari, Anjan Trikha, Chandralekha , Rajeev Kumar, Prem Nath Dogra
DOI:10.4103/0970-9185.209753  
Background and Aims: Opioid-free anesthesia decreases postoperative nausea and vomiting, emergence agitation, prolonged sedation, ileus, and urinary retention. The feasibility of the use of dexmedetomidine as sole analgesic agent has been shown in patients undergoing bariatric and gynecological laparoscopic surgery. We explored its use for robotic urological surgery. Material and Methods: Thirty patients were randomized to receive either dexmedetomidine (Group D) or fentanyl (Group F) along with total intravenous anesthesia with propofol. The hemodynamic parameters and number of doses of rescue analgesics used intraoperatively and postoperatively were noted. Recovery parameters at the end of surgery were also recorded. Results: The dose of intraoperative rescue fentanyl was not significantly different between groups (P = 0.13). The hemodynamic profile of patients in the two groups was comparable except the heart rate was significantly more in Group D after intubation and at 60 min. The mean arterial pressure was significantly lower after the initial loading dose of study drug in Group D. The recovery profiles were not significantly different between groups. Conclusion: The study reveals that dexmedetomidine has equal analgesic efficacy as fentanyl for intraoperative use and can be used as the sole analgesic agent in patients undergoing robotic urological surgery.
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Effectiveness of transtracheal lidocaine as an adjunct to general anesthesia in providing patient immobility during total parotidectomy: A comparison with dexmedetomidine infusion p. 193
Sunil Rajan, Vineesh Arora, Pulak Tosh, Prasanth Mohan, Lakshmi Kumar
DOI:10.4103/0970-9185.209752  
Backgroud and Aims: Dexmedetomidine and propofol infusions are increasingly being used to ensure intraoperative patient immobility in the absence of muscle relaxants during parotidectomy. The primary aim of our study was to assess the effectiveness of transtracheal block as an adjunct to general anesthesia in providing patient immobility during total parotidectomy, as compared to dexmedetomidine infusion. Material and Methods: This prospective, randomized study was conducted in 58 patients. Group A patients received a transtracheal injection of 4 ml of 4% lidocaine before induction whereas in Group B, dexmedetomidine 1 mcg/kg was administered intravenously. Following induction and intubation, anesthesia was maintained with oxygen, nitrous oxide, and isoflurane and dexmedetomidine was administered in Group B at a rate of 0.7 mcg/kg/h. In both the groups, if the patient moved, bucked, or if there were signs of inadequate depth of anesthesia, plane of anesthesia was deepened with a bolus of propofol 0.5 mg/kg intravenously. Mann–Whitney U-test and Fisher's exact test were used for statistical analysis. Results: The number of patients who moved in the transtracheal group was significantly less as compared to dexmedetomidine group (3 vs. 11). Mean heart rates (HRs) were comparable in both groups till 10 min, but between 15 and 180 min, Group B had significantly low HR. Systolic blood pressure (SBP) was significantly high at 10 min following dexmedetomidine bolus in Group B. Though Group B showed low SBP values as compared to Group A from 10 min following induction, the difference became significant between 45 and 180 min. Changes in mean arterial blood pressures followed a similar trend as with SBP. Conclusion: Transtracheal lidocaine ensured patient immobility with hemodynamic stability during total parotidectomy with nerve stimulation studies as compared to intraoperative dexmedetomidine infusion.
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Evaluation of clonidine as an adjuvant to brachial plexus block and its comparison with tramadol p. 197
Prakash Kelika, Jamkar Maya Arun
DOI:10.4103/joacp.JOACP_58_13  
Background and Aims: It has been reported that clonidine when used as an additive in a dose of 90 μg in adults increases the duration of peripheral nerve blocks. Hence, this study was conducted to evaluate the effect of clonidine in brachial plexus blocks and to compare it with tramadol. Material and Methods: Ninety patients posted for upper limb orthopedic surgery were divided randomly into three groups. 40 mL of local anesthetic solution was prepared using 15 mL of 2% lignocaine-adrenaline-sodium bicarbonate solution, 15 mL of 0.5% bupivacaine, and 10 mL distilled water. Patients received a supraclavicular brachial plexus block with 0.7 mL/kg of this solution to which either 1 mg/kg tramadol, 1 μg/kg clonidine, or 1.5 μg/kg clonidine was added. The onset and duration of sensory and motor block and the duration of postoperative analgesia were recorded. Pulse rate, blood pressure, respiratory rate, saturation, sedation, and any side effect were monitored. Results were statistically analyzed using analysis of variance F-test and unpaired t-test. Results: There was a statistically significant difference in the onset of both the sensory and motor components of the block with the fastest onset seen when clonidine was used in a dose of 1.5 μg/kg. The block also lasted statistically significantly longer with clonidine as compared with tramadol although there was no statistically significant increase in the duration of the block when a higher dose of clonidine was used. The time for rescue analgesia was the longest in patients who received 1.5 μg/kg of clonidine (491.8 ± 33.9 min). This duration was also statistically significant. Patients who received tramadol reported a statistically significant higher incidence of nausea. Conclusion: Clonidine in a dose of 1.5 μg/kg body weight provided the fastest onset of sensory as well as motor block and the longest duration of postoperative analgesia and thus is a good additive to local anesthetic solutions for brachial plexus blocks.
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Intravenous dexmedetomidine as an adjunct to subarachnoid block: A simple effective method of better perioperative efficacy p. 203
Rekha Kumari, Anil Kumar, Sushil Kumar, Rakesh Singh
DOI:10.4103/joacp.JOACP_367_15  
Background and Aim: Dexmedetomidine (D) is a α2 agonist, has anesthetic and analgesic-sparing property. The objective of this study was to evaluate the effect of intravenous (I.V.) dexmedetomidine on the duration of sensory and motor block, postoperative analgesia, the level of sedation and side effect. Material and Methods: Sixty patients were randomly divided into two groups of thirty each. Group D received dexmedetomidine infusion @1 mcg/kg over 10 min and then @ 0.6 mcg/kg/h for rest of duration during surgery, Group C (control) received a similar volume of normal saline infusion before spinal anesthesia with 3 ml of bupivacaine 0.5%. Time of onset and regression time for sensory and motor blockade, the maximum upper level of sensory blockade, duration of postoperative analgesia, Ramsay sedation score and hemodynamic parameters were recorded. Intraoperative bradycardia and atropine requirement along with other side effect were also recorded. Results: The duration of sensorimotor block was significantly longer in D Group (341.7 ± 20.8 min for sensory block and 278.0 ± 11.0 min for motor block) as compared to control group (329.5 ± 22.1 min for sensory block and 250.0 ± 14.8 min for motor block), which was statistically significant (P < 0.05). The mean time for two dermatomal regression of sensory blockade was significantly prolonged in dexmedetomidine group (115.5 ± 8.7 min) compared to control group (95.8 ± 11.4) (P < 0.001). Intraoperative Ramsay sedation scores were significantly higher in D Group (mean - 3.4 ± 0.7, range – 2–4) as compared to C Group (mean - 2.9 ± 0.3, range – 2–4) (P < 0.001). 26.7% (8/30) cases had bradycardia that required atropine as compared to control group (2/30), and none of the patients in the dexmedetomidine group had postoperative shivering as compared to 10% in control group (P = 0.056). Statistical analysis was performed with statistical package for the social science version-20 using analysis of variance/Chi-square test/unpaired t-test, and P < 0.05 was considered statistically significant. Conclusion: I.V. dexmedetomidine significantly prolongs the duration of sensory and motor block of bupivacaine spinal anesthesia. Dexmedetomidine provides an excellent sedation during surgery.
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The efficacy of local dexmedetomidine during fiberoptic nasotracheal intubation: A randomized clinical trial p. 209
Alireza Mirkheshti, Elham Memary, Behzad Nemati Honar, Amirmohsen Jalaeefar, Parisa Sezari
DOI:10.4103/joacp.JOACP_242_16  
Background and Aims: The present study was designed and carried out aiming to evaluate the effects of local dexmedetomidine (Dex) on sedation rate and hemodynamic changes in candidate patients for fiberoptic nasotracheal intubation. Material and Methods: Candidate patients for fiberoptic nasotracheal intubation were randomly divided into three groups including intravenous (IV) Dex group, local Dex group, and control group. Local anesthesia using lidocaine was performed in all patients. After performing the intubation, propofol infusion was used to keep the patients on predetermined cerebral state index (CSI). Hemodynamic parameters, arterial blood O2saturation (SpO2), and CSI were monitored in all patients before, during, and after the procedure. Coughing score, intubation score, and patient tolerance score during and after nasotracheal intubation were assessed. Propofol consumption was also measured. Results: A total of 95 patients with the mean age of 45.4 ± 6.7 years were evaluated (54.2% of females). Hemodynamic parameters and SpO2were significantly different between the three groups (P < 0.001). The dose of propofol used for reaching proper CSI was significantly higher in the control group compared to IV and local Dex groups (P < 0.001). There is no significant statistical difference in propofol consumption between local and IV Dex groups. The number of patients who were cooperative during intubation was higher in local Dex group compared to IV Dex and control groups; however, the difference was not statistically significant. Conclusion: It is likely that using local Dex during fiberoptic bronchoscopy decreases sudden changes in hemodynamic values and decreases coughing and improves patient tolerance and intubation scores. Local Dex can be useful as IV form with the aim of propofol dose saving.
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Effects of propofol or sevoflurane anesthesia induction on hemodynamics in patients undergoing fiberoptic intubation for cervical spine surgery: A randomized, controlled, clinical trial p. 215
Chiara Robba, Ega Qeva, Beatrice Borsellino, Simone Aloisio, Giulia Tosti, Federico Bilotta
DOI:10.4103/0970-9185.209733  
Background and Aims: In patients undergoing surgery for cervical myelopathy, induction of general anesthesia can induce systemic arterial hypotension that may worsen spinal cord hypoperfusion and precipitate spinal injury. In this randomized, controlled, clinical trial study, we compared the hemodynamic changes related to anesthesia induction with intravenous (IV) propofol- and sevoflurane-based inhalational induction in patients undergoing fiberoptic intubation for cervical spine surgery. Material and Methods: A total of 72 patients were studied. Hemodynamic effects were assessed measuring mean arterial pressure (MAP), and the echocardiographic evaluation of the left ventricular function. A Student's t-test with Bonferroni correction or Chi-squared test was used, when appropriate, to assess differences in hemodynamic (extent of MAP drop and incidence of episodes of severe arterial hypotension) and other variables (occurrence and duration of episodes of apnea). Results: Patients assigned to total IV anesthetic approach had a lower MAP, and more significant changes in cardiac function compared to those who received the inhalational approach (68.1 ± 9.3 mmHg vs. 75.5 ± 10.3 mmHg; 25% vs. 5.5%). Conclusion: Anesthesia induction with both propofol or sevoflurane is safe and effective. However, total IV anesthesia induction is associated with more pronounced MAP drop which can worsen spinal cord hypoperfusion.
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A comparative study of McGrath and Airtraq videolaryngoscopes for tracheal intubation p. 221
Nadeem Raza, Muazzam Hasan, Syed Moeid Ahmed, Shahjahan Bano, Manazir Athar
DOI:10.4103/joacp.JOACP_370_15  
Background and Aims: Many cases of difficult tracheal intubation remain unrecognized until after induction of anesthesia. McGrath and Airtraq videolaryngoscopes are among the novel laryngoscopes that have an advantage over the conventional laryngoscopes in case of unanticipated difficult airway. Thus, we did a comparative study between McGrath and Airtraq videolaryngoscopes to evaluate their efficacy in routine anesthesia practice. Material and Methods: Sixty anesthetized patients were divided into two groups using computer-based randomization, and tracheal intubation was performed using either McGrath or Airtraq laryngoscope. The primary outcome measures were duration and incidence of successful tracheal intubation. Hemodynamic response, glottic view (percentage of glottic opening score [POGO]), ease of intubation, and airway complications were also measured. Results: Both McGrath and Airtraq groups were comparable in terms of incidence of successful tracheal intubation (93.3% vs. 96.6%), ease of intubation (70% vs. 77%), and POGO scoring. Intubation time was significantly shorter with Airtraq (13.5 vs. 17.8 s; P < 0.001). There were statistically significant changes in the heart rate and blood pressure after tracheal intubation in both the groups (P < 0.001); however, these parameters reached baseline within 5 min of intubation in both the groups. The incidence of injury was 10% with McGrath videolaryngoscope and 13.3% with Airtraq and was comparable. Conclusion: Both Airtraq and McGrath videolaryngoscope have high success rates of intubation. Airtraq is better than McGrath laryngoscope due to shorter tracheal intubation time.
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Insertion of i-gel™ by the reversed technique improves the success rate and reduces the time taken for its placement: A prospective, randomized, controlled, interventional trial p. 226
Megha Sharda, Mukul Chandra Kapoor, Rakesh Atray, Swaraj Garg
DOI:10.4103/joacp.JOACP_395_16  
Background and Aims: We hypothesized that the i-gel™ supra-glottic airway can be inserted with relative ease in a reversed manner just like a Guedel's airway. Material and Methods: A prospective, randomized, controlled interventional trial was conducted on 100 patients to compare reversed insertion of the i-gel™ (Group R) with the conventional insertion (Group C). In Group C, i-gel™ was introduced in a conventional manner, whereas in the Group R, i-gel™ was introduced into the oral cavity with the concavity facing the hard palate. On reaching the oropharynx, the device was rotated 180° and advanced further until it fitted over the larynx. The time of insertion, ease, and placement appropriateness were compared. Results: All patients completed the study. Better success rate of the first attempt insertion was achieved using the reversed technique (96% vs. 86%), but it was not statistically significant. Mean time required for i-gel™ insertion in Group R was 17.5 ± 6.9 s as compared to 20.8 ± 5.9 s in Group C, which was statistically significant. In Group R, it could be inserted within 20 s in 84% of cases, but only in 62% in Group C. The seal of the i-gel™ was similar in both the groups with the leak volumes (inspired – expired tidal volumes) being similar. Conclusion: Reversed insertion technique for the placement of i-gel™ resulted in appropriate placement with easier insertion and lower placement time than that with the conventional technique.
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Ultrasound assessment of subglottic region for estimation of appropriate endotracheal tube size in pediatric anesthesia p. 231
Pughal Vendan Gnanaprakasam, Venkatesh Selvaraj
DOI:10.4103/joacp.JOACP_232_16  
Background and Aims: Endotracheal tube (ETT) selection in pediatric patients is mainly done with the age, height, or weight-based formula. We compared ultrasound assessment of the subglottic area to predict the outer diameter of the ETT, with that of modified Cole's formula. The aim of the study is to compare the appropriateness of uncuffed ETT selection based on modified Cole's formula with that of ultrasound assessment method of subglottic diameter in children undergoing surgical procedures under general anesthesia. Material and Methods: This is a prospective, randomized, parallel group study. One hundred and fifty American Society of Anesthesiologists I and II patients of age 2–6 years were randomly allotted into two groups: Group A - ETT selection based on ultrasound assessment of subglottic diameter. Group B - ETT selection based on modified Cole's formula. The study parameters are the internal diameter and external diameter (OD) of the predicted ETT by the two methods and that of the appropriate size ETT used. Results: The incidence of appropriate tube selection was 74.7% in the ultrasound based group while it was 45.3% in the modified Cole's formula group. There was a strong correlation between OD of the optimal ETT used and the ultrasound assessed subglottic diameter. Bland–Altman analysis of OD of appropriately sized ETT and subglottic diameter by ultrasound assessment has a bias of 0.02 mm with limits of agreement of +1.78 to −1.74. Conclusion: Ultrasonographic assessment of the subglottic diameter at the cricoid region is a better tool in predicting the appropriate size uncuffed ETT than modified Cole's formula.
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Comparison between intranasal dexmedetomidine and intranasal midazolam as premedication for brain magnetic resonance imaging in pediatric patients: A prospective randomized double blind trial p. 236
Ayushi Gupta, Naina Parag Dalvi, Bharati Anil Tendolkar
DOI:10.4103/joacp.JOACP_204_16  
Background and Aims: Preprocedural preparation of children scheduled for magnetic resonance imaging (MRI) is challenging. This prospective, randomized trial compared intranasal midazolam with intranasal dexmedetomidine as premedication for children scheduled for brain MRI. Material and Methods: In total, 60 children, aged 1–8 years, scheduled for elective brain MRI, were randomly assigned to the intranasal dexmedetomidine (1 μg/kg; Group D) or intranasal midazolam (0.2 mg/kg; Group M) group. We compared hemodynamic and respiratory parameters, onset, level, sedation quality, and successful parental separation. All patients received intravenous propofol as an induction and maintenance agent for MRI. Results: No significant differences were observed in demographic, hemodynamic, and respiratory parameters. Group D (14.3 ± 3.4 min [10–20 min]) had a longer time of sedation onset than Group M (8.7 ± 3.7 min [5–15 min]; P < 0.001). The median and mean sedation scores were lower in Group D (3 and 3.7 ± 0.8, respectively) than Group M (4 and 4.3 ± 1.2, respectively; P = 0.055). Group D (80%) had a higher percentage of children achieving satisfactory sedation at the time of induction than did Group M (53.3%; P = 0.0285). Parental separation was successful in 73.3% of patients in Group D compared with 46.7% of patients in Group M (P = 0.035). Conclusion: Intranasal dexmedetomidine results in more successful parental separation and yields a higher sedation level at the time of induction of anesthesia than intranasal midazolam as premedication, with negligible side effects. However, its onset of action is relatively prolonged.
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Comparative study of caudal clonidine and midazolam added to bupivacaine during infra-umbilical surgeries in children p. 241
Sadhana Sanwatsarkar, Sahil Kapur, Dipti Saxena, Gaurav Yadav, Nagina Naz Khan
DOI:10.4103/0970-9185.209739  
Background and Aims: Caudal analgesia is a good, reliable, and easy method to provide intraoperative and postoperative analgesia for infra-umbilical surgeries in children. Many additives are being used in combination with local anesthetics in caudal block to prolong the postoperative analgesia (clonidine, midazolam, ketamine, fentanyl, and dexmedetomidine). The purpose of this study was to compare the intraoperative hemodynamics, postoperative analgesia, postoperative rescue analgesic requirement, postoperative sedation and side-effects of clonidine and midazolam used as adjuvants to bupivacaine for caudal analgesia. Material and Methods: Following approval from Institutional Ethical Research Committee, 75 American Society of Anesthesiologists I and II patients aged between 1 and 7 years undergoing various elective infra-umbilical surgical procedures were included in this study. The patients were randomly allocated into three groups of 25 patients each. Group B received 1 ml/kg 0.25% bupivacaine in normal saline, Group BC received 1 ml/kg 0.25% bupivacaine + 1 μg/kg clonidine in normal saline, and Group BM received 1ml/kg 0.25% bupivacaine + 30 μg/kg midazolam in normal saline. The various parameters studied were intraoperative hemodynamic changes, duration of postoperative analgesia, postoperative sedation, postoperative analgesic requirement, and incidence of side-effects. Results: All the groups were similar with respect to patient and block characteristics. The hemodynamic parameters before and after administering caudal analgesia were also comparable. The mean duration of analgesia was 724.80 ± 60.29 min in Group BC, 605.40 ± 82.37 min in Group BM and 295.00 ± 41.78 min in Group B. Thus, the duration of analgesia was significantly prolonged in Group BC compared to Groups BM and B. The FLACC pain score was higher in Group B at the end of 4th, 8th and 12th h compared with Group BC and Group BM. Furthermore at the end of 12th h, pain scores were significantly higher in Group BM compared to Group BC. Only 1 child in Group BC received three rescue medications compared to 15 (60%) children in Group B and 7 (28%) children in Group BM. None of the groups were treated for bradycardia or hypotension and no significant sedation was noted. Conclusion: This study showed that the addition of both clonidine (1 μg/kg) and midazolam (30 μg/kg) with bupivacaine administered caudally significantly increase the duration of postoperative analgesia with minimal side-effects in children. The use of clonidine as an additive to bupivacaine in caudal epidural is a superior choice to midazolam as it reduces the demand of postoperative rescue analgesics significantly.
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Comparison of acute physiology and chronic health evaluation II (APACHE II) and acute physiology and chronic health evaluation IV (APACHE IV) severity of illness scoring systems, in a multidisciplinary ICU p. 248
Yeldho Eason Varghese, MS Kalaiselvan, MK Renuka, AS Arunkumar
DOI:10.4103/0970-9185.209741  
Background and Aims: Outcome prediction of critically ill patients is an integral part of care in an Intensive Care Unit (ICU). Acute Physiology and Chronic Health Evaluation (APACHE) scoring systems provide an objective means of mortality prediction in ICU. The aim of this study was to compare the performance of APACHE II and IV scoring system in our ICU. Material and Methods: All patients admitted to the ICU between January and June 2014 and who met the inclusion criteria were evaluated. APACHE II and IV score were calculated during the first 24 h of ICU stay based on the worst values. All patients were followed up till discharge from the hospital or death. Statistical analysis was performed using SPSS version 19.0. Discrimination of the model for mortality was assessed using receiver operating characteristic curve and calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. Results: Of a total 1268, 1003 patients were included in this study. The mean (±standard deviation) admission APACHE II score was 19.4 ± 8.9, and APACHE IV score was 59.1 ± 27.2. The APACHE scores were significantly higher among nonsurvivors than survivors (P < 0.001). The overall crude hospital mortality rate was 17.6%. APACHE IV had better discriminative power area under the ROC curve ([AUC] –0.82) than APACHE II (AUC-0.75). Both APACHE II and APACHE IV had poor calibration. Conclusions: APACHE IV showed better discrimination compared to APACHE II in our ICU population. Both APACHE II and APACHE IV had poor calibration. However, APACHE II calibrated better compared to APACHE IV.
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FORUM Top

Combining glidescope and fiber-optic for intubation in oral maxillofacial surgery p. 254
Pui-San Loh, Kevin Wei Shan Ng
DOI:10.4103/0970-9185.209738  
Airway management for patients with recent oral facial injuries is always a challenge for the anesthetist. We describe how the glidescope (GLS) and fiber-optic (FOB) can be effectively combined in three patients undergoing oral maxillofacial surgeries after sustaining multiple facial fractures from trauma to allow less traumatic intubation, an option to visualize on either monitor and faster intubating time (mean 1 min 14 s for our cases) compared to the use of either one alone. Although it allows for better visualization of the vocal cords, it requires 2 trained anaesthetists to perform and this would need to be considered when using this technique.
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CASE REPORT Top

Anesthetic management in a patient of autosomal dominant polycystic kidney disease with end stage renal disease undergoing endovascular coiling for multiple intracranial aneurysms p. 256
Ranadhir Mitra, Girija Prasad Rath, Surya Kumar Dube, Neha Hasija
DOI:10.4103/0970-9185.173318  
A 27-year-old woman of autosomal dominant polycystic kidney disease presented with multiple intracranial aneurysms at anterior communicating artery and left middle cerebral artery bifurcation. She was undergoing hemodialysis every alternate day and was waiting for a renal transplantation. Endovascular coiling of both these aneurysms was performed under general endotracheal anesthesia. During the procedure special precaution was taken with regard to intra-procedural fluid management and maintenance of cerebral perfusion pressure. The procedure remained uneventful during which a stable hemodynamics was maintained. In this report, the implication of intraprocedural fluid infusion by the neuroradiologist its possible influence on overall anesthetic management has been described.
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LETTERS TO EDITOR Top

Rendell Baker Soucek mask for ventilation in a postrhinoplasty patient: Our experience p. 259
Teena Bansal, Jatin Lal
DOI:10.4103/joacp.JOACP_315_16  
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Thoracic epidural analgesia for type B aortic dissection Highly accessed article p. 260
Andrea Bortolato, Carlo Ori, Ulderico Freo
DOI:10.4103/0970-9185.168197  
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Continuous bilateral quadratus lumborum block after abdominal surgery Highly accessed article p. 261
Manuel Ángel Gómez-Ríos, David Gómez-Ríos
DOI:10.4103/0970-9185.168163  
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Reducing propofol injection pain by pretreatment with tramadol and butorphanol: Are they safe? p. 262
Hassan Sharifi, Amir Emami Zeydi, Afshin Gholipour Baradari, Abbas Heydari
DOI:10.4103/joacp.JOACP_281_16  
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Malfunction of adjustable pressure limiting valve p. 264
Apoorv Upendra Chaturvedi, Meenoti Pramod Potdar
DOI:10.4103/joacp.JOACP_243_16  
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Dose of propofol for successful insertion of I-gel and laryngeal mask airway p. 265
Aanchal Kakkar, Asha Tyagi
DOI:10.4103/0970-9185.209746  
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Airway obstruction following cervical spine surgery: A diagnostic dilemma p. 266
Navdeep Sokhal, Arvind Chaturvedi, Girija Prasad Rath, Renu Bala
DOI:10.4103/joacp.JOACP_33_16  
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Integration of monitoring aids: A scientific approach for better patient outcome during hyperthermic intraperitoneal chemotherapy p. 268
Rakhi Gupta, Amit Kumar Mittal, Manish Choudhary
DOI:10.4103/0970-9185.209736  
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Vorapaxar: The missing link in antiplatelet therapy! p. 269
Abhijit S Nair
DOI:10.4103/joacp.JOACP_363_16  
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Perioperative management of patient on aspirin: Current view p. 270
Teena Bansal
DOI:10.4103/joacp.JOACP_186_16  
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Anesthetic management of a case of achalasia cardia with mega-esophagus causing intraoperative cardio-respiratory compromise Highly accessed article p. 271
Ravindra Kumar Pandey, Amar Pal Bhalla, Rakesh Garg, Meenu Batra
DOI:10.4103/0970-9185.168193  
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Preplacement check of complete central venous pressure catheter assembly: Should it be made routine? p. 273
Devalina Goswami, Anuradha Borle
DOI:10.4103/0970-9185.173376  
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Isolated lower lip edema: A rare complication of prone positioning p. 274
Gladdy George, Sheetal A Awhad, Suma Mary Thampi, Madhu Andrew Philip
DOI:10.4103/0970-9185.209749  
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Occurrence of Kounis syndrome under anesthesia p. 276
Sukhyanti Kerai, Lalit Sehrawat, Kirti Nath Saxena, Bharti Taneja
DOI:10.4103/0970-9185.209737  
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Radiofrequency ablation of bilateral splanchnic nerve in acute pancreatitis pain: Interventional approach p. 278
Deepak Thapa, Vanita Ahuja, Satinder Gombar, Nirupa Ramakumar, Christopher Dass
DOI:10.4103/0970-9185.173383  
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Use of desflurane in a multiple sclerosis patient undergoing ophthalmic surgery: Discussing the individualized care Highly accessed article p. 279
Komal Gandhi, Sameer Sethi
DOI:10.4103/0970-9185.168200  
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Late onset Pneumothorax following bronchoscopic foreign body removal p. 280
Raylene J Dias, Nandini M Dave, Vaishali P Chaskar, Madhu B Garasia
DOI:10.4103/0970-9185.173378  
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Is a minimum dose of atropine in children justified? p. 282
Smita Prakash, Parul Mullick
DOI:10.4103/0970-9185.209735  
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