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   Table of Contents - Current issue
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January-March 2018
Volume 34 | Issue 1
Page Nos. 1-141

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EDITORIAL  

Medical Council of India's amended qualifications for Indian medical teachers: Well intended, yet half-hearted Highly accessed article p. 1
Sunita V S Bandewar, Amita Aggarwal, Rajeev Kumar, Rakesh Aggarwal, Peush Sahni, Sanjay A Pai
DOI:10.4103/joacp.JOACP_69_18  
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Perioperative Communication: Challenges and Opportunities for Anesthesiologists Highly accessed article p. 5
Sudhakar Subramani, Shuchita Garg, Ajay P Singh, Ashish C Sinha
DOI:10.4103/joacp.JOACP_37_18  
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REVIEW ARTICLE Top

WHO safe surgery checklist: Barriers to universal acceptance Highly accessed article p. 7
Divya Jain, Ridhima Sharma, Seran Reddy
DOI:10.4103/joacp.JOACP_307_16  
Development of the Safe Surgery Checklist is an initiative taken by the World Health Organization (WHO) with an aim to reduce the complication rates during the surgical process. Despite gross reduction in the infection rate and morbidity following adoption of the checklist, many health-care providers are hesitant in implementing it in their everyday practice. In this article, we would like to highlight the hurdles in adoption of the WHO Surgical Checklist and measures that can be taken to overcome them.
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ORIGINAL ARTICLES Top

Labor analgesia in parturients of fetal growth restriction having raised umbilical Doppler vascular indices p. 11
Sukhen Samanta, Kajal Jain, Neerja Bhardwaj, Vanita Jain, Preet Mohinder Singh, Sujay Samanta, Veenu Singla, Rini Saha
DOI:10.4103/joacp.JOACP_150_16  
Background and Aims: Fetuses with abnormal umbilical blood flow are at a higher risk of adverse perinatal outcome than those with normal flow. Epidural analgesia (EA) has shown to decrease villous vascular resistance in preeclamptic women during labor. The present study evaluates the effects of epidural ropivacaine and intramuscular (IM) tramadol on Doppler blood flow in parturients with fetal growth restriction and raised umbilical artery (UmA) blood flow. Material and Methods: In this prospective nonrandomized comparative study, 36 term parturients with sonographic evidence of UmA systolic-diastolic (S-D) ratio ≥3 were enrolled. Parturients received either continuous epidural ropivacaine 0.2% or 1 mg/kg IM tramadol 4–6 hourly. Doppler flow parameters of UmA and bilateral uterine arteries (UtAs) were measured at 0, 1, and 6 h of labor analgesia. Doppler indices change with time during labor analgesia was assessed as the primary outcome. Change of Doppler indices of UtAs, Apgar score, and cord blood gases was considered as secondary measures. Results: Data from thirty laboring women who completed the study were analyzed. The pulsatility index, resistance index, and S-D ratio in UmA and right UtA reduced significantly with continuous epidural infusion during first 6 h of labor. However, these values increased or unchanged with tramadol administration. Better neonatal pH and base deficit (P = 0.039) were observed with EA. Conclusions: Continuous epidural ropivacaine causes improved fetoplacental circulation in parturients with growth-restricted fetuses having raised Doppler indices during labor analgesia. We also found better neonatal outcome with continuous infusion of epidural ropivacaine as compared to IM tramadol.
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Comparison of ropivacaine (0.2%) with or without clonidine 1 μg/kg for epidural labor analgesia: A randomized controlled study p. 18
Indira Kumari, Kapil Sharma, Vikram Bedi, Madhan Mohan, Hemraj Tungaria, Manish Kumar Modi
DOI:10.4103/joacp.JOACP_233_16  
Background and Aims: The aim is to determine the effect of addition of clonidine to ropivacaine for epidural labor analgesia with regard to onset of analgesia, duration of analgesia, neonatal outcome, and quality of analgesia. Material and Methods: A total of 60 term parturients of the American Society of Anesthesiologists Grade I and II with uncomplicated pregnancy, vertex presentation, posted for on-demand epidural labor analgesia after informed consent were divided in two groups. Group R (n = 30) patients received 10 ml solution comprising 0.2% ropivacaine. Group RC (n = 30) patients received a total of 10 ml of 0.2% ropivacaine and clonidine 1 μg/kg. Characteristics of the block, onset and duration of analgesia, and total analgesic requirements were noted. Pain and overall satisfaction scores were assessed with a 10-point visual analog scale. Mode of delivery and neonatal APGAR scores were recorded. Results: Maternal demographic characteristics were comparable between the groups. Addition of clonidine to ropivacaine shortened the onset and prolonged the duration of analgesia with decrease in ropivacaine requirement in Group RC. There was a significant difference between the two groups regarding visual analog score and quality of analgesia, which was better in Group RC. There were no significant differences between the two groups regarding motor block, hemodynamic parameters, and neonatal outcomes. Conclusion: We conclude that clonidine in low doses is a useful adjuvant to local anesthetics for epidural labor analgesia and a good alternative to opioids.
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A randomized clinical trial of intrathecal magnesium sulfate versus midazolam with epidural administration of 0.75% ropivacaine for patients with preeclampsia scheduled for elective cesarean section p. 23
Sophia Paleti, P Krishna Prasad, B Sowbhagya Lakshmi
DOI:10.4103/joacp.JOACP_74_17  
Background and Aims: Magnesium sulfate and midazolam have been used as adjuvants to local anesthetics via intrathecal and epidural routes to augment the quality of block and prolong postoperative analgesia. This study compares addition of intrathecal magnesium sulfate versus intrathecal midazolam to epidurally administered isobaric ropivacaine as a part of combined spinal epidural technique in pre-eclamptic parturients undergoing elective cesarean section. Material and Methods: After institutional ethics committee approval and written informed consent, 50 pre-eclamptic parturients were randomly allocated to one of the two groups of 25 each to either receive intrathecal magnesium sulfate (50 mg) or intrathecal midazolam (1 mg) in combination with epidural ropivacaine (0.75%; 14–16 ml). The onset and duration of sensory and motor blockade, duration of postoperative analgesia, postoperative visual analogue scores for pain, and perioperative side effects were noted. Data were analyzed statistically using Graphpad.com software. Results: Onset times to sensory and motor blockade were faster in midazolam than in magnesium group (P < 0.01). Duration of sensory and motor blockade, and time to first request of analgesia were significantly longer in the magnesium group compared to the midazolam group (P < 0.01). The fetal outcomes according to APGAR scores were comparable in both the groups, the median APGAR score at 1 minute was 8 and at 5 minutes was 10 in both the groups. Conclusion: Intrathecal magnesium with epidural ropivacaine significantly prolonged postoperative analgesia compared to intrathecal midazolam without any complications. Perioperative hemodynamics were comparable in both groups.
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Comparison of continuous epidural infusion of 0.125% ropivacaine with 1μg/ml fentanyl versus 0.125% bupivacaine with 1μg/ml fentanyl for postoperative analgesia in major abdominal surgery p. 29
Shruti Shrikant Patil, Amala G Kudalkar, Bharati A Tendolkar
DOI:10.4103/joacp.JOACP_122_16  
Background and Aim: The present study was carried out to compare the efficacy of continuous epidural infusion of two amide local anesthetics, ropivacaine and bupivacaine with fentanyl for postoperative analgesia in major abdominal surgeries. Material and Methods: A total of 60 patients scheduled for major abdominal surgery were randomized into two study Groups B and R with thirty patients in each group. All patients were administered general anesthesia after placing epidural catheter. Patients received continuous epidural infusion of either 0.25% bupivacaine with 1 ug/ml fentanyl (Group B) or of 0.25% ropivacaine with 1 ug/ml fentanyl (Group R) at the rate 6 ml/h intraoperatively. Postoperatively, they received 0.125% bupivacaine with 1 ug/ml fentanyl (Group B) or 0.125% ropivacaine with 1 ug/ml fentanyl (Group R) at the rate 6 ml/h. Hemodynamic parameters, visual analog scale (VAS), level of sensory block, and degree of motor block (based on Bromage scale) were monitored for 24 h postoperatively. Results: Hemodynamic parameters and VAS scores were comparable in the two groups. The level of sensory block was higher in bupivacaine group. There were more patients with higher Bromage score in the (23.3%) bupivacaine group than in (6.7%) ropivacaine group though the difference was not statistically significant. Conclusion: Both ropivacaine and bupivacaine in the concentration of 0.125% with fentanyl 1 ug/ml are equally safe, with minimal motor block and are effective in providing postoperative analgesia.
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Opioid-free anesthesia for breast cancer surgery: An observational study Highly accessed article p. 35
Swagata Tripathy, Satyajit Rath, Suresh Agrawal, P Bhaskar Rao, A Panda, TS Mishra, Sukdev Nayak
DOI:10.4103/joacp.JOACP_143_17  
Background and Aims: Opioids are associated with postoperative nausea, vomiting, drowsiness, and increased analgesic requirement. A nonopioid anesthesia technique may reduce morbidity, enable day care surgery, and possibly decrease tumor recurrence. We compared opioid-free, nerve block-based anesthesia with opioid-based general anesthesia for breast cancer surgery in a prospective cohort study. Material and Methods: Twenty four adult American Society of Anesthesiologists grade I–III patients posted for modified radical mastectomy (MRM) with axillary dissection were induced with propofol and maintained on isoflurane (0.8–1.0 minimum alveolar concentration) through i-gel on spontaneous ventilation and administered ultrasound-guided PECS 1 and 2 blocks (0.1% lignocaine + 0.25% bupivacaine + 1 mcg/kg dexmedetomidine, 30 ml). Postoperative nausea, pain scores, nonopioid analgesic requirement over 24 h, stay in the recovery room, and satisfaction of surgeon and patient were studied. Twenty-four patients who underwent MRM and axillary dissection without a nerve block under routine opioid anesthesia with controlled ventilation were the controls. Results: MRM and axillary dissection under the nonopioid technique was adequate in all patients. Time in the recovery room, postoperative nausea, analgesic requirement, and visual analog scale scores were all significantly less in the nonopioid group. Surgeon and patient were satisfied with good patient quality of life on day 7. Conclusion: Nonopioid nerve block technique is adequate and safe for MRM with axillary clearance. Compared to conventional technique, it offers lesser morbidity and may allow for earlier discharge. Larger studies are needed to assess the long-term impact on chronic pain and tumor recurrence by nonopioid techniques.
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Evaluation of dexmedetomidine and fentanyl as additives to ropivacaine for epidural anesthesia and postoperative analgesia p. 41
S Kiran, Kavita Jinjil, Urvashi Tandon, Soumita Kar
DOI:10.4103/joacp.JOACP_205_16  
Background and Aims: The synergism between epidural local anesthetic agent and opioids is well established, but evidence for the combination of local anesthetic agent with dexmedetomidine in epidurals is limited. This study evaluates the clinical efficacy of dexmedetomidine versus fentanyl as an additive to ropivacaine for epidural anesthesia. Material and Methods: Patients undergoing infraumbilical surgeries were divided randomly into three groups - Group R (n = 25): received 18 ml of 0.5% ropivacaine for epidural anesthesia and 10 ml of 0.1% ropivacaine boluses for postoperative analgesia; Group RF (n = 25): received 18 ml of 0.5% ropivacaine with 20 μg fentanyl for epidural anesthesia and 10 ml of 0.1% ropivacaine with 10 μg fentanyl boluses for postoperative analgesia; and Group RD (n = 25): received 18 ml of 0.5% ropivacaine with 10 μg dexmedetomidine for epidural anesthesia and 10 ml of 0.1% ropivacaine with 5 μg dexmedetomidine boluses for postoperative analgesia. Results: The mean time for onset of sensory block, in minutes, was 18.6 ± 4.4 in R Group, 12.8 ± 1.8 in RF Group and 10.8 ± 2.7 in RD Group (P < 0.001). There was a statistically significant difference with regard to degree of motor block, with RD Group faring better than RF Group and R Group. The mean time to rescue analgesia, in minutes, was 139.8 ± 21.4 in Group R, 243 ± 29.7 in Group RF, and 312.4 ± 30.2 in Group RD (P < 0.001). Incidence of hypotension at 10 min was 4% and 48% in RF and RD Groups, respectively (P < 0.001). Conclusions: Epidural anesthesia achieved with 10 μg dexmedetomidine as an additive to 0.5% ropivacaine is more effective with respect to duration and intensity of analgesia when compared to 0.5% ropivacaine alone or addition of 20 μg fentanyl to 0.5% ropivacaine.
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Effect of intravenous dexmedetomidine administered as bolus or as bolus-plus-infusion on subarachnoid anesthesia with hyperbaric bupivacaine p. 46
Upadhya R Kavya, Shenoy Laxmi, Venkateswaran Ramkumar
DOI:10.4103/joacp.JOACP_132_16  
Background: Subarachnoid anesthesia is a widely practiced regional anesthetic for infraumbilical surgeries. Intravenous dexmedetomidine is known to prolong both sensory and motor blockade when administered along with subarachnoid anesthesia. Material and Methods: Seventy-five patients scheduled to undergo elective infraumbilical surgeries under subarachnoid anesthesia were randomly allocated to one of the three groups. Group B received intravenous saline over 10 min followed by 12.5 mg intrathecal bupivacaine and then intravenous saline over 60 min. Group bupivacaine + dexmedetomidine bolus (BDexB) received intravenous dexmedetomidine (1 μg/kg) over 10 min followed by 12.5 mg intrathecal bupivacaine and then intravenous saline over 60 min. Group bupivacaine + dexmedetomidine bolus-plus-infusion (BDexBI) received intravenous dexmedetomidine (0.5 μg/kg) over 10 min followed by 12.5 mg intrathecal bupivacaine and then intravenous dexmedetomidine (0.5 μg/kg) over 60 min. Onset of analgesia (at T10), complete motor block (Bromage score 3), and highest level of analgesia were noted. Sensory and motor levels were checked periodically till sensory recovery (at S2–S4) and complete motor recovery (Bromage score 0). Ramsay sedation score and incidence of bradycardia/hypotension were noted. Results: Sensory recovery was significantly longer in Group BDexB (303 min) and Group BdexBI (288 min) as compared to Group B (219.6 min). Motor recovery was also significantly prolonged in Group BDexB (321.6 min) and Group BDexBI (302.4 min) as compared to Group B (233.4 min). Patients receiving dexmedetomidine were sedated but were easily arousable. Conclusion: Intravenous dexmedetomidine given as bolus or bolus-plus-infusion with intrathecal hyperbaric bupivacaine prolongs both sensory and motor blockade.
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Effect of dexmedetomidine infusion on hemodynamic responses in microsurgery of larynx p. 51
Shakuntala Basantwani, Mayuresh Patil, Balasaheb Govardhane, Jyoti Magar, Bharati Tendolkar
DOI:10.4103/joacp.JOACP_136_16  
Background and Aims: Microlaryngeal surgery is a frequently performed ear, nose, and throat procedure used to diagnose and treat laryngeal disorders. Suspension laryngoscopy causes prolonged stimulation of the deep pressure receptors of the larynx leading to adverse circulatory responses and consequently cardiac complications. In this study, dexmedetomidine infusion was used to assess its effectiveness for attenuation of this hemodynamic stress response. Material and Methods: Sixty patients undergoing elective microlaryngeal surgery randomly received either dexmedetomidine 1 μg/kg over 10 min followed by continuous infusion of 0.5 μg/kg (Group D) or normal saline infusion at the same rate (Group P) till the end of surgery. Anesthesia in all patients was induced with propofol, succinylcholine to facilitate endotracheal intubation after premedication with fentanyl 2 μg/kg and glycopyrrolate. Intraoperative, vital parameters were maintained within 20% of baseline with rescue analgesic fentanyl 1 μg/kg and subsequently with propofol boluses up to 1 mg/kg. The percentage of patients and the total amount of intraoperative fentanyl and propofol required in each group were recorded. Sedation score at 10 minutes postextubation was assessed by Ramsay sedation score. Results: Intraoperative heart rate and mean arterial pressure in Group D were lower than the baseline values and the corresponding values in Group P (P > 0.05). The percentage of patients requiring rescue fentanyl and propofol was higher in Group P than Group D (36.6% and 30% vs. 6.6% and 3.3% P = 0.01). Recovery scores were better in dexmedetomidine group. Conclusion: Dexmedetomidine infusion attenuates the hemodynamic stress response during laryngoscopy, intubation, and microlaryngeal surgery and is associated better recovery profile.
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Effectiveness of Proseal laryngeal mask airway and laryngeal tube suction in elective non-laparoscopic surgeries of up to ninety minutes duration: A prospective, randomized study p. 58
Swapnil Verma, SP Sharma
DOI:10.4103/joacp.JOACP_101_16  
Background and Aims: Proseal laryngeal mask airway (LMA) and laryngeal tube suction (LTS) are both supraglottic devices with an esophageal suction port. In the present prospective, randomized study, the effectiveness of airway seal, hemodynamic variables, ability to pass orogastric tube, and postoperative complications with the two devices were evaluated. Material and Methods: This was a prospective, randomized, single-blind study conducted in a hospital-based setting. Sixty patients (American Society of Anesthesiologists Grade I and II) undergoing elective general surgery were randomly allocated to Group A (Proseal LMA) or Group B (LTS), and airway seal pressure (primary outcome), peak pressure, hemodynamic parameters (blood pressure, pulse rate and pulse oximetry) during and 5 min after insertion, insertion time, ease of insertion, and postoperative complications (sore throat and hoarseness of voice for a period of 24 hours) (secondary outcomes) were noted. The quantitative data was summarized as mean and standard deviation, and analyzed using Student's t-test. All the qualitative data were summarized as proportions and analyzed using Chi-square test. The levels of significance and α-error were kept 95% and 5%, respectively, for all statistical analyses. P ≤ 0.05 was considered significant (S). Results: Proseal LMA had shorter insertion time (16.4 ± 5.6 vs. 20.0 ± 3.9 s), higher seal pressure (27.6 ± 4.6 vs. 24.1 ± 5.6 cm of H2O), lesser peak pressure (16.3 ± 2.3 vs. 18.5 ± 3.9 cm of H2O), higher success rate of orogastric tube passage (86.7 vs. 76.7%), and lesser postoperative sore throat (3.3 vs. 10%). Conclusions: Both Proseal LMA and LTS were acceptable alternatives for airway management in elective surgeries with controlled ventilation, but the quality of ventilation was found to be significantly better with Proseal LMA (in terms of higher seal pressure, lesser peak pressure, lesser insertion time, and lesser complications).
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Formulation of a multivariate predictive model for difficult intubation: A double blinded prospective study p. 62
Anoop Kanwal Chhina, Richa Jain, Parshotam Lal Gautam, Jony Garg, Nidhi Singh, Anju Grewal
DOI:10.4103/joacp.JOACP_230_16  
Background and Aims: Various models were devised for prediction of difficult intubation but have low positive predictive value, sensitivity and specificity. We aimed to predict difficult intubation from various airway predictive indices, in isolation and combination, and to formulate a multivariate model that can aid in accurate prediction of difficult intubation. Material and Methods: A prospective double blinded study was conducted on 500 adult patients scheduled for elective surgery under general anaesthesia. Preoperatively, they were assessed for airway screening tests. After standardized induction of anaesthesia, laryngoscopic view was classified according to the Modified Cormack and Lehane (MCL) classification. Variables' association with intubation findings was evaluated using Chi-square statistic. Stepwise logistic regression identified the multivariate independent predictors of difficult intubation and combinations were made using forward selection process. 8 models were formulated and a receiver-operating characteristic (ROC) curve worked out for them. Sensitivity and specificity analysis validated the final model. Results: Age, sex, weight, BMI, snoring, obstructive sleep apnea (OSA), diabetes, hypertension, upper lip bite test (ULBT), Mallampati grade (MPS), thyromental distance (TMD), sternomental distance (SMD), neck movements (NM), neck circumference (NC) and inter-incisor gap (IIG) had significant correlation with difficult intubation. Based upon sensitivity and specificity analysis, model comprising of MPS, NM, NC and SMD was found to be most accurate. It had highest sensitivity 80%, specificity 87% and area under curve 0.90, thus validating the model. Conclusions: Our study found that a combination of MPS, SMD, NM and NC permits reliable, accurate and quick preoperative prediction of difficult intubation.
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Ratio of height-to-thyromental distance and ratio of height-to-sternomental distance as predictors of laryngoscopic grade in children p. 68
Swarup Ray, Shwethapriya Rao, Jasvinder Kaur, Yogesh K Gaude
DOI:10.4103/joacp.JOACP_135_16  
Background and Aims: Failure to secure the airway is an important cause of morbidity and mortality in children. Children are often uncooperative for routine examination and pose problems for obtaining external measurements. We aimed to evaluate ratio of height-to-thyromental distance (RHTMD) and ratio of height-to-sternomental distance (RHSMD) as predictors of laryngoscopic grade in children aged 1–12 years. Material and Methods: This study was an observational study conducted in children aged between 1 and 12 years scheduled for elective surgery under general anesthesia. Children unable to stand, having limited mouth opening/neck mobility, cleft palate or with midline neck masses were excluded. Weight, height, and thyromental and sternomental distances were measured preoperatively. Following induction of anesthesia and full-muscle relaxation, laryngoscopy was performed and Cormack–Lehane view with Cook's modification was noted. Receiver operating characteristic (ROC) curve analysis using RHTMD and RHSMD was performed for predicting poor laryngoscopic view. Results: A total of 138 children with mean age of 6.6 ± 3.4, RHTMD of 17.7 ± 2.1, and RHSMD of 10.0 ± 1.0 were included. No Grade 3 or 4 laryngoscopic views were obtained. ROC curve analysis was done for predicting 2b view (restricted), incidence of which was 10.1%. RHTMD was a better predictor of 2b laryngoscopic view with an area under curve (AUC) of 0.792 compared to RHSMD (AUC = 0.463). Conclusions: In children aged 1–12 years, RHTMD is a better predictor of restricted view compared to RHSMD.
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Predicting endotracheal tube size from length: Evaluation of the Broselow tape in Indian children p. 73
Shalini Subramanian, Madhavi Nishtala, Chandrika Yabagodu Ramavakoda, Gaurang Kothari
DOI:10.4103/joacp.JOACP_317_16  
Background and Aims: Several formulae are available to estimate endotracheal tube (ETT) size in children. This study was designed to compare the ETT estimated by the Broselow tape (BT) with age-based estimation of ETT size and to identify the most accurate formula for the prediction of uncuffed ETT size in Indian children. Material and Methods: Pediatric patients aged 1 month–6.5 years undergoing emergency or elective surgery under general anesthesia requiring endotracheal intubation with uncuffed ETT were included in this study. The ETT size was selected based on the age formula (Penlington formula). The ETT used was deemed to be of correct fit based on the delivery of adequate tidal volume and presence of minimal leak at 20 cm H2O. The actual ETT used was compared with that predicted by age, length of the child, BT, and fifth fingernail width of the child using Pearson's correlation. Results: In children aged <6 months, the ETT used was found to correlate with length (r = 0.286, P = 0.044) and finger nail width (r = 0.542, P< 0.001) of the children. In children >6 months, the ETT used correlated with that predicted from age, BT, length, and fingernail width of the children. In our study, BT has an overall correct predictability rate of 50.3% whereas the age-based formula has a correct prediction rate of 59.8% and length-based formula is 48.7% accurate. Conclusion: Length of the child has a good correlation with size of the ETT to be used in Indian children across all age groups. BT is an effective tool to predict ETT size in children >6 months.
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Pediatric critical incidents reported over 15 years at a tertiary care teaching hospital of a developing country p. 78
Shemila Abbasi, Fauzia Anis Khan, Sobia Khan
DOI:10.4103/joacp.JOACP_240_16  
Background and Aims: The role of critical incident (CI) reporting is well established in improving patient safety but only a limited number of available reports relate to pediatric incidents. Our aim was to analyze the reported CIs specific to pediatric patients in our database and to reevaluate the value of this program in addressing issues in pediatric anesthesia practice. Material and Methods: Incidents related to pediatric population from neonatal period till the age of 12 years were selected. A review of all CI records collected between January 1998 and December 2012, in the Department of Anaesthesiology of Aga Khan University hospital was done. This was retrospective form review. The Department has a structured CI form in use since 1998 which is intermittently evaluated and modified if needed. Results: A total of 451 pediatric CIs were included. Thirty-four percent of the incidents were reported in infants. Ninety-six percent of the reported incidents took place during elective surgery and 4% during emergency surgery. Equipment-related events (n = 114), respiratory events (n = 112), and drug events (n = 110) were equally distributed (25.6%, 25.3%, and 24.7%). Human factors accounted for 74% of reports followed by, equipment failure (10%) and patient factors (8%). Only 5% of the incidents were system errors. Failure to check (equipment/drugs/doses) was the most common cause for human factors. Poor outcome was seen in 7% of cases. Conclusion: Medication and equipment are the clinical areas that need to be looked at more closely. We also recommend quality improvement projects in both these areas as well as training of residents and staff in managing airway-related problems in pediatric patients.
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Intraoperative neurophysiological monitoring team's communiqué with anesthesia professionals Highly accessed article p. 84
Anurag Tewari, Lisa Francis, Ravi N Samy, Dean C Kurth, Joshua Castle, Tiffany Frye, Mohamed Mahmoud
DOI:10.4103/joacp.JOACP_315_17  
Background and Aims: Intraoperative neurophysiological monitoring (IONM) is the standard of care during many spinal, vascular, and intracranial surgeries. High-quality perioperative care requires the communication and cooperation of several multidisciplinary teams. One of these multidisciplinary services is intraoperative neuromonitoring (IONM), while other teams represent anesthesia and surgery. Few studies have investigated the IONM team's objective communication with anesthesia providers. We conducted a retrospective review of IONM-related quality assurance data to identify how changes in the evoked potentials observed during the surgery were communicated within our IONM-anesthesia team and determined the resulting qualitative outcomes. Material and Methods: Quality assurance records of 3,112 patients who underwent surgical procedures with IONM (from 2010 to 2015) were reviewed. We examined communications regarding perioperative evoked potential or electroencephalography (EEG) fluctuations that prompted neurophysiologists to alert/notify the anesthesia team to consider alteration of anesthetic depth/drug regimen or patient positioning and analyzed the outcomes of these interventions. Results: Of the total of 1280 (41.13%) communications issued, there were 347 notifications and 11 alerts made by the neurophysiologist to the anesthesia team for various types of neuro/orthopedic surgeries. Prompt communication led to resolution of 90% of alerts and 80% of notifications after corrective measures were executed by the anesthesiologists. Notifications mainly related to limb malpositioning and extravasation of intravenous fluid. Conclusion: Based on our institutions' protocol and algorithm for intervention during IONM-supported surgeries, our findings of resolution in alerts and notifications indicate that successful communications between the two teams could potentially lead to improved anesthetic care and patient safety.
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Comparison of pretreatment with dexmedetomidine with midazolam for prevention of etomidate-induced myoclonus and attenuation of stress response at intubation: A randomized controlled study p. 94
Swarnendu Dey, Meenakshi Kumar
DOI:10.4103/joacp.JOACP_297_16  
Background and Aims: Myoclonus is a common problem during induction of anesthesia with etomidate. A variety of drugs have been used to decrease the incidence of myoclonus. In this study we compared the effects of dexmedetomidine and midazolam pretreatment on the incidence of etomidate induced myoclonus. We also studied the effects of these drugs on attenuation of stress response at laryngoscopy and intubation on induction with etomidate. Material and Methods: Eighty adult patients (18 to 60 years age) of either sex, American Society of Anestheiologists physical status I and II undergoing elective general surgeries under general anesthesia were randomly allocated into two groups. Group D patients received Inj. Dexmedetomidine (0.5 μg/Kg) and Group M received Inj. Midazolam (0.015 mg/Kg) in 10 ml saline over ten minutes. Myoclonus was graded after intravenous administration of etomidate (0.3mg/Kg) and hemodynamic response to laryngoscopy and intubation were observed at various time intervals. Analysis of statistical data was done using Statistical Package for Social Sciences (SPSS) version 21.0. Quantitative variables were compared using Independent T Test/Mann Whitney test (for non-parametric data). Qualitative variables were compared using Chi-Square test/Fisher's Exact Test. A P value of < 0.05 was considered statistically significant. Results: In Group D, 22 out of 40 (55%) patients did not have any myoclonus during induction with etomidate, and none of the patients had grade 3 (severe) myoclonus. In Group M, 19 out of 40 patients (47.5%) had grade 2 (moderate) and 6 patients (15%) had grade 3 myoclonus. Stress response due to intubation was more effectively suppressed by dexmedetomidine as compared to midazolam. Conclusion: Incidence of myoclonus among patients who underwent pre-treatment with dexmedetomidine was significantly lesser than those who underwent pre-treatment with midazolam. Greater degree of attenuation of stress response in the dexmedetomidine group was observed as compared to midazolam group.
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FORUM ARTICLES Top

Safety of the medical gas pipeline system p. 99
Sushmita Sarangi, Savita Babbar, Dipali Taneja
DOI:10.4103/joacp.JOACP_274_16  
Medical gases are nowadays being used for a number of diverse clinical applications and its piped delivery is a landmark achievement in the field of patient care. Patient safety is of paramount importance in the design, installation, commissioning, and operation of medical gas pipeline systems (MGPS). The system has to be operational round the clock, with practically zero downtime and its failure can be fatal if not restored at the earliest. There is a lack of awareness among the clinicians regarding the medico-legal aspect involved with the MGPS. It is a highly technical field; hence, an in-depth knowledge is a must to ensure safety with the system.
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Venous gas embolism in operative hysteroscopy: A devastating complication in a relatively simple surgery p. 103
Amit Verma, Madhu Pandey Singh
DOI:10.4103/joacp.JOACP_235_15  
Venous air embolism can be a catastrophic iatrogenic complication during operative hysteroscopy and makes this simple surgical procedure very risky, especially with the lack of knowledge about its prevention, presentation, and immediate management. Three out of 13 hysteroscopic myoma resections at our center had venous gas embolism (VGE). The prevention, diagnosis, and management of VGE are described in this report of three cases.
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Anesthetic efficacy of 4% articaine and 2% lignocaine in achieving palatal anesthesia following a single buccal infiltration during periodontal therapy: A randomized double-blind split-mouth study p. 107
Balachandran Ashwath, Sundaram Subramoniam, Rajaram Vijayalakshmi, Muthukali Shanmugam, Bagavathiperumal Meena Priya, Vijayarangan Anitha
DOI:10.4103/joacp.JOACP_200_15  
Background: The aim of this randomized split-mouth double-blind study was to evaluate whether 4% articaine hydrochloride with 1:100,000 epinephrine administered as a single buccal infiltration in the maxillary posterior sextant can provide palatal anesthesia when compared with 2% lignocaine with 1:100,000 epinephrine during scaling and root planing and access flap surgery (AFS). Material and Methods: A total of 40 patients with chronic generalized periodontitis requiring periodontal therapy in the maxillary posterior sextants were recruited in this study. About 4% articaine and 2% lignocaine were administered as buccal infiltration in a split-mouth design randomly. The pain scores in the palatal aspect were recorded during scaling and root planing and open flap debridement using Heft-Parker visual analog scale. The onset of anesthesia was also recorded and compared. Results: The success rate for maxillary buccal infiltration to induce palatal anesthesia using articaine was 90% during scaling and root planing and 82.5% during AFS and for lignocaine solution was 20% and 15%, respectively. The difference between the two agents was statistically significant (P < 0.05). The onset of anesthesia between articaine and lignocaine was also found to be statistically significant (P < 0.05). Conclusion: In this study, we observed that the efficacy of 4% articaine was superior to 2% lignocaine to induce palatal anesthesia following maxillary buccal infiltration in maxillary posterior sextants.
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CLINICAL PHARMACOLOGY Top

Tanezumab: Therapy targeting nerve growth factor in pain pathogenesis p. 111
Mona K Patel, Alan D Kaye, Richard D Urman
DOI:10.4103/joacp.JOACP_389_15  
In recent years, nerve growth factor (NGF) and the NGF receptor have become potential therapeutic targets in the treatment of acute and chronic pain states. NGF is a neurotrophin involved in regulating the function of sensory and sympathetic neurons during development. Numerous pain states have been linked to elevated levels of NGF and its role in increasing the perception of pain. Tanezumab, a recombinant humanized monoclonal antibody (IgG), was developed to target NGF, binding both circulating and local tissue NGF preventing interaction with the tropomyosin-related kinase-A and p75 receptors. Recent clinical studies with tanezumab in different patient populations to date, including osteoarthritis, low back pain, and diabetic peripheral neuropathy, demonstrate efficacy with few side effects, including transient arthralgias, paresthesias, hypoesthesia, and rarely, osteonecrosis. Anti-NGF antibodies are a novel therapy in pain management and have shown promise in the treatment of certain pain conditions, which at present are poorly treated. Tanezumab offers an exciting new class of analgesics that has the potential to change the treatment of pain.
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CASE REPORTS Top

Regional anesthesia is safe and effective for lower limb orthopedic surgery in patient with renal tubular acidosis and hypokalemia p. 117
Indira Gurajala, Sapna Annaji Nikhar, Kavitha Jayaram, Ramachandran Gopinath
DOI:10.4103/0970-9185.168203  
Renal tubular acidosis (RTA) with hypokalemia may precipitate acute respiratory failure and potentially fatal arrhythmias like ventricular fibrillation. Though there are random reports of respiratory failure needing mechanical ventilation and sudden death in patients with RTA and hypokalemia, the anesthetic management of these patients has not been clearly elucidated. Acidosis and hypokalemia have significant interactions with both general and local anesthetics and alter their effect substantially. Proper preoperative planning and optimization are required for the safe conduct of anesthesia in this subset of patients. We describe a case of distal RTA, hypokalemia, and metabolic bone disease in whom central neuraxial anesthesia was effectively used for lower limb orthopedic surgery with no complications.
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Atypical presentation of posterior reversible encephalopathy syndrome: Two cases p. 120
Nishant Kumar, Ranju Singh, Neha Sharma, Aruna Jain
Posterior reversible encephalopathy syndrome (PRES) is a clinico-neuroradiological entity, first described in 1996. It is commonly associated with systemic hypertension, intake of immunosuppressant drugs, sepsis and eclampsia and preeclampsia. Headache, alteration in consciousness, visual disturbances and seizures are common manifestations of PRES. Signs of pyramidal tract involvement and motor dysfunction are uncommon clinical findings. However, clinical presentation is not diagnostic. On neuroimaging, lesions are characteristically found in parieto occipital region of the brain due to vasogenic edema. We report two cases of PRES with atypical clinical presentation-one which was suggestive of neurocysticercosis and the other in which agitation and opisthotonic posture were predominant features.
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LETTERS TO EDITOR Top

Neostigmine-induced coronary spasm: Beware of Kounis syndrome p. 123
Xiaofei Yang, Xiaozhi Feng, Feiru Duan, Zhiyong Wang, Monish S Raut, Baryon Swain
DOI:10.4103/joacp.JOACP_268_17  
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Anesthetic management of excision of laryngocele–role of transtracheal jet ventilation p. 124
S Parthasarathy, Kusha Nag, T Sivashanmugham, P Karthikeyan, M Ravishankar
DOI:10.4103/joacp.JOACP_143_15  
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Awake caudal anesthesia for anoplasty in a preterm newborn with complex cyanotic congenital heart disease p. 126
Murali Thiriloga Sundary, Srinivasan Parthasarathy, Kusuma Srividya Radhika
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An easy and feasible way of confirming correct placement of ventriculoatrial shunt intraoperatively p. 127
Gaurav Singh Tomer, Keerthi P Nandakumar, Vikas Chauhan, Surya Kumar Dube
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Pierre robin sequence with cervicothoracic kyphoscoliosis: An anesthetic challenge p. 128
V Abraham, S Grewal, G Bhatia, N Kaur, W Raghav, P Jain, N Gupta, M Singh, C George
DOI:10.4103/joacp.JOACP_256_15  
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Needle tip and peripheral nerve blocks p. 129
Smita Prakash, Amitabh Kumar
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Ultrasound-guided internal jugular vein cannulation: Can an artery be missed? p. 130
Gyaninder Pal Singh, Vikas Chauhan, Indu Kapoor, Abhyuday Kumar
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A Case of Gorhams Syndrome: An anesthetic challenge p. 132
Supriya Lynette Dsouza, Adarsh Kulkarni, Hashim Sageer, Naveen Pajai, Nirav Kotak
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“Look alike” packaging: Do we need a wake-up call? p. 133
Nandini M Dave
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Leak in anesthesia workstation: An unusual cause p. 135
Ritu Aggarwal, Ajay Kumar
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Propofol infusion in an infant with glucose-6-phosphate dehydrogenase deficiency p. 136
Vandana Sharma, Shilpi Verma, Pradeep Kumar Bhatia, Priyanka Sethi
DOI:10.4103/joacp.JOACP_112_16  
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Acute compartment syndrome in the postoperative period in an alcoholic patient with multiple injuries p. 138
J Balavenkatasubramanian, Niveditha Padma Meenakshi Karuppiah
DOI:10.4103/joacp.JOACP_167_16  
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Water contamination of the central air supply: Out of sight, out of mind! p. 139
Geeta Kamal, Anju Gupta, Sapna Bathla, Aikta Gupta
DOI:10.4103/joacp.JOACP_175_16  
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Minocycline: The second important antimicrobial in multidrug-resistant Acinetobacter baumanii infections p. 140
Abhijit S Nair
DOI:10.4103/joacp.JOACP_156_17  
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