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   Table of Contents - Current issue
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January-March 2017
Volume 33 | Issue 1
Page Nos. 1-140

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EDITORIAL  

Not just a separate consent for anesthesia! p. 1
Sandhya Yaddanapudi
DOI:10.4103/joacp.JOACP_364_16  
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REVIEW ARTICLES Top

Vasopressors: Do they have any role in hemorrhagic shock? Highly accessed article p. 3
Babita Gupta, Neha Garg, Rashmi Ramachandran
DOI:10.4103/0970-9185.202185  
The priority in the management of patients with traumatic hemorrhagic shock is to control the bleeding with simultaneous volume resuscitation to maintain adequate tissue perfusion. Fluid replacement remains the mainstay of initial resuscitation in hemorrhagic shock. Traditionally, vasopressors are contraindicated in the early management of hemorrhagic shock due to their deleterious consequences, although vasopressors may have a role in resuscitation when vasoplegic shock ensues and blood pressure cannot be maintained by fluids alone. Use of vasopressors is not recommended according to the Advanced Trauma Life SupportR management principles. The role of vasopressors remains controversial with no clear guidelines on the timing, type, and dose of these drugs in hemorrhagic shock. Among vasopressors, norepinephrine and vasopressin have been used in the majority of the trials, although not many studies compare the effect of these two on long-term survival in trauma patients. This article reviews the pathophysiology of hemorrhagic shock, adverse effects of fluid resuscitation, and the various experimental and clinical studies on the use of vasopressors in the early phase of resuscitation in hemorrhagic shock.
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Novel propofol derivatives and implications for anesthesia practice Highly accessed article p. 9
Aiden Y Feng, Alan D Kaye, Rachel J Kaye, Kumar Belani, Richard D Urman
DOI:10.4103/0970-9185.202205  
Propofol (2,6-diisopropylphenol) is the most commonly used intravenous agent for induction of anesthesia. It is also used for maintenance of anesthesia and sedation in both Intensive Care Units and outpatient procedural settings. Its success in the clinical setting has been a result of its rapid onset, short duration of action, and minimal side effects despite disadvantages associated with its oil emulsion formulation. Early attempts to alter the standard emulsion or to develop new formulations with cyclodextrins and micelles to resolve issues with pain upon injection, the need for antimicrobial agents, and possible hyperlipidemia have mostly failed. With these challenges in the foreground, attention has now shifted to the use of more prodrugs and exogenous alternatives, the success of which is yet to be determined. These new agents must offer significant clinical advantages over the well-entrenched, generic propofol oil emulsion to justify higher costs and to be well received in the increasingly cost-conscious healthcare marketplace.
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Localization of epidural space: A review of available technologies Highly accessed article p. 16
Hesham Elsharkawy, Abraham Sonny, Ki Jinn Chin
DOI:10.4103/0970-9185.202184  
Although epidural analgesia is widely used for pain relief, it is associated with a significant failure rate. Loss of resistance technique, tactile feedback from the needle, and surface landmarks are traditionally used to guide the epidural needle tip into the epidural space (EDS). The aim of this narrative review is to critically appraise new and emerging technologies for identification of EDS and their potential role in the future. The PubMed, Cochrane Central Register of Controlled Clinical Studies, and Web of Science databases were searched using predecided search strategies, yielding 1048 results. After careful review of abstracts and full texts, 42 articles were selected to be included. Newer techniques for localization of EDS can be broadly classified into techniques that (1) guide the needle to the EDS, (2) identify needle entry into the EDS, and (3) confirm catheter location in EDS. An ideal method should be easy to learn and perform, easily reproducible with high sensitivity and specificity, identifies inadvertent intrathecal and intravascular catheter placements with ease, feasible in perioperative setting and have a cost-benefit advantage. Though none of them in their current stages of development qualify as an ideal method, many show tremendous potential. Some techniques are useful in patients with difficult spinal anatomy and infants, and thus are complementary to traditional methods. In addition to improving the existing technology, future research should aim at proving the superiority of these techniques over traditional methods, specifically regarding successful EDS localization, better safety profile, and a favorable cost-benefit ratio.
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The effect of perioperative esmolol on early postoperative pain: A systematic review and meta-analysis p. 28
Richard Watts, Venkatesan Thiruvenkatarajan, Marni Calvert, Graeme Newcombe, Roelof M van Wijk
DOI:10.4103/0970-9185.202182  
Esmolol has been shown to improve postoperative pain and reduce opioid requirements. The aim of this systematic review was to evaluate the effect of perioperative esmolol as an adjunct on early postoperative pain intensity, recovery profile, and anesthetic requirement. Databases were searched for randomized placebo-controlled trials evaluating the effects of esmolol during general anesthesia. Primary outcomes were related to early postoperative pain whereas secondary outcomes were related to emergence time, postoperative nausea and vomiting, and intraoperative anesthetic requirement. Nineteen trials were identified involving 936 patients (esmolol = 470, placebo = 466). In esmolol group, numeric pain scores at rest in the immediate postoperative period were reduced by 1.16 (95% confidence interval [CI]: 1.97–0.35, I2 = 96.7%) out of 10. Opioid consumption was also decreased in the postanesthesia care unit compared with placebo, mean difference of 5.1 mg (95% CI: 7.0–3.2, I2 = 96.9%) morphine IV equivalents; a 69% reduction in opioid rescue dosing was noted (odds ratio [OR]: 0.31, 95% CI: 0.16–0.80, I2 = 0.0%). A 61% reduction in postoperative nausea and vomiting was also evident (OR: 0.39, 95% CI: 0.20–0.75, I2 = 60.7%). A reduction in propofol induction dose was noted in the esmolol group (mean difference: −0.53 mg/kg, 95% CI: −0.63–−0.44, I2 = 0.0%). A decrease in end-tidal desflurane equivalent (mean difference: 1.70%, 95% CI: −2.39–−1.02, I2 = 92.0%) and intraoperative opioid usage (fentanyl equivalent, mean difference: 440 μg, 95% CI: −637–−244, I2 = 99.6%) was observed in esmolol group. Esmolol had no effect on the emergence time. Perioperative esmolol as an adjunct may reduce postoperative pain intensity, opioid consumption, and postoperative nausea vomiting. Given the heterogeneity, larger clinical trials are warranted to confirm these findings.
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ORIGINAL ARTICLES Top

ASSIST - Patient satisfaction survey in postoperative pain management from Indian subcontinent p. 40
Balavenkata Subramanian, Naman Shastri, Lutful Aziz, Ramachandran Gopinath, Anil Karlekar, Yatin Mehta, Anand Sharma, Jitendra Suhas Bapat, Pradeep Jain, Aveek Jayant, Tanvir Samra, Ajantha Perera, Anil Agarwal, Vijay Shetty, Sushma Bhatnagar, Sunil T Pandya, Paramanand Jain
DOI:10.4103/joacp.JOACP_245_16  
Introduction: To compare pain scores at rest and ambulation and to assess patient satisfaction between the different modalities of pain management at different time points after surgery. Settings and Design: The ASSIST (Patient Satisfaction Survey: Pain Management) was an investigator-initiated, prospective, multicenter survey conducted among 1046 postoperative patients from India. Material and Methods: Pain scores, patient's and caregiver's satisfaction toward postoperative pain treatment, and overall pain management at the hospital were captured at three different time points through a specially designed questionnaire. The survey assessed if the presence of acute pain services (APSs) leads to better pain scores and patient satisfaction scores. Statistical Analysis: One-way ANOVA was used to evaluate the statistical significance between different modalities of pain management, and paired t-test was used to compare pain and patient satisfaction scores between the APS and non-APS groups. Results: The results indicated that about 88.4% of patients reported postoperative pain during the first 24 h after surgery. The mean pain score at rest on a scale of 1–10 was 2.3 ± 1.8 during the first 24 h after surgery and 1.1 ± 1.5 at 72 h; the patient satisfaction was 7.9/10. Significant pain relief from all pain treatment was reported by patients in the non-APS group (81.6%) compared with those in the APS (77.8%) group (P < 0.0016). Conclusion: This investigator-initiated survey from the Indian subcontinent demonstrates that current standards of care in postoperative pain management remain suboptimal and that APS service, wherever it exists, is yet to reach its full potential.
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An analysis of perioperative adverse neurological events associated with anesthetic management at a Tertiary Care Center of a developing country p. 48
Fauzia Anis Khan, Sobia Khan, Gauhar Afshan
DOI:10.4103/0970-9185.202195  
Background and Aims: Existing literature on neurological complications related to anesthesia is reported from affluent countries but the trends may vary in less affluent countries. Material and Methods: The objective was to find the associated factors contributing to neurological adverse events occurring within 48 h of anesthesia and surgery. The existing departmental morbidity and mortality database was reviewed from 1992 to 2012 for major adverse neurological events. A standardized methodology was used in reviewing and classifying the data. All adverse events were predefined and categorized before filling the form into the following headers; meningitis, cord/plexus/peripheral nerve injury, stroke, paraparesis/paraplegia/quadriparesis/or quadriplegia, new onset postoperative seizures, postoperative vocal cord injury, and a miscellaneous group. Results: During this period, 195,031 patients underwent anesthesia and twenty-nine patients had major neurological morbidity within 48 h (1:6700). There were three cases of meningitis/meningism, eight cases of cord, plexus or peripheral nerve injury, seven of stroke, four had new onset seizures, one had quadriparesis, five had vocal cord, and one had cranial nerve palsy. Forty-one percent cases received regional anesthesia alone or in combination with the general. In six cases, anesthesia was considered solely responsible. Human error contributed to 93% of these events. Conclusion: This data has helped in identifying areas of concern and can serve as a reference for further audits in the region.
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Intraoperative low tidal volume ventilation strategy has no benefits during laparoscopic cholecystectomy p. 57
Vandna Arora, Asha Tyagi, Surendra Kumar, Aanchal Kakkar, Shukla Das
DOI:10.4103/0970-9185.202200  
Background and Aims: Benefits of intraoperative low tidal volume ventilation during laparoscopic surgery are not conclusively proven, even though its advantages were seen in other situations with intraoperative respiratory compromise such as one-lung ventilation. The present study compared the efficacy of intraoperative low tidal volume ventilatory strategy (6 ml/kg along with positive end-expiratory pressure [PEEP] of 10 cmH2O) versus one with higher tidal volume (10 ml/kg with no PEEP) on various clinical parameters and plasma levels of interleukin (IL)-6 in patients undergoing laparoscopic cholecystectomy. Material and Methods: A total of 58 adult patients with American Society of Anesthesiologists physical status I or II, undergoing laparoscopic cholecystectomy were randomized to receive the low or higher tidal volume strategy as above (n = 29 each). The primary outcome measure was postoperative PaO2. Systemic levels of IL-6 along with clinical indices of intraoperative gas exchange, pulmonary mechanics, and hemodynamic consequences were measured as secondary outcome measures. Results: There was no statistically significant difference in oxygenation; intraoperative dynamic compliance, peak airway pressures, or hemodynamic parameters, or the IL-6 levels between the two groups (P > 0.05). Low tidal volume strategy was associated with significantly higher mean airway pressure, lower airway resistance, greater respiratory rates, and albeit clinically similar, higher PaCO2and lower pH (P < 0.05). Conclusion: Strategy using 6 ml/kg tidal volume along with 10 cmH2O of PEEP was not associated with any significant improvement in gas exchange, hemodynamic parameters, or systemic inflammatory response over ventilation with 10 ml/kg volume without PEEP during laparoscopic cholecystectomy.
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Evaluation of decision-to-delivery interval in emergency cesarean section: A 1-year prospective audit in a tertiary care hospital p. 64
Sunanda Gupta, Udita Naithani, C Madhanmohan, Ajay Singh, Pradeep Reddy, Apoorva Gupta
DOI:10.4103/0970-9185.202197  
Background and Aims: The American College of Obstetricians and Gynecologists (ACOG) committee on professional standards and the National Institute of Clinical Excellence (NICE) guidelines suggest that decision-to-delivery interval (DDI) and emergency cesarean section (CS) should not be more than 30 min, and a delay of more than75 min in the presence of maternal or fetal compromise can lead to poor outcome. This prospective 1-year study was conducted on emergency CS in a tertiary care hospital to evaluate the DDI, factors affecting it and to analyze their effects on maternal and neonatal outcome. Material and Methods: A structured proforma was used to analyze the data from all women undergoing emergency CS, during a 1-year period, included in Category 1 and 2 of NICE guidelines for CS. Results: A total of 453 emergency CSs were evaluated, with a mean DDI of 36.3 ± 17.2 min for Category 1 CS and 38.1 ± 17.7 min for Category 2 CS (P > 0.05). Only 42.4% emergency CSs confirmed to the 30 min DDI while 57.6% had a DDI of more than 30 min. Reasons of delay were identified as a delay in shifting the patient to operation theater (22.1%), anesthesia factors (18.1%), and lack of resources or manpower (16.1%). Maternal complications occurred in 15 (3.3%) patients with 3 (0.7%) nonsurvivors having a DDI of 91.0 ± 97.0 min as compared to survivors with a DDI of 36.8 ± 15.7 min, P = 0.001. There was no significant association between DDI and occurrence of neonatal complications. Conclusion: Failure to meet the current recommendations was associated with adverse maternal outcomes, but not with adverse neonatal outcome.
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Comparison of trapezius squeeze test and jaw thrust as clinical indicators for laryngeal mask airway insertion in spontaneously breathing children p. 71
KK Dinesh Kumar, Neerja Bhardwaj, Sandhya Yaddanapudi
DOI:10.4103/0970-9185.202204  
Background and Aims: It is not known whether trapezius squeeze test (TPZ) is a better clinical test than jaw thrust (JT) to assess laryngeal mask airway (LMA) insertion conditions in children under sevoflurane anesthesia. Material and Methods: After the Institutional Ethics Committee approval and written informed parental consent, 124 American Society of Anesthesiologists I and II children of 2–8 years of age undergoing minor surgical procedures were randomized into TPZ and JT groups. The children were induced with 8% sevoflurane in oxygen at a fresh gas flow of 4 L/min. TPZ or JT was performed after 1 min of start of sevoflurane and then every 20 s till the test was negative, when end-tidal (ET) sevoflurane concentration was noted. Classic LMA of requisite size was inserted by a blinded anesthetist and conditions at the insertion of LMA, insertion time, and the number of attempts of LMA insertion were recorded. Results: The mean LMA insertion time was significantly longer (P < 0.001) for TPZ (145 ± 28.7 sec) compared to JT group (111.8 ± 31.0 sec). ET sevoflurane concentration at the time of LMA insertion was comparable in the two groups. LMA insertion conditions were similar in the two groups. There was no difference between the two groups regarding total number of attempts of LMA insertion. Heart rate (HR) decreased in both groups after LMA insertion (P < 0.001) but TPZ group had significantly lower HR compared with the JT group up to 5 min after LMA insertion (P = 0.03). Conclusion: Both JT and TPZ are equivalent clinical indicators in predicting the optimal conditions of LMA insertion in spontaneously breathing children; however, it takes a longer time to achieve a negative TPZ squeeze test.
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Comparison between ketamine and hyoscine for the management of postoperative catheter-related bladder discomfort: A randomized controlled double-blind study p. 76
Atef Kamel Salama
DOI:10.4103/0970-9185.202191  
Background and Aim: Postoperative catheter-related bladder discomfort (CRBD) can be a distressing complication for patients in whom a urinary catheter was inserted intraoperatively and is accompanied with patients' dissatisfaction. This trial investigated the efficacy of hyoscine and ketamine on treatment of postoperative CRBD in patients undergoing various surgeries. Material and Methods: This was a prospective randomized, double-blind study, which included 60 American Society of Anesthesiologists Class I-II male patients undergoing elective nonurological operations requiring intraoperative urinary catheterization under general anesthesia after ethical approval and written informed consent. Patients were allocated randomly into two groups: The hyoscine group (H group) (n = 30) received 20 mg of hyoscine intravenously and ketamine group (K group) (n = 30) received 0.25 mg/kg of ketamine intravenously immediately after the occurrence of CRBD. The severity of CRBD was assessed at 0, 1, 2, and 4 h postoperatively. Adverse effects of hyoscine and ketamine were also examined. Data were summarized using mean ± standard deviation, and comparisons between groups were done by unpaired t-test. For comparison of serial measurements within each group, ANOVA was used. Results: There was a significant difference between the two groups in the severity of CRBD measured by visual analog scale score only 30 min after drug administration where it was higher in ketamine group (44.50 ± 7.70) compared to hyoscine group (36.00 ± 8.55) (P < 0.001), otherwise there was no significant difference at other time points between the two groups, also there was a significant rise in heart rate in hyoscine group but no significant difference in mean arterial pressure. Conclusion: Intravenous hyoscine 20 mg is more effective in control of CRBD than ketamine (0.25 mg/kg) in the first 30 min; later on they have the same effect.
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Efficacy of dexmedetomidine with ropivacaine in supraclavicular brachial plexus block for upper limb surgeries p. 81
Jithendra Chinnappa, Shivakumar Shivanna, Vinayak Seenappa Pujari, Tejesh Channasandra Anandaswamy
DOI:10.4103/0970-9185.202196  
Background and Aims: The primary aim of this study was to evaluate the effect of addition of dexmedetomidine on the duration of analgesia in patients undergoing upper limb surgeries under supraclavicular brachial plexus block. Material and Methods: Sixty patients of American Society of Anesthesiologists physical status I/II/III undergoing elective upper limb surgeries under supraclavicular brachial plexus block using nerve stimulator were randomized into two groups. Group A (n = 30) received 30 mL 0.5% ropivacaine and 1 mL normal saline, and Group B (n = 30) received 30 mL 0.5% ropivacaine and 1 μg/kg of dexmedetomidine. The primary outcome was the duration of analgesia. Secondary outcomes included time to onset and duration of sensory/motor blockade. Statistical Analysis: Results on continuous measurements are presented as mean ± standard deviation and compared using Student's unpaired t-test. Results on categorical measurements are presented in number (%) and compared using Chi-square test. Results: Onset of sensory and motor block in Group A (13.0 ± 4.1 and 23.5 ± 5.6 min) was slower than those in Group B (9.5 ± 5.8 and 15.6 ± 6.3 min; P = 0.009 for sensory and P < 0.001 for the motor block). Duration of sensory and motor block in Group A (400.8 ± 86.6 and 346.9 ± 76.9 min) was shorter than those in Group B (630.6 ± 208.2 and 545.9 ± 224.0 min; (P < 0.001). The duration of analgesia in Group A (411.0 ± 91.2 min) was shorter than that in Group B (805.7 ± 205.9 min; P < 0.001). The incidence of bradycardia and hypotension was higher in Group B than in Group A (P < 0.001). Conclusion: Perineural dexmedetomidine with ropivacaine provides prolonged postoperative analgesia, hastens the onset of sensory and motor block and prolongs the duration of the supraclavicular brachial plexus block.
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Work-related stress: A survey of Indian anesthesiologists p. 86
Sumitra Ganesh Bakshi, Jigeeshu Vasishtha Divatia, Sadhana Kannan, Sheila Nainan Myatra
DOI:10.4103/joacp.JOACP_390_15  
Background and Aims: Work-related stress is common among medical caregivers and concerns all perioperative care providers. Although anesthesiologists are known to experience stress, there are limited Indian data addressing this issue. This survey was conducted among Indian anesthesiologists to determine their awareness about work stress and views regarding prevention programs. Material and Methods: A survey questionnaire was distributed to delegates visiting the exhibits at the national anesthesiology conference in 2011. The questionnaire had ten questions on the work pattern, five on work-related stress, nine on opinion regarding the need and willingness to participate in stress-related programs. Results: There were 1178 responders. Forty-three percent were faculty in medical institutions, 26% were residents and 25% were in free-lance practice. Ninety-one percent of participants rated their stress as moderate-extreme. There was a significant correlation between the amount of stress and working for more than 8 h (P < 0.001), handling high risk patients (P = 0.002), working on weekends (P = 0.002), and carrying work back home (P < 0.001). Forty-one percent of respondents were very satisfied professionally. Seventy-six percent of doctors agreed that the questionnaire had made them think about work stress. Eighty-four percent of participants felt the need for stress management programs and 69% expressed their willingness to participate in the same. Conclusion: The majority of participants rated their stress as moderate-extreme and was higher in anesthesiologists working long hours, over the weekend and those handling high-risk patients. A majority of participants felt the survey made them think about work-related stress and expressed their willingness to participate in stress management programs.
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Comparing slow and rapid bolus of ephedrine in pregnant patients undergoing planned cesarean section under spinal anesthesia p. 92
Prabu Gunasekaran, Lenin Babu Elakkumanan, Hemavathi Balach, M. V. S. Satyaprakash
DOI:10.4103/0970-9185.202183  
Background and Aims: While ephedrine was the preferred drug for treating spinal-induced hypotension in pregnancy, its use has declined because of resultant fetal acidosis. The objective of this randomized control trial was to compare the effects of a slow and rapid bolus of ephedrine on fetal acidosis, maternal blood pressure, and heart rate (HR) during cesarean section performed under spinal anesthesia. Material and Methods: Eighty full-term parturients scheduled for cesarean section under spinal anesthesia were randomly allocated into two groups. While both groups received 6 mg of ephedrine to treat hypotension, Group R (n = 40) received it as a rapid intravenous bolus and Group S (n = 40) received it slowly over 20 s with an infusion pump. The maternal vital parameters were recorded until delivery of the baby using a video camera. Umbilical cord blood was obtained using the three clamp method. Hemodynamic parameters, fetal acidosis, total number of ephedrine bolus used, peak HR after the ephedrine bolus, and occurrence of postoperative nausea and vomiting (PONV) were compared between the groups. Results: Mean increase in HR and blood pressure were significantly higher in Group R than the Group S after the first ephedrine bolus. Umbilical artery pH was significantly lower in Group R than in Group S (7.2 [6.8-7.3] vs. 7.3 [7.3-7.4], P < 0.01). A total number of ephedrine boluses were comparable in the two groups. 35% of the patients had PONV in Group R, whereas none had it in Group S (P < 0.01). Conclusion: Slow bolus of ephedrine is better than rapid bolus to treat spinal-induced hypotension during cesarean section in view of less fetal acidosis.
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Comparison of sevoflurane and propofol for laryngeal mask airway insertion and pressor response in patients undergoing gynecological procedures p. 97
Shirishkumar Gulabrao Chavan, Surita Mandhyan, Sandhya Haridas Gujar, Gourish Prakash Shinde
DOI:10.4103/joacp.JOACP_313_15  
Background and Aims: A popular method of providing anesthesia for laryngeal mask airway (LMA) insertion is with the use of propofol. However, bolus propofol has been associated with adverse effects such as hypotension, apnea and pain on injection. Hence, time is needed to search an alternative. We aimed to compare the induction characteristics, ease of LMA insertion, hemodynamic changes and complications with inhalation of 8% sevoflurane vital capacity breath and propofol. Material and Methods: A prospective randomized study of 60 American Society of Anesthesiologists' Grade I and II patients was conducted and distributed among two groups with 30 each undergoing gynecological procedures under general anesthesia. Group P received the injection propofol and Group S received sevoflurane. At the end point of induction, the LMA insertion was attempted. Scoring systems were used to grade the conditions for insertion of the LMA. Induction, LMA insertion characteristics, hemodynamic changes, complications were assessed. Data were recorded and analyzed. Comparison among the study groups was done with unpaired t-test, Mann–Whitney test and Chi-square test. Results: Sevoflurane took a longer time for induction and for LMA insertion than propofol. There was no statistically significant difference between the two groups, with respect to LMA insertion characteristics, heart rate, mean arterial pressure. It is concluded that sevoflurane is associated with good hemodynamic stability and may prove useful incases where propofol is to be avoided. However, the ease of insertion provided with propofol is better.
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A comparative study of the effect of clonidine, fentanyl, and the combination of both as adjuvant to intrathecal bupivacaine for postoperative analgesia in total abdominal hysterectomy p. 102
Fareed Ahmed, Mamta Khandelwal, Anil Sharma
DOI:10.4103/0970-9185.202194  
Background and Aims: The aim of this study was to evaluate the level of sensory block, onset and duration of motor block, postoperative analgesia, and adverse effects of combination of clonidine and fentanyl given intrathecally with hyperbaric bupivacaine (HB). Material and Methods: Three hundred and twenty eight patients were randomized into four groups. Group bupivacaine (group B) received 15 mg of HB; group bupivacaine clonidine (group BC) received 15 mg of HB plus 25 μg clonidine; group bupivacaine fentanyl (group BF) received 15 mg of HB plus 25 μg fentanyl and group bupivacaine clonidine fentanyl (group BCF) received 15 mg of HB plus 25 μg clonidine and 25 μg fentanyl intrathecally. All groups were evaluated for level of sensory block, onset and duration of motor block, postoperative analgesia, VAS score, sedation score and adverse effects of study drugs. All the data were analyzed using unpaired t-test. P < 0.05 was considered significant. Results: The level of sensory block, onset, and duration of motor block were comparable in all groups. Total duration of analgesia was 407.3 ± 20 min in group BCF compared to 242.1 ± 2 min and 209.2 ± 16 in groups BC and BF, respectively. Lesser doses of rescue analgesic were required in group BCF. The time interval from intrathecal injection to two-segment regression was statistically significant in study groups. Only 2.4% patients showed mild sedation in BCF group. Conclusion: We found that combination of intrathecal clonidine and fentanyl along with bupivacaine increases the total duration of analgesia without significant side effects.
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Comparison of success of tracheal intubation using Macintosh laryngoscope-assisted Bonfils fiberscope and Truview video laryngoscope in simulated difficult airway p. 107
Bangaru Vivek, R Sripriya, Gayatri Mishra, M Ravishankar, S Parthasarathy
DOI:10.4103/0970-9185.202198  
Background and Aims: Restriction of head and neck movements prevents the alignment of the oral, pharyngeal, and laryngeal axes and increases the incidence of difficult tracheal intubation in patients with cervical spine fractures. Video laryngoscopes have gained an important role in the management of difficult intubation, especially in situations with limited head and neck movements. This study compares the success of intubation using Macintosh laryngoscope assisted Bonfils® fiberscope (ML-BF) with TruviewPCD video laryngoscope (TV) in patients with simulated restricted head and neck movements. Material and Methods: One hundred and fifty-two patients satisfying the inclusion criteria were randomly allocated to two groups of 76 each. Patients were made to lie supine on the table without a pillow and a soft collar was used to restrict head and neck movements. After a standardized premedication-induction sequence, tracheal intubation was done either with ML-BF or TV. Success of intubation, time taken for successful intubation, hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were noted. Results: Intubation was successful in all the 76 patients in direct laryngoscopy-Bonfils fiberscope group and 75 out of 76 patients in TV group within the specified time (90 s). The median time taken for successful intubation with TV and ML-BF were 44 (range 26–80) s and 49 (range 28–83) s, respectively. Hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were similar in both groups. Conclusion: Both TV and ML-BF are equally effective for successful tracheal intubation in patients with simulated restricted head and neck movements. In cases of difficult laryngeal visualization with routine Macintosh laryngoscope, Bonfils can be used as an adjunct to achieve successful intubation in the same laryngoscopy attempt.
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COMMENTARY Top

Is it time to separate consent for anesthesia from consent for surgery? p. 112
Tejinder Singh Swaran Singh
DOI:10.4103/0970-9185.202206  
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CASE REPORTS Top

Combined mitral and aortic stenosis in parturient: Anesthesia management for labor and delivery p. 114
Manish Kela, Madhvi Buddhi
DOI:10.4103/0970-9185.168169  
Maternal heart disease complicates 0.2-3% of pregnancies. The optimal management of the pregnant patient with cardiac disease depends on the co-operative efforts of the obstetrician, the cardiologist and the anesthesiologist involved in peripartum care. A comprehensive understanding of physiology of pregnancy and pathophysiology of underlying cardiac disease is of primary importance in provision of obstetric analgesia or anesthesia for these high-risk groups of patients. We report a successful and uncomplicated use of epidural anesthesia for labor and delivery in patient with combined aortic and mitral stenosis.
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Disseminated intravascular and intracardiac thrombosis after cardiopulmonary bypass p. 117
Deepak K Tempe, Parin Lalwani, Kapil Chaudhary, Harpreet S Minas, Akhlesh S Tomar
DOI:10.4103/0970-9185.173340  
Massive intracardiac and intravascular thrombosis is a rare complication following cardiopulmonary bypass (CPB). Most of the cases of the disseminated thrombosis have been reported in patients undergoing complex cardiac surgeries and those receiving antifibrinolytic agents during CPB. We report the occurrence of disseminated intravascular and intracardiac thrombosis after CPB in a patient undergoing mitral valve replacement in which no antifibrinolytic agent was used. The possible pathophysiology and management of the patient is discussed.
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Transversus abdominis plane catheters for postoperative pain relief in pediatric patients p. 121
Sumitra G Bakshi, Jeson R Doctor, Bhakti D Trivedi, Sajid S Qureshi
DOI:10.4103/0970-9185.202187  
Regional techniques provides excellent post operative pain relief in pediatric patients. Transversus abdominis plane (TAP) block is a newer regional technique available. Though there is emerging evidence proving the efficacy of TAP blocks, there is limited literature on use of TAP catheters in pediatric patients.TAP catheters were placed in two children following laparotomy with transverse incisions and in both epidural was avoided, with good post operative pain relief. Ultrasound guidance was used in one child, while in the other the catheter was placed under direct vision after dissection of the plane between transversus abdominis and internal oblique. Intermittent boluses of high volumes of local anesthetic (0.6-0.7 ml/kg) were used through the TAP catheter, ensuring that the maximum permissible level of bupivacaine was not exceeded. In adults, continuous abdominal catheters have found a place for post-operative pain management, when epidural analgesia is contraindicated. At present, the use of TAP catheters by pediatric anesthesiologists is limited, though there exists diverse clinical scenarios when these catheters may be of benefit. Contraindication of neuraxial blockade and septic patients are the two scenarios we have reported. In conclusion, TAP catheters are effective analgesia technique for laparotomies with transverse incision in pediatric patients.
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LETTERS TO EDITOR Top

De-addiction: A new risk for anesthesia p. 123
Gurkaran Kaur, Seema Jindal, Gurpreet Kaur
DOI:10.4103/0970-9185.202202  
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Obtaining external jugular venous access in the prone-positioned patient p. 124
Glen Atlas, Mina Mosaad, Faraz Chaudhry, Yuriy Gubenko
DOI:10.4103/0970-9185.202193  
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Intra-operative mechanical ventilation in amebic liver abscess surgery: Another paradigm p. 125
Aanchal Kakkar, Asha Tyagi, Ashok Kumar Sethi
DOI:10.4103/0970-9185.202189  
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Unusual case of endotracheal tube obstruction by caseous necrotic material p. 127
Madhu Gupta, Iti Shri
DOI:10.4103/0970-9185.202186  
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Green urine: A cause for concern? p. 128
Smita Prakash, Suman Saini, Parul Mullick, Mridula Pawar
DOI:10.4103/0970-9185.202190  
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LMA Proseal for the surgical procedures in prone positioning p. 130
Bimla Sharma, Jayashree Sood, Raminder Sehgal, Chand Sahai, Anjali Gera
DOI:10.4103/0970-9185.168194  
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In response to: Comparison of paravertebral and interpleural block in patients undergoing modified radical mastectomy p. 131
Souvik Maitra, Dalim Kumar Baidya, Sulagna Bhattacharjee
DOI:10.4103/0970-9185.168161  
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Response to the letter for the article: Use of transversus abdominis plane block as an anesthetic technique in a high-risk patient for abdominal wall surgery p. 132
Samina Ismail, Muhammad Rizwan Khan, Sana Urooj
DOI:10.4103/0970-9185.173327  
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Emergency airway management of intratracheal tumor in a patient with respiratory distress p. 133
Rakesh Garg, Shalini Saini, Vinod Kumar, Nishkarsh Gupta
DOI:10.4103/0970-9185.168258  
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Immediate onset of postdural puncture headache after spinal anesthesia p. 134
Swati Singh
DOI:10.4103/0970-9185.168166  
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Ketamine-induced QTc interval prolongation p. 136
Tejinder S. Swaran Singh, Foad Elahi, Brian Cheney
DOI:10.4103/0970-9185.173335  
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BOOK REVIEW Top

“MORBID OBESITY: Anesthesia and perioperative management” edited by Aparna Sinha p. 139
Anju Grewal
DOI:10.4103/joacp.JOACP_65_17  
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