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   2014| April-June  | Volume 30 | Issue 2  
    Online since April 9, 2014

 
 
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ORIGINAL ARTICLES
The association of gender and body mass index with postoperative pain scores when undergoing ankle fracture surgery
Samuel Robert Grodofsky, Ashish C Sinha
April-June 2014, 30(2):248-252
DOI:10.4103/0970-9185.130041  PMID:24803767
Background: Intraoperative administration of opiates for postoperative analgesia requires a dosing strategy without clear indicators of pain in an anesthetized patient. Preoperative patient characteristics such as body mass index (BMI), gender, age, and other patient characteristics may provide important information regarding opiate requirements. This study intends to determine if there is an association between gender or BMI and the immediate postoperative pain scores after undergoing an open reduction and internal fixation (ORIF) of an ankle fracture with general anesthesia and morphine only analgesia. Materials and Methods: Using a retrospective cohort design, the perioperative records were reviewed at a university healthcare hospital.One hundred and thirty-seven cases met all inclusion and no exclusion criteria. Postanesthesia care unit (PACU) records were reviewed for pain scores at first report and 30 min later as well as PACU opiate requirements. T-test, chi-square, and Mann-Whitney tests compared univariate data and multivariate analysis was performed by linear regression. Results: There were no statistically significant PACU pain score group differences based on gender or BMI. Post hoc analysis revealed that in the setting of similar pain scores, obese patients received a similar weight based intraoperative morphine dose when using adjusted body weight (ABW) compared to nonobese subjects. A further finding revealed a negative correlation between age and pain score (P = 0.001). Conclusion: This study did not find an association between obesity or gender and postoperative pain when receiving morphine only preemptive analgesia. This study does support the use of ABW as a means to calculate morphine dosing for obese patients and that age is associated with lower immediate pain scores.
  13 2,071 413
REVIEW ARTICLES
Are we causing the recurrence-impact of perioperative period on long-term cancer prognosis: Review of current evidence and practice
Jyotirmoy Das, Sudhir Kumar, Sangeeta Khanna, Yatin Mehta
April-June 2014, 30(2):153-159
DOI:10.4103/0970-9185.129996  PMID:24803749
Newer developments in the field of chemotherapeutic drug regimes, radiotherapy, and surgical techniques have improved the prognosis of cancer patients tremendously. Today increasing numbers of patients with aggressive disease are posted for surgical resection. The advances in reconstructive flap surgery offer the patient a near normal dignified postresection life. Hence, the expectations from the patients are also on the rise. Anesthetic challenges known in oncosurgery are that of difficult airway, maintenance of hemodynamics and temperature during long surgical hours, pain management, and postoperative intensive care management. But, recently acquired data raised the possibility of the anesthetic technique and conduct of perioperative period as a possible contributory factor in the growth and possible recurrence of the primary tumor. The foundation of the concept is somewhat fragile and not supported by conclusive evidence. In fact, like any other controversial topic in medicine, contradictory reports of the favorable effects of anesthetic technique and medications are plenty in the literature. This is the basis of our article where we have analyzed the current evidence available in the literature and how these and the forthcoming large scale studies may revolutionize the practice of oncoanesthesia.
  13 3,906 1,037
Antioxidants: The new frontier for translational research in cerebroprotection
Anurag Tewari, Vidhi Mahendru, Ashish Sinha, Federico Bilotta
April-June 2014, 30(2):160-171
DOI:10.4103/0970-9185.130001  PMID:24803750
It is important for the anesthesiologist to understand the etiology of free radical damage and how free-radical scavengers attenuate this, so that this knowledge can be applied to diverse neuro-pathological conditions. This review will concentrate on the role of reactive species of oxygen in the pathophysiology of organ dysfunction, specifically sub arachnoid hemorrhage (SAH), traumatic brain injury (TBI) as well as global central nervous system (CNS) hypoxic, ischemic and reperfusion states. We enumerate potential therapeutic modalities that are been currently investigated and of interest for future trials. Antioxidants are perhaps the next frontier of translational research, especially in neuro-anesthesiology.
  13 4,118 885
ORIGINAL ARTICLES
Prevention of propofol injection pain: Comparison between lidocaine and ramosetron
Dipali Singh, Sathyanarayan Jagannath, Shio Priye, Shivaprakash , Chandrashekar Kadli, Durgaprasad Reddy
April-June 2014, 30(2):213-216
DOI:10.4103/0970-9185.130023  PMID:24803760
Background: Propofol causes a high incidence of pain during intravenous (IV) injection. The aim of this randomized, placebo-controlled, double-blinded study was to determine whether pre-treatment with IV ramosetron, used for prophylaxis of postoperative nausea and vomiting (PONV), would reduce propofol-induced pain as an equivalent to lidocaine. Materials and Methods: Hundred and twenty American Society of Anesthesiologists grade (ASA) I and II patients were randomly assigned into three groups (40 in each). Group N received 2 ml of 0.9% saline, Group L received 2 ml of lidocaine, and Group R received 2 ml of ramosetron. Mid forearm was occluded manually before injection and released after 1 min and then propofol was injected over 5 s. Patients were observed and questioned 15 s later if they had pain in the arm and pain was scored on a four-point scale: 0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain. Unpaired Student's t-test and chi-square test/Fisher' exact test were used to analyze results. Results: The incidence of pain in groups N, L, and R were 65, 35, and 30%, respectively. Pain was reduced significantly in the groups L and R (P < 0.05). Two patients each in Groups L and R (5% each) had moderate and severe pain. This difference in pain was statistically insignificant, but when compared to Group N (25 and 30%, respectively) it was statistically significant. Conclusion: Pretreatment with ramosetron 0.3 mg and lidocaine 40 mg are equally effective in preventing pain from propofol injection.
  11 5,846 867
Prophylactic effect of ephedrine to reduce hemodynamic changes associated with anesthesia induction with propofol and remifentanil
Mansoor Masjedi, Farid Zand, Asif Perviz Kazemi, Ali Hoseinipour
April-June 2014, 30(2):217-221
DOI:10.4103/0970-9185.130024  PMID:24803761
Background: One of the complications of anesthesia induction with propofol is a substantial decrease in arterial blood pressure and heart rate (HR), which can be intensified by adding remifentanil. This study aimed to assess the prophylactic effects of two doses of ephedrine to control the hypotension and bradycardia caused by anesthesia induced with propofol and remifentanil. Materials and Methods: A total of 150 patients candidate for short-term minor elective orthopedic and ophthalmic surgery under general anesthesia were randomized to three groups receiving normal saline, low dose ephedrine (0.07 mg/kg) or high dose ephedrine (0.15 mg/kg). Anesthesia was induced in all groups with propofol 2.5 mg/kg and remifentanil 3 μg/kg. No neuromuscular blocking agent was used. Patients' hemodynamic status was assessed in the following four steps: Immediately before, 2 min after induction of anesthesia, as well as 1 and 5 min after intubation. Results: A total of 143 patients consisting of 46 patients in the low dose ephedrine (0.07 mg/kg) group, 49 patients in the high dose ephedrine (0.15 mg/kg) group and 48 controls completed the trial. In all three groups, after induction of anesthesia, significant decreases occurred in the mean systolic, diastolic and mean arterial pressures, as well as in the mean HR. This decline was highest in the control group and lowest in the high dose ephedrine (0.15 mg/kg) group. Conclusion: Our findings suggest that the administration of high dose ephedrine (0.15 mg/kg) may have a significant effect in preventing hypotension and bradycardia after anesthesia induction with propofol and remifentanil.
  10 6,829 856
Comparison of i-gel supraglottic airway and LMA-ProSeal™ in pediatric patients under controlled ventilation
Sai Saran, Sandeep Kumar Mishra, Ashok Shankar Badhe, Arumugam Vasudevan, Lenin Babu Elakkumanan, Gayatri Mishra
April-June 2014, 30(2):195-198
DOI:10.4103/0970-9185.130013  PMID:24803756
Background: i-gel™ and the ProSeal™ laryngeal mask airway (PLMA) are two supraglottic airway devices with gastric channel used for airway maintenance in anesthesia. This study was designed to evaluate the efficacy of i-gel compared with PLMA for airway maintenance in pediatric patients under general anesthesia with controlled ventilation. Materials and Methods: A total of 60 American Society of Anesthesiologists physical status 1 and 2 patients were included in the study and randomized to either i-gel or PLMA group. After induction of anesthesia using a standardized protocol for all the patients, one of supraglottic airway devices was inserted. Insertion parameters, ease of gastric tube insertion and fiber-optic scoring of the glottis were noted. Airway parameters such as end-tidal carbon dioxide (EtCO 2 ), peak airway pressures and leak airway pressures were noted. Patients were observed for any complications in the first 12 h of the post-operative period. Results: Both groups were comparable in terms of ease of insertion, number of attempts and other insertion parameters. Ease of gastric tube insertion, EtCO 2 , airway pressures (peak and leak airway pressure) and fiber-optic view of the glottis were comparable in both groups. There were no clinically significant complications in the first 12 h of the post-operative period. Conclusion: i-gel is as effective as PLMA in pediatric patients under controlled ventilation.
  10 3,848 846
EDITORIALS
Anesthesia and cancer recurrence: What is the evidence?
Jigeeshu V Divatia, Reshma Ambulkar
April-June 2014, 30(2):147-150
DOI:10.4103/0970-9185.129990  PMID:24803747
  9 5,666 1,266
ORIGINAL ARTICLES
Comparison of I-gel with proseal LMA in adult patients undergoing elective surgical procedures under general anesthesia without paralysis: A prospective randomized study
Gurudas Kini, Gopalkrishna Mettinadka Devanna, Koteswara Rao Mukkapati, Souvik Chaudhuri, Daniel Thomas
April-June 2014, 30(2):183-187
DOI:10.4103/0970-9185.130008  PMID:24803754
Background: We compared i-gel and ProSeal laryngeal mask airway (PLMA) regarding time taken for insertion, effective seal, fiberoptic view of larynx, ease of Ryle's tube insertion, and postoperative sore throat assessment. Materials and Methods: In a prospective, randomized manner, 48 adult patients of American Society of Anesthesiologists I-II of either gender between 18 and 60 years presenting for a short surgical procedure were assigned to undergo surgery under general anesthesia on spontaneous ventilation using either the i-gel or PLMA. An experienced nonblinded anesthesiologist inserted appropriate sized i-gel or PLMA in patients using standard insertion technique and assessed the intraoperative findings of the study regarding regarding time taken for respective device insertion, effective seal, fiberoptic view of larynx, ease of Ryle's tube insertion, and postoperative sore throat assessment. Postoperative assessment of sore throat was done by blinded anesthesia resident. Results: The time required for insertion of i-gel was lesser (21.98 ± 5.42 and 30.60 ± 8.51 s in Group I and Group P, respectively; P = 0.001). Numbers of attempts for successful insertions were comparable and in majority, device was inserted in first attempt. The mean airway leak pressures were comparable. However, there were more number of patients in Group P who had airway leak pressure >20 cm H 2 O. The fiberoptic view of glottis, ease of Ryle's tube insertion, and incidence of complications were comparable. Conclusion: Time required for successful insertion of i-gel was less in adult patients undergoing short surgical procedure under general anesthesia on spontaneous ventilation. Patients with airway leak pressure >20 cm H 2 O were more in PLMA group which indicates its better suitability for controlled ventilation.
  8 3,301 786
SPECIAL ARTICLE
VEINROM: A possible solution for erroneous intravenous drug administration
Anurag Tewari, Brady Palm, Taylor Hines, Trace Royer, Eric Alexander
April-June 2014, 30(2):263-266
DOI:10.4103/0970-9185.130055  PMID:24803770
Erroneous intravenous drug administration has a high probability of causing substantial financial consequences along with patient morbidity or mortality. Anesthesiologists and hospital administrators need to be cognizant of the problem. National and international anesthesiology bodies should be involved with the medical device manufacturing industry to alleviate this long standing enigma. We propose our concept Vassopressors, Emergency drugs, Induction agents, Reversal agents, Opioids and Miscellaneous (VEINROM) as a conceivable solution to this paradox.
  8 7,357 529
ORIGINAL ARTICLES
Transtracheal lidocaine: An alternative to intraoperative propofol infusion when muscle relaxants are not used
Sunil Rajan, Nitu Puthenveettil, Jerry Paul
April-June 2014, 30(2):199-202
DOI:10.4103/0970-9185.130016  PMID:24803757
Background: Facial nerve monitoring, often required during total parotidectomy, precludes use of long acting muscle relaxants and propofol infusion is used solely to ensure patient immobility. We aimed to compare intraoperative patient immobility, hemodynamic stability and propofol consumption during total parotidectomy following a transtracheal block. Material and Methods: Forty patients were allocated to 2 equal groups. Preoperatively, group A patients received transtracheal block with 4 ml of 4% lidocaine, while no block was given to patients in group B. If there was patient movement, tachycardia or hypertension, group A patients received a bolus of propofol 30 mg and propofol infusion was started (100mg/hr). In group B, propofol infusion was started (100mg/hr) soon after intubation. Result: Both group A and B were comparable with respect to patient immobility and hemodynamic stability. There was no intraoperative propofol requirement in group A. Conclusion: Transtracheal block is a safe and successful alternative to propofol infusion during surgeries where muscle relaxants are to be avoided.
  6 2,723 500
Perioperative management and post-operative course in preterm infants undergoing vitreo-retinal surgery for retinopathy of prematurity: A retrospective study
Renu Sinha, Praveen Talawar, Rashmi Ramachandran, Rajvardhan Azad, Virender Kumar Mohan
April-June 2014, 30(2):258-262
DOI:10.4103/0970-9185.130050  PMID:24803769
Background: Premature infants scheduled for surgery under general anesthesia are more prone to cardio-respiratory complications. Risk factors include post-conception age (PCA), cardiac and respiratory disease, anemia and opioid administration. This retrospective study evaluates the perioperative management and post-operative course (apnea and bradycardia) in premature infants undergoing surgery for retinopathy of prematurity (ROP). Materials and Methods: We analyzed the pre-operative data, anesthesia chart and post-operative course of 52 former premature infants for 56 general anesthesia exposures for ROP surgery. Results: At the time of procedure, median PCA was 51 (36-60) weeks. 71% of the infants were above 46 weeks of PCA. Five infants had cardiac disease and four had a history of convulsion. Four infants had a pre-operative history of apneic spells. The airway was secured with either endotracheal tube (46) or supraglottic device (10). Fentanyl (0.5-1 μg/kg), paracetamol, topical anesthetic drops and/or peribulbar block were administered for analgesia. Extubation was performed in the operating room for 54 cases. Three infants had apnea post-operatively. Seven infants were shifted to neonatal intensive care unit either for observation or due to delayed recovery, persistent apneic spells and pre-existing cardio-respiratory disease. Conclusion: In the present study, intravenous paracetamol and topical anesthetics reduced the total intra-operative opioid requirement, which resulted in low incidence of post-operative apnea. Regional anesthesia may be considered in infants with high risk of post-operative apnea. Infants with PCA > 42 weeks and without any co-morbidity can be managed in post-anesthesia care unit.
  6 3,020 527
The efficacy and hemodynamic response to Dexmedetomidine as a hypotensive agent in posterior fixation surgery following traumatic spine injury
Ramila H Jamaliya, Rajesh Chinnachamy, Jyotsna Maliwad, Varun P Deshmukh, Bharat J Shah, Indu A Chadha
April-June 2014, 30(2):203-207
DOI:10.4103/0970-9185.130021  PMID:24803758
Aim: This study was designed to evaluate the efficacy of dexmedetomidine (DEX) as a hypotensive agent in comparison to nitroglycerin (NTG) in posterior fixation surgery for traumatic spine injury. Materials and Methods: Forty patients ASA I or II aged 18-65 years scheduled for posterior fixation surgery were randomly assigned to receive either DEX 1 μg/kg over 10 min before induction of anesthesia followed by 0.2-0.7 μg/kg/h infusion during maintenance in DEX group or NTG 3-5 μg/kg/min infusion after induction of anesthesia in NTG group to maintain mean arterial blood pressure (MAP) between 65 and 70 mmHg. The two groups were compared for achievement of target MAP, intraoperative blood loss, and reversibility of hypotensive state.Student's t-test was used for continuous variables and chi-square test for categorical variables. P-value < 0.05 was considered significant. Results: Patients in DEX group achieved the target MAP with better heart rate (HR) control, as compared to NTG group during the period of observation. The blood loss was significantly lesser in the DEX group (422.11 ± 149.34 ml) than the NTG group (564.51 ± 160.88 ml), P = 0.01. The time to hypotension reversal in NTG group (5.63 ± 1.93 min) was lesser compared to DEX group (9.15 ± 2.16 min), P = 0.65. Conclusion: DEX is an effective and safe agent in achieving controlled hypotension in adults undergoing posterior fixation spine surgery.
  5 2,966 564
Low dose intrathecal clonidine and fentanyl added to hyperbaric bupivacaine prolongs analgesia in gynecological surgery
Pooja Chopra, Vandana Talwar
April-June 2014, 30(2):233-237
DOI:10.4103/0970-9185.130029  PMID:24803764
Background: We undertook this study to ascertain if a small dose of clonidine (30 μg) when added to a bupivacaine-fentanyl mixture improves spinal analgesia, without producing side effects, as compared to a bupivacaine-fentanyl or a bupivacaine-clonidine mixture. Materials and Methods: In this prospective, randomized, double-blind study, 75 (American Society of Anesthesiologists) ASA grade I-II patients, aged between 45 and 65 years, who were scheduled for vaginal hysterectomy with pelvic floor repair or non-descent vaginal hysterectomy under spinal anesthesia were recruited. The patients received hyperbaric bupivacaine (2.3 ml) with fentanyl 15 μg (Group BF) or clonidine 30 μg (Group BC) or both fentanyl (15 μg) and clonidine (30 μg) (Group BCF). The total amount of intrathecal mixture was constant (2.8 ml) in all the groups. Duration of sensory, motor block and effective analgesia, hemodynamic profile, postoperative pain score and analgesic requirements were recorded. Results: The duration of effective analgesia, mean time till two-segment regression, and duration of sensory and motor block were significantly longer in group BCF as compared to group BC (P ~ 0.002), and in group BC as compared to group BF (P ~ 0.01). The incidence of intraoperative pain and requirement of postoperative analgesics in the first 24 hours was significantly more in group BF as compared to the other groups (P ~ 0.01). There was no difference in the hemodynamic profile between the groups. Conclusion: Low-dose clonidine (30 μg) when added to a bupivacaine-fentanyl mixture increased the duration of effective analgesia and the duration of sensory and motor block in gynecological surgery. The incidence of intraoperative pain and requirement of postoperative analgesics was significantly less when clonidine was added to intrathecal bupivacaine with or without fentanyl.
  5 3,627 731
A comparative evaluation of hyperbaric ropivacaine versus hyperbaric bupivacaine for elective surgery under spinal anesthesia
Kalpana R Kulkarni, Sunetra Deshpande, Ismail Namazi, Sunil Kumar Singh, Konark Kondilya
April-June 2014, 30(2):238-242
DOI:10.4103/0970-9185.130031  PMID:24803765
Background: Recently introduced ropivacaine is 40% less potent than bupivacaine. Ropivacaine made hyperbaric by the addition of dextrose is known to provide reliable spinal anesthesia (SA).This study was designed to compare the clinical efficacy of equal doses of hyperbaric 0.5% ropivacaine with 0.5% bupivacaine for SA. Materials and Methods: Eighty American Society of Anesthesiologists grade I-II patients undergoing elective infraumbilical surgeries under SA were recruited and randomized to receive 3ml of hyperbaric ropivacaine 5mg/ml containing dextrose 83 mg/ml (by the addition of desired dose of 25% dextrose) in Group R or 3ml of hyperbaric bupivacaine 5mg/ml containing dextrose 80 mg/ml in Group B. Monitoring of vitals and observation for the block parameters were carried out. The data were presented as mean with a standard deviation and frequency with percentage. Statistical analysis was performed using InStat computer software with appropriate tests and P < 0.05 was considered to be significant. Results: Ropivacaine produced a slower onset of sensory block (ropivacaine 4.5 min; bupivacaine 3.2 min; P < 0.05) and the mean total duration of sensory block was significantly lesser (ropivacaine155 min; bupivacaine 190.5 min; P < 0.05). Patients in the ropivacaine Group R had significantly more rapid recovery from the motor blockade (ropivacaine120 min; bupivacaine 190 min; P < 0.05) and passed urine sooner than the patients in bupivacaine Group B (ropivacaine 257 min; bupivacaine 358 min; P < 0.05). Conclusion: Ropivacaine 15 mg in dextrose 8.3% provides reliable SA of shorter duration than bupivacaine 15 mg in 8% dextrose.
  4 4,143 803
CASE REPORTS
Percutaneous retrieval of malpositioned, kinked and unraveled guide wire under fluoroscopic guidance during central venous cannulation
Gopal Krishan Jalwal, Vanitha Rajagopalan, Ashish Bindra, Girija Prasad Rath, Keshav Goyal, Atin Kumar, Shivanand Gamanagatti
April-June 2014, 30(2):267-269
DOI:10.4103/0970-9185.130061  PMID:24803771
The placement of central venous catheter using Seldinger's technique, remains a commonly performed procedure with its own risks and benefits. Various complications have been reported with the use of guide wire as well as catheter. We report a unique problem during subclavian vein cannulation due to guidewire malposition which led to its kinking and difficult retrieval requiring removal in fluoroscopy suit. The probable mechanism of guide wire entrapment and possible bedside management of similar problems is described.
  3 2,134 352
ORIGINAL ARTICLES
Dexmedetomidine decreases requirement of thiopentone sodium and pentazocine followed with improved recovery in patients undergoing laparoscopic cholecystectomy
Suchit Khanduja, Anil Ohri, Manoj Panwar
April-June 2014, 30(2):208-212
DOI:10.4103/0970-9185.130022  PMID:24803759
Background: Pain relief remains the most fundamental and consequential aspect of surgery for patients throughout perioperative period. Dexmedetomidine has created an interest in α2-adrenoceptor agonists in the management of pain and hence the aim of this study was to evaluate the effectiveness of the drug in hilly population of North India. Materials and Methods: Patients, irrespective of gender, were randomly allocated to two groups, control and test, each having 30 patients. Test group received an infusion of dexmedetomidine at a rate of 0.5 μg/kg/h 30 min before induction and 0.6 μg/kg/h after inducing anesthesia. Control patients received a volume-matched infusion of normal saline as placebo. Approximately 2 min before induction, analgesia was provided in the form of pentazocine, 0.5 mg/kg in control and 0.3 mg/kg in the test group. Induction was performed by 2 mg/kg thiopentone sodium supplemented with intravenous boluses of 25 mg thiopentone sodium every 15 s until loss of eyelid reflex (determined every 15 s). Induction dose of thiopentone sodium and total pentazocine dose were recorded. Recovery was assessed on the clinical recovery score (CRS) scale. Results: Infusion of dexmedetomidine decreased the induction dose of thiopentone approximately by 33% and of pentazocine dose by approximately 39% in patients undergoing laparoscopic cholecystectomy. Moreover, incidence of pain was also decreased significantly. Improved CRS from 4.33 to 6.87 was noticed immediately post-operatively in dexmedetomidine group of patients. Conclusion: Infusion of dexmedetomidine during the laparoscopic cholecystectomy decreases the requirement of thiopentone sodium and pentazocine and leads to early recovery of patients.
  3 1,934 456
Minimum effective volume of normal saline for epidural volume extension
Asha Tyagi, Surendra Kumar, Rashmi Salhotra, Ashok Kumar Sethi
April-June 2014, 30(2):228-232
DOI:10.4103/0970-9185.130028  PMID:24803763
Background: Rescue strategies like changes in tilt of table are used to raise the level of an inadequate sensory block following intrathecal injection. Epidural volume extension (EVE) refers to an injection of normal saline through epidural catheter following an intrathecal block. It results in a rapid increase in the sensory level of subarachnoid block. Thus, it has been postulated that EVE may be used as a rescue strategy for an inadequate post-spinal sensory block. However, the minimum effective volume (MEV) of normal saline for EVE induced increase in level of spinal block has not been researched till date. We proposed to determine the MEV of normal saline required for EVE induced increase in post-spinal block sensory level. Materials and Methods: This prospective sequential allocation study was conducted in consenting adult males after institutional ethical committee approval scheduled for lower limb surgery under combined spinal epidural (CSE) anesthesia, who had an inadequate level of sensory block. Herein, an inadequate level was defined as lower than T 10 at 10 min after the intrathecal injection, with no ascent for two consecutive readings taken 2 min apart. The EVE was performed with normal saline injected through epidural catheter, and was considered successful if the level of sensory block increased by two or more dermatomal segments within 5 min of the injection. The volume of normal saline for EVE was decided by using the up-and-down method, with the first patient receiving 10 mL and a dosing interval of 1 mL in subsequent patients. The analysis was done using the formula of Dixon and Massey, which enabled calculation of the MEV with 95% CI. Quantitative parametric data is represented as mean ± SD and nonparametric data as median (range). Results and Conclusion: The MEV of normal saline to raise the level of sensory block by two or more dermatomal segments within 5 min of EVE is 7.4 mL (95% CI: 5.5-9.9 mL).
  3 3,808 600
CASE REPORTS
A rare occurrence of pyloric stenosis in an infant with osteogenesis imperfecta: Anesthetic implications
Sheetal R Jagtap, Rochana G Bakhshi, Ankit Jain
April-June 2014, 30(2):270-272
DOI:10.4103/0970-9185.130064  PMID:24803772
Congenital anomalies pose many challenges during anesthesia due to anatomic and physiological alterations. The inherent complications associated with the disorders necessitate vigilance for providing anesthesia to even seemingly simple surgical intervention. Here, we share our experience of anesthesia management of an infant of congenital osteogenesis imperfecta with pyloric stenosis for pyloromyotomy.
  2 2,565 282
Sevoflurane and thoracic epidural anesthesia for trans-sternal thymectomy in a child with juvenile myasthenia gravis
Valluvan Rangasamy, Kaushal Kumar, Amit Rai, Dalim Kumar Baidya
April-June 2014, 30(2):276-278
DOI:10.4103/0970-9185.130088  PMID:24803774
Literature on anesthetic management of juvenile myasthenia gravis (JMG) for thymectomy is limited. Recently, use of inhalational agents and total intravenous anesthesia with propofol and remifentanyl has been reported. All these techniques individually or in combination have been tried to avoid the use of muscle relaxant. We report successful use of sevoflurane as sole anesthetic agent for intubation and in combination with thoracic epidural anesthesia for intraoperative anesthetic management in a 5-year-old child with JMG.
  2 2,602 379
Airway management of a child with frontometaphyseal dysplasia (Gorlin Cohen syndrome)
Anuradha Ganigara, Madhavi Nishtala, Yabagodu Rama Vakoda Chandrika, Kunigal Ravishankar Chandrakala
April-June 2014, 30(2):279-280
DOI:10.4103/0970-9185.130100  PMID:24803775
Frontometaphyseal dysplasia (FMD), also called Gorlin-Cohen syndrome, is a rare hereditary X-linked dominant craniotubular bone disorder. The presentation describes the airway management of a 2-year-old child suffering from FMD with significant retrognathia, posted for major long bone corrective osteotomy. Induction with a combination of dexmedetomidine and ketamine preceded a successful endotracheal intubation under spontaneous ventilation.
  2 1,544 282
Incidental thrombocytosis: Should it concern the anesthesiologist?
Kiranlata Kiro, Pragati Ganjoo, Deepti Saigal, Upendra Hansda
April-June 2014, 30(2):281-283
DOI:10.4103/0970-9185.130102  PMID:24803776
Preoperative thrombocytosis, often detected incidentally in surgical patients and inadvertently overlooked, has important implications for the anesthesiologists. The primary form is a chronic clonal myeloproliferative disorder usually affecting adults while the secondary type is a benign reactive disease commonly found in children. Serious perioperative hemostatic complications are reported in primary thrombocytosis and hence, a detailed preoperative evaluation and initiation of therapy to lower the platelet count (PC) is required before undertaking surgery. Patients with reactive thrombocytosis however, usually have complication-free surgeries, and if there is no prior evidence of hemostatic complications and the reactive cause can be identified, no specific perioperative intervention may be required. A thorough preanesthetic checkup and implementation of basic thrombo-prophylaxis measures in all patients with a raised PC is advocated. We present here our experience with three infants diagnosed with high preoperative PC, presumably due to reactive causes, who underwent uneventful neurosurgeries at our institution.
  2 4,060 513
ORIGINAL ARTICLES
Cost efficiency of target-controlled inhalational anesthesia
Meenoti Pramod Potdar, Laxmi L Kamat, Manjeet P Save
April-June 2014, 30(2):222-227
DOI:10.4103/0970-9185.130026  PMID:24803762
Background: Cost and environmental pollution are two prime concerns with general anesthesia. We hypothesized that target-controlled (TC) anesthesia drug delivery system also called as end-tidal (ET) control is an effective and safe system that would reduce the cost and also environmental pollution. Materials and Methods: We studied 200 patients undergoing laparoscopic abdominal and pelvic surgeries and randomly distributed those in 2 groups of 100 each, TC and manual-controlled (MC) group. We reviewed the two groups in term of consumption of gases, time required to achieve the ET concentration of sevoflurane of 1.5%, maximum inspired concentration of sevoflurane achieved, and number of adjustments required to maintain the depth of anesthesia. Results: We found that the consumption of nitrous oxide and sevoflurane was significantly less in TC group than MC group (P < 0.05), oxygen consumption was also less in TC group but not statistically significant. The time required to achieve the desired levels, maximum inspired sevoflurane concentration achieved, and the number of drug delivery adjustments required were statistically significant in TC group (P < 0.05). As the consumption reduced in TC group, the cost of the inhalational anesthesia reduced by approximately Rs. 64/h ($1.12) and thus the environmental pollution. Conclusion: We concluded from our study that ET control is a good system for conserving the consumption of gases and thus is efficient as it reduces both the cost and the environmental pollution.
  2 2,938 539
CASE REPORTS
Transient unilateral brachial plexopathy and partial Horner's syndrome following spinal anesthesia for cesarean section
Jonathan A Anson, Patrick M McQuillan
April-June 2014, 30(2):273-275
DOI:10.4103/0970-9185.130073  PMID:24803773
A healthy 21-year-old primigravida presented for elective cesarean section. At 45 min after intrathecal (IT) injection of bupivacaine, morphine and fentanyl she developed dysphagia, right sided facial droop, ptosis and ulnar nerve weakness. This constellation of signs and symptoms resolved 2 h later. Based on the time course and laterality of her symptoms, as well as the pharmacologic properties of spinal opioids, we believe her symptoms can be attributed to the IT administration of fentanyl.
  1 2,111 299
Postoperative monitoring in pregnant patients undergoing surgery for advanced malignancy in last trimester: How long is enough?
Arushi Gupta, Abhishek Verma, Rajesh Sood
April-June 2014, 30(2):284-286
DOI:10.4103/0970-9185.130106  PMID:24803777
Surgery for advanced breast malignancy in the last trimester of pregnancy is uncommon. We present successful management of a 32-year-old woman, 30 weeks pregnant with stage 3 breast malignancy, for surgery followed by normal labor and chemotherapy. Surgery and intraoperative period were uneventful. Patient had uterine contractions 36 h postsurgery, which were managed timely with active interventions and tocolytics. Risk of premature labor following nonobstetric surgery in pregnant patients is estimated to be 8.3%, but majority of the studies have been carried out in second trimester following appendectomy. There is insufficient data in literature regarding the estimation and duration of persistence of risk of premature labor in these patients. No guidelines are available regarding how long they need to be monitored for premature labor. There is some evidence, although little that risk of premature labor persists for 7 days postsurgery. In the absence of convincing studies and guidelines, we recommend postoperative monitoring for at least 7 days in patients undergoing major surgeries for malignancies in last trimester. Multidisciplinary approach is required to manage these patients.
  1 1,846 315
LETTERS TO EDITOR
Incidental finding of organized thrombus in right inferior pulmonary vein extending in left atrium in the patient scheduled for esophagectomy: What should an anesthesiologist look for?
Rakesh Garg, Alka Bhatnagar, Sushma Bhatnagar, Seema Mishra
April-June 2014, 30(2):301-302
DOI:10.4103/0970-9185.130133  PMID:24803790
  1 1,099 221
Platelet function assessment for epidural catheter removal in patient receiving Plavix
Henry Liu, Eric Glenn, Judson Mehl, Frank Rosinia
April-June 2014, 30(2):290-290
DOI:10.4103/0970-9185.130118  PMID:24803781
  1 1,098 221
ORIGINAL ARTICLES
Respiratory complications associated with ketamine anesthesia for ophthalmic procedures following intraocular pressure measurement in children
Lei Wu, Kirk Lalwani, Karla A Hook, Bella M Almario, Rongwei Fu, Beth Edmunds
April-June 2014, 30(2):253-257
DOI:10.4103/0970-9185.130047  PMID:24803768
Background: We compared respiratory complications (RCs) in children who received intramuscular (IM) versus intravenous (IV) or no ketamine for intraocular pressure (IOP) measurement to test our observation that IM ketamine is associated with higher incidence of RCs. Materials and Methods: We analyzed 149 eye examinations under anesthesia with ketamine in 27 patients and 263 non-ketamine examinations under anesthesia in 81 patients using a mixed effects logistic regression model. Results: IM ketamine was strongly associated with increased odds of RCs compared to no ketamine (odds ratio (OR): 20.23, P < 0.0001) and to IV ketamine (OR: 6.78, P = 0.02), as were higher American Society of Anesthesiologists (ASA) classification (OR: 2.60, P = 0.04), and the use of volatile agents (OR: 3.32, P = 0.02). Conclusion: Further studies should be conducted to confirm our observation of increased RCs with IM ketamine.
  1 2,050 368
ProSeal laryngeal mask airway TM insertion in the prone position: Optimal utilization of operation theatre personnel and time?
Bimla Sharma, Jayashree Sood, Raminder Sehgal, Chand Sahai, Anjali Gera
April-June 2014, 30(2):177-182
DOI:10.4103/0970-9185.130005  PMID:24803753
Background: Positioning an anesthetized patient prone is challenging with regard to manpower requirement, time to surgical readiness and airway management. The ProSeal laryngeal mask airway TM (PLMA) is emerging as a suitable alternative, both as a primary and a rescue airway device to the tracheal tube (TT) for patients undergoing surgery in the prone position. Materials and Methods: In this prospective randomized study, 70 patients scheduled to undergo pilonidal sinus excision in prone position were allocated to two groups of 35 patients each, depending on the position of the patient at induction and device placement: Group S (device placed while supine) and Group P (device placed while prone). We compared the manpower requirement, time to surgical readiness, efficacy and safety of the PLMA for airway management in the two groups. Results: The number of personnel [5 (4-6) vs. 3 (3-3); P < 0.001] required for positioning the patient and surgical readiness time (22.1 ± 3 vs. 5.9 ± 0.9 min; P < 0.001) was higher in group S. There was no difference between the two groups with regard to efficacy and safety of the PLMA. Incidence of blood on the PLMA cuff and sore throat was comparable in the two groups (P = 1.000). Conclusion: We conclude that induction and placing the PLMA in the prone position by experienced users require fewer personnel and reduces surgical readiness time.
  1 3,263 677
BOOK REVIEW
Book Review
VP Kumra, Jayashree Sood
April-June 2014, 30(2):306-306
  - 1,244 237
COMMENTARIES
Best of both worlds-endotracheal intubation without paralysis
Basavana G Goudra, Preet Mohinder Singh
April-June 2014, 30(2):172-173
PMID:24803751
  - 3,092 625
Anesthesiologists, Anesthetics, and Cancer metastasis
Rakesh Garg
April-June 2014, 30(2):174-176
PMID:24803752
  - 2,370 543
EDITORIALS
Translational research and anesthesia
Fauzia Anis Khan
April-June 2014, 30(2):151-152
DOI:10.4103/0970-9185.129993  PMID:24803748
  - 1,912 389
LETTERS TO EDITOR
Fatal mediastinal hematoma following right internal jugular vein cannulation
Neeru Luthra, Namrata Goyal, Kamakshi Garg, Krishan Yogesh Sawhney, Harminder Kaur, Anju Grewal
April-June 2014, 30(2):290-291
DOI:10.4103/0970-9185.130119  PMID:24803782
  - 2,012 236
Hypobaric spinal anesthesia in a paraplegic patient
Alejandro Suarez de la Rica, Julio Ontoria, Fernando Gilsanz
April-June 2014, 30(2):292-292
DOI:10.4103/0970-9185.130120  PMID:24803783
  - 1,527 258
Intraoperative pulseless ventricular tachycardia after Ondansetron
Sukhen Samanta, Kajal Jain, Sujay Samanta, Tanmoy Ghatak
April-June 2014, 30(2):293-294
DOI:10.4103/0970-9185.130123  PMID:24803784
  - 1,818 337
Post thoracotomy cardiorespiratory arrest: Perhaps avoidable?
Amit Kumar Mittal, Anita Kulkarni, Ajay Kumar Bhargava
April-June 2014, 30(2):294-295
DOI:10.4103/0970-9185.130124  PMID:24803785
  - 1,501 217
Anesthetic management during electroconvulsive therapy in a patient with burn injury
Vinay Byrappa, Sriganesh Kamath, Sudhir Venkataramaiah, Sritam Jena Swarup
April-June 2014, 30(2):295-297
DOI:10.4103/0970-9185.130126  PMID:24803786
  - 1,565 262
Erdheim — Chester disease: Clinical pearls for the anesthesiologist
Uma Hariharan, Anu Vijayant Goel, Dhirja Sharma
April-June 2014, 30(2):297-298
DOI:10.4103/0970-9185.130127  PMID:24803787
  - 1,162 256
Ascaris: An unusual cause of airway obstruction during general anesthesia with ProSeal laryngeal mask airway
Smita Prakash, Narayanan Sitalakshmi, Jasmeet Singh, Madhu Dayal, Anoop R Gogia
April-June 2014, 30(2):298-300
DOI:10.4103/0970-9185.130129  PMID:24803788
  - 1,593 227
Regurgitant food particle causing intractable laryngospasm during emergence from anesthesia
Mouveen Sharma, Tim Thomas Joseph, Souvik Chaudhuri, Amrut K Rao
April-June 2014, 30(2):300-301
DOI:10.4103/0970-9185.130130  PMID:24803789
  - 1,296 243
The fatigued anesthesiologist: Improve operating room climate to minimize effect of residual anesthetics
Indu Sen, Randeep Kaur
April-June 2014, 30(2):302-303
DOI:10.4103/0970-9185.130134  PMID:24803791
  - 1,151 234
Anesthetic management for patients with perforation peritonitis
Pradeep Bhatia, Vandana Sharma
April-June 2014, 30(2):303-304
DOI:10.4103/0970-9185.130135  PMID:24803792
  - 2,564 556
In Reply: Anesthetic management of patients with perforation peritonitis
Kiran Sharma, Mritunjay Kumar, Upma Bhatia Batra
April-June 2014, 30(2):304-305
PMID:24803793
  - 1,039 221
Modification in Laryngeal mask airway CTrach tube design
Geetanjali Chilkoti, Medha Mohta, Ashim Banerjee, Mahendra Kumar
April-June 2014, 30(2):287-287
DOI:10.4103/0970-9185.130109  PMID:24803778
  - 1,226 214
Position of bite block in size 1 laryngeal mask airway ProSeal™ and stability during insertion
Sandeep Kumar Mishra, Anusha Cherian, Hemavathy Balchander, Niyaz C Ashraf
April-June 2014, 30(2):288-288
DOI:10.4103/0970-9185.130113  PMID:24803779
  - 1,218 209
A clinical evaluation of the pediatric i-gel™ for airway management during MRI examination
Ruggero M Corso, Daniele Battelli, Stefano Maitan, Salvatore Zampone, Vanni Agnoletti
April-June 2014, 30(2):288-290
DOI:10.4103/0970-9185.130115  PMID:24803780
  - 1,196 230
ORIGINAL ARTICLES
Early post-operative relief of pain and shivering using diclofenac suppository versus intravenous pethidine in spinal anesthesia
Ali Janpour Ebrahim, Rabiee Mozaffar, Bani-hashem Nadia, Jabbari Ali
April-June 2014, 30(2):243-247
DOI:10.4103/0970-9185.130038  PMID:24803766
Background: Pain and shivering are two challenging components in the post operative period. Many drugs were used for prevention and treatment of them. The aim of this study was to compare the effects of prophylactic prescription of diclofenac suppository versus intravenous (IV) pethidine in spinal anesthesia. Materials and Methods: We conducted a multi central, prospective, double-blind, randomized clinical trial on a total of 180 patients who were scheduled for surgery under spinal anesthesia including 60 patients in three groups. Patients were randomly allocated to receive 100 mg sodium diclofenac suppository or 30 mg IV pethidine or placebo. Categorical and continuous variables were analyzed by Chi-square test, t-test, Mann-Whitney and ANOVA or Kruskal-Wallis tests. Results: There was no statistical difference with regard to patient characteristics and hemodynamic indices among the three groups. Nine (15%), 10 (16.65%) and 24 (40%) of patients in diclofenac, pethidine and control groups reported pain and 2, 2, 7 patients received treatment due to it, respectively (P = 0.01). Prevalence of shivering in pethidine group and diclofenac group was the same and both of them were different from the control group (P < 0.001). Pruritus was repetitive in the pethidine group and was statistically significant (P = 0.036) but, post-operative nausea and vomiting was not significantly different among groups. Conclusion: A single dose of sodium diclofenac suppository can provide satisfactory analgesia immediately after surgery and decrease shivering without remarkable complications. This investigation highlights the role of pre-operative administration of a single dose of rectal diclofenac as a sole analgesic for early post-operative period.
  - 4,315 623
Bedside prediction of airway length by measuring upper incisor manubrio-sternal joint length
Sudipta Mukherjee, Manjushree Ray, Rita Pal
April-June 2014, 30(2):188-194
DOI:10.4103/0970-9185.130011  PMID:24803755
Background: Malpositioning of endotracheal tube may lead to serious complications like endobronchial intubation or accidental extubation. Using anatomical measurements for prediction of airway length would be more practical in resource constrained settings. Materials and Methods: One hundred adult patients of American Society of Anesthesiologists (ASA) grade 1 or 2, without any evidence of difficult airway, were randomly allocated to two cohorts - a model cohort of 70 (50 males) and test cohort of 30 (20 males) subjects. Height, the straight length from the upper incisor to manubrio-sternal joint in fully extended head position (IncManustL), the length from upper incisor to the carina in neutral head position (IncCarinaL), and degree of neck extension were measured in all subjects. Relationship between the two lengths in the model cohort was explored by Pearson's coefficient (r). Predictions were made for subjects in the test cohort and actual and predicted values assessed for agreement using intra-class correlation coefficient (ICC). Results: Good agreement was found between IncManustL and IncCarinaL for both male (r = 0.69) and female (r = 0.54) subjects. Multiple regression analysis suggested height to be another significant predictor, unlike age, weight, and neck extension. The gender-specific regression equations were used to predict IncCarinaL for the test cohort. ICC for absolute agreement between the actual and predicted values was 0.723 (95% CI 0.495-0.858). Conclusions: It is possible to predict airway length in adult Indian subjects by making two simple anatomical measurements, namely stature and incisor manubrio-sternal joint length.
  - 2,583 470
RETRACTION NOTICE
Retraction Notice

April-June 2014, 30(2):305-305
PMID:24803794
  - 937 193
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