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   2016| January-March  | Volume 32 | Issue 1  
    Online since February 4, 2016

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Postoperative analgesia for cleft lip and palate repair in children
Reena , Kasturi Hussain Bandyopadhyay, Abhijit Paul
January-March 2016, 32(1):5-11
DOI:10.4103/0970-9185.175649  PMID:27006533
Acute pain such as postoperative pain during infancy was ignored approximately three decades ago due to biases and misconceptions regarding the maturity of the infant's developing nervous system, their inability to verbally report pain, and their perceived inability to remember pain. More recently, these misconceptions are rarely acknowledged due to enhanced understanding of the developmental neurobiology of infant pain pathways and supraspinal processing. Cleft lip and palate is one of the most common congenital abnormalities requiring surgical treatment in children and is associated with intense postoperative pain. The pain management gets further complicated due to association with postsurgical difficult airway and other congenital anomalies. Orofacial blocks like infraorbital, external nasal, greater/lesser palatine, and nasopalatine nerve blocks have been successively used either alone or in combinations to reduce the postoperative pain. Since in pediatric population, regional anesthesia is essentially performed under general anesthesia, association of these two techniques has dramatically cut down the risks of both procedures particularly those associated with the use of opioids and nonsteroidal anti-inflammatory drugs. Definitive guidelines for postoperative pain management in these patients have not yet been developed. Incorporation of multimodal approach as an institutional protocol can help minimize the confusion around this topic.
  6,044 1,366 6
Airway fires during surgery: Management and prevention
Navaid Akhtar, Farrukh Ansar, Mirza Shahzad Baig, Akbar Abbas
January-March 2016, 32(1):109-111
DOI:10.4103/0970-9185.175710  PMID:27006554
Airway fires pose a serious risk to surgical patients. Fires during surgery have been reported for many years with flammable anesthetic agents being the main culprits in the past. Association of airway fires with laser surgery is well-recognized, but there are reports of endotracheal tube fires ignited by electrocautery during pharyngeal surgery or tracheostomy or both. This uncommon complication has potentially grave consequences. While airway fires are relatively uncommon occurrences, they are very serious and can often be fatal. Success in preventing such events requires a thorough understanding of the components leading to a fire (fuel, oxidizer, and ignition source), as well as good communication between all members present to appropriately manage the fire and ensure patient safety. We present a case of fire in the airway during routine adenotonsillectomy. We will review the causes, preventive measures, and brief management for airway fires.
  3,176 623 8
Addition of low-dose ketamine to midazolam and low-dose bupivacaine improves hemodynamics and postoperative analgesia during spinal anesthesia for cesarean section
Ahmed Sobhy Basuni
January-March 2016, 32(1):44-48
DOI:10.4103/0970-9185.173322  PMID:27006540
Background and Aims: Spinal anesthesia for cesarean section (CS) is associated with an incidence of hypotension of 60-94%. This study hypothesizes that intrathecal combination of low-dose ketamine, midazolam, and low-dose bupivacaine improves hemodynamics and postoperative analgesia compared with fentanyl and low-dose bupivacaine during CS. Material and Methods: Fifty parturients undergoing elective CS were randomized equally to receive ketamine (10 mg), midazolam (2 mg) and 0.5% hyperbaric bupivacaine (8 mg) in group ketamine-midazolam-bupivacaine (KMB) or fentanyl (25 μg) and 0.5% hyperbaric bupivacaine (8 mg) in group fentanyl-bupivacaine (FB). Heart rate (HR), mean arterial blood pressure (MAP), oxygen saturation, sensorimotor block characteristics, pain-free period, side-effects including: hypotension, bradycardia, nausea, vomiting, sedation, pruritus, respiratory depression and dissociative manifestations, Apgar score at 1 and 5 min, and patients' satisfaction visual analog scores (VAS) were recorded. Patients in group KMB were followed for 6 months in order to assess any neurological disorder. Results: Group KMB showed higher sensory level (P = 0.006), rapid sensory (P = 0.001) and motor (P = 0.005) onsets, prolonged sensory (P = 0.008) and motor (P = 0.002) blocks, and prolonged pain free period (P = 0.002). Ketamine-midazolam stabilized HR and MAP, and significantly reduced incidence of hypotension (P = 0.002), bradycardia (P = 0.013) and vomiting (P = 0.019). Apgar scores at 1 and 5 min were comparable in both groups (P = 0.699 and 0.646 respectively). Patients' satisfaction VAS scores were significantly higher in group KMB (P = 0.001). No patients in KMB group showed dissociative or neurotoxic manifestations. Conclusion: Intrathecal low-dose ketamine combined with midazolam and low-dose bupivacaine stabilizes hemodynamics and prolongs postoperative analgesia without significant side-effects in parturients undergoing CS.
  3,004 665 2
Comparative effectiveness of McCoy laryngoscope and CMAC ® videolaryngoscope in simulated cervical spine injuries
Divya Jain, Indu Bala, Komal Gandhi
January-March 2016, 32(1):59-64
DOI:10.4103/0970-9185.173349  PMID:27006543
Background: Videolaryngoscopes are increasingly being used in potentially difficult airway. McCoy laryngoscope provides definitive advantage over conventional laryngoscopes in cervical spine patients. The aim of this study was to compare the performance of the CMAC ® videolaryngoscope with the McCoy Laryngoscope in patients with a cervical collar. Material and Methods: Sample size of at least 22 patients in each group was calculated using Intubation Difficulty Scale (IDS) score as the primary outcome. 60 American Society of Anesthesiologists I and II patients requiring tracheal intubation for elective surgery were randomly allocated into the McCoy group (n = 30) and the CMAC ® videolaryngoscope group (n = 30). Anesthesia was induced with fentanyl 2 mcg/kg, propofol 2-3 mg/kg and rocuronium 0.6 mg/kg. A rigid collar was applied to immobilize the cervical spine. Comparative data on the IDS scale, Cormack-Lehane (CL) laryngoscopic view, time taken for glottis visualization, time taken to pass endotracheal tube, total time to intubate, number of optimizing maneuvers and hemodynamic variables were recorded in the two groups. Results: IDS score was significantly less in the CMAC ® group compared to the McCoy group (median [interquartile range (IQR)], 1 [0-1] vs. 4 [3-6], P < 0.05). CMAC ® videolaryngoscope required significantly less time for glottic visualization with median (IQR), 5 (5-7) versus 14 (8-15), P = 0.000 in McCoy laryngoscope, 29 (96.7%) patients in the CMAC ® group had Modified CL Grade I compared with 16 (53.3%) patients in McCoy group. The hemodynamic variables, number of optimizing maneuvers and incidence of side effects were comparable in the two groups. Conclusion: CMAC ® videolaryngoscope forms an effective tool for the airway management of cervical spine patients with a cervical collar.
  2,863 535 2
Double blind comparison of combination of 0.1% ropivacaine and fentanyl to combination of 0.1% bupivacaine and fentanyl for extradural analgesia in labour
Kishori Dhaku Bawdane, Jyoti S Magar, Bharati A Tendolkar
January-March 2016, 32(1):38-43
DOI:10.4103/0970-9185.173350  PMID:27006539
Background and Aims: Ropivacaine is considered as a safe alternative to bupivacaine for labor analgesia. The aim was to compare epidural ropivacaine and bupivacaine in intermittent doses for obstetric analgesia. Material and Methods: In this prospective, randomized, double-blind study, 60 women in labor were randomly allocated to receive either bupivacaine 0.1% with fentanyl 2 μg/mL (BF), or ropivacaine 0.1% with fentanyl 2 μg/mL (RF). Bromage scale, loss of cold sensation to ether swab in midclavicular line, visual analog scale were used to test for motor block, sensory block and pain, respectively. Hemodynamic parameters, onset of analgesia, dose requirement of drug to produce analgesia, duration of labor, and incidence of side effects were also recorded. Data were expressed as mean ± standard deviation and analyzed using students unpaired t-test, Chi-square and Mann-Whitney U-tests at P < 0.05. Results: Both drugs were similar with respect to hemodynamic stability, onset of analgesia, quality of analgesia, sensory blockade, neonatal outcome, requirement of drugs, duration of labor, and incidence of side effects. Three parturient in bupivacaine (B-F) group had a motor block of Bromage 1 and were delivered using forceps. None of the parturient in ropivacaine (R-F) group had any motor block, and all had spontaneous vaginal delivery, but this difference was not statistically significant (P = 0.081). Conclusions: Bupivacaine and ropivacaine provide equivalent analgesia in low (0.1%) concentration.
  2,732 608 6
Efficacy of a separate informed consent for anesthesia services: A prospective study from the Caribbean
Kavi Rampersad, Deryk Chen, Seetharaman Hariharan
January-March 2016, 32(1):18-24
DOI:10.4103/0970-9185.173364  PMID:27006535
Background and Aims: This study aimed to determine whether a separate written consent form improved the efficacy of the informed consent process for anesthesia in adult patients undergoing elective surgery at a tertiary care teaching hospital. Material and Methods: We randomized patients into two groups prospectively. The first group (Group A) signed the hospital's standard "Consent for Operation" form only while the second group (Group B) signed a separate "Consent for Anesthesia" form additionally. Patients were interviewed postoperatively with an eight-item questionnaire with responses in a 5-point Likert scale. A composite "adequacy of consent index" was generated from the responses and analyzed. Results: Two hundred patients (100 in each group) were studied. All patients indicated that the anesthesiologist(s) had their permission to proceed with their anesthesia care. The mean "adequacy of consent index score" in Group B was higher than that of Group A (30.6 ± 4.6 [standard deviation (SD)] vs. 27.9 ± 5.2 [SD]) (P < 0.001). The separate written consent had a positive impact on the patients' understanding of the nature and purpose of the intended anesthesia procedures (P = 0.04), satisfaction with the adequacy of information provided about common side effects (P < 0.001) and rare but serious complications (P = 0.008). Conclusions: A separate written consent for anesthesia improved the efficacy of the informed consent process with respect to better information about the nature and purpose of anesthesia, common side effects, and rare but serious complications.
  2,552 437 1
Laryngoscope decontamination techniques: A survey
Rajiv Chawla, Akhilesh Gupta, Anshu Gupta, Mritunjay Kumar
January-March 2016, 32(1):99-102
DOI:10.4103/0970-9185.175706  PMID:27006551
Background and Aims: India is a vast country with variable, nonuniform healthcare practices. A laryngoscope is an important tool during general anesthesia and resuscitation. The study aimed to determine the current practices of laryngoscope decontamination in India. Material and Methods: An online survey was conducted amongst 100 anesthesiologists to determine the common methods of laryngoscope decontamination adopted in their settings. The survey was done over 6 months after validating the questionnaire. Results: A total of 73 responses were received out of 100. The result of the survey revealed that there is no uniform technique of laryngoscope decontamination. There is marked variability in techniques followed not only among different institutions, but also within the same institution. Conclusion: There are no fixed protocols adopted for laryngoscope decontamination. Thus, there is a need to develop definitive guidelines on this subject, which can be implemented in India.
  2,393 585 -
Evaluation of postoperative pain scores following ultrasound guided transversus abdominis plane block versus local infiltration following day surgery laparoscopic cholecystectomy-retrospective study
Vasanth Rao Kadam, Stuart Howell, V Kadam
January-March 2016, 32(1):80-83
DOI:10.4103/0970-9185.168195  PMID:27006547
Background and Aims: Postoperative pain for day surgery laparoscopic cholecystectomy has traditionally been managed with the surgeon infiltrating the wound with local anesthetic (LA). However, transversus abdominis plane (TAP) block has recently been used, although its superiority over LA remains uncertain. The primary aim was to compare LA and TAP block pain scores and analgesia used. The secondary aim was to assess satisfaction score and cost. Material and Methods: This retrospective study was commenced after ethics committee approval and ANZ clinical trial registry (ACTRN: 12612000737831). The data were collected from the theatre database and medical records of patients presenting for day case laparoscopic cholecystectomy. The sample included patients who received either bilateral port site LA infiltration with 20 ml of 0.25% Bupivacaine or bilateral TAP block with 20 ml of 0.5% ropivacaine and fentanyl postoperative pain protocol. The patients with incomplete medical records were excluded as were those admitted to an inpatient ward. Demographics and clinical characteristics were obtained from the hospital record along with pain score and postsurgery analgesia use. Postoperative pain satisfaction scores were collected by telephonic interview 30-180 days postsurgery. Results: Of 51 patients analyzed, 19 were in TAP group 29 in LA group. There were no significant differences between the LA and TAP groups with respect to postoperative pain scores (P = 0.31) or patient satisfaction scores (1 and 2+) (P = 0.36). However, fentanyl consumption in the recovery room was significantly lower in TAP group (P = 0.0079.). The consumables cost were >3 times higher in the TAP when compared to LA group. Conclusion: The performance of the TAP block with respect to pain management was comparable to LA. However, LA remains more cost effective.
  2,118 532 6
Airway management and postoperative length of hospital stay in patients undergoing head and neck cancer surgery
Ali Sarfraz Siddiqui, Samie Asghar Dogar, Shankar Lal, Shabbir Akhtar, Fauzia Anis Khan
January-March 2016, 32(1):49-53
DOI:10.4103/0970-9185.173341  PMID:27006541
Background and Aims: General anesthesia and airway management of patients for head and neck cancer surgery is a challenge for the anesthesiologist. Appropriate assessment and planning are essential for successful airway management. Our objectives were to review airway management strategies in patients undergoing head and neck cancer surgery in our tertiary care institution and also to observe the effect of airway management techniques on postoperative length of hospital stay (PLOS). Material and Methods: A retrospective medical record review of 400 patients who underwent major head and neck cancer surgery in our institution was conducted. A special form was used, and records were searched for airway and anesthetic management in the operating room and recovery room, and for PLOS. Results: 289 (72.25%) of the patients were male, and 111 (27.75%) female. 49.8% of patients had Mallampati score of 3 and 4. Airway was managed with tracheostomy in 81 (20.25%) patients; nasal intubation was performed in 177 (44.25%) and oral intubation in 142 (35.5%) patients. Postoperative emergency tracheostomy was not done in any of the patients. Conclusion: Median postoperative hospital stay was significantly longer (P = 0.0005) in patients who had a tracheostomy performed compared with those where the airway was managed without it.
  2,038 593 3
Attenuation of pressor response following intubation: Efficacy of nitro-glycerine lingual spray
Indira Kumari, Udita Naithani, Vinod Kumar Dadheech, DS Pradeep, Khemraj Meena, Devendra Verma
January-March 2016, 32(1):69-73
DOI:10.4103/0970-9185.175668  PMID:27006545
Background and Aims: The role of nitro-glycerine (NTG) lingual spray for attenuation of the hemodynamic response associated with intubation is not much investigated. We conducted this study to evaluate the efficacy of NTG lingual pump or pen spray in attenuation of intubation induced hemodynamic responses and to elucidate the optimum dose. Material and Methods: In a prospective randomized controlled trial, 90 adult patients of ASA I, II, 18-60 year posted for elective general surgery under general anesthesia with intubation were randomly allocated to three groups as Group C (control) - receiving no NTG spray, Group N1 - receiving 1 NTG spray and Group N2 - receiving 2 NTG spray one minute before intubation. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate were recorded at baseline, just before intubation (i.e., 60 s just after induction and NTG spray), immediately after intubation, at 1, 2, 5 and 10 min after intubation. Results: Incidence of hypertension was significantly higher in Group C (60%, n = 18) as compared to Group N1 and N2 (10%, n = 3 each), P < 0.01. Mean value of SBP, DBP and MAP showed a significant rise as compared to baseline, following intubation in control group (15.31% in SBP, 12.12% in DBP, 17.77% in MAP) that persisted till 5 min, while no significant rise was observed in Group N1 and N2. There was a trend toward fall in blood pressure in Group N2 (4.95% fall in SBP, 4.72% fall in MAP) 1-min following spray, which was clinically insignificant. Mean value of SBP, DBP and MAP was significantly higher in Group C than in Group N1, which was in turn greater than Group N2 (Group C > N1> N2), P < 0.05. However, incidence of tachycardia was comparable in three groups (70% in group C, 63.33% in Group N1 and 67.77% in Group N2, P > 0.05). Conclusions: We concluded that the NTG lingual spray in dose of 0.4 mg (1 spray) or 0.8 mg (2 sprays) was effective in attenuation of intubation induced hemodynamic response, in terms of preventing significant rise in SBP, DBP and MAP compared to control group.
  2,241 373 -
Sonographic assessment of predictors of depth of the corner pocket for ultrasound-guided supraclavicular brachial plexus block
Naveen Yadav, Arshad Ayub, Rakesh Garg, Samridhi Nanda, Babita Gupta, Chhavi Sawhney
January-March 2016, 32(1):25-28
DOI:10.4103/0970-9185.175665  PMID:27006536
Background and Aims: There is wide variation in depth of brachial plexus in patient population at supraclavicular region. We plan to find the depth of the corner pocket and correlate it with age, weight, height and body mass index (BMI). Material and Methods: After approval from Ethics Committee, right-sided supraclavicular region of volunteers was scanned. Once an optimal image, which included subclavian artery, pleura, first rib and nerve bundles, was obtained, the "corner pocket" was kept in the middle of the screen and the image was frozen. Depth of the corner pocket from the skin was measured. Thereafter longest distance (LD) approximating needle trajectory was calculated. The Pearson correlation was used to calculate the relation between these two distances and various predictors such as weight, height, and BMI. Results: Mean shortest distance that is, vertical distance from skin to corner pocket for all volunteers was found to be 1.7 ± 0.8 cm and the mean LD that is, distance traveled by needle entering 1 cm from the edge of foot process to the corner pocket in an in-plane approach was 3.7 ± 0.2 cm. We did not find any significant correlation between age, height versus measured distances. However, significant correlation (0.11) was found between weights, BMI versus two lengths. Conclusion: Prescanning of supraclavicular region for estimating depth of corner pocket should be done before choosing an appropriate size needle. Furthermore, the needle should not be advanced more than the predicted corner pocket depth.
  2,056 499 -
Comparison of hemodynamic response to adrenaline infiltration in children undergoing cleft palate repair during general anesthesia with sevoflurane and isoflurane
Poojita Reddy Gunnam, Padmaja Durga, Indira Gurajala, Prasad Rao Kaluvala, Prardhana Veerabathula, Gopinath Ramachandran
January-March 2016, 32(1):12-17
DOI:10.4103/0970-9185.175650  PMID:27006534
Background and Aims: Systemic absorption of adrenaline often used for infiltration during cleft palate surgery leads to adverse hemodynamic responses. These hemodynamic responses may be attenuated by the volatile anesthetics. This study aims to compare the hemodynamic responses to adrenaline infiltration during isoflurane (ISO) and sevoflurane (SEVO) anesthesia. Material and Methods: Sixty children aged between 9 months and 48 months, weighing between 8 kg and 20 kg, undergoing primary repair of cleft palate were randomly allocated into two groups: Group ISO - anesthesia maintained with ISO (2 minimum alveolar concentrations [MAC]) and nitrous oxide 50% and group SEVO - maintained on SEVO (2 MAC) and nitrous oxide 50%. Surgical site was infiltrated with 1 ml/kg of 1:200,000 solution of adrenaline with 0.5% lignocaine. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial blood pressure (MAP) were noted at the end of infiltration and every 1 min for 5 min following infiltration. The percentage change of hemodynamic responses from baseline, following infiltration were compared between the two groups. Results: There was no significant change in HR from baseline, and the response was comparable between the agents at all times. The blood pressure (BP) increased from baseline in both the groups but the increase was greater in SEVO than ISO group at 2 and 3 min after infiltration. The maximum change in HR from baseline (group ISO median 10.9% [interquartile range (IQR) 4.5-23.0] vs. group SEVO 26.5% [11.9-44.6]) was comparable in both the groups (P = 0.169). The maximum change in SBP was significantly greater in group SEVO than group ISO (42.8% [IQR 20.0-60.9] vs. 26.0 [11.3-44.5], P = 0.04). The incidence of significant change (>20%) of SBP, DBP, and MAP from baseline was significantly greater in group SEVO after infiltration and 1 min and 2 min after infiltration. There were no arrhythmias in any of the groups. Conclusion: Isoflurane results in greater attenuation of rise in BP during adrenaline infiltration compared to SEVO at similar MAC.
  2,028 484 -
Epidural catheter fixation. A comparison of subcutaneous tunneling versus device fixation technique
Ashima Sharma, Sujay Kumar Parasa, Kiran Tejvath, Gopinath Ramachandran
January-March 2016, 32(1):65-68
DOI:10.4103/0970-9185.175667  PMID:27006544
Background and Aims: The technique of securing the epidural catheter has a major bearing on the efficacy of epidural analgesia. Specific fixator devices, for e.g., Lockit epidural catheter clamp, which successfully prevents catheter migration, are available. The possibility of catheter snapping and surgical retrieval has been reported with tunneling of catheters. These techniques have not been compared for safety, efficacy and appropriateness of achieving secure epidural catheter fixation in the postoperative period. Material and Methods: A total of 200 patients who required postoperative epidural analgesia were included. They were randomized into two groups: Group I (n = 100) in whom epidural catheters were tunneled vertically in the paravertebral subcutaneous tissue and group II (n = 100) wherein a Lockit device was used to fix the catheter. Likert score was used to quantify patient's comfort during procedure. The techniques were compared for migration, catheter dislodgement, local trauma, catheter snapping and catheter obstruction. Results: 12% of tunneled catheters had migrated significantly outward. 22% of patients had erythema and 77% had significant procedural discomfort in group I. In group II, 3% catheters had kinked and 14% had erythema from device adhesive. Conclusion: Our results support the use of Lockit device as a safe and comfortable fixation device compared to subcutaneous tunneling of catheters.
  2,117 377 4
Dexmedetomidine provides optimum conditions during awake fiberoptic intubation in simulated cervical spine injury patients
Pooja Chopra, Madhu Bala Dixit, Aashish Dang, Vibhuti Gupta
January-March 2016, 32(1):54-58
DOI:10.4103/0970-9185.175666  PMID:27006542
Background and Aims: We undertook this study to assess if a small-dose of dexmedetomidine (DEX) for conscious sedation during awake fiberoptic intubation (AFOI) in simulated cervical spine injury (CSI) patients provides optimum conditions and fulfills the need of postintubation neurological examination required in such patients. The aim was to assess the efficacy of DEX on arousability and patient's comfort during AFOI in simulated CSI patients. Material and Methods: In this prospective, randomized double-blind study, 100 American Society of Anesthesiologists Grade I-II patients aged between 18 and 65 years scheduled for elective surgery under general anesthesia underwent AFOI under conscious sedation with DEX. After locally anesthetizing the airway and applying a cervical collar, patients either received DEX 1 μg/kg over 10 min followed by 0.7 μg/kg/h maintenance infusion or normal saline in the same dose and rate during AFOI. Targeted sedation (Ramsay sedation score [RSS] ≥2) during AFOI was maintained with midazolam [MDZ] in both groups. Statistical Analysis was performed using unpaired Student's t-test, Chi-square test, Mann-Whitney test and Wilcoxon-w test. Results: The total number of patients requiring MDZ and the mean dose of MDZ required to achieve targeted sedation (RSS ≥2) was significantly less in DEX group compared to the placebo group (P < 0.001 ). Similarly, patient satisfaction score, heart rate, systolic, diastolic and mean arterial pressure and respiratory parameters were significantly better in DEX group (P < 0.001). Postintubation arousability in the two groups was comparable (P = 0.29). Conclusions: Dexmedetomidine provides optimum sedation without compromising airway or hemodynamic instability with better patient tolerance and satisfaction for AFOI. It also preserves patient arousability for the postintubation neurological assessment.
  1,877 428 10
Research Society of Anaesthesiology Clinical Pharmacology (RSACP) Minutes of AGBM held on 3 rd October 2015, at Amritsar (Punjab)
Naveen Malhotra
January-March 2016, 32(1):134-136
  2,151 143 -
The revised guidelines of the Medical Council of India for academic promotions: Need for a rethink
Rakesh Aggarwal, Nithya Gogtay, Rajeev Kumar, Peush Sahni, for the Indian Association of Medical Journal Editors
January-March 2016, 32(1):1-4
DOI:10.4103/0970-9185.175616  PMID:27006532
  1,756 515 -
Incidental finding of tracheal bronchus complicating the anesthetic management of a left video-assisted thoracoscopic procedure
Shvetank Agarwal, Mark A Banks, Sanjeev Dalela, William B Bates, Manuel R Castresana
January-March 2016, 32(1):106-108
DOI:10.4103/0970-9185.168167  PMID:27006553
Congenital abnormalities of the large airways are uncommon, but may occasionally pose significant difficulties for anesthesiologists. The tracheal bronchus is an anatomical variant in which an accessory bronchus originates directly from the trachea rather than distal to the carina, as a takeoff from the right mainstem bronchus. Anesthesiologists should be aware of this uncommon anomaly, its different variants, and its management in order to successfully establish one lung ventilation (OLV) for surgical isolation. In this article, we report the challenges encountered in establishing OLV in a patient with a previously undiagnosed aberrant right upper lobe bronchus arising directly from the trachea.
  1,918 292 2
Patient refusal for regional anesthesia in elderly orthopedic population: A cross-sectional survey at a tertiary care hospital
Asma Abdus Salam, Gauhar Afshan
January-March 2016, 32(1):94-98
DOI:10.4103/0970-9185.173372  PMID:27006550
Background and Aims: Improvements in pain management techniques in the last decade have had a major impact on the practice of orthopedic surgeries, for example, total hip arthroplasty and total knee arthroplasty. Although there are a number of treatment options for postoperative pain, a gold standard has not been established. In our institution, both general anesthesia and regional anesthesia (RA), are being offered to the elderly orthopedic population but RA is not frequently accepted by elderly population. The objective of this study was to determine the frequency of various reasons for refusal of RA in elderly patients undergoing orthopedic surgeries. Material and Methods: A prospective study conducted over a period of 1 year, had 549 patients with ages above 60 years who underwent different types of elective orthopedic procedures 182 patients who refused RA were interviewed according to a structured questionnaire designed to assess the reasons of refusal. Statistical Analysis: Frequencies and percentages were computed for categorical variables. Chi-square test was applied to compare proportion difference of reasons for refusal of RA between gender, age groups, occupation, and previous history of anesthesia. Results: Most common reason for the refusal of RA was surgeon's choice (38.5%), whereas 20.3% of the patients were unaware about the RA. There was a significant association between female gender and refusing RA due to backache (17.2%) and fear of being awake during the operation (24.1%) respectively. Conclusion: This survey showed that the main reasons among elderly female population were the fear of remaining awake and backache. However, overall it was the surgeon's choice which made patients refuse RA, and the anesthesiologists were the main source of information.
  1,613 463 5
Efficacy of tramadol and butorphanol pretreatment in reducing pain on propofol injection: A placebo-controlled randomized study
Arvinderpal Singh, Geeta Sharma, Ruchi Gupta, Anita Kumari, Deepika Tikko
January-March 2016, 32(1):89-93
DOI:10.4103/0970-9185.175703  PMID:27006549
Background and Aims: Pain of propofol injection has been recalled by many patients as the most painful part of the induction of anesthesia. Tramadol and butorphanol are commonly used analgesics for perioperative analgesia in anesthesia practice. However, their potential to relieve propofol injection pain still needs to be explored. Material and Methods: A randomized, double-blind, placebo-controlled study was conducted on 90 American Society of Anesthesiologists I and II adult patients undergoing elective surgery under general anesthesia with propofol as an induction agent. Consecutive sampling technique with random assignment was used to allocate three groups of 30 patients each. Group I patients received an injection of normal saline 3 ml intravenously (placebo) while Group II and Group III patients received injection of tramadol 50 mg and butorphanol 1 mg intravenously, respectively. Before induction of anesthesia patients were asked about the intensity of pain on propofol injection by using visual analog scale (VAS) before the loss of consciousness. Descriptive statistics and analysis of variance with Chi-square test were used to analyze the data. The value of P < 0.05 was considered as a significant and P < 0.0001 as highly significant. Results: The incidence of pain in Group I was observed in 80% of the patients, while it was observed in 23.33% and 20% of patients in Group II and III, respectively. Mean VAS scores were 2.27 ± 1.51, 1.14 ± 1.74, and 1.03 ± 1.72 in Group I, II, and Group III patients, respectively. The incidence of pruritus was 10% and 6.7% and erythema in 13.2% and 6.7% in Group II and III, respectively. Conclusion: Pretreatment with both butorphanol and tramadol significantly reduced pain on propofol injection; however, they exhibited comparable efficacy among each other. Thus, either of these two drugs can be considered for pretreatment to reduce propofol injection pain.
  1,662 363 -
Validation of simple and inexpensive algometry using sphygmomanometer cuff and neuromuscular junction monitor with standardized laboratory algometer
Padmaja Durga, Sreedhar Reddy Wudaru, Sunil Kumar Reddy Khambam, Shobha Jagadish Chandra, Gopinath Ramachandran
January-March 2016, 32(1):74-79
DOI:10.4103/0970-9185.173390  PMID:27006546
Background and Aims: The availability, ergonomics and economics prohibit the routine use of algometers in clinical practice and research by the anesthesiologists. A simple bedside technique of quantitative pain measurement would enable the routine use of algometry. We proposed to validate simple pain provocation using sphygmomanometer cuff and the electric stimulation of neuromuscular junction monitor (TOF-guard, Organon Teknika) to measure pain against a standardized laboratory pressure algometer. Material and Methods: Pain detection threshold (Pdt) and pain tolerance threshold (Ptt) were measured in forty healthy volunteers of both genders, using the above three techniques. All measurements were repeated three times. The co-efficient of inter-rater reliability (or consistency) between three independent measurements obtained from each of the techniques was determined by Cronbach's co-efficient alpha (α C). The correlation between the mean Pdt and Ptt values recorded by standardized algometer and the sphygmomanometer technique and nerve stimulator technique was performed using Pearson Correlation. An r >0.5 and a two-tailed significance of <0.05 were considered as good correlation between the standardized algometer and the tested techniques. Results: There was a good inter-rater reliability (α C > 0.7) for the three techniques. There was a good correlation with r >0.65 (P < 0.001) between the measurements of standardized pressure algometer and the two techniques being tested as alternatives for algometer to measure pain. Conclusion: The sphygmomanometer cuff technique and electrical stimulation with the peripheral nerve stimulator to measure pain threshold and tolerance provide a simple, efficient, repeatable measure of pain intensity and can be used as suitable alternatives to standard algometers.
  1,596 315 -
Clinically relevant exaggerated pharmacodynamic response to dual antiplatelet therapy detected by Thromboelastogram ® Platelet Mapping™
Kenneth N Hiller
January-March 2016, 32(1):112-114
DOI:10.4103/0970-9185.173347  PMID:27006555
Dual antiplatelet therapy (DAPT) is the standard of care for primary and secondary prevention strategies in patients with coronary artery disease after stenting. Current guidelines recommend that DAPT be continued for 12 months in patients after receiving drug eluting stents. Approximately 5% of these patients will present within this 12-month period for noncardiac surgery. This case report describes a clinically relevant exaggerated pharmacodynamic response to DAPT detected by preoperative assessment of platelet function. Based on the clinical history and physical exam and subsequent lab results, a general anesthetic was performed rather than a spinal anesthetic and the surgical procedure was changed. An exaggerated pharmacodynamic response to DAPT poses its own set of risks (unexpected uncontrolled bleeding, epidural hematoma following neuraxial block placement) that point-of-care aggregation testing may decrease or mitigate by altering clinical decision making. If the clinical history and physical exam reveal possible platelet dysfunction in patients receiving DAPT, preoperative platelet function testing should be considered.
  1,525 275 -
Perioperative management of a patient with left ventricular dysfunction and anomalous coronary arteries
Jyotsna Bhargava, Rajeev Lochan Tiwari, Mona Bana, Akhil Agarwal
January-March 2016, 32(1):103-105
DOI:10.4103/0970-9185.175707  PMID:27006552
Anesthetic management of patients with coronary artery disease undergoing noncardiac surgery is quite challenging. Such patients are at increased risk of perioperative cardiac complications and death. We report an illustrative case of a 62-year-old male with ischemic heart disease and anomalous coronary arteries for obstructed paraumbilical hernia repair.
  1,477 256 -
Comparative study evaluating efficacy of sufentanil versus midazolam in preventing myoclonic movements following etomidate
Mohammad Alipour, Masoumeh Tabari, Azadeh Mokhtari Azad
January-March 2016, 32(1):29-32
DOI:10.4103/0970-9185.173382  PMID:27006537
Background and Aims: Myoclonus is a major side-effect following etomidate injection requiring use of medical intervention. Material and Methods: In this double-blinded clinical trial, 50 consecutive patients, randomly received sufentanil 0.2 μg/kg or midazolam 0.015 mg/kg, 90 s before induction of anesthesia with etomidate (0.3 mg/kg). Then, the patients were monitored for any myoclonic movements during anesthesia. Results: The incidence of myoclonus was 28% in the sufentanil group and 84% in the midazolam group. The frequency and intensity of myoclonus were significantly higher in the midazolam group, compared to the sufentanil group (P < 0.001). Myoclonus duration in the sufentanil and midazolam groups were 5.8 ± 13.2 and 69 ± 47.8 s, respectively (P < 0.0010). Conclusion: The frequency, intensity and duration of myoclonus in the midazolam group, were significantly more prevalent than the sufentanil group.
  1,336 302 1
A comparative study of early and late extubation following transoral odontoidectomy and posterior fixation
Manish Marda, Mihir Prakash Pandia, Girija Prasad Rath, Shashank Sharad Kale, Harihara Dash
January-March 2016, 32(1):33-37
DOI:10.4103/0970-9185.173344  PMID:27006538
Background and Aims: Elective ventilation is the usual practice after transoral odontoidectomy (TOO) and posterior fixation. This practice of elective ventilation is not based on any evidence. The primary objective of our study was to find out the difference in oxygenation and ventilation in patients extubated early compared to those extubated late after TOO and posterior fixation. The secondary objectives were to compare the length of Intensive Care Unit (ICU)/hospital stay and pulmonary complications between the two groups. Material and Methods: After TOO and posterior fixation, patients were either extubated in the operating room (Group E) or extubated next day (Group D). The oxygenation (PaO 2 :FiO 2 ratio) and ventilation (PaCO 2 ) of the two groups before surgery, at 30 min and at 6/12/24 and 48 h after extubation were compared. Complications, durations of ICU and hospital stay were noted. Results: The base-line PaO 2 :FiO 2 and PaCO 2 was comparable between the groups. No significant change in the PaO 2 : FiO 2 was noted in the postoperative period in either group as compared to the preoperative values. Except for at 12 h after surgery, there was no significant difference between the two groups at various time intervals. No significant change in the PaCO 2 level was seen during the study period in either group. PaCO 2 measured at 30 min after surgery was more in Group E (37.5 ± 3.2 mmHg in Group E vs. 34.6 ± 2.9 mmHg in Group D), otherwise there was no significant difference between the two groups at various time intervals. One patient in Group E (7.1%) and two patients in Group D (13%) developed postoperative respiratory complication, but the difference was not statistically significant. The mean ICU stay (Group D = 42 ± 25 h vs. Group E = 25.1 ± 16.9 h) and mean hospital stay (Group D = 9.9 ± 4 days vs. Group E = 7.6 ± 2.2 days) were longer in Group D patients. Conclusion: Ventilation and oxygenation in the postoperative period in patients undergoing TOO and posterior fixation are not different between the two groups. However, the duration of ICU and hospital stay was prolonged in group D.
  1,340 261 -
A case of malpositioned catheter via supraclavicular approach for subclavian vein cannulation: A rare technique revisited
Parin Lalwani, Shiba Aggarwal, Rajeev Uppal, Somchandra
January-March 2016, 32(1):120-122
DOI:10.4103/0970-9185.175720  PMID:27006560
  1,307 221 1
Dual mode ventilation: Winning strategy in difficult-to-wean
Sukanya Mitra, Dheeraj Kapoor, Meghana Srivastava, Harpreet Sandhu
January-March 2016, 32(1):131-132
DOI:10.4103/0970-9185.168260  PMID:27006569
  1,242 237 -
No difference in pain reduction after epidural steroid injections in diabetic versus nondiabetic patients: A retrospective cohort study
Francis Wong, Bahram Namdari, Suzanne Dupler, Mario Farias Kovac, Natalya Makarova, Jarrod E Dalton, Alparslan Turan
January-March 2016, 32(1):84-88
DOI:10.4103/0970-9185.173334  PMID:27006548
Background and Aims: Diabetes affects peripheral and central neurons causing paresthesia, allodynia, hyperalgesia, and spontaneous pain. However, the effect of diabetes on response to epidural steroid injection (ESI) remains unknown. We hypothesized that diabetic patients receiving ESI will have different pain scores compared to nondiabetic patients. We tested a secondary hypothesis that pain reduction differs at different levels of hemoglobin A1c (HbA1c) for patients with diabetes. Material and Methods: Data from 284 consecutive patients given ESIs for radiculopathy were obtained via a manual review of electronic medical records. We initially compared diabetic and nondiabetic groups with respect to balance on baseline demographic and morphometric characteristics. Next, a linear regression model was developed to evaluate the association between existing diabetes and postinjection reduction in pain scores. And finally, we univariably characterized the association between HbA1c and pain reduction. Results: After exclusion of nine patients, 275 patients were analysed, including 55 (20%) who were diabetic. Pain reduction after ESI was comparable in diabetic and nondiabetic patients (Wald test P = 0.61). The degree of pain reduction generally decreased with the level of HbA1c until reaching HbA1c levels of approximately 7.5%, after which point it stayed fairly constant. Conclusion: There was no difference in pain reduction after ESIs comparing diabetic with nondiabetic patients; however, for diabetic patients, pain reduction may decrease with uncontrolled diabetes determined by high HbA1c values, thus suggesting pain physicians to take an active role in guiding their patients to have their blood glucose levels better regulated to improve outcomes of their ESIs.
  1,262 209 -
Management of pituitary apoplexy
Bikram Kumar Gupta, Anil Kumar Verma, MS Saravana Babu, Gynendra Gautam, Vanita R Mhaske, Chandrasekhar Singh
January-March 2016, 32(1):118-119
DOI:10.4103/0970-9185.173348  PMID:27006559
  1,194 259 -
An unusual case of subcutaneous emphysema without pneumothorax following brachial plexus block
Pushpavathi Ture, Madhuri Kurdi, Safiya Shaikh, Basavaraj Kallapur
January-March 2016, 32(1):117-118
DOI:10.4103/0970-9185.175718  PMID:27006558
  1,133 225 -
When everything failed, glidescope prevailed
Richa Saroa, Sukanya Mitra, Shradha Sinha, Anjali Singh
January-March 2016, 32(1):123-124
DOI:10.4103/0970-9185.175721  PMID:27006562
  1,153 201 -
Lignocaine jelly: A simple solution to intraoperative endotracheal tube cuff leak
Sukhminderjit Singh Bajwa, Rudrashish Haldar, Jasleen Kaur
January-March 2016, 32(1):130-131
DOI:10.4103/0970-9185.173386  PMID:27006568
  1,038 289 -
An unusual cause for concealed hemorrhagic shock in the second trimester of pregnancy resulting in fetal demise
Vinodhadevi Vijayakumar, Shaik Mushahida, Munuhur Srinivasan Prasanthkumar, Sulekha Soundararajan
January-March 2016, 32(1):127-128
DOI:10.4103/0970-9185.175727  PMID:27006566
  1,112 197 -
Fiber optic intubation of a neonate with Syngnathia under local anesthesia and sedation
Kirti Nath Saxena, Vipin Goel, Bharti Taneja, Prachi Gaba
January-March 2016, 32(1):128-130
DOI:10.4103/0970-9185.175729  PMID:27006567
  1,091 207 -
Anesthetic management in spontaneous esophageal rupture (Boerhaave's syndrome)
Jyotsna Bhargava, Rajeev Lochan Tiwari, Sundeep Jain
January-March 2016, 32(1):126-127
DOI:10.4103/0970-9185.175726  PMID:27006565
  1,071 183 -
Anesthetic management of a patient with severe neck dystonia during MRI
Vinay Byrappa, Shruti Redhu, Bhadrinarayan Varadarajan
January-March 2016, 32(1):115-116
DOI:10.4103/0970-9185.175717  PMID:27006556
  1,010 182 -
Anesthesia workstation ventilator malfunction due to accidental misplacement of a nasogastric tube
Prerana Nirav Shah, Rakesh Narayanaswamy, Shruti Khobragade
January-March 2016, 32(1):116-117
DOI:10.4103/0970-9185.173375  PMID:27006557
  990 200 -
Survey on neuromuscular management
Cyril Jacob Chacko, Manabendar Haldar
January-March 2016, 32(1):122-122
DOI:10.4103/0970-9185.173366  PMID:27006561
  944 209 1
In response to unanticipated cannot intubate situation due to difficult mouth opening
Raghu Sudarshan Thota, Renuka Purohit, Sohan Lal Solanki
January-March 2016, 32(1):125-125
DOI:10.4103/0970-9185.175725  PMID:27006564
  967 181 -
Retraction: Intrathecal sufentanil versus fentanyl for lower limb surgeries: A randomized controlled trial

January-March 2016, 32(1):133-133
DOI:10.4103/0970-9185.175731  PMID:27006570
  920 226 -
Extravasation of fluid in neck secondary to perforation of vein by venous catheter
Jeetinder Kaur Makkar, Divya Jain, Kajal Jain, Rajeev Subramanyam
January-March 2016, 32(1):124-125
DOI:10.4103/0970-9185.175723  PMID:27006563
  922 170 -