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  Citation statistics : Table of Contents
   2012| January-March  | Volume 28 | Issue 1  
    Online since January 31, 2012

 
 
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ORIGINAL ARTICLES
Reasons for cancellation of operation on the day of intended surgery in a multidisciplinary 500 bedded hospital
Rajender Kumar, Ritika Gandhi
January-March 2012, 28(1):66-69
DOI:10.4103/0970-9185.92442  PMID:22345949
Background: Cancellation of operations in hospitals is a significant problem with far reaching consequences. This study was planned to evaluate reasons for cancellation of elective surgical operation on the day of surgery in a 500 bedded Government hospital. Materials and Methods: The medical records of all the patients, from December 2009 to November 2010, who had their operations cancelled on the day of surgery in all surgical units of the hospital, were audited prospectively. The number of operation cancelled and reasons for cancellation were documented. Results: 7272 patients were scheduled for elective surgical procedures during study period; 1286 (17.6 %) of these were cancelled on the day of surgery. The highest number of cancellation occurred in the discipline of general surgery (7.1%) and the least (0.35%) occurred in Ear-Nose-Throat surgery. The most common cause of cancellation was the lack of availability of theater time 809 (63%) and patients not turning up 244 (19%) patients. 149 cancellations (11.6%) were because of medical reasons; 16 (1.2%) were cancelled by the surgeon due to a change in the surgical plan; 28 (2.1%) were cancelled as patients were not ready for surgery; and 40 (3.1%) were cancelled due to equipment failure.]. Conclusion: Most causes of cancellations of operations are preventable.
  56 8,853 1,134
Reduction in the incidence of shivering with perioperative dexmedetomidine: A randomized prospective study
Sukhminder Jit Singh Bajwa, Sachin Gupta, Jasbir Kaur, Amarjit Singh, SS Parmar
January-March 2012, 28(1):86-91
DOI:10.4103/0970-9185.92452  PMID:22345953
Background and Aims: Shivering is distressing to the patient and discomforting to the attending anesthesiologist, with a varying degree of success. Various drugs and regimens have been employed to abolish the occurrence of shivering. The present study aims to explore the effectiveness of dexmedetomidine in suppressing the postanesthetic shivering in patients undergoing general anesthesia. Materials and Methods: The present study was carried out on 80 patients, in American Society of Anesthesiologists I and II, aged 22-59 years, who underwent general anesthesia for laparoscopic surgical procedures. Patients were allocated randomly into two groups: group N (n = 40) and group D (n = 40). Group D were administered 1 ΅g/kg of dexmedetomidine intravenously, while group N received similar volume of saline during peri-op period. Cardiorespiratory parameters were observed and recorded during the preop, intraop, and postop periods. Any incidence of postop shivering was observed and recorded as per 4 point scale. Side effects were also observed, recorded, and treated symptomatically. Statistical analysis was carried out using statistical package for social sciences (SPSS) version 15.0 for windows and employing ANOVA and chi-square test with post-hoc comparisons with Bonferroni's correction. Results: The two groups were comparable regarding demographic profile (P> 0.05). Incidence of shivering in group N was 42.5%, which was statistically highly significant (P = 0.014). Heart rate and mean arterial pressure also showed significant variation clinically and statistically in group D patients during the postop period (P = 0.008 and 0.012). A high incidence of sedation (P = 0.000) and dry mouth (P = 0.000) was observed in group D, whereas the incidence of nausea and vomiting was higher in group N (P = 0.011 and 0.034). Conclusions: Dexmedetomidine seems to possess antishivering properties and was found to reduce the occurrence of shivering in patients undergoing general anesthesia.
  47 7,492 1,382
Evaluation of the efficacy of hyperbaric oxygen therapy in the management of chronic nonhealing ulcer and role of periwound transcutaneous oximetry as a predictor of wound healing response: A randomized prospective controlled trial
Sarbjot Kaur, Mridula Pawar, Neerja Banerjee, Rakesh Garg
January-March 2012, 28(1):70-75
DOI:10.4103/0970-9185.92444  PMID:22345950
Background: Hyperbaric oxygen therapy (HBOT) is a treatment option for chronic nonhealing wounds. Transcutaneous oximetry (TCOM) is used for wound assessment. We undertook a randomized prospective controlled trial to evaluate the role of HBOT in healing of chronic nonhealing wounds and to determine whether TCOM predicts healing. Materials and Methods: This study was conducted in 30 consenting patients with nonhealing ulcer. The patients were randomized into group HT (receiving HBOT in addition to conventional treatment) and group CT (receiving only conventional treatment). Duration of treatment in both the groups was 30 days. Wound ulcer was analyzed based on size of the wound, exudates, presence of granulation tissue, and wound tissue scoring. Tissue oxygenation (TcPO 2 ) was measured on 0, 10 th , 20 th , and 30 th day. Results: There was 59% reduction in wound area in group HT and 26% increase in wound area in group CT. Ten patients in group HT showed improvement in wound score as compared to five patients in group CT. Complete healing was seen in three patients in group HT as compared to none in group CT. Surgical debridement was required in 6 patients in group HT and 10 patients in group CT. One patient in group HT required amputation as compared to five patients in group CT. A positive correlation was found between TcPO 2 value and various markers of wound healing. Conclusion: HBOT has a definitive adjunctive role in the management of chronic nonhealing ulcers. It decreases the amputation rate and improves patient outcome. Periwound TcPO 2 may be used as a predictor of response to HBOT and has a positive correlation with wound healing.
  31 5,627 992
REVIEW ARTICLES
Effect of general anesthetics on the developing brain
S Velayudha Reddy
January-March 2012, 28(1):6-10
DOI:10.4103/0970-9185.92426  PMID:22345937
Studies on rodents and subhuman primates suggest that prolonged exposure to general anesthetics may induce widespread neuronal cell death and neurological sequelae; seriously questioning the safety of pediatric anesthesia. This review presents recent developments in this rapidly emerging field. There is mounting and convincing preclinical evidence in rodents and nonhuman primates that anesthetics in common clinical use are neurotoxic to the developing brain in vitro and cause long-term neurobehavioral abnormalities in vivo. Prior to the publication of animal data and after the publication of animal data, there are several human cohort studies that demonstrate the association of poor neurodevelopmental outcome in neonates, who underwent major surgery during their neonatal period. This review summarizes our present understanding of some of the key components responsible for anesthesia-induced neuroapoptosis and offers some of neuroprotective strategies that could be beneficial as adjunct therapy in preventing anesthesia-induced death of developing neurons in the neonates. A randomized literature search was carried out using search words apoptosis, general anesthetics, and developing brain from 1979 to 2011 for effects of general anesthetics on developing brain in PUBMED and relevant published literature reviewed. General anesthetics may produce neurotoxicity and enduring cognitive impairment in young and aged animals, but the issue has not been adequately studied in humans. It is premature to recommend a change clinical practice based on the present data.
  27 6,120 1,777
Perioperative vision loss: A complication to watch out
VK Grover, Kiran Jangra
January-March 2012, 28(1):11-16
DOI:10.4103/0970-9185.92427  PMID:22345938
Postoperative vision loss, a rare but devastating complication, has been reported after spine, cardiac, and head-neck surgeries. Its incidence following spine surgeries exceeds that after cardiothoracic surgeries. Various causes attributed to postoperative blindness include ischemic optic neuropathy, central or branch retinal artery occlusion, cortical blindness, and rarely external ocular injury. Other contributory factors described are microvascular diseases and intraoperative hemodynamic compromise. However, the exact association of these factors with postoperative blindness has not yet been confirmed. In this review, we describe causes, presentation, and treatment of postoperative blindness and also recommend practical guidelines to avoid this complication. The search strategies for this review included both search of electronic databases as well as manual search of relevant articles.
  24 7,286 1,760
CASE REPORTS
Challenges encountered with argatroban anticoagulation during cardiopulmonary bypass
Shvetank Agarwal, Beth Ullom, Yasser Al-Baghdadi, Michael Okumura
January-March 2012, 28(1):106-110
DOI:10.4103/0970-9185.92458  PMID:22345956
Use of argatroban as an alternative to heparin during cardiopulmonary bypass (CPB) in patients with heparin-induced thrombocytopenia has gained some attention in the past two decades. Dosing of argatroban during CPB is complex due to lack of complete understanding of its pharmacokinetic profile and the various elements during CPB that may alter its plasma levels. We report a case where the challenges in dosing argatroban led to failure to provide adequate anticoagulation during CPB, as evidenced by clot formation in the oxygenator, and extensive bleeding in the postoperative period.
  15 4,494 640
ORIGINAL ARTICLES
Retrospective analysis of snake victims in Northern India admitted in a tertiary level institute
Syed Moied Ahmed, Abu Nadeem, Mohd. Sabihul Islam, Shiwani Agarwal, Lalit Singh
January-March 2012, 28(1):45-50
DOI:10.4103/0970-9185.92434  PMID:22345945
Context: Snake bites are the common cause of morbidity and mortality in tropical countries. Aims: To analyze the outcome of snake bite victims Settings and Design: Retrospective analysis of data from Intensive care unit, Department of Anesthesiology. Materials and Methods: All the patients admitted in the intensive care unit for snake bite management during the year May 2004 - April 2009 were retrospectively reviewed. The data included age, sex, month and time of incident, site of bite, dose of anti--snake venom, time of anti--snake venom, administration, duration of mechanical ventilation, complications and death of a victim. Statistical analysis used: Pearson's correlation test, paired samples t-test. Results and Conclusions: 113 patients reported to the Accident and Emergency with history of snake bite. 26 patients were referred to other hospital, 17 patients were brought dead, and 70 patients were admitted to the intensive care unit. In 59 snake-bite victims, maximum data could be recovered. Krait was the most common type of snake bite reported. There was a male preponderance (69.4%) with age ranging between 20 and 40 years (52.5%). The mean lag time (time elapsed between bite and first dose of anti--snake venom) was 5.3 ± 1.4 h and the mean anti-snake venom dose was 12.3 ± 2.4 vials. There was a positive and significant correlation between lag time and total dose of anti--snake venom (correlation coefficient =0.956, P<0.0001). Overall 72.9% patients required mechanical ventilation with a mean duration of 56.2 ± 16.1 h. 10.2% patients sustained cardiac arrest, 8.7% patients developed ventilator associated pneumonia, 6.7% suffered mild anti-snake venom reaction, 6.7% had hypotension and 5.1% patients developed renal failure. The overall mortality was 5.1%.
  15 3,482 544
A comparative randomized study of paravertebral block versus wound infiltration of bupivacaine in modified radical mastectomy
Parul Bansal, Kirti Nath Saxena, Bharti Taneja, Bhuwan Sareen
January-March 2012, 28(1):76-80
DOI:10.4103/0970-9185.92449  PMID:22345951
Background: Paravertebral block (PVB) has the potential to offer long-lasting pain relief because it can uniquely eliminate cortical responses to thoracic dermatomal stimulation. Benefits include a reduction in postoperative nausea and vomiting (PONV), prolonged postoperative pain relief, and potential for ambulatory discharge. Aims: To compare PVB with local infiltration for postoperative analgesia following modified radical mastectomy (MRM). Methods: Forty patients undergoing MRM with axillary dissection were randomly allocated into two groups. Following induction of general anesthesia in group P, a catheter was inserted in the paravertebral space and 0.3 ml/kg of 0.25 % of bupivacaine was administered followed by continuous infusion, while in group L, the surgical incision was infiltrated with 0.3 ml/kg of 0.25 % bupivacaine. Statistical Analysis: The statistical tests were applied as unpaired student 't' test/nonparametric test Wilcoxon Mann Whitney test for comparing different parameters such as VAS score and consumption of drugs. The categorical variables such as nausea and vomiting scores, sedation score, and patient satisfaction score were computed by Chi square test/Fisher exact test. Results: VAS score was significantly lower in group P than in group L throughout the postoperative period. The mean alertness score (i.e., less sedation) was higher in group P in the postoperative period than group L. The incidence of PONV was less in PVB group. Conclusion: PVB at the end of the surgery results in better postoperative analgesia, lesser incidence of PONV, and better alertness score.
  13 3,591 847
CASE REPORTS
Perioperative management of a patient with an axial-flow rotary ventricular assist device for laparoscopic ileo-colectomy
Subramanian Sathishkumar, R Kodavatiganti, S Plummer, K High
January-March 2012, 28(1):101-105
DOI:10.4103/0970-9185.92456  PMID:22345955
The use of mechanical circulatory support devices as a bridge to transplant or destination therapy decreases mortality, improves quality of life, and functional status. The paucity of clinical data and the challenges faced by noncardiac anesthesiologists warrant us to present the perioperative care of a patient with a HeartMate II (Thoratec Corp. Pleasanton, CA, USA) left ventricular assist device (LVAD), who underwent a successful major laparoscopic abdominal surgery. Key issues highlighted are the limitations of oxygen saturation (SpO 2 ) monitoring, accuracy of blood pressure (BP) measurement, and the potential usefulness of intraoperative transesophageal echocardiography (TEE). The hemodynamic changes, impact on the LVAD function during laparoscopic surgery, and the multidisciplinary approach are addressed.
  11 6,852 666
ORIGINAL ARTICLES
Enteral nutrition practices in the intensive care unit: Understanding of nursing practices and perspectives
Babita Gupta, Pramendra Agrawal, Kapil D Soni, Vikas Yadav, Roshni Dhakal, Shally Khurana, MC Misra
January-March 2012, 28(1):41-44
DOI:10.4103/0970-9185.92433  PMID:22345944
Background: Adequate nutritional support is important for the comprehensive management of patients in intensive care units (ICUs). Aim: The study was aimed to survey prevalent enteral nutrition practices in the trauma intensive care unit, nurses' perception, and their knowledge of enteral feeding. Study Design: The study was conducted in the ICU of a level 1 trauma center, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India. The study design used an audit. Materials and Methods: Sixty questionnaires were distributed and the results analyzed. A database was prepared and the audit was done. Results: Forty-two (70%) questionnaires were filled and returned. A majority (38) of staff nurses expressed awareness of nutrition guidelines. A large number (32) of staff nurses knew about nutrition protocols of the ICU. Almost all (40) opined enteral nutrition to be the preferred route of nutrition unless contraindicated. All staff nurses were of opinion that enteral nutrition is to be started at the earliest (within 24-48 h of the ICU stay). Everyone opined that the absence of bowel sounds is an absolute contraindication to initiate enteral feeding. Passage of flatus was considered mandatory before starting enteral nutrition by 86% of the respondents. Everyone knew that the method of Ryle's tube feeding in their ICU is intermittent boluses. Only 4 staff nurses were unaware of any method to confirm Ryle's tube position. The backrest elevation rate was 100%. Gastric residual volumes were always checked, but the amount of the gastric residual volume for the next feed to be withheld varied. The majority said that the unused Ryle's tube feed is to be discarded after 6 h. The most preferred (48%) method to upgrade their knowledge of enteral nutrition was from the ICU protocol manual. Conclusion: Information generated from this study can be helpful in identifying nutrition practices that are lacking and may be used to review and revise enteral feeding practices where necessary.
  10 5,416 1,199
Anesthetic drug wastage in the operation room: A cause for concern
Kapil Chaudhary, Rakesh Garg, Anju R Bhalotra, Raktima Anand, KK Girdhar
January-March 2012, 28(1):56-61
DOI:10.4103/0970-9185.92438  PMID:22345947
Context: The cost of anesthetic technique has three main components, i.e., disposable supplies, equipments, and anesthetic drugs. Drug budgets are an easily identifiable area for short-term savings. Aim: To assess and estimate the amount of anesthetic drug wastage in the general surgical operation room. Also, to analyze the financial implications to the hospital due to drug wastage and suggest appropriate steps to prevent or minimize this wastage. Settings and Design: A prospective observational study conducted in the general surgical operation room of a tertiary care hospital. Materials and Methods: Drug wastage was considered as the amount of drug left unutilized in the syringes/vials after completion of a case and any ampoule or vial broken while loading. An estimation of the cost of wasted drug was made. Results: Maximal wastage was associated with adrenaline and lignocaine (100% and 93.63%, respectively). The drugs which accounted for maximum wastage due to not being used after loading into a syringe were adrenaline (95.24%), succinylcholine (92.63%), lignocaine (92.51%), mephentermine (83.80%), and atropine (81.82%). The cost of wasted drugs for the study duration was 46.57% (Rs. 16,044.01) of the total cost of drugs issued/loaded (Rs. 34,449.44). Of this, the cost of wastage of propofol was maximum being 56.27% (Rs. 9028.16) of the total wastage cost, followed by rocuronium 17.80% (Rs. 2856), vecuronium 5.23% (Rs. 840), and neostigmine 4.12% (Rs. 661.50). Conclusions: Drug wastage and the ensuing financial loss can be significant during the anesthetic management of surgical cases. Propofol, rocuronium, vecuronium, and neostigmine are the drugs which contribute maximally to the total wastage cost. Judicious use of these and other drugs and appropriate prudent measures as suggested can effectively decrease this cost.
  10 5,352 670
LETTERS TO THE EDITOR
Possible mitigation of rocuronium-induced anaphylaxis after administration of sugammadex
Cyrus Motamed, Pascal Baguenard, Jean louis Bourgain
January-March 2012, 28(1):127-128
DOI:10.4103/0970-9185.92464  PMID:22345962
  9 2,424 543
ORIGINAL ARTICLES
Comparative evaluation of midazolam and butorphanol as oral premedication in pediatric patients
Chandni Sinha, Manpreet Kaur, Ajeet Kumar, Anand Kulkarni, M Ambareesha, Madhusudan Upadya
January-March 2012, 28(1):32-35
DOI:10.4103/0970-9185.92431  PMID:22345942
Background: To compare oral midazolam (0.5 mg/kg) with oral butorphanol (0.2 mg/kg) as a premedication in 60 pediatric patients with regards to sedation, anxiolysis, rescue analgesic requirement, and recovery profile. Materials and Methods: In a double blinded study design, 60 pediatric patients belonging to ASA class I and II between the age group of 2-12 years scheduled for elective surgery were randomized to receive either oral midazolam (group I) or oral butorphanol (group II) 30 min before induction of anesthesia. The children were evaluated for levels of sedation and anxiety at the time of separation from the parents, venepuncture, and at the time of facemask application for induction of anesthesia. Rescue analgesic requirement, postoperative recovery, and complications were also recorded. Results: Butorphanol had better sedation potential than oral midazolam with comparable anxiolysis at the time of separation of children from their parents. Midazolam proved to be a better anxiolytic during venepuncture and facemask application. Butorphanol reduced need for supplemental analgesics perioperatively without an increase in side effects such as nausea, vomiting, or unpleasant postoperative recovery. Conclusion: Oral butorphanol is a better premedication than midazolam in children in view of its excellent sedative and analgesic properties. It does not increase side effects significantly.
  9 3,066 555
CASE REPORTS
Early presentation of postintubation tracheoesophageal fistula: Perioperative anesthetic management
Depinder Kaur, Saurabh Anand, Prakash Sharma, Ashwini Kumar
January-March 2012, 28(1):114-116
DOI:10.4103/0970-9185.92460  PMID:22345958
Tracheoesophageal fistula (TEF) in adults occurs as a result of trauma, malignancy, cuff-induced tracheal necrosis from prolonged mechanical ventilation, traumatic endotracheal intubation, foreign body ingestion, prolonged presence of rigid nasogastric tube, and surgical complication. Anesthetic management for repair of TEF is a challenge. Challenges include difficulties in oxygenation or ventilation resulting from placement of endotracheal tube in or above the fistula; large fistula defect causing loss of tidal volume with subsequent gastric dilatation, atelactasis, and maintenance of one lung ventilation. The most common cause of acquired nonmalignant TEF is postintubation fistula, which develops after prolonged intubation for ventilatory support. Acquired TEF, which occurs after prolonged intubation, usually develops after 12-200 days of mechanical ventilation, with a mean of 42 days. We present a rare case of TEF that developed after 7 days of intubation. It was a difficult case to be diagnosed as patient had a history of polytrauma, followed by emergency intubation and both these conditions can contribute to tracheobronchial injury.
  8 4,175 587
CLINICAL PHARMACOLOGY
Desflurane - Revisited
Mukul Chandra Kapoor, Mahesh Vakamudi
January-March 2012, 28(1):92-100
DOI:10.4103/0970-9185.92455  PMID:22345954
The search for an ideal inhalational general anesthetic agent continues. Desflurane, which was recently introduced in the Indian market, possesses favorable pharmacokinetic and pharmacodynamic properties and is closer to the definition of an ideal agent. It offers the advantage of precise control over depth of anesthesia along with a rapid, predictable, and clear-headed recovery with minimal postoperative sequelae, making it a valuable anesthetic agent for maintenance in adults and pediatric patients in surgeries of all durations. The agent has advantages when used in extremes of age and in the obese. Its use may increase the direct costs of providing anesthetic care. Methods or techniques, such as low-flow anesthesia, to reduce the overall cost and along with minimal environmental implications must be followed.
  7 9,573 2,094
CASE REPORTS
Parturient with kyphoscoliosis (operated) for cesarean section
David G Veliath, Raji Sharma, RV Ranjan, CP Rajesh Kumar, TR Ramachandran
January-March 2012, 28(1):124-126
DOI:10.4103/0970-9185.92463  PMID:22345961
Anesthesia for emergency cesarean section for the pregnant patient with surgically corrected scoliosis is associated with potential risks for both mother and the fetus due to alterations in maternal physiology and the pathological changes seen in scoliosis. The anesthetic management must address the well being of both mother and fetus. The need for anesthesia for obstetric delivery in pregnant women with scoliosis is much more than in the normal parturient. We report the successful use of spinal anesthesia in a patient with surgically corrected scoliosis for emergency cesarean section.
  6 3,922 580
ORIGINAL ARTICLES
Observational study to assess the effectiveness of postoperative pain management of patients undergoing elective cesarean section
Samina Ismail, Khurram Shahzad, Faraz Shafiq
January-March 2012, 28(1):36-40
DOI:10.4103/0970-9185.92432  PMID:22345943
Background: The study was designed to assess the strategy, effectiveness, and safety of postoperative pain management in patients undergoing elective cesarean section in the obstetric unit of our hospital. Materials and Methods: Patients having elective cesarean section from December 2008 to May 2009 were included in this observational study. We recorded patient's demographics, postoperative pain orders, and analgesia regime on the day of surgery. Anesthesia team, which included one of the investigators, assessed the overall pain since the time of surgery by visual analogue scale (VAS) and also recorded any complications since the time of surgery and patients' satisfaction with the pain management. Results: A total of 263 patients were reviewed during the study period. Postoperative analgesia regime was started by the obstetric team in 81% of patients and in rest by the anesthesia team. The common modality of pain management was intravenous opioid infusion (94%) and coanalgesia was used in 99% of patients. The analysis of pain at rest by VAS was between 1 and 3 in 89.7%, 4 and 6 in 9.5%, and 7 and 10 in 0.8% of patients. The VAS on movement was 1-3 in 60.1%, 4-6 in 33.1%, and 7-10 in 6.8% of patients. Patients' opinion regarding postoperative pain management was satisfactory in 91.6% of patients and unsatisfactory in 8.4% of patients. Overall, 9% of patients had minor complications, which responded well to treatment. Conclusion: The regime for postoperative pain management was mostly started and followed by the obstetric team at the hospital. Although the postoperative pain management was adequate in terms of patients' safety, it was not effective according to the goal set by Joint Commission on Accreditation of uniformly low pain score of not more than 3 out of 10 both at rest and with movement.
  6 5,417 1,035
Advancement of epidural catheter from lumbar to thoracic space in children: Comparison between 18G and 23G catheters
Dalim Kumar Baidya, Dilip Kumar Pawar, Maya Dehran, Arun Kumar Gupta
January-March 2012, 28(1):21-27
DOI:10.4103/0970-9185.92429  PMID:22345940
Backgrounds and Objectives: Lumbar-to-thoracic advancement of epidural catheter is a safe alternative to direct thoracic placement in children. In this prospective randomized study, success rate of advancement of two different types and gauges of catheter from lumbar-to-thoracic space were studied. Materials and Methods: Forty ASA I and II children (up to 6 years) undergoing thoracic or upper-abdominal surgery were allocated to either Group I (18G catheter) or Group II (23G catheter). After induction of general anesthesia a pre-determined length of catheter was inserted. Successful catheter placement was defined as the catheter tip within two segment of surgical incision in radio-contrast study. Intra-operative analgesia was provided by epidural bupivacaine and intravenous morphine. Post-operative analgesia was provided with epidural infusion of 0.1% bupivacaine+1mcg/ml fentanyl. Observations and Results: Catheter advancement was successful in 3 cases in Group I and 2 cases in Group II. Five different types of catheter positions were found on X-ray. Negative correlation was found between age and catheter advancement [significance (2-tailed) =0.03]. However, satisfactory post-operative analgesia was obtained in 35 cases. Positive correlation was found between infusion rate, the number of segment of gap between desired level and the level reached [significance (2-tailed) =0.00]. 23G catheter use was associated with more technical complications. Conclusion: Advancement of epidural catheter from lumbar to thoracic level was successful in only 10-15% cases but satisfactory analgesia could be provided by increasing the infusion rates.
  6 3,870 449
Effect of magnesium sulfate with propofol induction of anesthesia on succinylcholine-induced fasciculations and myalgia
Mahendra Kumar, Nalin Talwar, Ritu Goyal, Usha Shukla, AK Sethi
January-March 2012, 28(1):81-85
DOI:10.4103/0970-9185.92451  PMID:22345952
Background: Magnesium sulfate and propofol have been found to be effective against succinylcholine-induced fasciculations and myalgia, respectively, in separate studies. A prospective randomized double blind controlled study was designed to assess the effect of a combination of magnesium sulfate with propofol for induction of anesthesia on succinylcholine-induced fasciculations and myalgia. Materials and Methods: Randomly selected 60 adult patients scheduled for elective surgery under general anesthesia were allocated to one of the two equal groups by draw of lots. The patients of MG Group were pretreated with magnesium sulfate 40 mg/kg body weight in 10 ml volume, while patients of NS group were given isotonic saline 0.9% in the same volume (10 ml) intravenously slowly over a period of 10 min. Anesthesia was induced with fentanyl 1.5 mcg/kg and propofol 2 mg/kg, followed by administration of succinylcholine 2 mg/kg intravenously. Muscle fasciculations were observed and graded as nil, mild, moderate, or severe. Postoperative myalgia was assessed after 24 h of surgery and graded as nil, mild, moderate, or severe. Observations were made in double blind manner. Results: Demographic data of both groups were comparable (P> 0.05). Muscle fasciculations occurred in 50% patients of MG group versus in 100% patients of NS group with a significant difference (P< 0.001). After 24 h of surgery, no patient of MG group and 30% patients of NS group had myalgia with a significant difference (P< 0.002). Conclusion: Magnesium sulfate 40 mg/kg intravenously may be used with propofol for induction of anesthesia to control succinylcholine-induced fasciculations and myalgia.
  6 4,631 820
EDITORIALS
Pediatric epidurals
Navdeep Sethi, Ravindra Chaturvedi
January-March 2012, 28(1):4-5
DOI:10.4103/0970-9185.92409  PMID:22345936
  4 2,798 862
Nutrition in intensive care
Ramanathan Ramprasad, Mukul Chandra Kapoor
January-March 2012, 28(1):1-3
DOI:10.4103/0970-9185.92401  PMID:22345935
  4 3,102 943
ORIGINAL ARTICLES
Trapezius squeeze test as an indicator for depth of anesthesia for laryngeal mask airway insertion in children
Sarla Hooda, Kiranpreet Kaur, Kamal N Rattan, Anil K Thakur, Kirti Kamal
January-March 2012, 28(1):28-31
DOI:10.4103/0970-9185.92430  PMID:22345941
Background: Clinical tests, such as loss of verbal contact, eyelash reflex, corneal reflex, and jaw relaxation, are used to assess the depth of anesthesia. "Trapezius squeeze test" (TST) is one such clinical test. It is a simple test to perform in which 1-2 inches of trapezius muscle is held and squeezed in full thickness and response is evaluated in the form of toe/body movement. Materials and Methods: One hundred pediatric patients between 3 and 5 years of age, scheduled to undergo elective surgery, were included in this study. We evaluated negative TST as an indicator for optimal anesthesia depth for laryngeal mask airway (LMA) insertion in anesthetized spontaneously breathing children. Anesthesia was induced using 4% sevoflurane in oxygen. As the child lost the verbal contact or loss of body movement, TST was performed. Test was repeated every 15 s till it became negative. When the TST became negative, a well lubricated, appropriate-size LMA was inserted. Results: Mean time for TST to become negative in our study was 271.80 ± 55.8 s and ease of insertion was excellent in 91 patients and acceptable in 9 patients. LMA was successfully inserted in first attempt in 96% patients. Conclusions: Negative TST is a reliable indicator for placement of LMA in spontaneously breathing children. Excellent conditions for LMA placement are present in majority of the patients without any untoward effects at this point of time.
  4 3,591 590
Management of swine-flu patients in the intensive care unit: Our experience
Raktima Anand, Akhilesh Gupta, Anshu Gupta, Sonia Wadhawan, Poonam Bhadoria
January-March 2012, 28(1):51-55
DOI:10.4103/0970-9185.92436  PMID:22345946
Background: H1N1 pandemic in 2009-2010 created a state of panic not only in India, but in the whole world. The clinical picture seen with H1N1 is different from the seasonal influenza involving healthy young adults. Critical care management of such patients imposes a challenge for anesthesiologist. Materials and Methods: A retrospective analysis of hospitalized positive H1N1 patients was performed from July 2009-June 2010. Those requiring the ventilatory support were included in the study. Result: 54 patients were admitted in the swine-flu ward during the study period out of which 19 required ventilatory support. The average day of presentation to the health care facility was 6 th day causing delay in initiation of antiviral therapy and increased severity of the disease. 65% of the ventilated patients were having associated comorbidities. Mortality was 74% among ventilated patients. Conclusion: Positive H1N1 with severe disease profile have a poor outcome. Early identification of high-risk factors and thus early intervention in the form of antiretroviral therapy and respiratory care will help in reducing the overall mortality.
  3 2,896 472
LETTERS TO THE EDITOR
Paresthesias at multiple levels: A rare neurological manifestation of epidural anesthesia
Ravi Jindal, Sukhminder Jit Singh Bajwa
January-March 2012, 28(1):136-137
DOI:10.4103/0970-9185.92474  PMID:22345972
  2 3,413 276
Safe practices in epidural catheter tunneling
Mukesh Tripathi
January-March 2012, 28(1):138-139
DOI:10.4103/0970-9185.92476  PMID:22345974
  2 2,567 339
Delayed pharyngoesophageal perforation following anterior cervical spine surgery: An incidental finding
Tejesh C Anandaswamy, Vinayak Seenappa Pujari, Shivakumar Shivanna, AC Manjunath
January-March 2012, 28(1):139-140
DOI:10.4103/0970-9185.92477  PMID:22345975
  2 2,049 300
Playing music in operation theatre
Beuy Joob, Viroj Wiwanitkit
January-March 2012, 28(1):130-131
DOI:10.4103/0970-9185.92467  PMID:22345965
  2 1,469 340
Accidental intraoperative avulsion of external inflation tubing of armored endotracheal tube
Shyam Bhandari, Surender Pal Gupta, Kapil Gupta, Amitabh Kumar
January-March 2012, 28(1):132-133
DOI:10.4103/0970-9185.92470  PMID:22345968
  1 1,907 279
Leak in circuit: An unusual cause!
Jyotsna Punj, Meenu Batra, V Darlong, R Pandey
January-March 2012, 28(1):133-134
DOI:10.4103/0970-9185.92471  PMID:22345969
  1 1,447 309
Fospropofol: Pharmacokinetics?
Bharti Mahajan, Sandeep Kaushal, Rajesh Mahajan
January-March 2012, 28(1):134-135
DOI:10.4103/0970-9185.92472  PMID:22345970
  1 1,696 360
Videoendoscope-guided nasotracheal intubation in ankylozing spondylitis
Sabyasachi Das, Mohan C Mandal, Sunil K Sah, Pralay S Ghosh
January-March 2012, 28(1):141-143
DOI:10.4103/0970-9185.92479  PMID:22345977
  1 1,895 343
Anesthetic management of a 137-year-old patient fracture of neck femur
Samridhi Nanda, Anju Gupta, Amit Kulshreshtha, Poonam Kalra, Meenakshi Sharma
January-March 2012, 28(1):143-144
DOI:10.4103/0970-9185.92480  PMID:22345978
  1 1,679 374
ORIGINAL ARTICLES
A comparison of the effectiveness of predictors of caudal block in children-swoosh test, anal sphincter tone, and heart rate response
Nandini M Dave, Madhu Garasia
January-March 2012, 28(1):17-20
DOI:10.4103/0970-9185.92428  PMID:22345939
Objective: To study the effectiveness of three predictors of successful caudal block in children, viz. swoosh test, heart rate response to injection, and laxity of anal sphincter tone. Aim: To improve the success rates of caudal block in children by identifying the best predictor. Background: Caudal blocks in children are placed after induction of anesthesia. Although simple to learn and perform, the success rate of the blocks may be variable especially in teaching hospitals where trainee anesthetists perform these blocks. Materials and Methods: 223 patients, aged 2-12 years, undergoing lower abdominal and urologic surgery were studied. 0.25% Bupivacaine was administered after induction of general anesthesia according to the Armitage regimen. Results: The sensitivity and specificity were highest with the sphincter tone test (sensitivity 95.22%, specificity 92.86%), followed by the heart rate response (sensitivity 92.82%, specificity 78.57%) and the swoosh test (sensitivity 66.51%, specificity 35.71%). The anal sphincter tone test had the highest positive predictive value (99.5%) and positive likelihood ratio (13.33). The heart rate response had a positive predictive value of 98.48% and a positive likelihood ratio of 4.33. The swoosh test, in our study, had a positive predictive value of 93.92% and a positive likelihood ratio of 1.035. Conclusion: The anal sphincter tone test was the best predictor of successful caudal block. We recommend the use of these additional simple predictors of accurate needle placement to increase the success rate of caudal block especially in teaching hospitals.
  1 2,877 638
Practice trends in use of morphine for control of intraoperative pain: An audit
Ajai Kumar Jain, Surendra Kumar, Asha Tyagi
January-March 2012, 28(1):62-65
DOI:10.4103/0970-9185.92440  PMID:22345948
Background: When using morphine as the sole analgesic during conduct of anesthesia, the fear of its adverse postoperative effects primarily sedation and respiratory depression may impede adequate dosing and analgesia. Aim and Objectives: This audit aims to explore the dosing schedules of morphine used during general anesthesia in our institution and to analyze whether the fear of major side effects leads to suboptimal dosing of morphine with inadequate pain relief. Materials and Methods: All subjects scheduled for surgery under general anesthesia wherein morphine was used exclusively for intraoperative analgesia were included in the audit. The audit proforma was completed by the attending anesthesiologist wherein the study period extended from beginning of anesthesia to immediate postoperative period. Result: The study population comprised of 158 patients having mean age 33 ± 14 years and mean weight 52 ± 14 kg. The dose of morphine administered at induction varied widely from 0.05 to 0.3 mg/kg i.v. The VAS (Visual Analogue Scale) score in immediate postoperative period varied from 0 to 10 (mean 1.7 ± 2.0) and sedation score from 1 to 5 (mean 3.94 ± 1.05). Inadequate analgesia with a VAS score ≥4 was seen in 15% patients. Morphine dosage of >0.1 mg/kg was associated with highly significant increase in quality of postoperative analgesia with VAS score <4, and an increase in sedation with sedation score ≤3 (P value < 0.01). However, none of the patients required active intervention for cardiorespiratory support. Conclusion: The practice of dosing morphine in our institution is highly variable with doses ranging from 0.05 to 0.3 mg/kg. This results in inadequate analgesia in 15% patients in postoperative period. Titrating the dose of morphine to expected pain levels inflicted upon by surgical procedures may result in better pain control and less sedated patients postoperatively.
  1 5,980 522
CASE REPORTS
Anesthetic management of deep brain stimulator implantation in Meige's syndrome
Kalpesh V Bhoyar, Pinakin Gujjar, Shashikant Shinde, Nirav Kotak
January-March 2012, 28(1):111-113
DOI:10.4103/0970-9185.92459  PMID:22345957
Meige's syndrome is rare form of orofacial dystonia. There is unfortunately no cure, but occasionally patients may improve with time. We present the successful management of a palladial deep brain stimulator (DBS) implantation for Meige's syndrome. Dexmedetomidine infusion was used for sedation. The procedure lasted for around 12 h and the patient was comfortable, responsive, and cooperative over the extended period of time. The surgeons were comfortable with electrophysiologic brain mapping and clinical testing. DBS were implanted, through a burr hole, into the globus pallidus neurophysiological testing under guidance. The pulse generator battery was subcutaneously implanted into the chest wall under general anesthesia. The implanted pulse generator battery was started 2 days later and the patient showed dramatic improvement in his symptoms.
  - 2,509 407
Anaesthetic management of a child with massive extracranial arteriovenous malformation
Faisal Shamim, Hameed Ullah, Azhar Rehman
January-March 2012, 28(1):117-120
DOI:10.4103/0970-9185.92461  PMID:22345959
Vascular tumors affect the head and neck commonly but arteriovenous malformations are rare. Vascular malformations are often present at birth and grow with the patient, usually only becoming significant later in childhood. Embolization has been the mainstay of treatment in massive and complex arteriovenous malformations. We present a case of massive extracranial arteriovenous malformation in a 7-year-old boy causing significant workload on right heart and respiratory distress. The management of angioembolization under general anaesthesia and anaesthetic concerns are presented.
  - 4,176 400
Postoperative hypertension following radical neck dissection
Smita Prakash, Amy Rapsang, S Suresh Kumar, Parminder S Bhatia, Anoop R Gogia
January-March 2012, 28(1):121-123
DOI:10.4103/0970-9185.92462  PMID:22345960
Baroreflex failure results in wide excursions of blood pressure and heart rate. We report two cases that developed severe postoperative hypertension after radical neck dissection. Carotid sinus denervation during neck dissection may be the cause of the reflex hypertension once general anesthesia-induced vasodilatation has ended.
  - 2,487 371
LETTERS TO THE EDITOR
Response: Fospropofol: Pharmacokinetics?
Girish M Bengalorkar, K Bhuvana, N Sarala, TN Kumar
January-March 2012, 28(1):135-136
DOI:10.4103/0970-9185.92473  PMID:22345971
  - 1,351 260
Authors' reply
Shyjumon George, Shafiq Ahmed, Kim J Mammen, George Mathews John
January-March 2012, 28(1):131-131
PMID:22345966
  - 1,333 256
Intubating laryngeal mask airway with transplanted pilot balloon?
Vinod Bala, Anju Gupta, Nishkarsh Gupta, Mridula Pawar
January-March 2012, 28(1):131-132
DOI:10.4103/0970-9185.92469  PMID:22345967
  - 1,638 247
Anesthetic management of tuberculous retropharyngeal abscess in adult
Sridevi M Mulimani
January-March 2012, 28(1):128-129
DOI:10.4103/0970-9185.92465  PMID:22345963
  - 3,524 357
Airway management during anesthesia for stereotactic placement of intratumoral drug delivery system in a patient with anaplastic astrocytoma
Christina George, VJ Ramesh, Jagath Lal Gangadharan, Subhash Kanti Konar
January-March 2012, 28(1):129-130
DOI:10.4103/0970-9185.92466  PMID:22345964
  - 2,374 321
Posttracheostomy tracheoesophageal fistula
Manoj K Sanwal, Pragati Ganjoo, Monica S Tandon
January-March 2012, 28(1):140-141
DOI:10.4103/0970-9185.92478  PMID:22345976
  - 4,190 339
Use of loss of resistance, to carbon dioxide, in identifying the epidural space
RA Junka, L Chan, R Moises, E Panico, V Hazelwood, GM Atlas
January-March 2012, 28(1):137-138
DOI:10.4103/0970-9185.92475  PMID:22345973
  - 1,686 255
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