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   2015| July-September  | Volume 31 | Issue 3  
    Online since July 29, 2015

 
 
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REVIEW ARTICLES
Fluid management in patients with trauma: Restrictive versus liberal approach
Veena Chatrath, Ranjana Khetarpal, Jogesh Ahuja
July-September 2015, 31(3):308-316
DOI:10.4103/0970-9185.161664  PMID:26330707
Trauma is a leading cause of death worldwide, and almost 30% of trauma deaths are due to blood loss. A number of concerns have been raised regarding the advisability of the classic principles of aggressive crystalloid resuscitation in traumatic hemorrhagic shock. Some recent studies have shown that early volume restoration in certain types of trauma before definite hemostasis may result in accelerated blood loss, hypothermia, and dilutional coagulopathy. This review discusses the advances and changes in protocols in fluid resuscitation and blood transfusion for treatment of traumatic hemorrhage shock. The concept of low volume fluid resuscitation also known as permissive hypotension avoids the adverse effects of early aggressive resuscitation while maintaining a level of tissue perfusion that although lower than normal, is adequate for short periods. Permissive hypotension is part of the damage control resuscitation strategy, which targets the conditions that exacerbate hemorrhage. The elements of this strategy are permissive hypotension, minimization of crystalloid resuscitation, control of hypothermia, prevention of acidosis, and early use of blood products to minimize coagulopathy.
  31 13,651 3,553
Pheochromocytoma resection: Current concepts in anesthetic management
Harish Ramakrishna
July-September 2015, 31(3):317-323
DOI:10.4103/0970-9185.161665  PMID:26330708
Pheochromocytoma represents very significant challenges to the anesthetist, especially when undiagnosed. These chromaffin tissue tumors are not uncommon in anesthetic practice and have varied manifestations. The perioperative management of these tumors has improved remarkably over the years, in conjunction with the evolution of surgical techniques (open laparotomy to laparoscopic techniques and now to robotic approaches in the present day). This review attempts to comprehensively address the intraoperative and postoperative issues in the management of these challenging tumors with an emphasis on hemodynamic monitoring and anesthetic technique.
  19 42,351 8,082
ORIGINAL ARTICLES
Effect of dexmedetomidine as an adjuvant to levobupivacaine in supraclavicular brachial plexus block: A randomized double-blind prospective study
Haramritpal Kaur, Gurpreet Singh, Sunita Rani, Kewal Krishan Gupta, Mukesh Kumar, Amanjot Singh Rajpal, Shobha Aggarwal
July-September 2015, 31(3):333-338
DOI:10.4103/0970-9185.161668  PMID:26330711
Background and Aims: Regional anesthesia is a recommended technique for upper and lower limb surgeries with better postoperative profile. In this, randomized, double-blind study, we evaluated the effectiveness of the addition of dexmedetomidine to varying concentration of levobupivacaine for supra clavicular brachial plexus block. Material and Methods: After obtaining ethical Committee approval, a double-blind, randomized prospective clinical study was conducted on 90 American Society of Anesthesiologist Grade I and II patients in the age group of 18-55 years, divided randomly into two groups: Group A received 40 ml of solution containing 30 ml 0.5% levobupivacaine and 10 ml 1% lignocaine and group B received 40 ml of solution containing 30 ml 0.25% levobupivacaine and 10 ml 1% lignocaine with dexmedetomidine 1 microg/kg for supraclavicular brachial plexus block. Besides effectiveness, other parameters observed were: duration of sensory blockade; onset and duration of motor blockade; duration of postoperative analgesia; and patient satisfaction score. Results: Onset of sensory and motor blockade was 7.6 ± 1.006 min and 8.3 ± 0.877 min in group A, while it was 6.96 ± 1.077 min an 7.6 ± 1.1 min in group B, respectively. The difference was statistically significant (P < 0.05). Duration of sensory block was 8.5 ± 0.77 h in group A and 8.5 ± 0.98 in group B (P > 0.05). Duration of motor block was 8.45 ± 0.75 h in group A and 5.6 ± 0.98 in group B (P < 0.05). Duration of analgesia was 8.5 ± 0.77 h in group A and 9.2 ± 1.05 in group B (P < 0.05). Conclusion: Addition of 1 microg/kg dexmedetomidine to 0.25% levobupivacaine for supraclaviclar plexus block shortens sensory, motor block onset time and motor block durations, extends sensory block, and analgesia durations. Reduction in total levobupivacaine dose also increases the safety margin of the block.
  15 3,811 726
CLINICAL PHARMACOLOGY
Physiological and pharmacologic aspects of peripheral nerve blocks
Prasanna Vadhanan, Debendra Kumar Tripaty, S Adinarayanan
July-September 2015, 31(3):384-393
DOI:10.4103/0970-9185.161679  PMID:26330722
A successful peripheral nerve block not only involves a proper technique, but also a thorough knowledge and understanding of the physiology of nerve conduction and pharmacology of local anesthetics (LAs). This article focuses on what happens after the block. Pharmacodynamics of LAs, underlying mechanisms of clinically observable phenomena such as differential blockade, tachyphylaxis, C fiber resistance, tonic and phasic blockade and effect of volume and concentration of LAs. Judicious use of additives along with LAs in peripheral nerve blocks can prolong analgesia. An entirely new group of drugs-neurotoxins has shown potential as local anesthetics. Various methods are available now to prolong the duration of peripheral nerve blocks.
  14 4,151 870
REVIEW ARTICLES
Ultrasound guided distal peripheral nerve block of the upper limb: A technical review
Herman Sehmbi, Caveh Madjdpour, Ushma Jitendra Shah, Ki Jinn Chin
July-September 2015, 31(3):296-307
DOI:10.4103/0970-9185.161654  PMID:26330706
Upper extremity surgery is commonly performed under regional anesthesia. The advent of ultrasonography has made performing upper extremity nerve blocks relatively easy with a high degree of reliability. The proximal approaches to brachial plexus block such as supraclavicular plexus block, infraclavicular plexus block, or the axillary block are favored for the most surgical procedures of distal upper extremity. Ultrasound guidance has however made distal nerve blocks of the upper limb a technically feasible, safe and efficacious option. In recent years, there has thus been a resurgence of distal peripheral nerve blocks to facilitate hand and wrist surgery. In this article, we review the technical aspects of performing the distal blocks of the upper extremity and highlight some of the clinical aspects of their usage.
  14 10,990 2,565
ORIGINAL ARTICLES
Clonidine as an adjuvant to ropivacaine-induced supraclavicular brachial plexus block for upper limb surgeries
Kalyani Nilesh Patil, Noopur Dasmit Singh
July-September 2015, 31(3):365-369
DOI:10.4103/0970-9185.161674  PMID:26330717
Background and Aims: Ropivacaine is a new amide, long acting, pure S-enantiomer, local anesthetic, with differential blocking effect. The addition of clonidine to local anesthetic improves the quality of peripheral nerve blocks. This study was conducted to evaluate the effect of clonidine on characteristics of ropivacaine-induced supraclavicular brachial plexus block. Material and Methods: A total of 60 adult patients were randomly recruited to two groups of 30 each: Group I: 30 ml 0.75% ropivacaine + 1 ml normal saline. Group II: 30 ml 0.75% ropivacaine + 1 mcg/kg clonidine diluted to 1 ml with normal saline. Results: The onset of sensorimotor block was earlier in Group II (4.36 ± 0.81 min for sensory block and 9.83 ± 1.12 min for motor block) than in Group I (4.84 ± 0.65 min for sensory block and 10.85 ± 0.79 min for motor block). The duration of both sensory and motor block were significantly prolonged by clonidine (P < 0.001). The duration of analgesia was also prolonged in patients receiving clonidine (613.10 ± 51.797 min vs. 878.33 ± 89.955 min). Although incidence of hypotension and bradycardia was higher in Group II when compared to Group I, it was not clinically significant. Conclusions: Ropivacaine 0.75% is well-tolerated and provides effective surgical anesthesia as well as relief of postoperative pain. Clonidine as an adjuvant to ropivacaine significantly enhances the quality of supraclavicular brachial plexus block by faster onset, prolonged duration of sensory and motor block and improved postoperative analgesia, without associated adverse effects at the dose used.
  11 3,563 525
Comparison of dexamethasone and clonidine as an adjuvant to 1.5% lignocaine with adrenaline in infraclavicular brachial plexus block for upper limb surgeries
Dipal Mahendra Shah, Mahesh Arora, Anjan Trikha, Ganga Prasad, Rani Sunder, Prakash Kotwal, Preet Mohinder Singh
July-September 2015, 31(3):354-359
DOI:10.4103/0970-9185.161672  PMID:26330715
Background and Aims: The role of clonidine as an adjuvant to regional blocks to hasten the onset of the local anesthetics or prolong their duration of action is proven. The efficacy of dexamethasone compared to clonidine as an adjuvant is not known. We aimed to compare the efficacy of dexamethasone versus clonidine as an adjuvant to 1.5% lignocaine with adrenaline in infraclavicular brachial plexus block for upper limb surgeries. Material and Methods: Fifty three American Society of Anaesthesiologists-I and II patients aged 18-60 years scheduled for upper limb surgery were randomized to three groups to receive 1.5% lignocaine with 1:200,000 adrenaline and the study drugs. Group S (n = 13) received normal saline, group D (n = 20) received dexamethasone and group C (n = 20) received clonidine. The time to onset and peak effect, duration of the block (sensory and motor) and postoperative analgesia requirement were recorded. Chi-square and ANOVA test were used for categorical and continuous variables respectively and Bonferroni or post-hoc test for multiple comparisons. P < 0.05 was considered significant. Results: The three groups were comparable in terms of time to onset and peak action of motor and sensory block, postoperative analgesic requirements and pain scores. 90% of the blocks were successful in group C compared to only 60% in group D (P = 0.028). The duration of sensory and motor block in group S, D and C were 217.73 ± 61.41 min, 335.83 ± 97.18 min and 304.72 ± 139.79 min and 205.91 ± 70.1 min, 289.58 ± 78.37 min and 232.5 ± 74.2 min respectively. There was significant prolongation of sensory and motor block in group D as compared to group S (P < 0.5). Time to first analgesic requirement was significantly more in groups C and D as compared with group S (P < 0.5). Clinically significant complications were absent. Conclusions: We conclude that clonidine is more efficacious than dexamethasone as an adjuvant to 1.5% lignocaine in brachial plexus blocks.
  10 2,830 431
Intravenous granisetron attenuates hypotension during spinal anesthesia in cesarean delivery: A double-blind, prospective randomized controlled study
Ahmed A Eldaba, Yasser M Amr
July-September 2015, 31(3):329-332
DOI:10.4103/0970-9185.161667  PMID:26330710
Background and Aims: This study was conducted to determine the effectiveness of intravenous (IV) granisetron in the prevention of hypotension and bradycardia during spinal anesthesia in cesarean delivery. Material and Methods: A total of 200 parturients scheduled for elective cesarean section were included in this study. They were randomly divided into two groups. Group I was given 1 mg granisetron diluted in 10 ml normal saline slowly IV, 5 min before spinal anesthesia. Group II was given 10 ml of normal saline, 5 min before spinal anesthesia. Mean arterial blood pressure and heart rate (HR) were recorded every 3 min until the end of surgery (for 45 min). The total consumption of vasopressors and atropine were recorded. Apgar scores at 1 and 5 min were also assessed. Results: Serial mean arterial blood pressure and HR values for 45 min after onset of spinal anesthesia were decreased significantly in group II, P < 0.0001. The incidence of hypotension after spinal anesthesia was 64% in group II and 3% in group I (P < 0.0001). The total doses of ephedrine (4.07 ± 3.87 mg vs 10.7 ± 8.9 mg, P < 0.0001), phenylephrine (0.0 microg vs 23.2 ± 55.1 microg, P < 0.0001), and atropine (0.0 mg vs 0.35 ± 0.49 mg P < 0.0001) consumed in both the groups respectively, were significantly less in group I versus group II. Conclusion: Premedication with 1 mg IV granisetron before spinal anesthesia in an elective cesarean section significantly reduces hypotension, bradycardia and vasopressors usage.
  9 3,078 692
Spread patterns and effectiveness for surgery after ultrasound-guided rectus sheath block in adult day-case patients scheduled for umbilical hernia repair
Alberto Manassero, Matteo Bossolasco, Maurizio Meineri, Susanna Ugues, Chrysoula Liarou, Luca Bertolaccini
July-September 2015, 31(3):349-353
DOI:10.4103/0970-9185.161671  PMID:26330714
Background and Aims: We conducted a prospective study to examine the local anesthetic (LA) spread and the effectiveness for surgical anesthesia of ultrasound (US)-guided rectus sheath block (RSB) in adult patients undergoing umbilical hernia repair. Material and Methods: Thirty patients received at T-10 level a bilateral US-guided injection of 20 mL levobupivacaine 0.375% + epinephrine 5 μg/mL behind the rectus muscle to detach it from its sheath. Anesthetic spread into the rectus sheath was evaluated ultrasonographically at T-9 and T-11 levels and scored from 0 to 4. The RSB was defined effective for surgical anesthesia if it was able to guarantee an anesthetic level sufficient for surgery without any mepivacaine supplementation. Results: Overall, the block was effective for surgical anesthesia in 53.3% of patients (95% confidence interval, ±17.8). In the remaining patients, anesthesia supplementation was needed at cutaneous incision, whereas manipulation of the muscle and fascial planes was painless. No patients required general anesthesia. LA spreads as advocated (to T-9 and to T-11 bilaterally = spread score 4) in 8/30 patients (26.6%); in these cases, the block was 75% effective for surgery. The anesthetic spread was most negatively influenced by increased body mass index. Postoperative analgesia was excellent in 97% of patients. Conclusion: Use of RSB as an anesthetic management of umbilical herniorrhaphy is recommended only with anesthetic supplementation at the incision site.
  7 3,445 524
An evaluation of brachial plexus block using a nerve stimulator versus ultrasound guidance: A randomized controlled trial
Shivinder Singh, Rakhee Goyal, Kishan Kumar Upadhyay, Navdeep Sethi, Ram Murti Sharma, Anoop Sharma
July-September 2015, 31(3):370-374
DOI:10.4103/0970-9185.161675  PMID:26330718
Background and Aims: This study was carried out to evaluate the difference in efficacy, safety, and complications of performing brachial plexus nerve blocks by using a nerve locator when compared to ultrasound (US) guidance. Material and Methods: A total of 102 patients undergoing upper limb surgery under supraclavicular brachial plexus blocks were randomly divided into two groups, one with US and the other with nerve stimulator (NS). In Group US, "Titan" Portable US Machine, Sonosite, Inc. Kensington, UK with a 9.0 MHz probe was used to visualize the brachial plexus and 40 ml of 0.25% bupivacaine solution was deposited around the brachial plexus in a graded manner. In Group (NS), the needle was inserted 1-1.5 cm above mid-point of clavicle. Once hand or wrist motion was detected at a current intensity of less than 0.4 mA 40 ml of 0.25% bupivacaine was administered. Onset of sensory and motor block of radial, ulnar and median nerves was recorded at 5-min intervals for 30-min. Block execution time, duration of block (time to first analgesic), inadvertent vascular puncture, and neurological complications were taken as the secondary outcome variables. Results: About 90% patients in US group and 73.1% in NS group, had successful blocks P = 0.028. The onset of block was faster in the Group US as compared to Group NS and this difference was significant (P 0.007) only in the radial nerve territory. The mean duration of the block was longer in Group US, 286.22 ± 42.339 compared to 204.37 ± 28.54-min in Group NS (P < 0.05). Accidental vascular punctures occurred in 7 patients in the NS group and only 1 patient in the US group. Conclusion: Ultrasound guidance for supraclavicular brachial plexus blockade provides a block that is faster in onset, has a better quality and lasts longer when compared with an equal dose delivered by conventional means.
  6 3,451 561
Effect of a single bolus of dexamethasone on intraoperative and postoperative pain in unilateral inguinal hernia surgery
Muhammad Vaiz Asad, Fauzia Anis Khan
July-September 2015, 31(3):339-343
DOI:10.4103/0970-9185.161669  PMID:26330712
Background and Aims: Opioids are commonly used to provide perioperative analgesia, but have many side-effects. Addition of co-analgesics results in reducing the dosage and hence the side-effects of opioids. The objective of this study was to compare the analgesic efficacy of fentanyl (1 micro/kg−1) administered alone, with fentanyl (0.75 micro/kg−1) and dexamethasone (8 mg) combination, in patients undergoing day care unilateral inguinal hernia repair. Material and Methods: Patients scheduled for the day care unilateral inguinal hernia repair were randomized to receive either saline and fentanyl 1 micro/kg−1 (control group) or 8 mg dexamethasone with fentanyl 0.75 micro/kg−1 (study group) immediately before induction of anesthesia in a double-blind clinical trial. Anesthesia technique and rescue analgesia regimen were standardized. Intraoperatively, pain was assessed based on hemodynamic variability and postoperatively by visual analog scale. Results: The mean heart rate, systolic and the diastolic blood pressure at 1, 5, 20 and at 30 min after incision, were significantly higher in the control group (P ≤ 0.001) when compared to the study group. Intra-operative rescue analgesia was required in 32 (100%) and 19 (59.4%) patients in control group and study group respectively (P = 0.0002). Mean pain scores measured at fixed time periods postoperatively were significantly higher in the control group when compared to study group (P ≤ 0.001). Postoperative rescue analgesia was needed in 32 (100%) versus 24 (75%) patients in the control group and study group respectively, but this difference was not statistically significant (P = 0.285). Conclusion: We conclude that the addition of 8 mg of preoperative intravenous dexamethasone to 0.75 micro/kg−1 fentanyl was effective in reducing intraoperative and postoperative pain in the 1 st h after unilateral inguinal hernia surgery.
  5 3,232 581
Tramadol in traumatic brain injury: Should we continue to use it?
Saeed Mahmood, Hassan Al-Thani, Ayman El-Menyar, Mushrek Alani, Ammar Al-Hassani, Saji Mathrdikkal, Ruben Peralta, Rifat Latifi
July-September 2015, 31(3):344-348
DOI:10.4103/0970-9185.161670  PMID:26330713
Background and Aims: Tramadol is commonly used to treat moderate to moderately-severe pain in adults. We aimed to analyze the clinical relevance of tramadol use during weaning and extubation in patients with traumatic brain injury (TBI). Material and Methods: A retrospective observational study was conducted and included all the intubated TBI patients at the level I trauma center between 2011 and 2012. Data included patient's demographics, mechanism of injury (MOI), Glasgow Coma Scale (GCS), injury severity score, length of Intensive Care Unit (ICU) stay length of stay (LOS), agitation scale, analgesics, failure of extubation and tracheostomy. Patients were divided into two groups based on whether they received tramadol (Group 1) or not (Group 2) during ventilatory weaning. Chi-square and Student's t-tests were used for categorical and continuous variables; respectively. Logistic regression analysis was performed for predictors of agitation in ICU. Results: The study included 393 TBI patients; the majority (96%) was males with a mean age of 33.6 ± 14 years. The most common MOI were motor vehicle crash (39%), fall (29%) and pedestrian (17%). The associated injuries were mainly chest (35%) and abdominal (16%) trauma. Tramadol was administered in 51.4% of TBI patients. Tracheostomy was performed in 12.4% cases. Agitation was observed in 34.2% cases. Group 1 patients had significantly lower age (31.6 ± 12.4 vs. 35.7 ± 15.6; P = 0.005) and head AIS (3.5 ± 0.8 vs. 3.9 ± 0.9; P = 0.001) compared to Group 2. The incidence of agitation, ICU and hospital LOS were higher in Group 1. Failure of extubation and tracheostomy were reported more frequently in Group 1 (P = 0.001). On multivariate analysis, tramadol use was an independent predictor for agitation (adjusted odds ratio 21; P = 0.001), followed by low GCS. Conclusion: Patients with TBI who received tramadol are more likely to develop agitation, undergo tracheostomy and to have longer hospital LOS. Therefore, an extensive risk-benefit assessment would help to attain maximum efficacy of the drug in TBI patients.
  4 7,209 565
Effect of intravenous esmolol on analgesic requirements in laparoscopic cholecystectomy
Ritima Dhir, Mirley Rupinder Singh, Tej Kishan Kaul, Anurag Tewari, Ripul Oberoi
July-September 2015, 31(3):375-379
DOI:10.4103/0970-9185.161676  PMID:26330719
Background and Aims: Perioperative beta blockers are also being advocated for modulation of acute pain and reduction of intraoperative anesthetic requirements. This study evaluated the effect of perioperative use of esmolol, an ultra short acting beta blocker, on anesthesia and modulation of post operative pain in patients of laproscopic cholecystectomy. Material and Methods: Sixty adult ASA I & II grade patients of either sex, scheduled for laparoscopic cholecystectomy under general anesthesia, were enrolled in the study. The patients were randomly allocated to one of the two groups E or C according to computer generated numbers. Group E- Patients who received loading dose of injection esmolol 0.5 mg/kg in 30 ml isotonic saline, before induction of anesthesia, followed by an IV infusion of esmolol 0.05 μg/kg/min till the completion of surgery and Group C- Patients who received 30 ml of isotonic saline as loading dose and continuous infusion of isotonic saline at the same rate as the esmolol group till the completion of surgery. Results: The baseline MAP at 0 minute was almost similar in both the groups. At 8th minute (time of intubation), MAP increased significantly in group C as compared to group E and remained higher than group E till the end of procedure. Intraoperatively, 16.67% of patients in group C showed somatic signs as compared to none in group E. The difference was statistically significant. 73.33% of patients in group C required additional doses of Inj.Fentanyl as compared to 6.67% in group E. Conclusions: We conclude that intravenous esmolol influences the analgesic requirements both intraoperatively as well as postoperatively by modulation of the sympathetic component of the pain i.e. heart rate and blood pressure.
  4 3,874 746
Buprenorphine for postoperative analgesia: Axillary brachial plexus block versus intramuscular administration in a placebo-controlled trial
Deepali Thakur, Anila Malde
July-September 2015, 31(3):360-364
DOI:10.4103/0970-9185.161673  PMID:26330716
Background and Aims: Peripheral administration of opioids has been suggested for prolongation of regional analgesia. This prospective, randomized, double-blind placebo-controlled study was undertaken to compare the effect of regional (axillary brachial plexus block [ABPB]) versus intramuscular (IM) buprenorphine (2 μg/kg) in adults. Material and Methods: Seventy-five adults undergoing upper limb surgery received ABPB with local anaesthetic (15 ml 0.5% bupivacaine, 15 ml 2% lignocaine with adrenaline 1:200,000, 9 ml normal saline [NS]). In addition, regional group RB (n = 25) received buprenorphine 2 μg/kg in ABPB and 1 ml NS IM. Systemic Group SB (n = 25) received 1 ml NS in ABPB and buprenorphine 2 μg/kg IM. Group C (n = 25) received 1 ml NS in ABPB and IM. Onset, duration of sensory and motor block, hemodynamic parameters, sedation score, pain scores using visual analog scale, duration of postoperative analgesia, rescue analgesic (RA) requirement, adverse events, and patient satisfaction were noted. Results: Demographics, onset and duration of sensory, motor block were similar. RB group had longest duration of analgesia (20.61 ± 1.33 h) compared to SB (10.91 ± 0.90 h) and control group (5.86 ± 0.57 h) (P < 0.05 RB vs. SB/C and SB vs. C). RA requirement was highest in the control group and least in RB group (P = 0.000 RB vs. SB/C and SB vs. C). SB group had a maximum number of side effects (P = 0.041, SB vs. RB/C). Patient satisfaction was highest with group RB (P < 0.05 RB vs. SB/C, and P = 0.06 SB vs. C). Conclusion: Buprenorphine 2 μg/kg in axillary plexus block provides significantly prolonged analgesia with less RA requirement and greater patient satisfaction compared to IM administration. This is highly suggestive of action on peripheral opioid receptors.
  4 3,048 376
Propofol requirement for insertion of I-gel versus laryngeal mask airway: A comparative dose finding study using Dixon's up-and-down method
Aparna Ashay Nerurkar, Wasim Shaikh, Bharati Anil Tendolkar
July-September 2015, 31(3):324-328
DOI:10.4103/0970-9185.161666  PMID:26330709
Background and Aims: Propofol is the drug of choice when used as sole anesthetic agent for placement of supraglottic airway devices. We aimed to find and compare the propofol dose required for smooth first attempt insertion of I-gel versus the classic laryngeal mask airway (cLMA) using Dixon's up-and-down method. Material and Methods: Prospective randomized controlled trial (n-60) was planned. I-gel or cLMA was inserted 60 s after propofol injection whose dose was calculated based on previous patients response as per Dixon's up-and-down method. Propofol requirements for successful placement of devices was noted and compared. Difference between the groups was measured by ANOVA. A P < 0.05 was considered as statistically significant. Results: Significantly lower (P < 0.001) propofol dose was required for I-gel (2.02 ± 0.26 mg/kg) insertion than cLMA (2.70 ± 0.28 mg/kg). Conclusions: I-gel requires significantly lower dose of propofol for insertion when compared to cLMA.
  3 3,268 547
FORUM
Beautiful small: Misleading large randomized controlled trials? The example of colloids for volume resuscitation
Christian J Wiedermann, Wolfgang Wiedermann
July-September 2015, 31(3):394-400
DOI:10.4103/0970-9185.161680  PMID:26330723
In anesthesia and intensive care, treatment benefits that were claimed on the basis of small or modest-sized trials have repeatedly failed to be confirmed in large randomized controlled trials. A well-designed small trial in a homogeneous patient population with high event rates could yield conclusive results; however, patient populations in anesthesia and intensive care are typically heterogeneous because of comorbidities. The size of the anticipated effects of therapeutic interventions is generally low in relation to relevant endpoints. For regulatory purposes, trials are required to demonstrate efficacy in clinically important endpoints, and therefore must be large because clinically important study endpoints such as death, sepsis, or pneumonia are dichotomous and infrequently occur. The rarer endpoint events occur in the study population; that is, the lower the signal-to-noise ratio, the larger the trials must be to prevent random events from being overemphasized. In addition to trial design, sample size determination on the basis of event rates, clinically meaningful risk ratio reductions and actual patient numbers studied are among the most important characteristics when interpreting study results. Trial size is a critical determinant of generalizability of study results to larger or general patient populations. Typical characteristics of small single-center studies responsible for their known fragility include low variability of outcome measures for surrogate parameters and selective publication and reporting. For anesthesiology and intensive care medicine, findings in volume resuscitation research on intravenous infusion of colloids exemplify this, since both the safety of albumin infusion and the adverse effects of the artificial colloid hydroxyethyl starch have been confirmed only in large-sized trials.
  2 2,310 365
LETTERS TO EDITOR
Bernard-Soulier syndrome: A challenge for anesthetist in an emergency surgery
Muhammad Irfan Ul Haq, Muhammad Sohaib, Sobia Khan, Mohsin Nazir
July-September 2015, 31(3):416-417
DOI:10.4103/0970-9185.161709  PMID:26330734
  2 1,679 234
Fluoroquinolones: An under-recognized cause for delirium
Vivek Chowdhry, Manoranjan Padhi, Bipin Bihari Mohanty, Srikant Mohapatra
July-September 2015, 31(3):410-411
DOI:10.4103/0970-9185.161686  PMID:26330729
  2 2,036 373
CASE REPORTS
Subcutaneous emphysema: Unique presentation of a foreign body in the airway
Mahendra Kumar, Arun Goyal, Neelima Gupta, Rajesh Singh Rautela
July-September 2015, 31(3):404-406
DOI:10.4103/0970-9185.161682  PMID:26330725
Foreign body airway (FBA) is a common problem among the children. Variable presentation makes it difficult to diagnose a case of FBA, particularly, when no definite history of aspiration is available. Subcutaneous emphysema (SCE) and pneumomediastinum are rare presentations. We report a case of FBA who presented with SCE without any history of aspiration. A 3-year-old female child was admitted with respiratory distress, fever and SCE over the right side of chest, neck and face. Initially, she was diagnosed as a case of pneumonitis with barotrauma. X-ray of the chest revealed SCE with pneumomediastinum without pneumothorax. Diagnostic bronchoscopy with rigid ventilating bronchoscope was done under general anesthesia. A plastic foreign body with sharp projections embedded in the mucosa was detected and retrieved from right main bronchus. Postoperatively SCE regressed gradually.
  1 2,065 271
EDITORIALS
Empowering anesthesiologists
Mukul Chandra Kapoor
July-September 2015, 31(3):291-292
DOI:10.4103/0970-9185.161651  PMID:26330703
  1 2,312 577
Does the choice of colloids interfere with the outcome in critically ill patients? A critical appraisal
Jan Poelaert, Panagiotis Flamée
July-September 2015, 31(3):293-294
DOI:10.4103/0970-9185.161652  PMID:26330704
  1 2,138 486
LETTERS TO EDITOR
Intratumoral migration of central venous catheter in a patient with malignant bronchial carcinoid
Ranvinder Kaur, Tanvir Samra, Lalita Chaudhary, Aruna Jain
July-September 2015, 31(3):415-416
DOI:10.4103/0970-9185.161706  PMID:26330733
  1 1,537 184
Monopolar cautery: A rare, potential cause of perioperative cardiac arrhythmias
Akhil Agarwal, Rajeev Lochan Tiwari, Sundeep Jain
July-September 2015, 31(3):418-419
DOI:10.4103/0970-9185.161729  PMID:26330736
  1 1,772 233
Anesthetic considerations in a patient with Cornelia de-Lange syndrome
Lars Vestergaard, Nilanjan Dey, Robert Winding
July-September 2015, 31(3):419-420
DOI:10.4103/0970-9185.161732  PMID:26330737
  1 4,946 418
Procedural sedation for a child with a mediastinal mass and superior vena caval syndrome
Aparna Williams, Georgene Singh, Sajan Philip George
July-September 2015, 31(3):421-424
DOI:10.4103/0970-9185.161735  PMID:26330739
  1 2,762 234
Unexpected prolonged coma after general anesthesia in a patient with history of type II diabetes mellitus
Tariq Naseem, Pei-Shan Zhao
July-September 2015, 31(3):426-428
DOI:10.4103/0970-9185.161738  PMID:26330741
  1 6,276 312
Permissive hypotension in a head-injured multi-trauma patient: Controversies and contradictions
Subramanian Senthilkumaran, Suresh S David, Rishya Manikam, Ponniah Thirumalaikolundusubramanian
July-September 2015, 31(3):428-429
DOI:10.4103/0970-9185.161745  PMID:26330742
  1 1,844 328
BOOK REVIEW
"Understanding PAEDIATRIC ANAESTHESIA" by Dr. Rebecca Jacob
Anju Grewal
July-September 2015, 31(3):433-434
  - 4,485 864
CASE REPORTS
Acute intermittent porphyria: Diagnostic dilemma and treatment options
Mohan Deep Kaur, Nita Hazarika, Namita Saraswat, Rajesh Sood
July-September 2015, 31(3):407-408
DOI:10.4103/0970-9185.161683  PMID:26330726
Acute intermittent porphyria (AIP) presents with diverse group of symptoms making its early diagnosis difficult. Delaying diagnosis and treatment of AIP can be fatal or can cause long term or permanent neurological damage. We present here a case report of AIP where the diagnosis was missed. The diversity of symptoms and details concerning the treatment options for AIP are discussed.
  - 2,974 453
Unilateral pulmonary edema during laparoscopic resection of adrenal tumor
Smita Prakash, Pavan Nayar, Pooja Virmani, Shipra Bansal, Mridula Pawar
July-September 2015, 31(3):401-403
DOI:10.4103/0970-9185.161681  PMID:26330724
Despite technological, therapeutic and diagnostic advancements, surgical intervention in pheochromocytoma may result in a life-threatening situation. We report a patient who developed unilateral pulmonary edema during laparoscopic resection of adrenal tumor.
  - 1,903 265
COMMENTARIES
Ultrasound guided distal nerve blocks
Harsimran Singh
July-September 2015, 31(3):380-381
PMID:26330720
  - 1,899 261
Communication as a basic skill in critical care
Ornella Piazza, Giuseppina Cersosimo
July-September 2015, 31(3):382-383
PMID:26330721
  - 1,794 247
EDITORIALS
Ultrasound - a boon for distal peripheral nerve blocks
Balavenkatasubramanian
July-September 2015, 31(3):295-295
DOI:10.4103/0970-9185.161653  PMID:26330705
  - 1,972 409
LETTERS TO EDITOR
Of football and operation theatres
Vipul Krishen Sharma
July-September 2015, 31(3):409-409
DOI:10.4103/0970-9185.161684  PMID:26330727
  - 1,454 191
Match in the theatres
Madhuri Shreekrishna Kurdi, Ashwini Halebid Ramaswamy
July-September 2015, 31(3):409-410
DOI:10.4103/0970-9185.161685  PMID:26330728
  - 1,511 189
Does multiple transfusion history necessitate additional cross matching evaluation prior to subsequent transfusions?
Veena Sheshadri, Keshavan Hallimysore Venkatesh
July-September 2015, 31(3):411-412
DOI:10.4103/0970-9185.161688  PMID:26330730
  - 1,440 176
Postpartum seizures due to tuberculoma in brain
Sayeed Maqbool Tajammul, Ali Chemmala Shabbir, Mannengel Eledath Jubariya, Madampatt Nihmatulla
July-September 2015, 31(3):412-413
DOI:10.4103/0970-9185.161694  PMID:26330731
  - 1,527 178
Anesthetic consideration in patient with lateral nasal proboscis
Bikram Kumar Gupta, MS Saravana Babu, Apurva Agarwal, Shaily Agarwal, Vanita Mhaske, Samir Saxena
July-September 2015, 31(3):414-414
DOI:10.4103/0970-9185.161702  PMID:26330732
  - 1,639 196
Cervical epidural block in emergency hand surgery for a patient with untreated severe hypothyroidism
Srinivas Mantha, Nirmala Jonnavithala, Rahamathullah Mohammad, Narmada Padhy, Geetha Kanithi
July-September 2015, 31(3):424-425
DOI:10.4103/0970-9185.161737  PMID:26330740
  - 1,606 199
Anesthetic management of insulinoma
Leena Harshad Parate, Nagaraj Mungasuvalli Channappa, Tejesh Channasandra Anandaswamy, Bharath Srinivasaiah
July-September 2015, 31(3):420-421
DOI:10.4103/0970-9185.161734  PMID:26330738
  - 2,416 450
Cervico facial pharyngeal emphysema during endoscopic retrograde cholangio pancreatography
Karthik Ganesh Ramamoorthy
July-September 2015, 31(3):417-418
DOI:10.4103/0970-9185.161712  PMID:26330735
  - 1,398 173
What to do when your surgeon cuts off the patients' oxygen supply?
Uma Hariharan, Anita Kulkarni, Amit Kumar Mittal
July-September 2015, 31(3):429-430
DOI:10.4103/0970-9185.161747  PMID:26330743
  - 1,482 188
Anesthetic course of a patient with pineal gland cyst and osteogenesis imperfecta: A rare experience
Bashir Ahmad Dar, Iqra Nazir, Zulfiqar Ali, Altaf Kirmani
July-September 2015, 31(3):430-431
DOI:10.4103/0970-9185.161748  PMID:26330744
  - 1,549 195
Acute coronary syndrome and sinus node arrest complicating preoperative management of pheochromocytoma
Patrick Tauzin-Fin, Musa Sesay, Alice Quinart, Philippe Gosse, François Sztark
July-September 2015, 31(3):431-432
DOI:10.4103/0970-9185.161749  PMID:26330745
  - 1,408 216
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