Indian Journal of Anaesthesia  
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   Table of Contents - Current issue
January 2017
Volume 61 | Issue 1
Page Nos. 1-89

Online since Friday, January 13, 2017

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The Indian Journal of Anaesthesia in 2017: Time to make an impact p. 1
Jigeeshu V Divatia
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From the desk of the New President p. 3
BB Mishra
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The President's inaugural address during ISACON 2016, on 28th November 2016 at Ludhiana p. 4
AS Kameswara Rao
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Clinical application of point of care transthoracic echocardiography in perioperative period Highly accessed article p. 7
Swaroop Margale, Kurichi Marudhachalam, Sarvesh Natani
Transthoracic echocardiography (TTE) has established its role for diagnosis and management in cardiology and is used by various other specialities in medicine, but it is not routinely practised by anaesthesiologists in the perioperative period including the pre-admission clinic/outpatient clinic. The last decade has seen the emerging role of anaesthesiologist as a 'Perioperative physician'. This review article highlights the potential role and clinical utility, education, teaching and limitations of point of care (POC) TTE modality in perioperative care. Various echocardiography society guidelines and endorsements, diagnostic protocols and limitations are enumerated. This article also discusses some of the possibilities for future education and development related to clinical ultrasound including POC TTE in anaesthetic training curriculum.
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Comparison of volume controlled ventilation and pressure controlled ventilation in patients undergoing robot-assisted pelvic surgeries: An open-label trial p. 17
Rishabh Jaju, Pooja Bihani Jaju, Mamta Dubey, Sadik Mohammad, AK Bhargava
Background and Aims: Although volume controlled ventilation (VCV) has been the traditional mode of ventilation in robotic surgery, recently pressure controlled ventilation (PCV) has been used more frequently. However, evidence on whether PCV is superior to VCV is still lacking. We intended to compare the effects of VCV and PCV on respiratory mechanics and haemodynamic in patients undergoing robotic surgeries in steep Trendelenburg position. Methods: This prospective, randomized trial was conducted on sixty patients between 20 and 70 years belonging to the American Society of Anesthesiologist Physical Status I–II. Patients were randomly assigned to VCV group (n = 30), where VCV mode was maintained through anaesthesia, or the PCV group (n = 30), where ventilation mode was changed to PCV after the establishment of 40° Trendelenburg position and pneumoperitoneum. Respiratory (peak and mean airway pressure [APpeak, APmean], dynamic lung compliance [Cdyn] and arterial blood gas analysis) and haemodynamics variables (heart rate, mean blood pressure [MBP] central venous pressure) were measured at baseline (T1), post-Trendelenburg position at 60 min (T2), 120 min (T3) and after resuming supine position (T4). Results: Demographic profile, haemodynamic variables, oxygen saturation and minute ventilation (MV) were comparable between two groups. Despite similar values of APmean,APpeakwas significantly higher in VCV group at T2 and T3 as compared to PCV group (P < 0.001). Cdynand PaCO2were also better in PCV group than in VCV group (P < 0.001 and 0.045, respectively). Conclusion: PCV should be preferred in robotic pelvic surgeries as it offers lower airway pressures, greater Cdynand a better-preserved ventilation-perfusion matching for the same levels of MV.
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A retrospective study of transfusion practices in a Tertiary Care Institute p. 24
Babita Raghuwanshi, NK Pehlajani, Mithilesh K Sinha, Swagata Tripathy
Background and Aims: Excessive requests for cross matching blood which is more than the blood required for transfusion are usually based on worst case assumptions leading to overestimation of blood usage. We investigated the blood ordering pattern and transfusion practices so as to incorporate a blood ordering schedule for streamlining the use of blood in various hospital departments. Methods: The study was conducted over a period of 19 months in a 350 bedded tertiary teaching hospital. Source of data was blood bank requisition forms and blood bank registers of patients who underwent elective or emergency procedures in the hospital, for which blood was ordered. Data were entered in MS Excel and analysed using SPSS version 20. Results: The blood bank was requested to prepare 10,594 units of blood for 2556 patients. The blood utilised was 16.04% of total cross matched blood, leaving 83.9% of units cross matched but not transfused to patient for whom it was prepared, i.e., wasted. The surgery department had the highest number of units cross matched and transfused. The least number of units cross matched and wasted due to non-transfusion were from the Department of Oncology. Conclusion: The current deficiency of explicit maximum blood order schedule in our hospital is the major factor responsible for high cross match: transfusion ratio. Therefore, a maximal surgical blood order schedule has been suggested to the hospital transfusion committee to implement maximum surgical blood order schedules for selected procedures.
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Impact of modified quality control checklist on protocol adherence and outcomes in a post-surgical Intensive Care Unit p. 29
Lakshmi Kumar, Meenu Dominic, Sunil Rajan, Sanjeev Singh
Background and Aims: Quality improvement (QI) is the sum of all activities that create desired changes in the quality. An effective QI system results in a stepwise increase in quality of care. The efficiency of any health-care unit is judged by its quality indicators. We aimed to evaluate the impact of QI initiatives on outcomes in a surgical Intensive Care Unit (ICU). Methods: This was an observational study carried out using a compliance checklist, developed from the combination of the World Health Organization surgery checklist and Society for Healthcare Epidemiology of America guidelines for the prevention of infections. A total of 170 patients were prospectively evaluated for adherence to the checklist and occurrence of infections. This was compared with a random retrospective analysis of 170 patients who had undergone similar surgeries in the previous 3 months. Results: Introduction and supervised documentation of comprehensive checklist brought out significant improvement in the documentation of quality indicators (98% vs. 32%) in the prospective samples. There was no difference in mortality, health-care-related infection rates or length of ICU stay. Conclusion: The introduction of comprehensive surgical checklist improved documentation of parameters for quality control but did not decrease the rates of infection in comparison to the control sample.
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Evaluation of simple pre-determined length insertion technique (SPLIT) with conventional method for oral fibreoptic intubation: A randomised cross-over study p. 36
Elangovan Muthukumar, Lenin Babu Elakkumanan, Prasanna Udupi Bidkar, MVS Satyaprakash, Sandeep Kumar Mishra
Background and Aims: The difficulty during flexible fiber-optic bronchoscopy (FOB) guided tracheal intubation could be because of inability in visualising glottis, advancing and railroading of endotracheal tube. Several methods are available for visualising glottis, but none is ideal. Hence, this randomised controlled study was designed to evaluate the simple pre-determined length insertion technique (SPLIT) during oral FOB. Methods: Fifty-eight patients were randomised into Group C and Group P. General anaesthesia was maintained with sevoflurane and oxygen in spontaneous respiration. In Group C, conventional flexible fiberoptic laryngoscopy was done followed by SPLIT and vice versa in Group P. The time to visualise the glottis (T1), from glottic visualisation to pass beyond glottis (T2) and from incisors to pass beyond the glottis (T3) were noted from the recorded video. The time interval was analysed using Wilcoxon matched pairs test and Mann–Whitney U-test. Results: The T1was significantly less in SPLIT as compared to conventional technique (13 [10, 20.25] vs. 33 [22, 48] s). The T3was significantly less in SPLIT (24.5 [19.75, 30] vs. 44 [34, 61.25] s). The T1by SPLIT was comparable between residents and consultants (P = 0.09), whereas it was significantly more among residents than the conventional technique. The SPLIT was preferred by 91.3% anaesthesiologists. Conclusion: The SPLIT significantly lessened the time to visualise the glottis than conventional technique for FOB. The SPLIT was the preferred technique. Hence, we suggest using the SPLIT to secure the airway at the earliest and also as an alternative to conventional technique.
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Effects of avoiding neuromuscular blocking agents during maintenance of anaesthesia on recovery characteristics in patients undergoing craniotomy for supratentorial lesions: A randomised controlled study p. 42
Ruchi A Jain, Anita N Shetty, Shrikanta P Oak, Anjana S Wajekar, Madhu B Garasia
Background and Aims: Neuromuscular blocking agents have been one of the cornerstones of anaesthesia. With the advent of newer surgical, anaesthetic and neurological monitoring techniques, their utility in neuroanaesthesia practice seems dispensable. The aim of this prospective, comparative, randomised study was to determine whether neuromuscular blocking agents are required in patients undergoing supratentorial surgery when balanced anaesthesia with desflurane, dexmedetomidine and scalp block is used. Methods: Sixty patients with the American Society of Anesthesiologists physical status I or II, aged between 18 and 60 years were included in the study. All patients received anaesthesia including desflurane, dexmedetomidine and scalp block. The patients were randomly allocated to receive no neuromuscular blocking agent (Group A) or atracurium infusion to keep train-of-four count 2 (Group B). The two groups were compared with respect to haemodynamic stability, brain relaxation scores and recovery characteristics. Haemodynamic parameters and time taken to achieve Aldrete score >9 and other secondary outcomes were analysed using Student's t-test. Non-parametric data were analysed using the Mann–Whitney test. Results: The mean arterial pressure was comparable between the groups. The intraoperative heart rate was comparable; however, in the post-operative period, it remained higher in Group B for 30 min after extubation (P = 0.02). The brain relaxation scores were comparable among the two groups (P = 0.27). Tracheal extubation time, time taken for orientation and time required to reach Aldrete score ≥9 were comparable among the two groups. Conclusion: The present study suggests that balanced anaesthesia using desflurane, dexmedetomidine and scalp block can preclude the use of neuromuscular blocking agents in patients undergoing supratentorial surgery under intense haemodynamic monitoring.
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Attenuation of haemodynamic responses to laryngoscopy and endotracheal intubation with intravenous dexmedetomidine: A comparison between two doses p. 48
Bon Sebastian, Anand T Talikoti, Dinesh Krishnamurthy
Background and Aims: Laryngoscopic manipulation and endotracheal intubation are noxious stimuli capable of producing tachycardia, arrhythmias and hypertension. The aim of this study was to arrive at an optimal dose of dexmedetomidine by comparing two doses with placebo to attenuate stress response during laryngoscopy and endotracheal intubation. Methods: It was a randomised, prospective, double-blind placebo-controlled study. After Institutional Ethical Committee clearance, ninety patients of American Society of Anesthesiologists Physical Status 1 were enrolled in the study and divided into three equal groups. Group A received normal saline, Group B received injection dexmedetomidine 0.5 μg/kg and Group C received injection dexmedetomidine 0.75 μg/kg as infusion over 10 min. The general anaesthesia technique was standardised for all three groups. The primary outcome measures were haemodynamic response at 1, 3 and 5 min after intubation. The secondary outcome measures were to note down any adverse effects associated with drugs. The statistical package used was SPSS version 15. Results: Groups were well matched for their demographic data. There was a statistically significant difference (P < 0.05) between dexmedetomidine and normal saline in heart rate, systolic, diastolic and mean arterial pressures at all time points after tracheal intubation with dexmedetomidine 0.75 μg/kg being most effective. Sedation scores were more with dexmedetomidine. None of the patients had any adverse effects such as hypotension, bradycardia, respiratory depression and fall in oxygen saturation. Conclusion: Dexmedetomidine in a dose of 0.75 μg/kg intravenous is the optimal dose to attenuate stress response to laryngoscopy and endotracheal intubation.
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Comparison of fractionated dose versus bolus dose injection in spinal anaesthesia for patients undergoing elective caesarean section: A randomised, double-blind study p. 55
Jigisha Prahaladray Badheka, Vrinda Pravinbhai Oza, Ashutosh Vyas, Deepika Baria, Poonam Nehra, Thomas Babu
Background and Aims: Spinal anaesthesia (SA) with bolus dose has rapid onset but may precipitate hypotension. When we inject local anaesthetic in fractions with a time gap, it provides a dense block with haemodynamic stability and also prolongs the duration of analgesia. We aimed to compare fractionated dose with bolus dose in SA for haemodynamic stability and duration of analgesia in patients undergoing elective lower segment caesarean section (LSCS). Methods: After clearance from the Institutional Ethics Committee, the study was carried out in sixty patients undergoing elective LSCS. Patients were divided into two groups. Group B patients received single bolus SA with injection bupivacaine heavy (0.5%) and Group F patients fractionated dose with two-third of the total dose of injection bupivacaine heavy (0.5%) given initially followed by one-third dose after 90 s. Time of onset and regression of sensory and motor blockage, intraoperative haemodynamics and duration of analgesia were recorded and analysed with Student's unpaired t-test. Result: All the patients were haemodynamically stable in Group F as compared to Group B. Five patients in Group F and fourteen patients in Group B required vasopressor. Duration of sensory and motor block and duration of analgesia were longer in Group F (273.83 ± 20.62 min) compared to Group B (231.5 ± 31.87 min) P< 0.05. Conclusion: Fractionated dose of SA provides greater haemodynamic stability and longer duration of analgesia compared to bolus dose.
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Monitored anaesthesia care – Comparison of nalbuphine/dexmedetomidine versus nalbuphine/propofol for middle ear surgeries: A double-blind randomised trial p. 61
Srinivasa Rao Nallam, Sunil Chiruvella, Anjineswar Reddy
Background and Aims: Middle ear surgeries (MESs) are usually performed under sedation with local anaesthesia and can be well tolerated by the patient with minimal discomfort. In the present study, we compare the effect of nalbuphine/dexmedetomidine combination with nalbuphine/propofol on sedation and analgesia in monitored anaesthesia care. Methods: One hundred adult patients undergoing MESs under monitored anaesthesia care (MAC) were randomly allocated into two groups. All patients in both groups received injection nalbuphine 50 μg/kg intravenously (IV). Group D received a bolus dose of injection dexmedetomidine 1 μg/kg IV over 10 min followed by an infusion started at 0.4 μg/kg/h IV. Group P received a bolus dose of injection propofol 0.75 mg/kg followed by an infusion started at 0.025 mg/kg/min IV. Sedation was titrated to Ramsay Sedation Score (RSS) of 3. Patient's mean arterial pressure, heart rate, saturation peripheral pulse and need for intraoperative rescue sedation/analgesia were recorded and compared. The data analysis was carried out with Z test and Chi-square test. Results: Mean RSS was significantly more in Group D (4.24 ± 1.54) as compared to Group P (2.58 ± 0.95). Overall VAS score was also significantly less in Group D (3.5 ± 1.7) than in Group P (5.4 ± 1.8). In total, 16 patients (32%) in Group D had hypotension whereas 7 patients (14%) only in Group P had hypotension. Conclusion: Nalbuphine/dexmedetomidine combination is superior to nalbuphine/propofol in producing sedation and decreasing VAS in patients undergoing MESs under MAC. Better surgeon and patient satisfaction were observed with nalbuphine/dexmedetomidine. Haemodynamics need to be closely monitored.
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Combined liver and kidney transplantation: Our experience and review of literature p. 68
Kusuma Ramachandra Halemani, N Bhadrinath
Increased awareness of organ donation has increased the availability of deceased donors, and it has boosted the opportunities for treating patients with multiple organ dysfunction. Simultaneously replacing two organs gives advantages of single surgery, lower immunosuppression dose and better survival than when one organ alone is transplanted. We present reports of management of three cases of combined liver and kidney transplantation (CLKT) from deceased donors. Based on management of these cases we discuss the importance of CLKT and anaesthetic concerns during such complex procedures.
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Post-intubation tension pneumothorax and pneumoperitoneum in a low birth weight neonate with giant epulis p. 72
Tanvir Samra, Ranvinder Kaur, Lalitha Chaudhary, Kavita Meena
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Nasal ala pressure sores following head and neck reconstructive surgery: A retrospective analysis from a tertiary cancer hospital p. 74
Sonal Rastogi, Tshering Bhutia, Annu Singh, Pattatheyil Arun
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Anaesthesia for emergency caesarean section in a morbidly obese achondroplastic patient with PIH: Feasibility of Neuraxial anaesthesia? p. 77
Ridhima Sharma, Rohan Magoon, Ripon Choudhary, Punit Khanna
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Angelman syndrome and anaesthetic considerations p. 78
Jyotsna Agarwal, Rashmi Datta, CN Jaideep, Amit Sharma
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Calibrated polyvinyl chloride tube of urine bag in urine output measurement of neonates p. 80
Riaz Rameez, Shamim Rafat, Priya Vansh, Singh Prabhat Kumar
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Vocal cord closure leading to inadequate ventilation with Laryngeal Mask Airway ProSeal™ in a paralysed patient during laparoscopic surgery p. 81
Harihar Vishwanath Hegde, Krishna Sagar Sriram
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Acute life-threatening limb ischaemia from common femoral artery thrombosis following total hip arthroplasty surgery: A rare complication p. 83
Shiva Kumar Narayan, AK Ajith Kumar, Rajesh Mohan Shetty, Sunil Karanth
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Effective and cost-saving incisionless sub-Tenon's block p. 84
Chandra M Kumar, Edwin Seet
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Absent Uvula: What Mallampati Class? Highly accessed article p. 85
Geetanjali T Chilkoti, Medha Mohta, Ganeshan Karthik, Ashok Kumar Saxena
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Anaesthetic management in a patient of uncorrected double outlet right ventricle for emergency surgery p. 87
Manish Kotwani, Vivek Rayadurg, Bharati A Tendolkar
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Lighter Planes p. 89
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