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   Table of Contents - Current issue
Coverpage
Dec 2020
Volume 64 | Issue 12
Page Nos. 1003-1092

Online since Saturday, December 12, 2020

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EDITORIAL  

Exploring cocktails, remixes and innovations in regional nerve blocks: The clinical research journey continues Highly accessed article p. 1003
Lalit Mehdiratta, Sukhminder Jit Singh Bajwa, Naveen Malhotra, Muralidhar Joshi
DOI:10.4103/ija.IJA_1517_20  
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ORIGINAL ARTICLES Top

Evaluation of ultrasound-guided quadratus lumborum block for post-operative analgesia in unilateral laparoscopic renal surgeries – A randomised controlled trial Highly accessed article p. 1007
Rajagopalan Venkatraman, Ravi Saravanan, Koka Vatsalya Mohana, Anand Pushparani
DOI:10.4103/ija.IJA_335_20  
Background and Aims: Quadratus lumborum block (QLB) is a novel anaesthetic technique for abdominal wall block providing excellent post-operative analgesia. The primary objective of this study was to evaluate the duration of post-operative analgesia with QLB in unilateral laparoscopic renal surgeries. The secondary objectives were to assess total morphine consumption during the first 24 h postoperatively and observe for complications. Methods: Sixty patients undergoing unilateral laparoscopic renal surgeries were randomly divided into two groups, with patients receiving QLB (Group A) or no block (Group B) at the end of surgery. General anaesthesia was standardised in both the groups. The pain was assessed by a Visual Analogue Scale (VAS) of 1–10. The duration of analgesia was taken as time from extubation to VAS of ≥3. Morphine was administered in patient-controlled analgesia pump with a bolus of 1 mg and a lockout interval of 10 min (min). The total morphine consumption was recorded. The statistical analysis was performed with the Student's t-test and Chi-square test. Results: The duration of post-operative analgesia was significantly prolonged in Group A (1288 ± 288.92 min) than Group B (138 ± 54.92 min). Morphine consumption was also less in Group A (3.1 ± 0.87 mg) than Group B (10.46 ± 1.8 mg). There was a significant difference in the VAS score from 16 to 20 h. No complications were recorded. Conclusions: Ultrasound-guided QLB after laparoscopic renal surgery is safer to perform, effective with an increased post-operative duration of analgesia, reduces the consumption of opioids and is associated with fewer side effects.
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Comparison of laparoscopy-guided with ultrasound-guided subcostal transversus abdominis plane block in laparoscopic cholecystectomy – A prospective, randomised study Highly accessed article p. 1012
Rajagopalan Venkatraman, Ravi Saravanan, Meshach Dhas, Anand Pushparani
DOI:10.4103/ija.IJA_528_20  
Background and Aims: Subcostal transversus abdominis plane (TAP) block is usually done under ultrasound guidance in laparoscopic cholecystectomy. Laparoscopic-guided subcostal TAP block is an alternate technique where ultrasound is not available. Our primary objective was to compare the success rate of ultrasound and laparoscopic approaches to the subcostal TAP block. The secondary objectives were to assess the duration of postoperative analgesia and morphine consumption postoperatively for 24 h. Methods: Eighty patients undergoing laparoscopic cholecystectomy were randomly divided into two groups with patients receiving ultrasound-guided (group U) or laparoscopy-guided (group L) subcostal TAP block at the end of surgery. The success rate was assessed by a sensory blockade of T7 and T8 dermatomes 30 min after extubation. The duration of analgesia was taken as time from block administration to the visual analogue scale of ≥3. Morphine was administered in patient-controlled analgesia (PCA) pump with a bolus of 1 mg and a lock-out interval of 10 min. The total morphine consumption was recorded. The statistical analysis was performed with student t-test and Chi-square test. Results: The success rate of group U (100%) was higher than group L (88%) but it was not statistically significant (P = 0.054). The duration of postoperative analgesia was significantly prolonged in group U (867.24 ± 135.83 min) than group L (751.31 ± 311.22 min) (P = 0.033). Morphine consumption was also less in group U (4.72 ± 0.94 mg) than group L (5.57 ± 2.53 mg) (P = 0.049). There was no significant difference in the VAS scores after 4 h postoperatively. Conclusion: Laparoscopy-guided subcostal TAP block is a suitable alternative to ultrasound-guided block and can be utilised in places where an ultrasound machine is not available.
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A randomised controlled comparison of serratus anterior plane, pectoral nerves and intercostal nerve block for post-thoracotomy analgesia in adult cardiac surgery Highly accessed article p. 1018
Rohan Magoon, Brajesh Kaushal, Sandeep Chauhan, Debesh Bhoi, Akshay K Bisoi, Maroof A Khan
DOI:10.4103/ija.IJA_566_20  
Background and Aims: Enhanced recovery after cardiac surgery is centred around multimodal analgesia which is becoming increasingly feasible with the advent of safer regional analgesic techniques such as fascial plane blocks. We designed this prospective, single-blind, randomised controlled study to compare the efficacy of serratus anterior plane block (SAPB), pectoral nerves (Pecs) II block, and intercostal nerve block (ICNB) for post-thoracotomy analgesia in cardiac surgery. Methods: 100 adults posted for cardiac surgery through a thoracotomy were randomly allocated to one of the three groups: SAPB, Pecs II or, ICNB wherein the patients received 2.5 mg/kg of 0.5% ropivacaine for ultrasound-guided block after completion of surgery. Postoperatively, intravenous (IV) paracetamol was used for multimodal and fentanyl was employed as rescue analgesia. Visual analogue scale (VAS) was evaluated at 2, 4, 6, 8, 10 and 12 hours post-extubation. Results: The early mean VAS scores at 2, 4 and 6 hours were comparable in the 3 groups. The late mean VAS (8, 10 and 12 hours) was significantly lower in the SAPB and Pecs II group compared with that of the ICNB group (P value <0.05). The cumulative rescue fentanyl dose was significantly higher in ICNB group compared to SAPB and Pecs II group (P value <0.001). The SAPB group had the highest time to 1st rescue analgesic requirement in contrast to the other groups. Conclusion: SAPB and Pecs II blocks are simple single-shot effective alternatives to ICNB with a prolonged analgesic duration following thoracotomy and can potentially enhance pain-free recovery after cardiac surgery.
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Perioperative factors predicting delayed enteral resumption and hospital length of stay in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: Retrospective cohort analysis from a single centre in India p. 1025
Kalpana Balakrishnan, Nivedhyaa Srinivasaraghavan, Meenakshi V Venketeswaran, Thendral Ramasamy, Ramakrishnan A Seshadri, E Hemanth Raj
DOI:10.4103/ija.IJA_480_20  
Background and Aims: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an extensive procedure associated with significant morbidity, delay in return of gastrointestinal function and discharge from hospital. Our aim was to assess perioperative factors influencing enteral resumption (ER) and length of stay in the hospital (LOS) in CRS-HIPEC. Methods: A retrospective analysis was conducted in a major tertiary cancer centre. Sixty-five patients who underwent CRS-HIPEC between July 2014 and March 2019 were included in the study. The perioperative data were collected from patient records. The primary outcome measure was day of oral resumption of 500 ml of clear fluids and secondary outcome was the LOS. Univariate and multivariate logistic regression analysis was done for the various continuous and categorical perioperative variables for both ER and LOS to elicit the magnitude of risk for both outcomes. Results: Univariate logistic regression revealed that peritoneal carcinomatosis index score (PCI), duration of surgery, blood loss and postoperative ventilation influenced both ER and LOS. Serum albumin, plasma usage and total peritonectomy affected only the LOS but not ER. Multivariate analysis showed that duration of surgery (P = 0.006) and quantum of intravenous fluid infused (P = 0.043) were statistically associated with ER, while serum albumin level (P = 0.025) and postoperative ventilation (P = 0.045) were independently predictive of LOS. Conclusion: CRS-HIPEC is an extensive surgery and multiple factors are associated with ER; of these, duration of surgery and intraoperative fluid therapy are significant factors. Low serum albumin and prolonged postoperative ventilation are associated with increased LOS.
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Effect of adding dexamethasone to ropivacaine for ultrasound-guided serratus anterior plane block in patients undergoing modified radical mastectomy: A preliminary trial p. 1032
Vinod Kumar, Prashant Sirohiya, Nishkarsh Gupta, Sachidanand Jee Bharati, Rakesh Garg, Seema Mishra
DOI:10.4103/ija.IJA_261_20  
Background and Aims: Ultrasound-guided serratus anterior plane (SAP) block is a field block with high efficacy. We studied the analgesic effect of the addition of dexamethasone to ropivacaine in SAP block for modified radical mastectomy (MRM). Methods: Sixty patients undergoing MRM were randomised into two groups. Patients in Group P (n = 30) received 0.375% ropivacaine (0.4 ml/kg) with normal saline (2 ml) and those in group D (n = 30) received 0.375% ropivacaine (0.4 ml/kg) with 8 mg of dexamethasone (2 ml) in ultrasound-guided SAP block. The primary objective was to compare the time to first rescue analgesia and the secondary objectives were to compare the intraoperative fentanyl requirement, total diclofenac and tramadol requirements, and occurrence of nausea and vomiting in 24 hours, postoperatively. The statistical analysis was done using Mann–Whitney U-test, Chi-square test, Fisher's exact test, and Kaplan Meier survival estimates. Results: More patients required rescue analgesia in 24 hours in group P (33%) than group D (10%, P = 0.04). The probability of a pain free-period was significantly higher in group D than group P (P = 0.03, log-rank test). Intra-operative fentanyl requirement and postoperative diclofenac and tramadol requirements were comparable in both the groups. The incidence of postoperative nausea and vomiting was significantly more in Group P than Group D. Conclusion: Addition of dexamethasone to ropivacaine for SAP block increases the time to first rescue analgesic in the postoperative period.
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Comparison of pectoralis plane blocks with ketamine-dexmedetomidine adjuncts and opioid-based general anaesthesia in patients undergoing modified radical mastectomy p. 1038
Shagun B Shah, Rajiv Chawla, Akhilesh Pahade, Amit Mittal, Ajay K Bhargava, Rajeev Kumar
DOI:10.4103/ija.IJA_8_20  
Background and Aims: Regional anaesthesia attenuates surgical stress-response, provides superior analgesia, reduces recovery time with early mobilisation and is opioid-sparing [addresses post-operative nausea vomiting (PONV), constipation, immunosuppression and cancer-progression concerns with opioids]. Hence, we studied pectoralis (PECS) blocks for modified radical mastectomy (MRM). Methods: A prospective, interventional, double-blind, randomised, parallel-arm, active-controlled study comparing two anaesthetic techniques for post-operative pain relief in70 adult American Society of Anesthesiologists grade I/II carcinoma breast patients undergoing MRM was conducted. Patients were randomised to Group-O (opioids, sevoflurane) and Group-P (PECS-block, pre-incisional intravenous (IV) ketamine (0.5 mg/kg), pre-incisional IVdexmedetomidine (1 μg/kg over 10 min, then 0.6 μg/kg/h). Data were subjected to statistical analysis using the Statistical Package for Social Sciences, version-23 and independent sample t-test/Welch test for equality of means and expressed as dotted box-whisker plots. Nominal categorical intergroup data was compared using Chi-squared test/Fisher's exact test. P<0.05 was considered statistically significant. Clinical significance was calculated. Results: Higher Visual Analogue Scale (VAS)-scores were recorded in Group-O versus Group-P, immediately post-extubation [mean (SD) 3.6 ± 1.5 and 0.76 ± 0.6] and at 1h (3.1 ± 1.2 and1.4 ± 0.5), 2h (2.5 ± 0.9 and 1.2 ± 0.6) and 4h (2.2 ± 0.5 and 1.7 ± 0.9) respectively. At 8h and 24h post-surgery VAS was comparable. Cumulative-VAS was lower in Group-P. Intraoperative haemodynamics were comparable. Incidence of PONV and constipation was higher in Group-O where each patient received average 27.46 mg morphine-equivalents of opioids. Time to discharge from surgical intensive care unit was 2h shorter in Group-P. Conclusion: Pre-emptive PECS-blocks supplemented with low-dose ketamine and dexmedetomidine comprise a practical and useful alternative technique to the standard opioid-based general anaesthetic technique for MRM.
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Effect of ultrasound-guided–pressure-controlled ventilation on intraoperative blood gas and ventilatory parameters during thoracic surgery p. 1047
Deyashinee Ghosh, Gaurav Jain, Ankit Agarwal, Nishith Govil
DOI:10.4103/ija.IJA_548_20  
Background and Aims: Identifying an ideal intraoperative ventilation strategy remains an area of research. We evaluated the effect of ultrasound-guided–pressure-controlled ventilation (UG-PCV) on the blood-gas and ventilatory parameters, during both two-lung ventilation (TLV) and one-lung ventilation (OLV) for thoracic surgery of unilateral pulmonary disease, compared with volume-targeted PCV (VT-PCV). Methods: In a prospective, parallel-group and double-blinded design, 40 consecutive patients were randomised into two groups. Group A: Received VT-PCV at a tidal volume (TV) of 9 mL/kg for TLV and 5 mL/kg for OLV; group B: Received UG-PCV at an inspiratory pressure (2 cmH2O increments every 15 s) targeted to achieve the alveolar aeration at the base of the dependent lung (ultrasound-guided), for both TLV/OLV, respectively. Primary outcome included arterial oxygen partial pressure (PaO2) measured at baseline before anaesthesia induction (T1), at 30 min immediately before conversion from TLV to OLV (T2), at 30 min on OLV (T3) and before terminating OLV at the end of surgery (T4). Statistical tool included Mann-Whitney test. Results: The PaO2 (mmHg) was significantly higher in group B (374.5 ± 25.9, 321.7 ± 35.2 and 357.0 ± 24.7) as compared to group A (353.3 ± 38.1, 272.6 ± 37.9 and 295.3 ± 40.1), at T2, T3 and T4, respectively. The acid-base status remained preserved in group B, while gradual respiratory acidosis was observed in group A. The bicarbonate levels remained uniform in all patients. The TV and airway pressures were marginally higher in group B, with no intraoperative complications. Conclusion: The UG-PCV mode offered better oxygenation, homogenous acid-base balance and individualised alveolar ventilation for thoracic surgery.
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Comparison of airway blocks versus general anaesthesia for diagnostic direct laryngoscopy: A randomised comparative trial p. 1054
Sonali Dhawan, ManiRam Guri, Kanta Bhati, Neha Aeron
DOI:10.4103/ija.IJA_680_20  
Background and Objective: Direct rigid laryngoscopy and general anaesthesia (GA) are associated with many problems. Regional anaesthesia/airway blocks can be considered as safer and easier alternative techniques especially among old and comorbid patients and conditions with difficult airways as well. The present study was conducted to compare efficacy of regional anaesthesia/airway blocks versus general anaesthesia for diagnostic direct (rigid) laryngoscopy. Methods: A randomised comparative trial was conducted among patients undergoing diagnostic direct laryngoscopy (DLS) for perilaryngeal lesions. Eighty patients of either sex aged between 20and 80 years and categorised as American Society of Anesthesiologists(ASA) grade I, II, III or IV were divided under two groups of 40 patients each. Group-A underwent DLS with airway blocks and group-B underwent DLS under GA. Haemodynamic parameters and analgesia were interpreted statistically. Results: Difference in haemodynamic stability and quality of post- operative analgesia were primary outcomes. Patients in group-A were observed to be haemodynamically more stable as compared to group-B patients with statistically significant P value (0.003 and 0.016 for pulse rate at 6 min and mean arterial pressure at 4 min, respectively). In postoperative period, group-A patients were found to be more comfortable (lower VAS scores) than group-B patients with P value (0.040, 0.043, 0.044 at 0, 5, 15 min, respectively). Conclusion: Regional airway blocks provide better haemodynamic stability and postoperative analgesia than general anaesthesia.
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Comparison of effectiveness of the piston-pump method versus the pressure-infusor method for rapid infusion of crystalloids: A bench study p. 1059
Wataru Hashimoto, Ichiro Takenaka, Keisuke Yasunami, Tomoko Minami, Haruhiko Sano
DOI:10.4103/ija.IJA_864_20  
Background and Aims: The piston-pump method is a simple method for rapid administration of fluids but some problems are unsolved. We compared the effectiveness of using the piston-pump method with that of the pressure-infusor method. Methods: Twelve anaesthetists were classified randomly into the piston-pump and pressure-infusor groups. They were asked to infuse 500 ml of saline three times successively through a 16-G intravenous cannula as rapidly as possible using a pump with a 50-ml syringe or a pressure-infusor at 300 mmHg. The time taken for infusion and the maximum or minimum pressure in the infusion circuit and substitute vessel were measured. Bacterial culture of the saline infused sterilely was performed to estimate bacterial contamination. Results: The pressure-infusor group led to faster infusion of 500 ml of saline (233 ± 19 s) than the piston-pump group (301 ± 48 s) (P < 0.01). The infusion time at the third attempt (316 ± 43 s) was significantly longer than that at the first attempt (285 ± 53 s) only in the piston-pump group (P < 0.05). The maximum pressure (mmHg) in the circuit was 131 ± 9 and > 200 (P < 0.01) and in the substitute vessel was 5 ± 1 and 17 ± 7 (P < 0.01) in the pressure-infusor and piston-pump groups, respectively. A pressure of <-200 mmHg occurred at all infusion attempts in the piston-pump group. Bacterial contamination was not observed in either group. Conclusion: If fluids must be administered rapidly, the pressure-infusor method is more efficient than the piston-pump method because the latter is less effective in infusing fluids rapidly and associated with excessive positive and negative pressure in the infusion circuit.
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CLINICAL COMMUNICATION Top

Two manoeuvres to facilitate the oral insertion of LMA CTrach™ p. 1064
Handattu Mahabaleswara Krishna, Nandhini Joseph, Karri Pavani
DOI:10.4103/ija.IJA_515_20  
Background and Aims: LMA CTrachTM, a new intubating conduit, has a thicker shaft compared to that of the intubating laryngeal mask airway (ILMA) due to the embedded optical fibres of the system. This causes difficulty during insertion despite normal mouth opening. Utility of two manoeuvres to overcome this was evaluated. Methods: From our experience with LMA CTrachTM we found that two manoeuvres can be helpful to facilitate the insertion of LMA (a) dorsal and downward pressure over the shaft at the point where it hinges against the incisors while continuing the one handed rotational insertion of LMA (b) Lateral insertion of the LMA till the cuff is inside the oral cavity and then rotation of the LMA by 90° and then complete the insertion. A retrospective analysis of 200 insertions of LMA CTrachTM was done to evaluate the utility of these manoeuvres. Results: Out of 200 insertions, 15 were found to be difficult. Manoeuvre “a” was applied in 13 cases to facilitate the insertion and manoeuvre “b” was applied in 2 cases where insertion was not possible despite manoeuvre “a'. Insertion was successful in these cases after the application of the described manoeuvres. Conclusion: The two manoeuvres described above can be useful when LMA CTrachTM insertion into the oral cavity is obstructed by the incisor teeth.
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COVID-19 and its impact on pain management practices: A nation-wide survey of Indian pain physicians p. 1067
Rajendra K Sahoo, Ashok Jadon, Samarjit Dey, Pankaj Surange
DOI:10.4103/ija.IJA_1072_20  
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LETTERS TO EDITOR Top

Meralgia paraesthetica following total knee arthroplasty p. 1074
Rammurthy Kulkarni, Amjad Maniar, Lavanya Mandhal, Madona Stephen
DOI:10.4103/ija.IJA_719_20  
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LETTERS TO EDITOR Top

C-arm fluoroscopic -guided subarachnoid block in a super morbidly obese patient p. 1075
Hideki Tachibana, Yukihide Koyama, Haruko Nishikawa, Koichi Tsuzaki
DOI:10.4103/ija.IJA_770_20  
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Unilateral complete ptosis after scalp block: A rare complication of common procedure p. 1077
Situ Situ, Priyanka Gupta, Mageshwaran Thirunavukkarasu, Gyanendra Chaudhary
DOI:10.4103/ija.IJA_675_20  
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Ultrasound-guided combined supraclavicular brachial plexus and PECS II blocks for brachiobasilic fistula transposition surgery p. 1079
Zhi Yuen Beh, Siu Min Lim, Woon Lai Lim, Ahmad Rafizi Hariz Ramli
DOI:10.4103/ija.IJA_535_20  
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Customised face mask: Solution to facial nerve blocks in COVID-19 p. 1081
Ruchi Gupta, Ameesha Mahajan, Tavleen Kaur, Anshul Mahajan
DOI:10.4103/ija.IJA_1081_20  
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Sham block in a randomised controlled trial: Is it ethical? p. 1082
Abhijit Nair, Sandeep Diwan
DOI:10.4103/ija.IJA_836_20  
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Scapular surgery under combined thoracic paravertebral and interscalene blocks Highly accessed article p. 1083
Prasanna Vadhanan, Nikhilesh Bokka
DOI:10.4103/ija.IJA_825_20  
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Anti-fogging techniques as part of personal protective equipment (PPE) p. 1085
Karthik Ganesh Ramamoorthy
DOI:10.4103/ija.IJA_687_20  
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Erector spinae plane block as analgesic adjunct for traumatic rib fractures in intensive care unit p. 1086
Zhi Yuen Beh, Siu Min Lim, Woon Lai Lim, Premela Naidu Sitaram
DOI:10.4103/ija.IJA_1110_20  
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Direct PEC block: Simplified and effective alternative when US-PEC block is difficult p. 1090
Nidhi Arun, Raushan K Jha, Raja Avinash
DOI:10.4103/ija.IJA_988_20  
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Pulsed radiofrequency ablation of stellate ganglion for chronic facial pain p. 1091
Vilas S Gowler, Subrata Goswami
DOI:10.4103/ija.IJA_908_20  
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