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   Table of Contents - Current issue
October 2020
Volume 64 | Issue 10
Page Nos. 831-926

Online since Thursday, October 1, 2020

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Editing from the dungeons of the pandemic; an editor's agonisingly painful battle with COVID-19 Highly accessed article p. 831
Sukhminder Jit Singh Bajwa
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Hyperbaric oxygen therapy: Can it be a novel supportive therapy in COVID-19? Highly accessed article p. 835
Kirubanand Senniappan, Salome Jeyabalan, Pradeep Rangappa, Muralidhar Kanchi
The coronavirus disease 2019 (COVID-19) is a pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). Although 85% of infected patients remain asymptomatic, 5% show severe symptoms such as hypoxaemic respiratory failure and multiple end organ dysfunction (MODS) requiring intensive care unit (ICU) admission with a mortality rate of about 2.8%. Since a definitive treatment is yet to be identified, preventive and supportive strategies remain the mainstay of management. Supportive measures such as oxygen therapy with nasal cannula, face mask, noninvasive ventilation, mechanical ventilation and even extreme measures such as extracorporeal membrane oxygenation (ECMO) fail to improve oxygenation in some patients. Hence, hyperbaric oxygen therapy (HBOT) has been proposed as a supportive strategy to improve oxygenation in COVID-19 patients. HBOT is known to increase tissue oxygenation by increasing the amount of dissolved oxygen in plasma. HBOT also mitigates tissue inflammation thus reducing the ill effects of cytokine storm in COVID-19 patients. Though there is limited literature available on HBOT in COVID-19 patients, considering the present need for additional supportive therapy to improve oxygenation, HBOT has been proposed as a novel supportive treatment in COVID-19 patients.
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Comparison of effects of volume-controlled and pressure-controlled mode of ventilation on endotracheal cuff pressure and respiratory mechanics in laparoscopic cholecystectomies: A randomised controlled trial p. 842
SS Nethra, Swathi Nagaraja, K Sudheesh, Devika Rani Duggappa, Bhargavi Sanket
Background and Aims: One of the pathophysiological consequences of pneumoperitoneum is variations in endotracheal cuff pressure (ETTc). Volume-controlled mode and pressure-controlled mode of ventilation being two modes of ventilatory strategies; we intended to find out variations in ETTc governed by respiratory mechanics between these two modes during laparoscopic cholecystectomies. Methods: After obtaining ethics committee approval, this randomised (1:1), active-controlled, parallel-assigned study was done on 60 patients undergoing laparoscopic cholecystectomies. These patients were allocated into two groups by computer-generated randomisation: Volume-controlled mode (V) and pressure-controlled mode (P). We observed for variations in ETTc which was the primary aim and haemodynamic parameters; respiratory mechanics at baseline (T1), at pneumoperitoneum (T2), after 10 min (T3), 20 min (T4) of pneumoperitoneum and at desufflation (T5). Post-operative laryngotracheal co-morbidities were also observed. Analysis was done using Statistical Package for the Social Sciences version 16.0 (IBM SPSS Statistics, Somers NY, USA). Results: No statistically significant difference was found in both groups either concerning ETTc, haemodynamic parameters or complications. In both groups, ETTc variation was statistically significant when compared from baseline to desufflation (T1 versus T5) and in group V additionally from baseline to time of pneumoperitoneum (T1 versus T2). Group P showed lower peak airway pressure at desufflation and higher mean airway pressure throughout at all the time intervals. Conclusions: There is no variation in ETTc between the two modes. Group P appears to be better in terms of lower Ppeak and better Pmean.
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Role of ultrasonographic inferior venacaval assessment in averting spinal anaesthesia-induced hypotension for hernia and hydrocele surgeries—A prospective randomised controlled study p. 849
Basavaraja Ayyanagouda, BC Ajay, Chhaya Joshi, SY Hulakund, Anilkumar Ganeshnavar, E Archana
Background and Aims: Hypotension is one of the most common side effects of spinal anaesthesia and preoperative volume status is one of the predictive variables for developing spinal-induced hypotension (SIH). Inferior venacaval ultrasound (IVCUS) is effective to assess fluid responsiveness in critical care patients. The aim of this study was to evaluate the IVCUS-guided volume optimisation prior to spinal anaesthesia to prevent SIH and requirement of vasopressors. Methods: Eighty patients undergoing inguinal hernia/hydrocele surgeries under spinal anaesthesia were randomised into group A consisting of an IVCUS-guided volume optimisation before spinal anaesthesia and group B with no IVCUS assessment. Unpaired t-test and Z test were used for statistical analysis. Pearson's correlation coefficient was used to find correlation. The primary outcome was relative risk reduction in the incidence of SIH between the groups. Secondary outcomes were the need for vasopressor drugs, the total volume of fluids required throughout procedure, and correlation between IVC collapsibility index (IVCCI) versus prespinal fluids, IVCCI versus baseline mean arterial pressure (MAP). Results: The relative risk reduction in the incidence of SIH was lower in group A compared to group B which was 40% (P = 0.002 CI = 95%). The SIH in group A was 20% and group B was 50%. There was decreased requirement of vasopressors in group A compared to group B. Total IV fluids given was more in group A. There was a positive correlation between IVCCI and pre-spinal fluids. Conclusion: IVCUS assessment reduces the SIH as well as requirement of vasopressor for hernia and hydrocele surgeries.
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Role of videolaryngoscope in the management of difficult airway in adults: A survey p. 855
AH Shruthi, Deevish Dinakara, YR Chandrika
Background and Aims: A number of videolaryngoscopes (VLs) have flooded the Indian market. As per All India Difficult Airway Association 2016 guidelines, all anaesthesiologists should have access to a VL and must be trained to use it. We conducted an electronic survey to know the perception of Indian anaesthesiologists, who are members of the Indian Society of Anaesthesiologists (Karnataka State Chapter) towards the role of VL in the management of difficult airway (DA) and factors governing their use. Methods: An electronic survey was sent to 2580 ISA members to know the availability, use and attitude towards VLs in the management of DA in adults. The survey was open for a period of 2 months and responses analysed. Results: The response rate was 25.8% (666 out of 2580). A total of 280 (42%) respondents had access to VL. The respondents rated VL as 4th preference for anticipated DA and 1st for unanticipated DA (if available). The most widely used VLs were C-MAC, Airtraq, and Kingvision. As per 133 respondents (20%), access to VL in institutes was restricted only to consultants and the main reason being cost. The clarity of the image was the most important factor the respondents expected in a VL. Conclusions: Less than half of respondents had access to VLs. Most of them having access to it worked in corporate hospitals. The high cost of the device and steep learning curve are still barriers against its widespread use. We conclude that low-cost devices, with increased clarity may make usage of VLs frequent and available to residents.
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Dexmedetomidine nebulisation attenuates post-operative sore throat in patients undergoing thyroidectomy: A randomised, double-blind, comparative study with nebulised ketamine p. 863
Derlin Thomas, Lini Chacko, Paul O Raphael
Background and Aims: Endotracheal intubation is the predominant cause of airway mucosal injury, resulting in post-operative sore throat (POST), with an incidence of 20-74%, which brings immense anguish to patients. This study was conducted to evaluate and compare the efficacy of nebulised dexmedetomidine and ketamine in decreasing POST in patients undergoing thyroidectomy. Methods: Patients were randomly allocated into two groups of 50 each; Group 1 received ketamine 50mg (1mL) with 4mL saline nebulisation, while Group 2 received dexmedetomidine 50μg (1mL) with 4mL saline nebulisation for 15 min. GA was administered 15 min after completing nebulisation. POST monitoring was done at 0,2,4,6,12 and 24h after extubation. POST was graded on a four-point scale (0-3). The statistical analysis were performed using Statistical Package for Social Sciences (SPSS) software version 17.0. Fisher Exact-t-test, Chi square test, Student t-test, Paired t test and repeated measure analysis of variance (ANOVA) were used for analysis. Results: The overall incidence of POST in this study was 17%: POST was experienced by seven patients (14.3%) in ketamine and 10 patients (20.4%) in dexmedetomidine group (P = 0.424). There was no statistically significant difference in the incidence of POST between the two groups at 0,2,4,6,12 and 24h post-operatively. Severity of sore throat was also significantly lower in both groups at all time points. A statistically significant increase in heart rate, systolic and diastolic blood pressure was noted in ketamine group, post nebulisation. Conclusion: Pre-operative dexmedetomidine nebulisation can be utilised as a safe and ideal alternative to ketamine nebulisation in attenuating POST, with less haemodynamic derangement.
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Continuous quadratus lumborum block as post-operative strategy for pain control in spinal fusion surgery Highly accessed article p. 869
Jon Wilton, Helen Chiu, Natalie Codianne, Herschel Knapp, Vicente Roques Escolar, Shari Burns
Background and Aims: Lumbar spinal fusions have post-operative pain levels that can be difficult to treat. The objective of this study was to determine if using bilateral quadratus lumborum (QL) nerve block catheters for lumbar fusions changes the patient's post-operative recovery experience by reducing opioid consumption, thereby limiting potential risks and side effects and reducing recovery time. Methods: There were a total of 52 surgical lumbar fusion patients in this single-center, retrospective cohort review. In control Group A, there were 26 patients who received opioid regimens. In control Group B, there were 26 patients who received bilateral QL block catheters with breakthrough opioid regimens. Forty-eight hour post-operative opioid use in oral morphine milligram equivalents (MME) and length of stay (LOS) from the post-anaesthesia care unit to hospital discharge were examined. Results: Group A had a mean MME of 307.62 ± 305.37 mg. Group B had a statistically significant lower mean total MME of 133.78 ± 152.66 mg (P = 0.012, α = 0.05). On an average, Group A required 2.3 times the MMEs than Group B. Group A had a mean LOS of 2.34 ± 1.87 days, whereas Group B had a lower mean LOS of 1.98 ± 0.51 days. This difference of 0.36 days was not statistically significant (P = 0.522, α = 0.05). Conclusion: Surgical lumbar fusion patients who received the QL block catheter had a lower opioid requirement compared to standard opioid regimens. The study was underpowered to detect a difference in LOS.
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Evaluation of nebulised dexmedetomidine in blunting haemodynamic response to intubation: A prospective randomised study p. 874
Nimmagadda R R Kumar, Nirmala Jonnavithula, Shibani Padhy, Virinchi Sanapala, Vadithe Vasram Naik
Background and Aim: The process of laryngoscopy and endotracheal intubation is associated with intense sympathetic activity, which may precipitate intra-operative complications. Taking the advantage of dexmedetomidine's good bioavailability and rapid absorption through nasal mucosa; we contemplated this study to evaluate the effects of nebulised dexmedetomidine as a premedication in blunting the haemodynamic response to laryngoscopy and tracheal intubation. Methods: This prospective, randomised, comparative study was conducted in 100 American Society of Anesthesiologists (ASA) I, II patients. The primary outcome was to evaluate the effects of dexmedetomidine nebulisation in blunting the stress response to laryngoscopy and intubation. The secondary outcome was to study its adverse effects. The study population was divided randomly into two groups. Control group C (n = 50) received nebulisation with 5 ml of normal saline and group D (n = 50) received 1 μg/kg dexmedetomidine 5 ml 10 min before induction in sitting position. Results: Demographics were comparable. Following laryngoscopy and intubation, systolic (SBP), diastolic (DBP) and mean arterial pressure (MAP), response entropy (RE) and state entropy (SE) were markedly increased in the control group whereas in group D there was a fall in SBP (at 1 min-126.64 ± 26.37; P 0.01, 5 min-109.50 ± 16.83; P 0.02, 10 min-106.94 ± 17.01; P 0.03), DBP (at 1 min-83.18 ± 17.89; P 0.001, 5 min-66.40 ± 13.88; P 0.001, 10 min- 62.56 ± 14.91; P 0.01) and MAP (at 1 min-99.68 ± 19.22; P 0.001, 5 min- 84.08 ± 13.66; P 0.003, 10 min- 81.74 ± 14.79; P 0.008), RE and SE which was statistically significant (P 0.002). There was a dose sparing effect of propofol in group D; sedation score was comparable. Conclusion: Nebulised dexmedetomidine effectively blunts the stress response to laryngoscopy and intubation with no adverse effects.
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Substitution of propofol for dexmedetomidine in the anaesthetic regimen does not ameliorate the post-operative cognitive decline in elderly patients p. 880
Abrar A Chawdhary, Anita Kulkarni, Ala Nozari
Background and Aims: Post-operative cognitive dysfunction (POCD) is a poorly understood complication particularly observed in elderly patients, with long-term poor outcome. The randomised study was to compare the incidence of POCD in elderly with bispectral index (BIS)-guided intra-operative use of either dexmedetomidine or propofol with sevoflurane. Methods: Eighty-seven patients, planned for non-cardiac surgery under general anaesthesia, were included between June 2017 and March 2018. After exclusion of 7 patients, remaining 80 patients were randomised into dexmedetomidine group and propofol group with 40 patients each. In both the groups, BIS-guided anaesthesia was provided. Cognitive function was assessed by an anaesthesiologist using a battery of neuropsychological tests at baseline pre-operatively, third and seventh day after surgery. The data were entered into a Microsoft Excel spreadsheet and analysis was performed using Statistical Package for Social Sciences (SPSS) version 21. Results: Propofol group had a non-significant lower incidence of POCD on third day and dexmedetomidine group showed decreased incidence of POCD on seventh day, accompanied by lower anaesthetic requirement (inhalational as well as intravenous) concomitant with delayed emergence with an acceptable BIS value. Conclusion: Dexmedetomidine appeared to be anaesthetic sparing as compared to propofol. BIS monitoring for titrating depth of anaesthesia and hence the anaesthetic exposure is an invaluable tool as compared to routine care anaesthesia for reducing POCD. The patients in both groups did not develop significant POCD until the seventh post-operative day.
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The effect of post-operative ultrasound-guided transmuscular quadratus lumborum block on post-operative analgesia after hip arthroplasty in elderly patients: A randomised controlled double-blind study p. 887
Mohammad Ali Abduallah, Sameh Abdelkhalik Ahmed, Mohamed Shebl Abdelghany
Background and Aim: The best analgesic technique after hip surgeries is a matter of debate. This clinical trial aimed to assess the effect of transmuscular ultrasound-guided quadratus lumborum (QL) block on post-operative analgesic consumption after hip arthroplasty in elderly patients. Methods: This prospective randomised double-blind study was carried out on 60 patients aged 60–80 years presented for total hip replacement under unilateral spinal anaesthesia. Patients were randomly allocated to one of two groups: A control group, receiving sham transmuscular QL block (QLB) (1 ml of normal saline), and a QL group, receiving real transmuscular QLB (30 ml of plain bupivacaine 0.25%). Post-operative morphine consumption (primary outcome), post-operative pain score (secondary outcome), time to the first request of rescue analgesia, patient's satisfaction and the occurrence of post-operative complications were measured. Results: Compared to the control group, the use of QLB in the second group significantly decreased intravenous morphine consumption postoperatively from 8.50 ± 3.06 mg to 5.60 ± 3.22 mg (P = 0.0007) with a significant prolongation of the time to the first call for analgesia (P < 0.0001). It also decreased the post-operative visual analogue score 4 h, 6 h and 8 h postoperatively (P < 0.05). However, there was no difference between both the groups regarding patient's satisfaction and the occurrence of complications (P > 0.05). Conclusion: The use of transmuscular QLB in patients undergoing total hip replacement decreased post-operative analgesic consumption and post-operative pain score and prolonged post-operative analgesia. It did not affect patients' satisfaction and occurrence of post-operative complications.
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Incidence of acute kidney ınjury during the perioperative period in the colorectal division of surgery - Retrospective study p. 894
Vasanth Rao Kadam, Vincent Loo, Suzanne Edwards, Peter Hewett
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Peri-capsular nerve group block provides excellent analgesia in hip fractures and positioning for spinal anaesthesia: A prospective cohort study p. 898
Rajendra Kumar Sahoo, Ashok Jadon, Santosh Kumar Sharma, Philip W H Peng
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Weaning from cardiopulmonary bypass after minimally invasive partial tricuspid valvectomy with single-lung ventilation p. 901
Beth A Vander Wielen, Kimberly Hollander
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“Floating egg” appearance of para-pneumonic effusion in a COVID-19 patient p. 902
Samuel Haynes, Magdalene Chan, Gunmeet Dhingra, Santhana G Kannan
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A do-it–yourself video laryngoscope for endotracheal intubation of COVID-19 positive patient p. 904
Souvik Saha
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A simple suggestion for safer patient transfer during COVID pandemic! p. 906
Mayank Tyagi, Sourav Burman, Sharma Pradeep Brijkishore, Surya Kumar Dube
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Laryngoscopy-assisted fiberoptic intubation in an adult with a large vallecular haemangioma p. 907
Rajnish Kumar, Nishant Sahay, Bhartendu Bharti, Ashish Kumar
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Vitamin D toxicity presenting with altered sensorium and hypercalcaemia p. 909
Anuj Sarma
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Bronchial blocker as an aid in the management of endo-bronchial cuff malfunction of double-lumen tube during one-lung ventilation p. 911
GN Chennakeshavallu, S Sruthi
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Anaesthesia for frameless stereotactic neurosurgery in a patient with Cheyne-Stokes respiration p. 913
Kamath Sriganesh, Harsh Deora, GM Tejaswi
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Upper extremity arteriovenous dialysis fistula causing arterialised blood flow in internal jugular vein in patients with brachiocephalic vein occlusion p. 915
Vicko Gluncic, Ivan K Lukić, Lara Bonasera, Kenneth Candido
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Erector spinae plane block combined with low-dose intrathecal morphine allows opioid sparing after open radical cystectomy p. 917
Lorenzo Schiavoni, Carola Sebastiani, Giuseppe Pascarella, Felice Eugenio Agrò
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Online training for sensitisation on airway and ventilatory management as preparedness to combat COVID situation p. 919
Gaurav Jain, Bhavna Gupta, Priyanka Gupta, Shalinee Rao
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Aftermath of COVID-19: Wither postgraduate teaching and research? p. 921
Prakash K Dubey, Alok Ranjan
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Perioperative Fasting Guidelines- No oral intake upto 8 hours after caeserean section? p. 923
Harshal D Wagh
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Response to comments on “Perioperative fasting and feeding in adults, obstetric, paediatric and bariatric population: Practice guidelines from the Indian Society of Anaesthesiologists” p. 925
Pradeep A Dongare, S Bala Bhaskar, SS Harsoor, Rakesh Garg, Sudheesh Kannan, Umesh Goneppanavar, Zulfiqar Ali
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