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EDITORIAL |
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Critical incident reporting and learning system: The black pearls |
p. 185 |
SS Harsoor DOI:10.4103/0019-5049.65348 PMID:20885861 |
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REVIEW ARTICLE |
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Medication error in anaesthesia and critical care: A cause for concern  |
p. 187 |
Dilip Kothari, Suman Gupta, Chetan Sharma, Saroj Kothari DOI:10.4103/0019-5049.65351 PMID:20885862Medication error is a major cause of morbidity and mortality in medical profession, and anaesthesia and critical care are no exception to it. Man, medicine, machine and modus operandi are the main contributory factors to it. In this review, incidence, types, risk factors and preventive measures of the medication errors are discussed in detail. |
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SPECIAL ARTICLES |
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Tight bag |
p. 193 |
S Parthasarathy, M Ravishankar DOI:10.4103/0019-5049.65354 PMID:20885863Tight bag is a clinical situation where excessive pressure needs to be applied to a reservoir bag of a breathing system to an intubated patient, which may or may not produce satisfactory ventilation. The various clinical scenarios and the appropriate steps for its prevention are described. |
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Telemedicine and anaesthesia |
p. 199 |
Veena Chatrath, Joginder Pal Attri, Raman Chatrath DOI:10.4103/0019-5049.65357 PMID:20885864Telemedicine is the use of electronic information and communication technology to provide and support healthcare when distance separates the participants. India is characterised by low penetration of healthcare services where primary healthcare facilities for rural population are highly inadequate. The majority of doctors practice in urban and semi-urban areas, whereas the major proportion of population lives in rural areas. This calls for the innovative methods for utilisation of science and technology for the benefit of our society. There are few reports in the literature which support the use of telemedicine technology for pre-operative assessment, intra-operative consultation, monitoring and post-operative follow-up, which is discussed in this article. |
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CLINICAL INVESTIGATIONS |
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A comparative study of intrathecal and epidural buprenorphine using combined spinal-epidural technique for caesarean section |
p. 205 |
Shaloo Ipe, Sara Korula, Sreelatha Varma, Grace Maria George, Saramma P Abraham, Leena Rachel Koshy DOI:10.4103/0019-5049.65359 PMID:20885865Neuraxial opioids provide excellent analgesia intraoperatively and postoperatively while allowing early ambulation of the patient by sparing sympathetic and motor nerves. A prospective, randomised double blind study was conducted involving 90 patients of ASA 1 physical status coming for elective cesarean section to evaluate the analgesic effect of neuraxial buprenorphine. They were allocated into three groups. Spinal local anaesthetic was used as the main stay of anaesthesia for surgery and spinal and epidural analgesia with opioids continued as the main stay for postoperative analgesia. All the groups were given 0.5% Bupivacaine intrathecally for the surgery. Besides this, group I was given 150 mcg Buprenorphine intrathecally and group II and III were given 150 mcg and 300 mcg Buprenorphine respectively, epidurally. In the present study, we observed that 150 mcg of Buprenorphine given intrathecally provided much longer duration of analgesia compared to 150 mcg of Buprenorphine given epidurally. Increasing the epidural dose of Buprenorphine from 150 mcg to 300 mcg proved to produce prolonged analgesia comparable to intrathecal Buprenorphine without compromising patient safety and neonatal outcome. The minor side effects were more with intrathecal Buprenorphine than epidural Buprenorphine. We concluded that 300 mcg of Buprenorphine epidurally is equianalgesic to 150 mcg Buprenorphine intrathecally. |
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Comparison of two approaches of infraclavicular brachial plexus block for orthopaedic surgery below mid-humerus |
p. 210 |
Vikas Trehan, Uma Srivastava, Aditya Kumar, Surekha Saxena, Chandra Shekhar Singh, Ankit Darolia DOI:10.4103/0019-5049.65362 PMID:20885866The brachial plexus in infraclavicular region can be blocked by various approaches. Aim of this study was to compare two approaches (coracoid and clavicular) regarding success rate, discomfort during performance of block, tourniquet tolerance and complications. The study was randomised, prospective and observer blinded. Sixty adult patients of both sexes of ASA status 1 and 2 requiring orthopaedic surgery below mid-humerus were randomly assigned to receive nerve stimulator guided infraclavicular brachial plexus block either by lateral coracoid approach (group L, n = 30) or medial clavicular approach (group M, n = 30) with 25-30 ml of 0.5% bupivacaine. Sensory block in the distribution of five main nerves distal to elbow, motor block (Grade 1-4), discomfort during performance of block and tourniquet pain were recorded by a blinded observer. Clinical success of block was defined as the block sufficient to perform the surgery without any supplementation. All the five nerves distal to elbow were blocked in 77 and 67% patients in groups L and M respectively. Successful block was observed in 87 and 73% patients in groups L and M, respectively (P > 0.05). More patients had moderate to severe discomfort during performance of block due to positioning of limb in group M (14 vs. 8 in groups M and L). Tourniquet was well tolerated in most patients with successful block in both groups. No serious complication was observed. Both the approaches were equivalent regarding success rate, tourniquet tolerance and safety. Coracoid approach seemed better as positioning of operative limb was less painful, coracoids process was easy to locate and the technique was easy to learn and master. |
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Lateral approach for supraclavicular brachial plexus block |
p. 215 |
DK Sahu, Anjana Sahu DOI:10.4103/0019-5049.65364 PMID:20885867A lateral approach described by Volker Hempel and Dr. Dilip Kotharihas been further studied, evaluated and described in detail in the present study. The aim of this study was to evaluate lateral approach of supraclavicular brachial plexus block, mainly in terms of successes rate and complication rate. The study was conducted in secondary level hospital and tertiary level hospital from 2004 to 2008. It was a prospective nonrandomized open-level study. Eighty-two patients of both sexes, aged between 18 and 65 years with ASA Grade I and II scheduled to undergo elective major surgery of the upper limb below the midarm, were selected for this new lateral approach of brachial plexus block. The onset and duration of sensory and motor block, any complications and need for supplement anaesthesia were observed. Success and complication rate were calculated in percentage. Average onset and duration of sensory and motor block was calculated as mean ± SD and percentage. Out of 82 patients, 75 (92%) have got successful block with no significant complication in any case. |
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Comparative evaluation of ASA classification and ACE-27 index as morbidity scoring systems in oncosurgeries |
p. 219 |
Mary Thomas, Nebu Abraham George, Balagopal Prabhakar Gowri, Preethi Sara George, Paul Sebastian DOI:10.4103/0019-5049.65366 PMID:20885868The primary intention of the study was to find out whether Adult Comorbidity Evaluation Index (ACE-27) was better than the American Society of Anaesthesiologists' (ASA) risk classification system in predicting postoperative morbidity in head and neck oncosurgery. Another goal was to identify other risk factors for complications which are not included in these indexes. Univariate and multivariate analyses were performed on 250 patients to determine the impact of seven variables on morbidity-ACE-27 grade, ASA class, age, sex, duration of anaesthesia, chemotherapy and radiotherapy. In univariate analysis ACE-27 index, ASA score, duration of anaesthesia, radiotherapy and chemotherapy were significant. As both comorbidity scales were significant in univariate analysis they were analyzed together and separately in multivariate analysis to illustrate their individual strength. In the first multivariate analysis (excluding ACE-27 grade) ASA class, duration of anaesthesia, radiotherapy and chemotherapy were significant. The positive predictive value (PPV) of this model to predict morbidity was 60.86% and negative predictive value (NPV) was 77.9%. The sensitivity was 75% and specificity 62.2%. In the second multivariate analysis (excluding ASA class) ACE-27 grade, duration of anaesthesia and radiotherapy were significant. The PPV of this model to predict morbidity was 62.1% and NPV was 76.5%. The sensitivity was 61.6% and specificity 70.9%. In the third multivariate analysis which included both ACE-27 grade and ASA class only ASA class, duration of anaesthesia, radiotherapy and chemotherapy remained significant. In conclusion, ACE-27 grade and ASA class were reliable predictors of major complications but ASA class had more impact on complications than ACE-27 grade. |
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Caudal ropivacaine-clonidine: A better post-operative analgesic approach |
p. 226 |
Sukhminder Jit Singh Bajwa, Jasbir Kaur, Sukhwinder Kaur Bajwa, Geetika Bakshi, Kanwalpreet Singh, Aparajita Panda DOI:10.4103/0019-5049.65368 PMID:20885869The aim was to determine qualitative and quantitative aspects of caudal block, haemodynamic effects, and post-operative pain relief of ropivacaine 0.25% versus ropivacaine 0.25% with clonidine for lower abdominal surgeries in paediatric patients. A double-blind study was conducted among 44 paediatric patients in the Department of Anaesthesiology and Intensive Care of our institute. A total of 44 ASA-I paediatric patients between the ages of 1 and 9 years, scheduled for elective hernia surgery, were enrolled in this randomised double-blind study. The caudal block was administered with ropivacaine 0.25% (Group I) and ropivacaine 0.25% and clonidine 2 μg/kg (Group II) after induction with general anaesthesia. Haemodynamic parameters were observed before, during and after the surgical procedure. Post-operative analgesic duration, total dose of rescue analgesia, pain scores and any side effects were looked for and recorded. All the results were tabulated and analysed statistically. The variables in the two groups were compared using the non-parametric tests. For all statistical analyses, the level of significance was P < 0.05. Forty-four patients were enrolled in this study and their data were subjected to statistical analysis: 22 patients in both the groups were comparable with regard to demographic data, haemodynamic parameters and other vitals and were statistically non-significant (P>0.05). The duration of analgesia was significantly prolonged in Group II (P<0.05). The dose requirement for post-operative pain relief was also significantly lesser in Group II. The incidences of side effects were almost comparable and non-significant. A caudal block with 0.25% of isobaric ropivacaine combined with 2 μg/kg of clonidine provides efficient analgesia intra-operatively and prolonged duration of analgesia post-operatively. |
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Evaluation of the effect of intrathecal clonidine to decrease shoulder tip pain in laparoscopy under spinal anaesthesia |
p. 231 |
Poonam S Ghodki, Shalini P Sardesai, Shalini K Thombre DOI:10.4103/0019-5049.65370 PMID:20885870Sixty ASA grade I/II patients scheduled for elective short laparoscopic procedures under spinal anaesthesia were divided into two groups of 30 each. The first group (group C) received 3.5 ml of hyperbaric bupivacaine with 30 mcg of clonidine. The second group (group B) received plain bupivacaine 3.5 ml. Till date, the limiting factor for use of spinal anaesthesia for laparoscopy was patient's discomfort due to shoulder tip pain. From our study it can be concluded that bupivacaine along with clonidine in low doses provides good sedation and analgesia in intraoperative and post-operative period and at the same time abolishes shoulder tip pain during laparoscopic procedures. In addition, no significant changes in haemodynamics occur with the low dose of clonidine used. |
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CASE REPORTS |
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Combined femoral and sciatic nerve blocks for lower limb anaesthesia in anticoagulated patients with severe cardiac valvular lesions |
p. 235 |
Thrivikrama Padur Tantry, Dinesh Kadam, Pramal Shetty, Sanath Bhandary DOI:10.4103/0019-5049.65372 PMID:20885871Peripheral nerve block (PNB) in anticoagulated patients is controversial and guidelines are not defined. We report two patients with severe cardiac valvular lesions, who underwent emergency surgeries for lower limb. Both the patients were on anticoagulants, warfarin and heparin in one and aspirin and clopidogrel in the other, with abnormal coagulation profile in the former. Combined femoral and sciatic nerve blocks were used as a sole anaesthetic technique. Postoperatively, the patients were evaluated for bleeding complications at the injection site using high-frequency ultrasound probe. Both had uneventful surgery and recovery. A close postoperative monitoring following PNBs in anticoagulated patients is necessary. |
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Indoxacarb poisoning: A rare presentation as methemoglobinaemia |
p. 239 |
Roopam Chhabra, Ishwar Singh, Mansi Tandon, Ram Babu DOI:10.4103/0019-5049.65373 PMID:20885872Indoxacarb is a broad-spectrum non-organophosphorus oxidiazine insecticide widely used in farming. Once absorbed it acts on sodium channels and blocks the flow of sodium ions. We report a case of indoxacarb poisoning in a farmer following suicidal consumption, manifested as unconsciousness, cyanosis and stationary SpO 2 values. Methemoglobinaemia was suspected on clinical presentation which was successfully managed with inj. methylene blue and other symptomatic and supportive treatment. |
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Anaesthetic management of a child with "cor-triatriatum" and multiple ventricular septal defects - A rare congenital anomaly |
p. 242 |
Sriram Sabade, Anand Vagrali, Sharan Patil, Praveen Kalligudd, Vithal Dhulked, MD Dixit, Mohan Gan, A Dayal DOI:10.4103/0019-5049.65375 PMID:20885873Cor-triatriatum is a rare congenital cardiac anomaly. It accounts for 0.1% of congenital heart diseases. Its association with multiple ventricular septal defects (VSD) is even rarer. A five-month-old baby was admitted with respiratory distress and failure to thrive. Clinical examination revealed diastolic murmur over mitral area. Chest X-ray showed cardiomegaly. Haematological and biochemical investigations were within normal limits. Electrocardiogram showed left atrial enlargement. 2D echo showed double-chambered left atrium (cor-triatriatum), atrial septal defect (ASD) and muscular VSD with moderate pulmonary arterial hypertension. The child was treated with 100% oxygen, diuretics and digoxin and was stabilized medically. We used balanced anaesthetic technique using oxygen, air, isoflurane, fentanyl, midazolam and vecuronium. Patient was operated under cardiopulmonary bypass (CPB) with moderate hypothermia. Through right atriotomy abnormal membrane in the left atrium was excised to make one chamber. VSD were closed with Dacron patches and ASD was closed with autologous pericardial patch. Patient tolerated the whole procedure well and was ventilated electively for 12h in the intensive care unit. He was discharged on the 10 th postoperative day. |
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Anaesthetic management of difficult airway due to retropharyngeal abscess |
p. 246 |
Manjula Sudhakar Rao, YK Linga Raju, PN Vishwanathan DOI:10.4103/0019-5049.65376 PMID:20885875A one-and-half-year old girl weighing 7.5 kg presented with a history of neck swelling, difficulty in swallowing and breathing. She was posted for incision and drainage on an emergency basis. Diagnosis was confirmed by neck X-ray and computed tomography scan as retropharyngeal abscess. Here we present the successful anaesthetic management of this child at JSS Medical College Hospital, Mysore. |
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Transversus abdominis plane block for an emergency laparotomy in a high-risk, elderly patient |
p. 249 |
Surekha S Patil, Shonali C Pawar, VM Divekar, Rochana G Bakhshi DOI:10.4103/0019-5049.65377 PMID:20885876A 72-year-old male patient with gall bladder perforation and small intestinal obstruction from impacted gall stone was posted for emergency laparotomy. He had congestive heart failure, severe hypertension at admission and history of multiple other coexisting diseases. On admission, he developed pulmonary oedema from systolic hypertension which was controlled by ventilatory support, nitroglycerine and furosemide. Preoperative international normalized ratio was 2.34 and left ventricular ejection fraction was only 20%. Because of risk of exaggerated fall in blood pressure during induction of anaesthesia (general or neuraxial), a transversus abdominis plane block via combined Petit triangle and subcostal technique was administered and supplemented with Propofol sedation. |
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Fatal thyrocardiac event |
p. 255 |
Samit Kumar Khutia, Bhaskar Roy, Mohan Chandra Mandal, Sabyasachi Das DOI:10.4103/0019-5049.65374 PMID:20885877Atrial fibrillation occurs frequently (2-20%) in chronic hyperthyroidism patients. Poorly treated thyrotoxic patients may present with a life-threatening cerebrovascular accident giving little scope to revert the situation. At times, it is difficult to make a patient euthyroid with conventional management. The definitive treatment of choice is 131 I, radioiodine. An adjusted dose of an oral anticoagulant is highly efficacious for the prevention of all types of strokes. Timely intervention by a skilled airway manager with right instruments is the key to success in airway management. A 50-year-old thyrotoxic, semiconscious male presented with a sudden onset of haemiplegia. He had chronic AF, a huge thyroid swelling with gross tracheal deviation and dilated cardiomyopathy. A CT scan showed infarction in the left middle cerebral artery territory. After initial improvement with conservative management, patient's condition deteriorated in the next 48 h. Repeat CT scan showed increase in the infarct size with haemorrhage and midline shift. Finally, he died despite all resuscitative measures. |
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HISTORY |
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Dr. (Miss) Rupa Bai Furdoonji: World's first qualified lady anaesthetist |
p. 259 |
Narayana Ala, K Bharathi, PKJP Subhaktha, Manohar Gundeti, A Ramachari DOI:10.4103/0019-5049.65371 PMID:20885878 |
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LETTERS TO EDITOR |
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Capnography-guided awake nasal intubation in a 4-month infant with Pierre Robin syndrome |
p. 262 |
Rajeev Sharma DOI:10.4103/0019-5049.65349 PMID:20885879 |
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Utility of BIS for sedation management during monitored anaesthesia care |
p. 263 |
Satyen Parida DOI:10.4103/0019-5049.65350 PMID:20885881 |
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Management of a patient with Huntington's disease under spinal anaesthesia |
p. 263 |
Sanjeev Janardan Juwarkar, Chitra Sanjeev Juwarkar DOI:10.4103/0019-5049.65352 PMID:20885880 |
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Indigenous device for in circuit delivery of bronchodilator drugs through MDI |
p. 264 |
Balkar Singh, Nishkarsh Gupta, Bishnu Prasad Panigrahi, Deep Arora, Pradip Govil, Shibani Das, Manish Singh, Raj Tobin DOI:10.4103/0019-5049.65353 PMID:20885882 |
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Boneless occiput and awake fibreoptic intubation in lateral position |
p. 265 |
Keshav Goyal, Girija P Rath, Tumul Chowdhury, Charu Mahajan DOI:10.4103/0019-5049.65355 PMID:20885883 |
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Indigenous neonatal facemask |
p. 266 |
Lalit Kumar Raiger DOI:10.4103/0019-5049.65356 PMID:20885884 |
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Use of suction catheter as an aid to intubation in emergency situation of intraoral bleeding |
p. 267 |
Mohammad Aseem, Urmila Palaria, Umesh Kumar Bhadani DOI:10.4103/0019-5049.65358 PMID:20885885 |
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Centenarians: Hip fractures and peripheral lower limb nerve blocks |
p. 268 |
Anand Rampure V Rao, Aneesh Lakshmanan, Anita Ajith, Sudheendra M Rao DOI:10.4103/0019-5049.65360 PMID:20885886 |
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Oculocardiac reflex during endoscopic transsphenoidal removal of pituitary adenoma |
p. 269 |
Tumul Choudhury, Hemanshu Prabhakar, Gyaninder Pal Singh, Ashish Bindra DOI:10.4103/0019-5049.65361 PMID:20885887 |
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Unusual presentation of hypocalcaemia in a peri-operative period-cause unknown |
p. 270 |
Rachna Wadhwa, Seema Kalra DOI:10.4103/0019-5049.65363 PMID:20885888 |
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Parenteral nutrition: Few more facts |
p. 272 |
Preety Mittal Roy, Vijaya Pant, Jyotirmoy Das DOI:10.4103/0019-5049.65365 PMID:20885889 |
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How is that? Knotting of a peripherally inserted central venous catheter |
p. 272 |
Gnanamuthu Birla Roy, Ajit A Cheriyan, Manbha L Rymbai DOI:10.4103/0019-5049.65367 PMID:20885890 |
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MEDICOLEGAL ARTICLE |
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Thiopentone - Medicolegal views |
p. 275 |
AL Meenakshi Sundaram |
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CORRIGENDUM |
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Corrigendum |
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PMID:20885874 |
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OBITUARY |
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Dr. Ashok Jain |
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N Tandon |
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