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PRESIDENTS MESSAGE |
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Indian Journal of Anaesthesia (IJA) at 60 years |
p. 333 |
Brig T Prabhakar DOI:10.4103/0019-5049.118507 |
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EDITORIALS |
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The diamond jubilee of the Indian Journal of Anaesthesia: A look-back, for the future |
p. 334 |
S Bala Bhaskar DOI:10.4103/0019-5049.118510 PMID:24163444 |
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Pharmaco‑genomics and anaesthesia: Mysteries, correlations and facts |
p. 336 |
S Bala Bhaskar, Sukhminder Jit Singh Bajwa DOI:10.4103/0019-5049.118517 PMID:24163445 |
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REVIEW ARTICLE |
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One lung ventilation strategies for infants and children undergoing video assisted thoracoscopic surgery  |
p. 339 |
Teddy Suratos Fabila, Shahani Jagdish Menghraj DOI:10.4103/0019-5049.118539 PMID:24163446The advantages of video assisted thoracoscopic surgery (VATS) in children have led to its increased usage over the years. VATS, however, requires an efficient technique for one lung ventilation. Today, there is an increasing interest in developing the technique for lung isolation to meet the anatomic and physiologic variations in infants and children. This article aims to provide an updated and comprehensive review on one-lung ventilation strategies for infants and children undergoing VATS. Search of terms such as 'One lung ventilation for infants and children', 'Video assisted thoracoscopic surgery for infants and children', and 'Physiologic changes during one lung ventilation for infants and children' were used. The search mechanics and engines for this review included the following: Kandang Kerbau Hospital (KKH) eLibrary, PubMed, Ovid Medline, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. During the search the author focused on significant current and pilot randomized control trials, case reports, review articles, and editorials. Critical decision making on what device to use based on the age, weight, and pathology of the patient; and how to use it for lung isolation are discussed in this article. Furthermore, additional information regarding the advantages, limitations, techniques of insertion and maintenance of each device for one lung ventilation in infants and children were the highlights in this article. |
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SPECIAL ARTICLE |
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Inhalational anaesthesia with low fresh gas flow  |
p. 345 |
Christian Hönemann, Olaf Hagemann, Dietrich Doll DOI:10.4103/0019-5049.118569 PMID:24163447During the inhalation of anaesthesia use of low fresh gas flow (0.35-1 L/min) has some important advantages. There are three areas of benefit: pulmonary - anaesthesia with low fresh gas flow improves the dynamics of inhaled anaesthesia gas, increases mucociliary clearance, maintains body temperature and reduces water loss. Economic - reduction of anaesthesia gas consumption resulting in significant savings of > 75% and Ecological - reduction in nitrous oxide consumption, which is an important ozone-depleting and heat-trapping greenhouse gas that is emitted. Nevertheless, anaesthesia with high fresh gas flows of 2-6 L/min is still performed, a technique in which rebreathing is practically negligible. This special article describes the clinical use of conventional plenum vaporizers, connected to the fresh gas supply to easily perform low (1 L/min), minimal (0.5 L/min) or metabolic flow anaesthesia (0.35 L/min) with conventional Primus Draeger; anaesthesia machines in routine clinical practice. |
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CLINICAL INVESTIGATIONS |
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Bispectral index score and observer's assessment of awareness/sedation score may manifest divergence during onset of sedation: Study with midazolam and propofol |
p. 351 |
Dipanjan Bagchi, Mohan Chandra Mandal, Sabyasachi Das, Sekhar Ranjan Basu, Susanta Sarkar, Jyotirmoy Das DOI:10.4103/0019-5049.118557 PMID:24163448Background: Correlation between the clinical and electroencephalogram-based monitoring has been documented sporadically during the onset of sedation. Propofol and midazolam have been studied individually using the observer's assessment of awareness/sedation (OAA/S) score and Bispectral index score (BIS). The present study was designed to compare the time to onset of sedation for propofol and midazolam using both BIS and OAA/S scores, and to find out any correlation. Methods: A total of 46 patients (18-60 years, either sex, American Society of Anesthesiologists (ASA) I/II) posted for infraumbilical surgeries under spinal anaesthesia were randomly allocated to receive either injection propofol 1 mg/kg bolus followed by infusion 3 mg/kg/h (Group P, n=23) or injection midazolam 0.05 mg/kg bolus followed by infusion 0.06 mg/kg/h (Group M, n=23). Spinal anaesthesia was given with 2.5 ml to 3.0 ml of 0.5% bupivacaine heavy. When sensory block reached T6 level, sedation was initiated. The time to reach BIS score 70 and time to achieve OAA/S score 3 from the start of study drug were noted. OAA/S score at BIS score 70 was noted. Data from 43 patients were analyzed using SPSS 12 for Windows. Results: Time to reach BIS score 70 using propofol was significantly lower than using the midazolam (P<0.05). Time to achieve OAA/S score 3 using propofol was comparable with midazolam (P=0.358). Conclusion: A divergence exists between the time to reach BIS score 70 and time to achieve OAA/S score 3 using midazolam, compared with propofol, during the onset of sedation. |
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The effect of dexmedetomidine infusion on propofol requirement for maintenance of optimum depth of anaesthesia during elective spine surgery |
p. 358 |
Suvadeep Sen, Jayanta Chakraborty, Sankari Santra, Prosenjit Mukherjee, Bibhukalyani Das DOI:10.4103/0019-5049.118558 PMID:24163449Background: Maintenance of adequate depth of anaesthesia in spine surgery is vital to prevent awareness, to reduce stress response and possible autonomic instability frequently associated with spine surgery. Dexmedetomidine, a a2 -adrenoceptor agonist with analgesic and sedative adjuvant property has been found to reduce dose requirement of multiple anaesthetic agents both for induction and during the maintenance of anaesthesia. Aim: The aim of this study is to observe the effect of dexmedetomidine, on the requirement of propofol for induction and maintenance of adequate depth of anaesthesia during spine surgery. Methods: It was a prospective, randomised, double-blinded, parallel group, placebo controlled and open-lebel study in tertiary care hospital. A total of 70 patients aged 20-60 years, American Society of Anaesthesiologists GradeI and II, scheduled for elective spine surgery were randomly allocated into two groups. Each patient of Group D (n=35) received an initial loading dose of dexmedetomidine at 1 ΅g/kg over 10 min, started 15 min before induction of anaesthesia followed by an infusion at a rate of 0.2 mg/kg/h. Patients of Group P (n=35) received the same volume of 0.9% normal saline solution as placebo. Requirement of propofol at induction and during maintenance was calculated maintaining bispectral index between 40 and 60. P<0.05 was considered to be statistically significant. Results: Mean requirement of propofol was found to be lessened by 48.08% and 61.87% for induction and maintenance of anaesthesia respectively while using dexmedetomidine. Conclusion: Administration of dexmedetomidine significantly reduces the requirement of propofol while maintaining desired depth of anaesthesia without any significant complication. |
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Paramedian epidural with midline spinal in the same intervertebral space: An alternative technique for combined spinal and epidural anaesthesia |
p. 364 |
Deepti Saigal, Rama Wason DOI:10.4103/0019-5049.118559 PMID:24163450Background: Although different techniques have been developed for administering combined spinal epidural (CSE) anaesthesia, none can be described as an ideal one. Objectives: We performed a study to compare two popular CSE techniques: Double segment technique (DST) and single segment (needle through needle) technique (SST) with another alternative technique: Paramedian epidural and midline spinal in the same intervertebral space (single space dual needle technique: SDT). Methods: After institutional ethical clearance, 90 consenting patients undergoing elective lower limb orthopaedic surgery were allocated to receive CSE into one of the three groups (n=30 each): Group I: SST, Group II: SDT, Group III: DST using computerized randomization. The time for technique performance, surgical readiness, technical aspects of epidural and subarachnoid block (SAB) and morbidity were compared. Results: SDT is comparable with SST and DST in time for technique performance (13.42±2.848 min, 12.18±6.092 min, 11.63±3.243 min respectively; P=0.268), time to surgical readiness (18.28±3.624 min, 17.64±5.877 min, 16.87±3.137 min respectively; P=0.42) and incidence of technically perfect block (70%, 66.66%, 76.66%; respectively P=0.757). Use of paramedian route for epidural catheterization in SDT group decreases complications and facilitates catheter insertion. There was a significant number of cases with lack of dural puncture appreciation (SST=ten, none in SDT and DST; P=0.001) and delayed cerebrospinal fluid reflux (SST=five, none in SDT and DST; P=0.005) while performance of SAB in SST group. The incidence of nausea, vomiting, post-operative backache and headache was comparable between the three groups. Conclusion: SDT is an acceptable alternative to DST and SST. |
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A comparative study in the post-operative spine surgeries: Epidural ropivacaine with dexmedetomidine and ropivacaine with clonidine for post-operative analgesia |
p. 371 |
MS Saravana Babu, Anil Kumar Verma, Apurva Agarwal, Chitra MS Tyagi, Manoj Upadhyay, Shivshenkar Tripathi DOI:10.4103/0019-5049.118563 PMID:24163451Background: Anaesthesia for spine surgeries is not only concerned with relieving pain during surgeries but also during the post-operative period. A prospective randomised study was carried out to evaluate the efficacy of epidural route and to compare the efficacy and clinical profile of dexmedetomidine and clonidine as an adjuvant to ropivacaine, in epidural analgesia with special emphasis on their quality of analgesia and the ability to provide the smooth post-operative course. Methods: A total of 60 subjects, 33 were men and 27 were women between the age of 18 and 65 years of American Society of Anaesthesiologists (ASA) I/II class who underwent spine surgeries were randomly allocated into two groups, ropivacaine + dexmedetomidine (RD) and ropivacaine + clonidine (RC), comprising 30 patients each. Group RD received 20 ml of 0.2% ropivacaine and 1 μg/kg of dexmedetomidine while group RC received 20 ml of 0.2% ropivacaine and 2 μg/kg of clonidine through the epidural catheter. Onset of analgesia, time of peak effect, duration of analgesia, cardiorespiratory parameters, side-effects and need of rescue intravenous (IV) analgesics were observed. Results: The demographic profile and ASA class were comparable between the groups. None of the patients needed rescue analgesics in either group. Group RD had early onset, early peak effect, prolonged duration and stable cardiorespiratory parameters when compared with group RC. The side-effects profile was also comparable with a little higher incidence of nausea and dry mouth in both groups. Conclusion: Epidural route provided acceptable analgesia in spine surgeries and avoided the need of IV analgesics in either group. Dexmedetomidine is a better neuraxial adjuvant compared with clonidine for providing early onset and prolonged post-operative analgesia and stable cardiorespiratory parameters. |
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Are active warming measures required during paediatric cleft surgeries? |
p. 377 |
Sunil Rajan, Ramachandra Halemani, Nitu Puthenveettil, Ramasubramanian Baalachandran, Priyanka Gotluru, Jerry Paul DOI:10.4103/0019-5049.118565 PMID:24163452Background: During paediatric cleft surgeries intraoperative heat loss is minimal and hence undertaking all possible precautions available to prevent hypothermia and use of active warming measures may result in development of hyperthermia. This study aims to determine whether there will be hyperthermia on active warming and hypothermia if no active warming measures are undertaken. The rate of intraoperative temperature changes with and without active warming was also noted. Methods: This study was conducted on 120 paediatric patients undergoing cleft lip and palate surgeries. In Group A, forced air warming at 38°C was started after induction. In Group B, no active warming was done. Body temperature was recorded every 30 min starting after induction until 180 min or end of surgery. Intragroup comparison of variables was done using Paired sample test and intergroup comparison using independent sample t-test. Results: In Group A, all intraoperative temperature readings were significantly higher than baseline. In Group B, there was a significant reduction in temperature at 30 and 60 min. Temperature at 90 min did not show any significant difference, but further readings were significantly higher. Maximum rise in temperature occurred in Group A between 120 and 150 min and maximum fall in temperature in Group B was seen during first 30 min. Conclusion: In pediatric cleft surgeries, we recommend active warming during the first 30 minutes if the surgery is expected to last for <2h, and no such measures are required if the expected duration is >2h. |
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Diagnostic value of the upper lip bite test in predicting difficulty in intubation with head and neck landmarks obtained from lateral neck X-ray |
p. 381 |
Zahid Hussain Khan, Shahriar Arbabi DOI:10.4103/0019-5049.118567 PMID:24163453Background: Unanticipated difficult tracheal intubation remains a primary concern of anaesthesiologists and upper lip bite test (ULBT) is one of the assessments used in predicting difficult intubation. In this study, we aimed to check the utility of lateral neck X-ray measurements in improving the diagnostic value of the ULBT. Methods: In a prospective study conducted from January 2007 until December 2010, we recorded personal and demographic data of 4500 patients who entered the study and subjected them to standard lateral neck radiography. Before the induction of anaesthesia, clinical examination and ULBT results were recorded and during induction of anaesthesia laryngoscopic grading was evaluated and recorded in questionnaires. All the compiled data were analysed by SPSS 14.0 (SPSS Inc., Chicago, IL, USA) software. Diagnostic value for each test was calculated and compared. Results: Negative predictive values (NPVs) were high in all tests. ULBT had the highest specificity and NPV compared with the other tests. The positive predictive value for all the tests had been low, but marginally high in the ULBT. Conclusion: Although all the tests used had relatively acceptable predictive values, combination of tests appeared to be more predictive. Highest sensitivities were observed with ULBT, mandibulohyoid distance and thyromental distance respectively. Use of radiological parameters may not be suitable as screening tools, but may help in anticipating and preparing for a difficult scenario. |
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CASE REPORTS |
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Emergency laparotomy for necrotising enterocolitis in a newborn with hypoplastic left heart syndrome |
p. 387 |
Lulu Sherif, Sherif Jain, Kishan Shetty, Sharan Badiger DOI:10.4103/0019-5049.118562 PMID:24163454Necrotising enterocolitis (NEC) and congenital heart disease are two distinct disease processes, but they appear to be inter-related, particularly in patients with the congenital heart condition known as hypoplastic left heart syndrome (HLHS). Both NEC and HLHS are causes of significant morbidity and mortality in the neonatal population. As medical and surgical advances allow for the palliation and correction of complex heart lesions at an earlier gestational age and lower birth weight, the already high-risk of NEC in this population is likely to increase. In this article, we report a case of a neonate with unpalliated HLHS who underwent emergency laparotomy for NEC. We also discuss the pathophysiology of these two diseases and the perioperative care of this rare group of patients. |
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Tricuspid valve endocarditis following central venous cannulation: The increasing problem of catheter related infection |
p. 390 |
Suresh Babu Kale, Jagannathan Raghavan DOI:10.4103/0019-5049.118564 PMID:24163455A central venous catheter (CVC) is inserted for measurement of haemodynamic variables, delivery of nutritional supplements and drugs and access for haemodialysis and haemofiltration. Catheterization and maintenance are common practices and there is more to the technique than routine placement as evident when a procedure-related complication occurs. More than 15% of the patients who receive CVC placement have some complications and infectious endocarditis involving the tricuspid valve is a rare and serious complication with high morbidity and mortality. Overenthusiastic and deep insertion of the guide wire and forceful injection through the CVC may lead to injury of the tricuspid valve and predispose to bacterial deposition and endocarditis. We report a case of tricuspid valve endocarditis, probably secondary to injury of the anterior tricuspid leaflet by the guide wire or the CVC that required open heart surgery with vegetectomy and repair of the tricuspid valve. |
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Perioperative management of an elderly patient of hypertrophic obstructive cardiomyopathy for knee arthroplasty and the role of peripheral nerve blocks |
p. 394 |
Sunny Rupal, Adarsh C Swami, Swati Jindal, Sneh Lata DOI:10.4103/0019-5049.118566 PMID:24163456This case report exemplifies how the anaesthetic technique of general anesthesia with continuous bilateral femoral nerve block for bilateral knee arthroplasty was well chosen for the management of perioperative complications in an elderly patient with hypertrophic obstructive cardiomyopathy (HOCM). A 69-year-old female patient of HOCM was scheduled for bilateral total knee replacement. Echocardiography revealed severe left ventricular outflow tract obstruction with peak systolic gradient of 56 mmHg. The surgery was conducted under general anaesthesia with invasive monitoring and bilateral continuous femoral nerve blocks for postoperative analgesia. Postoperatively, she developed pulmonary oedema due to the liberal administration of fluids. This complication was successfully managed without interrupting the management of pain. Management of patients with HOCM for noncardiac surgery requires knowledge of variable presentation of two forms of disease. Also, this case report highlights the practical advantage of continuous femoral nerve block (CFNB)s over epidural anaesthesia. |
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Electrical storm: Role of stellate ganglion blockade and anesthetic implications of left cardiac sympathetic denervation |
p. 397 |
Shrinivas Gadhinglajkar, Rupa Sreedhar, M Unnikrishnan, Narayanan Namboodiri DOI:10.4103/0019-5049.118568 PMID:24163457An electrical storm is usually associated with catecholaminergic surge following myocardial ischaemia and manifest as recurrent ventricular arrhythmias, requiring frequent DC shocks. Delivering repeated DC shocks induces myocardial damage and further worsens the arrhythmias, which are resistant to the antiarrhythmic drugs. Cardiac sympathetic blockade abates the excessive catecholaminergic drive and help pacifying the malignant ventricular arrhythmias. We treated the electrical storm in a 52-year-old male with ultrasound-guided left sympathetic ganglion block followed by surgical left cardiac sympathetic denervation. The patient remained symptom-free without any incident of ventricular arrhythmias for 8 months after the surgery. The ultrasonography during blockade of the stellate ganglion enhances the success rate of the technique, reduces the quantity of local anaesthetic required to produce desired effects and prevents technical complications. Supraclavicular surgical access to the upper thoracic sympathetic chain obviates the necessity for one lung ventilation and lateral decubitus during surgery, when the patient is in hemodynamically unstable condition. Sympathectomy can be performed under general anaesthesia taking cautions to avoid sympathetic stimulation in intraoperative period. |
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Anaesthetic management of a case of idiopathic intracranial hypertension |
p. 401 |
Bina P Butala, Veena R Shah DOI:10.4103/0019-5049.118570 PMID:24163458Idiopathic intracranial hypertension (IIH) is a rare headache syndrome characterized by prolonged elevation of intracranial pressure without related pathology in either the brain or the composition of cerebrospinal fluid. Herein, we provide a brief review of the clinical presentation of IIH and the anaesthetic considerations in a female posted for transcervical resection of the endometrium and right nephrectomy with the disorder. Most of patients with IIH are reported during pregnancy and came for management of labour and delivery. To our knowledge no such case has been described previously. |
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BRIEF COMMUNICATIONS |
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Cerebral salt wasting syndrome in craniopharyngioma |
p. 404 |
Sankari Santra, Jayanta Chakraborty, Bibhukalyani Das DOI:10.4103/0019-5049.118533 PMID:24163459 |
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Predicting intraoperative cardiovascular complication in patients with anterior mediastinal mass-role of central venous pressure monitoring |
p. 406 |
T Sivashanmugham, Sameer Mahamud Jahirdar, S Parthasarathy, G Muthurangan DOI:10.4103/0019-5049.118534 PMID:24163460 |
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Does pre-operative echocardiography delay hip fracture surgery? |
p. 408 |
Mustansir Alibhai, Aadhar Sharma, Moiz K Alibhai, Ross A Fawdington, AP Moreau DOI:10.4103/0019-5049.118538 PMID:24163461 |
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Anaesthetic considerations in primary repair of tracheobronchial injury following blunt chest trauma in paediatric age group: Experience of two cases |
p. 410 |
Vinod Hosalli, Uday S Ambi, Anilkumar Ganeshnavar, Shivanand Hulakund, DS Prakashappa DOI:10.4103/0019-5049.118541 PMID:24163462 |
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Leiomyoma of trachea: An anaesthetic challenge |
p. 412 |
Archna Koul, Jayashree Sood DOI:10.4103/0019-5049.118543 PMID:24163463 |
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Breaking the midnight fast: An observational cross-sectional audit of preoperative fasting policies and practices at a Tertiary Care Hospital |
p. 414 |
Mayank Kulshrestha, Jean Jacob Mathews, M Kapadia, Sadhana Sanwatsarkar DOI:10.4103/0019-5049.118545 PMID:24163464 |
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LETTERS TO EDITOR |
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Modification of submental intubation using oral Ring-Adair-Elwyn tubes in faciomaxillary surgeries: A novel approach |
p. 418 |
Joseph I Raajesh, Tripathy K Debendra, Devakumari Shanmugam, Ravindra R Bhat DOI:10.4103/0019-5049.118513 PMID:24163465 |
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Nasal intubation in an adult male with Le Fort II fracture and pneumocephalus using a nasogastric tube |
p. 419 |
Upasana Goswami, Dipali Taneja DOI:10.4103/0019-5049.118514 PMID:24163466 |
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Unanticipated difficult airway |
p. 420 |
Vishnu Panwar, Pramod Kohli DOI:10.4103/0019-5049.118516 PMID:24163467 |
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Retained foreign bodies: Vigilance is the price of safety |
p. 422 |
Madhu Gupta, Deepika Govil, Iti Shri DOI:10.4103/0019-5049.118519 PMID:24163468 |
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Loss of integrity of a reinforced endotracheal tube by patient bite |
p. 424 |
Rashmi Jain, Nitin Sethi, Jayashree Sood DOI:10.4103/0019-5049.118520 PMID:24163469 |
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Dexmedetomidine as sedative and analgesic in a patient of sickle cell disease for total hip replacement |
p. 425 |
Tasneem Dhansura, Shakir Kapadia, Shweta Gandhi DOI:10.4103/0019-5049.118521 PMID:24163470 |
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Beware! defects in pipeline supplies can occur: Be aware of this possibility after engineering work in related areas of the hospital |
p. 426 |
SP Devanandan DOI:10.4103/0019-5049.118522 PMID:24163471 |
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Methemoglobinemia: What the anaesthetist must know |
p. 427 |
Sushama Tandale, Nandini M Dave, Madhu Garasia DOI:10.4103/0019-5049.118525 PMID:24163472 |
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A case of triple vessel disease posted for buccal mucosal graft urethroplasty under low dose spinal anaesthesia with dexmedetomedine |
p. 428 |
R Prabhavathi, Narasimha P Reddy, TS Chandra Sekhar, Vivek T Menacherry DOI:10.4103/0019-5049.118526 PMID:24163473 |
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Comment: Ondansetron: Timing and dosage |
p. 429 |
Deepak Hanumanthaiah, Vinod Sudhir DOI:10.4103/0019-5049.118527 PMID:24163474 |
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Response: Comparative electrocardiographic effects of intravenous ondansetron and granisetron in patients undergoing surgery for carcinoma breast: A prospective single blind randomised trial |
p. 430 |
Ashish Ganjare, Atul P Kulkarmi DOI:10.4103/0019-5049.118528 PMID:24163475 |
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Comment: Molar approach with backward, upward, right and posterior manoeuvre |
p. 431 |
Neeraj Kumar, Rajnish Kumar DOI:10.4103/0019-5049.118529 PMID:24163476 |
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Comment: Hard palate tumour: A nightmare for the anaesthesiologists: Role of modified molar approach |
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KL Subramanyam DOI:10.4103/0019-5049.118530 PMID:24163477 |
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