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2015| October | Volume 59 | Issue 10
Online since
October 19, 2015
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CLINICAL INVESTIGATIONS
Analgesic efficacy of three different dosages of intra-articular morphine in arthroscopic knee surgeries: Randomised double-blind trial
Babita Gupta, Sumantra Banerjee, Arunima Prasad, Kamran Farooque, Vijay Sharma, Vivek Trikha
October 2015, 59(10):642-647
DOI
:10.4103/0019-5049.167479
PMID
:26644611
Background and Aims:
Arthroscopic knee surgery is a common procedure and may cause enough pain to delay rehabilitation. Intra-articular (IA) morphine is a known modality for post-operative pain relief. However, the optimal dose of IA morphine has not been studied. The current study has been conducted to find out the optimal dosage of IA morphine when administered with 0.25% bupivacaine.
Methods:
Sixty adult patients of either sex, aged between 18 and 60 years, undergoing diagnostic/therapeutic knee arthroscopic surgery were included in the study and randomised into three groups. All patients underwent surgery under subarachnoid block. After the surgical closure, 20 ml of 0.25% bupivacaine with 1 mg, 3 mg and 5 mg of morphine as additive was injected intra-articularly in Group A, B and C patients, respectively. Post-operative pain assessment was performed with visual analogue scale score in the 1
st
, 2
nd
, 6
th
, 12
th
and 24
th
post-operative hour. The common complications were also recorded.
Results:
There was statistically significant analgesia in Group B and C than Group A in the 1
st
and 2
nd
post-operative hour; while at the 24
th
post-operative hour, Group C had statistically significant analgesia than the other two groups. Time to first rescue analgesia was statistically significantly less and consumption of supplemental analgesia was significantly higher in Group A than the other two groups.
Conclusion:
IA dose of 3 mg and 5 mg morphine with 20 ml of 0.25% bupivacaine provided adequate analgesia. However, 3 mg morphine group patients had fewer side effects than 5 mg group patients although the difference was not statistically significant.
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4
2,670
488
SPECIAL ARTICLE
Reversal agents in anaesthesia and critical care
Nibedita Pani, Pradeep A Dongare, Rajeeb Kumar Mishra
October 2015, 59(10):664-669
DOI
:10.4103/0019-5049.167484
PMID
:26644615
Despite the advent of short and ultra-short acting drugs, an in-depth knowledge of the reversal agents used is a necessity for any anaesthesiologist. Reversal agents are defined as any drug used to reverse the effects of anaesthetics, narcotics or potentially toxic agents. The controversy on the routine reversal of neuromuscular blockade still exists. The advent of newer reversal agents like sugammadex have made the use of steroidal neuromuscular blockers like rocuronium feasible in rapid sequence induction situations. We made a review of the older reversal agents and those still under investigation for drugs that are regularly used in our anaesthesia practice.
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5,350
1,408
LETTERS TO EDITOR
Anaesthetic management of a patient with amyotrophic lateral sclerosis undergoing laparoscopic diaphragmatic pacing
Shilpa Trivedi, Nasreen Tibrewala, KP Balsara
October 2015, 59(10):683-685
DOI
:10.4103/0019-5049.167488
PMID
:26644622
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2
1,753
298
CLINICAL INVESTIGATIONS
Comparative study of two doses of intrathecal dexmedetomidine as adjuvant with low dose hyperbaric bupivacaine in ambulatory perianal surgeries: A prospective randomised controlled study
K Sudheesh, RS Raghavendra Rao, M Kavya, J Aarthi, D Devika Rani, SS Nethra
October 2015, 59(10):648-652
DOI
:10.4103/0019-5049.167485
PMID
:26644612
Background and Aims:
Dexmedetomidine (DMT), as intrathecal adjuvant has been shown to successfully prolong duration of analgesia but delay the motor recovery. Hence, this study was designed to find out the dose of DMT which can provide satisfactory analgesia without prolonging motor block.
Methods:
A total of 50 patients scheduled for elective perianal surgeries were randomly allocated to Groups C or D (
n
= 25). Group D received hyperbaric bupivacaine 0.5% 4 mg + DMT 5 μg and Group C received hyperbaric bupivacaine 0.5% 4 mg + DMT 3 μg intrathecally. Onset and duration of sensory and motor blockade, duration of analgesia, time for ambulation and first urination were recorded. Adverse effects if any were noted.
Results:
Demographic characters, duration of surgery were comparable. The onset of sensory block to S1 was 9.61 ± 5.53 min in Group C compared to 7.69 ± 4.80 min in Group D (
P
= 0.35). Duration of sensory (145.28 ± 83.17 min – C, 167.85 ± 93.75 min – D,
P
= 0.5) and motor block (170.53 ± 73.44 min – C, 196.14 ± 84.28 min,
P
= 0.39) were comparable. Duration of analgesia (337.86 ± 105.11 min – C, 340.78 ± 101.81 min – D,
P
= 0.9) and time for ambulation (252.46 ± 93.72 min – C, 253.64 ± 88.04 min – D,
P
= 0.97) were also comparable. One patient in each group had urinary retention requiring catheterization. No other side effects were observed.
Conclusion:
Intrathecal DMT 3 μg dose does not produce faster ambulation compared to intrathecal DMT 5 μg though it produces comparable duration of analgesia for perianal surgeries.
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5,053
634
Efficacy and safety of low-dose ketamine as an adjunct analgesic and amnesic during caesarean section under general anaesthesia
Sunil Rajan, Anwar Hassain, Nitu Puthenveettil, Lakshmi Kumar
October 2015, 59(10):653-657
DOI
:10.4103/0019-5049.167487
PMID
:26644613
Background and Aims:
The practice of avoiding sedatives or anxiolytics during caesarean section under general anaesthesia (GA) until delivery of the baby could result in exaggerated haemodynamic responses and an increased risk of awareness. We aimed to assess the efficacy and safety of low-dose ketamine, used as an adjunct analgesic and amnesic, in attenuating these responses during caesarean section under GA.
Methods:
This prospective, randomised study was conducted in 40 patients. Group K (
n
= 20) received 0.25 mg/kg ketamine, whereas Group C received 5 ml normal saline intravenously (IV) just before induction of anaesthesia. After intubation, patients were ventilated with O
2
and N
2
O (40:60%) with 0.7% end-tidal isoflurane. Fentanyl and midazolam were given following delivery of the baby. Mann–Whitney and Fisher's exact tests were used for statistical analysis.
Results:
Preinduction haemodynamic parameters and those recorded at 1 min after induction were comparable in both groups. However, heart rate and systolic blood pressure recorded after intubation (at 3, 5, 7, 9, 12, 15, 20, 30 and 45 min after induction)showed significantly high values in Group C (
P
< 0.05). Mean arterial pressure also showed a similar pattern. Umbilical vein pO
2
, pCO
2
and pH were comparable in both groups. Though Apgar score at 1 min showed a higher scoring in Group K, at 5 min both groups had comparable scores. In Group C, intraoperative lacrimation (50% vs. 0%) and hallucinations/recall of intraoperative events (10% vs. 0%) were high.
Conclusion:
IV ketamine 0.25 mg/kg can be safely used as an adjunct analgesic and amnesic to attenuate haemodynamic responses during caesarean section under GA without affecting the foetal outcome.
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633
LETTERS TO EDITOR
Avascular necrosis of left Hip joint secondary to sickle cell anaemia for hip arthroplasty
Sharmila Borkar, Deependra Kamble, Vilas Gowler
October 2015, 59(10):682-683
DOI
:10.4103/0019-5049.167490
PMID
:26644621
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1,835
320
BRIEF COMMUNICATIONS
Magnification to avoid medication errors
Jagadevi Sajjanshetty, Somendra Mohan Sharma, Annavarapu Gopalakrishna, Keyur Mevada
October 2015, 59(10):673-675
DOI
:10.4103/0019-5049.167477
PMID
:26644617
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-
1,657
288
Video rhino-laryngoscope modified into a fibreoptic bronchoscope
Nikhil Kothari, Ghansham Biyani, Shilpa Goyal, Vandana Sharma
October 2015, 59(10):675-677
DOI
:10.4103/0019-5049.167481
PMID
:26644618
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1,390
228
Identification of the epidural space-loss of resistance to saline: An inexpensive modification
Tasneem Dhansura, Tarana Shaikh, Mohtassib Maadoo, Fatema Chittalwala
October 2015, 59(10):677-679
DOI
:10.4103/0019-5049.167483
PMID
:26644619
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3,383
610
Anaesthetic management of Ludwig's angina with comorbidities
MP Sujatha, Ravi Madhusudhana, KS Amrutha, Neha Nupoor
October 2015, 59(10):679-681
DOI
:10.4103/0019-5049.167486
PMID
:26644620
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-
4,846
832
CASE REPORT
Central neuraxial blockade for splenectomy in myeloproliferative disease: A word of caution
SN Myatra, A Kothekar, SS Siddiqui, JV Divatia
October 2015, 59(10):670-672
DOI
:10.4103/0019-5049.167493
PMID
:26644616
We describe management of portal vein thrombosis (PVT) in a patient with myeloproliferative disease after splenectomy. This case posed a unique therapeutic challenge in maintaining a fine balance between life-saving thrombolysis and the risk of neuraxial complications due to bleeding. The incidence of PVT after splenectomy in patients with myeloproliferative disorders is high (40%). Anaesthesiologists should be aware of this and avoid central neuraxial blockade in such cases. If post-operative emergency thrombolysis is required in a patient having an epidural catheter
in situ
, it should be done under close monitoring, weighing the risks and benefits. Fibrinogen levels should be monitored to evaluate the presence of residual thrombolytic effects and to time the catheter removal.
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1,816
288
CLINICAL INVESTIGATIONS
Evaluation of adjusted central venous blood gases versus arterial blood gases of patients in post-operative paediatric cardiac surgical intensive care unit
Naveen G Singh, SR Prasad, V Manjunath, PS Nagaraja, Pranav J Adoni, Divya Gopal, AM Jagadeesh
October 2015, 59(10):630-635
DOI
:10.4103/0019-5049.167492
PMID
:26644608
Background and Aims:
Central venous catheters are
in situ
in most of the intensive care unit (ICU) patients, which may be an alternative for determining acid-base status and can reduce complications from prolonged arterial cannulation. The aim of this study was to examine the reliability between adjusted central venous blood gas (aVBG) and arterial blood gas (ABG) samples for pH, partial pressure of carbon-di-oxide (pCO
2
), bicarbonate (HCO
3
−
), base excess (BE) and lactates in paediatric cardiac surgical ICU.
Methods:
We applied blood gas adjustment rule, that is aVBG pH = venous blood gas (VBG) pH +0.05, aVBG CO
2
= VBG pCO
2
- 5 mm Hg from the prior studies. In this study, we validated this relationship with simultaneous arterial and central venous blood obtained from 30 patients with four blood sample pairs each in paediatric cardiac surgical ICU patients.
Results:
There was a strong correlation (
R
i.e., Pearson's correlation) between ABG and aVBG for pH = 0.9544, pCO
2
= 0.8738, lactate = 0.9741, HCO
3
−
= 0.9650 and BE = 0.9778. Intraclass correlation co-efficients (ICCs) for agreement improved after applying the adjustment rule to venous pH (0.7505 to 0.9454) and pCO
2
(0.4354 to 0.741). Bland Altman showed bias (and limits of agreement) for pH: 0.008 (−0.04 to + 0.057), pCO
2
: −3.52 (–9.68 to +2.65), lactate: −0.10 (−0.51 to +0.30), HCO
3
−
: −2.3 (–5.11 to +0.50) and BE: −0.80 (−3.09 to +1.49).
Conclusion:
ABG and aVBG samples showed strong correlation, acceptable mean differences and improved agreement (high ICC) after adjusting the VBG. Hence, it can be promising to use trend values of VBG instead of ABG in conjunction with a correction factor under stable haemodynamic conditions.
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2,845
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Safety of post-operative epidural analgesia in the paediatric population: A retrospective analysis
Ramakrishna Chaitanya Kasanavesi, Suhasini Gazula, Ravikanth Pula, Nagarjuna Thakur
October 2015, 59(10):636-640
DOI
:10.4103/0019-5049.167494
PMID
:26644609
Background and Aims:
Epidural infusion analgesia (EIA) is among the common procedures performed in children to provide analgesia. However, the administration of epidural is not without complications. Limited studies are available regarding the safety of EIA in children with no studies from the Indian subcontinent. The aim of this study was to analyse all the complications that occured during administration and maintenance of EIA in paediatric patients.
Methods:
All children undergoing elective or emergency surgeries under general anaesthesia and given concomitant epidural analgesia for post-operative pain management were included. Data were collected by reviewing patient medical records, anaesthesia registers and post-operative intensive care unit charts. Statistical averages were drawn to assess the complication rates.
Results:
Seventy children received epidural analgesia during the span of study, of them five were neonates and fifteen were infants. No major complications that were life-threatening or leading to permanent disability were documented. Two children (2.85%) had blood tap during procedure. Eleven children (15%) had peri-catheter leaks and 14 children (20%) had catheter dislodgements.
Conclusion:
EIA seems to be a relatively safe method of providing analgesia. It is associated with the occurrence of complications which are at best temporary.
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2,270
513
Comparison between perivascular and perineural ultrasound-guided axillary brachial plexus block using levobupivacaine: A prospective, randomised clinical study
Uday Ambi, PVV Bhanupriya, Shivanand Y Hulkund, DS Prakashappa
October 2015, 59(10):658-663
DOI
:10.4103/0019-5049.167476
PMID
:26644614
Background and Aims:
Ultrasound (US)-guided regional blocks are becoming increasingly popular as its use increases success rate, shortens block onset time and reduces complications. Currently, there exist two methods to perform US-guided axillary brachial plexus block (US-ABPB), the perivascular (PV) and the perineural (PN) techniques. We compared the two techniques to study the block characteristics and other variables using levobupivacaine.
Methods:
In this prospective, randomised trial, 60 patients were randomly allocated to receive a PV (
n
= 30) or PN (
n
= 30) US-ABPB. The local anaesthetic agent, 0.5% levobupivacaine and total volume of 36 ml of solution were identical in all the subjects. For both the groups, the musculocutaneous nerve was first located and then anaesthetised with 6 ml. Subsequently in the PV group, 30 ml was deposited dorsal to the axillary artery (6 o'clock position). In PN group, the median, ulnar and radial nerves were individually anaesthetised with volumes of 10 ml each. The onset and duration of sensory block, the onset and duration of motor block, number of failed blocks and complications were noted.
Results:
No difference was observed between the two groups in terms of success rate (PV - 93.33%, PN - 96.66%), sensory onset (PN: 8.07 (standard deviation [SD] ± 0.651) min and PV: 8.14 [SD ± 1.079] min;
P
= 0.754), motor onset (PN: 14.62 [SD ± 2.077] min and PV: 14.93 [SD ± 1.844] min;
P
= 0.557) and total duration of anaesthesia. No complications were observed in both groups.
Conclusion:
The PV technique provides a simple alternative for PN US-ABPB. In the light of emerging needling positions for PV and PN techniques, this study calls for large scale trials and much research in this area before one defines best or safe approach. PV technique may be considered as an alternative method for US-ABPB in patients with anatomical variation or difficulties in identifying the individual nerves.
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COMMENTARY
Continuous epidural analgesia for post-operative pain relief in paediatric patients
Nagasamy Venkateswaran
October 2015, 59(10):640-641
PMID
:26644610
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1,318
345
EDITORIAL
Innovative studies, eloquent peer reviewing and cultured editing: Academic desires and tangible dreams of an editor
S Bala Bhaskar, Sukhminder Jit Singh Bajwa
October 2015, 59(10):627-629
DOI
:10.4103/0019-5049.167491
PMID
:26644607
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1,744
397
LETTERS TO EDITOR
Defibrillator maintenance policy
Pankaj Kundra, PS Vishnu Prasad, V Padmavathi, T Siva
October 2015, 59(10):685-687
DOI
:10.4103/0019-5049.167478
PMID
:26644623
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2,057
434
A child with difficult airway for magnetic resonance imaging: Is dexmedetomidine useful?
Ravi Bhat, Milon V Mitragotri
October 2015, 59(10):687-688
DOI
:10.4103/0019-5049.167475
PMID
:26644624
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1,211
283
Anaesthesia management in a patient with severe idiopathic thrombocytopaenia with antepartum haemorrhage for emergency caesarean section
Anjana Sagar Wajekar
October 2015, 59(10):689-690
DOI
:10.4103/0019-5049.167474
PMID
:26644625
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6,455
700
Anaesthetic management of a pregnant patient posted for laparoscopic appendectomy in third trimester
Priyamvada Gupta, Ruchika Choudhary, Durga Jethava, Brijesh Kumar Sharma
October 2015, 59(10):690-691
DOI
:10.4103/0019-5049.167480
PMID
:26644626
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2,461
556
Peripheral venous access in the obese patient
Smita Prakash, Gaurav Arora, HG Shobha Rani
October 2015, 59(10):692-693
DOI
:10.4103/0019-5049.167482
PMID
:26644627
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1,623
428
Local anaesthetic resistance in a young woman with history of scorpion bite
Ahmet Issin
October 2015, 59(10):693-694
DOI
:10.4103/0019-5049.167495
PMID
:26644628
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2,439
367
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