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2016| August | Volume 60 | Issue 8
Online since
August 4, 2016
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REVIEW ARTICLE
Angioedema: Classification, management and emerging therapies for the perioperative physician
Lopa Misra, Narjeet Khurmi, Terrence L Trentman
August 2016, 60(8):534-541
DOI
:10.4103/0019-5049.187776
PMID
:27601734
Angioedema is a rare condition which manifests as sudden localised, non-pitting swelling of certain body parts including skin and mucous membranes. It is vital that anaesthesiologists understand this condition, as it may present suddenly in the perioperative period with airway compromise. To identify literature for this review, the authors searched the PubMed, Medline, Embase, Scopus and Web of Science databases for English language articles covering a 10-year period, 2006 through 2016. Angioedema can be either mast-cell mediated or bradykinin-induced. Older therapies for histaminergic symptoms are well known to anaesthesiologists (e.g., adrenaline, anti-histamines and steroids), whereas older therapies for bradykinin-induced symptoms include plasma and attenuated androgens. New classes of drugs for bradykinin-induced symptoms are now available, including anti-bradykinin, plasma kallikrein inhibitor and C1 esterase inhibitors. These can be used prophylactically or as rescue medications. Anaesthesiologists are in a unique position to coordinate perioperative care for this complex group of patients.
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1
ORIGINAL ARTICLES
Submandibular intubation as an alternative for intra-operative airway management in maxillofacial fractures - our institutional experience
Praveer K Banerjee, Abhineet Jain, Bikram Behera
August 2016, 60(8):573-577
DOI
:10.4103/0019-5049.187789
PMID
:27601740
Background and Aims:
Airway management in anaesthesia for maxillofacial surgical procedures is tricky at times when the nasal/oral routes are contraindicated or are impossible. Tracheostomy as an alternative inherits its own complications. We present a case series of the submandibular route for tracheal intubation as an alternative.
Methods:
The procedure was performed in ten selected adult patients with maxillofacial/mandibular fractures associated with a fracture of skull base or nasal bone. All of them were medically stable with no need of intensive care or mechanical ventilation in post-operative period.
Results:
Submandibular intubation in all ten patients of panfacial fractures allowed uninterrupted surgical techniques with a secured airway. All patients were reverted to oro-tracheal tube at the end of surgery as immediate maxillomandibular fixation was not necessary. The patients were extubated after recovery from anaesthesia before they left the operating theatre. One patient in the post-operative period had a superficial infection of incision site that responded well to local treatment. No other complications were encountered in the intra-operative or post-operative period.
Conclusion:
In complex maxillofacial injuries, when oral or nasal intubation hampers surgeon's field of view, submandibular intubation offers an effective alternative to short-term tracheostomy along with small risk potential. There is a need to emphasise its regular application in such cases so that technique can be mastered by both surgeons and anaesthesiologist.
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3,768
671
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Comparative study of ultrasound-guided abdominal field blocks versus port infiltration in laparoscopic cholecystectomies for post-operative pain relief
Ruchi Saxena, Saurabh Joshi, Kuldeep Srivastava, Shashank Tiwari, Nitin Sharma, Umesh K Valecha
August 2016, 60(8):578-583
DOI
:10.4103/0019-5049.187790
PMID
:27601741
Background and Aims:
Post-operative pain is a major concern for day care surgeries like laparoscopic cholecystectomy. This study aimed to compare the efficacy of ultrasound guided abdominal field blocks (USAFB) with port site infiltrations for post-operative analgesia in terms of quality of pain relief, opioid consumption and patient satisfaction for day care surgeries
Methods
: Eighty patients presenting for laparoscopic cholecystectomy were randomly allocated to two groups either to receive port-site infiltration of local anaesthetic (
n
= 40, Group A) or USAFB (
n
= 40, Group B group). Numeric rating scores (NRS) were measured postoperatively to primarily assess the pain severity and opioid requirements. Data were analysed using Chi-Square test/Fisher's exact test for categorical data and Mann-Whitney test/unpaired
t
-test for quantitative data.
Results:
The study group (Group B) had significantly reduced NRS and opioid consumption over 24 h. The overall fentanyl consumption in patients receiving port infiltrations was approximately twice (200 100 μg) as compared to patients in USAFB group (120 74 μg) (
P
< 0.0001). Maximum fentanyl consumption was 400 μg (Group A) and 262 μg (Group B) over 24 h and the minimum requirement was 50 μg and zero, respectively.
Conclusion
: Superior post-operative analgesia was observed with USAFB which may help in minimising opioid-related adverse effects and facilitating faster recovery.
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An observational cohort study on pre-operative investigations and referrals: How far are we following recommendations?
Habib Md Reazaul Karim, Md Yunus, Prithwis Bhattacharyya
August 2016, 60(8):552-559
DOI
:10.4103/0019-5049.187783
PMID
:27601737
Background and Aims:
Pre-operative investigations are often required to supplement information for risk stratification and assessing reserve for undergoing surgery. Although there are evidence-based recommendations for which investigations should be done, clinical practice varies. The present study aimed to assess the pre-operative investigations and referral practices and compare it with the standard guidelines.
Methods:
The present observational study was carried out during 2014-2015 in a teaching institute after the approval from Institute Ethical Committee. A designated anaesthesiologist collected data from the completed pre-anaesthetic check-up (PAC) sheets. Investigations already done, asked by anaesthesiologists as well as referral services sought were noted and compared with an adapted master table prepared from standard recommendations and guidelines. Data were expressed in frequencies, percentage and statistically analysed using INSTAT software (GraphPad Prism software Inc., La Zolla, USA).
Results:
Seventy-five out of 352 patients (42.67% male, 57.33% female; American Society of Anesthesiologists physical status I to III) were included in this study. Nearly, all patients attended PAC with at least 5 investigations done. Of them, 89.33% were subjected to at least one unnecessary investigation and 91.67% of the referral services were not required which lead to 3.5 ( SD ±1.64) days loss. Anaesthesiologist-ordered testing was more focused than surgeons.
Conclusion:
More than two-third of pre-operative investigations and referral services are unnecessary. Anaesthesiologists are relatively more rational in ordering pre-operative tests yet; a lot can be done to rationalise the practice as well as reducing healthcare cost.
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Evaluation of timings and outcomes in category-one caesarean sections: A retrospective cohort study
Clare Newton Dunn, Qianpian Zhang, Josh Tjunrong Sia, Pryseley Nkouibert Assam, Shephali Tagore, Ban Leong Sng
August 2016, 60(8):546-551
DOI
:10.4103/0019-5049.187782
PMID
:27601736
Background and Aims:
A decision-to-delivery interval (DDI) of 30 min for category-one caesarean section (CS) deliveries is the standard of practice recommended by clinical guidelines. Our institution established a protocol for category-one ('crash') CS to expedite deliveries. The aim of this study is to evaluate DDI, factors that affect DDI and the mode of anaesthesia for category-one CS.
Methods:
This retrospective cohort study evaluated 390 women who underwent category-one CS in a tertiary obstetric centre. We analysed the factors associated with DDI, mode of anaesthesia and perinatal outcomes. Summary statistics were performed for the outcomes. The association factors were considered significant at
P
< 0.05.
Results:
The mean (standard deviation) DDI was 9.4 (3.2) min with all deliveries achieved within 30 min. The longest factor in the DDI was time taken to transfer patients. A shorter DDI was not significantly associated with improved perinatal outcomes. The majority (88.9%) of women had general anaesthesia (GA) for category-one CS. Of those who had an epidural catheter already
in situ
(34.4%), 25.6% had successful epidural extension. GA was associated with shorter DDI, but worse perinatal outcomes than regional anaesthesia (RA).
Conclusions:
Our 'crash' CS protocol achieved 100% of deliveries within 30 min. The majority (88.9%) of the patients had GA for category-one CS. GA was found to be associated with shorter anaesthesia and operation times, but poorer perinatal outcomes compared to RA.
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2
Comparative efficacy of ropivacaine and levobupivacaine in combined femoral and lateral femoral cutaneous nerve block with adjuvant magnesium for post-operative analgesia
Prakash Khairnar, Munisha Agarwal, Uttam Chandra Verma, Rakesh Kumar
August 2016, 60(8):584-589
DOI
:10.4103/0019-5049.187794
PMID
:27601742
Background and Aims:
Patients with burns may require multiple surgeries, but poor general condition and underlying protein energy malnutrition make them unsuitable candidates for general or spinal anaesthesia. This study evaluated the role of magnesium sulphate as an adjuvant with levobupivacaine and ropivacaine used in combined femoral and lateral femoral cutaneous nerve (LFCN) blocks in burn patients with relative sparing of thigh portion.
Methods:
This prospective, randomised, double-blind study included 54 adult patients of 18-65 years age, undergoing split-thickness skin graft harvest from the thigh, allotted to three equal groups of 18 each. Group L patients received femoral nerve (FN) block with 15 mL of 0.5% levobupivacaine and 8 mL for LFCN block; Group LM patients received 14 mL of 0.5% levobupivacaine along with 1.0 mL of 15% magnesium sulphate for FN block, 7.5 mL of 0.5% levobupivacaine with 0.5 mL of 15% of magnesium sulphate to LFCN block and Group R patients received 15 mL of 0.5% ropivacaine for FN block and 8 mL of 0.5% ropivacaine for LFCN block. Time to block onset and complete surgical block, duration of analgesia, total analgesic dose and the overall analgesia satisfaction score were measured in the first 24 h post-operatively. Quantitative data were analysed with ANOVA and qualitative data subjected to Chi-square tests. Intergroup comparison was performed with independent
t
-test.
Results:
The duration of post-operative analgesia did not differ with the addition of magnesium (
P
= 0.610). Time to onset of the block was significantly decreased with the addition of magnesium (
P
= 0.0341), but time to complete surgical block onset was similar across the groups.
Conclusion:
Both ropivacaine and levobupivacaine have good perioperative analgesic efficacy. Magnesium as an analgesia adjuvant with levobupivacaine does not prolong the duration of post-operative analgesia.
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3,086
616
1
Comparison of effects of ProSeal LMA™ laryngeal mask airway cuff inflation with air, oxygen, air:oxygen mixture and oxygen:nitrous oxide mixture in adults: A randomised, double-blind study
Mona Sharma, Renu Sinha, Anjan Trikha, Rashmi Ramachandran, C Chandralekha
August 2016, 60(8):566-572
DOI
:10.4103/0019-5049.187787
PMID
:27601739
Background
and
Aims
: Laryngeal mask airway (LMA) cuff pressure increases when the air is used for the cuff inflation during oxygen: nitrous oxide (O
2
:N
2
O) anaesthesia, which may lead to various problems. We compared the effects of different gases for ProSeal LMA™ (PLMA) cuff inflation in adult patients for various parameters.
Methods:
A total of 120 patients were randomly allocated to four groups, according to composition of gases used to inflate the PLMA cuff to achieve 40 cmH
2
O cuff pressure, air (Group A), 50% O
2
:air (Group OA), 50% O
2
:N
2
O (Group ON) and 100% O
2
(Group O). Cuff pressure, cuff volume and ventilator parameters were monitored intraoperatively. Pharyngolaryngeal parameters were assessed at 1, 2 and 24 h postoperatively. Statistical analysis was performed using ANOVA, Fisher's exact test and step-wise logistic regression.
Results:
Cuff pressure significantly increased at 10, 15 and 30 min in Group A, OA and O from initial pressure. Cuff pressure decreased at 5 min in Group ON (36.6 ± 3.5 cmH
2
O) (
P
= 0.42). PLMA cuff volume increased in Group A, OA, O, but decreased in Group ON (6.16 ± 2.8 ml [
P
< 0.001], 4.7 ± 3.8 ml [
P
< 0.001], 1.4 ± 3.19 ml [
P
= 0.023] and − 1.7 ± 4.9 ml [
P
= 0.064], respectively), from basal levels. Ventilatory parameters were comparable in all four groups. There was no significant association between sore throat and cuff pressure, with odds ratio 1.002.
Conclusion:
Cuff inflation with 50% O
2
:N
2
O mixture provided more stable cuff pressure in comparison to air, O
2
:air, 100% O
2
during O
2
:N
2
O anaesthesia. Ventilatory parameters did not change with variation in PLMA cuff pressure. Post-operative sore throat had no correlation with cuff pressure.
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Importance of fibrinogen in dilutional coagulopathy after neurosurgical procedures: A descriptive study
Shalini Nair, Bijesh Ravindran Nair, Ajay Vidyasagar, Mathew Joseph
August 2016, 60(8):542-545
DOI
:10.4103/0019-5049.187778
PMID
:27601735
Background and Aims
: The routine management of coagulopathy during surgery involves assessing haemoglobin, prothrombin time (PT), activated partial thromboplastin time (aPTT) and platelets. Correction of these parameters involves administration of blood, fresh frozen plasma and platelet concentrates. The study was aimed at identifying the most common coagulation abnormality during neurosurgical procedures and the treatment of dilutional coagulopathy with blood components.
Methods
: During 2 years period, all adult patients undergoing neurosurgical procedures who were transfused two or more units of red cells were prospectively evaluated for the presence of a coagulopathy. PT, aPTT, platelet count and fibrinogen levels were estimated before starting a component therapy.
Results
: After assessing PT, aPTT, platelet count and fibrinogen levels following two or more blood transfusions, thirty patients were found to have at least one abnormal parameter that required administration of a blood product. The most common abnormality was a low fibrinogen level, seen in 26 patients; this was the only abnormality in three patients. No patient was found to have an abnormal PT or aPTT without either the fibrinogen concentration or platelet count or both being low.
Conclusion
: Low fibrinogen concentration was the most common coagulation abnormality found after blood transfusions for neurosurgical procedures.
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EDITORIAL
Are we ready for submental diversions?
Pankaj Kundra, Stalin Vinayagam
August 2016, 60(8):531-533
DOI
:10.4103/0019-5049.187768
PMID
:27601733
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2,294
487
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ORIGINAL ARTICLES
Intra-operative electrooculographic monitoring to prevent post-operative extraocular motor nerve dysfunction during skull base surgeries
Veena Sheshadri, Suparna Bharadwaj, BA Chandramouli
August 2016, 60(8):560-565
DOI
:10.4103/0019-5049.187784
PMID
:27601738
Background and Aims:
Intra-operative identification and preservation of extraocular motor nerves is one of the main goals of surgeries for skull base tumours and this is done by monitoring the extraocular movement (EOM). Intra-operative electromyographic monitoring has been reported, but it is a complex and skilful process. Electrooculography (EOG) is a simple and reliable technique for monitoring EOMs. We aimed to assess the utility of EOG monitoring in preventing extraocular motor nerve dysfunction during skull base surgeries.
Methods:
In this retrospective cohort study, intra-operative EOG recordings were obtained using disposable needle electrodes placed on the periorbital skin and the polarity of the waves noted for interpretation. Triggered as well as continuous EOG responses were recorded after monopolar electrode stimulation of cranial nerve (CN) during tumour removal which helped the surgeon with careful dissection and avoiding potential nerve injuries.
Results:
Of the 11 cases monitored, oculomotor and abducent nerves were identified in all cases, but the trochlear nerve could not be definitively identified. Six patients had no pre- or post-operative extraocular motor nerve dysfunction. The other five patients had pre-existing deficits before surgery, which recovered completely in two, significantly in one, and did not improve in two patients at 3-6 months follow-up.
Conclusions:
EOG was found to be a simple and reliable method of monitoring extraocular motor nerves (CNs III and VI) intraoperatively.
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1
LETTERS TO EDITOR
Effective management of post-labour analgesia-post-dural puncture headache with mannitol
Kalpana Rajendra Kulkarni, Rahul Rajarm Patil, Abhishek Ajay Wadhawan
August 2016, 60(8):612-613
DOI
:10.4103/0019-5049.187820
PMID
:27601753
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1,975
437
1
Prolonged hoarseness following endotracheal intubation - not so uncommon?
S Kiran, Urvashi Tandon, Deepak Dwivedi, Rajit Kumar
August 2016, 60(8):605-606
DOI
:10.4103/0019-5049.187816
PMID
:27601749
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1,996
367
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Internal jugular venous valve: Well known but mostly neglected
Sangeeta Dhanger, Bhavani Vaidiyanathan, Debendra Kumar Tripathy
August 2016, 60(8):602-603
DOI
:10.4103/0019-5049.187813
PMID
:27601747
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1,939
338
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CASE REPORTS
Back to the drawing board-relearn the clinical skills: A root cause analysis of a missed case of bilateral vocal cord paralysis
Suruchi Ambasta, Ankita Dey, Lenin Babu Elakkumanan, Rajkumar Sundararaj
August 2016, 60(8):594-596
DOI
:10.4103/0019-5049.187805
PMID
:27601744
Bilateral vocal cord paralysis being misdiagnosed as bronchial asthma has been reported in the literature on several occasions. Diagnosing this condition needs precise clinical acumen which could lead us to make an integrated diagnostic and treatment plan. Here, we report another missed case of bilateral vocal cord paralysis and the root cause analysis of the incident. This report emphasises the need for appropriate clinical examinations and workup during the pre-operative assessment.
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1,910
309
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BRIEF COMMUNICATIONS
Successful management of a case of Tessier's cleft number 0 and 14 with associated encephalocoele
Udismita Baruah, Madhu Dayal, KK Giridhar, Virender
August 2016, 60(8):597-599
DOI
:10.4103/0019-5049.187807
PMID
:27601745
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1,936
254
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LETTERS TO EDITOR
Bradycardia induced polymorphic ventricular tachycardia during living donor liver transplantation
Sunaina Tejpal Karna, Chandra Kant Pandey, Vijay Kant Pandey, Mandeep Dhankhar
August 2016, 60(8):610-612
DOI
:10.4103/0019-5049.187819
PMID
:27601752
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1,919
247
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BRIEF COMMUNICATIONS
Airway management in Hurler's syndrome: A persistent challenge for anaesthesiologists
Sukhyanti Kerai, Vandana Saith, Rakesh Kumar, Saipriya Tewari
August 2016, 60(8):599-601
DOI
:10.4103/0019-5049.187811
PMID
:27601746
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1,853
285
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CASE REPORTS
Visual evoked potentials monitoring in a case of transient post-operative visual loss
Marie Capon, Michel Van Boven, Vincent van Pesch, Philippe Hantson
August 2016, 60(8):590-593
DOI
:10.4103/0019-5049.187800
PMID
:27601743
Post-operative visual loss (POVL) is a rare, albeit potentially serious complication of general anaesthesia. This report describes the case of a 54-year-old woman who developed transient POVL after general anaesthesia following a left posterior parietal meningioma surgery in the prone position and discusses the usefulness of visual evoked potentials monitoring in such situations.
[ABSTRACT]
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1,769
258
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LETTERS TO EDITOR
Epidural catheterisation for perioperative therapeutic external lumbar cerebrospinal fluid drainage
Varun Suresh, K Asish
August 2016, 60(8):603-604
DOI
:10.4103/0019-5049.187814
PMID
:27601748
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1,656
259
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Oropharyngeal continuous positive airway pressure: An alternative to intubation for newborns not applied nasal continuous positive airway pressure
Mehmet Semih Demirtas, Hatice Turgut, Emine Ozdemir, Ahmet Karadag
August 2016, 60(8):609-610
DOI
:10.4103/0019-5049.187818
PMID
:27601751
[FULL TEXT]
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1,630
255
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Stress cardiomyopathy and other resembling conditions
Monish S Raut, Arun Maheshwari
August 2016, 60(8):615-616
DOI
:10.4103/0019-5049.187823
PMID
:27601755
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1,584
279
1
Atypical or Variant stress cardiomyopathy
Kusuma Ramachandra Halemani, Komal Choudhary
August 2016, 60(8):613-615
DOI
:10.4103/0019-5049.187821
PMID
:27601754
[FULL TEXT]
[PDF]
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[EPub]
[PubMed]
1,493
262
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Refractory hypotension during paraganglioma removal - do we have to worry?
Rashmi Ramachandran, Vimi Rewari, Shikha Jain, Rajeev Kumar
August 2016, 60(8):606-608
DOI
:10.4103/0019-5049.187817
PMID
:27601750
[FULL TEXT]
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1,459
212
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