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2017| August | Volume 61 | Issue 8
Online since
August 11, 2017
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ORIGINAL ARTICLES
Perfusion index as a predictor of hypotension following spinal anaesthesia in lower segment caesarean section
Devika Rani Duggappa, MPS Lokesh, Aanchal Dixit, Rinita Paul, RS Raghavendra Rao, P Prabha
August 2017, 61(8):649-654
DOI
:10.4103/ija.IJA_429_16
PMID
:28890560
Background and Aims:
Perfusion index (PI) is a new parameter tried for predicting hypotension during spinal anaesthesia for the lower segment caesarean section (LSCS). This study aimed at investigating the correlation between baseline perfusion index and incidence of hypotension following SAB in LSCS.
Methods:
In this prospective observational study, 126 parturients were divided into two groups on the basis of baseline PI. Group I included parturients with PI of ≤3.5 and Group II, parturients with PI values >3.5. Spinal anaesthesia was performed with 10 mg of injection bupivacaine 0.5% (hyperbaric) at L3–L4 or L2–L3 interspace. Hypotension was defined as mean arterial pressure <65 mmHg. Statistical analysis was performed using Chi-square test, independent sample
t
-test and Mann–Whitney U-test. Regression analysis with Spearman's rank correlation coefficient was done to assess the correlation between baseline PI and hypotension. Receiver operating characteristic (ROC) curve was plotted for PI and occurrence of hypotension.
Results:
The incidence of hypotension in Group I was 10.5% compared to 71.42% in Group II (
P
< 0.001). There was significant correlation between baseline PI >3.5 and number of episodes of hypotension (
r
s
0.416,
P
< 0.001) and total dose of ephedrine (
r
s
0.567,
P
< 0.001). The sensitivity and specificity of baseline PI of 3.5 to predict hypotension was 69.84% and 89.29%, respectively. The area under the ROC curve for PI to predict hypotension was 0.848.
Conclusion:
Baseline perfusion index >3.5 is associated with a higher incidence of hypotension following spinal anesthesia in elective LSCS.
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CASE REPORTS
Laryngeal mask airway protector™: Advanced uses for laparoscopic cholecystectomies
Leng Zoo Tan, Daryl Jian'An Tan, Edwin Seet
August 2017, 61(8):673-675
DOI
:10.4103/ija.IJA_240_17
PMID
:28890564
The laryngeal mask airway (LMA) Protector™ is a second-generation perilaryngeal sealer type supraglottic airway device recently introduced into clinical practice. We describe our initial experiences with the use of the LMA Protector™ in three patients undergoing laparoscopic cholecystectomies. In all patients, we found the LMA Protector™ to have acceptable placements on the first attempt, adequate oropharyngeal leak pressures and ventilation adequacy.
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Anaesthetic management of infants posted for repair of anomalous origin of left coronary artery from pulmonary artery
Chitralekha Patra, Naveen G Singh, N Manjunatha, Anand Bhatt
August 2017, 61(8):676-678
DOI
:10.4103/ija.IJA_212_17
PMID
:28890565
First described in 1908, anomalous origin of left coronary artery from pulmonary artery is a very rare congenital anomaly. Here, the right coronary artery is usually enlarged and has a normal origin from aorta. Numerous collaterals connect the two coronary arteries over right ventricular outflow tract or interventricular septum. It is one of the most common causes of myocardial ischaemia and infarction in children.
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EDITORIAL
Difficult airway: Challenges, phobias and options
Goneppanavar Umesh
August 2017, 61(8):611-613
DOI
:10.4103/ija.IJA_492_17
PMID
:28890554
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LETTERS TO EDITOR
Airway management with a rigid external distractor in place
Masanori Tsukamoto, Jun Hitokawa, Takeshi Yokoyama
August 2017, 61(8):679-680
DOI
:10.4103/ija.IJA_268_17
PMID
:28890566
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204
Novel use of transoesophageal echocardiography in a pregnant patient undergoing neurosurgery
Keshav Goyal, Kunal Singh, Ranadhir Mitra, Gaurav Singh Tomar
August 2017, 61(8):681-682
DOI
:10.4103/ija.IJA_332_17
PMID
:28890567
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Transdermal fentanyl patch in post-operative patients: Is it justified?
Abhijit S Nair
August 2017, 61(8):682-683
DOI
:10.4103/ija.IJA_349_17
PMID
:28890568
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Yet another cause for difficult extubation of nasotracheal tube
Sheeba J Annie, R Sripriya, Areti Archana, T Sivashanmugam
August 2017, 61(8):684-685
DOI
:10.4103/ija.IJA_275_17
PMID
:28890569
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Encountering caudal cyst on ultrasound: What do we do?
Vrushali Chandrashekhar Ponde, Vinit Vinod Bedekar
August 2017, 61(8):685-687
DOI
:10.4103/ija.IJA_144_17
PMID
:28890570
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1,644
207
A novel position for D2 kyphoplasty: Swimmer's position
Shagun Bhatia Shah, Ajay Kumar Bhargava, Ramandeep Singh Jaggi
August 2017, 61(8):687-688
DOI
:10.4103/ija.IJA_386_17
PMID
:28890571
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Capnography in the endoscopy suite: A necessity, not a luxury!
Jeson Rajan Doctor, Reshma Ambulkar, Rohit Patnaik, Jigeeshu V Divatia
August 2017, 61(8):689-690
DOI
:10.4103/ija.IJA_406_17
PMID
:28890572
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LIGHTER PLANES
Lighter Planes
August 2017, 61(8):691-691
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ORIGINAL ARTICLES
A comparison of the efficacy of intercostal nerve block and peritubal infiltration of ropivacaine for post-operative analgesia following percutaneous nephrolithotomy: A prospective randomised double-blind study
Nirmala Jonnavithula, Raveendra Reddy Chirra, Sai Lakshman Pasupuleti, Rahul Devraj, Vidyasagar Sriramoju, Murthy VLN Pisapati
August 2017, 61(8):655-660
DOI
:10.4103/ija.IJA_88_17
PMID
:28890561
Background and Aims:
Intercostal nerve blockade (ICNB) and peritubal infiltration of the nephrostomy tract are well-established regional anaesthetic techniques for alleviating pain after percutaneous nephrolithotomy (PCNL). This prospective study compared the efficacy of ICNB and peritubal local anaesthetic infiltration of the nephrostomy tract in providing post-operative analgesia following PCNL.
Methods:
Sixty American Society of Anesthesiologist physical status 1 and II patients scheduled for PCNL requiring nephrostomy tube were randomised to receive either peritubal infiltration or ICNB. At the completion of the procedure, patients in Group P received peritubal infiltration and those in Group I received ICNB at 10, 11, 12
th
spaces using fluoroscopy guidance. Postoperatively, patients were followed for 24 h for pain using Visual Analogue Scale (VAS) and Dynamic VAS. Rescue analgesia was inj. tramadol 1 mg/kg IV when pain score exceeded 4. Time to first rescue analgesia, number of doses and patient's satisfaction were noted in all patients.
Results:
Pain scores were lower in the group I at all points of measurement than group P. The mean time to first demand for rescue analgesia was higher in Group I (13.22 ± 4.076 h vs 7.167 ± 3.92 h
P
- 0.001). The number of demands and the amount of analgesics consumed were less in Group I.
Conclusion:
ICNB provided superior analgesia as evidenced by longer time to first demand of analgesic, reduced number of demands and consumption of rescue analgesic. Peritubal infiltration, although less efficacious, may be a safe and simple alternative technique.
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Efficacy of atomised local anaesthetic versus transtracheal topical anaesthesia for awake fibreoptic intubation
Bindu K Vasu, Sunil Rajan, Jerry Paul, Lakshmi Kumar
August 2017, 61(8):661-666
DOI
:10.4103/ija.IJA_249_17
PMID
:28890562
Background and Aims:
Successful awake fibreoptic intubation (AFOI) depends on adequate topical anaesthesia of the airway. We aimed to compare efficacy of atomised local anaesthetic versus transtracheal topical anaesthesia for AFOI.
Methods:
It was a prospective, randomised controlled study of 33 patients with the American Society of Anesthesiologists' physical status 1–3 with anticipated difficult airway requiring AFOI. The primary objective was to compare the patient comfort after topical anaesthesia of the airway using atomiser with transtracheal injection of the local anaesthetic agent for AFOI in patients with anticipated difficult airway. The secondary objectives were to compare the ease of intubation, time required to intubate and the haemodynamic changes during intubation. After topical anaesthesia of nostrils, patients in Group T received transtracheal injection of 4 ml of 4% lignocaine whereas Group A patients received 4-5mL of 4% atomised lignocaine using DeVilbiss atomiser before AFOI. Patient comfort assessed objectively by the anaesthetic assistant during the procedure, ease of intubation assessed using cough and gag reflex score, time taken to intubate and the haemodynamic changes during the procedure were compared.
Results:
Ease of intubation, patient comfort and the time taken to intubate were significantly better in Group T patients, with
P
= 0.001, 0.009 and 0.019, respectively, compared with the patients in Group A. There were no significant changes in haemodynamic parameters.
Conclusion:
Topical anaesthesia by transtracheal injection in patients with anticipated difficult airway made AFOI easier and faster with better patient comfort compared to atomiser with no clinically significant untoward side effects.
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Comparison of intrathecal clonidine and magnesium sulphate used as an adjuvant with hyperbaric bupivacaine in lower abdominal surgery
Mamta Khandelwal, Debojyoti Dutta, Usha Bafna, Sunil Chauhan, Pranav Jetley, Saikat Mitra
August 2017, 61(8):667-672
DOI
:10.4103/ija.IJA_610_16
PMID
:28890563
Background and Aims:
Use of various adjuvants to spinal anaesthesia is a well-known modality to provide intra- and post-operative analgesia. This study was designed to evaluate and compare the analgesic efficacy of clonidine and magnesium when used as an additive to intrathecal 0.5% hyperbaric bupivacaine.
Methods:
Ninety patients of the American Society of Anesthesiologists' physical status grade I or II, scheduled for lower abdominal surgery under spinal anaesthesia, were randomly allocated into three groups. Group B received 3 mL of 0.5% hyperbaric bupivacaine with 1 mL of normal saline, Group C received 3 mL of 0.5% hyperbaric bupivacaine with 1 mL (30 μg) of clonidine and Group M received 3 mL of 0.5% hyperbaric bupivacaine with 1 mL (50 mg) magnesium sulphate. The primary outcome variable was duration of analgesia and secondary outcome variables included onset and duration of sensory and motor block, sedation level and adverse effects. Data were analysed with ANOVA, Kruskal–Wallis and Chi-square tests.
Results:
The time to first rescue analgesia was significantly (
P
< 0.01) longer in the Group C (330.7 ± 47.7 min) than both Groups. Group M (246.3 ± 55.9 min) showed significantly prolonged analgesia than Group B (134.4 ± 17.9 min). Group C and Group M showed significantly prolonged duration of both sensory and motor block compared to Group B.
Conclusion:
Intrathecal clonidine added to bupivacaine prolongs the duration of post-operative analgesia, and hastens the onset and prolongs the duration of sensory and motor block compared to magnesium or controls.
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Ethnicity and upper airway measurements: A study in South Indian population
Kalpana P Balakrishnan, Punitha A Chockalingam
August 2017, 61(8):622-628
DOI
:10.4103/ija.IJA_247_17
PMID
:28890556
Background and Aims:
Most studies on upper airway are conducted based on airway measurements in the western population. We set out to find the normal values of upper airway measurements in South Indian population. The aim of this study was to perform various upper airway examinations and to set standards for normal measurements in the South Indian population as well as to analyse the data for predictors of difficult intubation.
Methods:
This prospective observational study was conducted in a tertiary cancer hospital in Southern India. Airway assessment parameters, including modified Mallampati classification (MPC), upper lip bite test (ULBT), sternomental distance, thyromental distance (TMD), and the inter-incisor distance were documented for 2004 patients meeting the inclusion criteria. Laryngoscopic view after induction was graded as per Cormack and Lehane's (CL) classification. Any CL ≥3 was considered to be difficult laryngoscopy. The collected data (2004 cases) was analyed with SPSS software version 17. Receiver operating characteristics (ROC) curve was used to determine cut-offs in the population. Sensitivity, specificity, positive and negative predictive value were computed.
Results:
MPC, ULBT, and ratio of height to TMD (RHTMD) predicted difficult intubation with sensitivity of 40.86%, 45.53% and 64.60%, respectively and these were statistically significant with
P
< 0.001. Using the area under the curve of the ROC curve and discrimination analysis normal RHTMD in our population had a cut off value of 17.1.
Conclusion:
The cut off value for RHTMD to predict difficult laryngoscopy in the South Indian population is 17.1.
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Are cardiac surgical patients at increased risk of difficult intubation?
Deepak Prakash Borde, Savani Sameer Futane, Vijay Daunde, Sujata Zine, Nayana Joshi, Sumit Jaiswal, Sadhana Chinchole, Prasannakumar Kulkarni, Amit Hiwarkar, Priti Bhagyawant, Dilip Deshmukh, Manisha Takalkar
August 2017, 61(8):629-635
DOI
:10.4103/ija.IJA_283_17
PMID
:28890557
Background and Aims:
Safe airway management is the cornerstone of contemporary anaesthesia practice, and difficult intubation (DI) remains a major cause of anaesthetic morbidity and mortality. The surgical category, particularly cardiac surgery as a risk factor for DI has not been studied extensively. The aim of this study was to test the hypothesis whether cardiac surgical patients are at increased risk of DI.
Methods:
During the study, 627 patients (329 cardiac and 298 non-cardiac surgical) were enrolled. Pre-operative demographic and other variables associated with DI were assessed. Patients with Cormack Lehane grade III and IV or use of bougie in Cormack grade II were defined as DI. The incidence of anticipated and unanticipated DI was assessed. Factors associated with DI were described using univariate and multivariate logistic regression models.
Results:
The overall incidence of DI was 122/627 (19.46%). The incidence of DI was higher in cardiac surgery patients (24%) as compared to non-cardiac surgery patients (14.4%
P
= 0.002). On multivariate analysis, factors independently associated with DI were greater age, male sex, higher Mallampati grade, and anticipated DI, but not cardiac surgery. The incidence of unanticipated DI was 48.1% and 53.4% in cardiac and non-cardiac surgery patients, respectively.
Conclusion:
Although there was a higher incidence of DI in cardiac surgical patients, cardiac surgery is not an independent risk factor for DI. Rather, other factors play more important role. About half of the DI both in cardiac and non-cardiac surgeries were unanticipated.
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A cohort evaluation of clinical use and performance characteristics of Ambu
®
AuraGain™: A prospective observational study
Devangi A Parikh, Ruchi A Jain, Smita S Lele, Bharati A Tendolkar
August 2017, 61(8):636-642
DOI
:10.4103/ija.IJA_285_17
PMID
:28890558
Background and Aims:
Ambu
®
AuraGain™ (AG) (Ambu, Ballerup, Denmark) is a supraglottic device which has a design facilitating its use as a conduit for intubation. We designed this prospective observational study to assess the ease of AG placement in paralysed patients, determine its position and alignment to the glottis and assess its utility as a conduit for intubation.
Methods:
One hundred patients, aged 18–60 years, American Society of Anesthesiologists physical status I–II, undergoing elective surgery under general anaesthesia were included in the study. The ease and number of attempts for successful insertion, ease of gastric tube insertion, leak pressures, fibre-optic grade of view, number of attempts and time for tracheal intubation, time for AG removal and complications were recorded. The mean, standard deviation (SD), interquartile range (IQR) and range were calculated. The upper limit of confidence interval for overall failure rate was calculated using Wilson's score method.
Results:
AG was successfully inserted in all patients. The mean (SD) time taken for insertion was 17.32 (8.48) s. The median [IQR] leak pressures were 24 [20–28] cm of H
2
O. Optimal laryngeal view for intubation was obtained in 68 patients. Eighty-eight patients could be intubated in the first attempt. Five patients could not be intubated. The overall failure rate of device was 9%.
Conclusion:
AMBU
®
AuraGain™ serves as an effective ventilating aid, but caution is suggested before using it as a conduit for endotracheal intubation.
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Comparison of the post-operative analgesic effect of paravertebral block, pectoral nerve block and local infiltration in patients undergoing modified radical mastectomy: A randomised double-blind trial
Kartik Syal, Ankita Chandel
August 2017, 61(8):643-648
DOI
:10.4103/ija.IJA_81_17
PMID
:28890559
Background and Aims:
Paravertebral block, pectoral nerve (Pecs) block and wound infiltration are three modalities for post-operative analgesia following breast surgery. This study compares the analgesic efficacy of these techniques for post-operative analgesia.
Methods:
Sixty-five patients with American Society of Anesthesiologists' physical status 1 or 2 undergoing modified radical mastectomy with axillary dissection were recruited for the study. All patients received 21 mL 0.5% bupivacaine with adrenaline in the technique which was performed at the end of the surgery prior to extubation. Patients in Group 1 (local anaesthetic [LA],
n
= 22) received infiltration at the incision site after surgery, Group 2 patients (paravertebral block [PVB],
n
= 22) received ultrasound-guided ipsilateral paravertebral block while Group 3 patients [PECT] (
n
= 21) received ultrasound-guided ipsilateral Pecs blocks I and II. Patients were evaluated for pain scores at 0, 2, 4, 6, 12 and 24 h, duration of post-operative analgesia and rescue analgesic doses required. Non-normally distributed data were analysed using the Kruskal-Wallis test and Analysis of variance for normal distribution.
Results:
The post-operative visual analogue scale scores were lower in PVB group compared with others at 0, 2, 4, 12 and 24 h (
P
< 0.05). Mean duration of analgesia was significantly prolonged in PVB group (
P
< 0.001) with lesser rescue analgesic consumption up to 24 h.
Conclusion:
Ultrasound-guided paravertebral block reduces post-operative pain scores, prolongs the duration of analgesia and decreases demands for rescue analgesics in the first 24 h of post-operative period compared to ultrasound-guided Pecs block and local infiltration block.
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REVIEW ARTICLE
Perioperative fluid management: From physiology to improving clinical outcomes
Victoria A Bennett, Maurizio Cecconi
August 2017, 61(8):614-621
DOI
:10.4103/ija.IJA_456_17
PMID
:28890555
Perioperative fluid management is a key component in the care of the surgical patient. It is an area that has seen significant changes and developments, however there remains a wide disparity in practice between clinicians. Historically, patients received large volumes of intravenous fluids perioperatively. The concept of goal directed therapy was then introduced, with the early studies showing significant improvements in morbidity and mortality. The current focus is on fluid therapy guided by an individual patient's physiology. A fluid challenge is commonly performed as part of an assessment of a patient's fluid responsiveness. There remains wide variation in how clinicians perform a fluid challenge and this review explores the evidence for how to administer an effective challenge that is both reliable and reproducible. The methods for monitoring cardiac output have evolved from the pulmonary artery catheter to a range of less invasive techniques. The different options that are available for perioperative use are considered. Fluid status can also be assessed by examining the microcirculation and the importance of recognising the possibility of a lack of coherence between the macro and microcirculation is discussed. Fluid therapy needs to be targeted to specific end points and individualised. Not all patients who respond to a fluid challenge will necessarily require additional fluid administration and care should be aimed at identifying those who do. This review aims to explain the underlying physiology and describe the evidence base and the changes that have been seen in the approach to perioperative fluid therapy.
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