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   2018| March  | Volume 62 | Issue 3  
    Online since March 14, 2018

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Low-flow anaesthesia – underused mode towards “sustainable anaesthesia”
Madhusudan Upadya, PJ Saneesh
March 2018, 62(3):166-172
DOI:10.4103/ija.IJA_413_17  PMID:29643549
Any technique that employs a fresh gas flow that is less than the alveolar ventilation can be classified as low-flow anaesthesia. The complexities involved in the calculation of uptake of anaesthetic agents during the closed-circuit anaesthesia made this technique less popular. However, the awareness of the dangers of theatre pollution with trace amounts of the anaesthetic agents and the prohibitively high cost of the new inhalational agents, have helped in the rediscovery of low-flow anaesthesia. Moreover, the time has arrived for each of us, the practicing anaesthesiologists, to move towards the practice of low-flow anaesthesia, to achieve lesser theatre and environmental pollution and also to make anaesthesia more economical. The article also reviews low-flow anaesthesia (LFA) in paediatrics, recent advances such as automated LFA and updates on currently undergoing research to retrieve and reuse anaesthetic agents.
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Effectiveness of transnasal humidified rapid-insufflation ventilatory exchange versus traditional preoxygenation followed by apnoeic oxygenation in delaying desaturation during apnoea: A preliminary study
Sunil Rajan, Nandhini Joseph, Pulak Tosh, Dilesh Kadapamannil, Jerry Paul, Lakshmi Kumar
March 2018, 62(3):202-207
DOI:10.4103/ija.IJA_717_17  PMID:29643554
Background and Aims: Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) during apnoea has shown to delay desaturation. The primary objective was to compare time to desaturate to <90% during apnoea with THRIVE versus traditional preoxygenation followed by apnoeic oxygenation. Methods: This prospective, randomised, single-blinded study was conducted in 10 adult patients presenting for direct laryngoscopy under general anaesthesia without endotracheal intubation. Group P patients were preoxygenated with 100% oxygen, and in Group H, high-flow humidified oxygen was delivered using nasal cannula for 3 min. After induction and neuromuscular blockade, time to desaturate to 90%, while receiving apnoeic oxygenation, was noted. Chi-square test and Mann–Whitney tests were used. Results: Group H had a significantly longer apnoea time as compared to Group P (796.00 ± 43.36 vs. 444.00 ± 52.56 s). All patients in Group H continued to have nearly 100% saturation even at 12 min of apnoea. However, in Group P, 80% of patients desaturated to <90% after 6 min of apnoea. Baseline blood gases, that following preoxygenation and at 3 min of apnoea time were comparable in both groups. At 6 min, Group H had a significantly higher PaO2 (295.20 ± 122.26 vs. 135.00 ± 116.78) and PaCO2 (69.46 ± 7.15 vs. 59.00 ± 4.64). Group H continued to have a PaO2of >200 mmHg even at 12 min of apnoea with a significant rise in PaCO2along with fall in pH after 6 min. Conclusion: During apnoeic periods time to desaturate to <90% was significantly prolonged with use of THRIVE.
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Appropriate angled-tip front width facilitates tracheal tube introducer placement in difficult-to-displace epiglottis situations
Amitabh Dutta, Manish Gupta, Prabhat Kumar Choudhary, Jayashree Sood
March 2018, 62(3):229-232
DOI:10.4103/ija.IJA_639_17  PMID:29643559
Tracheal tube introducers (TTIs) are a useful aid to a conventional laryngoscopy-intubation method of upper airway access in adults. However, even when TTIs are used, successful tracheal intubation is not guaranteed. Apart from suboptimal practice proficiency and unavailability of the complete repertoire of TTI, the physical attributes of the TTI have a role to play. Our report on the management of two cases highlights the importance of selecting a TTI with appropriate angled tip characteristics to facilitate successful guided intubation.
  6,137 193 -
Anaesthetic management and perioperative outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: A retrospective analysis
Kalpana P Balakrishnan, Sreedevi Survesan
March 2018, 62(3):188-196
DOI:10.4103/ija.IJA_39_18  PMID:29643552
Background and Aims: Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is becoming the standard treatment option for peritoneal carcinomatosis but is associated with high rates of morbidity and mortality. Our aim was to retrospectively analyse and evaluate intra-operative factors associated with morbidity and mortality of CRS and HIPEC. Methods: Intra-operative data were collected for cases done over 1 year (24 cases) and analysed for the primary outcome of post-operative ventilation >24 h, and secondary outcome of length of the Intensive Care Unit (ICU) stay >5 days. Statistical analysis was carried out in STATA 11 software. Results: Higher peritoneal carcinoma index (PCI), (P = 0.0047), longer duration of surgery (P = 0.0016), higher delta temperatures (P = 0.0119), increased estimated blood loss (EBL) (P = 0.0054), high intraoperative fluid requirement (P = 0.0038), lower mean arterial pressure (MAP) (P = 0.0021) and higher blood products requirement were associated with >24 h ventilation. These factors were also associated with longer ICU stay. All these factors associated with >24 h ventilation and prolonged ICU stay are related to the PCI which is an indicator of the extent of surgery. Conclusion: Higher PCI, longer duration of surgery, higher delta temperatures, increased EBL, high intraoperative fluid requirement, lower mean arterial pressure and higher blood products requirement were associated with >24 h postoperative ventilation as well as ICU stay >5 days. All these factors are related to the PCI, which is a major predictor of post-operative morbidity.
  3,685 596 -
Securing of supraglottic airway devices during position change and in prone position
Pankaj Kundra
March 2018, 62(3):159-161
DOI:10.4103/ija.IJA_164_18  PMID:29643547
  2,904 666 -
Reversal agents: do we need to administer with neuromuscular monitoring – an observational study
Shilpa Goyal, Nikhil Kothari, Deepak Chaudhary, Shilpi Verma, Pooja Bihani, Mahaveer Singh Rodha
March 2018, 62(3):219-224
DOI:10.4103/ija.IJA_652_17  PMID:29643557
Background and Aims: In clinical practice, in the majority of patients, recovery from the effect of muscle relaxants is assessed using subjective methods such as head lift, eye-opening, or by sustained hand grip after giving anticholinesterases (neostigmine) at the end of surgery. We planned a prospective observational cohort study to test the hypothesis that objective neuromuscular monitoring can help us in avoiding the use of anticholinesterases for reversal. Methods: The patients posted for surgery of <2 h duration were included in the study. The cohort of patients was formed on the basis of those who were exposed to objective neuromuscular monitoring of recovery (train-of-four [TOF] ratio of 0.9 or more; exposed group) and the patients who were not exposed to objective neuromuscular monitoring (non-exposed group) acting as a control. Using objective neuromuscular monitoring, the time required for recovery from muscle relaxation when neostigmine was not given for reversal was noted and it was then compared with that of the control group. Results: A total of 190 patients were enrolled over a period of 3 years. With the use of TOF ratio of 0.9 for extubation, patients safely recovered from neuromuscular blockade, without using neostigmine, with no difference in the mean recovery time (14.48 ± 1.138 min) as compared to the control group (12.14 ± 1.067 min, P = 0.139). There was no incidence of reintubation in post-operative period. Conclusion: With objective neuromuscular monitoring, we can ensure complete recovery from the neuromuscular blockade while avoiding the use of anticholinesterases.
  2,983 537 -
Perioperative concerns and management of pressurised intraperitoneal aerosolised chemotherapy: Report of two cases
Sohan Lal Solanki, Pooja P Kumar, Ashwin DeSouza, Avanish P Saklani
March 2018, 62(3):225-228
DOI:10.4103/ija.IJA_623_17  PMID:29643558
Pressurised intraperitoneal aerosolised chemotherapy (PIPAC) is a new, mostly supportive approach to help patients with advanced peritoneal metastasis to increase the lifespan. It carries occupational hazards to health-care workers and especially anaesthesiologist during the procedure. The aerosolised chemotherapy can also cause chemical peritonitis and organ dysfunction in the perioperative period. In this case report, we present the report of two cases and discuss the perioperative concerns and management related to PIPAC.
  2,818 324 -
The effect of pre-emptive gabapentin on anaesthetic and analgesic requirements in patients undergoing rhinoplasty: A prospective randomised study
Eman Ramadan Salama, Asmaa Fawzy Amer
March 2018, 62(3):197-201
DOI:10.4103/ija.IJA_736_17  PMID:29643553
Background and Aims: Hypotensive anaesthesia is necessary in rhinoplasty for better visualisation of surgical field and reduction of surgery time. Gabapentin is a new generation anticonvulsant with anti-hyperalgesic and anti-nociceptive properties. We aimed to investigate the effect of pre-operative administration of oral gabapentin (1200 mg) on anaesthetic requirements and post-operative analgesic consumption and its role in hypotensive anaesthesia for rhinoplasty. Methods: Seventy adult patients undergoing rhinoplasty, were randomly allocated to two groups. Group I (G I) (n = 35) received gabapentin 1.2 g and Group II (G II) (n = 35) received oral placebo capsules 2 h before surgery. General anaesthesia was maintained with sevoflurane in oxygen-nitrous oxide to maintain bispectral index value between 40 and 60, and remifentanil infusion to keep mean arterial pressure (MAP) at 55–60 mmHg. End-tidal sevoflurane concentration, intra-operative remifentanil consumption and time to intended MAP were recorded. Visual analogue scale (VAS) scores, post-operative analgesic requirements and side effects for the first 24 h were recorded. Results: G I required significantly lower intra-operative remifentanil (G I = 0.8 ± 0.26 mg and G II = 1.7 ± 0.42 mg; P = 0.001) and end-tidal sevoflurane concentration, with reduced doses of post-operative tramadol and diclofenac sodium. Time to the intended MAP was significantly less in G I than G II (59.1 ± 12.3 vs. 73.6 ± 16.4, respectively, with P = 0.001). Conclusion: Pre-operative oral gabapentin significantly reduced intra-operative remifentanil and sevoflurane requirements during hypotensive anaesthesia along with decreased post-operative analgesic requirement.
  2,612 383 -
Ultrasound guided internal jugular vein cannulation in infants: Comparative evaluation of novel modified short axis out of plane approach with conventional short axis out of plane approach
Amit Rastogi, Aarti Agarwal, Puneet Goyal, Vansh Priya, Sanjay Dhiraaj, Rudrashish Haldar
March 2018, 62(3):208-213
DOI:10.4103/ija.IJA_676_17  PMID:29643555
Background and Aims: Central venous cannulation (CVC) through right internal jugular vein (IJV) route is routinely performed in paediatric patients undergoing major surgery and in those admitted to intensive care units. A novel technique (modified short-axis out-of-plane [MSA-OOP]) to improve first pass success rate of ultrasound-guided IJV CVC in neonates and infants is being compared with conventional SA-OOP method. Methods: A total of 120 patients were enroled in the study over a period of 6 months. All paediatric patients with age <1 year and weight <10 kg who underwent a major surgery requiring CVC were included. Patients were randomised to either of the two approaches of ultrasound-guided IJV cannulation; SA-OOP and modified SA-OOP (MSA-OOP). In modified approach, the midline of probe footprint was marked with a radio-opaque barium wire that casted a central acoustic shadow on ultrasound screen. Results: In MSA-OOP group, 83.1% of patients were cannulated in the first attempt as compared to 49.2% patients in group SA-OOP. Patients in MSA-OOP group required significantly fewer attempts for successful CVC as compared to patients in the SA-OOP group ( MSA-OOP: median = 1, interquartile range [1-1]; SAOOP: median = 2, interquartile range [1-2], P < 0.001, Mann–Whitney U-test). Conclusion: The use of MSA-OOP ultrasound technique for IJV CVC cannulation results in a higher first-attempt success rate and reduces the number of cannulation attempts.
  2,536 352 -
Role of dexmedetomidine as an anaesthetic adjuvant in breast cancer surgery as a day-care procedure: A randomised controlled study
Rekha Das, Rajat Kumar Das, Sushrita Sahoo, Suchismita Nanda
March 2018, 62(3):182-187
DOI:10.4103/ija.IJA_752_17  PMID:29643551
Background and Aims: Breast cancer surgery can be carried out as day-care procedure to increase patient turnover, decrease disease progression and financial burden. The present study was carried out to assess the role of dexmedetomidine in breast cancer surgery as a day-care procedure. Methods: This prospective randomised, double-blind study was carried out on 100 patients screened for day-care breast cancer surgery. They were divided into two groups of 50 each; who received either normal saline (Group NS) or 0.6 μg/kg/h dexmedetomidine (Group D) infusion from 10 min before induction until skin closure. All patients were given general anaesthesia. The incidence of discharge, post-operative pain (POP), average rescue analgesia (fentanyl) required and side effects were noted. Statistical analysis was performed using Student's t-test and Chi-square test. Results: Incidence of discharge in group NS was 60% compared to 88% in Group D (P = 0.001). Average rescue analgesia requirement by group NS was 136.07 ± 43.06 μg, whereas it was 77.5 ± 29.86 μg in Group D (P = 0.01). The incidence of POP in 6 h and within 2 h of expected discharge time in Group NS was 56% and 28%, respectively, and in Group D, it was 8% in both the periods (P < 0.001 and 0.01). Side effects such as post-operative nausea, vomiting and bleeding were encountered in eight and two patients, respectively, in Group NS and two and one patients, respectively, in Group D. Conclusion: Dexmedetomidine as an anaesthetic adjuvant makes breast cancer surgery feasible on day-care basis.
  2,410 459 -
Evaluation of performance of Streamlined Liner of the Pharynx Airway™, Laryngeal Mask Airway-ProSeal and endotracheal tube in prone position: A prospective, randomised study
Harihar Vishwanath Hegde, Joshiraj Bandi, Mahantesh S Mudakanagoudar, Kiran A Honnannavar
March 2018, 62(3):173-181
DOI:10.4103/ija.IJA_691_17  PMID:29643550
Background and Aims: Airway used in prone position should be efficacious and safe. The Streamlined Liner of the Pharynx Airway (SLIPA™) and Laryngeal Mask Airway-ProSeal (PLMA) provide better airway seal and protection against aspiration. We planned to evaluate the performance of SLIPA™, PLMA and endotracheal tube (ETT) in prone position. Methods: 114 adult patients undergoing elective surgery in prone position under general anaesthesia were randomised into Group-T (ETT), Group-S (SLIPA™) and Group-P (PLMA). Airways were inserted in supine position and patients turned prone subsequently. Airway characteristics, ventilatory parameters and complications were noted. One-way analysis of variance, Mann–Whitney U-test and Chi-square or Fisher's exact test were used. Results: Tidal volumes, peak airway pressure and compliance were comparable at all times. Leak pressure was significantly higher (P < 0.001) in Group-T (mean leak pressure = 40 cmH2O) when compared to Group-S and Group-P at all the times of recording, and there was no significant difference between Group-S and Group-P. The number of patients requiring airway/neck manipulation in prone position was significantly higher (P < 0.001) in Group-S (19 [55.9%]) when the three groups were compared (none in Group-T) and in comparison with Group-P (5 [14.7%], P < 0.001). On airway removal, the incidence of complications and airway reaction was significantly higher in Group-T. Group-S had a significantly higher incidence of dysphagia at 2 h postoperatively. Conclusion: ETT was most efficacious. SLIPA™ and PLMA were efficacious, safe and less stimulating to the airway during removal. More patients required SLIPA™ airway/neck manipulation.
  2,455 397 -
Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: Fluid and temperature remain the culprit!
Rakesh Garg
March 2018, 62(3):162-165
DOI:10.4103/ija.IJA_170_18  PMID:29643548
  2,250 437 -
A prospective observational study of injection pain in children with medium plus long chain triglyceride and long chain triglyceride propofol premixed with lignocaine
Bhavika Singla, Anila D Malde
March 2018, 62(3):214-218
DOI:10.4103/ija.IJA_506_17  PMID:29643556
Background and Aims: Propofol injection pain is an unresolved problem in children. Although medium and long chain triglyceride (MCT-LCT) propofol has shown promising results in adults, its efficacy in children is not proven. In a prospective observational study the incidence and severity of pain with MCT-LCT and LCT propofol in children was compared. Methods: After obtaining approval from the Institutional Ethics Committee, 170 children (age group 6 months to 8 years) scheduled for various surgeries were included in this study. Following standard pre-medication, propofol 1% either LCT or MCT-LCT in a dose of 2–4 mg/kg along with preservative-free lignocaine (2% lignocaine 1 mg in propofol 10 mg) was administered. The primary objective was to study injection pain on scale of 0–6. For children ≤2 years doubling of motor event score (0–3) and for children >2 years, addition of motor (0–3) and verbalisation scores (0–3) were considered. Mann–Whitney U test was used for statistical analysis. Results: MCT-LCT group had lower incidence of pain (17 patients (20%) versus 35 patients (35.3%), P = 0.026) and severe pain (zero patients (0%) versus six patients (7.1%), P = 0.029) as compared to LCT group. MCT-LCT group had significantly lower mean rank of motor (79.65 versus 91.35), verbal (77.29 versus 90.79) and total score (77.76 versus 93.24) as compared to LCT group (P = 0.037, 0.002, and 0.009, respectively). Conclusion: MCT-LCT propofol is associated with significantly lower injection pain as compared to LCT propofol in children, when both are combined with lignocaine.
  2,000 275 -
Kawasaki disease and general anaesthesia: The Know - Hows
Vrushali C Ponde, Vinit Vinod Bedekar, Carlo A Manalang
March 2018, 62(3):234-235
DOI:10.4103/ija.IJA_627_17  PMID:29643561
  1,655 242 -
The utility of the oxygen reserve index™ in a neonate undergoing re-exploration of a tracheoesophageal fistula
Swarup Ray, Ketan Sakharam Kulkarni, Nandini Malay Dave, Indrani Chincholi
March 2018, 62(3):233-234
DOI:10.4103/ija.IJA_778_17  PMID:29643560
  1,489 285 -
WhatsApp: Is it a solution to daily human resources management in institutional practice?
Sumitra G Bakshi
March 2018, 62(3):236-236
DOI:10.4103/ija.IJA_731_17  PMID:29643562
  1,460 228 -
Acute exacerbation of Chiari malformation: A rare cause for non-awakening from anaesthesia
Sourabh Vig, Kanil Ranjith Kumar, Deepak Poudel
March 2018, 62(3):238-239
DOI:10.4103/ija.IJA_760_17  PMID:29643564
  1,468 209 -
Induction of anaesthesia in cyanotic heart diseases: 'Ketomidate' to the rescue!
Nupur Dua, Anju R Bhalotra
March 2018, 62(3):237-237
DOI:10.4103/ija.IJA_395_17  PMID:29643563
  1,320 250 -
Scavenging tubing compression: A rare cause for anaesthesia ventilator malfunction
Stalin Vinayagam, Sangeeta Dhanger, Diana Thomas, TA Venkatesh Babu
March 2018, 62(3):239-240
DOI:10.4103/ija.IJA_20_18  PMID:29643565
  1,358 152 -
Reply: Only with an optimal position of the supraglottic airway in situ, valid conclusions can be drawn about oropharyngeal airway pressure
Divya Jain, Komal Gandhi
March 2018, 62(3):243-243
DOI:10.4103/ija.IJA_151_18  PMID:29643567
  1,171 166 -
Only with an optimal position of the supraglottic airway in situ, valid conclusions can be drawn about oropharyngeal airway pressure
André AJ Van Zundert, Kerstin H Wyssusek
March 2018, 62(3):241-242
DOI:10.4103/ija.IJA_135_18  PMID:29643566
  1,141 172 -