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   2018| July  | Volume 62 | Issue 7  
    Online since July 11, 2018

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Efficacy of dexmedetomidine for prevention of emergence agitation in patients posted for nasal surgery under desflurane anaesthesia: A prospective double-blinded randomised controlled trial
Akaansha Garg, Manoj Kamal, Sadik Mohammed, Geeta Singariya, Dilip S Chouhan, Ghanshyam Biyani
July 2018, 62(7):524-530
DOI:10.4103/ija.IJA_788_17  PMID:30078855
Background and Aims: Nasal surgery under desflurane anaesthesia is more prone to develop emergence agitation (EA). The present study aimed to evaluate the efficacy of dexmedetomidine for prevention of EA. Methods: A total of 72 patients were randomised to group C and group D. Group C patients received placebo while group D patients received dexmedetomidine 1.0 μg/kg bolus followed by 0.4 μg/kg/h after induction of anesthesia. End tidal desflurane was adjusted to keep the bispectral index (BIS) 45–55. Study drug was stopped at extubation. EA was evaluated from extubation till the patient was shifted to postanaesthesia care unit (PACU). Primary outcome was incidence of EA. Secondary outcome measures were requirement of desflurane, haemodynamic stability, and recovery after anaesthesia. The results were analyzed using SPSS version 21. Results: Infusion of dexmedetomidine significantly reduced the incidence of EA (Group C 52.8%; Group D 5.6%) by 89.5% (P = 0.00001). The endtidal desflurane concentration was significantly lower and there was an average 28.87% reduction in requirement of desflurane in group D compared to group C (P < 0.001). The mean heart rate was significantly higher in Group C (P < 0.001). In group C time to extubation, time to achieve BIS 90 and time to response on verbal command was significantly lesser compared to group D (P < 0.0001). Conclusion: Dexmedetomidine significantly reduced the incidence of EA and requirement of desflurane in patients undergoing nasal surgery. However, it was associated with delayed extubation, residual sedation, and prolonged PACU stay.
  7,491 434 -
Erector spinae plane block in abdominal surgery: Case series
Juan Carlos Luis-Navarro, Maria Seda-Guzmán, Cristina Luis-Moreno, Ki-Jinn Chin
July 2018, 62(7):549-554
DOI:10.4103/ija.IJA_57_18  PMID:30078859
The aim of this study is to report 11 cases of erector spinae plane (ESP) block used for unilateral or bilateral abdominal surgery, adding to the overall limited experience with abdominal ESP block. The procedures were carried out at a teaching hospital in 11 patients (eight males, three females, ages 36–80 years) requiring abdominal surgery, including laparoscopic surgery. Each patient required surgery under different physical circumstances and likely different conceptions of what constituted pain. Two of the eleven patients were administered the ESP block and did not require general anaesthesia. Most of the patients with the ESP block maintained a numerical rating scale (NRS) for pain of 0–2/10 postoperatively. An occasional patient required paracetamol analgesia. There were no cases of opiate rescue. Obesity in a 46-year-old woman was believed to cause unclear ultrasonographic visualisation, interfering with entry of the ESP catheter. She, however, had no post-operative pain. She was given the usual intravenous metamizole 2 g for 10 h and required only analgesics at 16 h. ESP block, which produces analgesia by blocking trunk nerves, is an appropriate approach to patients requiring abdominal surgery, whether laparoscopic or open.
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Comparison of ultrasound-guided bilateral subcostal transversus abdominis plane block and port-site infiltration with bupivacaine in laparoscopic cholecystectomy
Indu Suseela, Krishnadas Anandan, Arun Aravind, Suvarna Kaniyil
July 2018, 62(7):497-501
DOI:10.4103/ija.IJA_55_18  PMID:30078851
Background and Aims: Many patients experience moderate-to-severe pain after laparoscopic cholecystectomy. We aimed to compare the efficacy of ultrasound-guided bilateral subcostal transversus abdominis plane (TAP) block with port-site infiltration for post-operative analgesia after laparoscopic cholecystectomy. Methods: Patients undergoing elective laparoscopic cholecystectomy under general anaesthesia were divided into two groups of 40 each to receive ultrasound-guided bilateral subcostal TAP block (T) with 0.25% bupivacaine 20 ml each side or port-site infiltration with 0.5% bupivacaine 5 ml each at 4 ports (I) at the end of the surgery before extubation. All patients received paracetamol 1 g intravenous 8th hourly. Tramadol 1 mg/kg intravenous bolus and diclofenac 1 mg/kg intravenous infusion were used as the first- and second-line rescue analgesics when Numerical Rating Scale (NRS) ≥4, or when the patient complained of pain. NRS at 1, 2, 3, 6, 12 and 24 h after surgery, time to first analgesic request and total dose of analgesics in 24 h were recorded. Chi-square test and independent t-test were used to compare qualitative and quantitative data, respectively. Results: Time to first analgesic (mean±SD) in Group I and Group T was 292.7 ± 67.03 and 510.3 ± 154.55 min and mean tramadol required was141.8 ± 60.01 mg and 48.69 ± 36.14 mg, respectively (P = 0.001 for both). Mean NRS at 2, 3, 6, 12 and 24 h was significantly lower in Group T. Conclusion: Ultrasound-guided bilateral subcostal TAP block provides superior post-operative analgesia after laparoscopic cholecystectomy compared to port-site infiltration.
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Assessment of perioperative difficult airway among undiagnosed obstructive sleep apnoea patients undergoing elective surgery: A prospective cohort study
Krishnakumar Mathangi, Jacob Mathews, Chandrasekar D Mathangi
July 2018, 62(7):538-544
DOI:10.4103/ija.IJA_158_18  PMID:30078857
Background and Aims: Obstructive sleep apnoea (OSA) is largely undiagnosed in surgical population. Airway-related complication account for 35% of anaesthesia-related deaths and OSA patients have higher occurrence of difficult intubation (DIT). The aim of the study is to estimate the occurrence and compare utility of OSA screening parameters in predicting difficult mask ventilation (DMV) and DIT in patients with undiagnosed OSA. Methods: A prospective observational study was conducted in a tertiary care centre in patients undergoing elective surgery. STOP-BANG questionnaire was administered preoperatively along with collection of demographic data and airway assessment. Population was divided in to OSA and non-OSA groups based on STOP-BANG score >3. Occurrence of DMV, laryngoscopy (DL), and DIT were compared between both groups using DMV score, Cormack–Lehane grading, and intubation difficulty scale score, respectively. Results: A total of 54 patients in OSA and 46 patients in non-OSA group were studied. A total of 49 cases of DMV, 14 cases of DIT, and 25 cases of DL were encountered. In the OSA group, there was 77.7% DMV, 22.2% DIT, and 33.3% DL. History of snoring had the highest sensitivity and negative predictive value while history of apnea, body mass index >35, sleep apnoea clinical score had the highest specificity in determining occurrence of difficult airway. Multivariate logistic regression analysis demonstrated STOP-BANG score as the single most important predictor of DMV (odds ratio 3.15, 95% confidence interval, 2.06–4.8). Conclusion: Positive screening test for OSA is associated with difficult airway management.
  2,527 617 -
Comparison of bispectral index and end-tidal anaesthetic concentration monitoring on recovery profile of desflurane in patients undergoing lumbar spine surgery
R Sudhakaran, Jeetinder K Makkar, Divya Jain, Jyotsna Wig, R Chabra
July 2018, 62(7):516-523
DOI:10.4103/ija.IJA_172_18  PMID:30078854
Background and Aims: Several techniques have evolved over time to monitor depth of anesthesia and ensure enhanced recovery. This randomized double-blinded trial was designed to compare bispectral index (BIS) or end-tidal anaesthetic concentration (ETAC) monitoring on the recovery characteristics of patients undergoing thoracolumbar spine surgeries. Methods: Seventy American Society of Anesthesiologist I–II patients of either sex were randomized to Group B – BIS-guided protocol, Group E – ETAC-guided protocol, or Group S – Standard protocol. After intravenous induction, anaesthesia was maintained with desflurane in O2/N2O (50:50) mixture. In BIS, ETAC and Standard groups, inspired end-tidal desflurane concentration was varied to achieve BIS of 45–55, 0.8–1.0 age-corrected minimum alveolar concentration, and haemodynamic parameters within 20% of the baseline, respectively. Time to eye opening (emergence time, the primary outcome), time to extubation, and time to name recall from the discontinuation of the anaesthetic agent were recorded. Incidence of nausea, vomiting, and total analgesic consumption was noted for 24 h. Results: Emergence time (mean ± SD) in ETAC (5.1 ± 1.53 min) and BIS (5.0 ± 2.12 min)-guided groups was significantly lower than Standard group (7.5 ± 2.90 min). Extubation time in ETAC (6.3 ± 2.22 min) and BIS-guided group (6.5 ± 1.78 min) was significantly lower than Standard group (9.0 ± 3.20 min) (P < 0.001). Time to achieve fast track score of more than 12 was significantly less in BIS-guided group (13.12 ± 2.59 min). Conclusion: ETAC-guided anaesthesia is comparable to BIS-guided anaesthesia in achieving early recovery.
  2,639 476 -
Standards of care for procedural sedation: Focus on differing perceptions among societies
Satyen Parida, Pankaj Kundra, VK Mohan, Sandeep K Mishra
July 2018, 62(7):493-496
DOI:10.4103/ija.IJA_201_18  PMID:30078850
Adherence to established standards of care is important for anaesthesiologists to avoid undesirable legal consequences of their actions. The judiciary lays stress on the need to perpetuate healthy doctor–patient correspondence, good documentation, and to bestow a justifiable standard of care. But what defines standard of care and who delineates such standards is something that lacks clarity. The American Society for Gastrointestinal Endoscopy (ASGE) has recently released updated guidelines on the use of sedation and anaesthesia for gastrointestinal endoscopic procedures. Almost simultaneously, the American Society of Anesthesiologists (ASA) has brought out practice guidelines for moderate sedation and analgesia. In contrast to the ASA recommendations, ASGE does not view capnography as an essential monitoring modality for endoscopic procedures with moderate sedation because it has apparently not been shown to improve patient safety. However, they do agree that evidence supports its deployment during deep sedation. These differences in views between guidelines published by societies of substantial academic and clinical standing can confuse the agreement over what constitutes standard of care for the particular speciality. It is the expectation that guidelines and consensus statements in anaesthesiology be preferably issued by national or international organizations of the same speciality.
  2,471 633 -
Effect of epidural levobupivacaine with or without dexamethasone soaked in gelfoam for postoperative analgesia after lumbar laminectomy: A double blind, randomised, controlled trial
Kamlesh Kumari, Manoj Kamal, Geeta Singariya, Rama Kishan, Sunil Garg, Sharad Thanvi
July 2018, 62(7):509-515
DOI:10.4103/ija.IJA_128_18  PMID:30078853
Background and Aims: Postoperative pain results in prolonged hospital stay and delayed return to normal activity. This study was conducted with the aim of evaluating the analgesic efficacy of gelfoam soaked in levobupivacaine with or without dexamethasone placed in the epidural space in patients undergoing lumbar laminectomy. Methods: Ninety adult patients were randomised into three groups. Gelfoam was soaked in 12 mL of 0.9% sodium chloride in Group P, 10 mL of 0.25% levobupivacaine + 2 mL of 0.9% sodium chloride in Group L, and 10 mL of 0.25% levobupivacaine + 2 mL of dexamethasone in group LD. The primary outcome was time to first request for rescue analgesia. Total 24-h tramadol consumption, and postoperative visual analog scale (VAS) scores were recorded. Chi-square test and analysis of variance test were used, and P < 0.05 was considered significant. Results: 75 patients completed the study. Time to first rescue analgesia was longer in group LD [10.11 ± 3.10 h] compared with group L [6.48 ± 2.36 h] and group P [1.76 ± 1.13 h]. Total 24-h tramadol consumption was lower in group LD (88 ± 66.58 mg) and group L (120 ± 70.7 mg) compared with group P (280 ± 64.5 mg). Postoperative VAS scores were lower in group LD and group L compared with group P, both at rest and on movement. Conclusion: Epidural gelfoam soaked in levobupivacaine and dexamethasone prolongs the duration of analgesia and decreases rescue analgesic consumption and VAS score postoperatively, in patients undergoing lumbar laminectomy.
  2,448 450 -
Management of a case of ventricular bigeminy using central neuraxial blockade
Gunjan Singh, Manpreet Kaur, Maya Dehran
July 2018, 62(7):567-568
DOI:10.4103/ija.IJA_182_18  PMID:30078867
  2,561 311 -
Acute pain service: Round the clock vigilance
PN Jain
July 2018, 62(7):491-492
DOI:10.4103/ija.IJA_471_18  PMID:30078849
  2,211 573 -
Dexmedetomidine–propofol vs ketamine–propofol anaesthesia in paediatric and young adult patients undergoing device closure procedures in cardiac catheterisation laboratory: An open label randomised trial
Kunal Tewari, Vishal V Tewari, Subroto K Datta
July 2018, 62(7):531-537
DOI:10.4103/ija.IJA_692_17  PMID:30078856
Background and Aims: Several drug combinations have been tried in patients with acyanotic congenital heart disease (ACHD) undergoing transcatheter device closure in the cardiac catheterisation laboratory (CCL). Adequate sedation, analgesia, akinesia, cardiorespiratory stability, and prompt recovery are key requirements. Ketamine with propofol is used for this purpose. Dexmedetomidine carries a shorter recovery time. This study compared dexmedetomidine–propofol (DP) with ketamine–propofol (KP) in patients in the CCL. Methods: This was an open label randomised trial at a CCL over a 2-year period from August 2012 to August 2014. Fifty-six paediatric and 44 young adults with ACHD underwent device closure and were randomised to receive DP or KP. The primary outcome studied was time to regain full consciousness, airway and motor recovery. Results: Baseline characteristics were similar in the study groups. In the DP arm as compared to the KP arm, the time to recovery of consciousness (mean ± SD) was significantly faster in both paediatric patients [30 ± 15 vs. 58 ± 13 min (P < 0.001)] and in young adult patients [22 ± 10 vs. 35 ± 12 min (P < 0.001)]. There was significantly faster motor recovery also (mean ± SD) [paediatric: 25 ± 05 vs. 40 ± 14 (P < 0.001); young adult: 10 ± 05 vs. 22 ± 10 min (P < 0.001)]. Conclusion: Procedural anaesthesia with DP in paediatric and young adult patients with ACHD undergoing device closure in the CCL resulted in faster recovery of consciousness and motor recovery compared to KP.
  2,025 348 -
Laryngeal Mask Airway Protector™ for intubation and extubation in thyroid surgeries: A case report
Leng Zoo Tan, Daryl Jian An Tan, Edwin Seet
July 2018, 62(7):545-548
DOI:10.4103/ija.IJA_43_18  PMID:30078858
The laryngeal mask airway (LMA) Protector™ has recently made its way into clinical practice. As little is reported on this novel supraglottic airway device, we describe our experiences through intubation and Bailey manoeuvre using the LMA Protector™, and the assessment of vocal cord mobility using a flexible bronchoscope through it in three patients undergoing hemithyroidectomies.
  1,914 385 -
Impact of basic medical writing workshop on case report writing by post-graduate anaesthesia trainees: A pilot study
Anjana S Wajekar, Sweta V Salgaonkar, Indrani H Chincholi, Anita N Shetty
July 2018, 62(7):502-508
DOI:10.4103/ija.IJA_98_18  PMID:30078852
Background and Aims: Research is an integral component of medical education and practice. However, the art of medical writing remains neglected. Case report writing marks foray into the world of publications and presentations. We assessed and compared the impact of basic medical writing workshop about case report writing and their perception levels of confidence in these skills, among post-graduate anaesthesia students. Methods: A needs assessment for medical writing skills was performed among all anaesthesia residents. A total of 20 students were enrolled in this study. The pre-workshop assignment consisted of writing one case report per participant within 30 days, followed by students' confidence assessment in these skills. A workshop on basic medical writing including analytical writing, scientific writing and plagiarism were conducted. Post-workshop a similar assignment was provided, followed by students' confidence assessment. Results: Moderate-to-high need for help was felt by 92.63% for analytical skills, 100% for scientific skills and writing without plagiarism, 95.78% for overall writing skills. For case report writing, the analytical and scientific writing significantly improved after the workshop (P = 0.01 and P = 0.016, respectively). There was a significant improvement in the students' confidence levels post-workshop in their analytical writing skills, avoiding plagiarism and overall writing capabilities (P = 0.02, P = 0.016 and P = 0.002, respectively). Conclusion: Writing skills of participants and their confidence in these skills improved post-workshop.
  1,991 308 -
Elastomeric pumps: How cautious should we be?
Swarup Ray, Barkha Agrawal, Raylene Dias, Nandini Dave
July 2018, 62(7):558-559
DOI:10.4103/ija.IJA_347_18  PMID:30078861
  1,491 799 -
Ultrasound-guided continuous transmuscular quadratus lumborum block- L4 or L2 level catheter insertion for analgesia in open abdominal surgery: Case series
Vasanth Rao Kadam, S Howell
July 2018, 62(7):555-557
DOI:10.4103/ija.IJA_242_18  PMID:30078860
  1,871 313 -
Electronic medical record system: A critical viewpoint
Sumitra G Bakshi, Bhakti Trivedi
July 2018, 62(7):564-565
DOI:10.4103/ija.IJA_178_18  PMID:30078865
  1,537 223 -
Document for patient's sake.... for your colleague's sake! Document.... for GOD'S sake!!
Swati Chhabra, Pradeep Bhatia, Sadik Mohammed, Rakesh Kumar
July 2018, 62(7):562-563
DOI:10.4103/ija.IJA_272_18  PMID:30078864
  1,443 258 -
Anesthetic considerations in Stevens–Johnson syndrome with epilepsy for bilateral amniotic membrane grafting in eye
Vinod K Parashar, Sanwar M Mitharwal, Ankita Chaudhary
July 2018, 62(7):569-570
DOI:10.4103/ija.IJA_49_18  PMID:30078868
  1,420 215 -
Major leak during controlled ventilation due to faulty exhaust valve missed during pre-use machine check
Apala Roy Chowdhury, Kanil Ranjith Kumar, Renu Sinha
July 2018, 62(7):560-562
DOI:10.4103/ija.IJA_143_18  PMID:30078863
  1,332 200 -
In the plane, but not in plane: Mind the gap in the transversus abdominis plane
Bikram Kishore Behera, Satyajeet Misra
July 2018, 62(7):565-566
DOI:10.4103/ija.IJA_218_18  PMID:30078866
  1,286 202 -
Acute gastric conduit dilatation after oesophagectomy as a cause of respiratory distress
Abhijit S Nair, Vibhavari Milind Naik, Suresh Seelam, Basanth Kumar Rayani
July 2018, 62(7):559-560
DOI:10.4103/ija.IJA_203_18  PMID:30078862
  1,240 154 -