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   2020| March  | Volume 64 | Issue 3  
    Online since March 11, 2020

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The 2019 novel corona virus outbreak – An institutional guideline
Varun Suresh
March 2020, 64(3):242-243
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Advances in vaporisation: A narrative review
Pankaj Kundra, Shreya Goswami, Aruna Parameswari
March 2020, 64(3):171-180
The output of inhalational agents from modern vaporisers are both electronically and pneumatically controlled. They are designed to deliver set agent concentrations accurately with low fresh gas flows and possess enhanced safety features. The purpose of this review article is to give an overview of three modern vaporisers, namely, the Aladin cassette vaporiser, injection vaporisers and AnaConDa™. The Aladin cassette is integrated with Datex Ohmeda S/5 ADU and GE Aisys anaesthesia machines. The electronic vapour control unit is incorporated within the anaesthesia machine. The agent specific cassettes act as a detachable vaporising chamber. The system can work as a variable bypass and measured flow vaporiser but requires a power supply to function. Injection vaporisers can achieve the set end-tidal agent concentration very rapidly with even metabolic flow rates. Hence, anaesthetic depth can be rapidly altered with minimal wastage and theatre pollution. The two types of injection vaporisers, namely, Maquet and DIVA™ are customised to function with Maquet FLOW-i and the Drager Zeus anaesthesia machine, respectively. AnaConDa™ is a combination of vaporiser and humidity and moisture exchange filter which can be fitted in the ventilatory circuit. It is primarily designed for use in intensive care for sedation and out of operating room use.
  2,478 689 -
A prospective, randomised, comparative study to evaluate long axis, short axis and medial oblique axis approach for ultrasound-guided internal jugular vein cannulation
Jatin Lal, Mamta Bhardwaj, Meenakshi Verma, Teena Bansal
March 2020, 64(3):193-198
Background and Aims: The Ultrasound (USG)-guided internal jugular vein (IJV) cannulation can be performed using different approaches like short axis (SAX), long axis (LAX), oblique axis (OAX) or medial oblique axis (M-OAX). We aimed to determine which view was optimal for IJV cannulation. Methods: After ethical committee approval and written informed consent, this prospective, randomised, controlled trial was conducted on 108 patients. Patients were allocated into one of the three groups: A (SAX), B (LAX) and C (M-OAX approach) for USG-guided IJV cannulation. The number of needle passes, the success of IJV cannulation and its diameter, venous access time, guidewire time, catheterisation time and complications if any were recorded. Statistical analysis was performed by SPSS version 17.0. Results: First needle pass success rate was highest in M-OAX (97.2%) followed by SAX (88.9%) and then LAX (77.8%) but it was statistically insignificant among the groups. Mean venous access, guidewire insertion and catheterisation time were shortest in M-OAX followed by SAX and then LAX approach. It was statistically significant between LAX and SAX and between LAX and M-OAX group. (P < 0.001). The carotid puncture was noticed in two patients in the LAX group. The overall success rate and the number of needle passes were comparable among the groups. Conclusion: The M-OAX approach is a safe and effective technique for USG-guided IJV cannulation when compared to SAX and LAX approaches.
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Development of a scoring system for predicting difficult intubation using ultrasonography
Harith Daggupati, Indubala Maurya, Roshan D Singh, M Ravishankar
March 2020, 64(3):187-192
Background and Aims: Ultrasound measurement of anterior neck soft tissue thickness by skin to epiglottis distance (SED) has been shown to predict difficult laryngoscopy. In this study, we developed an airway scoring system incorporating SED into three clinical predictors and assessed whether it would improve accuracy in prediction of difficult intubation. Methods: Mentohyoid distance, mandibular subluxation, head extension and ultrasound measurement of skin to epiglottis distance were measured a day before surgery in 310 adult patients. During direct laryngoscopy, Cormack–Lehane grading was noted (Grade 1 and 2 = Easy, Grade 3 and 4 = Difficult). We constructed a score named MSH, which included mentohyoid distance, mandibular subluxation and head extension. Then, SED was added to the MSH score to form another new score named USED-MSH. Student's t-test, Mann-Whitney U test and Chi-square test or Fisher exact tests were used. Both scoring systems were compared under the receiver-operating characteristic curve and area under the curve (AUC) were calculated. Results: Difficult intubation was observed in 62/310 patients (20%). The AUC for USED-MSH score was greater than the MSH score (0.93, 95% CI [0.89–0.97] vs 0.76, 95% CI [0.69–0.84], P value <0.001). USED-MSH score had higher sensitivity (93.6% vs 59.7%) and lower specificity (85.9% vs 91.1%) with similar positive predictive value (62.7% vs 62.4%) in comparison with MSH score. Conclusion: An airway scoring system using the ultrasound measurements of skin-to-epiglottis distance along with the clinical predictors would be helpful in the prediction of difficult intubation.
  1,133 348 -
A prospective 3 year study of clinical spectrum and outcome of dengue fever in ICU from a tertiary care hospital in North India
Prakash S Shastri, Prasoon Gupta, Rahul Kumar
March 2020, 64(3):181-186
Background and Aims: The incidence of specific complications and adverse outcomes in dengue patients needing admission to intensive care units (ICU) may be quite variable in different regions of India presumably because of different strains of dengue virus or due to re infection. Methods: Patients admitted with acute febrile illness (AFI) with either positive IgM antibody or NS1 antigen for dengue were enrolled. Data were collected for 3 years (2015-2017). A total of 313 patients with acute febrile illness were admitted in the study period (2252 total ICU admissions). A total of 137 (43.76%) cases were serologically proven as dengue fever. Results: Median age (IQR) of study population was 36.0 (26.0–52.0) years. Liver (65.7%) was the main organ involved followed by acute kidney Injury (AKI) (18.6%). Dengue Shock Syndrome (DSS) was found in 18.6% of cases. Fifty-two patients died and the crude mortality was 38.0%. On multivariate analysis APACHE Score <10, thrombocytopenia, hepatic dysfunction, AKI and dengue shock syndrome (DSS) were associated with the risk of mortality. Conclusion: This study in ICU patients showed high mortality in relatively younger patients. Liver (in the form of raised Bilirubin) was the most common organ dysfunction. The need to recognise early warning signs for ICU admission is highlighted.
  1,077 158 -
Comparison of cross-legged sitting position with the traditional sitting position for the ease of insertion of an epidural catheter in parturient for providing labour analgesia: A randomised control trial
Nitu Puthenveettil, Sai Sandhya, Nandhini Joseph, Sobha Nair, Jerry Paul
March 2020, 64(3):199-203
Background and Aims: The patient's position during the insertion of the epidural catheter plays a major role in the success of labour analgesia. In our study, we compared the ease of insertion of the epidural catheter in either traditional sitting position (TSP) or crossed-legged sitting position (CLSP). The primary objective was to compare the number of successful first attempts at epidural placement between the groups. Secondary objective included patient comfort, ease of landmark palpation and the number of needle-bone contacts. Methods: The prospective non-blinded randomised control study was conducted on 50 parturient with uncomplicated pregnancy during active labour. Patients were randomly assigned into two groups using a computer-generated random sequence of numbers by closed envelope technique. Group TSP received epidural in a traditional sitting position and group CLSP received an epidural in a crossed-legged sitting position with knee and hip flexed. Results: The parturient in both groups were comparable with respect to the distribution of age, height, weight and parity. The baseline visual analogue score (VAS) and VAS scores at 15 min were comparable between groups. Percentage of a parturient with successful epidural placement in the first attempt was higher in CLSP group than in TSP group (88% versus 44%, P = 0.004). The landmark, needle-bone contact and comfort during positioning were comparable between the two groups. Conclusion: Cross-legged sitting position is a better position than the traditional sitting position for the ease of insertion of labour epidural catheter.
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Severe Dengue: Lessons learnt from an observational study
Subhash K Todi
March 2020, 64(3):169-170
  925 186 -
A rare occurrence of accidental exposure to UV radiation among operating theatre personnel
Mansi U Vaidya, Gauri R Gangakhedkar, Anita N Shetty, Pallavi V Waghalkar
March 2020, 64(3):230-232
Ultraviolet (UV) lamps are commonly used in operation theatres for disinfection. Accidental exposure causes damage to superficial tissues especially the skin, the eyes and has the potential to cause various malignancies. Nine previously asymptomatic operation theaters (OT) personnel experienced, foreign body sensation with intense tearing of eyes and erythematous rash on exposed body parts 2 to 4 hours after leaving work. They required symptomatic treatment with oral and topical antihistaminics and lubricant eye drops. Two of the nine required intravenous steroids. UV exposure was diagnosed as diagnosis of exclusion. There is a lack of knowledge regarding presence UV radiation in OT and a lack of safety measures in place to prevent exposure. This case report emphasises the threats poses by UV exposure, the need to bring about awareness about the presence of UV lamps and adopting safety measures to avoid exposure among healthcare providers.
  934 98 -
Parents' perception and factors affecting compliance with preoperative fasting instructions in children undergoing day care surgery: A prospective observational study
Karan Singla, Indu Bala, Divya Jain, Neerja Bharti, Ram Samujh
March 2020, 64(3):210-215
Background and Aims: Fasting guidelines have been recommended in the paediatric population to minimise the risk of pulmonary aspiration. The present study was planned to assess the compliance with fasting instructions in children undergoing ambulatory surgery and identify the factors affecting it. Methods: A total of 1,050 ASA I and II children aged 1–12 years, scheduled for day care surgery were enrolled. Parents of these children were given a questionnaire with specific questions like fasting instructions, source of instructions, actual fasting times and reasons for not following instructions. Results: Only 90 (8.5%) parents followed fasting instructions as advised. Of the 960 non-compliant patients, 31 (2.9) inadequately fasted while 929 (88.4%) fasted more than advised. While only 5.2% mentioned aspiration, 25% cited vomiting as the reason for fasting. Younger parents (OR = 0.853, 95% CI-0.796 to 0.915), fasting instructions in writing (OR = 10.808, 95% CI-1.459 to 80.059) and separate instruction for solids and liquids (OR = 6.016, 95% CI- 3.663 to 9.883) were found to affect compliance with fasting instructions. Conclusion: To avoid risks of prolonged or inadequate fasting in day care surgical patients, good coordination between the anaesthetist and the surgeon and an updated knowledge about the preoperative fasting instructions among the health-care providers is essential. Separate written fasting instructions for liquids and solids should be given to the parents according to their order in the operating list to ensure better compliance with fasting instructions.
  880 136 -
An observational case-control study comparing the recovery profile in patients receiving additional dose of anticonvulsant vs. regular dose during supratentorial craniotomy
Rosen Roy Mathew, Krishnaprabhu Raju, Bijesh Ravindran Nair, Ramamani Mariappan
March 2020, 64(3):222-229
Background and Aims: Anticonvulsants are used routinely for seizure prophylaxis in patients with supratentorial tumour who present with/without seizures. Excessive use of prophylactic anticonvulsant may delay the recovery from anaesthesia. We have studied the recovery profiles of patients who received an additional dose of anticonvulsant in comparison with those who received only the regular dose. Methods: In this prospective observational study, patients were anaesthetised using standard anaesthesia protocol. An additional dose of anticonvulsant was administered in one group, while the other group received only the regular dose. Time taken for extubation, eye opening, obeying commands and orientation were compared between the two groups. Haemodynamics, depth of anaesthesia, the plasma anticonvulsant levels and the incidence of seizures were compared between the two groups. Results: A total of 36 patients were studied, of which 19 received regular dose and 17 received an additional dose. There was no significant difference in recovery time between the two groups. Subgroup analysis was performed for phenytoin and sodium valproate. There was a clinically significant delay in recovery in patients who received an additional phenytoin compared to those who received regular dose (time to obey commands >15 min and orientation time >1hour) but, it was not statistically significant. Administration of an additional dose of valproate did not prolong the recovery time. Conclusion: An additional dose of sodium valproate did not cause a delay in recovery both, clinically and statistically. However, the administration of an additional dose of phenytoin caused a clinically significant delay in recovery but was not statistically significant.
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Flickering diaphragm sign, an indicator of laparoscopy-associated pneumothorax secondary to pleural breach
Syed Nusrath, Sujit Chyau Patnaik, Asiel Christopher, Ajesh Raj Saksena, Subramanyeshwar Rao Thammineedi, R Pratap Reddy
March 2020, 64(3):233-235
During laparoscopic mobilisation of the oesophagus around hiatus in transhiatal oesophagectomy; commonly the pleura is breached causing iatrogenic pneumothorax. Often small breaches in pleura goes unnoticed till the attention is drawn by anaesthetist when pressures drop with building up of end-tidal CO2(etCO2) and other haemodynamic changes occur. We describe the flickering movements of the diaphragm associated with the pleural breach, a useful sign to alert the surgeon and anaesthetist to detect pneumothorax earlier than it is clinically evident.
  694 125 -
Perioperative factors impacting intensive care outcomes following Whipple procedure: A retrospective study
R Udhayachandhar, J Otokwala, Pritish J Korula, Manbha Rymbai, Tony T Chandy, Philip Joseph
March 2020, 64(3):216-221
Background and Aims: Whipple procedure is associated with perhaps the most perioperative morbidity and mortality amongst surgical procedures. Current data regarding their ICU profile and outcomes are lacking. Thus, in the present study, we aimed to determine perioperative factors affecting patient-centred outcomes following the Whipple procedure. Methods: In a cohort of patients undergoing pylorus-sparing pancreaticoduodenectomies, we strove to determine perioperative variables that may impact outcomes. Unfavourable outcomes (composite of mortality, prolonged ICU stay of more than 14 days or ICU readmission) of patients who underwent the procedure were recorded and logistic regressions analysis of significant variables conducted. Results: Around 68 patients recruited over a 20-month period which included 57 males (83.8%); mean age was 53.4(±11.2) with mean acute physiology and chronic health evaluation (APACHE) II score12.5 (±6.1). Nineteen patients remained intubated at the end of procedures (27.9%). Median ICU stay was 2 days (IQR 2–3). Unfavourable ICU outcomes were 14 in number (20.6%) and 2 (2.9%) hospital deaths occurred. Pulmonary complications occurred in 12 patients (17.7%) and non-pulmonary complications occurred in 41 patients (60.3%). In a multiple logistic regression analysis, the APACHE score 1.34 (1.09–1.64) and pulmonary complications 17.3 (2.1–145) were variables that were identified as predictors of unfavourable outcomes. Conclusion: The APACHE II score may reliably predict adverse outcomes following Whipple procedure. Although non-pulmonary complications are common, pulmonary complications in these patients adversely impact patient outcomes.
  651 153 -
An alternative and novel usage for ultrasound-guided erector spinae plane block: Extracorporeal shock wave lithotripsy in a paediatric patient
Mursel Ekinci, Bahadir Ciftci, Selcuk Güven, David T Thomas
March 2020, 64(3):247-248
  692 97 -
Why not non-physician anaesthesia providers?
Mukul C Kapoor
March 2020, 64(3):254-254
  631 134 -
Benefits of N-acetylcysteine on liver functions in living donor hepatectomy
Mona A Ammar, Amr M Hilal Abdou
March 2020, 64(3):204-209
Background and Aims: The proportion of patients undergoing living donor liver transplantation is high especially in countries without or with limited cadaver organ sharing programs. The aim of this study was to evaluate the post-hepatectomy effect of using N-Acetylcysteine (NAC) infusion in living donors undergoing donor hepatectomy. Methods: In a prospective randomised non-blinded study, 50 healthy donors were enrolled; following hepatectomy patients were randomised into 2 groups: Group NC receiving NAC 150 mg/kg diluted in 100 ml glucose 5% over 40 minutes, followed by NAC 12.5 mg/kg in 500 ml glucose 5% over 4 hours. This was followed by NAC 6.25 mg/kg for 2 post-operative days, Group C (Control group) received ringer acetate infusion at same rate for 2 days. The primary outcome was serum lactate levels. Secondary outcomes were liver function tests, serum creatinine and urine output on intensive care unit (ICU) admission (0 hr.), after 24 hours and 48 hours, length of ICU stay. Results: Our study revealed significant reduction in serum lactate in Group NC at 0, 24 and 48 hours compared to C group (P = 0.017, 0.002, 0.014). INR values showed significant reduction after 48 hours in Group NC compared to Group C (P = 0.049). Total Bilirubin, ALT, and Creatinine, urine output and ICU stay showed no statistical difference between the 2 groups. Conclusion: The NAC protocol is a safe, cost-effective tool for improvement of post hepatectomy liver function and early stabilisation of the metabolic profile.
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Short and/or long laryngoscope handle—“Sandesh Combihandle”
Sandesh Udupi
March 2020, 64(3):250-251
  616 123 -
Intraoperative anaphylaxis—highlighting the dilemmas in living donor nephrectomy
V Muralidhar, Atish Pal
March 2020, 64(3):236-237
  619 101 -
Ganglionic trigeminocardiac reflex: A less known presentation of a well-known entity
Nidhi Singh, Sabina Regmi, Ketan K Kataria, Hemant Bhagat
March 2020, 64(3):245-246
  573 104 -
Difficult central venous cannulation in Cushing's syndrome: Ultrasound-guided brachiocephalic vein cannulation to the rescue
Poonam Kumari, Amarjeet Kumar, Ajeet Kumar, Neeraj Kumar, Abhyuday Kumar
March 2020, 64(3):243-244
  578 80 -
Postoperative pulmonary complications in robot-assisted uro-oncological surgeries: Our experience in a tertiary cancer care centre
Monotosh Pramanik, Anshuman Sarkar, Aditi Gupta, Mayukh Chattopadhyay
March 2020, 64(3):238-241
  550 95 -
Evolution of anaesthesia
Dipankar D DasGupta
March 2020, 64(3):252-253
  519 116 -
Inadvertent dural puncture: Is excess flexion of spine a possible cause?
Amarjeet Kumar, Ajeet Kumar, Chandni Sinha, Subhash Kumar
March 2020, 64(3):248-249
  514 95 -