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   2021| February  | Volume 65 | Issue 2  
    Online since February 10, 2021

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Comparison of analgesic efficacy of intrathecal 1% 2-chloroprocaine with or without fentanyl in elective caesarean section: A prospective, double-blind, randomised study
Geeta Singariya, Kusum Choudhary, Manoj Kamal, Pooja Bihani, Himani Pahuja, Pradeep Saini
February 2021, 65(2):102-107
Background and Aims: Preservative free 1% 2-chlorprocaine is a short acting local anaesthetic agent suitable for day care surgical procedures. Potentiation of analgesic action of intrathecal local anaesthetics by the addition of opioids is well known. In this study, we investigated the effect of intrathecal fentanyl as an adjuvant to 1% 2-chloroprocaine (2-CP) in parturients undergoing elective lower segment caesarean section (LSCS). Methods: This prospective randomised comparative study was performed on 150 healthy, term parturients planned for elective low risk LSCS, divided into two equal groups. The group CS received 1% preservative-free 2-CP 3 ml (30 mg) + 0.5 ml normal saline and group CF received 1% preservative-free 2-CP 3 ml (30 mg) + 0.5 ml fentanyl (25 μg) with a total volume of 3.5 ml intrathecally in both groups. The duration of sensory blockade, duration of motor blockade, maximum height of sensory block, haemodynamic parameters, quality of block, neonatal outcome, patient satisfaction and any side effects were recorded. Results: There were no significant differences in demographic characteristics, haemodynamic parameters, onset of sensory block, onset of motor block and duration of motor block between the groups. The duration of sensory block and duration of analgesia was statistically prolonged in group CF than group CS (P value < 0.0001). There was no statistical difference in the Apgar score of newborns in both groups. The adverse effects (hypotension, bradycardia, nausea/vomiting, shivering and transient neurological symptoms) were comparable in both the groups. Conclusion: The addition of fentanyl to 1% 2-chloroprocaine intrathecally prolonged the duration of sensory block and postoperative analgesia in patients undergoing LSCS.
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Deep versus superficial erector spinae block for modified radical mastectomy: A randomised controlled pilot study
Chandni Sinha, Amarjeet Kumar, Ajeet Kumar, Poonam Kumari, Jitendra Kumar Singh, Chandan Kumar Jha
February 2021, 65(2):97-101
Background and Aims: Forero et al. described two approaches of erector spinae (ES) plane block: superficial and deep to erector spinae muscle. We hypothesised that the superficial technique would not lead to optimum analgesia as the drug would have to cross one more muscle layer. We aimed to compare the techniques in terms of analgesia and sensory blockade in patients undergoing modified radical mastectomy (MRM). Methods: Forty American Society of Anesthesiologists (ASA) I/II female patients in age group 18–60 years undergoing unilateral MRM were included in this prospective study. Group D patients received 20 mL 0.2% ropivacaine deep to erector spinae at the T4 level. Group S patients received 20 mL 0.2% ropivacaine superficial to erector spinae. Sensory level of block, perioperative opioid consumption, and adverse effects were noted. Results: Twenty four hours morphine consumption was less in group D: 5.47 ± 1.1 mg and in group S was 7.66 ± 0.74 mg (P < 0.001). The sensory spread was more in deep group in the posterior axillary and mid axillary line. There were no reported adverse effects in either group. Conclusion: Injection of drug deep to ES muscle provides more cranio-caudal blockade of posterior and lateral chest wall, hence providing better analgesia following breast surgery. Injection of the drug superficial to the muscle leads to inferior analgesia.
  1,779 322 -
Enhanced recovery after surgery (ERAS)…. still a distant speck on the horizon !
Lalit Mehdiratta, Sandeep Kumar Mishra, Stalin Vinayagam, Abhijit Nair
February 2021, 65(2):93-96
  1,660 371 -
Implementation and adherence to a speciality-specific checklist for neurosurgery and its influence on patient safety
Varun Suresh, PR Ushakumari, C Madhusoodanan Pillai, Raja Krishnan Kutty, Rajmohan Bhanu Prabhakar, Anilkumar Peethambaran
February 2021, 65(2):108-114
Background and Aims: Neurosurgery involves a high level of expertise coupled with enduring and long duration of working hours. There is a paucity of published literature about the experience with a speciality-specific checklist in neurosurgery. We conducted a cross-sectional observational study to identify the adherence to various elements of the Modified World Health Organization Surgical Safety Checklist (WHO SSC) for neurosurgery by the operating room (OR) team. Methods: We implemented an intra-operative Modified WHO SSC consisting of 40 tools for neurosurgery, in 200 consecutive elective cases. Trained anaesthesiologists assumed the role of checklist co-ordinator. The checklist divided the surgery into 5 phases, each corresponding to a specific time-period. The adherence rates to various tools were evaluated and areas where the checklist prompted a corrective measure were analysed. Results: A total of 131 cases undergoing craniotomy and 69 cases undergoing spine surgery were studied. With the 40-point modified SSC applied in 200 cases, we analysed a total of 8000 observations. The modified checklist prompted the OR team to adhere to speciality-specific safety practices about application of compression stockings (9.5%); airway precautions in unstable cervical spine (2.5%); precautions for treatment of raised intracranial pressure (10.5%); and intraoperative neuro-monitoring (5%). Conclusion: The implementation of Modified WHO SSC for Neurosurgery, by a designated checklist co-ordinator, can rectify anaesthetic and surgical facets promptly, without increasing the OR time. The anaesthesiologist as SSC coordinator can effectively implement an intraoperative checklist ensuring excellent participation of operating room team members.
  1,655 176 -
Postoperative analgesic efficacy of the pulmonary recruitment manoeuvre compared to intraperitoneal hydrocortisone in laparoscopic gynaecological surgeries
Ahmed Elsakka, Nisreen Elrefai, Jihan Shehata, Atef Galal Abdel Mawla
February 2021, 65(2):115-120
Background and Aims: Laparoscopic surgeries are becoming attractive because of early recovery. Adequate postoperative pain relief may be a major concern. Several methods have been used to relieve laparoscopic postoperative pain. Methodology: This prospective, randomised, controlled study was conducted during the period between February and June 2019. Patients were assigned into three groups. Patients in the hydrocortisone group received intraperitoneal 100mg hydrocortisone in 150 ml normal saline together with the routine method to remove carbondioxide (CO2). For patients in the pulmonary recruitment group, CO2 was exsufflated by pulmonary recruitment manoeuvre together with the routine method to remove CO2. In the control group CO2 was removed by applying gentle abdominal pressure allowing passive exsufflation through the port site. Results: A total of 57 patients were included in the study. There was no statistically significant difference between the three groups as regards demographic characteristics. There was a statistically significant difference in the 24 h postoperative analgesic consumption (primary outcome) in the hydrocortisone and pulmonary recruitment groups in comparison to the control group:P value <0.001. Also, time to first request for analgesia was significantly longer and the visual analogue scale (VAS) score was significantly lower in the hydrocortisone and pulmonary recruitment groups compared to the control group:P value <0.001. Conclusion: Intraperitoneal hydrocortisone and pulmonary recruitment manoeuvre could both effectively reduce pain after gynaecological laparoscopic surgeries, however, intraperitoneal hydrocortisone might give a longer pain-free time.
  1,591 208 -
Effect of hand-holding and conversation alone or with midazolam premedication on preoperative anxiety in adult patients—A randomised controlled trial
Bhavna Sriramka, Diptimayee Mallik, Jayanti Singh, Megha Khetan
February 2021, 65(2):128-132
Background and Aims: Anxiety causing stress is most profound before surgery. Anxiolytics are used routinely to combat perioperative anxiety. Studies have shown that hand-holding and communication are useful in reducing anxiety levels intraoperatively. This study compares the effectiveness of the same with pharmacological interventions in allaying preoperative anxiety. Material and Methods: This is a three-arm parallel-group randomised controlled trial. A total of 90 adult patients aged <45 years and of American Society of Anesthesiologists (ASA) grade 1–2, undergoing laparoscopic surgery were enroled in this study. Patients received either intravenous (IV) midazolam (group M) or hand-holding and conversation (group HC), or a combination of IV midazolam and holding and conversation (group HCM) in the preoperative room. Anxiety, heart rate (HR) and mean blood pressure (MBP) were recorded before and 20 minutes after the intervention. Anxiety was measured using the Amsterdam preoperative anxiety and information scale. The analysis of covariance (ANCOVA) test was done to analyse the difference between the groups. Results: The mean anxiety scores were significantly different in the three groups (p = 0.04) after intervention, with the lowest score in group HCM, followed by group HC and the highest score in group M. The mean heart rates were also significantly different in the three groups after intervention but MBP was not significantly different in the three groups. Conclusion: A combination of hand-holding and conversation and midazolam is best for allaying preoperative anxiety in patients undergoing laparoscopic surgeries than either method alone.
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Unique technique of rescue ventilation in malignant critical airway obstruction during airway stenting
Ram Niwas, Gopal Chawla, Nishant Chauhan, Swati Chabbra
February 2021, 65(2):158-160
  722 84 -
External jugular vein cannulation – A double-edged sword
Suma Rabab Ahmad, Snigdha Bellapukonda, Chitta Ranjan Mohanty, Priyank Tapuria
February 2021, 65(2):173-174
  631 155 -
Comparison of aerosol box intubation with C-MAC video laryngoscope and direct laryngoscopy—A randomised controlled trial
Nitu Puthenveettil, Sajan Rahman, Sundeep Vijayaraghavan, Sneha Suresh, Dilesh Kadapamannil, Jerry Paul
February 2021, 65(2):133-138
Background and Aims: Severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) is a highly infectious disease and healthcare workers are at constant risk for contracting it. Nowadays, aerosol box is used in conjunction with WHO-recommended safety kits, to avoid health workers from getting SARS-CoV-2 infection during aerosol-generating procedures. In our study, we compared the ease of oral intubation with C-MAC video laryngoscope and direct laryngoscopy, when the aerosol box was used. The secondary objectives were to compare the incidence of airway loss, haemodynamic changes, number of attempts, and time required for intubation between these two techniques. Methods: This prospective randomised controlled study was conducted on 60 non-coronavirus disease (COVID) patients presenting for elective surgery under general anaesthesia. Patients were randomly assigned into two groups:C and D using a computer-generated random sequence of numbers by closed envelope technique. In group D, laryngoscopy was performed with Macintosh blade and in group C, with Storz® C-MAC video laryngoscope. Results: The ease of intubation was better (grade 1) in group C than D (68.6% vs. 31.4% respectively) with a P value of < 0.001. 10% of patients required more than one intubation attempt in group D compared to none in group C, but this difference was not statistically significant. The intubation time was comparable between the two groups. There were no incidences of loss of airway or failure to intubate in both groups. Conclusion: The use of C-MAC video-laryngoscopy resulted in easier orotracheal intubation as compared to intubation with direct laryngoscopy when the aerosol box was used.
  667 118 -
Assessment of the perioperative effect of vasopressin in patients undergoing laparoscopic myomectomy: A double-blind randomised study
Rabie Soliman, Abdelbadee Yacoub, Assem A M Elbiaa
February 2021, 65(2):139-145
Background and Aims: Myomectomy is associated with perioperative bleeding. The aim of the study is to evaluate the effect of intramyometrial vasopressin on blood loss and the associated cardiovascular complications during myomectomy. Methods: The study included 194 patients classified into two groups- 1) Vasopressin group: the vasopressin was diluted as 0.1 unit/ml and 15 ml was injected by the surgeon in the plane between the myometrium and the myoma. 2) Control group: The patients received an equal amount of normal saline. The monitored parameters included the amount of blood loss, required blood transfusion, heart rate, mean arterial blood pressure, the incidence of hypertension, hypotension, bradycardia, tachycardia, electrocardiogram (ECG) changes and the blood troponin I level. Results: The heart rate decreased significantly in both groups, but the decrease was lower with vasopressin than the control group through the time points T3 to T5 (P < 0.05) The mean arterial blood pressure increased significantly in both groups, but the increase was higher with vasopressin than the control group through T3 to T5 (P < 0.05). The amount of blood loss decreased significantly with vasopressin than the control groups (P = 0.001). The number of transfused packed red blood cells was lower with vasopressin than the control group (P = 0.001). The incidence of hypertension, bradycardia and atrial extrasystole was higher with vasopressin than the control group (P = 0.005, P = 0.012, P = 0.033, respectively). Conclusion: Intramyometrial vasopressin decreases blood loss and blood transfusion, but it is associated with cardiovascular complications that may be serious as reported in other studies. Therefore, anaesthesiologists and gynaecologists must follow the precautions to avoid and minimise the incidence of complications with intramyometrial vasopressin.
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A rare incident of accidentally cut inflation tube in a critically ill intubated patient: Quick and simple approach that proved lifesaving
Prakash Deb, Prithwis Bhattacharyya
February 2021, 65(2):180-181
  565 107 -
Preoperative gabapentin versus bisoprolol for haemodynamic and surgical field optimisation during endoscopic sinus surgery: A randomised controlled trial
Abeer M Elnakera, Maram H Wagdy, Aymen A Abd-Elgelyl, Mohamed W EL-Anwar
February 2021, 65(2):121-127
Background and Aims: Appropriate premedication can optimise haemodynamics and hence surgical field visibility during endoscopic sinus surgery (ESS). This study aimed to compare the intraoperative effect of gabapentin 1200 mg versus bisoprolol 2.5 mg, given 2 hours before ESS. Methods: Patients were assigned into one of three groups. Patients of gabapentin group received preoperative oral gabapentin 1200 mg while, patients of bisoprolol and control groups received oral bisoprolol 2.5 mg and placebo respectively 2 hours before ESS. Primary outcome: reduction of blood loss and surgical field quality. Secondary outcome: haemodynamic control. mean arterial pressure (MAP) and heart rate (HR) were recorded as baseline, before and after induction of anaesthesia, at 1, 5, 10, 15 minutes after intubation and then every 15 minutes until the end of surgery. Data also included Fromm and Boezaart category scale (assessed every 15 min), intraoperative blood loss, surgeon satisfaction score, intraoperative anaesthetic/analgesic and vasoactive medications requirements. Results: Out of 66 eligible patients, 60 patients completed the study. Intraoperative MAP and HR were significantly lower and more stable in gabapentin and bisoprolol groups compared to control group (p < 0.05). The volume of blood loss was significantly lower (p 0.000) and operative field was more visible in gabapentin and bisoprolol groups than those in control group (p 0.000). Conclusion: The beneficial effect of gabapentin 1200 mg on intraoperative haemodynamic control and surgical field visibility is comparable to that of bisoprolol 2.5 mg when either of them is given as a single oral dose 2 hours before ESS.
  578 82 -
A rare case report of unusual path of left internal jugular central line
Rajashekar Rangappa Mudaraddi, Hany Fawzi Greiss
February 2021, 65(2):176-178
  530 100 -
Placenta accreta spectrum anaesthetic management with neuraxial technique can be facilitated by multidisciplinary groups
Leidy Johanna Lopez-Erazo, Beatriz Sánchez, Luisa Fernanda Blanco, Albaro Jose Nieto-Calvache
February 2021, 65(2):153-156
Background: The concern about massive haemorrhage associated with placenta accreta spectrum (PAS) prompts the routine use of general anaesthesia (GA) at many centres. We aimed to describe the effects of establishing a fixed multidisciplinary team (PAS team) on anaesthetic practices and clinical results. Methods: In this before-and-after study, we included patients with prenatal PAS suspicion treated between December 2011 and December 2019. We evaluated the anaesthetic techniques used before (Group 1) and after (Group 2) a PAS team was established. Results: Eighty-one patients were included. Neuraxial anaesthesia (NA) was used in 23.3% of group 1 patients and 76.4% of group 2 patients. Likewise, the frequency of conversion to GA after initial management with NA decreased from 14.3% in group 1 to 7.7% in group 2. Conclusions: The establishment of a PAS team is related to increased use of NA during the management of PAS patients.
  522 84 -
Regional anaesthesia for complex gynaecological surgeries: Patient benefits and considerations
Nelson N Algarra, Sindhuja R Nimma
February 2021, 65(2):157-158
  517 72 -
A convenient assembly for drug dilution
Bharat Paliwal, Manoj Kamal, Shayak Roy, Kamlesh Kumari
February 2021, 65(2):162-163
  492 84 -
A case of operative hysteroscopy intravascular absorption syndrome: Gynaecological TURP syndrome
Shalendra Singh, Nitesh Kumar, Debashish Paul, Shibu Sasidharan
February 2021, 65(2):167-169
  478 93 -
Anti-NMDA receptor encephalitis with phenytoin toxicity: A diagnostic dilemma and management challenge
Abhyuday Kumar, Neeraj Kumar, Amarjeet Kumar, Subhajit Ghosh
February 2021, 65(2):164-165
  516 46 -
Fatal venous air embolism during lumbar spondylolisthesis surgery
Youssef Elouardi, Youssef Zarrouki, Hasna Darouich, Mohamed Khallouki
February 2021, 65(2):171-173
  479 52 -
Use of wireless respiratory rate sensor monitoring during opioid patient-controlled analgesia after gynaecological surgery: A prospective cohort study
Shang-Ming Cheng, Jason Ju In Chan, Chin Wen Tan, Enhong Lu, Rehena Sultana, Ban Leong Sng
February 2021, 65(2):146-152
Background and Aims: Respiratory depression is a rare but serious complication during opioid administration. Therefore, early detection of signs of deterioration is paramount. The current standard of care of using manual intermittent respiratory rate (RR) measurement is labour intensive and inefficient. We evaluated a wireless sensor monitor, Aingeal (Renew Health Ltd, Ireland), to continuously monitor RR, heart rate (HR) and temperature compared to standard clinical measurements. Methods: Patients who underwent major gynaecological operations and received postoperative opioid patient-controlled analgesia were recruited. Patients were connected to the sensor monitor via a central station software platform. The primary outcome was comparison of RR between sensor and nursing monitoring, with secondary outcomes being HR and temperature between two methods. Feedback from patients and healthcare providers was also collected. Bland-Altman analyses were used to compare the vital signs recorded in sensor against those in patient's electronic record. Results: A total of 1121 hours of vital signs data were analysed. Bias for RR was -0.90 (95% confidence interval (CI): -9.39, 7.60) breaths/min between nursing and averaged sensor readings. Bias for heart rate was -1.12 (95% CI: -26.27, 24.03) and bias for temperature was 1.45 (95% CI: -5.67, 2.76) between the two methods. Conclusion: There is satisfactory agreement of RR measurements, as well as HR and temperature measurements, by the wireless sensor monitor with standard clinical intermittent monitoring with overall good user experience.
  444 54 -
Anaesthesia management for Winchester syndrome
Ankita Sharma, Priyanka Sharma, Shibu Sasidharan
February 2021, 65(2):165-167
  400 78 -
A novel manoeuvre in succeeding rail-roading of tracheostomy tube
Suganya Srinivasan, Muthapillai Senthilnathan, Ranjith Kumar Sivakumar, Sandeep Kumar Mishra
February 2021, 65(2):174-176
  402 66 -
Spondylo-Epiphyseal dysplasia – A challenge for operative positioning
Konish Biswas, Priyanka Gupta, Ashutosh Kaushal, Ifthekar Syed
February 2021, 65(2):160-162
  387 45 -
Gas pipeline error: Time to verify all the terminal central outlets?
Akhya Kumar Kar
February 2021, 65(2):169-171
  349 46 -
Anaesthetic management in a case of vertebral haemangioma with Bidirectional Glenn Shunt
Mayank Tyagi, Surya Kumar Dube, Mihir Prakash Pandia
February 2021, 65(2):178-179
  324 37 -