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   2021| April  | Volume 65 | Issue 4  
    Online since April 15, 2021

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Research in COVID times—Innovations, revolutions and contentions
Lalit Mehdiratta, Sukhminder Jit Singh Bajwa, Madhuri S Kurdi, Pradip Kumar Bhattacharya
April 2021, 65(4):277-281
  744 206 -
Study comparing different airway assessment tests in predicting difficult laryngoscopy: A prospective study in geriatric patients
Pratibha Panjiar, Kharat Mohammed Bhat, Irshad Yousuf, Anjali Kochhar, Tanya Ralli
April 2021, 65(4):309-315
Background and Aims: Limited studies are available comparing diagnostic accuracy of various airway predictors in geriatric patients. We conducted this study with primary aim to evaluate and validate the predictive value of 'standard airway predictors' like modified Mallampati test, thyromental distance (TMD), sternomental distance, neck movement (NM), mouth opening (MO), dentition and 'new airway predictors' like upper lip bite test (ULBT), ratio of height to thyromental distance and thyromental height test (TMHT) for predicting difficult laryngoscopy in geriatric patients. Methods: This prospective, observational study was conducted on 140 patients above 65 years of age of either sex, scheduled for elective surgery under general anaesthesia requiring endotracheal intubation. The age, weight, height, body mass index (BMI) and airway parameters were recorded. The laryngoscopic view was assessed by modified Cormack-Lehane scale. Standard formulae were used to calculate validity indexes. Results: The incidence of difficult larygoscopy found in our study was 25%. The mean age of our study population was 69.37 ± 4.23 years. TMD exhibited the highest sensitivity (80%) and negative predictive value (NPV) (91.86%) as compared to other studied airway predictors. The positive predictive value (PPV) of ULBT was 100%. Moreover, ULBT exhibited highest accuracy (82.14%) and odds ratio (86.88) and high specificity (91.30%) for predicting difficult laryngoscopy in geriatric patients. NM and TMHT also exhibited high accuracy (77.85%, 77.14%) and PPV (59.09%, 52.94%). Conclusions: TMD and ULBT both showed good predictive value in diagnosing difficult laryngoscopy in geriatric patients. Furthermore, NM and TMHT also exhibited higher diagnostic accuracy in predicting difficult airway in these patients.
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Comparative study of recovery of airway reflexes and cognitive function following sevoflurane versus desflurane anaesthesia
Mousumi Saha, Kirti N Saxena, Bharti Wadhwa
April 2021, 65(4):282-288
Background and Aims: Sevoflurane and desflurane have almost similar blood-gas solubility but recent studies suggest that desflurane compared to sevoflurane leads to faster recovery of airway reflexes, but the recovery of cognitive function varies significantly. We conducted this study to compare the times of recovery from anaesthesia following desflurane versus sevoflurane anaesthesia. Methods: This randomised double-blinded study was conducted on 60 patients of American Society of Anesthesiologists (ASA) classification I–II, age between 18 and 60 years with body mass index (BMI) ≤30 kg/m[2] who underwent elective cholecystectomy. A standard general anaesthesia protocol was followed with either sevoflurane (group A = 30 patients) or desflurane (group B = 30 patients) along with bispectral index and neuromuscular monitoring. Following extubation, tests for recovery of airway reflexes and cognitive function were conducted and various time intervals were noted. Statistical analysis was carried out using Statistical Package for Social Sciences (SPSS) standard software version 17. Results: The mean time from first verbal response to first passing the swallowing test was comparable in both the groups (5.50 ± 3.45 vs. 4.10 ± 3.42 min, P value = 0.120). Patients receiving desflurane showed faster response to verbal commands (5.93 ± 4.13 vs. 8.20 ± 3.39 min, P value = 0.024), passed the swallowing test earlier (10.03 ± 4.97 vs. 13.70 ± 3.48 min, P value = 0.009) and Short orientation memory concentration test (SOMCT) earlier (9.83 ± 4.51 vs. 14.10 ± 4.31 min, P value ≤0.001) compared to sevoflurane. Conclusion: In patients undergoing laparoscopic cholecystectomy under controlled conditions, earlier recovery is seen with desflurane compared to sevoflurane.
  724 172 -
Intravenous paracetamol: Salvage and safety proposition
Anju Gupta, Aasim Ahmed
April 2021, 65(4):342-343
  742 138 -
Ultrasound-guided assessment of gastric residual volume in patients receiving three types of clear fluids: A randomised blinded study
Jeson Rajan Doctor, Pramila Chandan, Nitin Shetty, Kunal Gala, Priya Ranganathan
April 2021, 65(4):289-294
Background and Aims: Ultrasonography (USG) is used to evaluate gastric residual volume (GRV); however, this technique may have inter-assessor variability. This study aimed to measure GRV in three groups of fasted patients 2 h after they received 200 mL of water, clear apple juice or apple-flavoured oral rehydration solution (ORS) and to determine inter-assessor reliability of USG-guided GRV measurement. Methods: We randomised 90 adult patients planned for elective cancer surgery, with no risk factors for delayed gastric emptying, to receive 200 mL of water, clear apple juice or apple-flavoured ORS after overnight fasting. Two hours later, two blinded assessors (a trained anaesthesiologist and a radiologist) independently determined USG-guided GRV. The primary outcome was GRV measured by the radiologist. The secondary outcome was inter-assessor correlation and agreement in GRV measurements. Results: There was no statistically significant difference in median GRV between groups (apple-flavoured ORS 74.8 mL, apple juice 63.7 mL, and water 62.1 mL, P = 0.11). We found poor correlation between measurements of radiologist and anaesthesiologist (Intra-class correlation coefficient 0.3, 95% confidence intervals 0.09 to 0.48, P value 0.002). The average (mean) bias was 5.4 mL (standard deviation 42.3 mL) and the 95% limits of agreement were -79.2 ml to +90 ml. Conclusion: Patients receiving 200 mL of water, clear apple juice or apple-flavoured ORS had comparable GRV after 2 h. There was poor correlation and agreement between GRV measurements of different assessors, indicating that more training may be required for anaesthesiologists to attain proficiency in the quantitative assessment of GRV.
  698 122 -
Regional anaesthesia crossword puzzle
Kartik Sonawane, Tuhin Mistry
April 2021, 65(4):348-350
  625 142 -
Hypercoagulability on thromboelastography after living donor hepatectomy—The true side of the coin
Shankey Garg, Gaurav Sindwani, Neha Garg, Mahesh K Arora, Viniyendra Pamecha, Deepak Tempe
April 2021, 65(4):295-301
Background and Aims: Coagulation dynamics after donor hepatectomy are complex. Having complete knowledge of the actual changes in the coagulation status during donor hepatectomy is important to prevent complications such as pulmonary embolism, deep vein thrombosis, and bleeding. Hence, the present study aimed to study the coagulation dynamics following open donor hepatectomy both by thromboelastography (TEG) and conventional coagulation tests (CCT). Methods: A total of 50 prospective liver donors were included. TEG and CCT [activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalised ratio (INR), fibrinogen, and platelet counts] were performed for each patient before surgery (baseline), on postoperative day (POD) 0, 1, 2, 3, 5, and 10. Results: TEG showed hypercoagulability in 28%, 38%, 30%, 46%, 42%, and 48% patients; in contrast INR showed hypocoagulability in 58%, 63%, 73%, 74%, 20%, and 0% patients on POD 0,1,2,3,5, and 10, respectively. Patients demonstrating hypercoagulability on TEG had significantly decreased reaction time (P = 0.004), significantly increased maximum amplitude (P < 0.001), and alpha angle value (P < 0.001). Postoperatively, INR, PT, and aPTT values increased significantly, while platelets and fibrinogen levels decreased significantly when compared to their baseline values. There was no coagulation-related postoperative complication in any of the patients. Conclusion: Hypercoagulability after donor hepatectomy is common. TEG showed hypercoagulability and did not show any hypocoagulability as suggested by the CCT. In patients undergoing donor hepatectomy, CCT may not reflect the actual changes incoagulation status and tests such as TEG should be performed to know the correct nature of changes in coagulation following donor hepatectomy.
  612 140 -
Anaesthetic implications and transfusion practices in ABO incompatible living donor liver transplantation: Case series
Sindhu Balakrishnan, Lakshmi Kumar, Divya Daniel, Sudhindran Surendran
April 2021, 65(4):331-335
ABO incompatible liver transplants (ABOi LT) are considered as a life-saving option when compatible donor grafts are unavailable. Fourteen adults (right lobe graft) and three children (left lateral segment/lobe) who underwent ABOi LT from living donors between 2011 and 20 period were analysed for transfusions and desensitisation protocols. All recipients received packed red blood cells (PRBC) of their own group. AB plasma that does not contain any antibody was transfused in eight patients and donor group plasma in others. None of the patients developed transfusion related complications. Plasmapheresis and rituximab/bortezumab desensitisation was practised in 11 patients, only rituximab in four, only plasmapheresis in one, and no treatment in a 1 year child. Rejection was manifest in three patients while nine patients developed infections and sepsis. A working knowledge of the blood and product transfusions in ABOi LT is crucial for the anaesthesiologist. Perioperative management and impact of desensitisation protocol are discussed.
  624 126 -
Haemodynamic responses following orotracheal intubation in patients with hypertension---Macintosh direct laryngoscope versus Glidescope®videolaryngoscope
Tanvi M Meshram, Rashmi Ramachandran, Anjan Trikha, Vimi Rewari
April 2021, 65(4):321-327
Background and Aims: Glidescope®videolaryngoscope (GVL) is a video intubation system with 60° angle blade that provides excellent laryngeal view, does not require alignment of oral, pharyngeal, and laryngeal axes for visualisation of glottis, thus causing less stimulation of orolaryngopharynx. The aim of this study was to compare haemodynamic responses (blood pressure and heart rate) and airway morbidity using the Macintosh direct laryngoscope (MDL) and the Glidescope®videolaryngoscope (GVL) in hypertensive patients. Methods: Fifty patients with hypertension controlled on antihypertensive medications scheduled for elective surgery under general anaesthesia were randomly assigned to group GVL (n = 25) or group MDL (n = 25). Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP) were recorded at baseline, after induction, pre-intubation, at intubation, 1, 2, 3, 4, and 5 min after intubation. Time to intubation, number of attempts, complications during intubation, and postoperative airway complications (sore throat, hoarseness, dysphagia, and cough) were also recorded. Results: There was a statistically significant increase in SBP, DBP, and MBP at intubation [(P = 0.003, 0.013, 0.03), 1 min (P = 0.001, 0.012, 0.02), 2 min (P = 0.04, 0.02, 0.04), and 3 min (P = 0.02, 0.01)] in the MDL group as compared to GVL group. The time to intubate was significantly greater in the GVL group as compared to MDL group (P = 0.0006). There was no significant difference in the incidence of intraoperative and postoperative airway complications. Conclusion: In the hands of an experienced anaesthesiologist, the use of GVL in controlled hypertensive patients is associated with less haemodynamic response as compared to Macintosh Laryngoscope without any increase in airway complications.
  586 115 -
Correlation between radial and femoral arterial blood pressure during reperfusion in living donor liver transplantation
Manu Thomas, Lakshmi Kumar, Priyanka Jain, Chitra Sarma, Shabala Paul, Sudhindran Surendran
April 2021, 65(4):302-308
Background and Aims: Accurate blood pressure measurements are the mainstay for the efficient management of abrupt cardiovascular changes during reperfusion in liver transplant. We sought to compare the femoral and radial pressures during reperfusion and at T1:baseline, T2: 1 h in dissection: T3:portosystemic shunt, T4:reperfusion, T5: at bile duct anastomosis. Methods: A retrospective study was performed amongst 102 adult patients who underwent R lobe living donor liver transplantation. Mean arterial pressure (MAP) and systolic arterial pressure (SAP) at 10 s intervals at reperfusion and at five fixed time points were compared by intraclass correlation coefficient (ICC) and limits of agreement by Bland–Altman statistics. Results: MAP by both routes had a good correlation at all time points during reperfusion (overall ICC: 0.946 [0.938, 0.949]) in comparison with SAP (overall ICC: 0.650 [0.6128, 0.684]). At the lowest reperfusion pressure (reperfusion point), MAP showed high levels of agreements (ICC: 0.833 [0.761, 0.885]), whereas SAP showed only a poor level of agreement (ICC 0.343 [0.153, 0.508]). The Bland–Altman analysis for MAP showed a bias of 7.18 (5.94) mmHg and limits of agreement of − 4.5 mmHg to + 18.8 mmHg and for SAP a bias of 25.2 (22.04) mmHg and limits of agreement of − 18.0 mmHg to + 68.4 mmHg at the reperfusion point. The incidence of post-reperfusion syndrome (PRS) was 52.94% by femoral and 57.84% by radial routes. Conclusions: Radial MAP correlated well with femoral MAP during reperfusion and at predefined time points and can be used interchangeably for intraoperative monitoring. A high incidence of PRS was noted by our technique of measurement.
  604 88 -
A randomised comparative study of transversus abdominis plane block with or without intravenous diclofenac sodium as a component of multimodal regimen for post-operative analgesia following caesarean section
Bhati Kanta, Dhawan Sonali, Parveen Gazala, Khilji Yunus, Kuraning Kiran
April 2021, 65(4):316-320
Aims: Post-operative analgesia is a major component of perioperative care. An ideal method of pain relief after caesarean section should be cost-effective and safe for mother and baby. This study aims to evaluate the analgesic efficacy of transversus abdominis plane (TAP) block combined with intraoperative diclofenac aqueous for post-operative analgesia in caesarean section. Methods: A prospective randomised double-blind study was conducted on 60 patients over a period of six months. Patients were enrolled in two groups (n = 30). Group A and Group B both received bilateral landmark based TAP block using ropivacaine 0.75% (1.5 mg/kg), 20 ml at end of surgery. Group B received diclofenac sodium aqueous 75 mg intravenous intraoperatively. Results: The difference of visual analogue score (VAS) at movement was significant at 4 and 6 h in Group A versus Group B (3.00 ± 0.64 versus 2.37 ± 0.89, 4.43 ± 0.68 versus 3.53 ± 1.2). At rest, VAS score was lower in Group B than in Group A at all time intervals (P < 0.05). Time to demand of first dose of rescue analgesic was prolonged in Group B (11.5 ± 4.1 h) than in Group A (7.55 ± 1.41 h). Mean dose of analgesic consumption in first 24 h was lesser in Group B (61.67 ± 34.57 mg) than in Group A (98.33 ± 37.68 mg). Patient satisfaction score was higher in Group B (8 ± 1.04) than in Group A (6.23 ± 1.04). Conclusion: TAP block along with intraoperative diclofenac aqueous as component of multimodal regimen provides superior post-operative analgesia and better patient satisfaction as compared to TAP block alone.
  524 108 -
All epidural needle bevels are not the same
Amber C Benhardt, Bhavani Shankar Kodali
April 2021, 65(4):328-330
  508 109 -
Anaesthetic considerations in coeliac artery compression syndrome
Priyanka Sethi, BD Vaishnavi, Manbir Kaur, Pradeep Bhatia
April 2021, 65(4):344-345
  522 75 -
Infant with stridor due to vallecular cyst – Anaesthetic management
Mohankumar Archana, Sivakumar Segaran, Mamie Zachariah, Sagiev Koshy George
April 2021, 65(4):340-342
  446 93 -
An unrecognised risk in endotracheal intubation by a Truview laryngoscope
Pooja Singh, Raksha Kundal, Neha Sharma, Maitree Pandey
April 2021, 65(4):337-338
  424 83 -
Subarachnoid aneurysm coiling under conscious sedation
Biju Sekar, Priyanka Pavithran
April 2021, 65(4):339-340
  424 81 -
Fogging of desflurane vaporiser external sight glass: An interesting observation
Uma Hariharan, Devang Bharti, Shubhi Singhal, Mohandeep Kaur
April 2021, 65(4):336-337
  397 78 -
Post-oesophagectomy chylothorax: An unusual cause of postoperative stridor
Rashmi Syal, Rakesh Kumar, Vaibhav K Varshney, Pawan Garg
April 2021, 65(4):345-347
  382 70 -