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   Table of Contents - Current issue
July-December 2022
Volume 23 | Issue 2
Page Nos. 81-153

Online since Saturday, October 29, 2022

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Sensory blocks for knee surgery: The dawn of a new era p. 81
Ghansham Biyani, Rajasekhar Metta
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Use of ultrasound in pediatric airway: Revisiting the past, reviewing the present, and recommending for the future Highly accessed article p. 83
MV Eeshwar, Rajasekhar Metta, Ghansham Biyani
Despite few inherent issues, ultrasound (US) has emerged as a new frontier in the assessment and management of pediatric airway due to easy availability of US machines in operation theaters, noninvasive and radiation-free properties, and reproducibility. In this narrative review, we discussed the ergonomics and equipment needed to perform the airway scan, types of scans performed and their clinical applications, normal appearance of airway structures, and important clinical applications of US in the management of pediatric airway. The greatest advantage of US lies in accurate location of cricothyroid membrane and tracheal rings, in measuring the narrowest part of the airway (cricoid) to determine the size of the endotracheal tube, to rule out esophageal intubation, and in assessing the movements of the vocal cords, among others. In our view, upper airway US is a convenient, cost-effective, noninvasive, first-line airway assessment tool which is dynamic in nature. It can be used preoperatively, intraoperatively for real-time guidance in performing interventional procedures, and in the postoperative period.
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Comparison of ultrasound-guided transversus abdominis plane block and quadratus lumborum block for postoperative analgesia following laparoscopic living donor nephrectomy: A prospective randomized, double-blind study p. 91
Kaushik Sengupta, Jitendra Ladhania, Amit Kundu, Titisa Sarkar Mitra, Tuhin Mistry
Background and Aims: The application of ultrasound (USG)-guided interfascial plane blocks in transplant anesthesia is expanding. This study evaluates and compares the postoperative analgesic efficacy of USG-guided transversus abdominis plane block (TAPB) and quadratus lumborum block (QLB) in adult individuals undergoing laparoscopic living donor nephrectomy (LLDN). Materials and Methods: A hundred donors of either sex, aged 30–60 years, scheduled to undergo LLDN were randomly allocated into two groups. After completion of the LLDN, USG-guided unilateral TAPB and QLB were performed in lateral position in Groups A (n = 48) and B (n = 48), respectively. A volume of 20 ml of 0.375% ropivacaine was administered in both groups. Postextubation donors were shifted to the postanesthesia care unit (PACU). Heart rate, systolic blood pressure, diastolic blood pressure, and numeric rating scale (NRS) scores were recorded on arrival at PACU at the time of discharge from PACU. Subsequently, the donor was shifted to the intensive care unit, and the vitals and NRS scores (static and dynamic) were monitored postoperatively on the 2nd, 6th, 12th, 18th, and 24th h. Duration of analgesia and the number of donors who needed rescue analgesia were also noted. All the donors were observed for any side effects and complications. P <0.05 was considered statistically significant. Results: The NRS score was significantly lower in Group B (QLB) than in Group A (TAPB). Duration of analgesia was significantly prolonged in Group B (11.34 ± 1.53 h) compared to Group A (9.05 ± 1.58 min). (P < 0.001) Conclusion: The QLB effectively prolonged the duration of analgesia, lowers pain scores, and decreases the requirement of rescue analgesia compared to the TAPB. Hence, the donors remain comfortable in the postoperative period without any potential side effects.
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A prospective randomized study to compare intrathecal isobaric levobupivacaine with or without fentanyl in various infraumbilical surgeries p. 98
Veena Mathur, Anand Kumar Verma, Arvind Khare, Deepak Kumar Garg, Beena Thada, Maina Singh
Background and Aims: Subarachnoid block is the most preferred anesthetic technique for infraumbilical surgeries as it provides better postoperative analgesia, effective muscle relaxation, and cost-effectiveness. Levobupivacaine is preferable over bupivacaine due to its lower cardiotoxicity, prolonged sensory block, and shorter duration of motor block. Opioids as an adjuvant to intrathecal local anesthetics enhance the quality of both analgesia and anesthesia during intraoperative as well as postoperative period. The present study aimed to compare levobupivacaine with and without fentanyl in spinal anesthesia. Methods: In this prospective, randomized, double-blinded study, a total of 80 patients belonging to the American Society of Anesthesiologists Physical Status I and II were enrolled for infraumbilical surgeries. Patients were randomly allocated into two groups. Group Levobupivacaine (L) (n = 40) received isobaric levobupivacaine 0.5% 2.5 ml with 0.5 ml normal saline and Group Levobupivacaine + fentanyl (LF) (n = 40) received isobaric levobupivacaine 0.5% 2.5 ml with fentanyl 25 μg (0.5 ml). Time of onset and duration of both sensory and motor block, Visual Analog Scale score, duration of analgesia, hemodynamic changes, and any adverse events were noted in both the groups. Results: The onset of both sensory and motor block was significantly faster in Group LF (P < 0.05). The duration of sensory block was significantly longer in Group LF (P < 0.05). The duration of motor block was found to be comparable between two groups with stable hemodynamics and no perioperative sedation (P > 0.05). The duration of analgesia was significantly longer in Group LF (336.5 ± 31.3 min) compared to Group L (223.65 ± 32.17 min) P < 0.001. Conclusion: Intrathecal fentanyl (25 μg) can be effectively used as an adjuvant to isobaric 0.5% levobupivacaine as it provides better block characteristics with minimal adverse effects in patients undergoing infraumbilical surgeries.
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Prediction of endotracheal tube size for pediatric patients from the length of the middle finger in comparison with standard age-based formula in South Indian population p. 105
Rama Rani Krishna Bhat, Ramya Lakshmi Kamlekar, Malavika Kulkarni
Background: Determining the appropriate size of an endotracheal tube (ETT) in infants and children remains a challenge for anesthesiologists. We conducted this study to assess the accuracy of middle finger length (MFL) in predicting the appropriate ETT size for pediatric patients in comparison with the age-based estimation and derive a formula based on MFL for the estimation of ETT size. Materials and Methods: In the study, South Indian children 1–10 years of age, requiring general anesthesia were intubated by consultant anesthesiologists based on their discretion with an appropriately sized ETT. Subsequently, the MFL of the children was measured and tracheal tube size calculated from the age-based formula was also noted. The actual size of the ETT inserted was compared with the MFL and age-based formula using Pearson's correlation. Results: In children between 1 and 10 years of age, the age-based formulae (ABF) was found to correlate with ETT estimated with the correlation coefficient (r = 0.885; P < 0.001) and MFL (r = 0.783 and P < 0.001). ABF showed a stronger correlation with the ETT inserted compared to the MFL, nevertheless, we were able to arrive at a formula to predict tracheal tube size based on MFL: ETT ID (mm) =1.1+ (0.7 × MFL [cm]). Conclusion: Although age-based Cole's and Motoyama's formulae are better predictors of pediatric ETT size, MFL can still be used to predict the tube size in cases when age and weight are unknown.
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A Randomized comparative study to observe the safety and efficacy of I gel and blockbuster laryngeal mask airway used in patients undergoing short surgical procedure under general anesthesia p. 111
Arvind Khare, Poonam Awana, Beena Thada, Veena Mathur, Pradeep Kumar
Background and Aims: Blockbuster laryngeal mask airway (LMA), a newer supraglottic airway device, provides a quick and reliable seal of the airway, making it useful for positive pressure ventilation. This randomized comparative study was undertaken to compare the safety and efficacy of I-gel and Blockbuster LMA used in short surgical procedures under general anesthesia. Materials and Methods: Hundred patients of either sex aged between 18 and 60 years belonging to the American Society of Anesthesiologist physical Status I and II undergoing general anesthesia were randomized into two groups of 50 patients each, using either I-gel (Group IG) or Blockbuster LMA (Group BB). After standard monitoring and induction of anesthesia, LMA was inserted according to their randomized groups and adequate ventilation was achieved. The primary objectives were grading of ease of insertion and time taken for successful insertion of device, while number of attempts for insertion, oropharyngeal seal pressure (OSP), hemodynamic changes, and adverse effects such as blood staining of device, injury of lips, tongue and teeth, postoperative hoarseness of voice and sore throat were secondary objectives. Data were analyzed using SPSS version Results: The ease of insertion was graded as very easy in 46 patients in Group BB and 26 patients in Group IG (P < 0.001). The mean time for insertion was less with Group BB (24.30 ± 3.91 s) as compared to Group IG (29.50 ± 12.5 s) (P < 0.0001). 48 patients in Group BB while 37 patients in Group IG (P = 0.008) were required one attempt for insertion. The average OSP was 22.59 ± 1.44 cmH2O in Group BB as compared to 20.88 ± 2.22 cmH2O in Group IG (P < 0.0001). Hemodynamic changes were comparable at different time intervals. Complications such as blood stain of device and sore throat were more with I-gel. Conclusions: The Blockbuster LMA is an effective alternative to I-gel with faster, easier insertion, required a smaller number of attempts, high airway sealing pressure with stable hemodynamic, and less incidence of blood staining and postoperative sore throat.
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Comparative evaluation of intubating laryngeal mask airway with fiberoptic bronchoscopic intubation in anticipated difficult airway: A randomized controlled study p. 118
Neelakshi Koul, Vinod Bala Dhir, Nitin Choudhary, Jyoti Singh, Deepak Kumar Nohwar, Mohandeep Kaur
Background: Management of difficult airway remains a cornerstone of anesthesiology requiring constant probe into newer devices challenging set gold standards. Hence, we compared the effectiveness of intubating laryngeal mask airway (ILMA) with flexible fiberoptic bronchoscope (FOB) in anticipated difficult airway. Aims: The aim of this study was to compare and evaluate ILMA and FOB for tracheal intubation in patients with anticipated difficult airway. Settings and Design: The study design involves comparative randomized study. Materials and Methods: Fifty patients undergoing elective surgery under general anesthesia with anticipated difficult airway (Modified Mallampati Class III/Wilson's Score 6-7) were divided into Group I (ILMA) and Group F (FOB). Primary outcomes, i.e., ease of intubation (number and duration of attempts) and success rate; and secondary outcomes, i.e., hemodynamic parameters and adverse events were noted. Results: Both the groups were comparable in age, gender distribution, body mass index, and type of surgery. The number of attempts required and hemodynamics changes were similar in both groups. ILMA required lesser time, i.e., 59.76 s versus FOB, i.e., 109.88 s in the first attempt (DA1) and 62.67 s for Group I versus 120.86 s for Group F in the second attempt (DA2), being statistically significant. ILMA showed higher adverse event rate versus FOB; however, the difference was statistically insignificant. Conclusions: ILMA is an effective alternative to FOB in patients with anticipated difficult airway with respect to ease of intubation, with similar hemodynamic stability, success rate, and adverse events. Anticipated difficult airway, fiberoptic bronchoscope, intubating laryngeal mask airway
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Comparison of two doses of intravenous esmolol in attenuation of hemodynamic response to extubation in laparoscopic surgeries p. 125
SA Kshama, Laxmi Shenoy, Shweta Sinha
Aims and Objectives: The purpose of this study was the comparison of hemodynamic variables such as heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure during the extubation period following administration of two doses of intravenous (IV) esmolol. Materials and Methods: This prospective double-blind randomized controlled trial was conducted on patients (American Society of Anesthesiologists Physical Status), aged between 18 and 65 years, scheduled for elective laparoscopic procedure done under general anesthesia with endotracheal intubation. Sixty participants were randomized into three groups of 20 each, the first two groups received IV esmolol injection of 0.5 mg/kg and 1 mg/kg doses, respectively, and the third group received placebo injection of 10 ml of saline intravenously after the completion of surgery before extubation. Statistical Analysis: Statistical analysis of data was done using SPSS 20 software. Repeated measures analysis of variance (ANOVA) test was used for the analysis of trends of different parameters within the group. For comparison between the groups and to find if any significant difference exists, one-way ANOVA was used. Post hoc Tukey's test was used to find where the difference originated from, once significant difference was found. Results: Demographic data were statistically similar between groups. IV administration of esmolol at both 0.5 mg/kg and 1 mg/kg is effective in attenuating heart rate response but IV esmolol bolus of 1 mg/kg is more effective than bolus of 0.5 mg/kg in attenuating blood pressure response to extubation as it provided a more consistent hemodynamic control during the extubation as well as in the postextubation period. Conclusion: Extubation and emergence from general anesthesia cause significant increases in heart rate and blood pressure and emphasis must be given on attenuation of this sympathetic response, especially in vulnerable patients. IV administration of esmolol is effective in attenuation of heart rate response and blood pressure response with consistently good hemodynamic control during extubation postoperatively.
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Comparison of ketamine–propofol (ketofol) versus midazolam–fentanyl for procedural sedation and analgesia in emergency care department: An open-label randomized controlled study p. 131
K Charishma Begum, Kingsly Robert Gnanadurai, Chandrappa Sreekanth, DS Pushpa Latha
Background: Various anesthetic drugs are used for procedures conducted outside the operation theater. Very few studies are done in the emergency department to compare the combination of ketamine and propofol (ketofol) versus midazolam–fentanyl for procedural sedation and analgesia, thus we conducted this study to compare these drug combinations in terms of analgesic and sedation efficacy in the emergency department. Materials and Methods: A prospective, open-label, randomized, comparative study was conducted on 60 patients, who were randomly assigned to the ketofol and midazolam–fentanyl groups (30 each) to compare these drugs in terms of sedation efficacy using modified Ramsay sedation score, pain scores using Visual Analog Scale, and alteration of hemodynamic, adverse effects such as respiratory distress and nausea. The mean pain score before and after the study was compared using paired t-test, and the difference between the two groups was assessed using Student's t-test. Chi-square test and Fisher's exact test were employed to compare the distribution of qualitative data. Results: Our study showed that ketofol provides better analgesia as compared to the midazolam–fentanyl group because reduction in Visual Analog Scale scores was 1.27 ± 1.52 (mean ± standard deviation [SD]) in the ketofol group as compared to 3.07 ± 1.25 (mean ± SD) in the midazolam–fentanyl group. Ketofol 4.47±0.73 (mean ± SD) had a better modified Ramsay sedation score when compared to midazolam–fentanyl 3.47±0.90 (mean ± SD). There was reduction in systolic (from 119 ± 18.4 to 113.3 ± 18.81 mmHg) and diastolic blood pressure (from 72 ± 9.61 to 69.67 ± 10.33 mmHg) in the midazolam–fentanyl group during and after the procedure in comparison to the ketofol group where none had hypotension. Conclusion: Results concluded that ketamine–propofol (ketofol) combination is safe and better in providing adequate analgesia and sedation than midazolam and fentanyl combination in the emergency room.
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Preemptive analgosedation with ketamine-dexmedetomidine versus ketamine-propofol in upper limb surgeries under supraclavicular brachial plexus block: A randomized controlled trial p. 138
Mehul D Makwana, Bhumika P Pathak, Nirali Nimeshkumar Panchal, Madhavi Sanjay Chaudhari, Ajay Gajanan Phatak
Background and Aims: Analgosedation before and during regional anesthesia provides analgesia, anxiolysis, and amnesia. This study has been conducted to compare ketamine-dexmedetomidine (KD) versus ketamine-propofol (KP) for sedation, pain on needle prick while giving block, hemodynamics, and their side effects under supraclavicular brachial plexus block. Materials and Methods: After obtaining ethics committee approval, CTRI registration and patient consent, 75 patients were recruited who satisfy inclusion and exclusion criteria. Patients were divided into two groups. Group KP received a loading dose of ketamine 0.5 mg/kg, propofol 1 mg/kg over 10 min, followed by a maintenance dose of ketamine 0.3 mg/kg/h and propofol 10 μg/kg/min. Group KD received loading dose of ketamine 0.5 mg/kg, dexmedetomidine 0.5 μg/kg over 10 min, followed by maintenance dose of ketamine 0.3 mg/kg/h and dexmedetomidine 0.3 μg/kg/h. Patients were monitored for sedation, pain on needle prick while performing block, side effects of study drugs, hemodynamic and respiratory parameters. An independent sample t-test was used to compare continuous outcomes, descriptive statistics were used to depict the baseline profile of the study participants, Chi-square test was used to compare the categorical outcomes. A value of P < 0.05 was considered statistically significant. Results: Pain on needle prick was experienced in 5.7% and 42.9% in Group KD and Group KP, respectively. In Group KD, 28.6% and Group KP 5.7% of patients experienced nausea. Conclusion: In this study, group KD has adequate sedation as compared to group KP with less pain on needle prick while performing supraclavicular block. Group KD has higher incidence of nausea than gruop KP.
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A rare case of unintentional cannulation of superficial radial artery mistaken for the cephalic vein – An ultrasound evaluation p. 144
Vinod Krishnagopal, Raj Murugan, A Shanmuga Priya, S Divyashree
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A case of positional alopecia following prolonged surgery p. 145
Varshini Ravindran, Sunil Rajan, Susmitha Susan Mammen, Lakshmi Kumar
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Sacroiliac joint pain - A diagnostic dilemma p. 147
Vinod Krishnagopal, Sharanya Krishnakumar, R Purushotham, R Sudhakaran
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Trivia of an unnoticed miscreant at the glottis resulting in an unanticipated difficult airway p. 149
Sumit Roy Chowdhury, Amit Kumar Malviya, Anju Gupta
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An unusual appearance of capnograph - dilemma for an anesthesiologist! p. 150
Ruchi Ohri, SS Noufiya
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Anesthetic management of a rare case of an adolescent with goldenhar syndrome p. 152
Shalendra Singh, Voddepalli Rajesh, Ankit Singh
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