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   Table of Contents - Current issue
Coverpage
July-December 2021
Volume 22 | Issue 2
Page Nos. 117-200

Online since Wednesday, September 29, 2021

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EDITORIAL  

Perfusion index as a monitor to determine the success of a peripheral nerve block: Is the truth subjective or objective? p. 117
Sunita Sanghavi, Ghansham Biyani
DOI:10.4103/TheIAForum.TheIAForum_103_21  
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CLINICAL PRACTICE GUIDELINES Top

Indian association of paediatric anaesthesia advisory for pain management in neonates and preverbal children p. 120
Anju Gupta, Indu Mohini Sen, YR Chandrika, Gita Nath, Elsa Varghese
DOI:10.4103/TheIAForum.TheIAForum_4_21  
In the past, management of pain in neonates was regarded as unnecessary, with the belief that neonates have an immature nervous system and do not perceive pain. Later studies confirmed that neonates certainly do feel pain, though they lack the inhibitory mechanisms that modulate excruciating stimuli, unlike in older children. Repeated painful encounters experienced in the newborn period are associated with poor cognitive and motor development by 1 year of age. Pain in preverbal infants and children is also poorly recognized and often undertreated. Neonates and preverbal children cannot verbally communicate their pain and discomfort but express them through specific behavioral, physiological, and biochemical responses. Several pain measurement tools have been developed for young children as surrogate measures of pain. To achieve optimum postoperative or procedural pain relief, easily understandable tools and a multimodal treatment module should be tailor-made for each health-care facility that cares for neonates and young infants. The aim of this advisory is to outline key concepts of pain assessment in neonates and preverbal children and suggest a rational approach to its management by all anesthesiologists, pediatricians, nursing staff, and other medical personnel caring for these children. The Indian Association of Paediatric Anaesthesia (IAPA) convened an online meeting in April 2020 to formulate the advisory on pain management in neonates and preverbal children under the chairmanship of Dr. Elsa Varghese, President IAPA, and members of the guideline committee. After several such meetings and revisions using feedback from IAPA members, the final guidelines were released in October 2020 on the IAPA website. Recommendations: Pain relief should generally be accomplished with a combination of nonpharmacologic approaches and pharmacologic techniques in a stepwise tiered manner by escalating type and dose of analgesia with anticipated increases in procedural pain. Nonpharmacological distraction measures may be sufficient for minor needle procedures like vaccination and venipuncture and may be offered as a first step and to complement other pain management remedies. An interdisciplinary approach involving pharmacologic, cognitive-behavioral, psychologic, and physical treatments should be employed whenever feasible.
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ORIGINAL ARTICLES Top

Analgesic efficacy of ultrasound-guided erector spinae block and pectoral nerve block in patients undergoing modified radical mastectomy: A randomized control trial p. 129
Geeta Singariya, Himani Pahuja, Manoj Kamal, Kusum Choudhary, Saroj Meena, Pradeep Saini
DOI:10.4103/TheIAForum.TheIAForum_74_21  
Background and Aims: Modified radical mastectomy (MRM) is the commonest surgical procedure performed for carcinoma breasts. MRM is associated with considerable postoperative pain. This study was aimed to compare the analgesic efficacy of erector spinae plane (ESP) block and pectoral nerve (PECS) block. Materials and Methods: A total 70 female patients, American Society of Anesthesiologist Physical Status I-II, aged between 18 and 65 years, undergoing MRM surgery. Patients were randomly divided into two equal groups of 35 each, by computer-generated random number table. Group E patients, received ESP block with 20 mL of 0.25% levobupivacaine, and Group P patients, received PECS block with 30 mL of 0.25% of levobupivacaine. The surgical procedure was conducted under general anesthesia in both groups. The primary objective was total morphine consumption in the first 24 h and secondary objectives were intraoperative fentanyl needed, duration of analgesia, numeric rating scale (NRS) score, postoperative complications, and patient's satisfaction. The Statistical Package for the Social Science (SPSS) software version 22.0 used for statistical analysis. Results: Demographic data, hemodynamic parameters, and intraoperative fentanyl consumption were comparable between the two groups (P > 0.05). Postoperative morphine consumed in the first 24 h was less in the Group P compared to Group E (P = 0.018). The duration of analgesia was significantly prolonged in the Group P than Group E (P < 0.0001). The NRS score, postoperative complications, and patient's satisfaction were comparable. Conclusion: The PECS block is more effective analgesic modality compared to ESP blocks in patients undergoing MRM surgeries.
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A randomized, double-blinded comparative study of phenylephrine infusion and norepinephrine infusion for the prevention and treatment of spinal anesthesia-induced hypotension in elective and emergency cesarean deliveries p. 136
Payal Kalpesh Berawala, Sanket Hirenbhai Mehta, Madhavi Sanjay Chaudhari, Mayur Kiran Shinde
DOI:10.4103/TheIAForum.TheIAForum_9_21  
Context and Aims: Among vasopressors used to treat postspinal hypotension (PSH) in cesarean sections (CS), phenylephrine (PE) is the preferred drug at present but reflex bradycardia and thus reduction in cardiac output still pose a concern. Norepinephrine (NE), with its better pharmacological properties, may be a better alternative to overcome this risk. Hence, we did this study intending to compare both the drugs. Materials and Methods: A double-blinded, randomized, controlled trial (RCT) was carried out on 70 patients, 35 in each group-group P (PE) and group N (NE) undergoing CS, to compare and evaluate the efficacy of both drugs for preventing and treating PSH. Patients in Group P and Group N were given intravenous infusion of PE at the rate of 50 μg/min and NE at the rate of 2.5 μg/min, respectively, after the intrathecal injection of bupivacaine. The number of intermittent bolus doses required, heart rate, and mean arterial pressure (MAP) at predefined intervals were noted. Results: The incidence of hypotension calculated from the number of bolus doses required was lower in Group N than in Group P for the initial 15 min (P < 0.05). The incidence of bradycardia and vomiting was higher in Group P but were not statistically significant, while the incidences of nausea (P = 0.004) and oxygen requirement (P = 0.03) were statistically significantly higher in Group P. Conclusion: This study suggests that NE infusion is superior to PE infusion when used in the potency ratio of 20:1, to prevent and treat PSH in CS, with a lesser number of side effects.
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Comparison of 0.125% and 0.2% ropivacaine in continuous lumbar plexus block for postoperative analgesia after total hip arthroplasty p. 143
Anand Murugesan, Deepak Gurunathan, MS Raghuraman, Daivam Indumathi, M Thiriloga Sundary
DOI:10.4103/TheIAForum.TheIAForum_34_21  
Background: Lower concentrations of ropivacaine in continuous lumbar plexus block (LPB) have not been studied adequately. Thus, we designed this prospective, randomized, comparative study to evaluate the two different concentrations of ropivacaine (0.125% and 0.2%) in continuous LPB for postoperative pain relief following total hip arthroplasty (THA). Materials and Methods: Fifty patients undergoing THA under standardized subarachnoid block have been randomly allocated to receive a continuous infusion of either 0.125% (Group 1) or 0.2% (Group 2) of ropivacaine in LPB done under the guidance of peripheral nerve stimulator. The primary outcome was consumption of tramadol during the first 24 h and the secondary outcomes were quality of sensory and motor blockade and consumption of ropivacaine. Results: The total amount of tramadol did not differ significantly (P = 0.442) between the two groups. Furthermore, the duration of sensory and motor blockade did not differ significantly between the two groups. However, the average consumption of ropivacaine was significantly lower in Group 1 when compared to Group 2 (238.80 mg vs. 380.64 mg, P = 0.0001). Conclusion: Administration of 0.125% of ropivacaine can be a better alternative as it would decrease the total amount of the local anesthetic in continuous LPB.
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Liver fibrosis-4 score predicts mortality in critically ill patients with coronavirus disease 2019 p. 149
Mohammed Fawzi Abosamak, Ivan Szergyuk, Maria Helena Santos De Oliveira, Giuseppe Lippi, Ahmed Suliman Al-Jabbary, Amal H Al-Najjar, Marzooq A Albadi, Brandon M Henry
DOI:10.4103/TheIAForum.TheIAForum_49_21  
Background: Emerging evidence suggests that liver dysfunction in the course of coronavirus disease 2019 (COVID-19) illness is a critical prognostic factor for mortality in COVID-19 patients, and the Fibrosis-4 (FIB-4) score, developed to reflect level of hepatic fibrosis, has been associated with adverse outcomes in hospitalized COVID-19 patients. This study aimed to investigate intensive care unit (ICU) admitted patients, a high-risk subpopulation, research on which is lacking. Materials and Methods: This retrospective cohort study examined FIB-4 scores and clinical endpoints including death, acute cardiac injury (ACI), acute kidney injury, and need for mechanical ventilation in critically ill COVID-19 patients, without prior hepatic disease, throughout ICU stay. Results: Of 60 patients enrolled, 35% had ICU admission FIB-4 >2.67. Among nonsurvivors, FIB-4 was significantly higher at admission (median 3.19 vs. 1.44; P < 0.001) and only a minority normalized <1.45 (36.0%). Each one-unit increment in admission FIB-4 was associated with 67.4% increased odds of death (95% confidence interval [CI], 9.8%–162.6%; P = 0.017). FIB-4 >2.67 was associated with a median survival time of 18 days from ICU admission versus 40 days with FIB-4 <2.67 (P = 0.016). Admission FIB-4 was also higher in patients developing ACI (median 4.99 vs. 1.76; P < 0.001). FIB-4 correlated with age (r = 0.449; P < 0.001), and aspartate transaminase with alanine transaminase (r = 0.674; P < 0.001) and lactate dehydrogenase (r = 0.618; P < 0.001). Conclusion: High ICU admission FIB-4 is associated with mortality in critically ill COVID-19 patients, with failure to normalize at time of death, however, the high score is likely a result of generalized cytotoxicity rather than advanced hepatic fibrosis.
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Comparison of ropivacaine (0.2%) and ropivacaine (0.125%) with 2 μg/ml fentanyl for epidural labor analgesia: A randomized controlled study p. 157
Kalyani Manasa Rapeti, Santhisree Mulam, B Sowbhagya Lakshmi, Ankur Sharma
DOI:10.4103/TheIAForum.TheIAForum_156_20  
Aim: The aim of this study was to determine the minimum effective local anesthetic concentration required to provide good analgesia with less consumption of opioids. Objective: Among various labor analgesic techniques, epidural analgesia is the most effective form of analgesia. This study aimed to determine the minimum effective local anesthetic concentration required to provide good analgesia with less consumption of opioids. The objective of this study was to evaluate the efficacy of 0.125% and 0.2% ropivacaine, both with fentanyl 2 μg/ml for epidural labor analgesia. Materials and Methods: A total of 50 term parturients of American Society of Anesthesiologists physical status Grade I and II with vertex presentation in active labor were randomly assigned to two groups, Group R1 and Group R2, which received 10 ml of 0.125% ropivacaine with injection fentanyl 2 μg/ml and 10 ml of 0.2% ropivacaine with fentanyl 2 μg/ml, respectively, as an initial bolus dose and intermittent top-up doses epidurally. Characteristics of the block, onset and duration of analgesia, and total analgesic requirements were noted. Pain and overall satisfaction scores were assessed with the Visual Analog Scale score. The maternal and fetal outcomes were recorded. Results: Maternal demographic characteristics were comparable. Although both the concentrations are effective in providing optimal labor analgesia, decreasing the concentration of ropivacaine has resulted in an increased number of repetition of doses and thus an increased consumption of fentanyl. There were no significant differences between the two groups regarding motor block, hemodynamic, and neonatal outcomes. Conclusion: We conclude that 0.2% ropivacaine was found superior in terms of faster onset, prolonged duration, lesser breakthrough pain requiring lesser top-ups, and hence a lesser consumption of opioids. Hence, we conclude that the use of 0.2% ropivacaine is superior to 0.125% ropivacaine with fentanyl.
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Demographic profile and clinical characteristics of surgical patients operated in COVID-19 operation theater in a tertiary care hospital p. 164
Sapna Bathla, Mahak Mehta, Akshaya Kumar Das, Parul Mullick, Dharam Singh Meena, Usha Ganapathy
DOI:10.4103/TheIAForum.TheIAForum_53_21  
Background and Aim: Surgical procedures in patients with COVID-19 disease are associated with increased perioperative morbidity and mortality. A retrospective study was conducted to evaluate the demographic and clinical data of surgical patients with suspected or confirmed COVID-19 disease. Methods: After taking hospital ethics committee approval, medical records of surgical patients operated during the period from May 2020 to November 2020 in a COVID-19-designated tertiary care hospital of northern India were assessed. The demographic data such as age, gender, associated comorbidities, type of surgery, intraoperative complications, and data on the postoperative status of the patients were collected and analyzed. Results: Ninety-four patients underwent surgical procedures during the study period. Out of all patients, 87.2% were females. The median age of patients was 28 years (range: 1 month–59 years). The emergency cesarean section was the most common surgery performed. The subarachnoid block was the most commonly used anesthesia technique. Out of 94 patients, 70 patients were confirmed COVID-19 positive, and 24 were suspected cases. Most of the patients were American Society of Anesthesiologists II (83%) and 43.6% of patients had comorbidities. Conclusion: The cesarean section was the most commonly performed surgical procedure. The most common anesthesia technique used was the subarachnoid block. The patients operated under subarachnoid block had a better prognosis and did not require intensive care unit stays in the postoperative period.
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The comparison of arm and forearm double tourniquet in terms of the onset and duration of analgesia, tourniquet pain, and the return of sensation and movement in distal upper extremity surgery: A randomized clinical trial p. 169
Hesameddin Modir, Esmail Moshiri, Amirreza Modir, Saide Shakeri, Amir Hosein Moradi
DOI:10.4103/TheIAForum.TheIAForum_70_21  
Aims: The current study aimed at comparing arm and forearm double tourniquet in terms of the onset and duration of analgesia, tourniquet pain, and the return of sensation and movement in distal upper extremity surgery. Methods: This double-blind clinical trial was performed on 70 patients who were candidates for distal upper extremity orthopedic surgeries. The patients were randomized into two groups of arm and forearm double tourniquet. The onset time and duration of sensory and motor blocks were recorded. The pain level was recorded by visual Analog Scale (VAS) after inflating the tourniquet every 15 min till the end of operation at 15, 30, and 45 min as well as every 30 min for 2 h (at 30, 60, 90, and 120 min.) and at 6, 12, and 24 h after deflating the tourniquet. SPSS version 20 was used to analyze the data. Results: During 8–24 h after the surgery, the pain in arm double- tourniquet group was less than that in the other group (P < 0.05). There was no statistically significant difference in the time to onset of sensory–motor block between the two groups (P > 0.05). The duration of sensory block in arm double tourniquet was longer than that in forearm double tourniquet group (P = 0.002). In addition, the duration of motor block in arm double tourniquet was also longer than that in forearm double tourniquet group (P = 0.001). The pain level was equal in both the groups at all times except for the time interval of 8–24 h after the operation in arm double tourniquet group. Furthermore, there was no statistically significant difference in the pain level, and the time to onset of sensory–motor block was the same in both the groups as well. However, the duration of sensory–motor block was longer in the arm double tourniquet group, while no complication was found in either group. Conclusion: Both the techniques are applicable in hand and distal upper extremity surgeries provided that the surgical duration is not too long. Using forearm double tourniquet technique is preferable to arm double tourniquet, but the surgical duration should not exceed 60 min. That is because less amount of anesthetic drugs is needed in forearm double tourniquet technique, hence leading to a decrease in the potential side effects.
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CASE REPORTS Top

An encounter with Nager's syndrome: A case report of pediatric airway challenge p. 176
Reena Ravindra Kadni, K Varghese Zachariah, Madhuri Maganthi, LG Shyamsundar
DOI:10.4103/TheIAForum.TheIAForum_10_21  
Nager acrofacial dysostosis is a rare genetic syndrome. It has a potential threat of obstructed airway from birth. Associated with severe micrognathia, it poses a difficult airway challenge to the anesthesiologist. Tracheostomy may be required for the survival of these patients. We report a case of a 2½-month-old infant with Nager's syndrome for lip reconstruction and club foot management.
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Overcoming the obstruction, anesthetic management of hypertrophic obstructive cardiomyopathy: The prudent paradox of less is more! p. 180
Joseph Nascimento Monteiro, Unmesh Pramod Bedekar, Chandrashekhar Ponde, Milind Sankhe
DOI:10.4103/TheIAForum.TheIAForum_42_21  
Hypertrophic obstructive cardiomyopathy (HOCM) is a genetically mediated disease causing left ventricular outflow tract obstruction (LVOTO) predisposing the patient to systolic and diastolic dysfunction leading to arrhythmias and sudden cardiac deaths in the perioperative period. This case report describes the anesthetic management of a 76-year-old female posted for a semi-emergent three level lumbar canal decompression with severe HOCM with dynamic LVOTO with an initial resting gradient >70 mmHg, noninsulin-dependent diabetes mellitus, bronchial asthma, deep-vein thrombosis, and hypothyroidism as comorbidities. Preoperative evaluation of the risks, cardiac optimization, interdisciplinary shared decision making, preoperative invasive monitoring, preanesthetic placement of defibrillator pads, careful titration of anesthetic agents, with meticulous perioperative monitoring, and perioperative intensive care collaboration contributed to a successful outcome.
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Stellate ganglion block and neurolysis for refractory ventricular arrhythmia p. 183
Anurag Aggarwal, Rohit Balyan, Varun Suresh, Bhavna Gupta
DOI:10.4103/TheIAForum.TheIAForum_13_21  
Enhanced electrical activity, ventricular arrhythmia (VA), and cardiac instability due to increased sympathetic tone may be refractory to standard medical treatment and ablation procedures. Stellate ganglion block (SGB) has been used to treat refractory VA; however, there is insufficient information in the literature on its long-term outcome. Herein, we described three patients that were successfully treated with ultrasound-guided left SGB (LSGB) and chemical neurolysis. Ultrasound-guided LSGB may be considered as rescue or bridge therapy for stabilizing ventricular rhythm before a definitive procedure is planned.
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LETTERS TO EDITOR Top

The dilemma of extubation of a patient with congenital cyanotic heart disease p. 187
Hari Prasad Ramalingam, Ankur Sharma, Hareesh Ayyawar, Pradeep Kumar Bhatia, Nikhil Kothari
DOI:10.4103/TheIAForum.TheIAForum_25_21  
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Ultrasound-guided intermediate cervical plexus block added to thoracic epidural for pain management in multiple ribs and clavicle fracture p. 188
Hariprasad Ramalingam, Ankur Sharma, Shilpa Goyal, Nikhil Kothari
DOI:10.4103/TheIAForum.TheIAForum_26_21  
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Ultrasound-guided dilation of central venous catheter track to prevent dilator-related injury p. 190
Hariprasad Ramalingam, Shipra Roy, Ankur Sharma, Nikhil Kothari, Shilpa Goyal
DOI:10.4103/TheIAForum.TheIAForum_39_21  
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A migrated guidewire of a hemodialysis catheter in a COVID-19 patient p. 192
Sarfaraz Ahmad, Shagufta Naaz, Neeraj Kumar, Amarjeet Kumar
DOI:10.4103/TheIAForum.TheIAForum_44_21  
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Anesthetic management of an infant with uncorrected pentalogy of Fallot undergoing emergency exploratory laparotomy p. 193
Nitin Choudhary, Rohan Magoon, Sonia Wadhawan
DOI:10.4103/TheIAForum.TheIAForum_78_21  
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Persistent guidewire-induced arrhythmias following central venous catheterization in traumatic brain injury p. 195
Haneesh Thakur, Nidhi Singh, Jeetinder K Makkar, Kajal Jain
DOI:10.4103/TheIAForum.TheIAForum_46_21  
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Radiofrequency ablation of stellate ganglion for neuropathic pain due to brachial plexus neurofibroma in a patient with neurofibromatosis type 1 p. 197
Anand Murugesan, MS Raghuraman, Vinod Krishnagopal
DOI:10.4103/TheIAForum.TheIAForum_45_21  
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A bougie as a foreign body p. 199
Mahak Kakkar, Sushil Guria, Swati Jain, Sushmita Bairagi
DOI:10.4103/TheIAForum.TheIAForum_161_20  
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