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   Table of Contents - Current issue
Coverpage
January-June 2022
Volume 23 | Issue 1
Page Nos. 1-80

Online since Wednesday, March 23, 2022

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EDITORIAL  

Is there enough evidence to recommend routine use of preprocedural ultrasound for neuraxial blockade? p. 1
Ghansham Biyani, Rajasekhar Metta
DOI:10.4103/TheIAForum.TheIAForum_29_22  
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CLINICAL PRACTICE GUIDELINES Top

Indian Association of Paediatric Anaesthesiologists advisory for paediatric airway management p. 3
Shilpa Goyal, Ankur Sharma, Pradeep Bhatia, Indu Mohini Sen, Gita Nath, Elsa Varghese
DOI:10.4103/TheIAForum.TheIAForum_112_21  
The pediatric airway poses a challenge particularly for those who do not anesthetize small children on a regular basis. Anatomical and physiological variations of the airway at different ages have an impact on the decision of which medication to administer with regard to route, dosage, and duration of action as well as the choice of equipment. Knowledge of this helps in the routine management of airway in children. Technological advancements and research have rendered numerous pediatric airway devices available for securing the airway in elective and emergency scenarios. However, their availability alone does not solve all problems. Having the knowledge, the ability to promptly recognize difficulty and to know when to call for help early are key factors for a favorable outcome. This advisory is formulated as a guide for a successful and safe airway management in children for the anesthesiologist involved in the care of pediatric patients.
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ORIGINAL ARTICLES Top

Effect of nitrous oxide and dexmedetomidine on the consumption of propofol during general anesthesia in adult patients: A randomized controlled trial p. 12
Ghansham Biyani, Pradeep Kumar Bhatia, Sadik Mohammed, Pooja Bihani, Manoj Kamal, Swati Chhabra
DOI:10.4103/TheIAForum.TheIAForum_138_21  
Background: Use of both nitrous oxide and dexmedetomidine as anesthetic adjuvants has shown to reduce the consumption of propofol required for the maintenance of anesthesia. The present study evaluated these two agents for their propofol sparing effect which has not been compared so far. Materials and Methods: Sixty adult patients undergoing elective surgery were enrolled and randomly divided into three groups. Patients in group P received propofol started at 166 μg/kg/min and then titrated to maintain the Bi-Spectral Index (BIS) value between 40 and 60, while patients in group N and in group D received nitrous oxide as carrier gas and infusion of dexmedetomidine (1 μg/kg over 10 min followed by 0.5 μg/kg/h) respectively, in addition to propofol. Primary outcome of the study was total consumption of propofol. Secondary outcomes measured were intraoperative hemodynamics, recovery profile, residual sedation, rescue analgesic requirements, and relevant side effects. Results: Total consumption of propofol was significantly higher in group P (139.02 ± 65.24 μg) compared to group N (94.72 ± 48.04 μg) and group D (98.31 ± 39.45 μg) (mean difference [95% confidence interval] group P and N 44.3 [17.9–44.7]; group P and D 40.71 [26.0–52.8]; group N and D 3.59 [−5.3–21.5]) (P = 0.015). Although the recovery parameters (time to extubation, time to achieve BIS of 90, and time to verbal commands) were significantly prolonged in group D (P < 0.001), time to discharge from postanesthesia care unit (PACU) was comparable among all groups (P = 0.65). When arrived in PACU, patients in group D were significantly more sedated (P = 0.0005) however, the 30 min in PACU the difference was nonsignificant. None of the patients in group D had nausea and vomiting and did not require additional analgesics. Conclusion: Both nitrous oxide and dexmedetomidine significantly decreased the total consumption of propofol. Hence, both these agents can be used as potential anesthetic adjuvants to decrease the side effects associated with propofol infusion. Due to the lack of any reported environmental and long-term side effects, dexmedetomidine can be a safer and better alternative to nitrous oxide.
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Comparing the intraoperative and postoperative analgesic effect of transabdominal block versus caudal block in children undergoing laparoscopic appendectomy p. 19
Saraswathi Nagappa, Nethra H Nanjundaswamy, Vinay Maralusiddappa, Vinayak Nayak
DOI:10.4103/TheIAForum.TheIAForum_6_21  
Background: Laparoscopic appendectomy is commonly performed in children. Regional anesthesia in children is complementary to general anesthesia, which allows conscious postoperative analgesia and reducing hospital stay. Caudal anesthesia and transverses abdominis plane (TAP) block is commonly used in children because it is easy to practice and provides effective analgesia during surgery. However, its efficacy in laparoscopic appendectomy is not tested much. Aim: The aim of this study is to evaluate the analgesic efficacy of caudal block and TAP block, when used as pre-emptive analgesia using ropivacaine in terms of opioid consumption, postoperative visual analog score (VAS), duration of analgesia, time for rescue analgesia, postoperative nausea, and vomiting and other side effects following elective laparoscopic appendectomy. Methodology: The study design was a prospective, double-blinded, comparative randomized trial on children undergoing laparoscopic appendectomy. Sixty patients between 12 and 18 years were included in the study. They were allocated into any one of two groups of 30 patients each, employing computer-generated randomization. Group I: receive ultrasound-guided caudal block using 0.2% ropivacaine 1 mL/kg. Group II: receive ultrasound-guided TAP block using 0.2% ropivacaine 1 mL/kg. Results: Total intraoperative consumption of opioid fentanyl in Group I is 14.83 ± 18.78 compared to 25.50 ± 17.88 in Group II, which is statistically significant P = 0.028*. VAS score was significantly lower in Group II compared to Group I, P < 0.001**. Conclusion: Caudal block is effective for intraoperative management, whereas TAP block is effective for postoperative management in children undergoing laparoscopic appendectomy.
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Comparison of Intravenous Nefopam and Tramadol for Postoperative Analgesia in Adult Patients Scheduled for Laparoscopic Abdominal Surgeries under General Anesthesia: A Prospective, Randomized, Double-Blind Study p. 25
Yogesh Kumar Swarnkar, Rajiv Gupta, Anand Mohan Arora, Tuhin Mistry
DOI:10.4103/TheIAForum.TheIAForum_156_21  
Background and Aims: Nefopam and tramadol have been used for postoperative analgesia in the various clinical settings. This study aims to evaluate and compare the postoperative analgesic effects of intravenous nefopam and tramadol in adult patients undergoing laparoscopic abdominal surgeries. Materials and Methods: One hundred and twenty-six adult patients of the American Society of Anesthesiologists physical Status I and II, age group of 20–60 years undergoing elective or emergency laparoscopic abdominal surgeries under general anesthesia were allocated randomly into two groups. In the postanesthesia care unit, patients in Group A (n = 63) and Group B (n = 63) received Nefopam 20 mg and Tramadol 100 mg, respectively, as intravenous infusion in 100 ml 0.9% saline over 15 min. The same doses were repeated every 6th hour or if the Visual Analog Scale (VAS) score was ≥4. Postoperative VAS scores were recorded at 30 min, 1.5 h, 3 h, 6 h, 12 h, 18 h, and 24 h. The hemodynamic parameters were recorded just before and after the completion of the infusion of study drugs. P < 0.05 was considered statistically significant. Results: The pain score was significantly lower in Group A (Nefopam) than in Group B (Tramadol). The difference in mean VAS scores between the two groups was statistically significant at 1.5 h, 3 h, 6 h, 12 h, 18 h, and 24 h after postoperatively (P < 0.05). There was no statistically significant difference in the incidence of side effects in both groups. Conclusion: Intravenous nefopam provided better postoperative pain relief than Tramadol in patients undergoing laparoscopic surgeries under general anaesthesia.
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Addition of dexmedetomidine and nalbuphine as an adjuvant to ketofol for deep sedation during endoscopic retrograde cholangiopancreatography: A prospective, randomized, double-blind study p. 31
Chhabra Alka, Karuna Sharma, Neelam Chaudhary, Milan Dave, Neha Pandey, Sunanda Gupta
DOI:10.4103/TheIAForum.TheIAForum_69_21  
Background: Deep sedation has evolved as a better choice against general anesthesia in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). This study was aimed to evaluate the efficacy of dexmedetomidine and nalbuphine as an adjuvant to ketofol based deep sedation in ERCP. Methods: One hundred patients undergoing ERCP were randomly assigned to receive either IV dexmedetomidine 1 μg/kg (Group D, n = 50) or I. V nalbuphine 0.1 μg/kg (Group N, n = 50), 10 min before ketofol induction. The primary outcome was the total dose of ketofol used for induction and maintenance of deep sedation throughout the procedure. Hemodynamics and respiratory parameters, recovery characteristics, endoscopist's, and anesthetist satisfaction scores were secondary outcomes. P < 0.05 was considered statistically significant. Results: The dose of ketofol at the time of induction was significantly high in Group N as compared to Group D (P < 0.05). Supplemental dose of ketofol at the time of insertion of endoscope was equivalent in both the groups (P > 0.05) but significantly more number of patients in Group D (n = 19 vs. n = 11, P < 0.05) received supplement for facial pain score >5 compared to patients in Group N, where more patients received supplement for Ramsay Sedation Score <3 (n = 20 vs. n = 11 P < 0.05). Significant decrease in heart rate (HR) and mean arterial pressure from baseline values was found in Group D as compared to Group N (P < 0.001). Group N patients achieved postanesthesia recovery score >12 earlier than Group D (P < 0.001). Anesthetist satisfaction score was more in Group N (P < 0.05). Conclusion: Dexmedetomidine reduces the total consumption of ketofol and provides smooth hemodynamics whereas Nalbuphine provides better analgesia and early recovery with high anesthetist satisfaction for deep sedation in ERCP.
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Preprocedural ultrasound assessment of landmarks of paramedian approach for subarachnoid block in geriatric population p. 38
Tapan Kumar Ray, Shlok Saxena, Amrita Panda
DOI:10.4103/TheIAForum.TheIAForum_97_21  
Background: Paramedian spinal anesthesia is the preferred anesthetic technique in the elderly. This conventional approach is occasionally challenged by difficulty in identifying landmarks accurately. Neuraxial ultrasound aims to overcome these inaccuracies. Objective: The objective was that the routine use of preprocedural ultrasound assessment of landmarks for paramedian spinal in geriatric population improves the efficacy of spinal anesthesia by reducing the number of attempts and redirections. Materials and Methods: Sixty consenting elderly patients aged 60 year or above, posted for elective surgery under spinal anesthesia, were enrolled in the study. Participants were assigned at random to receive spinal anesthesia by the paramedian approach by either conventional landmark guidance (Group CP) or preprocedural ultrasound-assisted (Group PP) technique. Results: The number of needle redirections was not significant and the success rate at the first attempt with no redirection was higher in the ultrasound compared with the landmark group. However, the mean insertion attempts were indifferent. The preprocedural ultrasound-assisted approach required an insignificantly shorter time for administering spinal anesthesia than the landmark-guided technique (48.87s [67.65] vs. 50.67s [50.19]) [P = 0.90]. The periprocedural pain scores (2.90[2.07] vs. 2.87[1.57]) [P = 0.94] and willingness for a similar future intervention (66.7 vs. 66.7%) were comparable among the groups. Conclusion: The use of preprocedural ultrasonography for paramedian approach to spinal anesthesia is not superior to the conventional landmark guidance in achieving successful dural tap at L3-L4 interspace in elderly adult population and should be limited to a setting with expert operators and selected patients for whom conventional methods may be technically challenging.
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Ultrasound versus palpation method for accurate estimation of intervertebral space: A cross-sectional observational study p. 44
Ammu Seetha, Silvy Anna Varughese
DOI:10.4103/TheIAForum.TheIAForum_56_21  
Background and Aims: Spinal cord injury resulting from the central neuraxial blockade is a rare but dreadful complication. The most likely cause is believed to be misjudged level of the intervertebral space (IVS). In our study, we assessed the accuracy of IVS marked by the anesthesiologist in 170 patients who were posted for surgery under spinal anesthesia using ultrasonography. Methodology: This was a prospective examiner-blinded observational study in 170 patients. An anesthesiologist estimated and marked the IVS using conventional palpation method (based on intercristal line), and the level was counterchecked ultrasonically by another anesthesiologist, who was blinded to the initial marked level. Statistical Analysis: The agreement between the palpation method and ultrasound assessment of IVS was analyzed using the Chi-square test. P < 0.05 was considered statistically significant. Results and Conclusion: The IVS estimated by conventional palpation method correlated with ultrasound estimation in only 49.4% of patients.
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Knowledge, attitude, and practice of the use of personal protective equipment and its psychological impact among Indian anesthesiologists during the COVID-19 pandemic: A questionnaire-based, multicenter, cross-sectional nationwide survey p. 49
Jyothi Avula, Anand Babu, Donae Elizabeth George, Sakshi Rai, Raj Sahajanandan, Karen Ruby Lionel, Anita Shirley Joselyn
DOI:10.4103/TheIAForum.TheIAForum_125_21  
Background: Anesthesiologists, with their skills and expertise at performing various aerosol-generating procedures such as tracheal intubation and extubation, tracheostomies, and bronchoscopy-guided procedures, serve as frontline workers during the COVID-19 pandemic. They are exposed to the risk of infection as well as highly stressful environments in the operating theaters and intensive care units. Appropriate knowledge, attitudes, and practices (KAPs) with regard to the use of personal protective equipment (PPE) will help mitigate some of this stress. Materials and Methods: Owing to the nation's lockdown situation, an online questionnaire-based survey was conducted through WhatsApp, Facebook, and E-mail among anesthetists working at different health-care sectors in India. The KAP with regard to the use of PPE during the COVID-19 and its psychological impact were assessed by using a prevalidated questionnaire. All analyses were performed using SPSS version 25. Results: Among 301 study participants, 189 (62.8%) had good knowledge and 90% had favorable attitudes. Despite 66.4% of the study participants having received formal training regarding the use of PPE during the COVID-19 pandemic, good practices were seen only in 44.4%. Irrespective of the demographic variable assessed, 90% of the anesthesiologists felt that working was more stressful in the operating room during this pandemic, due to challenges with respect to effective communication, restrictions in movement and visibility attributed to PPE as well as an alteration in the usual routine. Conclusions: Despite adequate knowledge and attitudes regarding the use of appropriate PPE, the translation into practice was deficient. Emphasis on the checklist, protocol-based approaches, and regular updates on practice recommendations will help to improve adherence to quality practices. Donning of appropriate PPE contributes to significant physical and emotional stress among anesthesiologists during the COVID-19 pandemic. A platform to provide psychological support is the need of the hour.
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Knowledge regarding anesthesia and anesthesiologist among patients attending pre anesthetic check up in rural tertiary care hospital p. 57
Prashant Prakash Ahiwale, Bhavika Singla, Akshaya N Shetti, Rachita G Mustilwar
DOI:10.4103/TheIAForum.TheIAForum_38_21  
Introduction: Anesthesiologist plays an important role in intensive care units, trauma centers, pain clinics, and as a member of resuscitation team all over the world. Due to the lack of public awareness about anesthesia as a medical discipline, many patients assume an anesthesiologist to be an assistant of the surgeon and do not recognize the role played by the anesthesiologist in preoperative, perioperative, and postoperative periods. With the changing health-care environment and advancement in anesthesiology, the patients and general public need to be educated. Aims and Objectives: This study aimed to assess the knowledge of patients regarding anesthesia and anesthesiologist at rural tertiary care hospital. Design: This is a descriptive cross-sectional study done at a rural tertiary care hospital. Materials and Methods: After approval of the institutional ethical committee, the study was conducted in the form of a questionnaire for patients coming to preanesthetic checkup outpatient department (OPD) for elective surgery. Results: This study involves 602 (312 male; 290 females) for preanesthetic checkup OPD, of whom only 403 (67%) of them recognized anesthesiologists as doctors, while 401 (66.7%) knew that anesthesia is required prior to any surgical procedure and 209 (41.4%) of them knew anesthetists play a role in intraoperative and postoperative patient care. Conclusion: We can conclude that there is unawareness among the rural population regarding the role played by anesthesiologists; hence, initiatives are to be taken for educating the population.
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An audit on transfusion of blood products based on clinical judgment in patients undergoing cardiac surgery p. 62
Joseph Punnoose Paarel, Vinay Rao, Anand Ganesh, Sukesh Nair, Sathish kumar Dharmalingam, Ben Babu Kurien, Raj Sahajanandan
DOI:10.4103/TheIAForum.TheIAForum_41_21  
Background: Transfusion of blood and blood products is strongly associated with increased morbidity and mortality in cardiovascular surgery. This includes transfusion-related acute lung injury, transfusion-associated circulatory overload, renal injury, anaphylactic reactions to blood products, and sepsis. Transfusion of blood products based on the clinician's judgment often results in excessive transfusion. Research suggests that the use of point-of-care (POC) coagulation tests coupled to algorithm-based management decrease transfusion requirements in cardiac surgery. Objectives: To determine abnormal thromboelastograph (TEG) values among patients who received blood products based on clinical judgment and to determine if a POC coagulation test could have resulted in reduced transfusion rates in these patients. Methods: A total of 45 cardiac surgical patients who received blood products during a 3 months period were included in the audit. Coagulation profile and TEG were sent before transfusion for all patients. Data were entered using EPIDATA software. Descriptive analysis was used to define the data. The Fisher exact test was used to assess differences between groups for categorical variables. Results: The R time was abnormal in 4.4% of patients, the Alpha angle was abnormal in 51.1% of patients, maximum amplitude was abnormal in 2.2% of patients, and there was no evidence of fibrinolysis on TEG in these patients. Conclusion: Clinical judgment about the need for blood transfusion had poor correlation with dynamic tests of coagulation. A POC test-based algorithm would have avoided a significant amount of blood product transfusion both in terms of choice of therapy and the dose of component used.
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Pros of prone positioning with high-flow nasal oxygenation in morbidly obese patients with moderate-to-severe COVID-19 acute respiratory distress syndrome: A retrospective analysis p. 68
Reema Wadhawa, Visharad Trivedi, Anisha Singh, Anju Romina Bhalotra, Vivek Wadhawa, Pratik Shah, Deepa Jadav
DOI:10.4103/TheIAForum.TheIAForum_134_21  
Background: Coronavirus disease-2019 has rapidly spread globally and has become a global public health crisis. Obesity is the most frequent comorbidity exhibited by severe acute respiratory syndrome coronavirus-2. Many studies have highlighted the benefits of prone position (PP) with high flow nasal oxygenation (HFNC) in patients with moderate to severe acute respiratory distress syndrome (ARDS). This further delay intubation, reduce intensive care unit (ICU) stay and decreases overall morbidity. Methods: In this study, we analyzed case record data of morbidly obese patients (body mass index >35Kg/m2) with moderate-to-severe ARDS over 3 months. We evaluated the efficacy of early application of PP with HFNO in morbidly obese patients with moderate-to-severe COVID-19 ARDS on PaO2/FiO2 ratio. Results: A total of 24 morbidly obese patients were included in the study. Patients were divided into two groups: Group F (those who were intubated) and Group S (who did not require invasive mechanical ventilation). One hour of PP along with the use of HFNO, the P/F ratio was significantly higher in Group S (78.23 ± 7.16) than in Group F (63.58 ± 15.40) (P < 0.05). The ICU stay was longer in patients who required invasive mechanical ventilation, 17.33±2.52 days in Group F as compared to 8.11±1.05 days in Group S. Conclusion: PP with HFNO seems safe in morbidly obese patients and may improve oxygenation more than in nonobese patients. It is important to stress the necessity to start out postural treatment as early because the patient's clinical condition permits. PP with HFNO might avoid tracheal intubation and its inherent risks and prove beneficial in resource-limited scenarios.
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LETTERS TO EDITOR Top

Measurement of noninvasive blood pressure during general anesthesia in lateral decubitus position: A survey on existing knowledge and practice among anesthesiologists p. 73
Ramamani Mariappan, Karen Ruby Lionel, Jeyaseelan Lakshmanan
DOI:10.4103/TheIAForum.TheIAForum_37_21  
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Filter syringes: Knowing the unknown p. 74
Abhijeet Shekhawat, Manbir Kaur, Priyanka Sethi, Pradeep Bhatia
DOI:10.4103/TheIAForum.TheIAForum_117_21  
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Patchy or inadequate brachial plexus block: Bier block to our rescue! p. 75
Anju Gupta, Amita Gupta, Nishkarsh Gupta
DOI:10.4103/TheIAForum.TheIAForum_155_21  
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Caught between the devil and deep sea: Anesthetic management of a patient with hereditary cerebellar ataxia and iatrogenic median and ulnar entrapment neuropathy posted for fixation of both bone forearm p. 77
Vinod Krishnagopal, Raj Murugan, A Shanmuga Priya, Sharanya Krishnakumar
DOI:10.4103/TheIAForum.TheIAForum_168_21  
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A film you should definitely see: A case of endotracheal tube obstruction by packaging film p. 79
Bhavya Krishna, Nidhi Pathak, Sengottaian Sivakumar, Santvana Kohli
DOI:10.4103/TheIAForum.TheIAForum_169_21  
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