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   Table of Contents - Current issue
January-June 2023
Volume 24 | Issue 1
Page Nos. 1-86

Online since Wednesday, May 24, 2023

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Sugammadex: A disruptive innovation but will it stay? p. 1
Manila Singh, Swati Chhabra
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The relevance of the wake-up test in scoliosis surgery: A narrative review p. 4
Sapna Annaji Nikhar, Abinash Patro, Raju Iyengar, Ramachandran Gopinath
The corrective scoliosis surgery is associated with many complications; the neurologic complication is one of them. It is very important to assess spinal cord integrity intraoperatively to avoid postoperative damage and have a good outcome. Wake-up test was the standard of care in old generations but now with the availability of advanced neurophysiologic monitoring somatosensory and motor-evoked potentials; the relevance of wake-up test is questionable. This review aimed to assess the relevance of wake-up test in scoliosis surgery with availability of advanced technology. Comprehensive literature search was performed in PubMed, Google Search and Scopus, EndNote X6 version, and the keywords used for the search were scoliosis, neurophysiologic monitoring, and wake-up test. The different study results were interpreted to come to conclusion. This review gives us a detailed idea of the different tests available and pitfalls with each and finally what should be our stand. The review highlighted the good collaboration between surgeon, anesthesiologist, and neurologist to conclude the results of the tests of neurophysiologic monitoring. Intraoperative neurologic monitoring improves postoperative outcome. Wake-up test is only and strongly recommended, in case of unavailability of advanced monitoring, confusion on test results, and persistent signal reduction.
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Perioperative hemodynamic management in surgery for phaeochromocytoma: A narrative review p. 11
Bhavya Krishna, Deepa Kerketta Khurana, Santvana Kohli, Kavita Rani Sharma, Ranju Gandhi
Pheochromocytomas are rare adrenal tumors that produce excessive catecholamines and their surgical removal poses significant risks of intraoperative hemodynamic instability (HI) due to catecholamine release. This review article discusses the perioperative factors that impact hemodynamic lability and its management in patients undergoing surgical removal. A literature review was conducted by searching the electronic databases - Ovid MEDLINE, Embase, and Cochrane Library using appropriate Medical Subject Heading terms and keywords such as phaeochromocytoma, HI, and perioperative hemodynamic monitoring. The advancements in surgical and anesthetic techniques and appropriate preoperative medical optimization have contributed to a significant decrease in mortality rates. However, perioperative HI remains the biggest surgical and anesthetic challenge in treating pheochromocytomas. Patients with larger and more hormonally active tumors are at higher risk for extreme hypertensive episodes during surgery. Preoperative α-blockade, higher phenoxybenzamine doses, and laparoscopic approach improve the outcomes in phaeochromocytoma removal. Anesthetic techniques and drugs used during surgery may help prevent HI, but careful intraoperative management is essential. Perioperative HI can lead to increased surgical blood loss, patient morbidity, and prolonged intensive care unit (ICU) and hospital stay. Therefore, a multidisciplinary approach involving the surgeon, anesthesiologist, and ICU team is essential to ensure optimal perioperative management of patients with pheochromocytoma. Intensive hemodynamic monitoring may be required in the postoperative period to manage hypotension seen after tumor removal. In conclusion, perioperative HI is a significant risk during the surgical removal of pheochromocytomas, even with preoperative pharmacological treatment. Therefore, the use of appropriate preoperative medical optimization, surgical and anesthetic techniques, and careful intraoperative management can significantly improve the outcomes.
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Alleviating hemodynamic response to tracheal extubation: A comparative study between dexmedetomidine and lignocaine in surgical patients p. 21
Neha T Gaidhankar, K Chandra Mohan, R Arun Kumar, Amar Nandha Kumar
Background: Tracheal extubation is a crucial step during general anesthesia involving the removal of artificial airway when the indication for its placement no longer exists. Airway and circulatory interferences could be due to diminished tolerance to the tracheal tube, catecholamine surge, surgical pain, and airway irritation on behalf of suctioning or change in posture of the tube. Complications are more common during extubation than that occurring during induction and intubation. Aim: The main aim of the study was to compare the effectiveness of a single dose of dexmedetomidine and lignocaine in alleviating hemodynamic and stress responses during extubation and recovery. Materials and Methodology: Sixty patients of the age group between 20 and 65 years belonging to ASA 1 and 2 undergoing elective surgical procedures with a minimum anticipated duration of 60 min requiring endotracheal intubation were included in the study. The patients were assigned randomly into two groups with 30 participants in each group and were called as Group D receiving dexmedetomidine 0.5 μg/kg and Group L receiving lignocaine 1.5 mg/kg. Observation and Results: Data were statistically analyzed with the SPSS version 20.0 software. Independent t-test analysis was used, and all the statistical test was examined with P ≤ 0.05 level of significance. Hemodynamic response was noted as more significant in Group D, whereas emergence and extubation time was noted sooner in Group L. Conclusion: We conclude that Dexmedetomidine 0.5 mcg/kg causes significant attenuation of hemodynamic stress response and deeper sedation when compared to lignocaine 1.5 mg/kg.
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Comparative assessment of different doses of midazolam to prevent etomidate-induced myoclonus – A randomized, double-blind, placebo-controlled trial p. 29
Lokman Manish, Michell Gulabani, Medha Mohta, Geetanjali T Chilkoti
Background: Etomidate is a popular induction agent, due to its several advantages for example, an extremely stable hemodynamic profile with no effects on sympathetic nervous system and baroreceptors, minimal effect on respiration and also prevents histamine release in healthy patients or in those with reactive airway disease. It, however, may be associated with myoclonus whose incidence has been reported as 50%–80% in nonpremedicated patients. Ideally, a pretreatment drug for preventing myoclonic movements should be short acting, not have significant effects on respiration and hemodynamics, and not prolong recovery from anesthesia. Midazolam has been used as a pretreatment to attenuate myoclonus in different doses with varied results, but the optimal dose has not been established. The present study was planned to compare the effect of three doses of midazolam, i.e., 0.015 mg/kg, 0.03 mg/kg, and 0.05 mg/kg in preventing etomidate-induced myoclonus. Materials and Methods: This study comprised 164 American Society of Anesthesiologists I/II consenting patients between 18 and 60 years. They were randomly divided into four groups after which pretreatment with normal saline in group M0, midazolam 0.015 mg/kg in group M0.015, 0.03 mg/kg in group M0.03, and 0.05 mg/kg in group M0.05 was administered. The primary outcome was the incidence of myoclonus after etomidate. The secondary outcome measures included severity of myoclonus and changes in hemodynamic parameters. One-way analysis of variance with Bonferroni's correction was used to compare quantitative data. Chi-square test was applied for qualitative data. Further, as there were four groups with multiple comparisons, Bonferroni's correction was applied and P < 0.01 was considered statistically significant. Results: We observed a significant reduction in the incidence of myoclonus of group M0.015 as compared to group M0 (P < 0.001). A significant reduction in severity of myoclonus was observed in all the three midazolam groups compared to the control group (P < 0.001) without any significance among the patients receiving different doses of midazolam. Conclusion: We recommend using midazolam pretreatment in a dose of 0.015 mg/kg for prevention of etomidate-induced myoclonus.
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Comparison of safety and efficacy of dexmedetomidine, midazolam and propofol for elective fiberoptic bronchoscopy: A randomised prospective double blind study p. 36
Priya Chouhan, Shruti Gupta, Anita Vig Kohli, Rajdeep Kour
Background: Sedatives are used to improve the efficacy of fiberoptic bronchoscopy. This study was conducted to evaluate and compare the safety and efficacy of dexmedetomidine, midazolam, and propofol for elective fiberoptic bronchoscopy. Materials and Methods: One hundred and twenty patients of either gender aged between 18 and 80 years, belonging to the American Society of Anesthesiologists Grade I–III and requiring fiberoptic bronchoscopy, were randomly assigned in three groups of 40 patients each. Patients in Group D received intravenous dexmedetomidine 1 μg/kg; in Group M, received IV midazolam 0.05 mg/kg; and in Group P, received IV propofol 1.5 mg/kg before the start of bronchoscopy. Parameters such as composite score, ease of bronchoscopy, and adverse effects during the procedure were assessed and analyzed statistically. Results: Patients receiving dexmedetomidine showed significantly better tolerance and cooperation with ideal mean composite score compared to those receiving propofol and midazolam (P < 0.001). Bronchoscopist scoring showed significantly better ease of bronchoscopy in patients receiving dexmedetomidine compared to other two groups (P < 0.001). Adverse effects during the procedure were least in dexmedetomidine group compared to other two groups. Conclusion: Dexmedetomidine (1 μg/kg) provided a better sedation and comfort, better bronchoscopist satisfaction, and least adverse effect during elective fiberoptic bronchoscopy compared to midazolam (0.05 mg/kg) and propofol (1.5 mg/kg).
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Comparison of McGrath videolaryngoscope with conventional Macintosh laryngoscope for tracheal intubation in pediatric patients with normal airway p. 43
Stuti Bhamri, Devyani Desai, Darshit Chauhan, Neha Cheraya
Background and Aims: Videolaryngoscopes have attained prime importance in securing the airway in children in the present era. McGrath videolaryngoscope is available with single-use non-channeled fog-free disposable blades of various sizes showing its efficacy for intubation in adults but still lacunae in data related to children. Materials and Methods: In this prospective randomized controlled trial, a total of 88 children of the American Society of Anesthesiologists Grade I and II aged 1–10 years, weighing 10–20 kg undergoing general anesthesia were enrolled. Using the sealed envelope technique, the children were randomly allocated between Group G, in whom McGrath videolaryngoscope and Group M, in whom Macintosh laryngoscope was used for intubation. The primary aim was to compare intubation time between the two videolaryngoscopes. The secondary outcomes included glottic exposure time, Cormack and Lehane grading, number of attempts of intubation, intubation difficulty scale and complications. Statistical analysis was done using MedCalc software. The Student's t-test and Chi-square test were used for quantitative and categorical data, respectively. Results: The mean intubation time was comparable in both the groups (18.14 ± 17.80 s in Group G vs. 17.30 ± 16.74 s in Group M, P = 0.821). The mean time to glottic exposure was shorter (5.66 ± 4.58 vs. 8.50 ± 5.59 s, P = 0.0108) with decreased number of attempts of tube insertion and less incidences of trauma observed in patients with Group G as opposed to Group M. The Cormack and Lehane grading showed better glottic view in Group G. Conclusion: McGrath videolaryngoscope is as useful as the Macintosh laryngoscope for intubation in children with the added advantages of a better view of the larynx, lesser attempts to intubation, and fewer incidence of trauma.
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Evaluation of effect of dexamethasone and bicarbonate as adjuvants to intracuff lignocaine on endotracheal tube tolerance during emergence and incidence of postoperative cough and sore throat p. 49
Muazzam Hasan, Atif Javed, Kali Charan Das, Ashish Bindra
Background: Smooth uneventful extubation and prevention of postoperative complications such as cough and sore throat adds to the quality of perioperative care and patient outcome. This study was designed to compare tube tolerance and hemodynamics during extubation, as well as the incidence of postoperative cough and sore throat, in patients operated under general anesthesia of more than 2-h duration. Materials and Methods: This prospective double-blinded, randomized controlled study included 100 patients posted for elective surgical procedures with expected duration of more than 2 h, under general anesthesia. Patients were divided randomly into two equal groups, namely Group A and Group B. In Group A, endotracheal tube (ETT) cuff was filled with lignocaine with sodium bicarbonate as an adjuvant, while in Group B, dexamethasone was added as an adjuvant to intracuff lignocaine. ETT tolerance at the time of extubation was recorded and compared. Other parameters such as rate pressure product, volume of drug diffused through cuff, and incidence of postoperative cough and sore throat were also compared. Data analysis was done using unpaired t-test and Chi-square test as appropriate, where P < 0.05 was considered statistically significant. Results: Eighty-two percent of patients in Group A while 78% of patients in Group B were categorized as tube tolerant during extubation (P = 0.62). The incidence of postextubation sore throat at 1 h was 30% versus 16% (P = 0.09) while at 24 h was 20% versus 6% (P = 0.03) in Group A and Group B, respectively. The incidence of cough postextubation at 1 h was 6% versus 0 (P = 0.07) while at 24 h was 18% versus 4% (P = 0.02) in Group A and Group B, respectively. The volume of intracuff drug diffused during anesthesia was 0.71 ± 0.27 (mean ± standard deviation [SD]) ml in Group A and 0.5 ± 0.23 (mean ± SD) ml in Group B (P = 0.02). Majority of patients (>85%) in both the groups remained hemodynamic stable during emergence with no statistical difference between the groups. Conclusion: Both bicarbonate and dexamethasone as an adjuvant to 2% intracuff lignocaine offer smooth emergence in terms of tube tolerance and hemodynamic stability during extubation. However, dexamethasone when used as an adjuvant has a better effect on prevention of development of postoperative cough and sore throat.
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Cardiovascular complications in coronavirus disease-2019 patients p. 54
Nirav Parikh, Hasmukh Patel, Deepal Prajapti, Ankit Chauhan, Mrugesh Prajapati, Ramesh Patel, Himani Pandya, Varun Arora, Deepti Dhawalikar
Background and Aims: Cardiovascular (CV) complications of coronavirus disease 2019 (COVID-19) are neither well-defined nor comprehensively characterized. Hence, long-term studies are required to monitor silent but progressive CV complications postrecovery in COVID-19 patients. Our aim of the study was to assess and determine the presence of CV morbidity and mortality in COVID-19 patients. Materials and Methods: A retrospective study was conducted at our institute. All COVID-19-positive patients who were admitted in the intensive care unit during April 3, 2020–May 23, 2021, were recruited for the study. A total of 1460 patients were enrolled and monitored until discharge/death. Patients were evaluated based on demographics, clinical data, and laboratory values and 42 patients among them underwent coronary angiography for an adequate understanding of CV complications. Results: The total reported deaths among the study sample were 453 (31%). Common preexisting clinical conditions among them were hypertension 520 (35.6%), diabetes 211 (14.45%), CV disease 88 (6.02%), and hypothyroidism 61 (4.17%). A total of 149 patients displayed elevated creatine phosphokinase-MB (CPK-MB) levels, while 141 patients displayed elevated hs-TnI levels. The absolute rise of cardiac troponin (hs-TnI) and CPK-MB displayed a technically positive correlation, but a weaker relationship (r: 0.2113, P < 0.01 for correlation). Twenty-two out of 42 patients showed the presence of single/multivessel disease and 31 patients displayed mild-to-severe left ventricular dysfunction. Conclusions: The results of the current study provide evidence for the risk and burden of CV complications among COVID-19 patients. Hence, attention to long-term CV health and disease among COVID-19 survivors is necessary.
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Mortality predictors during the third wave of COVID-19 pandemic: A multicentric retrospective analysis from tertiary care centers of Western India Highly accessed article p. 58
Naveen Paliwal, Pooja Bihani, Sukhdev Rao, Rishabh Jaju, Sadik Mohammed, Arvind Khare, Sonali Dhawan, Vikas Rajpurohit, Mathura Lal Tak, Geeta Singariya
Background: The COVID-19 has a varied mode of presentation in different regions of the world. This multicentric study was planned to evaluate the survival outcomes in intensive care unit-admitted patients admitted during the third wave of the COVID-19 pandemic on the basis of clinicodemographic profile and vaccination status. Methodology: Data from 299 patients admitted to three tertiary care centers in Western India were collected and analyzed. Based on survival outcomes, all patients were divided into two groups: survivors and nonsurvivors. Univariate analysis of the demographic profile, comorbidities, vaccination status, and disease severity was performed, whereas multivariate analysis was performed to predict independent factors associated with mortality. Results: Among total 299 studied patients, 208 (69.5%) patients survived and 91 (30.4%) did not. The number of elderly patients and patients with comorbidities such as diabetes, tuberculosis, chronic obstructive pulmonary disease, cardiovascular and respiratory diseases, and malignancy were more prevalent among nonsurvivors. Patients who did not receive a single dose of vaccine were higher in the nonsurvivor group (P = 0.037); however, no significant difference in survival outcome was found if patients had received the first or both doses of vaccine. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score at 24 h after admission and Sequential Organ Failure Assessment (SOFA) score at admission were significantly higher in nonsurvivors compared to survivors (P < 0.0001). On multivariate analysis, APACHE II and SOFA scores were found to be independent predictors of outcome. Conclusions: Older age, presence of comorbidities, nonvaccination and higher disease severity scores affected mortality during the third wave of COVID-19.
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Efficacy of dexmedetomidine as an adjuvant with ropivacaine in USG guided erector spinae plane block for modified radical mastectomy surgery- prospective randomized double blind controlled study p. 65
Indira Kumari, Sandeep Sharma, Sandeep Kumar Ola, Krishna Boliwal, Santosh Choudhary, Vidhu Yadav
Background and Aims: Modified radical mastectomy (MRM) is associated with considerable acute postoperative pain and even chronic persistent pain. Erector spinae plane block (ESPB) is interfascial block for thoracic analgesia. This study was planned to evaluate efficacy of dexmedetomidine as adjuvant with ropivacaine in ESPB for postoperative analgesia in MRM surgery. Materials and Methods: In this prospective randomized double-blind controlled study, 60 American Society of Anesthesiologists Grade I and II female patients, aged 18–60 years scheduled for MRM surgery under general anesthesia were randomly allocated into Group R and RD to receive ultrasound (USG)-guided ESPB with 20 ml 0.375% ropivacaine and 1 μg/kg dexmedetomidine added to 20 ml 0.375% ropivacaine, respectively. Visual Analog Score (VAS) was recorded at 0, 2, 4, 6, 8, 10, 12, and 24 h postoperatively. Duration of analgesia together with total number and amount of analgesic drug required was recorded in first 24 h postoperatively. Patient's satisfaction score was recorded on 10-point scale. Chi-square test, t-test, and Wilcoxon signed-rank test were applied where deemed appropriate. P <0.05 was considered statistically significant. Results: VAS score was less in Group RD at all measured time points postoperatively. Duration of analgesia was prolonged in Group RD (683.00 ± 83.99 min vs. 620.63 ± 70.42 min). Total number and amount of intravenous diclofenac (rescue analgesic) was lower in Group RD (1.13 ± 0.57 vs. 1.46 ± 0.57, 85.00 ± 42.85 vs. 110.00 ± 42.85). Patients in group RD were better satisfied with their anesthesia experience (8 [8–9] vs. 8 [7–8], P = 0.00194). Group RD demonstrated a lower heart rate, systolic blood pressure, diastolic blood pressure, and mean blood pressure intraoperatively. Conclusion: Dexmedetomidine as an adjuvant to ropivacaine in USG-guided ESPB for MRM surgery leads to lower postoperative pain scores, prolongs postoperative analgesia, reduces postoperative rescue analgesics requirements, and provides better hemodynamic stability and good patient satisfaction.
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To study the effect of three different doses of dexmedetomidine as premedication on the incidence and severity of etomidate-induced myoclonus p. 72
Ketki Kaushal, Anita Kumari, Pooja Abbi, Ruchi Gupta
Background and Aims: Etomidate, a carboxylated imidazole is a rapid-acting nonbarbiturate, nonopioid hypnotic agent that has unique hemodynamic stability, favorable toxic profile, and rapid recovery after a single dose. Myoclonus may occur when etomidate is used for induction of general anesthesia. We tested the hypothesis that premedication with different doses of dexmedetomidine reduces the incidence and severity of myoclonus as well as the side effects induced by etomidate. Materials and Methods: This prospective, randomized, double-blinded study was done on ninety patients undergoing elective surgical procedures who were randomly allocated into three groups for intravenous administration of premedication of 0.3 μg/kg (Group DL), 0.5 μg/kg (Group DM), and 1.0 μg/kg (Group DH) dexmedetomidine in 100 mL normal saline 10 min before induction of general anesthesia with 0.3 mg/kg etomidate. The primary outcome was to evaluate the incidence of etomidate-induced myoclonus, while the severity of etomidate-induced myoclonus and the incidence of adverse effects were taken as secondary outcomes. Results: The incidence of etomidate-induced myoclonus was reduced by 13.3% in Group DL, 36.7% in Group DM, and 56.7% in Group DH. The severity of myoclonus was significantly reduced in Group DH as compared to Group DL and DM (P = 0.001). Side effects such as bradycardia, hypotension, and nausea and vomiting were comparable among the three groups. Conclusion: Premedication with dexmedetomidine 1 μg/kg before induction of general anesthesia not only resulted in a 56.7% reduction in the incidence of etomidate-induced myoclonus but also reduced the severity of myoclonus, without inducing any significant adverse effects, as compared to other two doses.
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Communication is the key – Let's not forget it!! p. 78
Rashmi Syal, Priyanka Sethi, Manbir Kaur, Pradeep Kumar Bhatia
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Rhythm disturbances and their management in a case of Ebstein's anomaly p. 79
Navneh Samagh, Minnu M Panditrao, Mridul Madhav Panditrao, Nimish Singh
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Is it popliteal artery? Is it popliteal vein? No it is persistent sciatic vein p. 81
Vinod Krishnagopal, Raj Murugan, Krishnakumar Sharanya, Raghuraman M Sethuraman
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Refractory hypokalemia in intensive care unit: Efforts in vain p. 82
Saurav Singh, Jayanth R Seshan, Gyaninder Pal Singh
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Curious case of central venous catheter leak p. 84
Manav Sharma, Sharmishtha Pathak
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Morbidly obese patient for percutaneous nephrolithotomy in prone position – Feasibility of unilateral spinal anesthesia? p. 85
Teena Bansal, Mamta Jain, Anish Kumar Singh, Jatin Lal
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