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January-March 2020
Volume 14 | Issue 1
Page Nos. 1-176

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EDITORIAL  

Tribute to the departed editor of anesthesia essays and researches: Professor Mohamed Taha Al-Jasser p. 1
Ragad Mani Takrouri, Mohamad Said Takrouri, Masoun M.T. Al-Jasser, Raed Alsatli
DOI:10.4103/aer.AER_20_20  
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ORIGINAL ARTICLES Top

A randomized controlled study to compare hemodynamic effects between clonidine and pregabalin in laparoscopic cholecystectomy p. 4
Mansi Jain, Monal Ramani, Seema Gandhi, Chirag Jain, V. K. Sarvanan
DOI:10.4103/aer.AER_15_20  
Background: Laparoscopic cholecystectomy (LC) is associated with pneumoperitoneum and hemodynamic disturbances. Pregabalin and Clonidine have been used for anesthetic effects, but a better drug for controlling hemodynamic parameters is being investigated. Aims: The study was done to assess and compare the efficacy of preoperative single oral dose of pregabalin and clonidine in maintaining the hemodynamic parameters in the LC. Settings and Design: The prospective, interventional, randomized, comparative, single-blinded study was conducted in the department of anesthesia and surgery from January 2015 to September 2016 after taking approval from the institutional ethical committee. Materials and Methods: The study included a total of 90 patients, aged between 18 and 56 years of both sexes scheduled for elective LC. Patients were randomized into three groups of 30 each who received oral pregabalin 150 mg, clonidine 200 ug, and placebo. The hemodynamic parameters were recorded at various time intervals along with any adverse events. Statistical Analysis: Quantitative variables were compared using unpaired t-test (when the data sets were not normally distributed) between the two groups. Qualitative variables were compared using Chi-square test/Fisher's exact test. P < 0.05 was considered statistically significant. Results: There was a significant increase in the heart rate (HR) and systolic, diastolic, and mean blood pressure during laryngoscopy and pneumoperitoneum in the control group as compared to both pregabalin and clonidine. HR was significantly lower in clonidine group after extubation and in postoperative period than both control group and pregabalin group. There was no major difference in the incidence of side effects. Conclusion: Both pregabalin (150 mg) and clonidine (200 ug) were effective in controlling the hemodynamic parameters during LC, with clonidine providing better hemodynamic stability than Pregabalin.
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Safety and efficacy of ultra-low-dose intracavernosal adrenaline for intraoperative penile erection in transurethral surgeries under spinal anesthesia p. 16
Rahul Gupta, Sunana Gupta, Arti Mahajan
DOI:10.4103/aer.AER_25_20  
Context: Penile tumescence during endoscopic urological surgeries is a rare but problematic complication that can lead to postponement of the surgery. This study was done to assess the efficacy of ultra-low-dose intracavernosal adrenaline in the management of intraoperative penile erection. Subjects and Methods: Between January 2015 and December 2019, all the patients who developed significant penile tumescence during endourology procedures following regional anesthesia were included. Twenty patients required intervention. They were given half milliliter of solution containing 2.5 μg of adrenaline with insulin syringe. Baseline systolic and diastolic blood pressure, heart rate, and oxygen saturation were noted and were recorded at 1, 2, 3, 4, and 5 min after giving adrenaline. Time to achieve complete detumescence and any other related complications were also noted. Results: Penile detumescence was achieved in 2.6 ± 0.47 min in all the patients. There was an increase in heart rate from baseline value which increased to maximum by 3 min and returned back to baseline by 5 min. Systolic and diastolic blood pressure remained unchanged. Conclusion: All the patients achieved penile detumescence without any significant adverse effects after receiving intracavernosal injection of ultra-low-dose adrenaline.
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Comparative evaluation of mcgrath MAC, Truview video laryngoscopes and Macintosh laryngoscope for endotracheal intubation in patients undergoing surgery under general anaesthesia p. 20
Gurleen Kaur, Sunana Gupta, Nandita Mehta, Jatanbir Singh Dhingra
DOI:10.4103/aer.AER_16_20  
Background: Videolaryngoscopy is a newly developed technique to improve tracheal intubation success. It was made to bypass the need of directly visualising the glottic inlet. These devices are advantageous as there is no need of aligning the laryngeal, pharyngeal and oral axes for a clear view, thus making intubation easier and faster. Aim and Objectives: Primary objective of the study was to determine the duration of laryngoscopy and intubation and Cormack - Lehane grading when intubating with McGrath MAC, Truview video laryngoscope and Macintosh laryngoscope. Secondary objectives of the study were to determine the number of attempts and optimization manouveres required to intubate. Materials and Methods: This study was conducted on total of 120 patients in age 20-70 years, either sex, with American Society of Anaesthesiologists physical status classes I or II scheduled for elective surgery under general anaesthesia. They were randomly assigned equally to group 1, 2 and 3 (n = 40) to be intubated by Mcgrath MAC video laryngoscope, Truview video laryngoscope and Macintosh laryngoscope respectively. Parameters recorded were duration of laryngoscopy and intubation, Cormack Lahane grading, ease of intubation, number of attempts and optimisation manouveres required for intubation. Statistical Analysis: Comparison of mean value among the three groups was done using student t test and percentage comparison was done using chi square test. To compare more than two variables ANOVA test was used. The P values of less than 0.05 was considered statistically significant. Results: Duration of laryngoscopy was significantly less in McGrath MAC group when compared to Truview group (P = 0.02) and to Macintosh group (P < 0.001) and the duration of intubation was comparable among all three study groups (P > 0.05). The difference in Cormack - Lehane grading was not significant between McGgrath MAC and Trueview (P = 0.71) but was significant between McGrath MAC and Macintosh (P = 0.002) and Trueview and Macintosh (P = 0.002). Ease of intubation was better in McGrath MAC and Truview groups compared to Macintosh group (P < 0.05). Intubation was successful in the first attempt in 39 (97.50%) patients in McGrath MAC group, 40 (100%) patients in Truview group and 35 (87.50%) patients in Macintosh group. McGrath MAC and Truview groups performed better with respect to optimization manoeuvres compared to Macintosh group (P < 0.05). Trauma was observed in 2 (5%) patients in Truview group and 5 (12.50%) patients in Macintosh group. In McGrath MAC group, no patient underwent any trauma. Conclusion: Although duration of laryngoscopy was significantly shorter in McGrath as compared to Truview video laryngoscope and Macintosh laryngoscope but the duration of intubation was comparable between the three groups. Both these video laryngoscopes performed significantly better than Macintosh laryngoscope with respect to laryngoscopic view, requirement of optimization manoeuvre and need for second attempt for intubation.
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Randomized controlled trial to compare Baska® mask versus ProSeal laryngeal mask airway for general anesthesia with intermittent positive pressure ventilation p. 25
Balwinderjit Singh, Arwinder Pal Singh, Joginder Pal Attri
DOI:10.4103/aer.AER_23_20  
Introduction: A myriad of supraglottic airway devices (SADs) are developed over time to search the device that conforms to the anatomy of the human respiratory tract noninvasively, but these devices are associated with the risk of aspiration. Baska® mask (BM) is the latest addition to the family of SADs to circumvent the incidence of aspiration. Aims of Study: The aim of the study was to compare the sealing pressure and rapidity of the insertion of BM with ProSeal laryngeal mask (PLM) airway and the incidence of laryngopharyngeal morbidity between two devices. Materials and Methods: A randomized prospective open-label study was done on sixty adult patients of the age group of 18–60 years after approval from the institutional ethical committee and registration of trial in the Clinical Trials Registry. The patients were randomly divided into two groups: Group I (BM) where BM was inserted after the induction of general anesthesia and Group II (PLM) where PLM was inserted after induction. The airway sealing pressure in BM was calculated. The mean time of insertion of respective SAD and the number of successful attempts were also recorded in both groups. For analysis of continuous variables, independent sample Student's t-test was applied, and for categorical variables, Chi-square test was used. P < 0.05 was considered statistically significant. Results: The rate of successful attempts of insertion was comparable in both the groups. The mean insertion time was 14.25 ± 3.82 s in BM group and 22.01 ± 2.64 s in PLM group, which was statistically significant. The airway sealing pressure was 30.25 ± 3.34 cmH2O in BM group and 23.50 ± 4.05 cmH2O in PLM group, which was also statistically significant. Conclusion: BM has better ease of insertion with adequate sealing pressure as compared to PLM airway, thus reducing the chances of aspiration and offering its potential application in securing airway in emergency situations.
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Comparison of paravertebral block with conventional spinal anesthesia in patients undergoing unilateral inguinal hernia repair p. 29
Roopa Rani K, R. Vaishnavi, K. N. Vikas, M. S. Ashok
DOI:10.4103/aer.AER_19_20  
Context: Although spinal anesthesia (also known as subarachnoid block [SAB]) is used widely for inguinal hernia repair, the paravertebral block (PVB) that produces unilateral, segmental analgesia is used with a high success rate in inguinal hernia repair. Aims: The aim of the study was to compare SAB and PVB in inguinal hernia repair, in terms of the duration of postoperative analgesia and adverse events. Settings and Design: This was a prospective, randomized, controlled double-blind study. Methods: This study was done on 60 male patients of American Society of Anesthesiology (ASA) I and II. Patients were categorized into 30 in each group, either to receive PVB block at two levels T10 and L1 using 15 mL and 5 mL of 0.5% bupivacaine and 1 μg.kg−1 of buprenorphine or SAB with 12.5 mg of 0.5% hyperbaric bupivacaine injected intrathecally. Statistical Analysis Used: SPSS 18.0 and R version 3.2.2 were used for analyzing the data. Categorical measurements were presented in number (%) and analyzed using Chi-square/Fischer's exact test. Continuous measurements were analyzed using Student's t-test. Results: Age, weight, height, and ASA status were comparable in both the groups. In the PVB group, eight patients had failure of block. Hemodynamic responses, time to first analgesia and ambulation, time required to perform the block, Bromage score, satisfaction score, failure rate, and intra- and postoperative drugs used showed a statistically significant difference between the groups (P < 0.001). Conclusion: PVB is not a sole anesthetic technique due to a higher failure rate and increased intraoperative fentanyl requirement but has advantages such as prolonged analgesia, stable hemodynamics, and early ambulation.
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Incidence of pressure-related skin injuries in patients operated for spine surgery in prone: A retrospective analysis of 307 patients p. 33
Parmod Kumar Bithal, Jan Ravees, Ward Vandan Daniel, Eisa Samar, Al Talhi Alaa, Anwar Abdulhamid Yanbawi
DOI:10.4103/aer.AER_11_20  
Background: Spine surgery in prone position frequently results in pressure skin lesions (PSLs). No study from Arabic world has published their incidence in literature. Methods: We retrospectively analyzed patients who underwent prone position spine surgery from December 1, 2017, to November 30, 2018. They received standardized anesthesia care and were made prone on Jackson table. The face was supported on a nonface contoured foam device, whereas the chest and pelvis were supported on soft cushions. Following completion of surgery, they were turned supine and their skin was inspected for any skin lesions. The lesions were categorized into five grades depending on severity. Results: Data of 307 patients were analyzed. Their mean age and weight was 41.5 years and 71 kg, respectively. The mean duration of prone positioning was 470 min. One hundred and three PSLs were observed in 45 patients (14.7%), giving a PSL incidence of 43.7% in affected patients. Majority of patients (18, 40%) with lesions remained in prone position between 421 and 600 min. Multiple lesions were observed in 53.3% of the affected patients. The highest number of patients (21, 46.7%) had one lesion only and it was restricted to face. All lesions were of Grade I, II, or III. Body weight >71 kg was more prone to developing PSLs. Females were more prone to PSLs. Conclusion: PSLs in prone position spine surgery occur frequently, and their incidence is proportional to the duration of positioning and weight of the patients. Face is the most commonly affected area.
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Comparison of duration of analgesic effect of nalbuphine and morphine as an adjuvant to bupivacaine in the supraclavicular block under ultrasound guidance p. 38
Aruna Vengadessane, Jayashri Devi Rajaraman, M. S. Raghuraman, R Krishna Prabu, Srilekha Damodaran, Britto Sabu
DOI:10.4103/aer.AER_13_20  
Background: Although many studies are available in the literature that has analyzed the effects of morphine, nalbuphine, and other opioids, no study had compared the effects of nalbuphine versus morphine as an adjuvant to bupivacaine in the supraclavicular block under the guidance of ultrasound. Methodology: A randomized, double-blinded, prospective study was carried out on 60 patients of the American Society of Anesthesiologists Class I and II who were undergoing upper limb surgeries under the supraclavicular block. Patients were randomly allocated into two groups (n = 30). Group N received 20 ml of 0.5% bupivacaine with 50 μg.kg−1 of nalbuphine, while Group M received 20 ml of 0.5% bupivacaine with 50 μg.kg−1 of morphine. The characteristics of sensory and motor blocks, hemodynamic changes, duration of analgesia, adverse effects, and analgesic requirements were studied at different time intervals. Results: In Group N, there was a statistically significant reduction in the time of onset of sensory block (9.9 ± 3.0 vs. 12.2 ± 2.6 min, P = 0.002) and motor block (14.4 ± 3.6 vs. 19.4 ± 3.6 min, P = 0.0005). The duration of sensory and motor blockade and duration of analgesia were comparable. There was no statistically significant difference regarding block characteristics and hemodynamic parameters. Conclusion: Nalbuphine when added to bupivacaine as an adjuvant had significantly shortened the time of onset of sensory and motor blockade than morphine. However, the duration of analgesia, sensory and motor blockade of nalbuphine versus morphine were comparable.
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Evaluation of gastric emptying by ultrasonography after recommended fasting period and administration of prokinetic in end-stage renal disease patients p. 42
Richa Gupta, Abhimanyu Singh Pokhriyal, Parul Jindal, Rajeev Sarpal, Mamta Goyal
DOI:10.4103/aer.AER_18_20  
Background: Delayed gastric emptying is observed in end-stage renal disease (ESRD). Aims: Evaluation of gastric emptying after recommended fasting period and on oral administration of prokinetic in ESRD patients using ultrasonography (USG). Settings and Design: Randomized, double-blind, prospective, controlled study. Materials and Methods: After institutional ethics committee approval, 200 patients were divided randomly into two equal groups. Three sessions of USG evaluation of gastric antrum were done in supine and right lateral position for assessing gastric emptying, first at 8 am, second after the light meal at 8.30 am, and third after 6 h of light meal. Group A received placebo (sugar-coated pill) and Group B received tablet metoclopramide hydrochloride 10 mg after second session of USG. In each session, measurement of anteroposterior and craniocaudal diameters of gastric antrum was done, and then cross-sectional area was estimated. Three-point grading system (Perlas) was used to perform qualitative evaluation. Statistical Analysis: Comparison of normally distributed continuous variables was performed using Student's t-test. Nominal categorical data were compared using Chi-squared test. Nonnormal distribution continuous variables were compared using Mann–Whitney U-test. Results: 6 h of fasting after light meal showed that Group A only had 14% incidence of complete gastric emptying, whereas Group B had 71% as compared by Perlas grading. Gastric antral cross-sectional area measured both in supine (480.89 ± 84.92) and right lateral (575.40 ± 92.62) position of Group A was more than Group B supine (394.15 ± 62.80) and right lateral (470.25 ± 73.63) position (P < 0.05). Conclusion: USG of ESRD patients preoperatively can evaluate gastric contents to assess risk of pulmonary aspiration and guide anesthetic management. Metoclopramide is a good drug to enhance gastric emptying in ESRD patients within the recommended fasting period.
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Sternomental distance ratio as a predictor of difficult laryngoscopy: A prospective, double-blind pilot study p. 49
Evangelia Kopanaki, Maria Piagkou, Theano Demesticha, Emmanouil Anastassiou, Panagiotis Skandalakis
DOI:10.4103/aer.AER_2_20  
Background: No single test has shown to be an accurate predictor of difficult laryngoscopy. Aims: This study aims to evaluate the effectiveness of the ratio of the sternomental distance (SMD) in neutral and full neck extension position SMD ratio (SMDR) as a predictor of difficult laryngoscopy and any need of assisted intubation. Settings and Design: Prospective, double-blind pilot study. Materials and Methods: This study included 221 consecutive adult patients scheduled to undergo elective surgery under general anesthesia. Physical and airway characteristics, SMDR, difficult laryngoscopy (using Cormack/Lehane [C/L] scale), and any kind of assisted intubation were assessed. Statistical Analysis: The optimal cutoff point for SMDR was identified using receiver operating characteristic (ROC) analysis. The association between SMDR and the intubation method was evaluated through multiple logistic regression analysis. Results: A SMDR below 1.55 led in 33% of the cases to assisted intubation and 33%–53% of C/L III–IV glottic views for McCoy and Macintosh blades, respectively. On the other hand, SMDR above 1.9 led to no C/L IV glottic views for both blades and 4% and 11% C/L III views glottic views for McCoy and Macintosh, respectively. The best sensitivity and specificity cutoff point as defined by the ROC curve was identified for an SMDR value of 1.7 (area[s] under the curve: 0.815; 95% confidence interval: 0.743–0.887). Assisted intubation rates were significantly higher in patients with an SMDR inferior to 1.7 (30.5% compared to 3.5%,P < 0.001). Conclusions: SMDR is a simple, objective, and easy to perform test. The present study indicates that SMDR may be helpful in predicting difficult laryngoscopy and assisted intubation.
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Effects of single dose of dexamethasone on perioperative blood glucose levels in patients undergoing surgery for supratentorial tumors – An observational study p. 56
Zulfiqar Ali, Mohammad Akbar Shah, Shahid Ahmad Mir, Nelofar Hassan, Shariq Rashid Masoodi
DOI:10.4103/aer.AER_21_20  
Introduction: Dexamethasone is commonly administered in intracranial tumors to reduce the cerebral edema. Its administration may be associated with hyperglycemia. The primary objective of this study was to study the magnitude of rise in blood sugar levels following the administration of a single 10 mg dose of dexamethasone. Methods: Seventy patients who underwent various neurosurgical procedures were enrolled in the study. Group D (n = 35 undergoing surgery for intracranial tumors) were administered injection dexamethasone 10 mg while as Group P (n = 35 undergoing surgery for subarachnoid hemorrhage) received placebo. Blood samples were obtained through the arterial line at baseline (before dexamethasone administration), 60, 120, 180, and 240 min after the dexamethasone administration and blood glucose concentrations noted. Results: Glucose concentrations were significantly increased in patients who received dexamethasone compared with those who received placebo (P < 0.05). Blood glucose concentrations at different time intervals were greater when compared with the baseline blood sugar levels in both the placebo and dexamethasone group (P < 0.05). The arterial blood glucose concentration in those who received 10 mg dexamethasone (n = 35) increased from 95.29 ± 13.69 mg.dl−1 to 139.97 ± 10.34 mg.dl−1 over 4 h, compared with a change from 94.74 ± 10.05 mg.dl−1 to 122.34 ± 10.68 mg.dl−1 in those who received placebo (n = 35) (P < 0.05). Conclusion: The administration of a single intravenous dose of 10-mg dose dexamethasone caused a significant increase in the blood glucose concentrations at different point intervals when compared with the placebo over a 4-h period. We recommend intensive monitoring of the blood sugar levels during the intraoperative period to prevent the development of severe hyperglycemia and its associated complications.
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Etomidate versus propofol for motor seizure duration during modified electroconvulsive therapy p. 62
Seema Jindal, Gurkaran Kaur Sidhu, Samiksha Kumari, Preeti Kamboj, Rajeev Chauhan
DOI:10.4103/aer.AER_5_20  
Background: Certain anesthetic agents on account of their anticonvulsant property have a negative impact on motor seizure duration. Etomidate and propofol being devoid of the strong anticonvulsant property may be beneficial for use in electroconvulsive therapy (ECT). ECT requires sedation with a short-term anesthetic agent that does not interfere with seizure activity and has rapid onset and recovery to facilitate fast-tracking. Aims: The primary objective of this study was to compare motor seizure duration, and the secondary objective was to compare induction time, hemodynamic parameters, recovery time, and adverse effects between propofol and etomidate in modified ECT. Settings and Design: This is a prospective, double- blind, randomized, controlled study conducted in the Department of Anesthesia and Intensive care in a tertiary care hospital during 2018-2019. Materials and Methods: After ethical clearance from institutional ethics committee and written informed consent, a total of 70 patients, aged 18–65 years were randomly allocated using computer generated random number list into two groups - Group A - Propofol (1%) - 1.0 mg.kg−1 and Group B - Etomidate 0.2 mg.kg−1 as an intravenous induction agent. Intraoperatively, motor seizure duration, induction time, and hemodynamic parameters and at the end of procedure recovery parameters were assessed. Statistical Analysis Used: Data were described in terms of number (%) and mean ± standard deviation. Comparison of quantitative variables between the study groups was done using Student t-test and Mann Whitney U test for parametric and nonparametric variables respectively. For comparing categorical data, Chi -square (χ2) test was performed. Results: Mean motor seizure duration with etomidate (55.17 ± 19.06 s) was longer as compared to propofol (27.80 ± 17.33 s), and the difference was highly significant (P < 0.001). Among hemodynamic parameters, there was a significant increase in heart rate (P = 0.016) and significant fall in mean arterial pressure (P = 0.005) after induction with propofol as compared to etomidate. Conclusion: Etomidate has the advantage of longer seizure duration and stable hemodynamics. It can be a useful alternative in patients achieving suboptimal therapeutic responses to ECT or where seizure duration is too short.
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Effect of intraoperative dexmedetomidine on postoperative pain and pulmonary function following video-assisted thoracoscopic surgery p. 68
Vinayaka Jannu, M. G. Dhorigol
DOI:10.4103/aer.AER_9_20  
Context: Acute postoperative pain following video-assisted thoracoscopic surgery (VATS) needs considerable attention, if untreated leads to chronic pain and postoperative lung dysfunction. Dexmedetomidine, α2adrenoceptor agonist has shown promising results of opioid-sparing effects. Aims: The objectives of this study are to investigate the effect of dexmedetomidine on postoperative analgesia and pulmonary mechanics in patients undergoing VATS. Settings and Design: This is a randomized controlled trial. Subjects and Methods: We conducted a prospective, randomized, double-blind study on lung cancer patients undergoing VATS. Each patient received either dexmedetomidine or comparable volume of normal saline during the intraoperative period. In the recovery unit, postoperative visual analog scale (VAS) score, rescue analgesic requirements, arterial blood gas values, and pulmonary function tests were recorded. Statistical Analysis Used: Data are analyzed using unpaired t- test, Mann–Whitney U-test, and Fischer's exact test. P < 0.05 was considered statistically significant. Results: VAS scores were significantly lower (P < 0.05) in the dexmedetomidine group at rest, on coughing and on mobilization from supine to sitting position. The partial pressure of arterial oxygen measured in postanesthesia care unit was significantly higher in the dexmedetomidine group (88 ± 8.2 vs 78 ± 9.1 mmHg). Forced expiratory volume in 1 was significantly greater in the dexmedetomidine group compared to the control group on the first 2 postoperative days (P < 0.05). The length of hospital stay was significantly reduced by dexmedetomidine. Conclusions: Intraoperative dexmedetomidine administration improves the quality of analgesia and postoperative lung function in patients undergoing VATS.
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To compare the changes in hemodynamic parameters and blood loss during percutaneous nephrolithotomy – General anesthesia versus subarachnoid block p. 72
Ravi Ranjan, Deepak Malviya, Shilpi Misra, Soumya Sankar Nath, Shivani Rastogi
DOI:10.4103/aer.AER_14_20  
Background: Percutaneous nephrolithotomy (PCNL) is done under general anesthesia (GA) in most of the centers. However, associated complications and cost are higher for GA than for regional anesthesia. Aim: The aim of the study was to compare the efficacy of GA versus subarachnoid block (SAB) with regard to intraoperative blood loss and postoperative drop in hemoglobin (Hb) in patients undergoing PCNL. Setting and Design: This prospective, randomized, comparative clinical trial was carried out at a tertiary care hospital. After obtaining the institute ethical committee clearance (vide no 57/15), patients were randomly allocated into two groups using table of randomization (n = 30 each), Group A – GA, Group B – SAB. Materials and Methods: Intraoperative blood loss was assessed by measuring the Hb of irrigated fluid and postoperative drop in Hb concentration. Other parameters such as intraoperative mean arterial pressure and heart rate were also compared in these groups. Statistical Analysis: The results are presented in frequencies, percentages, and mean ± standard deviation. The Chi-square test was used to compare the categorical variables between the groups. Unpaired t-test was used to compare the continuous variables between the groups. Results: Hemodynamic parameters were similar in both the groups preoperatively. The Hb drop was significant in Group A (1.28 ± 0.35 g.dl−1) as compared to Group B (1.10 ± 0.67 g.dl−1). On calculating Hb in irrigated fluid-blood mixture, it was found to be significantly higher in Group A (1.87 ± 0.44 g.L−1) as compared to Group B (1.25 ± 0.25 g.L−1). Conclusions: Both GA and SAB are effective and safe in PCNL. However, SAB is associated with less blood loss as estimated by intraoperative blood loss and Hb drop.
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Comparative study of effects of intraoperative use of positive end-expiratory pressure, intermittent recruitment maneuver, and conventional ventilation on pulmonary functions during long-duration laparotomy p. 75
Bhawna Singh, Pravin Kumar Das, Soumya S. Nath, Anurag Agarwal, Smita Chauhan, Deepak Malviya
DOI:10.4103/aer.AER_12_20  
Background: With an increase in the duration of general anesthesia, there is a gradual deterioration in pulmonary functions. Intraoperative atelectasis is the major cause of deterioration in pulmonary functions. This study was performed to compare and determine the best ventilatory strategy among conventional ventilation, application of positive end-expiratory pressure (PEEP), and intermittent recruitment maneuver. Materials and Methods: Seventy-five patients were divided into three groups each of 25 patients. In the first group (zero positive end-expiratory pressure [ZEEP]), we have applied zero PEEP intraoperatively. In the second group (PEEP), we have applied PEEP of 6 cm of H2O. In the third group (intermittent lung recruitment maneuver [IRM]), we have done intermittent recruitment maneuver intraoperatively. Pulmonary functions were analyzed by partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2)ratio (P/F) and static lung compliance (Cstat). Results: While comparing the mean P/F ratio between the groups, a significant decrease in P/F ratio of the ZEEP group was found from 90 min after induction up till the end (i. e. 24 h after extubation) of our observations as compared to both the PEEP and IRM groups. However, it did not differ (P > 0.05) between the PEEP and IRM groups at all time points on statistical analysis. On comparing the mean of Cstatbetween the groups, there was a significant decrease in lung compliance of the ZEEP group as compared to both the PEEP and IRM groups at all time points. However, like P/F ratio, compliance was also found to be statistically insignificant between the PEEP and IRM groups. Conclusions: Pulmonary functions are relatively preserved with application of either PEEP or doing intermittent recruitment maneuver.
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Comparison of orotracheal versus nasotracheal fiberoptic intubation using hemodynamic parameters in patients with anticipated difficult airway p. 81
Jitendra Singh Chahar, Pravin Kumar Das, Rakesh K. Dubey, Deepak Malviya, Mamta Harjai, Shivani Rastogi
DOI:10.4103/aer.AER_6_20  
Background: Both nasal and oral routes can be used for fiberoptic intubation. Often it leads to hemodynamic disturbances, which may have a significant effect in patients with limited cardiopulmonary reserve as well as with cerebrovascular diseases. Aims: The aim of the study was to evaluate whether there is a clinically relevant difference between the circulatory responses to oral and nasal fiberoptic intubation. Settings and Design: This was a prospective, randomized, and comparative study. Materials and Methods: In this study, a total of 90 patients with the American Society of Anesthesiologist physical status I and II of either sex in the age group of 18–60 years and having anticipated difficult airway (DA) posted for elective surgery under general anesthesia were randomly allocated into two groups. Patients underwent fiberoptic intubation via either oral or nasal route under sevoflurane anesthesia with bispectral index guidance. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), time taken to intubation, and need of maneuver were measured. Statistical Analysis Used: All the analyses were carried out on SPSS 16.0 version (Inc., Chicago, USA). Mean and standard deviation were calculated. The test of analysis between two groups was done by unpaired t-test. Results: Demographic and DA characteristics were similar in both the groups. Significantly (P < 0.01) lesser alteration in HR, SBP, DBP, and MAP was seen in oral fiberoptic intubation when compared to nasal fiberoptic intubation in the early phase of postintubation. Time taken to intubation was also significantly (P < 0.01) lesser in the oral route compared to the nasal route. Conclusions: Oral fiberoptic intubation causes less hemodynamic alteration and takes less time in comparison to nasal fiberoptic intubation.
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The comparison of two different volumes of 0.5% ropivacaine in ultrasound-guided supraclavicular brachial plexus block onset and duration of analgesia for upper limb surgery: A randomized controlled study p. 87
Mamta Chadha, Saibal Si, Devika Bhatt, Sushil Krishnan, Rakesh Kumar, Ashok Bansal, Anil Kumar Sharma
DOI:10.4103/aer.AER_4_20  
Background: The study is based on the fact that a lower volume of local anesthetic drugs for ultrasound-guided supraclavicular brachial plexus block is useful for upper limb surgeries lasting for a shorter duration, and result in a lower incidence of complications. Aim: The aim of this study is to compare the effectiveness of 35 mL of 0.5% ropivacaine with 20 mL of 0.5% ropivacaine in ultrasound-guided supraclavicular brachial plexus block for upper limb surgery. Setting: Patients undergoing upper limb surgery in an industry-based government hospital in New Delhi, India. Patients were followed in the operation theater and the recovery room. Design: The study design involves a prospective, double-blind, randomized controlled trial. Materials and Methods: A total of 40 participants were recruited for this study. Twenty participants in each group (referred to as group 20 and 30) received 20 mL and 35 mL of 0.5% ropivacaine, respectively, in ultrasound-guided supraclavicular brachial plexus block. Statistical Analysis: The statistical analysis was performed using the software SPSS version 15 and a value of P < 0.05% was considered statistically significant. The statistical tests used included Student's t-test to compare values between the two groups for the mean of parametric data, Mann–Whitney U-test for a median of nonparametric data, and Chi-square test or Fisher's exact test for the categorical data. Results: The sensory and motor block onset in group 20 was 18.06 ± 3.04 and 23.89 ± 2.14 min, respectively. The sensory and motor block onset in group 30 was 17 ± 2.01 and 23.75 ± 2.22 min, respectively. The duration of analgesia in group 20 and 30 was 575.56 ± 104.39 and 730.75 ± 102.09 min, respectively (P < 0.001). Conclusion: The onset of sensory and motor block of 20 mL of 0.5% ropivacaine is comparable to 35 mL of 0.5% ropivacaine for supraclavicular brachial plexus block for upper limb surgery. There was a 21% decrease in the duration of analgesia with a decrease in volume of 0.5% ropivacaine from 35 mL to 20 mL.
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Comparative study of retrobulbar block versus ketamine infusion during eye enucleation/evisceration (randomized controlled trial) p. 92
Hassan Mohamed Ali, Ahmed Mohamed Elbadawy
DOI:10.4103/aer.AER_146_19  
Background: The aim of this study is to compare the safety and efficacy of retrobulbar block versus intraoperative ketamine infusion in eye enucleation or evisceration under general anesthesia. Materials and Methods: Forty-five patients belonging to American Society of Anesthesiologists Physical Status I and II undergoing eye enucleation or evisceration were randomly allocated to three equal groups (15 patients each). General anesthesia was used as the standardized technique in all patients. Group R received a single retrobulbar injection, Group K received intravenous ketamine infusion, and Group C received normal saline with the same rate of ketamine infusion. Intraoperative heart rate and mean arterial pressure, recovery time, postoperative pain score, time to first rescue analgesic, number of patients who required rescue analgesia, and any adverse events were reported. Results: Postoperative pain Visual Analog Scale was significantly lower in R and K groups in comparison to the C group and was significantly higher in K than R group at 3, 6, 12, and 24 h. In addition, the time to first rescue analgesic was significantly longer in R group (429 ± 54 min) than that in K group (272 ± 34 min), but compared to both groups, it was longer in C group (52 ± 7 min). In K group, the recovery time was longer with higher sedation score in comparison to the other two groups. Conclusions: Single retrobulbar injection and low-dose ketamine infusion are safe and effective when used as adjuvants to general anesthesia, but retrobulbar block provides better control of postoperative pain with prolonged time to first rescue analgesic and reduced analgesic consumption.
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Effect of intervertebral level on interlaminar epidural steroid injection in lumbar spinal canal stenosis: A randomized controlled trial p. 100
Shalini Bajpai, Raghu Yelavarthi
DOI:10.4103/aer.AER_136_19  
Background: Interlaminar epidural steroid injection (ILESI) is commonly performed nonsurgical intervention in patients with lumbar spinal stenosis. There is no consensus regarding appropriate intervertebral level of ILESI that leads to maximum effectiveness. In this study, we compared the efficacy of ILESI on pain relief and functional improvement when given at the level of maximum stenosis versus at nearby less stenotic levels in patients of lumbar canal stenosis. Materials and Methods: In this study, 80 patients were randomly allocated to two groups: Group A received lumbar ILESI of 5mL bupivacaine (0.25%), 2 mL methylprednisolone acetate (40 mg/mL), and 1 mL normal saline at maximal stenotic intervertebral level, and Group B received the same drugs at less stenotic level, two intervertebral spaces cephalad or caudad to maximum stenosis. The effects were evaluated by Numeric Pain Rating Scale (NPRS) and Oswestry Disability Index (ODI) at 2, 6, and 12 weeks after the intervention. Results: Results of 30 patients in each group were assessed. Pain relief and improvement in ODI were observed in both groups after injection. Group A had significantly better pain relief at 2 and 4 weeks after injection. The ODI at 2, 6, and 12 weeks after injection was significantly lower in Group A as compared to Group B. Conclusion: ILESI at maximum stenotic intervertebral level leads to better pain relief and functional improvement as compared to injection given at less stenotic level in lumbar spinal canal stenosis.
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Prophylaxis versus treatment against transurethral resection of prostate syndrome: The role of hypertonic saline p. 104
Nazmy E. Seif, Hany A. Shehab, Ahmed M. Elbadawy
DOI:10.4103/aer.AER_148_19  
Background: This study aimed at investigating the usage and effects of prophylactic hypertonic saline (HS) to prevent the occurrence of transurethral resection of the prostate (TURP) syndrome. Materials and Methods: Sixty American Society of Anesthesiologists physical status classes I–III candidates for TURP using the monopolar resectoscope were randomized into three groups 20 patients each. Group A received 4 mL.kg-1.h-1 HS 3%; Group B received 2 mL.kg-1.h-1 HS 3%; and Group C received 6 mL.kg-1.h-1 normal saline. Hemodynamics, vasopressors need, electrolytes (sodium, potassium, and chloride), osmolality, and arterial-blood gas (ABG) were recorded. The incidence of transurethral resection syndrome, intensive care unit (ICU) admission, postoperative ventilation, hospital stay as well as any adverse events were noted. Results: Hypernatremia was detected in six patients (P = 0.002) of Group A only, while hyponatremia occurred in five patients (P = 0.009) of Group C alone. Serum sodium in Group C showed a significant decrease starting from T2 (1 h postresection) till Tp3 (48 h postoperative). In Group C, five patients experienced hypotension and bradycardia; hypertensive episodes also occurred in five patients and a hypervolemic state was noted in seven patients. TURP syndrome was confirmed in only five patients, all in Group C (P = 0.009). Postoperative ICU admission was needed for seven patients of C Group, five of which required assisted ventilation. The overall hospital stay was longer for Group C patients. Conclusion: Prophylactic administration of HS during TURP is superior to conventional treatment of an occurred TURP syndrome. Low dose (2 mL.kg-1.h-1 HS 3%) is effective without adverse effects or risk of contrary hypernatremia.
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Normothermia versus hypothermia during cardiopulmonary bypass in cases of repair of atrioventricular septal defect p. 112
Ghada F. Amer, Mostafa S. Elawady, Ahmad ElDerie, Mohammed Sanad
DOI:10.4103/aer.AER_123_19  
Background: Cardiopulmonary bypass (CPB) used for cardiac surgery is now uniformly carried out under normothermic conditions in adult patients; however, the temperature applied in pediatric CPB vary significantly, ranging from deep hypothermia to normothermia due to the lack of a consistent approach to CPB temperature in pediatric cardiac surgery, which is related to a lack of supportive evidence. Organs protection aim to decrease metabolic requirement and provide energy and oxygen, hypothermia has reached these goals by arresting and cooling the heart, delivering oxygen, and modifying reperfusion. Recently, a large number of studies investigated effect of hypothermia to decrease the negative impact of hypothermia. It has been suggested that the degree of hypothermia affects the inflammatory responses triggered by CPB. However, the use of normothermia during CPB had been introduced and resulted in acceptable results. We hypothesized that the use of normothermia during corrective surgery of AV septal defects improves the outcome of the CPB. Objective: The study aimed to compare the outcome of normothermic technique and mild hypothermic technique during (CPB) in pediatric cardiac patients undergoing repair of atrioventricular (AV) septal defect and their effect on tissue perfusion, serum lactate level, duration of patient intubation, and postoperative hospital stay. Patients and Methods: Forty patients presented for repair of AV defect aged from 1 month to 36 months were divided randomly into two equal groups (20 patients in each): Group I (Normothermic group) of body temperature more than 35°C up to 37°C and Group II (mild Hypothermic group) body temperature between (32°C–35°C). Basal data include complete blood count, electrolytes, arterial blood gases (ABGs), coagulation profile, and liver function tests were collected. Hemodynamic variables, ABG, serum lactate, and activated clotting time (ACT) measured in different time intervals related to CPB. With the termination of CPB, aortic cross-clamping time (minutes), CPB time (minutes), spontaneous regaining of the heart function, need for inotropic administration, and/or vasopressor requirements to wean the heart from CPB were reported in all patients. Results: This study showed statistically significant lower PH and HCO3 levels and significantly higher serum lactate levels in Group II (hypothermic) than Group I (normothermic) after weaning from CPB. Furthermore, ACT level was statistically significantly higher in Group II than Group I after weaning of CPB. During postoperative period, hypothermic group showed significantly higher liver enzymes than the normothermic group. The duration of inotropes administration and duration of intubation were significantly longer in Group II than Group I. Conclusion: Normothermia during CPB showed better global tissue perfusion than hypothermia in elective surgeries for repair of AV defects in the form of less degree of lactic acidosis, less effect on coagulation system, shorter duration of inotropic support, shorter intubation period, and shorter stay in the intensive care unit.
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Erector spinae plane block in laparoscopic cholecystectomy, is there a difference? A randomized controlled trial p. 119
Mohamed Ibrahim
DOI:10.4103/aer.AER_144_19  
Background: The ultrasound (US)-guided erector spinae plane (ESP) block and oblique subcostal transversus abdominis plane (OSTAP) block are used to decrease postoperative pain and subsequently opioids consumption. Aim: The aim was to test the hypothesis that US-guided ESP blocks can produce more reduction in opioid usage during the first 24 h after laparoscopic cholecystectomy when compared to OSTAP block. Settings and Design: Seventy adult patients (20–60 years old) who were planned to undergo elective laparoscopic cholecystectomy were allocated in three groups in randomized controlled trial. Materials and Methods: The three groups received either port site infiltration, US-guided bilateral ESP block (ESP group), or OSTAP (OSTAP group) with bupivacaine hydrochloride 0.25%. Statistical Analysis: Postoperative 24 h Morphine consumption, visual analogue scale (VAS), the intraoperative fentanyl (μg) and equivalent morphine dose in the recovery unit were recorded and analyzed using one-way analysis of variance. Results: The mean 24-h morphine consumption was statistically significant between groups (P < 0.001), but it was insignificant between ESP and OSTAP (P = 0.173). Median (range) and interquartile range of intraoperatively consumed fentanyl showed significance between the three groups (P < 0.001). There was insignificance between ESP block Group II and OSTAP block Group III (P = 0.95) by post hoc analysis. The mean values of VAS at both rest and movement of the control group were significantly higher than the ESP block group at 6 and 12 h postoperative. Conclusion: Bilateral US-guided ESP block was found to be as effective as bilateral US OSTAP block. There was more decrease in intraoperative rescue fentanyl, PACU morphine analgesia, 24-h morphine, and pain assessment score in both groups than the control port-site infiltration group. Clinical trial registration number: NCT03398564.
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Ultrasound-guided adductor canal block versus combined adductor canal and infiltration between the popliteal artery and the posterior capsule of the knee block for osteoarthritis knee pain Highly accessed article p. 127
El-Sayed M El-Emam, Enas A. Abd El motlb
DOI:10.4103/aer.AER_109_19  
Context: Minimally invasive therapeutic modalities have been used to relieve refractory pain of knee osteoarthritis (OA). Objective: The main objective of the study was to compare the adductor canal block (ACB) with combined ACB and infiltration between the popliteal artery and the posterior capsule of the knee (I-PACK) in patients suffering knee OA pain. Patients and Methods: Fifty-six patients were randomly allocated into two equal groups: Group I received ultrasound-guided ACB with 10 mL of 0.125 bupivacaine plus 40 mg methylprednisolone And Group II received ultrasound-guided ACB with 10 mL of 0.125 bupivacaine plus 40 mg methylprednisolone and I-PACK block using same volume and concentration as ACB. Results: Group II showed a statistically significant lower value of visual analog and Western Ontario and McMaster Universities scores at all follow-up intervals compared to Group I. Conclusion: Combined ACB and I-PACK block provide more effective analgesia and better functional outcome compared to the ACB alone.
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Efficacy of ultrasound-guided caudal epidural calcitonin for patients with failed back surgery syndrome Highly accessed article p. 132
El-Sayed M. El-Emam, Enas A. Abd El motlb
DOI:10.4103/aer.AER_98_19  
Context: Pain resulting from failed back surgery syndrome (FBSS) is generally resistant to physiotherapy and pharmacological treatment. Objective: The aim of this study is to evaluate the effect of adding calcitonin to local anesthetic and steroids during ultrasound-guided caudal epidural injection for patients suffering from FBSS. Patients and Methods: Fifty-six patients were randomly allocated into two equal groups. All patients underwent ultrasound-guided caudal epidural injection. Group A received 40 mg (1 mL) methylprednisolone +9 mL lidocaine 0.5% + 1500 iu hyaluronidase in 10 mL normal saline, whereas Group B received 40 mg (1 mL) methylprednisolone +9 mL of 0.5% lidocaine + 1500 iu hyaluronidase in 5 mL normal saline + 50 iu calcitonin in 5 mL normal saline. Results: A statistically significant decrease in visual analog scale, Oswestry Disability Index, and analgesic consumption was recorded in Group B as compared to Group A at 1, 2, and 3 months interval. No side effects were reported in Group A, whereas patients belong to Group B experienced nausea (2 cases), and diuresis for 24 h was detected in two cases. Conclusion: The addition of calcitonin to epidural steroid and local anesthetic injection resulted in better Oswestry disability scale, diminished pain intensity, and less analgesic consumption.
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Effect of adding hydrocortisone to intraperitoneal bupivacaine in laparoscopic bariatric surgery p. 137
Ghada F. Amer, Hosam Hamed, M. Said Salim, Mohammed A. Hegazy
DOI:10.4103/aer.AER_141_19  
Background: Bariatric surgery is the effective management of obesity; however, postoperative pain is associated with a great morbidity. The management of pain is important for the enhancement of patient recovery. Local anesthetics can be injected during laparoscopic surgery into the peritoneum throughout the ports produced either before the beginning of laparoscopy or before the closure of the wound to reduce postoperative pain. Our aim is to evaluate if there is an additive analgesic effect by the administration of intraperitoneal hydrocortisone with streamed intraperitoneal bupivacaine as a method of postoperative pain relief in laparoscopic bariatric surgeries. Patients and Methods: One hundred patients listed for laparoscopic bariatric surgery were the subject of this study. Patients were randomly allocated into two groups: Group I received 100 mg of 0.5% isobaric bupivacaine plus 20 mL normal saline intraperitoneally and Group II received intraperitoneal 100 mg of 0.5% isobaric bupivacaine + 100 mg hydrocortisone + 20 mL of saline at the end of the laparoscopic procedure. The primary outcome was the Visual Analog Scale (VAS) score for pain. The secondary outcomes were the time of first analgesic request, total opioid requirement, heart rate, and mean blood pressure. Results: VAS showed a significant decrease at 4, 6, and 12 h postoperative in Group II compared to Group I. There was a marked decrease in total meperidine requirement with prolonged time of the first analgesic request in Group II compared to Group I. Conclusion: Intraperitoneal hydrocortisone with bupivacaine had improved postoperative pain relief with a decrease in analgesic requirement.
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Comparison of magnesium sulfate and ketamine with ropivacaine in supraclavicular brachial plexus block: A randomized controlled trial Highly accessed article p. 143
Shubhdeep Kaur, Jonny Dhawan, Ruchi Gupta, Sunil Chawla
DOI:10.4103/aer.AER_96_19  
Background: Supraclavicular brachial plexus block offers good operating conditions with limited postoperative analgesia. Magnesium sulfate (MgSO4) and ketamine block peripheral nociception mediated via N-methyl-D-aspartate receptors. Aims: The aim of this study was to evaluate the effect of MgSO4 and ketamine on the duration of analgesia in brachial block. Settings and Design: This was a prospective, randomized, controlled double-blind study. Materials and Methods: One hundred and five adult patients were randomly divided into three groups: Group I = 27 mL of 0.5% ropivacaine; Group II = 27 mL of 0.5% ropivacaine + 250 mg MgSO4; and Group II = 27 mL of 0.5% ropivacaine + 2 mg.kg−1 ketamine. Normal saline was added to make a total volume of 30 mL. The onset and duration of the sensorimotor blockade, quality and duration of postoperative analgesia, and adverse effects were assessed. Statistical Analysis: Statistical analysis was performed using SPSS, version 17.0 software (SPSS, Inc., Chicago, IL, USA). Chi-square test was used for nonparametric and ANOVA for parametric data. Post hoc Student's paired t-test was applied wherever indicated. The results were expressed as mean and standard deviation or numbers (%). P < 0.05 was considered as statistically significant. Results: The duration of analgesia was significantly longer in Group II (8.78 ± 0.97 h) compared to Group I (6.76 ± 0.92 h; P < 0.001) and Group III (7.1 ± 0.89 h; P < 0.001). Intervention groups had lower postoperative visual analog scores at 8, 12, and 24 h compared to the control group. Sedation, nystagmus, and hallucinations were observed in Group III. Conclusion: The addition of MgSO4 to ropivacaine in supraclavicular brachial plexus block significantly prolongs the duration of analgesia. MgSO4 improves the quality of postoperative analgesia with lesser incidence of side effects when compared to ketamine.
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Postoperative analgesic effect of bupivacaine alone and with dexmedetomidine in wound instillation for lumbar laminectomy: A randomized control trial p. 149
Urvashi Yadav, Swati Srivastava, Dheeraj Srivastav
DOI:10.4103/aer.AER_3_20  
Background: Dexmedetomidine has been used as an effective adjuvant to local anesthetics in peripheral nerve blocks and at the incision site. Aims: We compared the postoperative analgesic effect of bupivacaine alone and in addition of dexmedetomidine to bupivacaine in wound instillation during lumbar laminectomy. Setting and Design: This was a prospective, double-blind, randomized control trial. Subjects and Methods: Sixty adults of the American Society of Anesthesiologists Grade I–II scheduled for elective lumbar laminectomy under general anesthesia were randomly allocated into two groups. Group B (control group) patients received wound instillation with 20 mL of 0.25% bupivacaine at the end of surgery and Group D patients received 2 μg.kg−1 dexmedetomidine diluted in 20 mL 0.25% bupivacaine as instillation over the incision site. If the NRS exceeded “4” at any point of time, rescue analgesia with injection diclofenac 75 mg deep intramuscular was administered. Postoperative pain score, duration of analgesia, total rescue analgesic required in the first 24 h, and side effects were compared between the groups. Results: Demographic data were comparable in both the groups. Duration of analgesia (19.93 ± 3.2 in Group D vs. 12.13 ± 1.8 in Group B) was significantly more in Group D, number of analgesic demands were less in group D as compared to Group B, and total rescue analgesic required (62.51 ± 39.13 vs. 95.68 ± 33.5) was significantly less in Group D as compared to Group B. Conclusions: We conclude that dexmedetomidine 2 μg.kg−1 is an effective adjuvant to bupivacaine for wound instillation in terms of quality and duration of postoperative analgesia following lumbar laminectomy.
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Study of tidal volume and positive end-expiratory pressure on alveolar recruitment using spiro dynamics in mechanically ventilated patients p. 154
Shobhit Saxena, Manoj Tripathi, Virendra Kumar, Deepak Malviya, Mamta Harjai, Sujeet Rai
DOI:10.4103/aer.AER_10_20  
Background and Aims: Ventilator setting in the intensive care unit patients is a topic of debate and setting of tidal volume (TV) should be patient-specific based on lung mechanics. In this study, we have evaluated to develop optimal ventilator strategies through continuous and thorough monitoring of respiratory mechanics during ongoing ventilator support to prevent alveolar collapse and alveolar injury in mechanically ventilated patients. Methods: In our monocentric, randomized, observational study, we had recruited 60 patients and divided them into two groups of 30 each. In Group 1 patients, TV and positive end-expiratory pressure (PEEP) were set according to pressure–volume (P/V) curve obtained by the mechanical ventilator in a conventional manner (control group), and in Group 2, TV and PEEP were set according to P/V curve obtained by the mechanical ventilator using intratracheal catheter. PEEP and TV were set accordingly. TV, PEEP, and PaO2/FiO2(P/F) ratio at days 1, 3, and 7, mortality within 7 days and mortality within 28 days were measured in each group and compared. Results: We found a significant difference between PEEP and P/F ratio in both groups while intragroup comparison at days 1, 3, and 7. After the intergroup comparison of Group 1 and 2, we observed a significant difference of PEEP and P/F ratio between the groups at day 7 and not on day 1 or 3. Conclusion: This study concludes that optimal PEEP is more accurate using an intratracheal catheter than the conventional method of deciding ventilator setting. Hence, it is recommended to use intratracheal catheter to obtain more accurate ventilator settings.
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An evaluation of the practice for the requisition of blood products and its utilization in neurosurgical patients undergoing elective surgery at a tertiary care hospital p. 160
Zulfiqar Ali, Talib Khan, Kiran Jangra, Sheikh Ubaid, Humaira Bashir, Abrar Ahad Wani
DOI:10.4103/aer.AER_29_20  
Background: Neurosurgical procedures are associated with profound blood loss that necessitates need for intraoperative and postoperative blood transfusion. Excessive ordering of blood based on physicians' habitual practice may lead to unintentional misuse of blood bank services. For the optimal use of blood resources, transfusion practices have to be appropriate. Aims: The aim of this study is to study the cross match to transfusion ratio and to review the blood utilization practices (transfusion index and maximal surgical blood order schedule) in elective neurosurgical procedures. Settings and Design: A prospective, observational study comprising 740 patients undergoing elective neurosurgical procedures. Materials and Methods: Blood requisition forms and patient records were analyzed of patients undergoing elective neurosurgical procedures from December 2017 to December 2018. A review and note was made of the patient's age, sex, and diagnosis. The number of units prepared, cross matched, and transfused were noted. Statistical Analysis: Statistical analysis was performed with the IBM SPSS software version 21.0. Blood utilization indices were computed and expressed as percentage. Results: A total of 740 patients underwent elective surgical procedures. Among these, 346 patients were requested to prepare 614 units of blood. Out of these 740 patients, there were 56 patients who were in the pediatric age group. A total of 178 units were transfused in 102 patients. One hundred and forty-two units were transfused in the intraoperative period, whereas as 36 units were transfused in the postoperative period. Conclusion: There is an efficient usage of blood for patients undergoing surgery for meningiomas, posterior fossa tumors, spinal dysraphism, and craniovertrebral junctional anomalies. However, the blood resources were poorly utilized in patients undergoing surgery for subarachnoid hemorrhage and pituitary tumors. A revision of blood transfusion policy within the hospital is needed.
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Evaluation of I-Gel™ versus classic LMA™ for airway management by paramedics and medical students: A manikin study p. 166
Ashish Kumar Kannaujia, Uma Srivastava, Tapas Singh, Rudrashish Haldar
DOI:10.4103/aer.AER_37_20  
Background and Aim: Airway management is a lifesaving skill which all health-care workers should possess. Currently, most of the resuscitation councils recommend supraglottic airway devices as the technique of choice for airway management during cardiopulmonary resuscitation by health-care providers without expertise in tracheal intubation. This is because of its high first-pass success rate and easy to acquire and retain skill even by novices. Materials and Methods: The present study was planned to compare the efficacy of two commonly available supraglottic airway devices, classic LMA (cLMA) and I-gel in securing airway in adult manikin by inexperienced persons (58 paramedics and 46 medical students), after a brief training. Our primary aim was to determine the first attempt success rate, and other parameters studied were the time and ease of insertion, overall success rate, and preference for device. Results: The first-attempt success rate of I-gel was higher in both groups of participants (74% in students and 69% in paramedicals) compared to that of cLMA (70% in l students and 53% in paramedics) although the overall success was the same. Majority of participants could secure airway quickly and easily by I-gel than by cLMA. More than 90% of participants preferred I-gel over cLMA. Conclusion: This study shows that inexperienced persons could learn to place the I-Gel and cLMA successfully in the manikin after a brief training in manikin. The first-attempt success rate and insertion of I-gel was easier and faster than that of cLMA by both groups of participants and most participants preferred I-gel due to ease of handling.
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CASE REPORTS Top

Anesthetic challenges in a patient with severe thoracolumbar kyphoscoliosis p. 170
Manbir Kaur, Kuljit Singh Aujla, Jaskaran Singh Gosal
DOI:10.4103/aer.AER_1_20  
Patients with thoracolumbar kyphoscoliosis present unique challenges to anesthesia. We report an interesting and challenging case of kyphoscoliosis presenting with a displaced right intertrochanteric femur fracture who was planned for spinal anesthesia. However, spinal anesthesia was not successful even with the use of intraoperative fluoroscopy. The patient was again planned for spinal anesthesia the next day after reviewing his preoperative lumbar X-rays, which were suggestive of severe canal stenosis and sclerosis of the spine at L4–L5and L5-S1level thus causing the failure of contrast to spread up. Using appropriate space (L3–L4) after viewing X-ray, successful spinal anesthesia could be given. This report underscores the importance of reviewing the preoperative radiology of the diseased spine by the anesthesiologist to administer an effective and safe spinal anesthesia in such patients.
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Surgical retrieval of embolized patent ductus arteriosus occluder device in an adult after 12 years of initial deployment: A case report with perioperative considerations and decision-making in resource-limited settings p. 173
Dheer Singh, Pooja Singh, Sunaina Tejpal Karna
DOI:10.4103/aer.AER_38_20  
Transcatheter closure of patent ductus arteriosus (PDA) is a well-established technique worldwide, with minimal incidence of associated major and minor complications. Surgical closure of PDA is equally effective with negligible mortality risk. We describe a case of an adult with unexpected diagnosis of PDA occluder device embolization in main pulmonary artery, presenting after 12 years of initial device deployment during childhood. Due to persistent duct flow, patient developed severe pulmonary hypertension and congestive heart failure. In this report, we are focusing on perioperative management of surgical retrieval of the embolized device along with the need of intermediate and sometimes long term follow up of patients planned for percutaneous closure, in order to avoid procedure-related complications and associated morbidity and mortality risk. At the same time, the socio-economic aspects of the patient should also be considered in decision-making in terms of choice of transcatheter versus surgical closure of the shunt.
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