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October-December 2018
Volume 12 | Issue 4
Page Nos. 769-971

Online since Tuesday, December 18, 2018

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ORIGINAL ARTICLES  

Effect and safety of labor epidural analgesia with intermittent boluses of 0.1% bupivacaine with fentanyl on fetal and maternal outcomes and wellbeing Highly accessed article p. 769
Rajesh Kesavan, Sunil Rajan, Lakshmi Kumar
DOI:10.4103/aer.AER_168_18  
Background: Labor analgesia has been shown to have few undesirable effects on the course and outcome of the labor as well as on the fetal well-being. Aims: This study aims to assess neonatal outcome following lumbar epidural analgesia with intermittent boluses of 0.1% bupivacaine with fentanyl. The secondary objectives included assessment of maternal analgesia, complications, and outcome of labor. Setting and Design: Prospective observational study conducted at a tertiary care teaching institute. Subjects and Methods: Sixty-three patients for labor epidural analgesia were recruited. Epidural catheter was inserted in L4–L5 or L3–L4 interspace. After confirmation of the position of catheter, 3 mL of 0.5% bupivacaine with 20 μg of fentanyl made to 15 mL was administered. After 30 min, efficacy of analgesia was assessed by visual analog scale (VAS). The same bolus dose was repeated after 90 min if the patient complained of pain. A maximum of five top-up doses were allowed. Statistical Test Used: Mean and standard deviation, number and percentage Results: After 30 min of first bolus dose, 93.3% had VAS score of <4. More than 90% patients had adequate analgesia till 4th epidural bolus. During contraction stress test, only two fetuses had late deceleration. About 80% and 98.3% newborns had Apgar of >7 at 1 and 5 min, respectively. Umbilical cord blood pH was ≥7.1 in 98.3% neonates with base excess of >−12. 58.3% delivered normally, 23.3% had instrumental vaginal delivery, and 18.3% required cesarean section. Conclusion: Lumbar epidural analgesia with 0.1% bupivacaine with fentanyl provides optimal neonatal outcome, labor analgesia, and labor outcome.
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Comparison between multisite infiltration analgesia versus adductor canal block for pain management in total knee arthroplasty: A prospective study p. 774
AV Gurava Reddy, Mohammed Shafeekh, Sukesh Rao Sankineani, Khubchand Jhakotia, Muralidhar Sagi, Deepesh Daultani, Vishesh Khanna, Krishna Kiran Eachempati
DOI:10.4103/aer.AER_124_18  
Background: Severe acute postoperative pain after total knee arthroplasty (TKA) may cause significant morbidity to patients. Recent techniques such as peripheral nerve blocks have shown promising hope in providing appropriate pain control without systemic side effects. Adductor canal block (ACB) and multisite infiltration analgesia (MIA) are two techniques that are proven to be effective individually. Aim: This study aims to compare the efficacy of ACB versus MIA in postoperative analgesia and functional recovery after unilateral knee arthroplasty. Settings and Design: A prospective study was conducted between July 2016 and December 2016 involving 200 patients undergoing unilateral TKA. Materials and Methods: Patients were either administered MIA (Group I, n = 100 patients) or ACB (Group II, n = 100 patients). All the patients were assessed for severity of pain by visual analog scale (VAS) at 8, 24, and 48 h postoperatively and knee range of motion (ROM) at 48 h after surgery. Statistical Analysis: The Statistical Package for the Social Sciences (SPSS 19.0, SPSS Inc., Chicago, IL, USA) was used for descriptive and inferential analysis. Results: Patients who received MIA showed significantly better VAS scores 8, 24, and 48 h after surgery. Furthermore, this subset of patients showed a marginally better ROM postoperatively. However, there was no difference number of patients requiring rescue analgesia for breakthrough pain or technique-related problems between both groups. Conclusion: This study demonstrates that MIA is a safe technique that provides effective analgesia at 8, 24, and 48 h postoperatively. This leads to faster rehabilitation compared to ACB in patients undergoing TKA.
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Intravenous low dose fentanyl versus lignocaine in attenuating the hemodynamic responses during endotracheal intubation: A randomized double-blind study p. 778
Ranjithkumar R Thippeswamy, Supreeth R Shetty
DOI:10.4103/aer.AER_111_18  
Background: The laryngotracheal stimulation is known to cause reflex sympathoadrenal response with a marked increase in heart rate and blood pressure. Arrhythmias can be precipitated. The harmful nature of this response has been noted in patients at risk. Therefore, it is important to find an effective means of attenuating sympathetic response to laryngoscopy and intubation. The present study is undertaken to determine the efficacy of intravenous low dose fentanyl (2 μg/kg) and lignocaine (1.5 mg/kg) in attenuating hemodynamic response to laryngoscopy and tracheal intubation. Aim: The aim of this study is to compare the efficacy of intravenous low dose fentanyl (2 μg/kg) versus lignocaine (1.5 mg/kg) in attenuating the hemodynamic responses during endotracheal intubation. Settings and Design: This was double-blinded randomized controlled study. Materials and Methods: After obtaining institutional ethical clearance and informed consent, a total of 90 patients, with the American Society of Anaesthesiologists Physical Status I and II scheduled for elective surgeries, were selected randomly and divided into three groups of 30 each. The general anesthesia technique was standardized for all three groups as follows: Group 1 (control-received normal saline), Group 2 (Lignocaine 1.5 mg/kg), and Group 3 (Fentanyl 2 μg/kg). Heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial blood pressure were recorded preinduction, postinduction and 1,3,5,7, and 10 min after endotracheal intubation. Statistical Analysis: Descriptive data presented as mean ± standard deviation and in percentage. Multiple group comparisons were made using one-way ANOVA followed by unpaired “t” test for pairwise comparison. “P” <0.05 was considered for statistical significance. Results: The fentanyl group showed significantly lesser rise (26%) in heart rate compared to lignocaine (33%) (P = 0.018) and control group (42.5%) (P = 0.000). The lignocaine group showed lesser rise in systolic blood pressure (14.5%) compared to control group (20%) (P = 0.000) at intubation. The fentanyl group showed a significant decrease in systolic blood pressure after administration, which came back to normal at 7 min following intubation and again decreased 10 min after intubation. Conclusion: Lignocaine and fentanyl both attenuated the rise in heart rate, though fentanyl was better. Lignocaine attenuated the rise in blood pressure with intubation whereas fentanyl prevented it totally. Of the two drugs low dose fentanyl 2 μg/kg i. v. bolus provides a consistent, reliable, and effective attenuation as compared to lignocaine 1.5 mg/kg i. v. bolus.
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Comparison of two different volumes of ropivacaine used in nerve stimulator guided inter-scalene block for arthroscopic shoulder surgery – A randomized controlled trial p. 786
Ghanshyam Kumar Sahu, Dharam Singh Meena, Suman Saini, Ajisha Aravindan, Priyankar Kumar Datta
DOI:10.4103/aer.AER_122_18  
Background: This study was conducted to compare the analgesic efficacy of 10 ml versus 20 mL of 0.5% ropivacaine in nerve stimulator guided interscalene brachial plexus block, in patients undergoing arthroscopic shoulder surgery. Methods: A total of 70 American Society of Anesthesiologists physical status classes 1 and 2 patients, aged 18–65 years, undergoing unilateral arthroscopic shoulder surgery, were randomized into two groups. Group A received single shot inter-scalene block with 20 mL of 0.5% ropivacaine whereas Group B received the same with 10 mL. The primary outcome was difference in the total postoperative fentanyl consumption over 24 h. Secondary outcomes were difference in block onset, intra-operative hemodynamic parameters, intra-operative fentanyl consumption, duration of effective analgesia, visual analogue scale (VAS) scores at various time intervals, duration of motor block, and incidence of hemidiaphragmatic (HD) palsy. Results: Total 24 h fentanyl consumption was significantly higher in Group B (558 ± 112 mcg) compared to Group A (296 ± 88 μg). Block onset was slower in Group B than Group A. There was no difference in intra-operative fentanyl consumption. Postoperative VAS scores were significantly higher in Group B compared to Group A, at 6 h and thereafter. Duration of motor block was significantly shorter in Group B (6.25 ± 1.25 h) compared to Group A. HD palsy was seen in all the cases in both the groups. Conclusion: Single shot nerve stimulator guided interscalene block with 10 ml of 0.5% ropivacaine was inferior to 20 mL of 0.5% ropivacaine with respect to postoperative analgesic efficacy.
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Evaluation and comparison of clonidine and dexmedetomidine for attenuation of hemodynamic response to laryngoscopy and intubation: A randomized controlled study p. 792
Sana Yasmin Hussain, Abhijit Karmarkar, Dhruv Jain
DOI:10.4103/aer.AER_123_18  
Background: Laryngoscopy and tracheal intubation are noxious stimuli which evoke a transient but marked sympathetic response. Alpha-2 adrenoceptor agonists attenuate the sympathoadrenal responses by inhibiting noradrenaline release. Aim: This study aims to evaluate and compare the effect of intravenous dexmedetomidine and clonidine on cardiovascular response resulting from laryngoscopy and endotracheal intubation. Settings and Design: This was a prospective randomized controlled study carried out in the operating room. Materials and Methods: Ninety American Society of Anesthesiologists Physical Status I and II patients were randomly allocated into three groups, that is, Group C (clonidine 2 μg/kg), Group D (dexmedetomidine 1 μg/kg), and Group S (normal saline) infused over 10 min. Blood pressures – systolic (SBP) and diastolic (DBP), mean arterial pressure (MAP), and heart rate (HR) were recorded after drug administration and intubation at subsequent intervals. Statistical Analysis Used: Quantitative data were analyzed using ANOVA test (with post hoc Bonferroni correction for intragroup comparison). Qualitative data were analyzed using Chi-square test. P < 0.05 was considered statistically significant. Results: HR, SBP, DBP, and MAP were lower in Group C and D compared to Group S at all times measured. HR was significantly lower in Group D compared to Group C after drug infusion. At 1 min after intubation, SBP and MAP were lower in Group D compared to Group C. At 3, 5, and 10 min after intubation, SBP, DBP, and MAP were lower in Group D compared to Group C. Conclusion: There was significant reduction in hemodynamic response by dexmedetomidine and clonidine as compared to controls. Furthermore, attenuation of the pressor response to intubation was better following premedication with dexmedetomidine than with clonidine.
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A prospective study on operation theater utilization time and most common causes of delays and cancellations of scheduled surgeries in a 1000-bedded tertiary care rural hospital with a view to optimize the utilization of operation theater p. 797
Shraddha Vidyadhar Naik, Vithal Krishna Dhulkhed, Rewa Hemant Shinde
DOI:10.4103/aer.AER_132_18  
Background: The operation theater (OT) complex is a costly component of a hospital budget expenditure. This area of hospital activity requires maximum utilization to ensure optimum cost benefit. To achieve a high level of utilization in the OT, it is necessary to efficiently coordinate number of activities and personnel. Methods: This study was conducted in a 1000-bedded tertiary care teaching hospital in rural maharashtra over aperiod of two months. The OT complex consists of eight major OTs. Normal working hours for routine scheduled cases on all working days except Sundays and public holidays. Results: Total study period consisted of 96 working days. There were a total of eight OT tables of various specialties, and parameters were observed during the routine hours excluding Sundays and holidays. The total procedure time was maximum for ENT followed by orthopedics and least for obstetrics. Room turnover time was maximum for obstetrics followed by general and oncosurgery. Case delays were maximum in general surgery and least for ophthalmology. The most common reason for delay in starting the operation table was patient getting shifted late from the ward and administrative causes. The most prominent reasons for cancellation were lack of operating room time followed by medical reasons of the patient. Conclusion: We concluded that most of the causes of delays and cancellations of surgeries were avoidable with proper preoperative planning and optimization of patients and resources and good communication between surgeon anesthesiologists and the nursing staff.
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The effect of intravenous dexamethasone on intraoperative and early postoperative pain in lumbar spine surgery: A randomized double-blind placebo-controlled study p. 803
Mamta Sharma, Shikha Gupta, Shobha Purohit, Amit Kumar Goyal
DOI:10.4103/aer.AER_115_18  
Background: The surgical procedures of spine are generally associated with intense pain in the postoperative period. Opioids are commonly used for perioperative analgesia but are associated with many side effects. Co-analgesic drugs are used to decrease these side effects. One such supplemental drug is dexamethasone. Its strong anti-inflammatory effect contributes to perioperative analgesia. Aim: This study was done to evaluate the effect of intravenous (i.v.) dexamethasone on intraoperative and early postoperative pain in lumbar spine surgery. Settings and Design: This was a hospital-based randomized, double-blind, placebo-controlled study, done between June 2016 and December 2016 after permission of institutional ethical committee. Materials and Methods: This Study was conducted on 60 patients undergoing lumbar spine surgery, and randomization was done in two groups. Group A (study) received dexamethasone 2 ml (8 mg) i.v. and Group B (control) received 2 ml normal saline. Anesthesia technique and rescue analgesia regimen were standardized. Intraoperative pain was assessed by hemodynamic variability and postoperative pain by verbal rating score. All the quantitative data were analyzed using Student's t-test and all the qualitative data using Chi-square test. Results: Heart rate in the control group was significantly higher than the study group during intraoperative period. Mean pain scores in the early postoperative period were significantly higher in control group than the study group (P < 0.001). Mean time of first rescue analgesic in the postoperative period was 149.17 min and 34.33 min in the study group and control group, respectively (P < 0.001). Conclusion: Hence, we conclude that administration of 8 mg of preoperative i.v dexamethasone was effective in reducing intraoperative and early postoperative pain in the lumbar spine surgery.
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Addition of dexmedetomidine to ropivacaine in subcostal transversus abdominis plane block potentiates postoperative analgesia among laparoscopic cholecystectomy patients: A prospective randomized controlled trial p. 809
B Sarvesh, BT Shivaramu, Kanchan Sharma, Amit Agarwal
DOI:10.4103/aer.AER_141_18  
Context: Laparoscopic cholecystectomy is associated with moderate intensity postoperative pain especially in the early postoperative period. Transversus abdominis plane (TAP) block has been shown to reduce pain scores and analgesic requirements after abdominal surgery. Aims: We hypothesized that a subcostal TAP block with ropivacaine and dexmedetomidine will prolong the duration of postoperative analgesia following laparoscopic cholecystectomy. Settings and Design: This prospective, randomized study was done in 60 patients undergoing laparoscopic cholecystectomy surgery done at a tertiary care institution. Subjects and Methods: Sixty patients undergoing laparoscopic cholecystectomy were randomized into two groups to receive either bilateral ultrasonography-guided subcostal TAP blocks with 18 mL 0.375% ropivacaine and 2 ml of normal saline (n = 30, Group R) or 18 ml. 375% ropivacaine with 0.5 μg/kg dexmedetomidine 2 mL (n = 30, Group RD). Numerical rating scale was measured postoperatively to primarily assess the pain severity and analgesic requirement for the first 24 h, hemodynamic parameters, and adverse effects were recorded. Statistical Analysis Used: Categorical data were analyzed using Chi-square test/Fisher's exact test and quantitative data were analyzed using Student's t-test and the Mann–Whitney U-test. Results: The study group (Group RD) had significantly prolonged postoperative analgesia (485.6 min) as compared to Group R (289.83 min). Moreover, consumption of morphine over 24-h period is significantly less in Group RD (14.5 mg) as compared to Group R (28.5 mg). Conclusions: Addition of dexmedetomidine to ropivacaine in TAP block prolongs postoperative analgesia and reduces opioid consumption without any major adverse effects.
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Topographic sonoanatomy of infraclavicular brachial plexus: Variability and correlation with anthropometry p. 814
Abhyuday Kumar, Ajeet Kumar, Chandni Sinha, Chhavi Sawhney, Rajnish Kumar, Debesh Bhoi
DOI:10.4103/aer.AER_140_18  
Objective: The aim of the study was to assess the effectiveness of ultrasound in analyzing topographic relationship of nerve cords with axillary artery at lateral infraclavicular level, their variations, and the distance from the skin and to correlate findings with anthropometric parameters. Materials and Methods: Two hundred patients aged 18–75 years were enrolled for the study after informed written consent. A 7–12 MHz linear ultrasonic transducer was used for scanning of the brachial plexus at lateral infraclavicular fossa. The results of the cord positions were expressed on a 12-section pie chart, and the number of arteries and veins was reported. Measurements included the vertical distance from the upper part of the artery to the skin, diagonal distance to the apical corner of the ultrasound image, and distances from center of cords to the center of artery. Age, sex, weight, height, body mass index, and biceps girth were recorded. Data were expressed as mean with standard deviation or frequency and percentage for categorical variables, and statistical analysis was done using correlation analysis and two-sample t-test. Results: The most frequent positions of the cords were observed in 2–4 sections (92%) for the medial cord, 6–7 sections (92%) for the posterior cord, 10–11 sections (89%) for the lateral cord, and 4–5 sections (95%) for the axillary vein. More than one axillary vein was seen in 12.5% and two axillary arteries were seen in 1.5% of cases. Cord visibility and distance between artery and apical corner of the ultrasound image correlated with anthropometric parameters. Conclusions: A topographical study of brachial plexus at lateral infraclavicular fossa showed anatomical variations and abnormal vascular formations. This sonoanatomic knowledge can be helpful in improving safety and success of nerve blocks.
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Clinical audit on the practice of documentation at preanesthetic evaluation in a specialized university hospital p. 819
Yophtahe B Woldegerima, Semira D Kemal
DOI:10.4103/aer.AER_131_18  
Background: Performing preanesthetic evaluation, documenting, and keeping readily accessible record are responsibilities of anesthetists. Documentation can improve overall patient outcome. It also has an irreplaceable role in medico-legal aspects. Documentation is one of the challenges of providing quality care. Aim: The aim of this study was to evaluate the quality of documentation practice during preanesthetic visits. Materials and Methods: This clinical audit was conducted in the University of Gondar Hospital. Predefined 22 practice quality indicators were prepared according to modified global quality index. Statistical Analysis: Descriptive statistics was performed using SPSS version 20. Results: A total of 122 preanesthetic evaluation tools (PAETs) were reviewed. None of PAETs found fully completed according to the indicators. Trends differ between elective and emergency conditions. Indicators with high completion rate (>90%) were signed a consent, medical history, history of medication, allergy, anesthesia and surgery, cardiopulmonary examination, airway examination, preoperative diagnosis, and planned procedure. Anesthetic plan, vital signs, a name, per-oral status, premedication, and age were found with below average (<50%) completion rate. Conclusions: Documentation practice during the preanesthetic visit was below the standard. Unclear instructions should be replaced with standardized contents. Providing regular trainings on clinical documentation for students and staffs, and introducing modern electronic-based documentation system and preanesthetic clinics may improve the practice.
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Comparison of ultrasound-guided lumbar erector spinae plane block and transmuscular quadratus lumborum block for postoperative analgesia in hip and proximal femur surgery: A prospective randomized feasibility study p. 825
Serkan Tulgar, Halil Cihan Kose, Onur Selvi, Ozgur Senturk, David Terence Thomas, Mehmet Nurullah Ermis, Zeliha Ozer
DOI:10.4103/aer.AER_142_18  
Study Objective: Lumbar Erector spinae Plane block (L-ESPB) is a modification of a recently described block. Both L-ESPB and Transmuscular Quadratus Lumborum block (QLB-T) have been reported to provide effective postoperative analgesia in hip and proximal femur surgery. Herein, we compare the effectiveness of L-ESPB and QLB-T in providing postoperative analgesia in patients undergoing hip and femur operations. Design: Double-blinded, prospective, randomized, feasibility study. Setting: Tertiary university hospital, postoperative recovery room and ward. Methodology: A total of 72 patients (American Society of Anesthesiology physical status classification II-III) were recruited. After exclusion, 60 patients were allocated to three equal groups (control, L-ESB and QLB-t). Interventions: Standard multimodal analgesia was performed in the control group while L-ESPB or QLB-T was performed in the block groups. Measurements: Pain intensity between groups was compared using Numeric Rating Scores. Furthermore, tramadol consumption and additional rescue analgesic requirement was measured. Results: There was no difference between demographic data or type of surgery. While there was no difference in Numeric Rating Scale (NRS) score at any hour between the block groups; NRS scores at the 1st, 3rd and 6th h, tramadol consumption during the first 12 h and total tramadol consumption, the number of patient required rescue analgesic in 24 h were significantly higher in the control group compared to both block groups. Conclusion: While L-ESPB and QLB-T have similar effect, they improve analgesia quality in patients undergoing hip and proximal femoral surgery when compared to standard intravenous analgesia regimen.
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Labor epidural analgesia: Comparison of two different intermittent bolus regimes p. 832
Nitu Puthenveettil, Anish Mohan, Sunil Rajan, Jerry Paul, Lakshmi Kumar
DOI:10.4103/aer.AER_144_18  
Background: Optimal labor analgesia can be provided with epidural by addition of opioid to the local anesthetic. Aims: The aim of this study is to compare the efficacy of labor epidural bolus regimes 20 mL of 0.1% ropivacaine with 40 μg fentanyl versus 15 mL of 0.1% ropivacaine with 15 μg fentanyl as epidural bolus dose. Settings and Design: This was prospective double-blinded randomized study. Materials and Methods: After approval from the Institutional Ethical Committee, 50 consenting parturients in active labor were allotted into two groups by closed envelope technique. Group A received 20 mL of 0.1% ropivacaine with 40 μg fentanyl, whereas Group B received 15 mL of 0.1% ropivacaine with 15 μg fentanyl as an epidural bolus dose. The onset, duration of analgesia, motor block, top-up doses required, consumption of ropivacaine, and fentanyl and fetomaternal outcome were compared. Statistical Analysis Used: Numerical variables are expressed as a mean and standard deviation and categorical variables are expressed as frequency and percentages. To obtain the association between categorical variables and different doses Fischer's exact test was applied. To compare clinical parameters between different drug doses independent two-sample t-test were applied. Mann–Whitney U-test applied for nonparametric data. Results: Effective labor analgesia with no motor blockade was observed in both groups with no failure rate. Duration of analgesia was significantly longer in Group A (166.8 ± 54.64 vs. 100.2 ± 32.39 min P < 0.001). The onset of analgesia was faster in Group A (88% vs. 16% within 7 min, P < 0.001). Conclusion: Labor epidural analgesia with larger volume boluses produces faster onset and prolonged duration of analgesia.
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Levobupivacaine versus levobupivacaine–dexmedetomidine in thoracic paravertebral block for laparoscopic sympathectomy p. 837
Alaa Eldin Adel Elmaddawy, Doaa Galal Diab, Mohammed A Farag
DOI:10.4103/aer.AER_126_18  
Background: Thoracic paravertebral block (TPVB) is a high-quality analgesic technique used for many types of surgery, trauma, and chronic pain. Aim: The aim of this study is to assess safety and efficacy of adding dexmedetomidine to levobupivacaine in TPVB for postoperative analgesia after unilateral laparoscopic thoracic sympathectomy. Patients and Methods: Sixty adult patients of the American Society of Anesthesiologists physical status classes I and II, aged 20–45 years, of either sex, submitted for unilateral laparoscopic thoracic sympathectomy under general anesthesia at Mansoura University Hospital. Patients were classified into two groups such as levobupivacaine (GL): patients received isobaric 0.5% levobupivacaine 1 mg/kg in 20-ml volume for TPVB and levobupivacaine–dexmedetomidine (GLD): patients received isobaric 0.5% levobupivacaine 1 mg/kg and 10-μg dexmedetomidine in 20 ml volume for TPVB. Statistical Analysis: Data were first tested for normality by Kolmogorov–Smirnov test. Normally distributed continuous data were analyzed using unpaired Student's t-test. Nonnormally distributed continuous and ordinal data were analyzed using Mann–Whitney U-test. Categorical data were analyzed by Chi-square test or Fisher's exact test as appropriate. Results: A faster onset and longer duration of sensory blockade was significantly higher in group GLD with mean ± standard deviation (SD) (8.57 ± 7.22 min and 11.98 ± 1.42 h) than in group GL (15.21 ± 4.35 min and 9.75 ± 3.29 h). Sensory block regression time was significantly longer in group GLD with mean ± SD (10.8 ± 2.31 h) compared to group GL (8.82 ± 1.71 h). Furthermore, a significant reduction in visual analog scale occurred in group GLD compared with the GL group up to 24 h postoperatively (P < 0.05). No significant difference in Ramsay Sedation Scale (RSS) between both groups. The number of patients asked for postoperative analgesia was significantly fewer in group GLD compared with group GL (14 compared to 21)*. The time (hours) of first request for analgesia was significantly longer in group GLD compared with GL group (7.8 ± 3.22 compared to 9.7 ± 2.51*). The total postoperative fentanyl requirements in 24 h (in micrograms) was significantly less in GLD group compared to GL group (320 ± 110 compared to 190 ± 120*). Conclusion: The addition of dexmedetomidine as adjuvant to levobupivacaine in TPVB for elective unilateral laparoscopic thoracic sympathectomy can markedly improve the postoperative analgesia with lower pain scores and a marked reduction of the postoperative analgesic requirements and low side effect profile.
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The study of intraoperative consciousness after tracheal intubation p. 843
Leena Harshad Parate, Sandyarani D Channaiah, Geetha C Rajappa, Rahul Singh, Akshara Madhav, Mariam Mahdiyyah
DOI:10.4103/aer.AER_139_18  
Introduction: Awareness following noxious stimuli like intubation could be as high as 25% compared to postoperative recall. The isolated forearm technique (IFT) allows us to assess consciousness by verbal command to move isolated hand. Hence we conducted study to establish IFT responses following intubation under standard general anaesthesia. Methods: We enrolled 132 adult patients undergoing general anaesthesia. A tourniquet was applied on other arm. Following intravenous induction of anaesthesia, torniquet was inflated 100mmhg above systolic BP. After giving muscle relaxant, three minutes patients were ventilated with oxygen and inhalational agent. Before laryngoscopy first verbal command (Squeeze my hand) was given to the patient. Once intubation and tube confirmation done, second verbal command was given. Lack of paralysis in isolated hand was confirmed with TOF stimuli and tourniquet was deflated. Surgery was carried in routine manner. Postoperatively all patients were evaluated for any explicit recall using Modified Brice questionnaire. The primary outcome is number of patients who responded to verbal command postintubation. Secondary outcome is number of patients responded prelaryngoscopy and number of patients reporting explicit recall in the Modified Brice interview. Results: None of the patients had positive IFT response. On postoperative interview none reported awareness. 10.7% of patients had dreams which were pleasant. Worst thing about surgery was pain.(43%). Conclusion: Our study suggests that intraoperative consciousness after intubation and postoperative recall is an uncommon occurrence.
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Comparison of efficacy of intra-articular plain bupivacaine and bupivacaine with adjuvants (dexmedetomidine and magnesium sulfate) for postoperative analgesia in arthroscopic knee surgeries: A prospective, randomized controlled trial p. 848
M Manjula Devi, Surbhi Gupta, Rajkumar Amaravathi, Sahana Udupa, Ajey Hegde, Santu Ghosh
DOI:10.4103/aer.AER_153_18  
Context: Intra-articular (IA) bupivacaine and adjuvants are used in multimodal analgesia for knee arthroscopy. Aims: To evaluate the efficacy of IA plain bupivacaine and bupivacaine with adjuvants (dexmedetomidine and magnesium [Mg] sulfate) for postoperative analgesia in knee arthroscopy. Settings and Design: This was a randomized controlled study in a tertiary care hospital. Methodology: Fifty-four patients were randomly allocated to receive 20 ml of study drug, 0.25% bupivacaine (Group B), 0.25% bupivacaine with 0.5 μg/kg of dexmedetomidine (Group D), and 0.25% bupivacaine with 10 mg/kg of Mg sulfate (Group M). Duration of analgesia, visual analog score for pain at rest (VAS-R) and movement (VAS-M), and number of times rescue analgesics were given in the first 24 h of postoperative period were assessed. Vital parameters and any side effects of the drugs were also noted at immediate (0, 5, 10, 15, and 30 min, 1 h) and late postoperative period (2, 4, 6, 12 and 24 h). Results: Duration of analgesia was prolonged in bupivacaine-dexmedetomidine and bupivacaine-Mg sulphate groups as compared to bupivacaine alone (5.97 ± 1.76 h, 13.44 ± 7.87 h, and 14.61 ± 8.83 h in Groups B, D, and M, respectively; P = 0.001). The VAS-R and VAS-M were less with Group D and Group M compared to Group B (P = 0.002 in VAS-R and P = 0.004 in VAS-M). The number of times rescue analgesic used was more in the Group B (2.06 ± 0.8, 0.94 ± 0.8, and 0.89 ± 0.9 in Groups B, D, and M, respectively; P < 0.001). The hemodynamic parameters were comparable and no side effects were noted among the three groups. Conclusion: IA bupivacaine with adjuvants prolongs duration and improves quality of postoperative analgesia as compared to bupivacaine alone.
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Investigation of mean platelet volume and platelet count in the blood of patients with lumbago and sciatica p. 855
Erhan Gokcek, Ayhan Kaydu
DOI:10.4103/aer.AER_209_17  
Background: Mean platelet volume (MPV) is a measurement defining the mean size of platelets in the blood. There has been no previous study of MPV and the level of platelets in lumbago/sciatica patients. Aim: The aim of this study was to investigate whether or not an increase is seen in platelet count and MPV which are indicators of platelet activation in lumbago/sciatica patients compared to a healthy control group. Patients and Methods: The study included 151 patients (79 females, 72 males, mean age 43.1 ± 12.9 years) who presented at the Pain Clinic of our hospital and were diagnosed with lumbago/sciatica between July 2017 and September 2017. A control group was formed of 80 healthy individuals (40 females, 40 males, mean age 42.4 ± 12.5 years). Results: No statistically significant difference was determined in the MPV of the lumbago/sciatica patients (9.76 ± 1.09 fL) compared with the control group (9.56 ± 0.92 fL) (P = 0.34). The platelet level of lumbago/sciatica patients (263.3 ± 68.7 103/mL) was determined to be statistically significantly lower than that of the control group (277.27 ± 70.7 103/mL) (P = 0.02). Conclusion: The results revealed that the platelet count of the lumbago/sciatica patients was lower than that of the control group while no statistically significant increase was determined in MPV. These findings may show platelet activation that is not statistically significant in lumbago/sciatica patients.
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Comparison of the efficacy of intrathecal isobaric ropivacaine and bupivacaine in day care knee arthroscopy: A randomized controlled trial p. 859
S Suresh Kumar, Vandana Talwar, Poonam Gupta, Anoop Raj Gogia
DOI:10.4103/aer.AER_135_18  
Background: The primary goal of ambulatory anesthesia is a rapid recovery with minimal side effects. Ropivacaine, due to its property of sensory-motor dissociation, maybe a useful agent when equivalent spinal anesthesia and quicker recovery of motor function is desirable. Aim: The aim of this study is to compare the efficacy of intrathecal isobaric ropivacaine with bupivacaine and to assess their postoperative recovery profile in patients undergoing arthroscopic knee surgery. Setting and Design: This randomized controlled study was conducted at a tertiary care hospital. Materials and Methods: A total of 90 adult American Society of Anaesthesiologist physical status Classes 1 and 2 patients were randomized into two groups to receive 2 ml plain solution of either 0.5% bupivacaine (Group B) or 0.75% ropivacaine (Group R). In the intraoperative period, onset, efficacy, duration, and regression of sensory and motor block were noted in both the groups at regular intervals. Postoperatively, the groups were compared for pain score, recovery profile, analgesic requirement, and complications. Statistical Analysis: Data analysis was performed using Chi-square test and Student's t-test. Results: The mean onset time of sensory block at L1 was significantly less (P = 0.025) and duration of sensory and motor block was significantly more (P = 0.001) with bupivacaine as compared to ropivacaine. The analgesic requirement on the 1st postoperative day (P = 0.011) and incidence of delayed voiding of urine (P = 0.022) were significantly more with ropivacaine. The postoperative recovery profile and discharge times were similar between the groups. Conclusion: Isobaric ropivacaine was associated with a longer onset and shorter duration of sensory and motor block, increased postoperative analgesic requirement, higher complication rate, and similar discharge times as compared with bupivacaine. Therefore, isobaric bupivacaine may be preferred over isobaric ropivacaine for day care knee arthroscopy, especially in cases with an anticipated longer duration of surgery.
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Emergency intubation outside operating room/intensive care unit settings: Are we following the recommendations for safe practice? p. 865
Kamal Kajal, Amarjyoti Hazarika, Seran Reddy, Kajal Jain, Shyam Charan Meena
DOI:10.4103/aer.AER_151_18  
Context: Although international guidelines have been developed for emergency tracheal intubation (ETI), there is little evidence of their applicability in developing countries. Aims: The aim of this study was done to evaluate the different methods of ETI that are practiced among anesthetist and anesthesia trainees in India outside operating room (OR)/intensive care unit (ICU) settings. Settings and Design: This was prospective observational audit did among anesthesia personals managing ETI outside OR and ICU. Materials and Methods: The study was conducted through an online survey using electronic media. Certified anesthetists and anesthesia trainees were sent a questionnaire where they were asked to complete and submit it online. Results: Out of 145 respondents, 52% were certified anesthetists. Availability of equipment, technical staff, and visual monitors was a big constraint. About 28% of the participants do not examine the airway before ETI, 61% of participants invariably do not perform rapid sequence induction and intubation, and 89% of the participants have only the bougie at their disposal with the availability of videolaryngoscope (10%) and Fibreoptic bronchoscopy (FOB) (6%) being scarce. About 12% of the respondents use capnography for ETI confirmation. Only 48% of the participants accompany the patient during shifting. Conclusions: Our survey has reported wide disparity during ETI with poor compliance to the international guidelines.
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Endocavitary versus linear array high-frequency probe in ultrasound-guided supraclavicular subclavian vein central access p. 873
Maged Labib Boules
DOI:10.4103/aer.AER_146_18  
Background: Vascular access is a top priority in the critically ill patients. Cannulation – venous and/or arterial – is the first step in any emergency situation. Ultrasound (US)-guided vascular cannulation was found to have a higher success rate and a decreased incidence of mechanical complications as compared with the landmark one. Aim: This study aims to compare subclavian vein (SCV) access through supraclavicular (SC) approach by endocavitary (EC) probe technique versus linear array high-frequency probe technique. Settings and Design: A prospective, randomized controlled study conducted on 60 patients. Patients and Methods: Study was carried out on 60 adult patients presenting for the surgical intensive care unit in Fayoum University Hospital. Patients were classified into two groups: Group (A) (n = 30): Catheter was inserted using the EC probe and Group (B) (n = 30): Catheter was inserted using the linear array high-frequency probe. Statistical Analysis Used: Student's t-test was applied for calculation of normally distributed variables and Mann–Whitney U-test for nonnormally distributed variables. Categorical data between the groups were compared using Chi-squared test. P < 0.05 indicated a statistically significant difference. Results: The frequency of successful cannulation of the SCV at first attempt was significantly higher in Group A compared to Group B (P = 0.044). The number of attempts and the time needed for venous access were significantly lower in Group A compared to Group B (P = 0.038, <0.001 respectively). No significant difference was found regarding the incidence of posterior wall puncture, arterial puncture, or hematoma, (P = 0.671, 0.055, 1 respectively). Conclusion: The use of EC probe technique for Subclavian venous access through the SC approach significantly increased the success rate compared to the linear array high-frequency probe.
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Comparison between colloid preload and coload in bone cement implantation syndrome under spinal anesthesia: A randomized controlled trial p. 879
Ayca T Dumanlı Özcan, Elvin Kesimci, Cemile Altın Balcı, Orhan Kanbak, Hülya Kaşıkara, Abdulkadir But
DOI:10.4103/aer.AER_127_18  
Background: Bone cement implantation syndrome (BCIS) is characterized by hypoxia hypotension cardiac arrest. There is not any research that investigated the hemodynamic effects of colloid use during and before cement implantation regarding BCIS development. Aims: We aimed to compare the effects of colloid preloading before or coloading simultaneously at cement implantation on BCIS development and hemodynamic parameters in patients who underwent total knee arthroplasty. Settings and Design: This is a prospective, randomized, clinical trial with the participation of 109 patients over 60 years of age and patients physical status American Society of Anesthesiologists Classes I and II to undergo knee surgery. The patients were administered spinal anesthesia, divided into three groups. Subjects and Methods: The patients in Group I were infused 8 mL/kg hydroxyethyl starch (130/0.4) 20 min before the cement implantation, those in Group II were infused the same simultaneously during cement implantation. Group III was infused 8 mL/kg/h sodium chloride during the anesthesia management. Hemodynamic parameters of the patients were recorded at before and after cement implantation and once the tourniquet was removed. Statistical Analysis Used: The descriptive statistics were presented as the mean ± standard deviation for normally distributed variables, as the median for nonnormally distributed variables, and as the number of cases and (%) for nominal variables. Pearson's Chi-square test and Fisher's exact test were used in the analysis of categorical variables. Results: Compared to the control group, Groups I and II were hemodynamically more stable. The development of moderate hypoxia during cement implantation was significantly different between the study groups (P < 0.05). Conclusions: We suggest that avoiding intravascular volume depletion by using the colloids, particularly in elderly patients, is important for preventing from the BCIS.
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Comparison of nebulized ketamine with nebulized magnesium sulfate on the incidence of postoperative sore throat p. 885
Sivakumar Segaran, Arish T Bacthavasalame, Ranjan R Venkatesh, Mamie Zachariah, Sagiev Koshy George, Ravichandran Kandasamy
DOI:10.4103/aer.AER_148_18  
Background: Postoperative sore throat (POST) is a known complication following general anesthesia requiring endotracheal intubation. Its incidence ranges from 21% to 65% and remains the eighth most undesirable postoperative event. Various measures have been tried to decrease the incidence of sore throat with various success rates. Aim: This study aimed at reducing the incidence of POST with ketamine and magnesium sulfate nebulization. Settings and Design: This study is a prospective randomized, double-blinded study. Materials and Methods: After Institutional Ethics Committee approval and written informed consent, 80 patients who fulfilled the inclusion and exclusion criteria were randomly divided into two groups to receive magnesium sulfate 250 mg in 5 ml saline in Group A and ketamine 50 mg in 5 ml saline nebulization in Group B before the start of general anesthesia. All patients received standard anesthesia protocol. After extubation, all patients were enquired about the incidence and severity of sore throat at 0, 2, 4, 6, and 24 h. Statistical Analysis Used: Paired t-test and Wilcoxon signed-rank test were used to compare hemodynamic variables and Chi-square test to compare the incidence and severity of sore throat. Results: There were no differences in the demographic profile, duration of laryngoscopy, time taken to intubate, and duration of surgery between the two groups. The incidence and severity of sore throat were significantly decreased in ketamine group at 4 and 6 h when compared to magnesium sulfate group. Conclusion: Nebulization with ketamine 50 mg significantly decreases the incidence of POST when compared to magnesium sulfate 250 mg.
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Postintubation sequels: Influence of fluticasone and technique of intra-operative muscle relaxation p. 891
Choro Athiphro Kayina, Rashmi Salhotra, Ashok K Sethi, Medha Mohta, Arun K Sharma
DOI:10.4103/aer.AER_157_18  
Background: Postintubation sequels (PIS) are a cause of serious concern in the postoperative period. Aim: The aim of this study is to find the influence of preoperative inhaled steroid and technique of muscle relaxation on PIS. Settings and Design: This prospective, exploratory pilot study was conducted on 120 adult American Society of Anesthesiologist physical status Class I and II patients undergoing general anesthesia (GA) with muscle relaxation and cuffed endotracheal tube (ETT) insertion. Patients and Methods: Patients were randomized into four groups as follows: intermittent muscle relaxation with preanesthetic inhalation of either distilled water puffs (Group ID) or fluticasone puffs (Group IF); continuous infusion of muscle relaxant with preanesthetic inhalation of either distilled water puffs (Group CD) or fluticasone puffs (Group CF). After induction of GA, ETT was inserted. The intra-cuff pressure was maintained constant. The trachea was extubated in the light plane in intermittent groups and in the deep plane in continuous groups. Statistical Analysis: Qualitative parameters were compared using the Chi-square test and quantitative parameters using repeated measure ANOVA followed by Tukey's test. Results: Group CF had significantly less incidence of sore throat and hoarseness compared to groups ID and IF. The severity of sore throat was more in groups ID and IF than in groups CF and CD (P < 0.002). The severity of hoarseness was least in group CF (23.3%) and highest in group IF (90%). None of the patients had a cough in group CF. The incidence and severity of dysphagia were significantly less in group CF as compared to other groups (P < 0.005 and P < 0.008, respectively). Conclusion: Continuous infusion of muscle relaxant with extubation in deep plane of anesthesia with preanesthetic inhalation of fluticasone puffs results in lesser incidence and severity of PIS.
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Comparative evaluation of different doses of intravenous dexmedetomidine on hemodynamic response during laryngoscopy and endotracheal intubation in geriatric patients undergoing spine surgeries: A prospective, double-blind study p. 897
Ravi Kumar Keshri, Mukesh Kumar Prasad, Amit Kumar Choudhary, Gurdeep Singh Jheetay, Yashowardhan Singh, Kali Kapoor
DOI:10.4103/aer.AER_156_18  
Background: Dexmedetomidine, a selective alpha 2 (α2)-adrenergic receptor agonist, has been used to blunt the hemodynamic response associated with laryngoscopy and tracheal intubation, which is a common concern for the anesthesiologist, especially in high-risk patients and geriatric age group. Aim and Objectives: The current study is to evaluate and compare the effects of different doses of dexmedetomidine in controlling hemodynamic response during tracheal intubation in geriatric patients. Materials and Methods: After getting approval from the Ethical Committee, 90 patients of the American Society of Anesthesiologist Physical Status Classes I and II, aged ≥60 years, were randomly assigned into three groups: Group I (normal saline, n = 30), Group II – dexmedetomidine (0.50 μg/kg, n = 30), and Group III – dexmedetomidine (1.00 μg/kg, n = 30). Dexmedetomidine was infused for 10 min before induction. Data were recorded as before infusion (T0), at the end of infusion (T1), before tracheal intubation (T2), at the moment of tracheal intubation (T3) 5 min after tracheal intubation (T4), and 10 min after tracheal intubation (T5). Modified observer's assessment of alertness/sedation scale score was observed at the time of T0 and T1. All statistical analyses were done using SPSS version 22. Results: Mean systolic blood pressure was statistically significantly (P < 0.05) more among Group I compared to Group II and III at T2, T3, and T4. Mean heart rate (HR) value was significantly (P < 0.05) more among Group I compared to Group III from T1 to T5, whereas there was no significant change in HR between Group I and Group II and at T4 and T5 h was comparable in Group II and Group III. Conclusion: This study concluded that more acceptable hemodynamic changes were seen with 0.50 μg/kg dexmedetomidine when compared with 1.0 μg/kg dexmedetomidine during intubation. A lower dose besides being cost-effective is also free of side effects associated with the higher dose of 1 μg/kg dexmedetomidine.
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Validating the role of steroid in analgesic cocktail preparation for local infiltration in total knee arthroplasty: A comparative study p. 903
AV Gurava Reddy, Chiranjeevi Thayi, Nandkumar Natarajan, Sukesh Rao Sankineani, Deepesh Daultani, Vishesh Khanna, Krishna Kiran Eachempati
DOI:10.4103/aer.AER_138_18  
Background: Pain control after total knee arthroplasty (TKA) through local analgesic cocktail preparation has gained widespread popularity in recent times. Local steroids have potent anti-inflammatory effect leading to reduced postoperative swelling and pain which might increase the efficacy and duration of local infiltration analgesia. Aim: The aim is to evaluate whether the addition of local steroid to an injectable analgesic cocktail for periarticular infiltration leads to better pain control and knee range of motion (ROM) in the immediate postoperative period compared to patients who do not receive steroid in their cocktail. Settings and Designs: A prospective study was conducted in a group of 140 patients undergoing unilateral TKA between June 2017 and December 2017. Materials and Methods: All the patients in the study group received either periarticular infiltration with an analgesic cocktail (Group I, n = 70) or analgesic cocktail with 100 mg methylprednisolone (Group II, n = 70) for postoperative pain with ultrasound-guided adductor canal block (ACB). Patients were evaluated with visual analog scale (VAS) for pain at 8, 24, and 48 h postoperatively and ROM at 48 h after surgery. Statistical Analysis: The SPSS 19.0 software (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis. Student t-test has been used to find the pairwise significance. Results: Group II had a statistically significant decrease in VAS scores at 8 h (P = 0.096), first postoperative day (P = 0.0001) and second postoperative day (P = 0.0001) as compared to Group I. However, there was no statistically significant difference seen with early ROM in both the groups at 48 h (P < 0.361). Conclusion: Patients who received steroid cocktail infiltration plus ACB had an improved and better postoperative analgesia in an early postoperative period of 24–48 h; however, there was no significant difference in clinical ROM and functional outcome when compared to the study group.
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Practice pattern of fresh gas flow and volatile agent choices among anesthesiologists working in different Indian hospitals: An online survey p. 907
Mayank Kumar, Mamta Sinha, Habib Md Reazaul Karim, Chinmaya Kumar Panda, Subrata Kumar Singha
DOI:10.4103/aer.AER_164_18  
Background: Fresh gas flow (FGF) during volatile inhalational agent-based anesthesia is a concern for many reasons. Advancement in anesthesia workstation (WS) and monitoring of anesthesia gas concentrations has led to the feasibility of lower flow safely. However, the practice pattern is not yet well known. The information can help us in better protocol formation. Aim: The survey was aimed to know the prevailing practice pattern of FGF and volatile agent choices and compare them among anesthesiologists of different working setups and experiences. Materials and Methods: With approval, the present cross-sectional survey was conducted using SurveyMonkey® software from January 2018 to May 2018. Anesthesiologists working in different organizations across India were approached through E-mail and WhatsApp. Anonymous responses were collected, expressed in number and percentage scale, as well as compared using INSTAT software and appropriate tests; P < 0.05 was considered statistically significant. Results: A total of 251 (15.2%) responses were received and 249 were analyzed. Overall, 87% of respondents were using anesthesia WS and 71% were using nitrous oxide as balance gas. The FGF of <600 mL/min was highest with desflurane. Minimum alveolar concentration (MAC) monitoring was very poor in nonteaching (NT) hospitals as compared to teaching hospitals; P < 0.0001. The Boyle's machine was more common in use in NT hospitals as compared to medical colleges and corporate hospitals; P < 0.0001. Conclusion: Low-flow anesthesia (LFA) use is still suboptimal, and there are ample opportunities to increase and optimize the FGF used. The use of Boyle's machine is associated with higher flow use. MAC monitoring and LFA use are poor in NTs.
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Transdermal ketoprofen patch in comparison to eutectic mixture of local anesthetic cream and subcutaneous lidocaine to control pain due to venous cannulation p. 914
Ayman Anis Metry, Manal M Kamal, Milad Z Ragaei, George M Nakhla, Rami M Wahba
DOI:10.4103/aer.AER_166_18  
Background: This study was established to compare the analgesic and side effects between transdermal ketoprofen patch 30 mg and eutectic mixture of local anesthetic (EMLA) cream applied to the peripheral venous cannulation site and lidocaine injection before cannulation. Patients and Methods: One hundred and five adult patients who had been scheduled for elective general surgery with patients' physical status American Society of Anesthesiologists classes I and II were randomly divided into three groups: Group I (EMLA group) received EMLA cream, Group II (lidocaine group) received subcutaneous infiltration of 1 ml of 2% lidocaine HCl 10 min before cannulation, and Group III (ketoprofen group) received a transdermal ketoprofen patch 30 mg. Groups I and III received their cream or patch 60 min before cannulation. The pain resulting from cannulation by an 18G cannula was assessed by a visual analog scale (VAS) at the time of cannulation and every 2 h for another 6 h for all groups. Signs of inflammation at the site of cannulation (erythema, induration, edema, and blanching) were observed at the site of cannulation for 24 h. Results: Ketoprofen patch, EMLA cream, and lidocaine injection were found to be equal in controlling pain caused by venous cannulation with no significant difference in VAS. Signs of inflammation at the site of cannulation (blanching, erythema, and induration) were very evident in Group I (EMLA) which showed significant difference than in other two groups. Conclusions: EMLA cream, ketoprofen patch, and lidocaine injection have equal ability to alleviate pain due to cannulation when applied before the procedure, but ketoprofen patch is more superior as it had less local inflammatory effect in comparison to EMLA cream and without double puncture as with lidocaine injection.
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A comparative study of transversus abdominis plane block versus quadratus lumborum block for postoperative analgesia following lower abdominal surgeries: A prospective double-blinded study p. 919
G Dilip Kumar, N Gnanasekar, Pranjali Kurhekar, T Krishna Prasad
DOI:10.4103/aer.AER_158_18  
Context: Traditional truncal blocks are devoid of visceral analgesia. Quadratus lumborum (QL) block has shown greater efficacy in providing the same. Aims: This study was done to compare the efficacy of transversus abdominal plane (TAP) block versus QL block in providing postoperative analgesia for lower abdominal surgeries. Settings and Design: This was a prospective, randomized, double-blinded study. Subjects and Methods: Seventy adult patients were randomly allocated into two groups, where Group A received TAP block with 20 ml of 0.25% ropivacaine on each side (n = 35) and Group B received QL block with 20 ml of 0.25% ropivacaine on each side (n = 35). The time of block, duration of surgery, Numerical Pain Intensity Scale (NPIS) score at the 1st, 2nd, 4th, 8th, 12th, 16th, and 24th postoperative hours, and the total analgesic drug requirements were noted and compared between the two groups. Statistical Analysis Used: Data were analyzed with SPSS version 23 (IBM corporation, Armonk, NY, USA) with independent t-test and Chi-square test as appropriate. P < 0.05 was considered statistically significant. Results: The time for first analgesic requirement was 243.00 ± 97.36 min and 447.00 ± 62.52 min and the total analgesic consumption (morphine in mg) was 5.65 ± 1.55 and 3.25 ± 0.78 in Group A and Group B, respectively, both of which were statistically significant (P < 0.01). There was a significant difference in postoperative pain scores (NPIS scale 0–10) at rest, between the two groups, up to 16 h. Conclusions: Patients who received QL block had a significant improvement in postoperative pain relief with reduced consumption of opioids.
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Effect of dexmedetomidine as an adjuvant to ropivacaine in ilioinguinal-iliohypogastric nerve blocks for inguinal hernia repair in pediatric patients: A randomized, double-blind, control trial p. 924
Daisy Karan, Swastika Swaro, Pratik Ranjan Mahapatra, Anwesha Banerjee
DOI:10.4103/aer.AER_169_18  
Background: Bulk of published data support the efficacy of dexmedetomidine for prolongation of peripheral nerve block; but most of the studies are in adults. Ample data regarding use of dexmedetomidine in setting of paediatric peripheral nerve blocks is scarce. Aim and Objective: To determine whether adding dexmedetomidine to ropivacaine in ilioinguinal-iliohypogastric nerve block prolongs postoperative analgesia in children undergoing inguinal hernia repair. Material and Methods: Sixty children of American Society of Anesthesiologist (ASA) grade I – II aged between 2-11 years scheduled for elective hernitomy were randomly allocated to receive an ultrasound guided ilioinguinal-iliohypogastric nerve block (IINB) with 0.2 ml/kg dose of plain ropivacaine 0.2% (group R; n = 30) or ropivacaine 0.2% with adjunct dexmedetomidine 1 μg/kg (group RD; n = 30).Time to first post-operative need for supplemental analgesia triggered by pain score ≥4 according to Children's and infants postoperative pain scale (CHIPPS scale) was the primary end point of study. Number of analgesic doses during first 24 hours; intraoperative hemodynamic changes; sedation; postoperative adverse effects were noted. Results: The mean duration of analgesia was significantly prolonged in group RD (970.23 ± 46.71minutes) as compared to group R (419.56 ± 60.6 minutes). Children in group RD had significantly lower CHIPPS score, and less number of rescue analgesic requirements during first 24 hours postoperatively. No adverse effects were recorded in any group. Conclusion: The present study concluded that combined use of ropivacaine and dexmedetomidine in IINB provided profound prolongation of post operative analgesia in children following inguinal hernia repair.
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Tunneling does not prevent dislodgment of epidural catheters: A randomized trial p. 930
Hussein Y Abukhudair, Esam N Farhoud, Khalid M Abufarah, Abdullah T Obaid, Ola A Yousef, Aqel M Aloqoul
DOI:10.4103/aer.AER_159_18  
Background: Epidural analgesia is preferred in postoperative pain control, but dislodgment is a major factor for failure. Tunneling is well known to control displacement of catheters. In this study, we evaluated if we can depend on tunneling in preventing dislodgment of epidural catheters. Aims: The aim is to study if tunneling is effective and safe in reducing the rate of epidural catheters' dislodgment. Setting and Design: The study was carried out at a single tertiary cancer center. The trial was parallel, simple randomized, controlled, and single blind. Allocation of treatments was generated using random number tables. Subjects and Methods: Two hundred patients undergoing major surgeries were randomized. Epidural catheters were affixed to the skin through subcutaneous tunneling to a length of 5 cm or using standard adhesive tape without tunneling. Patients were on follow-up for 6 days postsurgery according to policy. Statistical Analysis Used: Categorical variables were analyzed by Chi-square and Fisher's exact test. Student t-test was used for continuous variables. Results and Conclusion: A total of 200 patients were randomized, 92 patients received tunneled catheters and 108 received nontunneled catheters. Patients were between 20 and 85 years; 63% were male. The mean days of epidural analgesia were similar in both groups (2.7 compared to 2.5 days). About 7.6% of epidurals were dislodged in the tunneled group compared to 10.2% in the nontunneled group (P = 0.699). No differences were identified in the incidence of pain or adverse events between the groups. Tunneling did not improve the rates of dislodgment in epidural catheters. There were no safety concerns associated with tunneling epidural catheters.
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Comparative evaluation of ropivacaine and ropivacaine with dexamethasone in transverse abdominis plane block for lower abdominal surgeries: a prospective, randomized, double-blinded study p. 937
N Gnanasekar, G Dilip Kumar, Pranjali Kurhekar, MS Raghuraman, T Krishna Prasad
DOI:10.4103/aer.AER_162_18  
Context: Dexamethasone as an adjunct to ropivacaine has shown promising results in prolonging the duration of analgesia in transverse abdominis plane (TAP) block. Only limited studies evaluated the effects of dexamethasone with ropivacaine in TAP block in specific population. Aims: The effects of adding dexamethasone to ropivacaine on the quality and duration of TAP block in lower abdominal surgeries in multiple specialties were studied. Settings and Design: This was a prospective, randomized, double-blinded study. Subjects and Methods: Seventy adult patients undergoing lower abdominal surgeries were allocated into two groups to receive general anesthesia with TAP block with 20 ml 0.25% ropivacaine with 8 mg dexamethasone (2 ml) (Group A, n = 35) or 20 mL 0.25% ropivacaine with 2 ml saline (Group B, n = 35) each side. The analgesic efficacy in terms of pain scores, morphine consumption, and occurrence of nausea and vomiting was compared between two groups. Statistical Analysis Used: Data were analyzed with SPSS 23 with independent t-test and Chi-square test as applicable. P < 0.05 was considered statistically significant. Results: The duration of analgesia was significantly prolonged in Group A (P = 0.000). The total morphine consumption was significantly lesser in Group A (P = 0.000). The pain scores (numerical pain intensity scale) were significantly lesser in Group A till the 8th postoperative hours. The occurrence of nausea and vomiting was comparable between the groups (P = 0.3821). Conclusions: Addition of dexamethasone to ropivacaine significantly improved the quality of analgesia with reduced consumption of opioids as compared to plain ropivacaine in TAP block.
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Comparative analysis of duration of postoperative analgesia between levobupivacaine and levobupivacaine with clonidine after ultrasound-guided transversus abdominis plane block in patients undergoing lower segment cesarean section p. 943
Ranjita Acharya, Ranjita Baksi, Pratik Mohapatra
DOI:10.4103/aer.AER_163_18  
Background: Transversus abdominis plane (TAP) block in cesarean section is carried out by local anesthetics such as bupivacaine or ropivacaine with a limited duration of analgesia. The addition of adjuvants such as clonidine and dexmedetomidine has increased the duration of postoperative analgesia. Aims, Settings and Design: The aim of this study was to compare the duration of postoperative analgesia between clonidine and levobupivacaine (0.25%) versus levobupivacaine (0.25%) alone in the bilateral TAP block after lower segment cesarean section (LSCS). Materials and Methods: In this prospective randomized double-blind interventional study, 100 parturients undergoing elective LSCS were included in the study. Patients were randomly divided to receive either 20-ml levobupivacaine 0.25% (Group A; n = 50) or 20-mL levobupivacaine (0.25%) +1-μg/kg clonidine bilaterally (Group B; n = 50) in TAP block in a double-blind fashion. The total duration of analgesia, patient satisfaction score, postoperative visual analog scale score, total requirement of analgesics in the first 24 h, and the side effects of clonidine were observed. Statistical Analysis: Statistical tests were conducted using SPSS. P < 0.05 was considered as statistically significant. Results: A total of 92 patients were analyzed. Duration of analgesia was significantly longer in Group B (17.94 ± 0.76 h) compared to Group A (7.16 ± 0.41 h) (P < 0.001). Mean consumption of tramadol was 197.77 ± 14.90 mg and 8.889 ± 28.77 mg in Groups A and B (P < 0.001), respectively. All patients in Group B were extremely satisfied while those in Group A were satisfied (P < 0.01). None of the patients experienced hypotension or bradycardia. Conclusion: The addition of clonidine 1 μg/kg to 20-ml levobupivacaine 0.25% in TAP block bilaterally for cesarean section significantly increases the duration of postoperative analgesia, decreases postoperative rescue analgesic requirement, and increases maternal comfort compared to 20 ml of levobupivacaine 0.25% alone.
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Are female children more likely to be born to Indian anesthesiologists? – A nationwide survey p. 949
Divya Gupta, Gurjeet Khurana, Parul Jindal, Pradeep Aggarwal
DOI:10.4103/aer.AER_170_18  
Context: Exposure to medications (prescribed or over-the-counter) or exposure to chemicals (unintentional or occupational) during pregnancy have always been of great scientific concerns. Aims: This study aims to ascertain whether the recently documented offspring sex ratio (OSR) skew in medical literature is reproducible among our respondent population and how our respondents' characteristics relate to the OSR skew (if any) in our respondent population. Settings and Design: A survey questionnaire uploaded on the SurveyMonkey® Online Portal. Subjects and Methods: The survey was completed by the Indian anesthesiologists about themselves and their spouses during the periconceptional periods of their offspring. Statistical Analysis Used: Analysis of variance for means and Chi-square test for proportions with P < 0.05 as statistically significant. Results: Respondents (irrespective of gender) who sired first-born or second-born male children were anyway more likely to sire male children as reflected in the personal sex ratios among all offspring sired by them, and similarly respondents (irrespective of gender) who sired first-born or second-born female children were anyway more likely to sire female children. Male parents were significantly more common to have worked in operating rooms around the time of conception of first-born or second-born children. As compared to female anesthesiologists, male anesthesiologists significantly reported that they were practicing inhalational induction of anesthesia more often around the conception of their second-born female children as compared to around the conception of their second-born male children. Conclusions: Practice of inhalational induction of anesthesia was reportedly more common among Indian male anesthesiologists during periconceptional period of their second-born female children.
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CASE REPORTS Top

Pantoea dispersa it the next emerging “monster” in our intensive care units? A case report and review of literature p. 963
Mridul Panditrao, Minnu Panditrao
DOI:10.4103/aer.AER_147_18  
Hospital-acquired infections and their consequences are the main cause of morbidity/mortality in critically ill and immunocompromised patients. It becomes interesting when an unusual and uncommon microorganism is found to be the causative agent, rather than the known commensals and opportunists. We present such a case, when a multiparous female, in post lower uterine segment cesarean section period presented with fulminant septic shock, hepatic failure, coagulopathy, and ventilator-associated pneumonitis. The organism grown in the tracheal secretions turned out to be an uncommon, unusual Gram-negative Coccobacillus by the name of Pantoea dispersa, resistant to almost all the conventional antimicrobial agents. In spite of all the efforts, the patient could not be saved. However, the case has opened up a virtual “Pandora's box” of questions. Are these microorganisms, known plant pathogens, really harmful to humans? Are they commensals or virulent opportunists? Are we once again on the way to a new “Acinetobacter,” like near-epidemic? This is an attempt to try and find some insight about this presently uncommon and not well known genus of Pantoea! We have tried to trace and review the related available literature in the clinical medicine.
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Anesthesia management in an adult patient with sleep-disordered breathing and difficult intubation: A case report p. 967
Devika Bhatt, Ulpesh Shelke, Varsha Vyas, RP Gehdoo
DOI:10.4103/aer.AER_171_18  
Obstructive sleep apnea may be associated with numerous comorbidities and perioperative complications. Poor laryngeal anatomy visualization can be a cause of failed tracheal intubation after multiple attempts in patients with sleep-disordered breathing due to the underlying adenoid enlargement. We present a case of difficult endotracheal intubation in a 52-year-old menopausal female patient posted for tonsillectomy with adenoid resection with a history of snoring and difficulty in breathing while asleep. A thorough preoperative assessment focusing on history and investigating obstructive sleep apnea, and preparing and planning for difficult tracheal intubation in such patients can lead to successful endotracheal intubation inside the operation theater.
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ERRATUM Top

Erratum: Assessment of relationship between vitamin D deficiency and pain severity in patients with low back pain: A retrospective, observational study p. 970

DOI:10.4103/0259-1162.247666  
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Corrigendum: Epidural ketamine in post spinal cord injury-related chronic pain p. 971

DOI:10.4103/0259-1162.247665  
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