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October-December 2020
Volume 14 | Issue 4
Page Nos. 545-652

Online since Thursday, May 27, 2021

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REVIEW ARTICLE  

Management of obstetric analgesia in the developing countries during the coronavirus disease pandemic: A narrative review Highly accessed article p. 545
Ravi Shankar Sharma, Aditya Pal Mahiswar, Ajit Kumar, Praveen Talawar, Girish Kumar Singh, Gaurav Purohit
DOI:10.4103/aer.AER_10_21  
Coronavirus disease (COVID), also known as COVID-19, has brought the immense challenges for the health-care system globally. All the branches of medicine are equally involved in managing these patients. During this pandemic, care of obstetric patients in terms of obstetric analgesia becomes crucial. Hence, the purpose of this review was to draft a basic model of strategies related to the provision of safe obstetric analgesia during this coronavirus pandemic, which will assist the health-care providers across the developing countries to formulate their own protocols depending upon the resource availability. All research articles related to obstetric analgesia during the COVID-19 pandemic from January 2020 to December 01, 2020 available on PubMed, Cochrane, Google scholar, and Embase are included in this study. The keywords used for data search were “obstetric analgesia during COVID-19,” “coronavirus pandemic,” “Labor pain,” “obstetric pain management guidelines,” and “regional anesthesia during COVID-19.” Eventually, our review yielded the most recentmodel for the provision of safe and effective obstetric analgesia practices during the COVID-19 pandemic across the developing countries.
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ORIGINAL ARTICLES Top

A comparative study of periarticular infiltration with dexmedetomidine versus ketorolac as an additive to ropivacaine after total knee arthroplasty: A prospective, randomized double-blind study Highly accessed article p. 550
Sapna Annaji Nikhar, Monu Yadav, Shashi Damera, Lalith Mohan, V Jyotsna Ch, Gopinath Ramachandran
DOI:10.4103/aer.AER_18_21  
Background: Periarticular infiltration (PAI) analgesia has been found to be an effective analgesia modality after total knee arthroplasty (TKA). Dexmedetomidine has many beneficial effects on postoperative analgesia by different routes, but studies on PAI are lagging. Aims and Objectives: In this study, we compared postoperative analgesia after PAI with dexmedetomidine versus ketorolac as an additive to ropivacaine after TKA. Setting and Design: This is a prospective, randomized, double-blind study conducted on 75 patients belonging to American Society of Anesthesiologists I to III, undergoing total knee arthroplasty, of either gender, belonging to American Society of Anesthesiologists I to III. Materials and Methods: After institutional ethics committee approval and written informed consent, patients were randomly allocated into three groups. Group C (n = 25) received cocktail of 60 mL ropivacaine (0.25%) infiltration with adrenaline 5 mL (0.1 mg.mL−1), Group D (n = 25) received additive dexmedetomidine 1 ug.kg−1 to above cocktail, and Group K (n = 25) received ketorolac 30 mg. Postoperatively pain by Visual Analog Scale, vitals, total duration of analgesia, need for rescue analgesia, sedation, patient satisfaction, mobilization time, and complications were recorded. Statistical Analysis: The Statistical Package for the Social Sciences version 20 was used for statistical analysis. Analysis of variance has been used to find the significance of study parameters between the three groups of patients. P < 0.05 was considered statistically significant. Results: Postoperative pain score was lesser in the ketorolac group (1.52 ± 0.71, P = 0.001) than the other two groups. Duration of analgesia was more with ketorolac (343.00 ± 144.45, P < 0.001) compared with the other two groups, and epidural activation timings (462 ± 235.84) were significantly delayed in Group K compared to Group C and Group D. There was no significant difference in mobilization time, patient satisfaction, and complications between the three groups. Conclusion: Ketorolac was a better additive to ropivacaine than dexmedetomidine for postoperative analgesia after TKA.
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Retrospective analysis of pain relief in total knee replacement surgeries p. 555
Shruti Shrikant Patil, Deepa Kane, Anoop Dhamangaonkar, Valmik Avhad
DOI:10.4103/aer.AER_117_20  
Background and Aims: The aim of the study is to measure the postoperative adequacy of pain relief and functional recovery after unilateral primary total knee arthroplasty or total knee replacement (TKR) with a multimodal approach. Settings and Design: This was a retrospective observational study done in a tertiary care center. Materials and Methods: Eighty patients aged 18–65 years (yrs) with ASA Physical Status Classes I, II, and III operated for unilateral primary TKR surgery under suitable Anaesthesia and was administered ultrasound-guided adductor canal block + periarticular infiltration (PI) from January 2018 to January 2019 were included. Thereafter, the patients visual analog scale (VAS) scores at rest, 45° knee flexion, and mobilization as well as additional analgesia given were noted after going through the records at following time points: 12 hourly for 24 h and thereafter on postoperative day 1 (POD1) and POD2. Level of block, adverse events, and functional recovery (time up and go [TUG] test, 10 s walk test) on POD1 and POD2 were also noted. Statistical Analysis and Results: The statistical software namely SPSS 18.0 were used for the analysis of the data. The mean VAS score at 12 h was 4.33 ± 1.3 which worsened at 24 h with steady improvement over the next 2 days. Similarly, the case with a mean VAS score at 45° flexion and on mobilization showed a similar trend. At 12 h postadductor block, besides intravenous (i.v.) paracetamol, 32.6% of patients were given tramadol 50 mg i.v. whereas one patient was given a buprenorphine patch in addition to tramadol. The number of patients requiring additional tramadol and buprenorphine patch steadily increased over the next 2 days. The average time taken for the TUG test at 24 h was 30.98 ± 4.77 s, and the average time taken for the 10 s walk test at 24 h was 6.16 ± 1.10 steps with improvement in performance over the next 2 days. Conclusion: In our study, our multimodal analgesia model did not provide satisfactory analgesia though mobilization was not hampered.
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Is ultrasonography a better method of endotracheal tube size estimation in pediatric age group than the conventional physical indices-based formulae? Highly accessed article p. 561
Gunjan, Ankesh , Md Alam Faseehullah
DOI:10.4103/aer.AER_115_20  
Background: Providing safe anaesthesia to paediatric patients is a challenging task. This requires a thorough knowledge of the soft and pliable paediatric airway. Owing to the vulnerability of the anatomical structures involved, choosing an appropiate sized endotracheal tube (ETT) is important in these cases. A larger sized ETT may lead to trauma and a smaller one would result in leakage and risk of aspiration. Both situations demand an immediate tube change, thereby complicating the condition. The physical indices- based formulae have often failed to justify the purpose leading to repeated laryngoscopy and tube change during intubation. The increase in availability of the modern ultrasound devices have shown promise in these cases. Aims and Objectives: In this study we examine the accuracy of ultrasonography (USG)to assess the appropriate ETT size, comparing it with physical indices based formulae suggested ETT size so that repeated attempts on intubation can be minimized. Materials and Methods: The study group included 100 patients of 1-5 years, ASA I- II, requiring orotracheal intubation under general anaesthesia. The tracheal sub-glottic diameter was estimated by pre-anaesthetic USG to determine the ETT size, both cuffed and uncuffed. ETT data obtained by these methods were compared by Pearson's correlation coefficient and t-test. Results: USG predicted ETT size were significantly more consistent than the physical indices based formulae. Also the age based formulae were found to be more precise than the height based ones. Seven patients required change of tube once. Conclusion: Ultrasonography is an effective tool in predicting paediatric ETT size.
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The effect of adding magnesium sulfate to local anesthetic in patients undergoing middle ear surgery p. 566
Maha Younis Youssef Abd Allah, Mohamed Abdelbadie Salem, Mohamed Younes Yousef Abd Allah
DOI:10.4103/aer.AER_23_21  
Background: The use of local anesthesia has been proved to be beneficial in ear surgeries. Aims: This study was conducted to compare between local anesthesia alone and in combination with magnesium sulphate as an adjuvant in ear operations. Materials and Methods: This prospective study included a total of 164 cases prepared for elective ear surgeries were included. They were divided into two equal groups, group C or control group included cases who received local anesthesia alone, and group M which included cases who received local anesthesia in addition to magnesium sulphate. Ear ring block was performed in all cases. Monitoring of blood pressure, heart rate, and oxygen saturation was performed. Post-operative pain was assessed by visual analogue score. The total analgesic time and total analgesic requirement were recorded. Statistical Analysis: IBM's SPSS statistics (Statistical Package for the Social Sciences) for windows (version 25, 2017) was used for statistical analysis of the collected data. Shapiro-Wilk test was used to check the normality of the data distribution. All tests were conducted with 95% confidence interval. P (probability) value < 0.05 was considered statistically significant. Charts were generated using SPSS' chart builder and Microsoft Excel for windows 2019. Results: The onset of sensory blockade was significantly earlier in the Mg group. Mg group showed a significant decrease in intraoperative and post-operative analgesic consumption. In addition, the first request for analgesia after operation was markedly delayed in the Mg group compared to controls. Regarding intraoperative VAS, it was significantly lower in the Mg group compared to controls at 15-minute reading. Post-operative VAS was significantly lower in Mg group during the first two hours. Conclusion: Addition of magnesium to local anesthesia causes early onset of sensory blockade, delayed call first for analgesia, and better VAS scores during the early post-operative period.
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Dexmedetomidine and magnesium sulfate as adjuvant to 0.5% ropivacaine in supraclavicular brachial plexus block: A comparative evaluation p. 572
Usha Shukla, Dheer Singh, Jay Brijesh Singh Yadav, Mahendra Singh Azad
DOI:10.4103/aer.AER_28_21  
Background: Dexmedetomidine and magnesium sulfate (MgSO4) as an adjuvant to local anesthetics and ultrasound guidance improves the quality of peripheral nerve block. Aim: We aim to compare the efficacy of dexmedetomidine and MgSO4 as an adjuvant to ropivacaine in supraclavicular brachial plexus block. Methodology: Sixty patients undergoing upper extremity orthopedic surgery were randomly allocated into three groups of 20 each. Group A received 29 mL of 0.5% ropivacaine plus 1 mL of normal saline, Group B received 29 mL of 0.5% ropivacaine plus 1 mL dexmedetomidine (100 μg), and Group C received 29 mL of 0.5% ropivacaine plus 1 mL MgSO4 (250 mg). Onset and duration of sensory and motor block, duration of analgesia, quality of anesthesia, total 24 h analgesic consumption, sedation, and complications were recorded. Statistical Analysis: Software SPSS-16 was used for statistical analysis. Results: The onset of sensory block and motor block was fastest for Group B, followed by Group C and slowest in Group A. The duration of sensory block and motor block was maximum for Group B, followed by Group C and minimum for Group A. The duration of analgesia was maximum for Group B, followed by Group C and minimum for Group A. Analgesic consumption was minimum for Group B. Quality of anesthesia was better in Group B than other groups. The visual analog scale was higher in Group A than other groups. Group B reported higher sedation score. Conclusion: Dexmedetomidine provides earlier onset of sensory and motor block as well as prolonged duration of sensory and motor blocks and duration of analgesia is longer and postoperative rescue analgesia is less as compared to patients receiving MgSO4. The incidence of hypotension and bradycardia and sedation score was higher with dexmedetomidine.
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Premedication for induced hypotension in functional endoscopic sinus surgeries: Intravenous dexmedetomidine infusion vs oral metoprolol vs placebo: A comparative study p. 578
Lakshmi Mahajan, Arvinder Pal Singh, Sunil Chawla, Sukhman Gill
DOI:10.4103/aer.AER_19_21  
Background: Controlled hypotension has been used to reduce bleeding and the need for blood transfusions and provide a satisfactory bloodless surgical field. In this double-blind, randomized controlled trial, we are comparing intravenous (i.v.) dexmedetomidine infusion and oral metoprolol as a premedication for controlled hypotension in functional endoscopic sinus surgery (FESS) for evaluating surgical field visibility. Subjects and Methods: A total of 90 patients undergoing FESS were randomly divided into three groups of 30 each. Group A received intraoperative i.v. infusion of dexmedetomidine (loading 1 μg.kg−1 over 10 min followed by the maintenance of 0.2–0.5 μg.kg−1.h−1), Group B received oral metoprolol 50 mg on night and 2 h before surgery as a premedication, and Group C was taken as a control group and patients received oral placebo tablet as premedication and intraoperative normal saline infusion. General anesthesia was given using sevoflurane. Intraoperative target mean arterial blood pressure was set 55–65 mmHg. Various parameters were recorded and statistically compared. Results: The three groups were statistically comparable in demographics. Quality of surgical field was better in Group A compared to other two groups. Total blood loss was also less in Group A. The incidence of adverse reactions was more in Group A. Conclusion: Dexmedetomidine provides a better surgical field compared to oral metoprolol in FESS along with the desired hemodynamics with lesser blood loss and better outcome.
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Perioperative obstetric care in coronavirus infectious disease 2019: Anesthetic perspective p. 584
Amrita Panda, Saswati Das, GC Satapathy
DOI:10.4103/aer.AER_4_21  
Background: The novel coronavirus infectious disease-2019 (COVID-19) is a global pandemic involving many countries and has affected more than seventy-nine million people worldwide, with greater than a million deaths in the current scenario. Aims: The aim of the study is to improvise perioperative obstetric healthcare in a tertiary healthcare center. Settings and Design: This is a retrospective case series of parturients infected with COVID-19. Materials and Methods: We present a case series of COVID-19–infected parturients. There is no evidence that pregnant women are more likely to become seriously affected by coronavirus, yet these groups of patients are vulnerable to infection. Hence, the objectives in the management of such patients which includes caring for the range of the asymptomatic to critically ill women in the peripartum period and protection of healthcare providers from exposure to the disease while treating them while treating them is of paramount importance. Results: There is limited literature available about the effect of this disease and the risk of complications in pregnancy. The variables affect the respiratory system and exacerbate the susceptibility to infections. This complicates or delays the diagnosis in COVID-19–infected parturients, which affect their clinical outcome. Thus, there is a need on focused and optimal management in a tertiary healthcare center. Of the total 109 lower segment cesarean section patients in our hospital, there were only two maternal and neonatal deaths among the 12 emergency cases performed. Conclusions: Collaborative efforts are imperative among experts such as anesthesiologists and obstetricians to tackle the impact of this disease. There must be surveillance systems in place for reporting maternal and fetal data during this pandemic.
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A comparative study of modulation of neuroendocrine stress response by dexmedetomidine versus fentanyl premedication during laparoscopic cholecystectomy p. 589
Usha Shukla, Manoj Kumar, Saumya Srivastava, Swati Srivastava
DOI:10.4103/aer.AER_22_21  
Introduction: Surgical stress is the systemic response to surgical injury. Analyzing these surgical stress responses and pharmacologically modulating them can be of immense use to an anesthetist for optimal patient care. Aim: The aim of the present study was to investigate the influence of dexmedetomidine and fentanyl premedication on the modulation of neuroendocrine stress response during laparoscopic cholecystectomy under general anesthesia. Methods: After obtaining approval from the institutional ethical committee [Date - 05/11/2020, Ethical Clearence Number - 133/2018], 60 patients undergoing laparoscopic cholecystectomy under general anesthesia were randomized into three study groups of 20 patients each. Group D patients were given intravenous (i.v.) dexmedetomidine 1 μg.kg−1, Group F patients fentanyl 2 μg.kg−1 and Group C patients 10 mL of normal saline. All patients received the same anesthetic drugs and surgical procedure. Patients were assessed for changes in hemodynamic parameters such as heart rate (H) and mean arterial pressure (MAP). Blood samples were analyzed for glucose, serum albumin, C-reactive protein (CRP), and serum cortisol levels at various time intervals. Results: H and MAP differed among the groups after intubation, 5 min after pneumoperitoneum (POT), and 10 min after POT. The increase in these parameters from their baseline values was less in the dexmedetomidine group when compared to other groups. Among the biological markers, the increase in serum cortisol levels and decrease in albumin levels could be detected 6 h after induction while blood glucose levels rose immediately after the incision. CRP levels started significantly rising only after 24 h of induction. All these changes were much less pronounced in patients receiving dexmedetomidine premedication as compared to other groups. Conclusion: i.v. dexmedetomidine 1 μg.kg−1 is better than injection fentanyl 2 μg.kg−1, in the modulation of neuroendocrine response in patients undergoing laparoscopic cholecystectomy under general anesthesia.
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The impact of sevoflurane and propofol anesthetic induction on bag mask ventilation in surgical patients with high body mass index p. 594
Ahmed M Farid, Hani I Taman
DOI:10.4103/aer.AER_20_21  
Background and Aims: Obesity is associated with restrictive ventilatory pattern which causes rapid oxygen desaturation. Although obesity is considered as a risk factor for difficult airway management, failure to achieve effective bag mask ventilation (BMV) can be catastrophic. This study tried to assess the effect of both propofol and sevoflurane on the efficacy of BMV during anesthetic induction in obese patients. Patients and Methods: A total of 200 cases were included, and they were randomly divided into two equal groups; Group S which included 100 cases who underwent sevoflurane induction, and Group P which included the remaining 100 cases who underwent propofol induction. Results: No statistically significant difference was detected between the two groups regarding patient and air way characteristics (P > 0.05). Difficult BMV (DBMV) was encountered in 19% and 37% of cases in Groups S and P, respectively. The incidence of DBMV was significantly increased in the P group (P = 0.005). Furthermore, the severity of difficulty was more marked in the P group. Logistic regression analysis revealed that thyromental distance, presence of macroglossia, presence of beard, lack of teeth, history of snoring, as well as propofol induction were risk factors for DBMV. Conclusion: Sevoflurane can facilitate BMV and provide better intubation conditions in comparison to propofol during anesthetic induction in morbidly obese patients. Moreover, decreased thyromental distance, presence of macroglossia and beard, lack of teeth, and history of snoring are considered preoperative indicators of DBMV.
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Comparison of end-tidal anesthetic gas concentration versus bispectral index-guided protocol as directing tool on time to tracheal extubation for sevoflurane-based general anesthesia p. 600
Usha Shukla, Urvashi Yadav, Jay Brijesh Singh Yadav, Sanket Agrawal
DOI:10.4103/aer.AER_25_21  
Background: Modalities for titrating anesthetic drug-like bispectral index (BIS) and end-tidal anesthetic gas (ETAG) concentration in predicting early extubation had been studied with old anesthetic agents such as isoflurane. Aim: The aim of this study is to compare the effect of ETAG concentration versus BIS-guided protocol as directing tool on time to tracheal extubation for sevoflurane-based general anesthesia. Materials and Methods: This prospective, randomized, double-blind trial studied sixty patients with American Society of Anesthesiologists physical status classes I and II who received sevoflurane-based general anesthesia and were allocated to either BIS–guided anesthesia group (n = 30) or ETAG–guided anesthesia group (n = 30). Time to tracheal extubation was measured. BIS value was kept between 40 and 60 in BIS group, whereas minimum alveolar concentration value was kept between 0.7 and 1.3 in ETAG group. The two groups were compared using Student's t-test, and P < 0.05 was considered statistically significant. The statistical analysis was performed using the open source “R” programming language. Results: Mean time to tracheal extubation was significantly shorter in BIS group (308.77 ± 20.48 s) as compared to ETAG group (377.90 ± 25.06 s) (P < 0.001). The sevoflurane concentration used was also significantly less in group BIS than group ETAG at multiple time intervals (P = 0.001). Conclusion: Prediction of extubation was significantly early with BIS monitoring as compared to ETAG monitoring in sevoflurane-based general anesthesia.
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Efficacy of ketofol in blunting hypotensive effects of propofol during induction and its effect on intraoperative anesthetic requirements and recovery profile p. 605
Niranjan Kumar, Sunil Rajan, Lakshmi Kumar
DOI:10.4103/aer.AER_27_21  
Background: Major disadvantage of propofol is dose-dependent hypotension. Aim of the Study: The aim of the study was comparison of changes in heart rate (HR) and mean arterial pressure (MAP) after induction with propofol versus ketofol (a combination of ketamine and propofol). Settings and Design: This was a prospective randomized study conducted in a tertiary care institute. Subjects and Methods: Sixty patients were recruited. Group A patients were induced with 1.5–2.5 mg.kg−1 propofol. In Group B, ketamine 1 mg.kg−1 was given intravenously followed by propofol 1–2 mg.kg−1. All patients received standardized intraoperative management. Statistical Tests Used: Chi-square test, independent sample t-test, and paired t-test were used for statistical analysis. Results: Baseline HR and HR immediately after induction were comparable in both groups. There was a significant decrease in mean HR at 3 min postinduction in Group A compared to Group B (65.7 ± 5.4 vs. 80.8 ± 12.4). At 1 min postintubation, there was a significant rise in HR in Group A (103.5 ± 12.4 vs. 84.8 ± 9.5). HR remained comparable in both groups at other timelines. Baseline MAP was comparable between groups. Mean MAP in Group A was significantly lower than Group B immediately after induction and at 3 min postinduction. MAP was significantly higher in Group A at 1 min postintubation and remained comparable at other time points. The incidence of hypotension was significantly higher in Group A compared to Group B. Conclusion: Combining ketamine 1 mg.kg−1 to propofol blunted hypotensive and bradycardic effects of propofol. Ketofol effectively attenuated hemodynamic responses to intubation and was associated with reduced intraoperative opioid consumption with no added risks of excessive postoperative sedation or emergence delirium.
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Elective cesarean section in obstetric COVID-19 patients under spinal anesthesia: A prospective study p. 611
Masrat Jan, Wasim Mohammad Bhat, Muqtasid Rashid, Basharat Ahad
DOI:10.4103/aer.AER_29_21  
Background: Managing obstetric emergencies in COVID-19 pandemic is a real challenge as these patients need timely intervention to save the life of the mother and the baby. Hence, to avoid life-threatening challenges, all pregnant patients were electively admitted and tested for COVID-19 near term to anticipate the difficulties and prevent complications. Aim: Our aim was to assess the impact of COVID-19 infection on maternal morbidity and mortality as well as the effect on the neonate under spinal anesthesia. Settings and Design: This was a prospective observational study. Materials and Methods: One hundred and fifteen COVID-19-positive pregnant patients in the age group of 20–40 years from July 2020 to December 2020 were electively taken for cesarean section under spinal anesthesia. Patients who needed emergency cesarean delivery were excluded from the study. Emergency cesarean delivery was avoided to reduce the risk of aerosol generation under general anesthesia as endotracheal intubation of COVID-19 patients poses a significant risk of viral exposure to doctors and staff. Written informed consent was obtained from all patients. Spinal anesthesia was given at L4–L5 intervertebral space. Demographic parameters, anesthetic and surgical parameters, and neonatal parameters were observed. Any inadvertent event was noted. Statistical Analysis: Data were expressed as mean, median, percentage, or number. Results: All pregnancies were singleton. None of the patients was converted to general anesthesia. One hundred and ten were either mildly symptomatic or asymptomatic. Five of our patients had severe symptoms and needed intensive care unit care preoperatively and postoperatively. Seven patients developed spinal hypotension and were managed by vasopressors. No significant thrombocytopenia was noted in any of our patients. None of our patients developed symptomatic thromboembolism. Vertical transmission was not reported in any of the cases. All babies were born with weight >2500 g and good APGAR score. Conclusion: Spinal anesthesia for LSCS is safe and effective for obstetric anesthesia in COVID-19 both for the parturient and the newborn.
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Diagnostic accuracy of various biomarkers of sepsis (serum pro-calcitonin, high-sensitivity C-reactive protein, and C-reactive protein) and band cell percentage in critically lll patients: A prospective, observational, cohort study p. 615
Bikram Kumar Gupta, Badri Prasad Das, Vanita Ramesh Mhaske, Shubham Tomar, Kapil Rastogi
DOI:10.4103/aer.AER_3_21  
Background: Despite the advances in medical sciences, the morbidity and mortality due to sepsis in critically ill medical or surgical patients remains high, hence the need for an early and accurate diagnosis. In the current armamentarium, we have various biomarkers such as procalcitonin (PCT), high-sensitivity C-reactive protein (hs-CRP), CRP, and band cell percentage for an early clue. Aims: This study explores the accuracy of these markers in distinguishing sepsis from systemic inflammatory response syndrome (SIRS) and their correlation with sequential organ failure assessment (SOFA) scoring in critically ill patients. Materials and Methods: After ethical committee approval and written informed consent from guardians, 180 consecutive patients, with clinically suspected infection from any source fulfilling at least two criteria of SIRS, were enrolled and 150 eligible patients were investigated and analyzed prospectively in one cohort, which was later subdivided into two different groups (Group A and Group B) based on microbiology reports, as having SIRS or sepsis, respectively. Samples for cultures (blood, tracheal, or urine as required), biomarkers such as PCT, hs-CRP, and CRP, and band cell percentage were sent from each patient on days 1, 2, 3, and 5 and whenever there were fever spikes. Clinical follow-up was done for 28 days, and demographics, ventilator days, duration of intensive care unit (ICU) stay, and the survival rates were noted. Statistical Analysis: Receiver operating characteristics, area under curve (AUC-ROC) was used for each of the biomarker variables to decide the cutoff values and performance. Correlation coefficient was also seen for each of the biomarkers with SOFA scoring. Results: Attributes of performance for all the biomarkers were satisfactory but was best for PCT (AUC-ROC of 0.987) followed by band cell percentage (0.881). SOFA scoring could also be used with good diagnostic accuracy (AUC-ROC of 0.920). SOFA score correlated best with PCT among the four biomarkers in diagnosing sepsis (Spearman's coefficient of + 0.734). Band cell percentage was significantly higher in the expired group of sepsis patients than survived patients (P = 0.02) and correlated well with ICU stay and 28-day mortality than rest (Spearman's coefficient of − 0.54). Conclusions: The addition of PCT to the standard workup of critically ill patients with suspected sepsis increases diagnostic certainty and generates improved patient management. Band cell percentage also provides a cost-effective alternative to PCT with an analogous diagnostic performance.
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Effect of minimally invasive pain intervention in frozen shoulder patients: A cross-sectional study p. 620
Anurag Agarwal, Shivani Rastogi, Sujeet Rai, Manoj Giri, Samiksha Parashar, Deepak Malviya, Deepti Sharma
DOI:10.4103/aer.AER_94_20  
Background: Adhesive capsulitis or frozen shoulder (FS) is the second most common disorder accounts for 15%–30% shoulder pain and functional disability. Suprascapular nerve (SSN) interventions with corticosteroid alone have shown limited duration efficacy, adding pulsed radiofrequency (PRF) provides long-term relief. Aims and Objective: We aimed to analyze the efficacy of SSN intervention on pain relief and range of mobility in patients with FS. Settings and Design: This is a cross-sectional study of 37 patients of FS who underwent SSN interventions in a dedicated pain medicine unit of the department of anesthesiology. Materials and Methods: Thirty-seven patients, who underwent SSN interventions for FS and followed for 6 months, were included in this study. Pain (Visual Analog Scale [VAS]), range of motion (ROM) (17), and Oxford 12 point Shoulder Score (OSS) for functional outcomes were recorded. In the final analysis, two subsets of patients who underwent SSN steroid injection or SSN PRF plus steroid were found and compared using Student's t-test paired and independent with P < 0.05 considered significant at 95% confidence interval. Results: The patient population was demographically comparable. Mean VAS score and ROM improved at 1, 3, and 6 months to statistically significant. On comparing the subgroups, the VAS score and OSS in both the SI and PRF groups were significantly improved, but the PRF group showed highly significant improvement, showing better and sustained improvement in the PRF group. Conclusion: PRF with steroid injection of the SSN provides better and long-lasting relief from pain and improved mobility in FS patients in comparison to steroid alone.
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Assessment of success and ease of insertion of proseal™ laryngeal mask airway versus I-gel™ insertion by paramedics in simulated difficult airway using cervical collar in different positions in manikins p. 627
Arushi Gupta, Ankita Kabi, Divya Gaur
DOI:10.4103/aer.AER_72_20  
Background: Tracheal intubation, a critical intervention, performed by paramedics for airway management in trauma, has an unacceptably low success rate due to difficult airway, restricted access, and inexperience. Thus, the use of supraglottic devices to achieve ventilation has gained popularity. Aims: We aimed to compare the success rate, time to achieve ventilation, and ease of insertion of two popular supraglottic devices, ProSeal™ laryngeal mask airway (PLMA) and I-gel™, in simulated difficult airway with limited access in manikins in different positions which were supine, head against the wall, and sitting position like in car seat. Settings and Design: This was a prospective interventional study. Materials and Methods: After a brief training, 35 paramedics were asked to insert I-gel™ and PLMA in a manikin with cervical collar in 3 positions: head end free (Group A), head against the wall (Group B), and sitting position (Group C), to simulate difficult airway. Success rate and time to achieve ventilation in each position were noted. Each participant graded ease of insertion. Statistical Analysis: Statistical analysis was performed using SPSS 24.0. Categorical variables were analyzed using a Pearson's Chi-square test. Continuous variables were analyzed using the Kolmogorov–Smirnov test. If there was a normal distribution, a paired t-test was performed. Otherwise, a Wilcoxon signed-rank test was performed. P < 0.05 was considered statistically significant. Results: Success rate with I-gel™ was significantly higher than PLMA, 91% versus 77% in Group A, 100% versus 88% in Group B, and 100% versus 74% in Group C. Time to achieve ventilation was shorter with I-gel™ than PLMA, 8.9 versus 15 s in Group A (P < 0.001), 13.1 versus 21.3 s in Group B (P < 0.01), and 18.5 versus 30.3 s in Group C (P < 0.001). Conclusion: I-gel™ can be an effective device to achieve ventilation in difficult airway with limited access in trauma. More studies are required to validate its success and safety.
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Effect of use of high-flow nasal cannula during fiberoptic intubation under general anesthesia: A randomized controlled trial p. 632
Shashank Rao, Sujeet Rai, Pravin Kumar Das, Suraj Kumar, Deepak Malviya, Manoj Tripathi
DOI:10.4103/aer.aer_55_21  
Background: Oxygenation by high-flow nasal cannula (HFNC) is being widely studied in the intensive care unit and operation theater settings. Aims and Objectives: The aim of this study is to determine the effect of HFNC during fiberoptic intubation in terms of time taken and ease of intubation. Settings and Design: Randomized, prospective, and controlled study. Materials and Methods: In this study, we have recruited 40 patients according to the inclusion criteria (patient's body mass index [BMI] >22.99 kg.m−2 and patients with a history of stridor and/or obstructive sleep apnea) and after randomization divided them into two groups of 20 each – Group C: Intubation done with conventional fiberoptic after muscle relaxation and Group S: Intubation done with high flow nasal cannula during fiberoptic after muscle relaxation. We have observed and compared between the groups time taken for intubation, oxygen saturation during fiberoptic intubation, need of jaw thrust and difficulty in gliding endotracheal tube over fiberscope. Results: No significant difference was found in time taken for intubation, oxygen saturation, and need of jaw thrust (P > 0.05). We have found a significant difference in gliding of endotracheal tube over fiberscope (P = 0.001). Conclusion: We found high flow nasal cannula better and beneficial in patients with high BMI and having a history of stridor/obstructive sleep apnea for fiberoptic intubation after muscle relaxation.
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Effect of added alpha 2 agonists with local anaesthetic in infraclavicular brachial plexus block: A comparative study between dexmedetomidine and clonidine p. 638
R Sreeja, Abbey Mathew, Madhu Velayuden
DOI:10.4103/aer.aer_54_21  
Background: Many adjuvant drugs are added with local anesthetics to increase the quality of regional blocks. Aim: To compare the effects of dexmedetomidine and clonidine added to bupivacaine in infraclavicular brachial plexus block in prolonging the duration of analgesia in patients undergoing orthopedic surgery of forearm or hand and also to compare the duration of sensory and motor block, sedation, and hemodynamic changes like bradycardia and hypotension in two groups. Settings and Design: This was an observational study conducted in a tertiary care hospital. Materials and Methods: A study was conducted among 60 patients admitted for elective upper limb surgeries under ultrasound-guided infraclavicular block. Patients who received bupivacaine 0.5% (20 mL) + Clonidine 1 μg.kg−1 were classified as Group A and those received bupivacaine 0.5% (20 mL) + dexmedetomidine 1 μg.kg−1 were classified as Group B. Statistical Analysis: Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) software version 25. Results: Duration of analgesia was significantly higher in Group B as compared to Group A (mean + standard deviation = 764 ± 17.573 min vs. 526 ± 9.958 min, respectively, P = 0.001). The mean time for onset of a sensory block as well as motor block was significantly less in Group B when compared to Group A (P = 0.001). The mean duration of both sensory block and motor block was higher in Group B as compared to Group A (P = 0.001). Conclusions: The dexmedetomidine group (Group B) provides a quicker and prolonged analgesic action without major adverse effects.
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To compare the efficacy of postoperative analgesia between clonidine and dexmedetomidine as adjuvants with 0.5% ropivacaine by ultrasound-guided supraclavicular brachial plexus block for upper limb surgeries: A prospective, double-blind, randomized study p. 644
Preeti Kumari, Raj Bahadur Singh, Kumar Saurabh, Shilpi Pal, Ganesh Kumar Ram, Rakesh Kumar Anand
DOI:10.4103/aer.aer_57_21  
Context: The supraclavicular brachial plexus block is a very safe, useful and effective method for upper limb surgeries. Among local anesthetics, ropivacaine has special applications in neuraxial and peripheral nerve blocks due to its low cardiotoxicity and less toxicity to central nervous systems compared to bupivacaine and lignocaine. Dexmedetomidine is a newer and potent alpha-2 receptor agonist which has 10 times higher selectivity for alpha-2 receptors as compared to clonidine, So far, very few studies have been undertaken to compare the efficacy of clonidine and dexmedetomidine to provide and prolong postoperative analgesia, especially with the use of ultrasound for nerve localization. Aims: To compare the efficacy of postoperative analgesia between clonidine and dexmedetomidine as adjuvants with 0.5% ropivacaine by ultrasound-guided supraclavicular brachial plexus block for upper limb surgeries. Settings and Design: Prospective, randomised, double-blind interventional study. Subjects and Methods: Eighty patients of ASA grade I or II undergoing elective upper limb surgery were randomly divided into two groups:- Group RC (n = 40) received 35 ml of 0.5% ropivacine with 1 μg.kg−1 of clonidine.Group RD (n = 40) received 35 ml of 0.5% ropivacaine with 1 μg.kg−1 of dexmedetomidine. Statistical analysis used: The statistical software SPSS version 20 has been used for the analysis. By using Pearson's Chi-Square test for Independence of Attributes/Fisher's Exact. Continuous variables were expressed as Mean, Median, and Standard Deviation and compared across the groups using unpaired t-test. Results: In our comparative study, dexmedetomidine 1 μg.kg−1 with 35 ml of 0.5% ropivacaine provided significantly longer duration of postoperative analgesia and earlier sensory block as compared to clonidine 1 μg.kg−1 with same dose of ropivacaine in ultrasound-guided supraclavicular brachial plexus block. Conclusions: The ropivacaine-dexmedetomidine group in our study provided earlier sensory block and more prolonged postoperative analgesia as compared to ropivacaine-clonidine group. Thus ropivacaine-dexmedetomidine combination may be effectively used in all painful upper limb surgeries specially orthopaedic procedures.
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